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

raw_content: Bedroom with the blue door and bunkbed contained lower bed with no mattress cover. Pillow was ripped as well.


state: TX

facility_name: K Star Emergency Shelter

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

raw_content: Training records are missing hours.

Category: Reports and Record Keeping

Standard Risk Level: Medium

Corrected at Inspection: No

Deficiency Narrative: Training records are missing hours.

Correction Narrative: We are in the process of going all digital with employee trainings and files.  During this transition there have been glitches.  The training coordinator will ensure that all training has the length of time the lesson took listed on the training log.


summary: 748.363(12) - Personnel records - Include any documentation of the person's performance with the operation

raw_content: No performance evaluation was provided for one of the two employee records reviewed. That same employee has been at the facility for about 2 years while a 90 day performance evaluation was received for the other employee.

Standard Risk Level: Medium Low

Correction Narrative: Moving forward facility will only be conducting yearly performance evaluations on employees in order to meet minimum standards.


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

raw_content: Two of the childrens records contained no "Chronic Health Condition" on the front cover and on the Allergies section it contain "N/A" instead of "No Known Drug Allergies".

Standard Risk Level: Medium High

Correction Narrative:
K'STAR has updated our cover sheets to include an area to log Chronic Health Condition, and we will no longer put N/A will we enter No Known Drug or other Allergies.
If a child has known allergies, it will be prominently logged on the case file cover sheet.  In addition, all staff will be made aware of the children's allergies.
Sample new cover sheet attached to the email and uploaded to digital storage.


facility_name: Thompson Emergency Shelter

summary: 748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline

raw_content: The operation did not report the allegation.

Category: Individual Standards Evaluated

Correction Narrative:
The date of the follow-up: Pending
The follow-up method: Pending
The extension was approved
The extension was approved on 12/22/2025
The original compliance date 12/23/2025
The new compliance date 01/06/2026

The operation sent the compliance plan via email on 1/6/2025. A staff training was conducted to review incident reporting. The information reviewed and sign in sheets signed by staff who attended were provided.


summary: 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)

raw_content: The Serious Incident Report did not contain the names and roles of the adults involved in the incident..

Correction Narrative: The operation sent the compliance plan via email on 7/18/2025. All serious incident reports will be reviewed by the Shelter Director and Chief Operations Officer to ensure compliance with all minimum standards.


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

raw_content: Medication closet was open and unlocked.

Standard Risk Level: High

Correction Narrative: During inspection all medication was observed to be stored correctly


summary: 748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave

raw_content: Hotdogs were left out to thaw in the kitchen sink.

Correction Narrative: Walk-thru was conducted during inspection, food was viewed. There were no concerns.


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: It was found that the staff has exceeded their ratio capacity at the time of the incident relevant to this investigation.

Correction Narrative:
Operation provided Compliance Plan via email on 1/10/2025: Corrective Action Plan: Boysville staff have received training in regard to this specific standard. Staff have a good understanding of correct ratio for child/caregiver. Going forward, all new staff will be given training on child/caregiver ratios by the emergency shelter staff director. Training was provided for staff on 1/10/2025 to review subchapter G: Child/Caregiver Ratio. Participants names and signatures were provided, including the information covered during the training.

An unannounced follow-up inspection was conducted on 1/14/2025. Three staff interviewed reported a training meeting was held to review ratio standard and supervision. Staff are aware of the ratio requirements that must be maintained at the operation. No concerns observed. Meeting sign-in sheets were provided.


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

raw_content: Children in care confirmed staff threw a hairbrush at them while staff was upset. Staff did admit to throwing hairbrush but not directly at children in care.

Correction Narrative:
Operation provided Compliance Plan via email on 6/10/24: Corrective Action Plan: Staff member was provided feedback during consultation by the Shelter Director on April 7, 2024. Feedback included using control when interacting with children in care that may not be following instructions and practice being a role model to children. A staff meeting with all staff will also cover this and will occur on June 21, 2024.

A Follow Up inspection at the operation on 6/19/2024. Staff confirmed a debrief with the shelter director was conducted on 6/18/2024 and were able to share specifics of caregiver responsibilities and using good judgement when supervising children in care. Two children in care were asked about staff supervision and how their caregivers keep them safe.


summary: 748.3271(3) - First Aid Kits-Each one must be in good condition and not have expired medications or supplies

raw_content: During the walk through of the physical site it was noted that the vehicle used to transport the children had expired medication (aspirin) in the first aide kit.

Category: Safety and Emergency Practices

Corrected at Inspection: Yes


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: While reviewing child files out of four files one was noted to not have a signature of the child rights.

Correction Narrative: The resident signed the document immediately.


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

raw_content: Staff members have been observed to be sleeping on duty by multiple children in care. Operation policies require staff be awake during night hours to properly supervise children in care.

Correction Narrative:
Shelter Director discusses sleeping policies and procedures with staff to ensure compliance. Also, nightly monitoring is conducted randomly by Administrators twice
monthly.


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

raw_content: Bathroom in boys' section of younger childrens' building had one shower that failed to provide hot water.

Category: Physical Site

Standard Risk Level: Low


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

raw_content: During inspection, one building did not have thermometers in neither the fridge nor freezer.


raw_content: During walkthrough, one of the mattresses did not have a plastic cover over it.

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

Correction Narrative: Mattress covers were being procured at time of inspection.


summary: 748.3475(b)(1) - Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly

raw_content: During walkthrough, playground was observed to have damage taped over it, however it is still accessible to children.


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:
During inspection, amount of pills remaining logged did not match what is in the cannister. Staff member stated this medication was also supposed to have been administered at 6, but was not due to child being asleep.

This supplemental Form 2936 dated 7/8/22 replaced the  form 2936 dated 6/30/22. The supplemental form dated 7/8/22 is due to this deficiency requiring an administrative penalty.

Category: Medication


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

raw_content: During walkthrough of operation, windowsills in kitchen of older kids' building and bedrooms in younger kids' building were in disrepair. Bedroom door frame in older kids' building also in disrepair.  Possible termite issue.


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: Child in care was denied the right to call her caseworker.

Correction Narrative: Corrective action plan was received regarding this concern. Staff has been retrained on operation policy and procedure, specifically regarding children's ability to contact caseworkers.


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

raw_content: Staff was sleeping while being the only caregiver in charge. If an incident had occurred they would not have been able to intervene. Staff was locked out of cottage while children in care awake.

Correction Narrative: Staff involved was terminated prior to investigation. Operation administration will continue unannounced evening visits.


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

Correction Narrative:
Boysville has completed the compliance plan in reference to the findings in Investigation #2876843 that
alleged that children in care were threatened.
 Standard 748.2307 (9) Other Prohibited Punishments  subjecting a child to abusive or profane
language
Specifics: Staff has been cursing towards children in an inappropriate manner heard by staff
and residents.
Technical Assistance Given: Staff should not use inappropriate language to threaten children.
The purpose of this rule is to prevent harm to children due to the use of behavior management
techniques that inflict physical or emotional pain or discomfort. These prohibited methods of
punishment are considered physically, psychologically and/or emotionally abusive.
Corrective Action Plan: Staff involved in the incident has retaken the EBI Satori Alternatives to
Managing Aggression (SAMA) training on 6/1/2022. Staff has also received written feedback
from their supervisor and will be monitored closely with weekly check ins. Staff will also not
work alone with children to ensure all compliance for policies/procedures


raw_content: A staff member antagonized two children by mocking their preferred pronouns.

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

Correction Narrative: Operation provided a corrective action plan on 06/21/2022. Corrective action plan states that the staff member in question will receive training on LGBTQ/Cultural Competency within 30 days. Staff will also receive check ins/supervision by the Director to ensure all procedures are being followed.


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

raw_content: It was confirmed through interviews, a staff member would regularly yell at children in care.

