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: Operation failed to timely report allegations of abuse to a child.

Correction Narrative:
04/28/2023- The Executive Director submitted the operation's Corrective Action Plan consisting of ensuring the operation will respond to allegations of serious incidents of Abuse and Neglect according to the operation's Reporting Serious Incidents, Abuse and Neglect Allegations Policy. The operation will ensure that any abuse or neglect allegations will be reported to the Texas Hotline immediately but no later than 24 hours. The operation will also ensure that all Serious Incidents, Abuse and Neglect allegations are reported via email or phone call to the assigned DFPS Residential Contract Manager and assigned Residential Child Care Licensing Rep within 24 hours of being notified of such an occurrence.

The operation's Case Manager will be responsible for notification of DFPS Contract Manager. The Executive Director will be responsible for notifying the assigned licensing representative.

The operation will continue to require all employees to complete pre-service and annual trainings regarding reporting Serious Incidents, Abuse and Neglect and will conduct an additional refresher course for all employees to be completed within 30 days of this date (02/22/2022).

According to the Executive Director, on January 31st, 2022, a broadcast MEMO document was sent to all of the operation's employees to notify them of the Abuse/Neglect refresher training scheduled for February 2022. The scheduled dates for trainings were 02/08/2022,02/10/2022, and 2/19/2022.

The operation's Administrative Assistant currently provides oversight and ensures compliance with trainings by performing quarterly audits and will continue in that capacity. The Administrative Assistant will be listed as the Training Coordinator and will ensure that all trainers utilized by the operation to facilitate this training on Reporting Serious Incidents, Abuse and Neglect who are selected provide through signature their title and name at the time of training.

The operation's Licensed Child Care Administrator will ensure that all serious Incidents, Abuse/Neglect are reported timely and will be reported to the Residential Contract Manager.

At the conclusion of the trainings that are scheduled, the operation's Executive Director will submit proof of training for all staff, case managers and caregivers on reporting Serious Incidents, Abuse and Neglect. The documentation will include training certificates along with the participants' signature.


state: TX

facility_name: Promise Rose Residential Care Home, Inc.

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 medical care for an injury.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative:
A physical follow up took place at Young & Lockhart Elementary Schools. Three of 3 children received medical treatment for their injuries timely. The interviews are available in the Chronology.

A/R was submitted on 12/9/21. A corrective action plan along with documents were sent to be reviewed. An email was sent to the PA, Mrs. Adetona showing timely submission.


summary: 748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth

raw_content: One file was observed without any reference to the child's religious preference.

Standard Risk Level: Medium Low

Correction Narrative:
7/15/2021- The operation submit a plan stating they will ensure that a reference of the child's religious preference is located on the 72-hour Admission Assessment. Treatment Director Keoni Franks will ensure that a reference of the child's religious preference is located on the 72-hour Admission Assessment.
The operation submit the 72-hr Preliminary Service plan that stated the the child's religious preference.


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

raw_content: One of four staff files reviewed indicated that they did not receive EBI training every six months.

Standard Risk Level: Medium High

Corrected at Inspection: Yes


facility_name: Adiee, LLC

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

raw_content: The child file reviewed did not include an updated service plan for review.

Correction Narrative:
The following corrective action plan was provided by the operation via email:

The administrator reviewed Minimum Standard 748.1381(2) and has implemented corrective measures to ensure all service plans are properly filed and readily available for review at all times. The administrator, in coordination with the case manager, will conduct routine audits of all service plans to verify timely completion and to ensure documentation is accurate, complete, and fully compliant with minimum standards.

The operation provided the updated service plan for the child. There were no concerns.


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

raw_content: During the walkthrough of the facility, several windows upstairs were noticed without any curtains, blinds or shades.

Correction Narrative: The corrective action plan provided via email by the administrator stated the operation was in the process of painting all of the rooms and temporarily removed them for proper painting. The window dressing will be reinstalled upon completion of the painting project.


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

raw_content:
During a review conducted on October 2, 2025, it was determined that:

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

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

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

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

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

Correction Narrative: An HM extension was approved effective 10/3/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 4/3/2026.


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

raw_content: During an investigation review, a child stated they were not provided snacks for a few weeks and photographs reviewed showed limited amounts of food in the pantry and refrigerator.

Correction Narrative: A physcal follow up was conducted where adequate amounts of food were observed. Two children expressed receiving adequate meals and snacks daily. Staff interviewed also expressed that during the morning shift the children receive one to two meals and snacks upon request.


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

raw_content: A staff member belittled a child in care when expressing to them that they do not deserve respect and should stay in a child's place.

Correction Narrative: Interviews were conducted with children and staff who denied ever witnessing or being belittled at the operation.


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

raw_content: Children in care were reported to have left the operation at 12:24 pm. Parents (CPS workers) were not notified until 7:43 pm and 7:51 pm, which is after the 6 hour requirement.

Standard Risk Level: Medium

Correction Narrative: The corrective action plan from the operation via email stated that the administrator will ensure that all personnel receive refresher training on mandated reporting timelines and emergency communication protocols on 12/08/2025. Additionally, supervisory staff will implement scheduled audits of all incident reports to verify that required notifications are made within prescribed timeframes and documented with accuracy and completeness in accordance with minimum standards.


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

raw_content: Multiple employees were observed in  CLASS that are no longer employed at the operation.

Correction Narrative: In partnership with Human Resources, the administrator will ensure that former employees are inactivated within seven days of separation from employment.


summary: 748.1385(9) - Service Plan Review-Must document in the child's record the review and update of the plan

raw_content: The child's file reviewed did not include the service plan update that was scheduled for June 11th.

Correction Narrative: The administrator will ensure that all service plan updates are filed in accordance with established timelines.


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

raw_content: The policy reviewed did not include the required components for child orientation regarding emergency behavior interventions.

Category: Organization and Administration

Correction Narrative: The administrator submitted documentation of EBI policy-for orientation.


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

raw_content: A serious incident report reviewed did not include the age of the child involved or interventions made during or after the incident.

Correction Narrative: The administrator will ensure full compliance with all applicable minimum standards by verifying that staff review, complete, and sign all required documentation.


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

raw_content: A child's file reviewed did not have an admission assessment for the child's re-admission; the child was previously admitted to the operation in Aug. 2024 and re-admitted on Jan. 4, 2025.

Correction Narrative:
The following corrective action plan was provided via email by the operation:

When a child is re-admitted to care, Adiee LLC will ensure that all required admission documentation is completed as if the child were being admitted for the first time.

If the child was discharged from our care within the previous 12 months, Adiee LLC may update the existing admission documentation instead of completing new forms. However, even if all information remains the same, the previous documentation will be reviewed, verified, and updated with a new admission date to reflect the current re-admission.


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

raw_content: A video recording was provided of a staff member using inappropriate language towards a child in care.

Correction Narrative: During individual interviews staff and children interviewed denied any abusive or profane language at the operation.


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

raw_content: A video recording indicates that a staff member provoked a child by using verbal commands and hand gestures in a manner that challenged the child to fight.

Correction Narrative: During individual interviews staff and children interviewed denied any knowledge of staff provoking a child to engage in a physical altercation.


