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

raw_content: Upon review of a DFPS investigation, it was determined that staff member put a child in care in the closet as a means to control or immediate the child.

Correction Narrative:
Director sent email stating the following: Ray's of Life GRO Executive Director/ Administrator will Conduct mandatory trainings for all staff on children's rights, emphasizing the prohibition of demeaning, harmful, or isolating behaviors. For accountability Ray's of Life will reinforce an incident reporting system and establish a safe system for children to provide feedback or report concerns about their treatment where any suspected violations of children's rights can be reported confidentially and addressed promptly. Increase supervision and monitoring of staff interactions with children to ensure compliance with children's rights policies and the Minimum Standards. Provide additional coaching and corrective feedback to staff demonstrating inappropriate behavior.
Please


state: TX

facility_name: Ray's of Life

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

raw_content: Upon arrival at the operation, RCCR Inspectors knocked on the door. Staff was not around and one of the children at the operation answered the door allowing Inspectors inside the operation.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative: Upon arrival the staff answered the door, and the children were active in the Livingroom area. The staff was active and no children came to the door.


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

raw_content: During the inspection, 1 out of the 3 files reviewed did not contain verification for all requirred trainings.Staff did not complet EBI training.

Category: Training and Professional Development

Standard Risk Level: Medium High

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating she will be responsible for ensuring all new hire requirements are obtained upon hire moving forward. The email also contained a copy of all employee's current EBI training certificates.


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

raw_content: During the inspection, all beds were observed missing flats sheets.

Standard Risk Level: Medium

Corrected at Inspection: Yes


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

raw_content: During the inspection, 1 out 3 employee files did not contain verification of TB.

Category: Reports and Record Keeping

Correction Narrative: An email was received from the operation's administrator that included a corrective action plan indicating she will be responsible for ensuring all new hire requirements are obtained upon hire moving forward. The email also contained a copy of the employee's TB test.


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

raw_content: One out of three youth files reviewed did not contain a PLSP signature on the admission assessment.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Correction Narrative: An email was received from the operation's administrator which included a corrective action plan indicating the administrator/executive director will be responsible for completing an audit of all current files to ensure all signatures are on the required documents. It also indicated the administrator/executive director will ensure the PLSP signs all required documents moving forward.


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

raw_content: One child's medication record was reviewed and did not contain a signature of who administered the medication.

Correction Narrative: An email was received from the operation's administrator which included a corrective action plan indicating the administrator/executive director will be responsible for conducting daily audits of the medication log. It also indicated a secondary auditor will also check for completion of the med logs daily.


raw_content: Two out of three employee files reviewed did not contain a TB test or drug test. One out of three employee files reviewed did not contain verification of educational requirements.

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

Correction Narrative: An email was received from the operation's administrator which included a corrective action plan indicating the administrator/executive director will complete an audit of all personnel files to ensure their accuracy and completion. It also indicated the administrator/executive director will ensure all employees have obtained a TB and drug test before employment.


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

raw_content: One out of three youth files reviewed did not contain an initial or preliminary service plan. One out of three youth files reviewed did not contain an admission assessment.

Correction Narrative: An email was received from the operation's administrator which included a corrective action plan indicating the administrator/executive director will be responsible for utilizing a checklist at admission to ensure all required documents are obtained/completed. It also indicated routine audits will be conducted of the files to ensure their completion and accuracy.


raw_content: One child's file reviewed was missing the Admission Assessment, Child Orientation, and Service Plan.

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

Correction Narrative: Corrected


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

raw_content: One child's file reviewed did not have the required criteria on the exterior or in a clearly visible location.


raw_content: One child's medication record was reviewed and did not contain the time a dosage was given or a signature of who administered the medication.

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


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

raw_content: The fire extinguisher on the second floor expired October of 2023.


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

raw_content: One employee of the operation is under age 21 and has been the only staff working on shift with the group of youth who are more than 13 years old.

Standard Risk Level: Medium Low

Correction Narrative: An email was received from the operation's administrator, Adrienne Lee, which included a corrective action plan that indicated a manager/supervisor will be present to monitor any employee under the age of 21 who is only allowed to work with the youth under the age of 12.


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: Two out of three employee files reviewed contained a drug test taken more than 1 year prior to employment with the operation.

Correction Narrative: An email was received from the operation's administrator, Adrienne Lee, which included a corrective action plan indicating she will be responsible for ensuring all newly hired staff complete a drug test before being allowed access to youth in care.


raw_content: Three out of three admission assessments reviewed were not signed by the PLSP.

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

Correction Narrative: An email was received from the operation's administrator, Adrieene Lee, which included a corrective action plan that indicated she will be responsible for following up with the PLSP/Treatment Director to ensure all service plans have been signed timely.


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

raw_content: Three out of three youth files reviewed did not contain a preliminary service plan.

Correction Narrative: An email was received from the operation's administrator, Adrieene Lee, which included a corrective action plan that indicated she will be responsible for ensuring the Treatment Director completes a preliminary service plan that addresses all the youth's needs within the timeframe moving forward. She stated during the inspection that the operation lost their Treatment Director and many of the responsibilities for that position has not been completed. She indicated they are searching to hire a new one though.


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

raw_content: Several documents reviewed contained errors such as wrong dates or names listed on the documents.

Correction Narrative: An email was received from the operation's administrator, Adrieene Lee, which included a corrective action plan that indicated either the executive director or administrator will ensure all documents are kept true, current, accurate, and complete.


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

raw_content: One out of one child files reviewed did not contain in a visibly accessible place the known allergies or medical conditions for the child.

Correction Narrative: An email was received from the operation's administrator that included a file face sheet for the child in care that shows known allergies. This is intended to be placed on the exterior of the child's file.


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

raw_content: Two out of two employee files reviewed did not included a concrete date of employment. One out of the two employee files reviewed did not have the affidavit for employment notarized.

Correction Narrative: An email was received from the operation's administrator, Adrienne Lee, that included New Hire Checklists to show the date of employment. It also included the completed affidavit for the employee as well.


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

raw_content: The operation needs to hire a Treatment Director based on the services they will provide. Verification of this will need to be by the intended Treatment Director having an active background check under the operation.

Category: Personnel

Correction Narrative: An email was received from the operation's owner, Armando Richardson, indicating a treatment director will be hired by the comply by date as there is one the operation has in mind of hiring. The operation is actively working to hire one.


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

raw_content: One out of four employee files reviewed did not contain an affidavit for employment. Another employee file reviewed did not have the affidavit for employment notarized.

Correction Narrative: An email was received from the operation's owner, Armando Richardson, which included a copy of the completed notarized affidavits for the two employee files.


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

raw_content: Two out of four employee files reviewed did not contain a job description.

Correction Narrative: The job descriptions for the two employees missing theirs in their files were provided via an email from the operation's owner, Armando Richardson.


summary: 748.863(a)(1) - Pre-Service Training-All caregivers must receive 8 hrs of general pre-service training & 4hrs before being counted in child/caregiver ratio.

raw_content: 4 out of 4 files that were reviewed were missing complete pre-service trainings.

Correction Narrative: Trainings logs were provided for all 4 employees via an email from the operation's owner, Armando Richardson.


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

raw_content: One out of four employee files reviewed did not include any record of trainings.

Correction Narrative: A training log was provided for the employee missing the record from their file via an email from the operation's owner, Armando Richardson.


raw_content: Several documents reviewed in employee files contained another operation's name.

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

Category: Organization and Administration

Correction Narrative: A corrective action plan was received via email from the operation's owner, Armando Richardson, that indicated the operation's executive director and or LCCA will be responsible for ensuring the operation's records are kept true and accurate by completing quality assurance on the documents.


summary: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

raw_content: Missing from evacuation diagram.

Category: Safety and Emergency Practices

Deficiency Narrative: Missing from evacuation diagram.