Correction Narrative: The operation responded with a corrective action plan on 06/21/2022. The operation stated that the staff member in question will complete the next Satori Alternatives to Managing Aggression (SAMA) which is July 6th. Staff will also receive weekly check ins/supervision by the Director to ensure all procedures are being followed. Staff also does not work alone.


summary: 748.1337(b)(1)(B) - Initial Service Plan-Include plans for maintaining and improving child's family relationships, including recommendations for visitation and contacts

raw_content:
Initial Service Plan was not available.

Staff allowed child to visit with their parent against the service plan stating the child must have approved visits by and through CPS.

Correction Narrative: All staff have been spoken to regarding the minimum standard requirements. The case manager overseeing service plans has been terminated due to not completing paperwork and meeting deadlines. The current case manager is aware of the requirements and ensuring all staff are aware of visitation approvals.


raw_content: Staff allowed child to visit with their mom at an outing and allowed the child to drive their mom home after an incident.

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

Correction Narrative: The staff involved in this incident that allowed the child to drive their mother home has been terminated due to making inappropriate decisions that can be harmful to children. All staff have been informed of visitation approvals, demonstrating proper judgement regarding children and appropriate boundaries.


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: The operation failed to report a child who ran away to RCCR within the required timeframe. The child ran away on 1/18/22 and it was reported on 1/19/22.

Correction Narrative:
Boysville has completed the compliance plan in reference to the findings in Investigation #2847191 that occurred on February 1, 2022 concerning a child in care eloping and Boysville not reporting it in a timely manner.
 Standard 7483.03(a)(9)(A) Serious Incident  Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 years old or older
Specifics: The operation failed to report a child who ran away to RCCR within the required timeframe. The child ran away on 1/18/22 and it was reported on 1/19/22
Corrective Action Plan: All staff have been spoken to regarding the minimum standard requirements. Training has occurred and will be reiterated during staff meetings. A Senior Director position has been developed and will also ensure compliance with all minimum standards including notification of runaways in a timely manner.


summary: 748.303(a)(9)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older

raw_content: The child ran away from the operation on 01/03/22 at 11:30pm. The incident was not reported to  the hotline until 01/04/22 at 1:22pm.

Correction Narrative: On 01/25/22 RCCR Inspector Annie Bagnato received a corrective action plan from LeAnna McKinney from email address lmckinney@boysvilletexas.org. The corrective action plan states on 01/14/22 Boysville informed all staff to report unauthorized absences within 6 hours for children 13 years and older. Boysville has ensured all staff and the shelter director have been informed to notify law enforcement and licensing within 6 hours of an unauthorized absence of a child 13 years and older.


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

raw_content: On November 4, 2021 Inspector was made aware of staff member with documented conditions to job duties was left in charge of supervision of other employees. Employee was on provisional status and found to be non complaint.

Correction Narrative:
Letter from operation :

Boysville completed the compliance plan in regards to provisional employee.

1)	Standard 745.635(3) AP Background check determination-if provisionally eligible w/conditions or eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions.

a.	Staff job description has changed from Program Supervisor' to Program Coordinator'.  Her job duties entail intakes and scheduling.  She is not left in the role of providing supervision to employees.  Staff continues to await the results of her administrative review.

Please let me know if you have any further questions or concerns.

Sincerely,
Operation


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

raw_content: A child in care was not supervised appropriately resulting in self harm with potential serious injury

Correction Narrative:
Boysville has completed the compliance plan for the standard violation on investigation:

Standard 748.1101(b)(1)(B) Childrens Rights -Adhere to the child right to be free of abuse,neglect, and exploitation.

Facility is being cited on assumption that a child in care was not properly supervised resulting in self harm with potential serious injury.
Facility is currently requesting an administrative result on this citation.

Training was provided to staff in regards to ensure proper supervision of all residents in cottage. Staff were especially trained on the importance of of abiding by safety for all youth in care.


raw_content: Per agency documentation received and reviewed children in care eloped and was on runaway status for more than six hours before reported to hotline.

Standard Number / Description: 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

Correction Narrative: Email from Chief Operation Officer - All direct care staff at Boysville received training on incident reporting on October 5,2021.


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

raw_content: Staff did not practice best judgment when contacting child in care after they had left placement.

Correction Narrative:
Boysville has completed the compliance plan in reference to the findings on investigation #27729703.

Boysville will be asking for administrative review for this standard violation.

1. Standard 748.507(1) employee general demonstrate competency, prudent judgement, self control in presence of children and when performing assigned tasks. Staff did not practice best judgement when contacting child in care after they had left placement.

Upon notification that staff has possibly acted inappropriate with a child after they placement , he was immediately placed on a work suspension. After further review, Boysville felt he was no longer a sustainable employee, thus his employment was terminated.


facility_name: Serving Children and Adults

summary: 748.2851(c)(1) - EBI Follow-Up-Caregivers involved in EBI must debrief with each other about incident as soon as possible after situation has stabilized

raw_content: Caregivers did not debrief with each other or with child who witness restraint after incident.


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

raw_content: Prone restraint lasted more than one minute.


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

raw_content: Operation did not report suicide attempt of a child to licensing.


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: Caregiver placed childs arm behind back during a restraint.


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

raw_content: Medication administered to child did not have include all required medication documentation.

Correction Narrative:
follow conducted on 1/13/24 insp#4093301
Staff was interviewed and stated items were reviewed with them during a meeting.  Staff stated they are to confirm every medication belongs to the appropriate child being administered medication.  They stated they are to confirm the dosage is correct or call the doctor/pharmacist  for correct dosage/medication.  Staff stated they are to fill out serious incident reports, even if not serious, and ensure follow-ups are conducted.  Staff stated they are report all incidents to the administrator and program direct and send a copy of all incident and medical reports to all CPS workers for all appointments and ER visits.

Email received from Admin 1/5/26: Staff were retrained on medication records during the week of December 13 to 16, 2025. The Program Director reviewed all medication records. The Program Director will conduct a weekly check of medication records to ensure compliance.


summary: 748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident

raw_content: Child was admitted to the emergency room due to a non-critical illness. Due to childs age and vulnerability, a serious incident report should have been completed.

Correction Narrative:
follow conducted on 1/13/24 insp#4093301
Staff was interviewed and stated items were reviewed with them during a meeting.  Staff stated they are to confirm every medication belongs to the appropriate child being administered medication.  They stated they are to confirm the dosage is correct or call the doctor/pharmacist for correct dosage/medication.  Staff stated they are to fill out serious incident reports, even if not serious, and ensure follow-ups are conducted.  Staff stated they are report all incidents to the administrator and program direct and send a copy of all incident and medical reports to all CPS workers for all appointments and ER visits.

Emailed received from admin 1/5/26: Reviewed with staff the definition of serious incident reports, especially in regard to infants and small children. This was done in the week of December 13 to 16, 2025. The Program Director and Child Care Administrator will be informed of all medical interventions and will ensure that appropriate incident reporting is documented.


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

raw_content: Staff did not obtain consent from childs medical consenter to administer prescribed medication.

Correction Narrative:
follow conducted on 1/13/24 insp#4093301
Staff was interviewed and stated items were reviewed with them during a meeting.  Staff stated they are to confirm every medication belongs to the appropriate child being administered medication.  They stated they are to confirm the dosage is correct or call the doctor/pharmacist for correct dosage/medication.  Staff stated they are to fill out serious incident reports, even if not serious, and ensure follow-ups are conducted.  Staff stated they are report all incidents to the administrator and program direct and send a copy of all incident and medical reports to all CPS workers for all appointments and ER visits.

Email received from Admin 1/5/26: The Child Care Administrator and Program Director will be notified of all emergency medical interventions and will instruct staff to utilize phone and email to reach out to medical consenter to obtain approval.


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

raw_content: Health inspection is expired.

Deficiency Narrative: Health inspection is expired.

Correction Narrative:
Email received: Health Inspection was conducted September 23, 2025. The Shelter Administrator will ensure inspection is conducted annually. He has set reminders on his calendar. In case the Health Department has issues issuing invoices, the Shelter Administrator will go in person to the Health Department's Office to resolve the issues and obtain the inspection on time.