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

raw_content: The two service plans obtained for the investigation were not signed by the youth nor was their refusal to sign documented.

Standard Risk Level: Low

Correction Narrative:
The following corrective action was provided by the operation via email:
The administrator reviewed standard 748.1349(b)(2) concerning this incident. To prevent future occurrences, the administrator will implement quality assurance checks to verify that all Service Plans are signed by the youth. In cases where the child refuses to sign, the refusal will be formally documented in accordance with agency policy and minimum standards.


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

raw_content: The childs medication reviewed did not indicate the accurate count of the remaining pills.

Correction Narrative:
Two children's medications were reviewed and were observed to include the accurate daily count of each prescribed medication.

A face-to-face interview was conducted with staff. She stated that the new form works better for the children who have to take medication for AM and Midday which allows them to use the same sheet and accurately track the count medication instead of using separate sheets for the same medication that is administered multiple times a day.


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

raw_content: A video recording indicated a staff member yelling at a child in care.

Correction Narrative:
A corrective action plan was submitted via email by the Administrator stating that the staff member involved was immediately terminated, as ADIEE maintains a zero-tolerance policy for such behavior. To prevent future occurrences, the administrator will continue providing staff training to reinforce compliance with licensing standards and ensure the health, safety, and well-being of all children in care. ADIEE remains committed to maintaining a safe and supportive environment through consistent supervision and adequate care.

Interviews were conducted with children in care during inspection #4071230. The children interviewed staff yell at them.


raw_content: A video recording indicated a staff member cursing at a child in care.

Standard Number / Description: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

Correction Narrative:
A corrective action plan was submitted via email by the Administrator stating that the staff member involved was immediately terminated, as ADIEE maintains a zero-tolerance policy for such behavior. To prevent future occurrences, the administrator will continue providing staff training to reinforce compliance with licensing standards and ensure the health, safety, and well-being of all children in care. ADIEE remains committed to maintaining a safe and supportive environment through consistent supervision and adequate care.

Interviews were conducted with children in care during inspection #4071230. The children interviewed denied the use of profane language.


summary: 748.313(3)(D) - Serious Incident - Unauthorized absence of a child-document whether child returned to operation and how long child was gone from operation

raw_content: Incident report received regarding AWOL was missing departure and return times.

Correction Narrative: The administrator will ensure incident reports regarding AWOL will have departure and return times.


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

raw_content: AWOL log provided was for 1 child. Missing age, gender, and date of admission.

Correction Narrative: The administrator reviewed standard 748.453(a)1 and will ensure that all minimum standards are followed by verifying that all staff review and complete all documents in their entirety.


summary: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

raw_content: Discharge plan provided is missing several details including circumstances of discharge.

Correction Narrative: The Discharge form has been updated and complies with minimum standards.


summary: 748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals

raw_content: A service plan for a child in care identified as receiving treatment services did not contain two professionals on the service planning team.

Correction Narrative: The following corrective action plan was provided by the operation indicating:  MOVING FORWARD WE WILL ALWAYS PLAN AND MAKE SURE THAT THERE ARE TWO PROFESSIONAL SIGNATURES ON THE SERVICE PLAN.


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

raw_content:
During a review conducted on March 31, 2025, it was determined that:

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

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

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

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

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

Correction Narrative: An HM extension was approved effective 4/1/2025.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 10/01/2025.


raw_content: The operation did not report two children in care's unauthorized absences to their CVS workers within the required time frame by minimum standards.

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

Correction Narrative: Email received from the operation: "THE CORRECTIONS THAT WE MAKE MOVING FORWARD WILL BE TO CALL, TEXT AND/ OR EMAIL THE CASEWORKER THE SAME TIME WE CALL INTAKE. WE HAD A MEETING AND DISCUSSED THIS PROCESS WITH ALL STAFF."


summary: 748.303(a)(6)(B) - Serious Incident-Report to parents as soon as facility aware that child is indicted, charged, or arrested

raw_content: During the investigation, it was learned that the operation failed to notify the conservator of the child timely. Notification was not made about the incident until the following day.

Correction Narrative: Director sent email stating they will email and call the case worker whether the youth is detained or arrested. This was discussed with all staff.


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

raw_content: There was no documentation indicating that a debriefing took place with all of the required components according to the minimum standards.

Correction Narrative: Email received from the operation with a new form for the Runaway Report and Debriefing Report. Form meets all components required.


summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content: The operation reports they were unaware staff was required to complete an annual suicide prevention training.

Correction Narrative:
Training certificates for staff members were sent and reviewed.

 Email received from the operation: "Our corrective action moving forward is to make sure that all direct care staff will be trained annually on suicide prevention."


raw_content:
During a review conducted on September 30, 2024, it was determined that:

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

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

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

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

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

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

Correction Narrative: An HM extension was approved effective 9/30/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 3/30/2025.


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

raw_content: During a review of incident reports and runaway incident reports, on multiple records the documentation was incomplete.

Correction Narrative: This standard was evaluated and found to be compliant.


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

raw_content: The operation failed to employ a licensed administrator within the 120-day allotted timeframe.

Correction Narrative: The operation hired an administrator that was present during Inspection #4017860 on 09/03/2024.


raw_content: The operation failed to employ a licensed administrator within the 90-day allotted timeframe.

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


summary: 748.463(e) - Unauthorized Absence Eval-results of each overall operation eval for unauth absences must be avb to CCR for review and reproduction upon request

raw_content: The operation was not able the triggered reviews and stated they are not required to complete triggered reviews.

Correction Narrative:
Received the following email from the operation:
CORRECTIVE ACTION
On 08/12/24 RCCL came out to conduct an investigation : It is alleged that children in care being inappropriately supervised.
Standard # 748.463(e) Unauthorized Absence Evaluation -results of each overall operation evaluation for unauthorized absences must be available to CCR for review and reproduction upon request.
Corrective Action: Adiee has created an unauthorized absence log that covers: the child name; time he left; time he returned; and the facility will be using form 3300 to document the trigger review and post action upon the residents return. All unauthorized absences will be documented on each child that is out of area.


raw_content: The operation failed to employ a licensed administrator within the 60-day allotted timeframe.


summary: 748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child

raw_content: The caregiver did not have any type of discussion after the incident with the child.

Correction Narrative: I, RCCL Inspector Michonne Chandler received an email from the operation with a corrective action plan from the operation's case manager stating the following. A training was conducted on documenting serious incident reporting and the form that the facility uses to document the EBI's on was covered in its entirety. Training was conducted on 6/19/2024. A copy of this form is attached to this corrective plan. This form will be attached in the Document Library.


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

raw_content: There was an indication that containment was required in the serious incident report, but the operation did not complete a restraint report.


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

raw_content: The operation staff confirmed they do not conduct triggered reviews following 3 unauthorized absences within a 60-day timeframe.