Correction Narrative: An email was received from the operation's administrator which included a copy of the updated document to include the missing component.


raw_content: Missing from 2/2 employee files.

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

Deficiency Narrative: Missing from 2/2 employee files.

Correction Narrative: An email was received from the operation's owner which included a copy of employment verification letters for both employees including dates.


summary: 748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs

raw_content: Immediate dental needs not included in preliminary service plan.


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

raw_content: Not included in mock incident report form


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: Missing from 1/2 employee files.

Deficiency Narrative: Missing from 1/2 employee files.

Correction Narrative: An email was received from the operation's owner which included a copy of the missing TB skin test documentation.


summary: 748.111(14) - Child-care policy - Procedures for routine and emergency diagnosis, including treatment of medical and dental problems

raw_content: Missing from policy

Deficiency Narrative: Missing from policy


summary: 748.311(11) - Serious Incident Documentation-Must include an update regarding the unauthorized absence and the childs return.

Deficiency Narrative: Not included in mock incident report form


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

Correction Narrative: An email was received from the operation's owner which included a copy of the missing documents.


summary: 748.341(a) - Operating policies retention requirements - Maintain copy at operation available for review upon request

raw_content: A copy of operational policies were not available at operation upon request.

Correction Narrative: The operation's owner and administrator stated during the inspection they will ensure to maintain a hard copy of the policies at the operation moving forward.


summary: 748.111(12) - Child-care policy - Child grievance procedures

Correction Narrative: During the inspection, the operation's owner provided a copy of their intended grievance form for the youth in care which details the procedures of their grievance process.


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

raw_content: The menu doesn't indicate snacks to be given, the date, or any substitutions.

Category: Child Care


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

raw_content: Missing form 2/3 first aid kits.

Deficiency Narrative: Missing form 2/3 first aid kits.


summary: 748.363(9) - Personnel records-Include proof of request for background checks

Correction Narrative: An email was received from the operation's administrator which included a copy of the originally missing documents.


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


Standard Number / Description: 748.363(3) - Personnel records-Include current job description


facility_name: Harris County Youth Shelter

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

raw_content: Three of four employee records reviewed did not include reference checks completed prior to employment.

Correction Narrative:
Corrective action received from agency:

This is my formal response to an unannounced inspection that took place on August 4, 2025. The standard 748.7539(a)(1) concerning pre-employment reference checks was cited as a deficiency. A total of 4 employee files were reviewed. Three employees were hired after the standard went into effect. Attached you will find the references letters for the three files that need the reference check. Moving forward HR will send the reference letters for all newly hired employees as well as any employees that were hired after the standard became effective. Please let me know if you have any questions.


raw_content: The facility emergency evacuation diagram does not have a shelter in place designation indicated on it.

Standard Number / Description: 748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather

Correction Narrative: Agency provided amended emergency evacuation plan which now included the shelter in place meeting point.


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

raw_content: An injury requiring medical attention was not reported to until Licensing four days after it occurred.

Correction Narrative:
The operation emailed the following corrective action:
1.	Each shift will review the serious incident reporting standards found in the licensing minimal standards manual.
2.	All youth will be asked to report any injury right away no matter how small they may think it is. This instruction will also be discussed during the intake process moving forward.
3.	Staff will be instructed to document any injury or illness and notify myself or the administrator on call within two hours of the situation for instructions to be giving concerning the next steps.

**During the inspection two staff and one child was interviewed. Each staff confirmed knowledge of the procedure of reporting SIR to licensing. The child reported that she was aware to notify staff if she was injured or ill.**


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

raw_content: After thorough review of the ANE investigation contacts it was determined that a staff did not demonstrate competency, prudent judgment or self-control in a situation with a child in care. It was reported by the staff involved in the incident, victim child, additional children, and a paternal aunt that staff engaged in a verbal dialog with a child that escalated into the staff not choosing the most appropriate way to communicate with the child.

Correction Narrative: The operation reviewed the standard with the staff and discussed ways to communicate appropriately in a stressful situation. The staff was enrolled in a communication training that takes place on 11/4/2024 and will submit the training certificate to Licensing upon worker's completion of the training. The staff participated in role play scenarios to evaluate how the staff would respond and to correct the staff if the response could be perceived as negative.


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: It was found during inspection several molded vegetables and expired condiments not fit for consumption.

Correction Narrative: The administrator conducted a walkthrough of the kitchen and assisted the staff in discarding all expired food items. Photos were taken of the discarded items in the trash. A new checklist was implemented for staff to make daily checks of all areas containing food. A copy of the checklist was provided to Licensing.


summary: 748.3393(b)(1) - Toilets-Provide 1 toilet for every 8 children with individual privacy, including doors to individual toilet stalls

raw_content: It was found that there were broken toilet lids in children's bathrooms.

Correction Narrative: On 6/10/2024, a maintenance request was placed, and the toilets were both replaced. The receipt for the replacements was provided to Licensing. The new toilets have been installed.


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

raw_content: It was found that their indication of any known allergies or chronic conditions on the exterior of the child's file.

Correction Narrative: On 6/10/2024, all active youth files were reviewed for the allergy and chronic condition form. All forms have been placed in the appropriate area of the file.


summary: 748.753(b) - Pre-Employment Screening- At least one reference must be an employer who has supervised or familiar with the history of the applicant.

raw_content: It was found that a staff did not have an reference from their previous employee in their employee file.

Correction Narrative: On 6/11/2024 the administrator reviewed all active personnel files. The documents were requested form HR, and all active personnel files have the required documentation.


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

raw_content: It was found that staff files did not have the applicant's 5 year employment history.

Correction Narrative: On 6/11/2024, the administrator reviewed all active personnel files. The necessary documents were requested from HR, and all active personnel files have the required information.


summary: 748.363(7) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: It was found that a staff's file did not have an Licensing Affidavit for the employee.

Correction Narrative: On 6/11/2024, the administrator reviewed all active personnel files. All active personnel files have the required documentation. In the future, the supervisor will check for the Licensing Affidavit for Applicants form on the first day the worker arrives for duty.


summary: 748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered

raw_content: It was found that one vehicle that transports children had an expired registration.

Category: Transportation

Correction Narrative: On 6/10/2024, facilities took the vehicle to get the inspection and registration. The vehicle inspection and registration receipt were provided to Licensing.


summary: 748.363(9) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: It was found in staff files there was no signed statement stating that they will report any suspected child abuse, neglect, or exploitation

Correction Narrative: On 6/11/2024, all active personnel files were reviewed, and all Abuse and Neglect reporting statements have been updated. Supervisors are required to check files for accuracy. The administrator will review each file at the onset of the onboarding process to ensure this form has been completed.


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

raw_content: It was found that the staff list had employees that were no longer working at the operation.

Correction Narrative: The staff list has been corrected prior to Licensing exiting the building.


summary: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children

raw_content: Based on the review of the investigation it was determined that a staff member left children in care with unqualified caregivers while escorting a child to the clinic.


summary: 748.936(1) - Annual Training-  Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services

raw_content: Licensing observed three staff files with no documentation of six month emergency behavior intervention training (CPI).

Correction Narrative: Up to date training certifications were provided via email by the operation.


summary: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

raw_content:
Van 30636 has a tire pressure indicator on.
Van 31238  does not have operable A/C for rows 2-5.

Correction Narrative: Operation emailed service receipt for tire pressure check for both vehicles. Operation emailed that a/c was turned on for vehicle.


raw_content: 2 of 3 vans had service lights on, requiring maintenance service for an oil change and low tire pressure.

Standard Number / Description: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

Correction Narrative: Operation emailed maintenance receipts.


summary: 748.4007(6) - Overnight Excursion-Each vehicle must have approved fire extinguisher, secured in passenger compartment & accessible to adults

raw_content: 3 of 3 vans had fire extinguishers that were out of compliance.


raw_content: A child's Medication Record does not list the amount of medication administered.