Passed health inspection submitted in email.


summary: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

raw_content: A new hire file is missing reference checks.

Category: Personnel

Correction Narrative:
Email received by Administrator: The Shelter Administrator will ensure that all new hire documentation (including references) is submitted to Human Resources within a working day of
the interview. The HR Director will ensure documentation is received and placed in the employee's file.


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

raw_content: Four employee files did not contain suicide prevention annual training and one employee file had incomplete annual training records.

Category: Training and Professional Development

Correction Narrative: Email received by admin: Training has been scheduled for the last two weeks of October 2024.  Proof of training will be placed in the staff members' personnel files before October 31, 2024.


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: One employee file did not have the require two references.

Correction Narrative: Email sent by Admin: Documentation has been conducted and placed in employee's personnel file.


raw_content: Bruises to child were not documented in an incident report.

Standard Number / Description: 748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident

Correction Narrative:
Email corrections submitted 10/18/23.
On October 12, 2023, Staff were been
trained on incident reporting and to
inspect daily for possible minor
injuries that may not be readily visible.


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: EBI quarterly report not submitted within required time frame.

Correction Narrative: EBI quarterly report was submitted via online portal. Operation staff will mark their calendars for upcoming quarters in an effort to make this deadline in the future.


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

raw_content: Topical medications (vicks vapor rub and arnica gel) located on table in the main common area accessible to children in care.

Correction Narrative:
Follow up for Monitoring Inspection #3954830. Unannounced follow up inspection conducted 7/11/23. Walk through of the operation revealed no concerns. Medications observed stored properly inaccessible to children in care. There were no visible safety/health hazards observed. New first aid kits observed in the operation. Hazardous chemicals removed from the vehicle. Severe weather drill documentation was unavailable for review at inspection. 2 youth care workers present and counselor.
Emailed corrections submitted: All medications have been secured. The shelter administrator Instructed staff to place them in a secure location after their use. The Shelter Coordinator will review daily that to topical medications are locked away.


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

raw_content: Bottle of brake fluid found in transportation vehicle accessible to children.

Correction Narrative:
Follow up for Monitoring Inspection #3954830. Unannounced follow up inspection conducted 7/11/23. Walk through of the operation revealed no concerns. Medications observed stored properly inaccessible to children in care. There were no visible safety/health hazards observed. New first aid kits observed in the operation. Hazardous chemicals removed from the vehicle. Severe weather drill documentation was unavailable for review at inspection. 2 youth care workers present and counselor.
Emailed corrections submitted: All poisonous/flammable materials have been removed from vehicles and facility and
placed in locked, stored areas. The Shelter Coordinator will conduct monthly random
inspections of vehicles and facility to ensure all materials are properly stored.


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: Severe weather drills are not being conducted as required per minimum standards.

Correction Narrative:
Follow up for Monitoring Inspection #3954830. Unannounced follow up inspection conducted 7/11/23. Walk through of the operation revealed no concerns. Medications observed stored properly inaccessible to children in care. There were no visible safety/health hazards observed. New first aid kits observed in the operation. Hazardous chemicals removed from the vehicle. Severe weather drill documentation was unavailable for review at inspection. 2 youth care workers present and counselor.
Emailed corrections submitted: Severe weather drills will be conducted bi-annual! . Next drill will be conducted the first week of July and then every six months thereafter. Proof of drills
will be available to licensing staff for review.


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

raw_content: First aid kits in transportation vehicles and operations were missing items.

Correction Narrative:
Follow up for Monitoring Inspection #3954830. Unannounced follow up inspection conducted 7/11/23. Walk through of the operation revealed no concerns. Medications observed stored properly inaccessible to children in care. There were no visible safety/health hazards observed. New first aid kits observed in the operation. Hazardous chemicals removed from the vehicle. Severe weather drill documentation was unavailable for review at inspection. 2 youth care workers present and counselor.
Emailed corrections submitted: Purchase order for First Aid Kits have been placed 06-24-2023 and expected to be placed in
vehicles/facility 06-30-2023.


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

raw_content: Caregiver failed to perform after hours supervision checks as required in the child service plan.

Correction Narrative:
4/14/22 Physical follow up at the operation revealed the administrator had been performing night time audits ensuring staff were completing bed time checks in a timely manner. Documentation was provided by administrator.

3/25/22 Email Corrections submitted
The Program Director will ensure
that bed checks are conducted
by staff by conducing randoms
inspections twice a month
utilizing the facility's cameras and
once a month in person.


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

raw_content: There were no weekly updates on the discharge plan after the first month for a child in placement for 5 months.

Correction Narrative:
4/14/22 Physical follow up at the operation and file review revealed documentation placed in the file regarding discharge plan. A detailed description of discharge plan was placed in childs file and updated regularly.

3/25/22 The Program Director and the
Counselor will call or email the
case worker to update SCAN on
the status of placement and will
be recorded in the child's file in
weekly progress notes.


summary: 748.4211(b) - Placement Extension-child's record must include documentation of additional continuations every 30 days after initial documentation by 16th day

raw_content: Only 2 of the 4 continuations were documented for a child in emergency placement for five months.  T

Correction Narrative:
4/14/22 Physical follow up at the operation and file review revealed corrections had been completed. Documentation regarding continuation of placement conversation was placed in file. Documentation included printed out email correspondence between CPS worker and operation staff.
3/25/22 The Program Director and the
Counselor will call or email the
case worker to update SCAN on
the status of placement and will
be recorded in the child's file in
weekly progress notes.


summary: 748.1347(b) - Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it

raw_content: Initial service plan did not include signatures of all members involved in the development of the service plan. Signatures missing included the child in care as well as the service provider.

Correction Narrative:
4/14/22 Physical follow up at the operation revealed child service plans were completed and signed by all necessary individuals.

3/25/22 Counselor will meet with youth
and review and discuss service
plans and ensure all appropriate
signatures are obtained before
the plan is placed in the child's
file. The Program Director will
review weekly all children's plans
to ensure they are appropriately
developed and siqned.


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: 16 year old and 17 year old youths in care engaged in sexual activity due to lack of supervision by caregiver.

Correction Narrative:
Physical follow up performed 4/4/22. Night staff stated meeting regarding expectations was held. Night staff stated that there has yet to be a night inspection performed by administration.

The Program Director conducted
a meeting with the staff and
discussed the incident as well as
preventing future incidents by
providing ongoing supervision
and conducting bed checks. Staff
were informed of the random
checks the Program Director will
conduct to ensure staff comply
with bed checks.


summary: 748.931(a)(2)(B)(iv) - Annual Training-Must include 2 hours on transportation safety if caregiver transports children chronologically/developmentally less than 9 years old

raw_content: A staff file reviewed has a late transportation training.

Correction Narrative: The Person in Charge of the Operation submitted the Transportation Safety Training Certificate for the Staff Member who had it pending due to it being expired.


facility_name: Laurel Ridge Treatment Center

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

raw_content: The operation completed its annual fire inspection on time; however, the operation did not pass the inspection.  The operation must address and correct all identified code violations to achieve compliance.


summary: 745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605

raw_content: During an inspection, two therapists were observed to be counted within ratio; however, one therapist did not have a background check on file.

Correction Narrative: During a follow-up inspection the therapist were not observed to be in the room while the children were conducting their group.


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:
During an unannounced monitoring inspection, one staff was observed to be responsible for 12 children for an unknown amount of time. Another staff member eventually joined the unit, however, the unit was still out of ratio as the ratio requirements are 1:5.
During the inspection, an additional staff member joined the unit, bringing the unit into compliance with the 1:5 ratio requirements.
Of note, the operation was counting two therapists within ratio for this group for a period, however, one therapist did not have the appropriate background check on file and would therefore not count in meeting the ratio requirements.