Correction Narrative:
CORRECTIVE ACTION
Licensing officials recently investigated at our facility regarding Serious Incident. After their thorough examination, it was determined that Adiee Emergency Shelter failed to meet the minimum standard 748.303(a)(10)(A) For Serious Incident Reporting; Minimum Standard: 748,457(a): 748.455(a) Specifically, it was found that caregivers did not report the incident in a timely manner; there was no trigger review conducted after the third occurrence; and the child was not debriefing upon his return.
To rectify these deficiencies and ensure the safety and well-being of all children, Adiee Emergency Shelter will undertake the following corrective actions.
1. Review and Update Policies: We will carefully evaluate our current policies concerning Serious Incident Reporting; Trigger Reviews, and debriefing the children upon their return. We will ensure that these policies align with best practices, local laws, and regulations. If necessary, we will make updates to clearly emphasize the importance of reporting in a timely manner; trigger review after the third occurrence; and debriefing the children upon there return.
2. Training and Education: Comprehensive training will be provided to all staff members involved in the reporting of serious incidents; trigger reviews; and debriefing the children upon their return. This training will cover important topics such as how, when, where and who you report the serious incident report. The time that you are supposed to report the unauthorized absence, who you call to report the unauthorized absence and how to write the reported information correctly.
3. Clear Guidelines: We will develop clear guidelines and protocols for staff to follow when reporting a serious incident; trigger reviews, and unauthorized absence. These guidelines will strongly encourage the importance of reporting serious incident report; trigger reviews; and unauthorized absences. We will ensure that these guidelines are easily accessible, well-communicated, and regularly reviewed with all staff members.
4. Continuous Supervision: We will implement a system of continuous supervision, where staff members will actively monitor and assess the completion of all paperwork required for the task at hand. This proactive approach will allow the facility to ensure that all documentation is being reviewed.
5. Reporting and Documentation: Establish a clear procedure for reporting and documenting instances where Serious Incident reporting: Trigger reviews, and unauthorized absence occur. We will do everything in our power to ensure that all children receive the utmost care and protection they deserve.


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

raw_content: The operation failed to report the serious incident after the children AWOL

Correction Narrative:
Subject: Corrective Action
CORRECTIVE ACTION
Licensing officials recently investigated at our facility regarding Serious Incident. After their thorough examination, it was determined that Adiee Emergency Shelter failed to meet the minimum standard 748.303(a)(10)(A) For Serious Incident Reporting; Minimum Standard: 748,457(a): 748.455(a) Specifically, it was found that caregivers did not report the incident in a timely manner; there was no trigger review conducted after the third occurrence; and the child was not debriefing upon his return.
To rectify these deficiencies and ensure the safety and well-being of all children, Adiee Emergency Shelter will undertake the following corrective actions.
1. Review and Update Policies: We will carefully evaluate our current policies concerning Serious Incident Reporting; Trigger Reviews, and debriefing the children upon their return. We will ensure that these policies align with best practices, local laws, and regulations. If necessary, we will make updates to clearly emphasize the importance of reporting in a timely manner; trigger review after the third occurrence; and debriefing the children upon there return.
2. Training and Education: Comprehensive training will be provided to all staff members involved in the reporting of serious incidents; trigger reviews; and debriefing the children upon their return. This training will cover important topics such as how, when, where and who you report the serious incident report. The time that you are supposed to report the unauthorized absence, who you call to report the unauthorized absence and how to write the reported information correctly.
3. Clear Guidelines: We will develop clear guidelines and protocols for staff to follow when reporting a serious incident; trigger reviews, and unauthorized absence. These guidelines will strongly encourage the importance of reporting serious incident report; trigger reviews; and unauthorized absences. We will ensure that these guidelines are easily accessible, well-communicated, and regularly reviewed with all staff members.
4. Continuous Supervision: We will implement a system of continuous supervision, where staff members will actively monitor and assess the completion of all paperwork required for the task at hand. This proactive approach will allow the facility to ensure that all documentation is being reviewed.
5. Reporting and Documentation: Establish a clear procedure for reporting and documenting instances where Serious Incident reporting: Trigger reviews, and unauthorized absence occur. We will do everything in our power to ensure that all children receive the utmost care and protection they deserve.


raw_content: Operation staff confirmed that they do not debrief the children following serious incidents.

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


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

raw_content: During the inspection, it was found that there is no incident report regarding the unauthorized absence that took place on March 14, 2024

Correction Narrative:
Received the following email from the operation:

CORRECTIVE ACTION
On March 14,2024 RCCL came to do an unannounced visit and the following deficiency was cited Standard: 748.311: Serious Incident Documentation -Documented in written report.
Corrective Action-  Adiee Shelter will ensure that all unauthorized absence are documented on a Serious Incident report. The facility also has in place a unauthorized absence log, so that each unauthorized absence is documented in the log so each occurrence is documented. The information on the log contain: the name of the child; the date of the occurrence; what time the child left; what time the child returned; who was contacted about the child absence; the intake individual ID #; the name of the intake person; police officer ID#; the police officer name; and the Case #. This process has been initiated immediately. The Executive Director will ensure that this process is implemented.


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

raw_content: During the inspection, it was observed that the AWOL annual summary log did not display the proper information.

Correction Narrative:
The following email was received from the operation's owner:
"CORRECTIVE ACTION
On 04/10/2024 RCCL came to do an unannounced investigation on an alleged case of medical care and reporting serious incidents. The Minimum Standards that were found deficient was as follows:
standard 748.453(a)(2) Unauthorized Absence Annual Summary Log
Corrective Action: Administrator will ensure that all staff will be trained on recording Unauthorized Absences and documentation to the logbook by June 1, 2024

Thank you,
[Redacted] / Owner"
Additionally, a sign in sheet was provided for the training.


raw_content:
During a review conducted on March 26, 2024, it was determined that:

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

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

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

Further details of the failure of your operations administrator to ensure compliance include the following:
- Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s).

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

Correction Narrative: An HM extension was approved effective 3/26/2024.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 9/27/2024.


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: The medication logs for two children could not be provided.

Correction Narrative:
I received an email from the operation stating "all residents being discharged will have their discharge and medication paperwork scanned upon discharge and filed.

5/7/24 - Received a message requesting more information for compliance to be met. I emailed the operation and asked if they could provide additional information on how they plan to prevent medication logs from going missing.


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

raw_content: During the review of the summary log it was noted that the incident that occurred on 03/14/24 involving a child jumping from the second floor window and leaving unbeknownst staff was not recorded on the log.

Correction Narrative:
Response received from the operation:
Corrective Action: Administrator will ensure that all staff will be trained on recording Unauthorized Absences and documentation to the logbook by June 1, 2024.


raw_content: During the review of the incident report, it was noted that there was no report for March 12, 2024.

Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report


raw_content: During the course of the inspection, it was determined that the adminstrator does not maintain full time hours.

Correction Narrative:
On 03/28/2024, I received the following email from the operation:

"On March 1,2024 RCCL came to do an unannounced visit and the following deficiency was cited Standard: 748.151(1) Operational responsibilities- Designate a qualified full-time child-care administrator.
Corrective Action-  Adiee Shelter will actively start searching for a License Childcare Administrator. [The administrator's] last day will be April 11,2024. In the interim of finding an Administrator [the owner] with the assistance of the Case Manager will oversee the day - today operation of the business of Adiee Shelter. If there are any question, please contact [the owner]."