Correction Narrative: Operation emailed a copy of medication log and stated that they have talked to staff members who administer medication to ensure that they are filling out the form in its entirety to include the dosage amount provided to children in care. The operation reported to have added another layer of documentation onto the form having staff document the dosage given.


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

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


summary: 748.685(b)(5) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's physical, mental, emotional, and social needs

raw_content: 4 of 5 staff stated that the child was allowed to a razor before shower time. Staff stated that they knew the child had self harm behavior in her past. 2 of 2 children stated that the child was allowed to have her razor before shower time.

Correction Narrative: Kinder Shelter has changed its procedures regarding  razor during shower time . Youth with current History of Self  harm will be provided with Nair hair removal during shower time to prevent cutting.


facility_name: Aspire 2 Dream

summary: 748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy

raw_content: During the walk-through of the inspection, it was noticed that there was no shower curtain in one of the bathrooms.

Category: Physical Site

Correction Narrative: A photo was sent of the bathroom shower having a shower curtain installed.


summary: 748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof

raw_content: During the walk-through of the inspection, one bed did not have a mattress protector. This was corrected at inspection by a staff member adding a mattress protector to the bed.


summary: 748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available

raw_content: During the review of documentation, the operation did not have documentation to show that the city/county is no longer providing health inspections.

Correction Narrative: An email containing a letter from the City of Beaumont was received regarding health inspection no longer being conducted.


summary: 748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826

raw_content: During the review of documentation, it was found that a pet's vaccine was expired.

Correction Narrative: An updated pet vaccination was sent via email. Exp. 3/2/2029


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

raw_content: During the walk-through of the inspection, hot dog buns were seen on the floor of the pantry. This was corrected at inspection by a staff member picking the hot dog buns off the floor of the pantry.


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

raw_content: During the inspection, it was found that the operation did not have an updated fire inspection completed.

Correction Narrative: A fire inspection was completed, and documentation was sent showing completion via email.


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

raw_content: 2 of 4 youth preliminary service plans were completed past the 72 hour requirement.

Correction Narrative:
08/22/2023-The operation's LCCA submitted to licensing the operation's Corrective Action Plan indicating the two 72-Hour Preliminary Service Plans had two different dates in two different fields; however, Extended Reach has been updated as related to the field to show placement date and auto populate completed.  LCCA signed the Corrective Action Plan on 08/22/2023.

LCCA will ensure that the correct date is on the plan as well as the date of placement is on the plan as well.

Additionally, LCCA submitted a revised copy of the operation's 72-Hour Preliminary Service Plan.


summary: 748.1439(b)(1)(A) - Discharge Documentation-Discharge summary must include services provided to the child while in your care

raw_content: 3 of 3 discharge summaries evaluated were observed to be missing information as required by 748.1439(b)(1)(A-F).

Correction Narrative:
08/22/2023-The operation's LCCA submitted licensing the operation's Corrective Action Plan indicating a new Discharge Summary has been created displaying all required information.  The LCCA signed as well as dated the Corrective Action Plan on 08/22/2023.

The LCCA provided licensing a copy of the operation's revised Discharge Summary.


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

raw_content:
2 of 3 non-emergency discharge summaries were observed to have provided 2 days advance notice of planned discharge.
There was no documented justification for not meeting the 4 days notice requirement.

Correction Narrative:
08/22/2023-The operation's LCCA submitted licensing the operation's Corrective Action Plan indicating youth are notified of discharge as soon as the operation know the decision is accepted no later than four days of discharge date.  The LCCA indicated this has been added to the Discharge Summary.  According to the LCCA, if a decision has been made not to notify the youth less than four days the Treatment Director will approve.  The LCCA signed as well as dated the Corrective Action Plan on 08/22/2023.

The LCCA provided licensing a copy of the operation's revised Discharge Summary.


summary: 748.1433(a)(2) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one PLSP involved in child's service planning

raw_content: 3 of 3 discharge summaries reviewed did not contain PLSP (Treatment Director) involvement in the discharge planning.

Correction Narrative:
08/22/2023-The operation's LCCA submitted licensing the operation's Corrective Action Plan indicating the Treatment Director is involved in discharge planning with the Licensed Administrator as well as both will sign the Discharge Summary.  The LCCA signed as well as dated the Corrective Action Plan on 08/22/2023.

The LCCA provided licensing a copy of the operation's revised Discharge Summary.


summary: 748.721(b) - Volunteer personnel record-Include signed/dated statement that volunteer will report child abuse/neglect to Tx Abuse & Neglect hotline & administrator

raw_content: Based on information gathered during an evaluation of two volunteer records, it was determined two out two volunteer records reviewed did not contain a statement signed and dated by the volunteer indicating the volunteer must immediately report any suspected incident of abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the operations administrator.

Correction Narrative:
04/12/2023- The LCCA submitted via email one signed volunteer Report Abuse and Neglect Statement to licensing staff.
Additionally, the LCCA attempted to contact the other volunteer via email as well as by telephone in efforts for the volunteer to sign as well as submit the Report Abuse and Neglect Statement; however, was unsuccessful in contacting the volunteer.  The LCCA demonstrated an attempt in meeting compliance requirements.

The operation is creating a new Abuse and Neglect Statement form for the use with volunteers meeting compliance.

04/14/2023- The LCCA contacted licensing staff via email stating both volunteers were removed from the background system as of 04/13/2023.


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 2nd. Quarter EBI Report has not been submitted to Child Care Regulation.

Correction Narrative: The operation's 2nd. Quarterly EBI Report was submitted into the system.  The report was reviewed in CLASS.


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

raw_content: Three of the three child files did not have the PLSP signatures on the Admission Assessment/Preliminary Service Plan.

Correction Narrative: An email was received from Ms. Nikki Relford showing the separation between the preliminary service plan and the admission assessment. Ms. Relford also submitted a photo of the new change requiring a PLSP/Treatment Director before the document can be approved and considered completed.


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

raw_content: One out of the three child  files reviewed showed an admission assessment that was missing information. There were a few pages that were blank with no entered information.

Correction Narrative: In extended reach we have set due dates in the system to flag when a document is due or if it is incomplete. With the new settings the treatment director will automatically be notified on the date of arrival that the plan is due then another reminder if incomplete next day. The Program Administrator will also receive the same reminder to ensure that oversight of completion of documents does not occur. Admission Assessment will be completed prior to arrival on all youth or upon arrival to facility.


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's  medication logs  documentation reviewed for the month of December of 2021 showed the child was not administered one of the required  prescribed medications two times.

Category: Medication

Correction Narrative: An email was sent to rccr staff on 01/13/2022 stating Aspire 2 Dream administrator has held a meeting with all Staff to go over the medication log and the additional information section. It also states that the agency Staff have been notified to always document any error or give explanation on any medication not given.  An email was sent on 01/20/2022 with the staff sign-in sheet from the staff meeting conducted with the staff regarding medication errors conducted on 12/27/2021.


summary: 748.2203(c)(1) - Medication Error-Document the time & date of the error

raw_content: One child's  medication log documentation reviewed showed the child was not administered one of the required  prescribed medications two times in the month of December 2021.  The medication error was not documented.

Correction Narrative: An email was sent to rccr staff on 01/13/2022 stating the medication error was related to the pharmacy not having the medication available, and the administrative staff has spoken with Superior concerning the medication and was advised that the emergency line can be utilized and assistance is available with 1-3 days meds in event this ever happens again.


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

raw_content: Two employees resigned approximately one month ago and the two staff still has active background checks.

Correction Narrative: BGC invalidation verified for the 2 former staff. An email was sent to rccr staff on 01/13/2022 stating Aspire 2 Dream will ensure that any employee no longer affiliated with the organization will be inactive in the background system within 7 days of departure. A2D has added a checklist to ensure that this is apart of the exit process for all Staff.