Category: Child/Caregiver Ratios

Correction Narrative: During a follow-up inspection, the inspector observed the operation to be within child/caregiver ratio in both units.


summary: 748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code §42.0563

raw_content: Three out of six staff records reviewed were missing the Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) in their files.

Correction Narrative: During a follow up inspection four out of four pre-emplyment affidavits were observed in the personell files.


raw_content: During an unannounced follow up inspection there were two groups of children requiring a ratio of 1:5 however they were observed at a ratio of 1:7, putting the groups out of ratio.

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


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

raw_content:
During a follow-up inspection a wall was obsevred to have a water leak as well as the brick around the shower was warped due to the leak. Shower 413 was observed to be clogged and no draining adequately. The operation is blocking off the room with the wall damage caused by the water leak and will not be used until corrections are approved.
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This was re-cited during a separate follow up inspection as the bathroom remains inoperable while repairs are being completed.


raw_content: During the winter storm the heating system was not operating appropriately and there were multiple reports of heating issues in the units, including children's bedrooms. It was a noted a condenser fan motor failed and needed to be replaced. In addition, the thermostats are locked preventing accessibility by staff.

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

Correction Narrative: The director of residential services has been given a key for the thermostat in the case there is a time when the maintenance supervisor is not available to go to the operation during an emergency.


summary: 748.2855(a)(7) - EBI Documentation-Must include the name of the caregiver(s) involved in the EBI and in the circumstances that led to the EBI

raw_content: The provided EBI Report does not include staff members conducting the restraint/containment or the witnesses to the containment.

Correction Narrative:
The follow up was conducted via email requesting and extension due to a document needing to be edited to add the witness text box. The extension was granted by supervisor Martina Beltran 03/05/2026. The original compliance date was 03/05/2026 a new compliance date is approved for 03/09/2026.

---------------------------------------
Upon further review of the documents Laurel Ridge concluded the current documents are sufficient for documenting the requirements asked by RCCR. The operation supervisors will conduct a point of service audit on incident reports to ensure the documents are filled out accurately.


summary: 748.535(3)(C) - Child-care administrator responsibilities-Having system in place to ensure an employee is available for emergencies

raw_content: It was determined on site staff did not have any support or assigned person to respond to the heating system failing in one of the units. In addition, no one with a key was available to unlock the thermostat so temperature could be adjusted.

Correction Narrative: A key was left on site, in the case of an emergency when a maintenance supervisor cannot arrive after hours to the facility. A supervisor will have the ability to open the thermostat and change the temperature.


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

raw_content: It was discovered staff were conducting inappropriate text conversations where children's behaviors were discussed and described as gossip. In addition, staff were facilitating contact with former employees who were terminated or resigned from the operation.

Correction Narrative: The staff involved in the incident were terminated, additionally staff currently at the operation were given an additional training and asked to sign stating they agree to maintain the privacy if the patients in care confidential at all times.


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

raw_content: A child in care did not receive timely care following requests from nursing staff for X-Rays/an assessment by a Physician's Assistant. Requests/submitted consults from nursing staff were declined leading to the child having to be sent to the ER. In addition, per the Serious Incident Report, a second child did not receive X-Rays until 36 hours after consult was submitted.

Correction Narrative: Two serious incident reports were reviewed and it was determined the operation sought medical care as necessary for those incidents.


raw_content: A nurse who worked in the RTC was found to not have a BGC under the RTC as required.

Standard Number / Description: 745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605

Correction Narrative: The following compliance plan was a submitted to RCCR. In an ongoing plan to ensure all initial background checks are submitted will become part of the hiring process for all MHWs and Nurses. This process began 2/10/2026.


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

raw_content: The operation failed to inactivate background checks for two staff members who has not been employed by the operation for 16 days and over three weeks respectively.

Correction Narrative: During a follow-up inspection, all persons requiring background checks were verified to have the correct background check.


summary: 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)

raw_content: Serious Incident Report does not contain all required information related to staff/witnesses. In addition, the phone number provided for one staff member is not correct (different employee), and the other direct care staff member stated she was not present at the operation from December 25-27th.

Correction Narrative: A new Serious Incident report form was rolled out January 2026, all requested phone numbers will be verified by Human Resource Department prior to being provided to any investigators.


raw_content: During an investigation it was determined the children and staff caring for the children in care were not within ratio during an emergency incident. During investigation interviews it was determined this is an ongoing issue at the operation.


raw_content: During an investigation it was determined that prudent judgment was not used when a staff member brought in a blanket with a ribbon tied around it. Subsequently, a child in care used the ribbon to attempt to hang themselves.

Correction Narrative:
Tonya Roberts created a form staff were asked to review and sign if they agreed with the information given. The information stated the staff should not allow items into the operation which children in care could use to act out a suicide attempt/hurt themselves. The documents is saved and added to the document library for further review.
Response:RTC staff will sign an attestation that policy must be followed for any items needed for RTC residents. This includes gifts, prizes, and rewards. All resident needs are purchased through Central Supply and strictly prohibited from being brought into the facility as well as the RTC. Signatures are being collected from 1/30/26 thru 2/15/26. Signed documents will become part of the employee's record.
*****************************************
During an unannounced follow up inspection on 2/4/26 this was observed to be in compliance.


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

raw_content:
During an investigation inspection it was found that the shower curtain to one bathroom was not installed. The children showered in a shower without a shower curtain the night before.
This was corrected at inspection when operation staff replaced the shower curtain.


summary: 748.1011 - Child/caregiver ratio-Includes only qualified caregivers working directly with a child or group of children

raw_content: During an investigation it was determined the Nursing Staff are being counted in ratio. The Nursing staff do clerical work and do not work directly with the children at all times, as they have other work duties that prevent them from doing so. The Nursing staff remain behind the nurses' station as well.


summary: 748.3231(b) - Evacuation-In an emergency, move all children to designated safe area known to employees, caregivers, & volunteers

raw_content: The emergency evacuation and relocation plan did not specify which employee is responsible for contacting emergency response, which employee is responsible for securing child records and medications, and how staff will account for all children at the relocation spot.

Correction Narrative: The emergency plan was evaluated and found to be in compliance with the minimum standard requirements.


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

raw_content: During an unannounced inspection a shower was observed to have a leak and two showers were observed to not be draining adequately. Note: this was corrected at inspection when the leak was fixed and the showers were unclogged and were able to drain.


summary: 748.3271 - First Aid Kits-All separate living areas & buildings must have first-aid kit available; first-aid kit must be available for field trips

raw_content: During an unannounced inspection a first aid kit clearly labeled was not found in each living area.

Correction Narrative: During an unannounced follow up inspection this was observed to be in compliance. Pictures of the first-aid kit were sent to the inspector and uploaded to the doucment library.


raw_content: During a follow-up inspection a wall was obsevred to have a water leak as well as the brick around the shower was warped due to the leak. Shower 413 was observed to be clogged and no draining adequately. The operation is blocking off the room with the wall damage caused by the water leak and will not be used until corrections are approved.


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

raw_content: During a follow-up inspection 16/18 bathrooms were found to be without proper ventilation.

Correction Narrative: During unannounced inspection on 12/17/25, all bathrooms were found with proper ventilation.


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

raw_content: Two rooms did not have paper towels available in the restroom. This was corrected at inspection when the direct care staff placed paper towels in the two restrooms..


raw_content: Eight of the showers had mold in the grout. One shower had mold observed in the ceiling of the shower area. One of the bedrooms was missing part of a baseboard which had small nails sticking out from the wall.


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: A reportable incident occurred 09/01/2025 at 2:40 pm; however, the operation did not report the incident to Statewide Intake until 09/04/2025 at 11:52 pm.

Correction Narrative: During a follow-up inspection administrator Tonya Roberts agreed to report incidents as soon as the operation staff become aware of the iinjury/incident to allow for the appropriate 24-hour timeframe.


summary: 748.705(b)(7) - Reasonable & prudent parent standard-must consider the surrounding circumstances, hazards, and risks of the activity

raw_content: During the investigation, staff confirmed they gave a child permission to punch a chair, and the child ended up fracturing their arm.