During an inspection on 04/01/2024, the operation stated that they are developing [a co-owner], and preparing him to test for his LCCA License, but continuing the search online via a job-seeking website, depending on how long the process takes.

No concerns.


raw_content: During a Heightened Monitoring Inspection, it was found that an incident of three children running away from the operation was not reported to licensing until 9 hours after the incident occured.

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

Correction Narrative:
I received the following email from the operation on 12/29/2023:

"Corrective Action: The administration will carry out a retraining session on the correct procedure for promptly reporting to licensing when a child has left our facility without permission.

1. Organize a training session on how to handle situations involving a runaway child.
2. Make sure the staff is fully informed about the age restrictions of our youth and the required waiting period before we report a runaway child to licensing.
3. Ensure our staff is aware of when to contact our local authorities in the event of a child running away.

By implementing these steps, we can ensure that our organization is well-structured, organized, and knowledgeable, ensuring us to work cohesively as a team."


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

raw_content: The victim child and several children who witnessed the restraint indicated that the staff used more physical force than required while conducting the restraint.

Correction Narrative:
I, Andrew Ward, received the following email from Eric Harris:

Licensing officials recently investigated at our facility regarding a two-person restraint that was performed on a child. After their thorough examination, it was determined that Adiee Emergency Shelter failed to meet the minimum standard 748.2551 (c) (2) for EBI implementation. Specifically, it was found that caregivers did not use the minimal amount of reasonable and necessary physical force.

To rectify this deficiency and ensure the safety and well-being of all children, RCC will undertake the following corrective actions.

1. Review and Update Policies: We will carefully evaluate our current policies concerning physical force used during child restraints. We will ensure that these policies align with best practices, local laws, and regulations. If necessary, we will make updates to clearly emphasize the importance of minimal force and prioritize the child's safety.

2. Training and Education: Comprehensive training will be provided to all staff members involved in restraining children. This training will cover important topics such as child development, de-escalation techniques, and alternative methods of restraint that do not involve physical force. Staff members will be educated on the potential risks of excessive force and the vital importance of using the least amount of physical force necessary.

3. Clear Guidelines: We will develop clear guidelines and protocols for staff to follow when restraining a child. These guidelines will strongly encourage the use of non-physical techniques whenever possible. They will also outline the specific circumstances in which physical force may be deemed necessary. We will ensure that these guidelines are easily accessible, well-communicated, and regularly reviewed with all staff members.

4. Continuous Supervision: We will implement a system of continuous supervision, where staff members will actively monitor and assess a restrained child's behavior and needs. This proactive approach will allow for early intervention and minimize the need for physical force.

5. Regular Evaluation and Feedback: Conduct regular evaluations of staff performance and provide constructive feedback. Encourage open communication to address any concerns or questions regarding the use of physical force on child restraints. This will help maintain accountability and ensure that staff members are consistently following the established guidelines.

6. Reporting and Documentation: Establish a clear procedure for reporting and documenting instances where physical force is used on a child restraint. This will help identify any patterns or area.

implementing these corrective actions will enhance the safety and well-being of the children under our care. We fully understand the importance of using only the minimal amount of reasonable and necessary physical force. We will do everything in our power to ensure that all children receive the utmost care and protection they deserve.


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

raw_content: Medication logs reviewed did not have an accurate count, in addition the medication that was administered last night was not fully documented as the staff did not sign the log for the 7pm dose on 10/24/23 as required per the minimum standards.

Correction Narrative: A medication error sheet was added to each resident's medication log so that all medication errors can be documented and reported in a timely manner. Medication logs have the resident name, time and date of error, name of medication, type of error, and signature slots for staff and children. The operation also identified key staff to administer medications and retrained those staff.


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

raw_content: There is no medication error protocol or documentation regarding children who have missed a dose of medication.

Correction Narrative: The operation update medication records to include the following documentation: The child's name, prescription number, the prescribing physician, medication name, instructions, date/day of week/month/year, side effects, why the medication is administered, the name and address of the pharmacy, the medication count, whether the child refused or took the medication, and a signature slot for both the child and staff member. The operation also identified key staff to administer medications and retrained those staff.


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

raw_content: Children in care are running out of medication and miss doses of medication until the operation is able to get a refill.

Correction Narrative:
The following email was received from Adiee Emergency Shelter:
We acknowledge the seriousness of this issue and the violation of Minimum Standard 748.2003(b)(3) regarding the administration of prescription medication. We are committed to ensuring the health and well-being of all children in our care and understand the importance of administering medication according to instructions or a prescribing healthcare professional's order.

In response to this, we have implemented a corrective action plan. The LCCA will ensure all children in our care do not miss doses of medication. The following measures have been put in place:

1. The case worker is no longer allowed to leave the resident at the facility without 30 days of medication.
2. Placement agencies have been notified of the final changes to the intake process when placement is occurring with the child.
3. If the child does not have the proper amount of medication, the placement will be denied until the medication is received.

In addition, the medication is currently being counted by the incoming staff with the staff that is present at shift change. We have also requested that placement agencies do not send children to the facility with less than 30 days of medication.

Currently, the medication is correct for all our residents. We believe these measures will ensure that our residents do not miss their medication and that we follow all relevant standards.

During a Heightened Monitoring Inspection conducted 12/11/2023, medications were counted, and documentation was reviewed. The standard was found to be in compliance.


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

raw_content:
During a review conducted on September 25, 2023, it was determined that:

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

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

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

Further details of the failure of your operations administrator to ensure compliance include the following:

-	Your operation received a Medium-High weighted citation in a pattern/trend category on March 31, 2023. Specifically, the operation was cited for 748.3353(c)- Monitoring Devices. The operation met compliance April 13, 2023.

-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and

-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

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

Correction Narrative: An HM extension was approved effective 9/25/2023.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your CPA/GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 3/26/2024.


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 caregiver neglectfully supervised multiple children in care when she transported them in the trunk of a vehicle.

Correction Narrative: Employee involved in the interaction with the children was terminated immediately (05/08/2023). The administrator ensured that all employees were updated on the transportation policy, and how to supervise while transporting children on 10/13/2023.


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 found that a caregiver failed to exercise prudent judgement in the presence of children when the caregiver failed to actively search for children in the vicinity from which they had gone missing and when the caregiver transported children in the trunk of a vehicle.

Correction Narrative: Employee involved in the interaction with the children was terminated immediately. (05/08/2023). The administrator ensured that all employees were trained on the procedures of how and when to report. A copy of the AWOL policy was attached with this email.


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

raw_content: During the investigation it was found that six children and one caregiver went on an outing in a vehicle that had five seatbealts.

Correction Narrative: The Administrator ensured that all staff members are of aware of how to transport children in care, specifically on not exceeding capacity of seatbelts. This review was completed on 10/13/2023.


summary: 748.2307(13) - Other Prohibited Punishments-denying basic child rights as discipline or punishment

raw_content: During the investigation, multiple children were not allowed to back inside the facility following a short period of unauthorized absence.

Correction Narrative: The employee involved in the interaction with the children was terminated immediately (05/08/2023). Going forward all employees will be advised on how to handle situations that prudent judgement is necessary to be used. The administrator ensured all employees were retrained on children's rights on 10/13/2023. Training sign-in sheet revieiwed.