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 follow-up inspection conducted at the operation. the wardrobe in the front bedroom has been dismantled and removed from bedroom, and is located on the front porch away from the front door. One bedroom door is damaged and does not close, which does not allow for privacy. Another bedroom door is warped and separating. The two holes in the walls have been covered with plastic door protector. One set of blinds was observed to have broken slats.

Correction Narrative: Executive Director submitted photos and video footage of doors replaced and/or repaired, new blinds installed, and old wardrobe closet removed. All repairs have been completed.


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

raw_content:
One child's service plan reviewed,supervision requirements  addressed/ stated, at no time should the child be alone with younger children.
It was founded that the child was sharing a bedroom with a younger child.

Correction Narrative:
An email was sent to rccr staff on 01/13/2021 stating Aspire 2 Dream administrative staff reassigned child's bedroom. Administrator also reviewed and corrected the child's plan of service to reflect actual information regarding the child's necessary care.
RCCR requested the updated service plan.


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 complained of pain and was asked to be taken to the doctor by the staff after being punched approximately 10 times in the back of head by another child during an incident at the facility. The child was not taken to the doctor.

Correction Narrative:
Anytime a child complains of illness or pain, we will seek medical attention for that child. Staff will contact administrator and administrator will assess injury and provide the immediate medical attention needed.
If a child complains of an illness that is not an emergency, we are able to call Teladoc at 1-800-835-2362. This is a 24/7 access to a doctor by phone or video.
If there is an urgent need for medical attention, the child will be taken to urgent care facility to be examined.
In the event of an extreme emergency, we will call 911 or take the child to the nearest emergency room.


summary: 748.603(a)(1) - Treatment director-responsible for the overall treatment program and therapeutic interventions

raw_content:
A review of the treatment plans of the 2 youth who ran away from the facility identified significant required information missing.
One youth's service plan review was overdue and had not been completed.
One youth's service plan review did not describe the trauma history or known triggers; identified the youth as a victim of or at risk of being victim of human trafficking, however, did not identify high risk behaviors or plans to address any; did not identify any progress/efforts made by the provider towards achieving the permanency goal; did not address transitioning to successful adulthood or life skills strengths/challenges; and describes that the youth receives 24/7 supervision.

Correction Narrative: An email was sent to rccr staff on 01/21/2022 stating:Aspire 2 Dream Executive Director has assumed the role of LCCA and has been working closely with the Treatment Director ensure understanding of role of Treatment Director. We also contracted with a experienced Treatment Director to do a training with Treatment Director and to review the CPOS. The 2 youth in question are no longer in care at Aspire 2 Dream. All future plans will be updated by Treatment Director using information she obtain from working with the kids, psychological reports, cans, and therapy notes. The treatment team will participate in all plans with notification to dfps caseworker to join the review.


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

raw_content: Based on interviews conducted and records reviewed, it was determined the unauthorized absence debriefing for the 2 youth was not conducted timely.

Correction Narrative: An email was sent to rccr on 01/22/2022 stating the operation will conduct a befriefing within 24 hours of a child returning and send a copy to the rccr to ensure that the information is appropriately documented with the date and time stamped.


summary: 748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work

raw_content: Based on interviews conducted and records reviewed, it was determined a caregiver who was in ratio, was pulled away from the group of children to the hallway by the treatment director to discuss a youth, allowing 2 youth the opportunity to runaway from the operation. At the time of the unauthorized absence of the 2 youth, there were 6 children in care (5 treatment services) with 2 caregivers assigned to ratio, as well as the office manager and administrator who were both engaged in administrative duties (not counted in ratio). The youth remained gone until the following day.

Correction Narrative: An email was sent to rccr staff on 01/21/2022 stating the operation will ensure that adequate staff are scheduled for each group of youth that are not engaged in administrative duties. The email states the schedule will reflect if an administrative is counted in ratio within the timeframe.


raw_content: During an inspection a wardrobe cabinet was observed to be severly damaged. Thier was blinds in one of the bedrooms that were observed to be damaged. Their were 2 holes observed in 2 different child's bedroom walls and one of the bedroom doors would not close where the hole was present.

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


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

raw_content: Based on information obtained in interviews and records reviewed, there was only one staff on shift during the weekday mornings with 7 children in care, 6 of which were treatment services children.

Correction Narrative: An email was sent to rccr staff on 01/13/2022 stating Aspire 2 Dream administrator have corrected scheduling to ensure adequate staffing. The email also states Staff has access to time app with updated scheduling information and a copy of the schedule is printed at the home.


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

raw_content: Based on information obtained in interviews and records reviewed, it was founded that there were seven children in care  at the operation, all of which were located in the t.v. room and two direct care staff present at the operation, both staff  were putting away the children's medications located in the hallway of the facility. While both direct care staff were in the hallway, a fight started between two youth in the t.v. room where the children were located. Based on the layout of the facility the t.v. room can not be seen while a person is in the hallway and there is also a door located in the t.v. room.

Correction Narrative: An email was sent to rccr staff on 01/13/2022 stating Aspire 2 Dream staff has been reorientated about the supervision requirements and will ensure that children are monitored at all times. The email also states Staff will ensure that they will not put themselves in the position where they can't see or hear children to ensure the children are safe and they are able to quickly respond to any situation.


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

raw_content: A direct care staff with a hire date of 8/2/21, does not have an active background check.


summary: 748.2309(b) - Restrictions of activities-restrictions of activities imposed for more than 14 days must have prior approval

raw_content: A youth's activities were restricted for 30 days. There is no documentation in the youth's record showing approval by a PLSP nor the Treatment Director.

Correction Narrative:
LCCA submitted correction response: Aspire 2 Dream will ensure that any restriction has Treatment Director or PLSP prior approval in writing going forward. The incident report will have the signature of the treatment director or plsp. **The specific child that the 30 day special outing (movies, skating, bowling) was imposed on was approved by the LCCA/PLSP prior to deciding the consequence for the action. This was stated in exit however I was told that the incident report was completed by Amanda L and approved by myself (Nikki Relford). The case notes indicate that Lillian Harris and Nikki Relford discussed the consequence on this incident report. In extended reach this report automatically had my signature for approval because I accepted the report in the system. Lillian was apart of this and approved therefore this should not be a cite. (Admin review will be submitted on this for review).
As of 12/10/21, LCCA has not submitted AR request.


summary: 748.863(a)(4) - Pre-Service Training-Caregiver for tx svcs (not PMN) must have 16 hrs EBI training or 8 hrs if EBI prohibited, 1/2 pre-service & rest within 90 days

raw_content: After a review of the staff training records, it was found that one staff caregiver did not have the required EBI training.

Correction Narrative:
LCCA submitted corrective response: As discussed in exit all preservice EBI is being completed in accordance with standards. 8 hours preservice with additional 8 hours within 90 days. The certificate for the completed preservice has
been submitted prior to exit for review per our discussion. Annie Clark was the only employee who had completed SAMA prior to start work at Aspire 2 Dream however she did complete PAPH with A2D which was also submitted. Annie Clark is no longer employed at A2D.


summary: 748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs

raw_content: A child's service plan review did not document high risk behavior history of self harm and substance abuse, nor any plans to address. The service plan review did not address treatment services for emotional disorders nor any services to address substance abuse. The review plan did not include information from the recent psychological completed, did not include trauma history and triggers, did not include therapy information, nor any progress summary. The review plan did not identify/document efforts to transition to a lesser restrictive setting (plans for discharge).

Correction Narrative:
11/29/21-LCCA Nikki Relford submitted corrective plans: This child is no longer in care at A2D however all future child's service plan will document any high risk behaviors of self harm with plans to address them documented. All recent psychological, cans report, weekly therapy notes and treatment director notes will be utilized when creating plans. Plans will also
include any efforts for transition. Also, Treatment Director and LCCA will work together with entire treatment team to collect all updated data to include in plans. A PLSP will be identified at later date.


summary: 748.1001(a) - Children's rights-A child's rights are cumulative of any other rights granted by law or other Licensing rules

raw_content: Youth are being subjected to random drug testing conducted at the operation by the operation staff.