Correction Narrative: The operation met compliance by providing an education discussion to the staff member involved in the incident.


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

raw_content: Emergency evacuation plan was not posted in 3 of the 4 areas.


summary: 748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children

raw_content: During the walkthrough the showers in the residential areas were found to be without warm and hot water.

Correction Narrative: In person follow-up conducted and confirmed all restrooms had hot water available.


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: During the walkthrough of the operation multiple safety hazards were identified to include walkways, mold on an exterior walls and glass shards on the outside back deck.

Correction Narrative: In person follow-up conducted and confirmed safety concerns had been addressed.


summary: 748.1337(b)(1)(E)(v) - Initial Service Plan-If child is 13 years old or older, include plan for education on human reproduction

raw_content: When reviewing four out of four records reviewed did not have required educational plans.

Category: Admission, Service Planning, Discharge

Correction Narrative:
Operation requested additional time to complete the updated form as corporate is in the process of reviewing the changes. A checklist is being created to ensure that all required information is listed on the service plans. Comply by date 3/31/25.

Operation provided an updated Master Treatment Plan that will be implemented.


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

raw_content: Emergency Evacuation Diagram was found to not have all the required information.

Correction Narrative: In person follow-up conducted and confirmed new evacuation plans had been posted


summary: 748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health

raw_content: A child in care was not taken to a follow up appointment pertaining to an injury.

Correction Narrative:
Email received from operation on 4/11/25 advising that RTC Supervisors will be responsible for scheduling all medical appointments with the transportation department. Effective Date 3/20/25.
-Training on the new process was provided to all staff on 4/30/25 and a sign in sheet was provided.


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

raw_content: Operation has not obtained required yearly fire inspection.

Correction Narrative: Operation provided completed fire inspection on 2/27/25.


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

raw_content: Child in care was injured during an unnecessary restraint when excessive physical force was used.

Correction Narrative: Staff interviewed confirmed that additional training had been completed regarding Understanding the Risks of Disengagements and Restrictive Interventions.


summary: 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply

raw_content: Staff member administered an unnecessary restraint to get a child to comply.


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

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

Correction Narrative: Staff interviewed confirmed that additional training was received regarding Understanding Trauma and the impact on patient care


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

raw_content: Operation staff did not provide immediate care or treatment after seeing child was injured and unresponsive.

Correction Narrative: Staff interviewed confirmed that additional training had been received regarding Rapid Response Procedures.


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

raw_content: It was confirmed by operation staff and a child that medication was kept in a child's backpack and not in a locked container.

Correction Narrative:
On 12/23/24, compliance plan received by operation stating Policy #PHR-167 NURSING UNIT INSPECTION FORMS will be reviewed with current nursing staff 12/23/24 and a signed acknowledgment forms will be required and placed in the appropriate HR file.

An additional Nursing Supervisor was added to the RTC schedule beginning 12/16/24. This will ensure comprehensive oversight and guidance for nursing staff as well as direct care staff 7 days a week.
Nursing Supervisor will be able to oversee that procedures regarding medication administration, documentation, and storage will be consistently implemented.

Sign in sheets regarding additional training provided and meeting notes were received on 12/27/24.


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

raw_content: It was confirmed that a child did not receive their prescription medications for two days.

Correction Narrative:
On 12/23/24, compliance plan received from operation stating Policy #PHR-127 MEDICATION ERRORS/ ADVERSE DRUG EVENTS will be reviewed with current nursing staff 12/23/24 and a signed acknowledgment forms will be required and placed in the appropriate HR file.

An additional Nursing Supervisor was added to the RTC schedule beginning 12/16/24. This will ensure comprehensive oversight and guidance for nursing staff as well as direct care staff 7 days a week.

Nursing Supervisor will be able to oversee that procedures regarding medication administration, documentation, and storage will be consistently implemented.

Sign in sheets regarding additional training provided and meeting notes were received on 12/27/24.


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

raw_content: A child was told that they should not smile because they should not be happy to be at the operation.

Correction Narrative:
On 12/23/24, compliance plan received by operation stating LCCA reviewed policy on prohibitive methods and appropriate disciplinary measures for RTC on 11/26/24 and ongoing education for staff not present.

RTC Nursing Supervisors will ensure any pool or PRN staff working on RTC receive this information at the beginning of their shift. This will be documented in there HR file.

New employees will receive a copy of Prohibitive Methods during their shadowing, prior to being in ratio on RTC.

This information will be reviewed at monthly RTC staff meeting every January and July. RTC Director will be responsible for ensuring this process is adhered to and documented for licensing review upon request.

Sign in sheets regarding additional training provided and meeting notes were received on 12/27/24.


summary: 748.1101(b)(3)(C) - Children's rights-Adhere to the child's rights to have religious needs met

raw_content: A child was denied access to a bible.

Deficiency Narrative: A child was denied access to a bible.

Correction Narrative: On 12/23/24, compliance plan received by operation stating Bibles have been placed in the nurse's station for all RTC residents to utilize. This information has been added to the RTC resident handbook as of 12/19/24.


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

raw_content: Staff were unaware that a child was in the shower leading to a maintenance worker walking in on the child while they were using the bathroom.

Correction Narrative:
On 12/17/24, compliance plan received via email from operation.

LCCA reviewed supervision expectations with RTC staff at the staff meeting on 11/20/24 and ongoing for staff not able to attend. Attached is the handout received by staff and the meeting sign in sheet.

As of 10/25/24 staff were notified the new UHS policy requiring directors, one camera or one in person audit per day, looking for noncompliance of supervision. Staff were also made aware of what active supervision is, and what the follow-up Actions would be from the training department as well as the HR department. This information has been in attached to this email.


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

raw_content: It was confirmed that a caregiver threatened to deny a child hygiene time if they did not comply.

Correction Narrative:
On 12/17/2024, compliance plan was received from operation via email.

LCCA reviewed policy on prohibitive methods and appropriate disciplinary measures for RTC on 11/26/24 and ongoing education for staff not present. Attached is the policy and sign in sheet of acknowledgment.

RTC Nursing Supervisors will ensure any pool or PRN staff working on RTC receive this information at the beginning of their shift. This will be documented in there HR file.

New employees will receive a copy of Prohibitive Methods during their shadowing prior to being in ratio on RTC. This information will be reviewed at monthly RTC staff meeting every January and July. RTC Director will be responsible for ensuring this process is adhered to and documented for licensing review upon request.


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

raw_content: Allegations involving inappropriate sexual comments made by a staff member were not reported timely to Licensing.

Correction Narrative: Operation reported allegations to hotline and advised that a comprehensive review of the standard for reporting serious incidents, conducted by the RTC director, will mitigate the risk of future occurrences.


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

raw_content: Outdoor area in Lavaca Unit had animal feces, a cracked plastic weight stand and broken wooden bench head rest.

Correction Narrative: In person follow-up conducted and areas were clean and free of hazards. Operation implemented new checklist to include outdoor furniture maintance and animal feces.


raw_content: Operation did not have yearly fire inspection conducted timely.

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


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: Lavaca Unit had 3 staff for 16 children in care.

Correction Narrative: In person follow-up conducted and ratio was in compliance.Two staff interviewed confirmed that additional training was provided regarding ratio requirements.


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

raw_content: Two staff supervising children in care did not have active background checks.

Correction Narrative: Operation advised that two full time employees from the acute facility were moved to work on the Lavaca Unit after the unit had two full time staff members call in for their shift. The two employees that were present during the unannounced survey had background checks run at their time of hire but because they were employees of the acute facility, had been deactivated in the system in July 2024. The current list of active employees in the system has been reviewed and additional full-time weekend staff from the acute facility have been added for emergency situations or when there are coverage needs due to multiple, unexpected RTC staff outages. The list of employees has been shared with the Staffing Coordinator, the Overnight, and the Weekend Nursing Supervisors to ensure that only staff with confirmed background checks work on the RTC units.