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

raw_content: The operation failed to follow their own policy when they transported children without the use of seatbelts and when they failed to report several children's unauthorized absences from the facility within the timeframes required by their policy.

Correction Narrative: The administrator ensured that Adiee's policy to never transport children without seatbelts was reviewed by staff. All staff members have had a refresher training on Adiee Transportation policy. A copy of the policy and signature seat was reviewed. All vehicles were provided a transportation binder that includes transportation logs, policy, medical information, phone numbers, and the AWOL policy.


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

raw_content: During the investigation it was found that a child's (with a history of unauthorized absences) preliminary service plan failed to address their supervision needs.

Correction Narrative: The administrator of Adiee Shelter reviewed each child's preliminary service plan to ensure all children's individual supervision needs were addressed and documented in the child's preliminary service plan.


summary: 748.3353(c) - Monitoring Devices-Video cameras may not be used to tape the child, and images may not be accessible except to operation employees and caregivers

raw_content: A child in care was able to access the operation's camera system to review the previous altercation he had with another resident. This caused him to re-escalate and try to fight a second time.

Correction Narrative: ADIEE will continue to change the passcode to the camera panel. Staff will continue to monitor residents to ensure that they are not engaging in any physical altercations. ADIEE will place a plastic covering over the panel to add an extra step of security to protect access to the box. We are open to any further suggestions.


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

raw_content: It was observed that the needle of the fire extinguisher on the second floor of the facility was not in the green zone.

Correction Narrative:
 The fire extinguisher will be service by Fire Equipment Comex Fire & Safety on
OL/7712023. Phone # 281-491-1783.


summary: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

raw_content: Discharge summary was not completed for child who was discharged on 06/26/2022.

Correction Narrative:
The operation emailed the following corrective action: The facility will keep all documents of discharge of the children on file, with all
accurate information on the document.


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

raw_content: It was observed before todays HM inspection that the facility did not have Passed fire inspection. However, the facility was able to provide me with a copy of a recent Fire Inspection which is marked as Pass by Rosenberg Fire Department during my Inspection today.


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

raw_content: During audit of medication sheet today, it was observed that a child on medication has not been able to take his sertraline HCL 50mg medication since 11-2-22 and also has not taking his Sertraline HCL 100mg medication since 11-6-22 because the child is out of medication. Sertraline HCL 100 mg was taken last on 11-5-22 and Sertraline HCL 50mg was taken last on 11-1-22. However, the facility was able to get a refill of the medications from the pharmacy during my inspection.


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

raw_content: The operation did not have an annual summary log available for review and reproduction upon request.

Correction Narrative: Operation provided the summary log


raw_content: A child in care did not take his medication as prescribed for his morning dose of medication.

Standard Number / Description: 748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed


raw_content: There was no discharge summary in the inactive child file.

Standard Number / Description: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

Correction Narrative: Administrator / Administrator assistant will ensure that discharge documentation for both programs (TEP Included) will be included in the client files and will include the dates and circumstances surrounding the discharge or transfer.


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

raw_content: The operation did not have an annual summary log.

Correction Narrative: The operation sent over a AWOL log and stated they will continue to use that format in the future.


summary: 745.621(b)(1)(B) - AP Renewal background checks submitted -No later than 2 yrs from date you last submitted subjects initial or renewal name-based TX criminal hist check

Correction Narrative:
One staff member who supervises children in care did not have an active background check with the operation.

It appears that we ran Mr. McClain but did not hit the submit button in order for the information to be submitted.

Moving forward to ensure that we have submitted the background check for processing, we will print out the confirmation page after submission and keep as a part of our employee records.

We immediately ran Mr. McClain's background and it was returned back as eligible. Our case manager and administrator will ensure this is followed to reduce the room for error.


summary: 748.881(3) - General pre-service training curriculum-Includes procedures to follow in emergencies

raw_content: Both of the staff records evaluated were missing the emergency procedures in the pre-service curriculum.

Category: Training and Professional Development


summary: 748.981(a)(1) - First-aid-CPR training-Each caregiver must have current certification in first-aid

raw_content: One of the two employee records evaluated did not have first-aid / cpr documentation


summary: 748.4207(a)(2) - Placement Extension-if there is appropriate reason for continuing care, a child five or older may continue placement for a total of 90 days

raw_content: One child in care has been at the operation for longer than 90 days.


summary: 748.881(4) - General pre-service training curriculum-Includes steps to preventing the spread of communicable diseases

raw_content: All of the staff records evaluated were missing communicable diseases training.


summary: 748.881(5) - General pre-service training curriculum-Includes location and use of fire extinguishers and first aid equipment

raw_content: Both of the employee records evaluated did not contain training regarding the fire extinguishers nor first aid equipment.


summary: 748.881(1) - General pre-service training curriculum-Includes topics appropriate to the needs of children for whom the caregiver will be providing care

raw_content: Both of the staff records evaluated did not address the topics appropriate to the needs of the children in care in their pre-service curriculum.


summary: 748.941(d) - Training Criteria-A health-care professional or a pharmacist must lead the training in administering psychotropic medication.

raw_content: Both of the staff records evaluated were missing the second half of psychotropic medication training that must be instructor led.


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

raw_content: Both of the staff records evaluated did not have a document showing the results of their TB screening in their records.

Category: Personnel


summary: 748.831(a)(3) - Orientation-Orientation must include the needs and characteristics of children that the operation serves

raw_content: Both employee records evaluated did not address the characteristics of children in the orientation.


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

raw_content: One of the children records evaluated had an inaccurate count.

Category: Medication


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

raw_content: There was no restraint documentation provided.

Correction Narrative:
*Correction  Restraint report has been written and filed in client file. Staff has been counseled with on the importance of documentation regarding restraints that last over 1 minute. ADIEE has a new administrator that is scheduling a re-train on restraints and documentation with all staff.
NOTE: the administrator that was here at the time is no longer employed with ADIEE.


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

raw_content: The operation failed to provide a written serious incident report.

Correction Narrative: The operation sent the required document. They operation stated that the document was there but their computer was not allowing it to be sent.


summary: 748.1337(b) - Initial Service Plan-Document in child's record and include preliminary service plan requirements

raw_content: The operation failed to provide Initial service plan documents for two children previously in their care.

Correction Narrative: The operation sent the required documents.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: The operation did not report that a resident was arrested.

Correction Narrative:
Correction: Staff will document on a serious incident report if and when clients engage in altercations. Staff will contact abuse and neglect to report serious incident. Administrator and case manager will follow up to ensure that this is taking care of in the allotted time from.
NOTE: we contacted licensing to confirm the incident number and was given: Report ID#76467345 Stephanie #5088 for documentation purposes.


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

raw_content: Two fire extinguishers were observed to be expired as of February '22 and one lacked an inspection tag.

Correction Narrative:
748.3115(3)
Fire Extinguisher-Must ensure fire extinguishers are serviced as required by manufacturer's instructions, or as required by fire inspector
	Two fire extinguishers were observed to be expired as of February 22 and one lacked an inspection tag	Per minimum standards and polices and procedures of the organization will receive annually inspections in a timely manner.	Ongoing

Photos of the updated  fire extinguisher .