Correction Narrative:
11/29/21-LCCA Nikki Relford submitted corrective plans: Aspire 2 Dream will no longer conduct drug testing on site by staff. If a child should need to be tested A2D will get written permission from the DFPS Caseworker then take the child to a physician office or lab to conduct the test. I was still unable to find the exact standard related to this and caseworker had previously consented to drug testing therefore we will request admin review for this
standard/rule. As of 12/10/21, LCCA has not submitted an AR request.


summary: 748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly

raw_content: The 2nd quarter EBI report has not been submitted to Child Care Regulation.

Correction Narrative: The operation's 2nd quarter EBI report was submitted into the system. The report was reviewed in CLASS.


summary: 748.1337(b)(1)(A)(v) - Initial Service Plan-Include educational needs and how needs will be met; include any school evaluations or recommendations

raw_content: One initial service plan did not include the child's school information (grade, 504 accommodations, need for tutoring).

Correction Narrative: Operation submitted updated service plan review with additional education information.


summary: 748.1337(b)(1)(J) - Initial Service Plan-Include plans for discharge

raw_content: One initial service plan did not include plans for discharge.

Correction Narrative: Service plan submitted with discharge plans updated.


summary: 748.1337(b)(3)(A) - Initial Service Plan-For ID treatment services, include all child-care and treatment services planning requirements

raw_content: One initial service plan did not incude conditions that require treatment services.

Correction Narrative: Operation submitted a service plan review with updated psychological information showing the youth was not diagnosed with an intellectual disability.


summary: 748.1337(b)(1)(A)(vii) - Initial Service Plan-Include therapeutic needs, including plans for evals, follow-up treatment, testing and use of psychotropic medications

raw_content: Two initial service plans did not include information from the child's psychological or CANS assessment.

Correction Narrative: Operation submitted service plans with the updated information included.


summary: 748.1337(b)(1)(A)(i) - Initial Service Plan-Include medical needs, including scheduled medical exams and plans for recommended follow-up treatment

raw_content: One initial service plan did not include the child's allergies to medication.

Correction Narrative: Operation submitted corrected service plan


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: Two of two initial plans reviewed did not include description of high risk behaviors and plans to address.

Correction Narrative: Operation submitted corrected service plans with the updated information.


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

raw_content: One child record did not include chronic health condition in the electronic nor the paper file.

Correction Narrative: Operation submitted documentation correcting allergy information.


summary: 748.1337(b)(2)(B) - Initial Service Plan-For treatment services, include description of the emotional, behavioral, & physical conditions that require treatment services

raw_content: One intial service plan did not address conditions that require treatment services.

Correction Narrative: Operation submitted updated treatment plan with required content.


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

raw_content: The background check validation for the operation was not submitted quarterly as required.

Correction Narrative: Employee list validation was reviewed in CLASS, verified the operation validated the person list on 4/26/21.


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

raw_content: The operation s Professional Level Service Provider (PLSP) does not meet the qualifications to perform the PLSP required activities for having 7 children in care requiring more than 30% treatment services for emotional disorders.

Correction Narrative:
4/30/21-The operation submitted corrective plan: Management staff will utilize minimum standards as a guide when developing job descriptions, staff qualifications, and experience.
Note: this position PLSP has been eliminated. The individual is no longer employed by the operation and BGC has been inactivated.


summary: 748.863(a)(2) - Pre-Service Training-Administrative & professional staff must have 2 hrs normalcy training before designated or within 90 days of beginning duties

raw_content: The operation s Professional Level Service Provider (PLSP) training record was evaluated and revealed that the PLSP did not complete pre-service training regarding normalcy.

Correction Narrative:
4/30/21-Operation submitted corrective plan: Management staff will utilize a checklist to ensure that all requirements have been met for pre-service prior to staff beginning job duties.
Note: This position PLSP has been eliminated.


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

raw_content: The operation s Treatment Director does not meet the qualifications to oversee treatment services for children with intellectual disabilities nor emotional disorders.

Correction Narrative:
5/18/21-Reviewed TD education and experience qualifications. TD meets the education requirements and meets the minimum professional experience.
5/7/21-Operation contacted regarding the qualifications of the TD, not meeting the required professional experience. Requested additional information regarding TD experience.
4/30/21-The operation has hired a Treatment Director and submitted resume and LPC license for review for compliance.


summary: 748.1439(b)(1)(A) - Discharge Documentation-Discharge summary must include services provided to the child while in your care

raw_content: 2 discharge files reviewed did not include a discharge summary. The child s case file did not include documentation that the child was informed of his discharge, who the child was discharged to, their contact information, and a list of the child s medications.

Correction Narrative:
4/30/21-The operation submitted corrective plan: When Aspire 2 Dream becomes aware of a child's discharge, the child will be informed of the discharge and the discharge process will occur in accordance with minimum standards based on whether the discharge is an emergency or non-emergency discharge.
The discharge summary will be completed and provided to the managing conservator as required. The summary will be maintained in the child's record. A copy of both discharge summaries were submitted for review.


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

raw_content: 2 of 2 employee records were evaluated and revealed that employees have a TB skin test completed and showing a record of them being free of contagious TB.

Correction Narrative:
5/18/21-Verified TB test results during inspection.
5/7/21-Operation contacted requesting the TB test results for the identified staff.
4/30/21-Aspire 2 Dream utilizes a checklist to ensure that all pre-hire requirements have been met. The LCCA will ensure that documentation is in the Extended Reach system in the record of each staff as required. Random audits of records will be conducted to ensure ongoing compliance. Staff will not be allowed access to children
until requirements are met.


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

raw_content:
The fire inspection for the operation was completed 14 days after the 12 month due date requirement from the last inspection.
*A copy of the current fire inspection was obtained during the inspection.


summary: 748.1337(a) - Initial Service Plan-Base on needs identified in admission assessment; justify delay in addressing needs if service planning team prioritizes goals

raw_content: During the inspection, 2 initial plans were late, and 1 initial plan did not have a signature from the PLSP.

Correction Narrative:
4/30/21-The operation submitted corrective plan: Aspire 2 Dream will utilize the Extended Reach software system to determine the due dates for service plans. The system provides an alert when service plans and service plan reviews are due. The LCCA will review the system daily for due dates to ensure the plans are completed timely.
The LCCA will ensure that the required signatures have been documented at the time of the completion of the plan. In addition, the operation made a decision that it was in best interest of the operation to terminate the former Director; due to not meet operation  expectations for Administrative Duties. Op hired a new LCCA and have updated everything with the new LCCA information.


summary: 748.863(a)(5) - Pre-Service Training-Administrative and professional staff must have 8 hrs EBI training within 90 days of beginning job duties

raw_content: The operation s Professional Level Service Provider (PLSP) training record was evaluated and revealed that the PLSP did not complete pre-service training regarding emergency behavior intervention.


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: 4 employee files were evaluated and determined to not have drug test results on file prior to having access with children.

Correction Narrative: 4/30/21-Operation submitted drug test results via email for 3 of the staff. The 4th staff has been terminated. Aspire 2 Dream utilizes a checklist to ensure that all pre-hire requirements have been met. The LCCA will ensure that documentation is in the Extended Reach system in the record of each staff as required. Random audits of records will be conducted to ensure ongoing compliance. Staff will not be allowed access to children until requirements are met.


facility_name: Dream Residential Treatment Center, Inc.

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

raw_content: One med record reviewed did not contain a time of administration.


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 children record reviewed indicated child, caregiver, and CPS worker did not participate or reviewed the child's service plan.