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

raw_content: Date of admission is not present in the annual summary log.

Correction Narrative: An email was received from the operation advising that the Annual Elopement Log for Laurel Ridge was modified to include the time of the incident along with the admission date. A copy of the modified log was provided.


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

raw_content: Time of the incidents listed in the annual log is not present.


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: During an interview with former staff member, it was stated they have not been employed by the operation since 10/17/2023. The staff member's background is showing active as of 11/13/2023.

Correction Narrative:
Compliance plan received via email from operation:
1 .This finding was discussed with the Assistant Director of Human Resources, who handles the TDFPS background verifications.
2.Upon notification that an employee is terminating employment, an electronic personnel action form is completed, which sends a notification to the Director of Human Resources for approval. Once the approval for termination has been given by the Director of Human Resources, an automated email gets sent to the payroll system and the Human Resources Assistant to deactivate the employee.
3.A process was put in place on November 17, 2023, in which a weekly report for RTC employee terminations will be run each Friday by the Assistant Director of Human Resources to verify that any employee that has left LRTC employment in the past week has been deactivated by the HR assistant, to include removing them from the TDFPS background check list.
4.The Assistant Director of Human Resources will send the LCCA a monthly report of all RTC terminations and the date they were deactivated in the TDFPS.


summary: 748.111 - Child-care policy required

raw_content: Operation did not have a documented Child Care Policy.

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

Category: Organization and Administration

Correction Narrative: Email received from administrative staff, on 10/11/23 with attached Childcare Policy for the operation. Policy provided met all the standard requirements.


summary: 748.2307(15) - Other Prohibited Punishments-using or threatening to use emergency behavior intervention as discipline or punishment

raw_content: Children in care were told they would be put in Seclusion for not obeying directives given by staff memer.

Correction Narrative: Staff member involved in incident is no longer employed at the operation. All remaining staff attended additional training on appropriate discipline.


raw_content: During the investigation it was determined that caregivers are caring for more than five children with treatment services at a time.

Correction Narrative:
Email received on 3/13/23 from operation with compliance plan:

1. Staffing for the RTC will be reviewed by the Nursing Supervisor and/or the Staffing Coordinator prior to the start of each shift.
2.The one staff to five patients staffing ratio (during waking hours) will be visually verified at random times throughout the shift by the Program Director and/or Nursing Supervisors.
3.Staffing will be adjusted throughout the shift as needed due to admissions/discharges and/or off ground passes or activities.
4.The Program Director, RTC therapists, and/or Nursing Supervisors may be needed at times throughout the day to assist with maintaining staffing ratio compliance.
5.Staffing rosters will be reviewed for compliance daily by the LCCA.
6.The Staffing Coordinator will be responsible for storage of all reviewed staffing logs.

In person follow-up also conducted on 3/28/23. Ratio was reviewed and found to be in compliance.


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

raw_content: During the investigation it was determined a caregiver did not demonstrate prudent judgement when they failed to redirect inappropriate comments made towards them from a child in care.

Correction Narrative:
Email received on 3/13/23 from Operation with the following plan:
1.The staff member cited in this investigation will be removed from the RTC unit for 30 days.
2.The staff member cited in this investigation will be required to complete two assigned trainings, presented by Valerie Devereaux, RN, DNP, MSN, Vice President of Nursing, United Health Services, before being allowed to return to the RTC program:
Therapeutic Nurse-Patient Relationships
Therapeutic Milieu and Communication
3.Upon return to the RTC program, the staff member cited in this investigation will meet weekly for 90 days with the RTC Nursing Supervisor to discuss patient care/therapeutic milieu issues.


raw_content: During the investigation it was determined that caregivers yelled directly at children in care.

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

Correction Narrative:
-Email received on 3/13/23 from the operation with the following information:

The GRO Subchapter M-Discipline and Punishment and standard 5748.2307, 'VVhat other methods of punishment are prohibited?" was reviewed with staff.
2.Staff were trained by the Program Director and RTC Nursing Supervisor on the requirements of disciplinary measures in residential care.
3. Attached training/sign-in roster was provided.


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

raw_content: Operation did not report a serious incident to licensing involving inappropriate behaviors between children in care.

Correction Narrative:
1 . All RTC direct care staff and therapists were educated by the RTC Director of Clinical Services and RTC Nursing Director on the GRO Standard "When must I report and document a serious incident?"
2.	Training included definitions of the types of serious incidents that the facility is required to report: substantial physical injury or critical illness; allegations of abuse neglect or exploitation of a child; physical abuse committed by a child against a child; and, sexual abuse committed by a child against another child.
This is not an inclusive list of serious incidents that require reporting.
3.	Training included how to make a direct report of a serious incident or occurrence to TDPFS by phone or online through the Texas Abuse and Neglect Hotline.
4.	Training included reviewing the GRO Standard 5748.31 1 "How must I document a serious incident?" Training included discussion of what information needs to be included as part of the investigative process.


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

raw_content: Upon inspection, it was observed that medications counted did not match the amount recorded in the medciation log.

Correction Narrative: Compliant: Follow-up inspection was conducted on 5/20/22; CAP was provided.


summary: 748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements

raw_content: Upon review of background checks, it was found that staff statuses for one person are not accurate.


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: Severe weather drills are not being conducted every six months.


summary: 748.1103(b)(1) - Informing child of rights-Child rights must be written in simple, non-technical terms

raw_content: Upon inspection, it was found that child's rights provided to children are missing many of the rights as provided by the standards.

Category: Children's Rights


summary: 748.947(a) - Annual training emergency behavior intervention-Reinforce basic principles covered in 748.901 and 748.903 and develop and refine skills

raw_content: Staff did not have the required annual emergency behavioral intervention training, normalcy training or trauma informed care training.

Correction Narrative:
1. All RTC staff completed the two hour training classes and have course completion certificates in the föllowihg areas:
a.Trauma and Trauma-informed Care: An Introductory Training Provided by DFPS
b.Need for Normalcy Training provided by DFPS
2.All RTC staff completed an additional 4 hours of Milieu Management and Crisis Intervention Training with the facilities Nurse Educator and CPI Instructors.
a.Staff completing training signed an acknowledgment that they agree to provide a positive and safe environment by using the milieu management and crisis intervention techniques learned in training.
b.See attached sign in rosters and copy of blank acknowledgement
3.Trauma Informed Care, Normalcy, and the four hour Milieu Management and
Crisis Intervention training have been added to the New Employee Orientation.

4. All training certificates and acknowledgements have been placed in the individual's training files in Human Resources, as well as a copy kept in the
LCCA's office.
5. An annual training calendar was developed to include the required elements for GRO standard 748.947(a) and 748.945(2).
6. Additional training will be provided by the Medical Director, the Program Director and the Nursing Director at mandatory, monthly meetings.


summary: 748.945(2) - Annual Training-Caregiver that administers psychotropic medication must receive annual psychotropic medication training every 12 months

raw_content: Staff did not have the required annual psychotropic medication training.

Correction Narrative:
1)All licensed care staff completed the two hour Psychotropic Medication for Children in Texas Foster Care training presented by TDFPS.

2)New Employee Orientation Schedule-Week 2 has been adjusted to include the required two hour medication training.

3)An annual training calendar was developed to include the required elements for GRO standard 748.947(a) and 748.945(2).


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: Staff did not have the required pre-service training hours regarding EBI or trauma informed care.


summary: 748.885(1) - General pre-service training curriculum-Includes identification of psychotropic medications if caregiver administers psychotropic medication

raw_content: Staff did not have the required pre-service training regarding psychotropic medications.

Correction Narrative:
1) All licensed care staff completed the two hour Psychotropic Medication for Children in Texas Foster Care training presented by TDFPS.

2)New Employee Orientation Schedule-Week 2, has been adjusted to include the required two hour medication training.