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

Correction Narrative:
748.2003(b)(5)
Administration of prescription medication-Ensure the child has taken the medication as prescribed	A child in care was not provided two different medications for multiple days.	Administration staff will continue Q & A medications on a weekly basis and order refill medication in a timely manner.	Ongoing


summary: 748.1223(a) - Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available

raw_content: The medical exam for a child in care was conducted -- days after admission.

Correction Narrative:
748.1223(a)
Admission-Medical exam by health-care professional within 30 days after admission, unless documentation of medical exam within past year available
	The medical exam for a child in care was conducted days after admission.	Per minimum standards and polices and procedures of the organization administration staff will schedule medical appointments in a timely manner.	Ongoing


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

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

	The initial service plan required for a child in care was not completed within the 45 days.	Per minimum standards and policies and procedures of the organization initial reports for youth in care will be completed in a timely manner.	Ongoing
service plan sent


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

raw_content: Two child files reviewed did not contain a preliminary service plan in their file. One child file reviewed did not have an initial service plan in their file.

Correction Narrative: The operation sent the following corrections: Per minimum standards records will be available and accessible to licensing. Completed documents will be filed in youth chart in a timely manner.


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

raw_content:
One staff file reviewed did not contain a signed statement stating he will immediately report suspected child abuse, neglect, or exploitation.
One staff file reviewed did not have a job description.


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

raw_content: One child's service plan reviewed contained inaccurate information in several areas.

Correction Narrative: The operation sent the correct service plan. They stated that they had the correct information but sent the wrong copy. Ms. Staci informed me that they will now download the information on to a drive to ensure they have no data mixed up.


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

raw_content: Children and staff witnessed a staff use their body weight to restrict a child's movements.

Correction Narrative:
An inspection was also conducted for these concerns.
INSPECTION #3874001
Staff will be refreshed on EBI and safety of youth in care.
Timeline:When needed, and per minimum standards and the policies and procedures of the organization a mandatory 4 hour training every six months


summary: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso

raw_content: A child's movements were restricted by a staff holding him across the chest from behind, and then staff using their hands to hold him against the wall.

Correction Narrative:
INSPECTION #3874001
Staff will be refreshed on EBI and safety of youth in care.
Timeline: When needed, and per minimum standards and the policies and procedures of the organization a mandatory 4 hour training every six months


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

raw_content: Two children in care restrained two other children in care.

Correction Narrative:
INSPECTION #3874001
Staff will be refreshed on EBI and safety of youth in care
Timeline: When needed, and per minimum standards and the policies and procedures of the organization a mandatory 4 hour training every six months


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

raw_content: A staff was downstairs of the facility while all of the children were upstairs awake and a fight ensued.

Correction Narrative: Per minimum standards and polices and procedures of the organization staff will be refreshed on supervision. Staff will be accountable for ratio during awake hours to ensure the safety of the children. Timeline: on going


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

raw_content: A child's movements were restricted after refusing to go to bed.

Correction Narrative:
INSPECTION #3874001
Staff will be refreshed on EBI and safety of youth in care
When needed, and per minimum standards and the policies and procedures of the organization a mandatory 4 hour training every six months


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

raw_content: One out of four youth files reviewed did not contain an acknowledgement signed by the youth of their rights.


summary: 748.4207(a)(2) - Placement Extension-if there is appropriate reason for continuing care, a child five or older may continue placement for a total of 90 days

raw_content: Two children in care have been in placement past their maximum 90 day mark and without the proper extension paperwork.


summary: 748.1269(a) - Emergency Admission-Complete all requirements for an admission assessment within 40 days of admission

raw_content: one out of the four children records reviewed did not contain their admission assessments.

Category: Admission, Service Planning, Discharge

Correction Narrative:
-Plan
Admission assessment will be completed in a timely manner.
Timeline: Ongoing


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

raw_content: One out of two serious incident reports reviewed did not indicate which staff were involved in the incident.

Category: Reports and Record Keeping


summary: 748.1209(b)(10) - Child Orientation-Include policies on trips away from the operation

raw_content: All of the children records reviewed had orientation documents that did not address trips away from the operation.

Correction Narrative:
During orientation the section regarding trips will be discussed with the youth and caseworker during intake.
Timeline: Ongoing.


summary: 748.4211(a) - Placement Extension-Must document reason for continuing emergency care services in child's record by 16th day that child is in care

raw_content: Three out of four youth files reviewed did not contain paperwork explaining the youth's reason for placement extension.


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

raw_content: None of the first aid kits observed contained cotton balls.

Category: Safety and Emergency Practices

Correction Narrative:
-Plan
The first aid kits will be checked weekly to assure they are fully stocked and all the necessary material is included.
Timeline: Ongoing


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

raw_content: None of the first aid kits observed contained a thermometer.


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

raw_content: One out of four youth files reviewed did not contain documentation to indicate the youth had received an orientation.


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

raw_content: All the children records reviewed did not contain a preliminary service plan.

Correction Narrative:
-Plan
Preliminary Service Plan will be completed in a timely manner.
Timeline: Ongoing


summary: 748.1209(b)(9) - Child Orientation-Include policies on the educational program

raw_content: All the children records had orientation documents that did not address the education program.

Correction Narrative:
-Plan
Prior to intake we will gather the previous education needs and implement into his services, and update if any current services are needed.
-Timeline: Ongoing


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

raw_content: The first aid kits observed did not contain scissors.


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

raw_content: three children's medication logs were observed with count errors.


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

raw_content: During the inspection food was observed on the counter uncovered waiting to be eaten by children. Flies were also present in the kitchen.


summary: 748.153(3)(A) - Notification - Change in child-care administrator

raw_content: The operation hired a new administrator and failed to notify licensing. They have had a new administrator since 07/06/2021.


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

raw_content: During the walk through there were 6 mattresses that did not have protectors on them. Pictures were taken.

Correction Narrative: During a walk through the mattress protectors were observed on all the beds.


raw_content: Five children's medication logs were observed with count errors.

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


facility_name: Moving Forward

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

raw_content: A locked used by children displayed inappropriate content.

Category: Physical Site

Correction Narrative: Compliance was met when the administrator sent a photo of the locker being cleaned. There is no longer any inappropriate content or any content on it at all.


summary: 748.913(a) - CPR Training- Must adhere to AHA guidelines & include curr. that incudes use of a CPR manikin & written & hands-on instruction/practice & testing

raw_content: The CPR trainings certificates show that the organization used is National CPR foundation which only offers online trainings.

Correction Narrative: Compliance was met when the administrator sent the training certificates for CPR/First Aid showing that all staff received in-person training on 3/16/26.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: Police responded to a GRO due to a serious incident that a child could have had criminal charges pressed against them.

Correction Narrative: Compliance was met when the administrator sent an email confirming that she reviewed this standard with the staff and conducted a training for the staff.


raw_content: While reviewing medication logs, it was discovered that the pill count on a child's medication log did not match the number of pills in the medication bottle.