Correction Narrative:
The agency submitted their corrective action plan as follows:

1.Our Case Manger sends a Service Plan invitation to the Case Worker requesting their attendance no later than 14 days prior to the meeting.
2.Our Case Manager after the meeting is completed reviews the updated Service Plan with the resident and obtains the resident signature.
3.Our Case Manager emails a copy of the Service Plan to the Case Worker within 10 days of the meeting, requesting the Case Worker's signature and to return the signed Service Plan
4.Our LCCA conducts a monthly quality review of the Service Plan to ensure signatures from the resident, case worker and staff have been obtained.
5.Our Case Manager files a copy of the updated Service Plan in the resident's binder.


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

raw_content: Three residents left the facility without staff knowledge while under supervision.

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


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 facility became aware of the missing children at 10:00AM, but the incident was not reported to licensing, law-enforcement, and CPS until 6:30PM.

Correction Narrative:
An email was received from the operation which included a corrective action plan indicating the LCCA will be responsible for a=calling in all AWOL reports. It also indicated the LCCA will conduct daily audits of AWOL incidents to ensure they have been called in timely, all notifications have been made, and they are documented accordingly.
On 2/19/25 Interviews were completed with multiple children have been interviewed and advise of no additional concerns for supervision as they are never left alone.


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

raw_content: According to interviews with residents and staff, residents ride the bus to and from school daily and walk to and from the bus stop on their own.  The children's service plan specifies that they are to be transported to and from school by shelter staff due to their history of running and/or leaving school or assigned areas without permission.

Correction Narrative: of the youth on the way to the bus stop. A copy of the updated service plans along with email notifications sent to the caseworkers were also provided for verification.


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: The couch in the game room was observed to have a hole in the material.

Correction Narrative: Corrected.


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

raw_content: During the review of documents obtained, the victim child's service plan was not signed by any of the participating parties.

Correction Narrative: A corrective plan was provided by the administrator, which states the following: The case manager will review the service plan with the resident and obtain the child signature and date of participation. The case manager will email the service plan to the case worker within 10 days of the meeting, requesting signatures, date of participation and request to return the signed and dated service plan. The administrator will conduct a monthly quality review of the service plan to ensure residents, case workers, and other participants have signed and dated the service plan. Lastly, the case manager will file the signed and dated service plan in the resident's binder.


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

raw_content: The children's service plans are missing the signatures of persons who participated in the completion of the service plan.

Correction Narrative:
1. Our Case Manager notify participants who attend the Service Plan meeting via virtual or phone that a copy of the Service Plan has been emailed for them to review, sign and return within 14 days of the service plan meeting
2. Our Case Manager receives the signed Service Plan and files a copy in the resident's folder.
3. The LCCA or designee conducts an audit of the resident's file to ensure the Service Plan is signed by participants.


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

raw_content: The operation Gas inspection expired in Jan 2024.

Correction Narrative:
1.
On 9/10/24, our LCCA hired a contractor to perform the facility's Gas Inspection. On September 13, 2024, the Gas Inspection was inspected by the City of Houston and passed inspection (see attached tag of approval).
2.
The LCCA developed a spreadsheet with the date of the current inspection and the next inspection due date and will monitor the spreadsheet.


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 in the refrigerator reads that 46.

Correction Narrative:
1. Our LCCA developed a weekly Refrigerator Thermometer log for staff to monitor the temperature and to ensure food is stored at 40 degrees Fahrenheit.
2. Staff will check the refrigerator thermometer weekly and document the temperature on the log.
3. Staff report to the LCCA when the thermometer does not read 40 degrees Fahrenheit.


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

raw_content: A child right form has not been by the child.

Correction Narrative:
1.	The Case Manager informs residents of their Child Rights during the admission process and the youth signs the statement indicating that he read and understands the rights and a copy is filed in the child's record.
2.	The LCCA or designee conducts a monthly audit of the child's record to ensure a copy of the Child Rights has been signed by the youth and filed in the record.


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

raw_content: During walk through, it was observed that the far left window, on the back of the home, was missing a screen.

Correction Narrative:
1.	On June 17, 2024, the LCCA or designee completed a maintenance request, and the screen was replaced with a new screen on June 20, 2024.
2.	The LCCA or designee conducts a daily walk through to ensure windows or doors are in good repair and free of broken class or hazards
3.	Staff complete a maintenance request form if there are windows, doors, any broken glass or other hazards that are identified.


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

raw_content: The medication log does not have an accurate count of remaining medication.

Correction Narrative:
1.	The accurate remaining amount of medication is counted by staff administering the medication and the accurate remaining count is documented on the medication log.
2.	The LCCA conducted medication training on June 20, 2024, to ensure staff counts the remaining medication and document the correct amount on the medication log.
3.	The staff or designee conducts a QA medication audit every shift to ensure the accurate amount of medication is remaining.


summary: 748.2203(c)(5) - Medication Error-Document the health-care professional's medical recommendations

raw_content: There is no medication error report completed for a medication log that shows a change in medication dosage prescribed vs. the dosage of medication administered.

Correction Narrative:
Plan of Action:
1. The Case Manager or staff completes a medication error report for a medication log that shows a change in medication dosage prescribed vs. the dosage of medication administered.
2. The LCCA or designee conducts a monthly quality review audit to ensure medication error reports are completed.


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

raw_content: Medication logs reviewed listed "N/A" as reason for medication.

Correction Narrative: The Case Manager will document the reason the medication is administered on the medication log. The use of N/A is not used as a reason for medication.


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

raw_content: Records reviewed show multiple staff members did not renew annual trainings timely.

Correction Narrative:
Plan of Action:
1. An annual training calendar was implemented on June 25, 2024, and an alert is received by the LCCA 30-45 days prior to training expiration date.

2. The LCCA or designee notify staff 30-45 days prior to the expiration date of the required training via text or email. A reminder notice is sent 15 days prior to the training expiration.


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

raw_content: Records reviewed show service plans not signed by all required parties as a form of acknowledgment or a child's refusal to sign is not noted.

Correction Narrative:
Plan of Action:
1. The Case Manger obtain the resident signature on the service when completed or the case manager document the child's refusal to sign.
2. The Case Manger email a signed copy of the service plan with the residents signature to the DFPS case worker and a copy of the service plan is filed in the residents folder.


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: Records reviewed did not documented how identified high-risks behaviors will be mitigated.

Correction Narrative:
Plan of Action:
1. On June 12, 2024 a Runaway Prevention Plan was completed by the Case Manager along with the resident and copy was emailed to the DFPS case worker, supervisor and proof of email was attached to the plan.
2. The Case Manger review the Runaway Prevention plan monthly or until the high-risk behavior is mitigated.


summary: 748.363(7) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: Staff file is missing an Affidavit for Employment.

Correction Narrative:
1.	The notarized affidavit was completed by the staff involved on September 8, 2023 and placed in the staff's personnel record.

2.	The LCCA will conduct an audit on all new hire personnel file to ensure that a notarized affidavit and other required documents have been received and the new hire process has been completed.


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 operation has not conducted a weather drill.

Correction Narrative:
1.	The LCCA conducted a severe weather drill on September12, 2023 for a tornado warning. There were 9 residents present during the drill and the facility was evacuated within 3 minutes of receiving evacuation instructions.  The staff retrieved resident's medical records and medications prior to evacuating.  In the event that the center received actual evacuation instructions the administrator will notify licensing.

2.	A debriefing was conducted by the LCCA and the drill was evaluated for improvements and there were no improvements needed.

3.	The LCCA will ensure that Severe Weather drills are conducted at least once every 6 months.


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

raw_content: The operation failed to report a serious incident in time.