3)An annual training calendar was developed to include the required elements for GRO standard 748.947(a) and 748.945(2).


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

raw_content: Staff were aware of allegations made by child in care regarding alleged inappropriate touching from a staff member. Staff were aware of the outcry and did not report to licensing.

Correction Narrative: 05/03/21, email received from operation staff with compliance plan to the following citation. Operation staff reviewed reporting A/N and focused the training on minimum standards for GRO; when must I report and document serious incident. This was completed with full time staff and PRN RTC therapists. Operation also completed Reporting A/N training in their annual training completed on 04/26/21. Logs were provided of all staff who were present and completed this training. Compliance has been met.


facility_name: Texas Hill Country School

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

raw_content: Through interviews and documentation it was determined that staff did not follow the 1:1 supervision requirement noted in the service plan.

Correction Narrative:
The operation emailed the following compliance plan :

The staff member involved has received a formal corrective action in accordance with Bright Springs policy. In addition, the student's required level of supervision was
reiterated to all staff to ensure clarity and consistency in practice.
Our facility remains committed to maintaining the highest standards of supervision and
safety. Proper supervision protocols will con9nue to be followed to ensure the wellbeing of all students in our care.


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

raw_content: Child in care saw two staff sleeping while in ratio on their assigned overnight shift.

Correction Narrative:
An email was received from the administrator on 7/10/24. The two staff involved were suspended and eventually terminated after results of the investigation were determined. A meeting was held with all overnight staff led by the program directors. The meeting reemphasized the importance of wake supervision. Tips to remain awake and work as a team to ensure others are awake were discussed with the staff. The operation will continue to staff above the minimum standard for staffing ratios during the overnight shift, and managers will continue to sporadically check in unannounced during the overnight shift.

An in-person inspection was conducted on 7/17/24. Interviews were conducted with 1 child and 1 staff. The child in care and staff reported that no staff have been observed sleeping overnight. Staff were observed monitoring children in the hallway.


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

raw_content: Through interviews with children and staff, a child in care obtained a nosebleed during a restraint.

Correction Narrative: The corrective action plan was received from the operation on 4/26/24 and reports that the staff involved will be retaking the YSIS refresher on 4/26/24. A follow-up inspection was conducted at the operation on 4/29/24. Interviews were conducted with 2 staff and 1 child in care. The training certificate for the staff involved was received and reviewed and shows a completion date for an 8-hour refresher for YSIS training on 4/26/24. There were no concerns regarding force used during emergency behavior interventions when reviewing records and during interviews.


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

raw_content: It was confirmed that a staff member used profanity towards a child in care.

Correction Narrative: An email was received from the operation stating the staff member we self-reported unfortunately chose to go against our de-escalation protocol. Other staff members immediately intervened and notified supervisor of the staff member's inappropriate language. He was immediately suspended and terminated soon after. An in-person inspection was conducted on 4-11-24 at the operation. The administrator stated the staff was suspended on 2-1-24 when the incident occurred and was terminated on 2-2-24. The background check for this staff was evaluated and is inactive as of 2/6/24. Interviews were held with 2 children and 2 staff on profane language being used and there were no concerns.


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

raw_content: Through interviews with children in care and staff, it was determined that a staff used an improper restraint on a child in care during a non-emergency situation.

Correction Narrative: An inspection was conducted at the operation. Training documentation was received to show the date and hours of training, and the topics discussed in the training. 2 children in care were interviewed and there were no concerns with EBI and when they are conducted, and the amount of force used. 2 staff were interviewed, and stated they both completed the EBI training on 2/16/24 on campus.


summary: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force

raw_content: Through interviews with staff and children in care, it was determined that a staff member slammed a child in care to the ground when performing a restraint on the child.


raw_content: Children in care were able to take part in inappropriate behaviors because staff failed to supervise them appropriately.

Correction Narrative: The staff members involved in this incident are no longer employed by THCS. All staff members were retrained on levels of supervision on 7/18/23 and a new lanyard hand off protocol was introduced on 7/27 to ensure clarity and accountability regarding supervision.


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: Based on the review of the information gathered during the investigation, there is sufficient evidence to find that neglectful supervision of children in care occurred.

Correction Narrative: It was found during the investigation that neglectful supervision occurred. Two staff members violated the operations supervision policy and exposed children to substantial risk of physical or mental harm.


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 did not notify Licensing about the second injury the child sustained five days after the first injury.

Correction Narrative:
The operation has requested an administrative review for this investigation citation.
The operation will continue to ensure timely reporting. The administrator will report all reportable incidents via phone call instead of using the online system going forward.


summary: 748.309 - Reporting Serious Incident - All serious incident reports to Licensing must be made to the Texas Abuse & Neglect Hotline

raw_content: It was confirmed all facilities incidents are not being reported in a timely matter.

Correction Narrative:
The operation has requested an administrative review for this citation.
The operation will continue to ensure timely reporting. The operation will report all reportable incidents via phone call instead of using the online system going forward.


raw_content: There are concerns with children in care getting injured due to lack of supervision.

Correction Narrative:
The operation has requested an administrative review for this citation.
The operation will continue to provide appropriate levels of supervision to ensure the safety of all students.


raw_content: A child in care was restrained in a non-emergency situation. The child refused to shower and had their homework taken away as a result. The child went to their room upset. The shadowing staff followed the child and began taking the child's clothes off. The child reacted and grabbed the staff's wrists, not attacking the staff but keeping the staff from taking their clothes off. The staff responded by completing a restraint on the child.

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

Correction Narrative:
RCCR Inspector received a corrective action plan from the operation on 02/23/23. The administrator stated they will be requesting an admin review. The administrator reported due to this incident the operation will now utilize a formal document to be signed and reviewed by all new staff members stating they are not permitted to physically redirect a student, and that physical restraint is never used to gain compliance.

On March 8, 2023, RCCR Inspector Martha Bull conducted an unannounced follow up inspection at Texas Hill Country School for this investigation. Two staff were interviewed, and two children were interviewed. Interviews confirmed that EBI is utilized only for an emergency situation, particularly when a youth is being physically aggressive towards themselves, or others.


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

raw_content: Staff member was recorded sleeping on duty, which the administrator acknowledged during interview. Additionally, the staff member admitted to possibly dozing off in the past.

Correction Narrative: On March 8, 2023, RCCR Inspector Martha Bull conducted an unannounced follow up inspection at Texas Hill Country School for this investigation. Two staff were interviewed, and two children were interviewed. Administrator reported that a meeting was held with all overnight staff members immediately following this incident and discussed the importance of complying with 24-hour awake supervision. The operation schedules to have two to three staff members on overnight at Chaparral, and one to two staff at the main.


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

raw_content: During the investigation, it was determined a caregiver utilized inappropriate discipline that was demeaning, unnecessary, and contributed to negatively impacting children in care.

Correction Narrative:
The caregiver in question related to this operation is currently suspended and will not be returning to the operation per the administrator.
On March 6, 2022, Administrator advised the employee had been terminated from the operation.

On March 8, 2023, RCCR Inspector Martha Bull conducted an unannounced follow up inspection at Texas Hill Country School for this investigation. Two staff were interviewed, and two children were interviewed. Interviews confirmed that staff do not utilize inappropriate discipline and focus on positive reinforcement over discipline.


raw_content: It was found during the investigation that neglectful supervision occurred. A staff member violated a safety plan by not maintaining 1:1 supervision of a child which exposed the child to substantial risk of physical or mental 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:
Staff member understood protocol but did not follow it. Staff member has been terminated.
Admin Review


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

raw_content: A caregivers actions were noted to have escalated a situation which ultimately led to a child being placed in an inappropriate restraint.


raw_content: A staff members actions were noted to have presented a genuine threat of substantial harm from physical injury to the child when the staff member placed the child in an inappropriate restraint.


summary: 748.2461(b)(2) - Short Personal Restraint-Caregiver may not use restraint that impairs child's breathing by putting pressure on torso

raw_content: A caregiver was noted to have applied pressure to a childs chest area, which was noted to have caused the child difficulty breathing. The information gathered during the investigation also establishes a reasonable likelihood to conclude that this action by the caregiver caused injury to the childs person.


raw_content: The assigned caregiver did not provide the level of supervision specified in the service plan; subsequently, resulting in the child sustaining an injury requiring medical attention.