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: Prescribed medication was not being administered to child as per health care professional orders.


raw_content: One bedroom has a blind with broken slats and a hole in the door. Another bedroom has a hole in the closet and writing on the wall.

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

Correction Narrative:
In Room 1 a picture was taken of the hole in the closet being repaired. In Room 1 a picture was taken of the writing on the wall being cover.

In Room 2 a picture was taken of the blinds being repaired and the hole in the door.

 In Room 2 a picture was taken of the blind and hole in the door being repair.


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

raw_content: Service plan did not include a plan to address the three high-risk behaviors documented.

Correction Narrative: An email was received from the administrator addressing the three high-risk behaviors. The administrator stated that the operation will ensure that the high-risk behaviors are documented in all service plans. High-risk behaviors will be staff with staff prior to the plan to ensure it is being implemented. The service plan can be found in the document library.


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

raw_content: Four of four staff interviewed were not aware of the operation's policies and procedures regarding searches.

Correction Narrative: A meeting was conducted on 3/18/2024 at the operation. Each staff sign a memo stating that they understand the policies and procedures regarding searches. The signature page can be found in the document library.


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

raw_content: The operation was not following safety requirements listed in a child's service plan. The operation allowed a child in care to possess a sharp object and have access to social media.

Correction Narrative: The operation conducted a meeting with each staff member on 3/18/2024. Each signed the memo stating that they will read, understand and implement and follow all the information listed on each child service plan. The signature page can be found in document libaray.


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

raw_content: An initial service plan did not include all required signatures of the service planning team.

Correction Narrative: I, RCCR Tommie Moore received a copy of the initial service plan with all required signatures. The initial service plan can be found in the document library.


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

raw_content: The child's age, gender and date of admission was missing in eight of the eight serious incident reports reviewed.

Correction Narrative: An email was sent from the case manager showing eight of the eight serious incidents reports with child's age, gender and date of admission on each report. Each serious incident report can be found in the document library.


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

raw_content: Five children were administrator medications at the wrong time. Medications log was not documented correctly. Medications log shows that medications were administer at 8:00 PM. Medications  and medications log were review at 7:38 PM.

Correction Narrative: Five children were administrator medications in a timely manner. During the inspection staff was observed recieving medcations.


raw_content: Information gathered indicates that the operation failed to give a child in care the prescribed dosage of 1 ½ tablets (75mg) of Seroquel on 09/21/2022. The medication log shows the child was administered 1 (50mg) tablet instead.

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

Correction Narrative: A follow-up inspection was conducted. Medication was compliance with the medication orders.


summary: 748.455(a)(2) - Unauthorized AbsenceDebrief include trauma informed strategies child can use to avoid future unauth absences & how op. can support strategies

raw_content: Two unauthorized debriefing forms were reviewed, and they did not document the trauma strategies that a child can use to avoid any future runaway behaviors.

Correction Narrative: The facility created a form to hold staff if accountable to ensure that when a child informs staff that they have urges to abscond from the facility, the Moving Forward Staff will utilize the trauma informed strategies so that they can avoid absconding from the facility.  When the staff completed the Unauthorized Debriefing form, they will list the strategies used to assist the youth with not absconding from the facility. Even if the youth refused to utilize the strategies, the staff will document the strategies that were used to assist the youth with changing their mind to abscond from the facility without out permission. The staff will also document on the Unauthorized-Debrief form that the youth refused to utilize the strategies. The administrator stated that staff was made aware of the changes by having a meeting with all personnel.


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

raw_content: One of the service plans reviewed was not signed by the child in care.

Correction Narrative: The facility created a form to hold staff if accountable to ensure the youth Service Plan is signed by the youth once completed by the Case Manager. If the youth refuses to sign Moving Forward staff will document the youth's refusal to sign the Service Plan.  The Moving Forward staff will inform the youth's Case Manager of the refusal to sign. The administrator stated that staff was made aware of the form during a meeting the first week of May.


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

raw_content: 2 children records were review and both did not have dates entered on the unauthorized log summary for how long they were away from the operation.

Correction Narrative: An email was received from the administrator. The administrator stated that the two children who did not have dates entered on the unauthorized log were discharge from the facility. The administrator stated that both kids never returned to the operation. The kids were discharged from the operation. The discharge notices can be found in the share drive.


summary: 748.463(c)(2) - Unauthorized Absence Evaluation must include specific trauma informed strategies to reduce the number of unauthorized absences at operation

raw_content:
The operation did not meet criteria for 2022 unauthorized absence evaluation.

Compliance was met the operation provided documentation for 2023.


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: 1 out of 5 children did not have their child rights sign in their file.

Category: Children's Rights

Correction Narrative: I received an email from the administrator showing that the child did sign the child rights form. The form can be found in the share drive.


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

raw_content: The operation did not receive written consent from the child's conservator before allowing a physician to change the child's psychotropic medication.

Correction Narrative: The operation provided documentation from the physician for that child's medication change and has obtained written consent for this change from the medical consenter. The signed document from the medical consenter was completed and signed on 12/2/2022. This document was provided to licensing for review.


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:
Child records reviewed did not contain any medication logs.

One child does not have any medication logs for one medication.

One child's total medication count on the medication log did not match the medication remaining in the container.

Medication logs do not have the signatures of staff and only have initials.

Correction Narrative:
The agency has submitted a written plan for compliance that includes their policy for staff placing medication logs in the child records each month and to include staff signatures on medication logs. A photo and documentation were also provided of a child's medication to show that the medication count is accurate.
On 12/13/2022 a follow-up inspection was conducted at the operation. Completed medication logs are now located in the child files. The missing medication log was found and observed to be accurate.


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

raw_content: The first aid kit in the vehicle used for transporting children in care does not contain tape, scissors, thermometer, tweezers or disposable loves.

Correction Narrative: The operation's director sent an email to licensing with photos of two complete first aid kits that have been purchased for the operation.


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

raw_content: Caregiver did not follow the operation's policies that states staff cannot sleep during their shift.

Correction Narrative: The operation's management staff conducted additional training on the minimum standard requirements and the operation's policy which states "At no time should staff be asleep during their shift" and staff should have audio and visual supervision of all children in care while both at the operation and accompanying children away from the operation. Staff were provided with a document to sign stating that they agree to follow this policy and understand that violating this policy will result in corrective action, sanctions and/or termination from the operation. The operation provided a copy and accompanying staff signatures for review.


raw_content: Caregiver did not follow the service plans of children in care that require 24 hours supervision and 15 minute bed checks during sleeping hours.

Standard Number / Description: 748.685(c)(6) - Implement and follow the children's service plans.

Correction Narrative: The operation's management staff conducted additional training on the requirements for following the initial service plans requirements for children in care. All staff were provided with a document stating that they agree to follow the operation's policy requiring 24 hour monitoring of all children in care at the operation; which includes staggered, visual checks on all children no more than 15 minutes apart and every child's specific supervision requirements, and they understand that failure to do so will result in corrective action, sanctions or termination from the operation. The operation provided a copy and accompanying staff signatures for review.


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

raw_content: Children in care had possession of a vape pen and used the vape while residing at the operation.