Correction Narrative:
An Email was sent that stated:

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

Deficient: The Operation failed to report a serious incident on time

Plan of Action:
1.The LCCA developed and implemented a process on September 20, 2023 to ensure that serious incident reports are reported to Licensing no later than 24 hours after injury/illness that warrant treatment by a medical professional or hospitalization.
2.Direct Care Staff received an updated training on September 20 on the timely reporting of a serious incident.
3.The Direct Care Staff who transports the resident to the Emergency Room/hospital calls the Neglect and Abuse Hotline to report the incident.
4.The Direct Care Staff documents the time incident reported, name of reporter, reporter ID and Incident Report Number.
5.The LCCA conducts daily Quality Assurance audits, reviewing Serious Incident Reports to ensure serious incident reports are reported to Licensing no later than 24 hours


summary: 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures

raw_content: An overnight shift staff member did not follow the RTC's policy when they prefilled out the bed check log form, notating all children were asleep the entire night until 6am.

Correction Narrative:
A review of the operations night check logs have been reviewed and met compliance.

Correctives have been emailed over and advise that Action Plan:
1.	Education/Policy Review: Employees received education training by the LCCA on appropriate documentation of bed check logs and the 24 Hour Continuous Awake Supervision Policy in order to maintain compliance with our continuous awake supervision.

2.	Supervision:
A random audit is conducted monthly or as needed by the On Call administrative team during the night shift to monitor staff compliance with bed check documentation.

Additional Information:
On April 27, 2023, the employee involved in the investigation received a disciplinary action and was informed that any new occurrences of not following Dream RTC's bed check documentation policy will result in termination of employment.


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

raw_content: In review of two child service plans, it was found that service plans are being reviewed after 90 days from the last service plan.

Correction Narrative:
Plan of Action:
1.	The Clinical Director updates the resident's service plan and monitor the next service plan date to ensure the next service plan is reviewed at least 90 days from the last service plan.
2.	The Clinical Director/LCCA reviews Dream RTC online Resident Data base monthly for the next service plan due date.
3.	The Clinical Director/LCCA receives a notification from Dream RTC Resident Data base when the next service plan review date is due.
4.	The LCCA provide monthly Service Plan Quality Assurance audits, reviewing service plans to ensure plans are reviewed at least 90 days from the date of the last service plan.


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

raw_content: A child in care in missing documentation of the TB exam.

Correction Narrative:
The operation sent over a copy of the child's TB exam results.
The LCCA developed a spreadsheet with residents' TB skin test due dates.  The spreadsheet ensures that residents TB skin test are completed annually.. The spreadsheet is reviewed monthly and appointments are made for the resident when their TB test is due.  The results of the test are placed in the residents file.


summary: 748.3237(c) - Safety Practices-Children must be able to open emergency exit doors easily from inside, unless written approval on file from fire inspector

raw_content: Both the front and rear exit doors from the facility required a code/key to leave building.

Correction Narrative: A walk-through of the operation was conducted, and both the front and back doors were observed to have the coded door locks removed and replaced with regular turn locks. The operations permit holder opted out of having the fire inspectors come to access if she can reapply the coded locks due to the cost of the inspection.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: Two out of three youth interviewed stated multiple staff have twisted their arms behind their back and held them in this position as a restraint.


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

raw_content: Three out of three youth interviewed stated staff will get in their personal space as a means of intimidating or getting them to comply.

Correction Narrative:
on 10/10/22: 4 children were interviewed and there no new areas of concerns. On 09/30/2022 there were a plan of actions/corrections initialed to address the following:
Action Plan:
1.	Staff will receive appropriate refresher training by an outside trainer. During the trainings staff objective is to learn  how to use appropriate de-escalation techniques and what actions are disciplinary actions are prohibited.

2.	Our LCCA and Program Director supervise and monitor our staff daily to ensure staff are adhering to regulatory standards and policies.

3.	Our staff receive a 90 day and an annual performance evaluation to provide feedback on their performance.

4.	Our residents meet with our Program Director daily as our Open Door communication and during these meetings residents are given an opportunity to express issues and concerns.  During these monthly meetings our residents will express any concerns.

5.	After Hour Supervisory Visits are made by our LCCA or Program Director after hours and weekends.  During these visits staff interaction with residents are observed and residents are given an opportunity to provide feedback

6.	Staff are required to sign an Abuse and Neglect Exploitation and a Prohibited Discipline Acknowledgement during General Orientation.  Any violation of these policies will result in immediate termination of employment.


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

raw_content: There is a whole in the upstairs bathroom

Correction Narrative: During the followup, the wall was  observed to be repaired.


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

raw_content: During the medication review, it was found that the Medication log for one of the 5 children shows that he should have a remaining 7 pills and the count reflects a remaining 6.

Correction Narrative: Medication logs have been reviewed and pills have been counted for all residence living in the home. Review of all information meets compliance.


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

raw_content: Two out of the four medication records reviewed were missing the health professionals name or had the wrong health care professional's name on the form and did not reflect the medication.


raw_content: Four medication records were reviewed and all of them contained medication count errors.

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


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

raw_content: Staff put residents at risk for substantial physical injury when she failed to remove both from an unsafe environment. Staff continued to put resident at risk by allowing another resident to restrain and hit the resident numerous times without removing either from the situation, resulting in the resident receiving a black eye due to the other resident striking him in the face with no intervention from Staff. Staff continued to put resident at risk by allowing him to remain present after resident broke the glass. Due to the severity of the situation, resident was transported to the hospital because he had major cuts on his arm and lost a lot of blood.

Correction Narrative: Interviews were conducted with four of the five children that currently live in the home. Interviews are located in chronology.


raw_content: One of the two child files reviewed were missing documentation of a TB screening.

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

Correction Narrative:
To ensure residents have TB exam w/in 30 days,  the following action plan implemented:
1.	Completed TB exam for child without TB exam documentation and placed documentation in child's record.
2.	Director or designee schedule TB exam for residents within 30 days and place documentation in child's record.


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

raw_content: Both staff files reviewed were missing a signed statement for reporting and suspected incident of child abuse, neglect or exploitation.

Correction Narrative:
To ensure personnel records include signed dated statement that staff must immediately report suspected child abuse, neglect, or exploitation, the following action plan was implemented:
1.	Developed and implemented an Abuse/Neglect Acknowledgement Statement form that staff sign and certify receipt of information on their rights to report abuse and neglect.
2.	Educated staff on signs of Abuse and Neglect and mandatory reporting to the Neglect and Abuse Hotline.
3.	Staff signed Abuse/Neglect Acknowledgement statement and acknowledgement statement placed in personnel record.


summary: 748.461(1) - Unauthorized Absence-Triggered Review must include review of childs records abt previous unauth absences, including previous debriefings

raw_content: Trigger review has not been conducted for a child who has run away more than 3 times within a 60 day period.

Correction Narrative:
To ensure Unauthorized Absence-Triggered Review must include review of child's records and previous unauthorized absences, including previous debriefings, the following action plan implemented:
1.	Developed and implemented a Triggered Review Form completed by the Director for residents with three (3) unauthorized absences within 60 days.
2.	Conduct monthly audit on unauthorized absences log to ensure Triggered Reviews are conducted timely.


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

raw_content: One of the two child files reviewed is missing a signed statement for the child's rights.

Category: Children's Rights

Correction Narrative:
To ensure child informed of rights and that the child  informed must sign statement indicating he read and understands the rights-signed and copy filed in child's record, the following action plan implemented:
1.	Director contacted DFPS case worker for the file missing a signed statement and requested a copy of the child rights.
2.	Revised Admission Checklist to include patient rights statement to ensure child's rights are received from DFPS during admission and rights discussed and signed by child.


summary: 748.303(a)(9)(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: Staff did not report to Licensing that a child ran away within the 6 hour timeframe.

Correction Narrative:
Letter has been uploaded into sharepoint

To ensure Licensing is aware of significant incidents of unauthorized absence of a child 13 yrs. or older the following action plans were implemented:
1.	Staff were educated on completing the AWOL Log.
2.	Staff were educated on reporting unauthorized absences to the Neglect and Crisis Hotline within the 6 hr time frame.
3.	 Case Manager or designee will review each AWOL case to ensure timely reporting.