Correction Narrative:
 In response to the citation the operation has come to the realization that the wording n the service plan is too rigid and added this statement to the service plans: There are circumstances in the day-to-day operation of the program where the levels of supervision documented above may not be possible for temporary and limited periods of times.  These times will be guided by the prudent parent standard as well as staff judgement to maintain levels of safety with the stipulation of returning to the level of supervision in a timely manner.

In addition, the employee that was involved in the incident, had a discussion with the Administrator to ensure staff has a good understanding of when it is appropriate/not appropriate to leave a student briefly unattended in their bedroom.   Administrator will review/provide Supervision and Normalcy training with the staff involved.


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

raw_content: The operation had a fire inspection in July, the fire marshal marked deficiencies. The operation has not followed up with the fire marshal. The operation still needs one building that was under construction in July to be inspected by the fire marshal.

Correction Narrative: Administrator CCed me in an email to the fire marshal requesting a follow up inspection.


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

raw_content: A caregiver did not deny when questioned and was overheard by multiple individuals informing a child in care that they would force the child to throw up their food if the child did not comply.

Correction Narrative:
After informing the Administrator of the citation, it was expressed that OP will question children in care on safety and interactions with staff to ensure fair treatment is implemented towards children by staff.

Administrator sent the following response in email regarding how the OP will meet compliance from the citation issued above:

"Until the admin review, I will have our safety committee lead scan me the SAC (student advocacy committee) meeting notes to review weekly.  During the meetings the students can express any concerns, etc."


summary: 748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free

raw_content: Three of the five showers in one building were in need of cleaning. The counters next to one stove were in need of cleaning.


facility_name: Trinity Home of Faith 1, Inc.

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

raw_content: A staff member yelled at a child in care.

Correction Narrative: Follow-up inspection staff received additional trauma inform intervention training.


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

raw_content: During the investigation, records were reviewed for personnel trainings, with employees not completing trainings within annual year of employment at the operation.

Correction Narrative:
Corrective Actions Planned and/or Taken:
1. Letitia Dugay will send an e-mail to the named staff, with copy to Barbara Cartwright, 2 months in advance to let them know what training is due, the date it is due and where to put the certificate for completion when the training is completed.

2. If the training is not complete, the Executive Director will meet with the employee and send an e-mail to the named staff, with copy to Barbara Cartwright 1 month in advance to let them know what training is due, the date it is due and where to put the certificate for completion when the training is completed

3. The Executive also utilize the training audit form to document the above.

4. If the training is not complete by due date, The Executive Director will use the performance plan development note to document the conversation, and corrective action that was used to enhance the employee's growth. This is to ensure this does not occur in the future.

5. The training audit form and the performance development note will be filed in the employee's employment folder.

6. Barbara Cartwright will the develop forms

The Barbara Cartwright will train Letitia Dugay and all staffing personnel to this corrective plan process.


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

raw_content: Three of the seven children interviewed reported that a female staff member entered the bathroom without knocking, which made them feel uncomfortable.

Correction Narrative:
The operation will be training staff on the Rights of Children in care with an emphasis on:
Children's rights-privacy to send/receive unopened mail, have phone conversations, keep a journal, have visitors, unless the child's best interest.


summary: 745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605

raw_content: During an investigation, it was found that a staff member being counted in the ratio does not have a current background check.

Correction Narrative: Background checks for inactive staff counted in the ratio are in compliance.


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: During a walkthrough of the facility, it was discovered that the fire extinguisher was past due for inspection.

Correction Narrative: Operation sent photos of new inspected fire extinguisher dated 10/2024. Moving forward a google calendar has been setup and will give the first reminder 3 months prior to inspection date, initially. Thereafter, very two weeks until all fire extinguishers have been serviced and updated. Responsibility: Executive Director


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

raw_content: In reviewing the staff work schedule, it was found a current Caregiver was allowed to supervise children alone which is a violation of the caregiver's condition.


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

raw_content: A review of interviews that were conducted with the residents, four of six residents stated staff used profane language.


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

raw_content: It was found that there was no child plan of service completed by the operation for the child admitted on 2/23/24 who was discharged from the operation on either 4/19/24 or 4/20/24.

Correction Narrative:
On 5/13/24, this rep received an email from the operation reporting that the Administrator will ensure all Children's 45 day Service plan is completed in a timely manner.

On 5/14/24, the operation sent another email and reported they spoke with their assigned licensing rep yesterday and this morning. They reported that the operation staff met with a program administrator and a regional director, this actual resident was staffed and discussed then, and this matter is being looked into. This meeting was face-to-face at THOF. The operation reported they are waiting for a return phone call. They reported they will be requesting an Administrative Review.

On 5/28/24, the assigned licensing rep for this operation conducted an unannounced in-person follow up visit to the operation and interviewed staff and did a physical site inspection and found no concerns.


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

raw_content: The child was observed wearing earrings during the interview.  The staff were unaware of the child's special need to have objects the child has used to self-harm removed.

Correction Narrative: Based on information gathered during the follow up inspection the operation would create a safety plan and concerning items would be removed from a child in care. If items are needed to be used the child in care would then be required to request them and they could only use under the supervision of caregivers and then it would be returned after use.


summary: 748.125(f)(2)(C) - Post hospitalization protocols must include removing harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt.

raw_content: The operation did not remove harmful objects from the child post hospitalization.


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

raw_content: This standard was found deficient as part of a DFPS Investigation. During the review, evidence was observed to support that caregivers were not aware that two children in care, under the age of ten had left the operation.


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

raw_content: This standard was found deficient as part of a DFPS Investigation. During the review evidence was observed that supports that facility staff did not follow the operations policies on conducting ten-minute checks when children in care are in their rooms for longer than five minutes.


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: This standard was found deficient as part of a DFPS Investigation. During the review, evidence was observed that there were only two staff members present for 11 residents. There is also evidence to support that one of the staff members left the operation due to an emergency leaving one staff member with 9 children in care.


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

raw_content: This standard was found deficient as part of a DFPS Investigation. During the review evidence was observed that the operation did not follow the victim's preliminary service plan in regard to conducting 10 minutes checks and conducting one-on-one supervision.


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

raw_content: It was determined during interviews and documentation review that the suicide screening was not completed with the child immediately following the child exhibiting warning signs.

Correction Narrative: An email was received from the operation explaining the compliance manager will review all suicide screenings once they are completed to ensure accuracy. Along with this, all signs of suicide will be reported by staff to the case manager and SWI.


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

raw_content: It was observed by the RCCI Inspector that the operation does not have a window with properly fitted and secure screens.

Correction Narrative: On 11/21/2023, a follow-up inspection was conducted by RCCL Inspector Bambrick at Trinity Home of Faith. The operations windows were checked to ensure that a properly fitting screen was placed in the window. Two windows during the inspection did not have window screens, one of the rooms was unoccupied and one room was occupied by a child in care. A phone call was made to Ms. Dugay and concerns were discussed. The child in the room without a window screen was moved to a room with a window screen until a window screen can be placed in the window. Ms. Dugay stated that the remaining window screens would be placed in by their maintenance man as soon as he could. All occupied rooms have window screens.


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

raw_content: During the inspection, it was observed that the vehicle used for  transportating children in care had a hole in the seat revealing the stuffing and wood. The wood in the seat could be a possible hazard for children getting in and out of the vehicle. The vehicle was also observed to have had a large amount of trash left inside it, including wrappers and bottles.

Category: Transportation

Correction Narrative: The operation provided RCCL Inspector with photos of the fixed van seat with a copy of their receipt/summary from the mechanic. Photos were saved in the document library.