Correction Narrative: The operation's management staff conducted additional training on the minimum standard requirements and the operation's policy for e-cigarette and tobacco usage at the operation. All staff are no prohibited from possessing any e-cigarettes/vapes or tobacco products on their person while on duty; all products will remain in the staff's personal vehicle while on duty. All staff were provided with a document stating that they agree to follow the operation's policy and minimum standards regarding e-cigarette and tobacco usage, and they understand that failure to do so will result in corrective action, sanctions or termination from the operation. The operation provided a copy and accompanying staff signatures for review.


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

raw_content: A caregiver did not exercise prudent judgement when they provided a vape pen to two children in care.


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

raw_content: A child in care was able to access and ingest a staff member's prescription medication.

Correction Narrative: A follow-up inspection was conducted at the operation. Medication storage was found to be triple locked behind the office door. The staff member involved in the incident is no longer bringing medication into the operation and has signed the agency new policy on staff medication storage. The agency's administrator emailed a copy of the new policy that all staff are required to review and sign stating all staff personal items should be stored in a secure location. If staff cannot lock their personal items in their car, then they should be locked in the closet in the office on the 2nd Floor. If any staff has medication that they have to take while at work, only bring enough medication that will be needed during the shift. The medication should placed in a pill container marked for staff only and locked in the closet in the office on the 2nd Floor.


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

raw_content: A child had a safety plan in place due to behaviors, that required being checked on every 15 minutes. The caregivers were not checking on the children every 15 minutes.

Correction Narrative: The operation's administrator emailed a copy of the form all staff must sign to acknowledge their understanding of the supervision checks on all children that are not in their view. The form states they will agree to perform all checks in the recommended staggered intervals. The administrator also emailed a copy of their new log sheet that all staff must fill out to document the time for every supervision check.


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content:
The administrator was not present at the operation during their scheduled work hours and arrived during the inspection.

This standard is being re-cited due to the administrator not following up on this deficiency from a previous inspection.

Correction Narrative: The agency's administrator has created a timesheet to document the days and hours that they are present at the operation. The administrator has also adjusted their work schedule to accommodate the hours needed at this operation and their second job.


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

raw_content: Two staff records reviewed did not have signed statements for reporting abuse and neglect.

Correction Narrative: The director emailed copies of the signed statement by the employees for reporting suspected child abuse/neglect.


raw_content: The administrator was not present during their scheduled work time and arrived during the inspection.

Standard Number / Description: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation


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

raw_content: Of the ten serious incident reports reveiwed, four reports did not have the operation's address & phone number, and one incident did not have the name of the adult staff that was involved in the incident.

Correction Narrative: The operation's director emailed copies of the corrected serious incident reports.


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

raw_content: One staff record reviewed did not contain a signed, notarized Affidavit for Applicants for Employment.

Correction Narrative: The operation's director emailed a copy of the notarized Affidavit for Applicants for Employment.


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

raw_content: Two personnel files reviewed did not have documentation of the staff meeting the minimum job qualifications.

Correction Narrative: The operation's director emailed copies of the signed documentation for caregiver qualifications.


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

raw_content: One staff record reviewed did not contain documentation of their TB test.

Correction Narrative: The operation's director emailed a copy of the staff member's TB test.


summary: 748.1337(b)(1)(D) - Initial Service Plan-Include specific goals and strategies to meet the child's needs, including instructions to caregivers

raw_content: A child's service plan does not state specific supervision requirements based on the child's age, behaviors, and level of care.

Correction Narrative:
The operation's Adminsitrator emailed copies of the child's updated service plan that reflects the changes made to the child's supervision requirements.

The plan now states specific details about the level of supervision required that is based on the child's behaviors and history.


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

raw_content: A caregiver did not follow the operation's policies on supervision when they left two children unattended while away from the operation.

Correction Narrative:
The operation's Administrator emailed a copy of the Active Supervision Agreement that all staff are required to sign. The affidavit states the following :

 This memo is concerning Active Supervision. What is Active Supervision? Active supervision requires focused attention and intentional observation of children at all times. Staff position themselves so that they can observe all of the children: watching, counting, and listening at all times. This means that staff should have constant audio and visual of all youth in their care at the facility and while away from the facility.  At no time should a youth be left unsupervised.

The agency has also implemented a new policy that requires two staff to accompany the residents when away from the operation. This policy is required to be signed by all staff and states the following:

This memo is concerning transporting youth away from the facility. In accordance with DFPS §748.685(a)(4) Caregiver responsibility- providing the level of supervision necessary to ensure each child's safety and well-being. The following rules will be followed when youth are transported away from the facility for an outing:

1.	There will be at least two staff present to transport the youth on an outing
2.	Both staff will ensure that their cellphones are fully charged before leaving the facility
3.	All youth will be given the contact information for the facility in the event of an emergency and they need to call the facility in the event they are separated from the staff.
4.	At no time will the youth be left unattended, there should be a staff member in close proxemics of all youth where they have audio and visual of youth at all times


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

raw_content: A child was left unsupervised while away from the operation despite their service plan stating they are to be supervised at all times.

Correction Narrative:
The operation's Administrator emailed a copy of the Active Supervision Agreement that all staff are required to sign. The affidavit states the following :

 This memo is concerning Active Supervision. What is Active Supervision? Active supervision requires focused attention and intentional observation of children at all times. Staff position themselves so that they can observe all of the children: watching, counting, and listening at all times. This means that staff should have constant audio and visual of all youth in their care at the facility and while away from the facility.  At no time should a youth be left unsupervised.

The agency has also implemented a new policy that requires two staff to accompany the residents when away from the operation. This policy is required to be signed by all staff and states the following:

This memo is concerning transporting youth away from the facility. In accordance with DFPS §748.685(a)(4) Caregiver responsibility- providing the level of supervision necessary to ensure each child's safety and well-being. The following rules will be followed when youth are transported away from the facility for an outing:

1.	There will be at least two staff present to transport the youth on an outing
2.	Both staff will ensure that their cellphones are fully charged before leaving the facility
3.	All youth will be given the contact information for the facility in the event of an emergency and they need to call the facility in the event they are separated from the staff.
4.	At no time will the youth be left unattended, there should be a staff member in close proxemics of all youth where they have audio and visual of youth at all times

The Administrator stated that a meeting was held on June 4, 2021 with all staff to review and sign the new policies and discuss the necessity of following each child's individual service plan.


summary: 748.685(d)(4) - Supervision caregiver responsibility- Child participating in unsupervised activity - caregiver must give child way to contact him/her in an emergency

raw_content: While away from the operation, two children were left unattended with no way to contact the staff when the caregiver left to charge their cellphone that had died.


raw_content: A caregiver left two children unsupervised while away from the operation.

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


facility_name: The Hemple Shelter LLC

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

raw_content: There is an entry on the annual AWOL log missing the duration of the unauthorized absence.

Correction Narrative:
The Hemple Shelter re-trained all employees on Unauthorized Absence Summary Log documentation.
If a child leaves the facility without approval, in addition to all the required notification and documentation, the summary log will be completed as well in a timely manner.
The administrative team to include,Ms Chidinma Ndukwe AND Mr. Ugo will ensure that this is done.