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

raw_content: Children reported that 2 children were smoking vape pens in the game room and a child in care was able to offer drugs to other children in care in their bedroom.

Correction Narrative:
To ensure Caregiver responsibility of being aware of and accountable for each child's on-going activity and ensure adequate care and supervision of residents the following action plan was implemented:
1.	Implemented a Daily Staff/Resident Assignment. Staff are assigned residents for their shift in order to ensure residents are supervised and residents receive adequate care.


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

raw_content: Two children have more than three documented Unauthorized Absences, with no documented Triggered Review.

Correction Narrative:
To ensure Triggered Review of child's unauthorized absences occur ASAP, but no later than 30 days after third absence within 60-days the following action plan was implemented:
1.	Case Manager conducts Triggered Review of child's unauthorized absences ASAP, but no later than 30 days after third absence within 60-days.
2.	Case Manger review the resident's debriefing, service plan, trauma informed alternatives, and develop a plan to reduce continued unauthorized absences of the resident and documents on the Triggered Review Form.
3.	Staff educated on the residents Triggered Review Plan in order to reduce resident continued unauthorized absences.


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

raw_content: Unauthorized Absence Log is missing pertinent information required by standards: (1) gender, DOA, (2) time the unauthorized absence was discovered, (4) the name of the caregiver responsible for the child at the time the childs absence was discovered, (5) the intake report number,if a report was made to Licensing or the DFPS, and (6) whether law enforcement was contacted, including the name of any law enforcement agency that was contacted and the number of the police report, if applicable.

Correction Narrative:
To ensure Unauthorized Absences are documented in full detail and include name, age, gender, date of admission the following action plan was implemented:
 1). Revised Unauthorized Absences Annual Summary Log to include name, age, gender date of admission, time unauthorized absence was discovered, name of the caregiver responsible for the child at the time of absence discovered, intake report number, if a report made to Licensing or DFPS and name of any law enforcement agency that was contacted and the number of the police report, if law enforcement was contacted.
2). Conducted Staff education on the accurate documentation and completion of the Unauthorized Absence Annual Summary Log.


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

raw_content: Staff members use corporal punishment by punching a child and pushing another.

Correction Narrative:
To ensure Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work, the following action plan implemented:
1.	Terminated the employee for pushing resident and another staff punched another child submitted a letter of resignation. Both staff members are classified as Do Not Rehire.
2. Conducted staff education on Discipline Policy and Prohibited Practice:
a)	Staff do not use corporal punishment, aversive stimuli or any interventions that inflict physical, psychological, and/or emotional pain to modify behavior.
b)	Failure of caregivers to abide by the Discipline Policy result in disciplinary action, up to and including termination

Interviews of residents have been uploaded into Chronology.


summary: 748.3(a) - The permit holder must ensure compliance with applicable minimum standards rules

raw_content: The permit holder allowed a contractor access to the facility with children in care without a background check.

Correction Narrative:
Operation come into compliance by submitting a CAP for the background check standard. Email has been uploaded into SharePoint.
To ensure an initial background check is submitted at the time Dream RTC contracts with some who requires a background check the following action plan implemented:
1.	Conduct and review initial background check on contractors, to ensure DFPS permission to be on property and allowed to enter facility.
2.	Developed Contractor Background Manual with contractor's completed DFPS background check results on file.
3.	Developed background compliance spreadsheet to ensure background compliance with list of all persons requiring background checks.
4.	Conduct audit on contractor's background file prior to being allowed to enter the facility and to ensure compliance with DFPS permission to enter facility


raw_content: The owner of the operation was negligent in their duty by allowing a contracted person to continue being present at the facility, despite admitting knowledge that the contracted person was not allowed to be on the property, and in doing so exposed the children placed at the facility at immediate risk of harm.

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

Correction Narrative:
To ensure and adhere to residents rights to be free of abuse, neglect, and exploitation the following action plan  implemented:
1.	Conduct background check on contractors, to ensure background cleared by DFPS prior to being present at the facility.
2.	Review contractor's background file to ensure DFPS approval and permission granted to be present at the facility.


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

raw_content: A background check for a maintenance person was submitted on 12/01/2021 as a Contracted Service Provider.  It was cancelled by the operation on 12/16/2020 but the person was still allowed to be at the operation performing work for the operation.


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

raw_content: The medication record for one child was for March but he arrived at the facility in April.

Correction Narrative:
Revised our Medication Administration Record in July to ensure the record is current, true, and accurate and reflects the current month.
Staff education conducted on reviewing the Medication Administration Record prior to administering medication to ensure the accurate date/month is reflected.
The LCCA or designee conducts a monthly quality assurance audit on each medication record to ensure the correct date/month.


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: Over five medication records reviewed determined that the operation did not administer the meds as the doctor prescribed for certain days.

Correction Narrative: The standard was reviewed and meets compliance.


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

raw_content: Mulitple medication logs did not include the date and time.

Correction Narrative:
Revised our Medication Administration Record in July to ensure the record reflects the time, date (day/month/year) off each medication administered.
Staff education conducted on completing the date and time of medication administration.
Staff education conducted to follow the time and frequency prescribed by healthcare provider..
The LCCA or designee will conduct monthly quality assurance audit on each medication record to ensure the accurate date and time of each medication administered.


raw_content: Multiple records did not include the daily amount given each day.

Correction Narrative:
Revised our Medication Administration Record in July to include the accurate daily amount given.
Staff education conducted on completing the daily amount given to reflect the accurate daily count.
The LCCA or designee will conduct monthly quality assurance audits on each medication record to ensure the daily amount given is indicated.


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

raw_content: Two of five children interviewed stated that when they are restrained, they are in a supine position. Two of five children interviewed stated that other residents are restrained in a supine position. One of five children interviewed stated that during restraints, residents are in a supine position or prone position.

Correction Narrative: The facility has not submitted a corrective action plan due to requesting an administrative review of this investigation. Interviews for three of the six residence residing in the operation have been conducted and compliance has been meet. Interviews have been uploaded into SharePoint.


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

raw_content: no documentation of siblings

Deficiency Narrative: no documentation of siblings

Correction Narrative: Admission documentation was updated to reflect sibling information (names, address, telephone numbers, etc.)


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

raw_content: 1 out of 3 staff files reviewed did not have the date of hire documented in the file.

Correction Narrative: Staff file was updated with the date of hire documented in the file (see attachment A).


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

raw_content: The 72 hours plan provided is the exact same information found in the admissions assessment.

Correction Narrative: 72 hour preliminary Service plan was updated to include details of the child and also reflect the services provided during his treatment.


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

raw_content:
2 children's medication count wrong
all children's medication count prefilled

Correction Narrative: The Medication Administration Record was revised to include an accurate daily count of each prescribed medication (see attachment B).


summary: 748.1219(1)(C) - Treatment Services Admission-ED or ASD: Admission assessment includes reason(s) for choosing treatment services for child

raw_content: No documentation of the reasons in 2 out of the 2 files reviewed.

Correction Narrative: Treatment service admission was updated to include the reason(s) for choosing treatment in the admission assessment (attachment D)


summary: 748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement

raw_content: No place to document high risk behaviors

Correction Narrative: Admission assessment was update to reflect residents high risk behavior (see attachment C)


summary: 748.1217(b)(15) - Admission Assessment-At admission, must include determination of whether operation can meet immediate needs of child

raw_content: No documentation of how operation will meet the needs of the child being admitted.

Correction Narrative: Admission assessment was updated to include determination of operation being able to meet the needs of the children.


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

raw_content: Serious Incident report document does not list all minimum standard requirements.

Correction Narrative: Serious Incident Report form revised to list all minimum standard requirements (attachment E).