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

raw_content: Form does not include a date or time the child was informed of their discharge or transfer.

Correction Narrative: A revised form was sent and compliant.


state: TX

facility_name: The Residence By Infinity Elite II

summary: 748.2855(a)(8) - EBI Documentation-Must include the name of the person(s) who observed the child

raw_content: EBI form does not contain a designated area for the person who observed the restraint

Category: Emergency Behavior Intervention

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: Revised EBI policy was e-mailed to me.


summary: 748.121(2) - Abuse and neglect policy-Methods for employee awareness regarding child abuse/neglect, including signs that a child may be a victim of abuse/neglect

raw_content: Abuse/neglect policy does not include methods for employee awareness regarding child abuse/neglect.

Category: Organization and Administration

Standard Risk Level: Medium High

Correction Narrative: Revised abuse/neglect policy was e-mailed to me.


summary: 748.1437(7) - Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction

raw_content: Form does not contain information regarding an emergency discharge/transfer.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative: Revised form was sent and compliant.


summary: 748.113(2) - EBI policy - the specific techniques that caregivers can use

raw_content: The EBI policy did not list the specific techniques a staff member is allowed to use.


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: Signed abuse/neglect statement states the corporation would do their own investigation for reports of abuse/neglect and exploitation.

Category: Reports and Record Keeping


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

raw_content: Admission form does not contain a designated place to put siblings phone numbers.

Standard Risk Level: Low

Correction Narrative: A revised admission form was sent which included the names and telephone numbers for the child's siblings.


summary: 748.119(1) - Volunteer policy - Include job descriptions and/or responsibilities for the volunteers

raw_content: Missing volunteer job description.

Deficiency Narrative: Missing volunteer job description.

Correction Narrative: A volunteer job description was e-mailed to me by the owner.


summary: 748.121(4) - Abuse and neglect policy - Strategies for coordination between the operation and appropriate community organizations

raw_content: Abuse/neglect policy does not include strategies for coordination between the operation and appropriate community organizations.


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

raw_content: Discharge/transfer form does not request to list the circumstances of the discharge or transfer.

Correction Narrative: A revised discharge form was e-mailed and compliant.


facility_name: Inspirational Hope House

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

raw_content: A child in care was physically assaulted by staff member at the operation.

Category: Individual Standards Evaluated

Standard Risk Level: High

Correction Narrative: Abuse prevention corrective action plan was developed by the operation to address the physical abuse that occurred at the operation.  The operation conducted a virtual re-fresher training on corporal punishment, discipline, the safety policy, and children's rights. The new lead checklist being implemented for the operation was also reviewed at the training. The training was completed on 1/17/26 and the sign in sheet was provided.


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

Deficiency Narrative: A child in care was physically assaulted by staff member at the operation.


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

raw_content: A staff member at the operation did not complete the post emergency behavior intervention with the child whom they performed the intervention on.

Correction Narrative: Abuse prevention corrective action plan was developed by the operation to address the physical abuse that occurred at the operation. The operation conducted a virtual emergency behavior intervention training with staff on 1/24/26 due to the winter weather storm and followed up with staff and completed an in-person emergency behavior intervention training on 1/28/26.


summary: 748.2553(1)(A) - EBI Release-Child released from short personal restraint immediately in emergency health situation and treatment obtained immediately

raw_content: Child in care was not released by staff member from emergency behavior intervention when the child stated it hurt them.


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

raw_content: A staff member performed emergency behavior intervention immediately on a child in care before attempting de-escalation.


summary: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child

raw_content: A staff member at the operation performed an inappropriate restraint on a child in care, restricting the child's ability to breathe and causing pain.


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

raw_content: A staff member performed emergency behavior intervention on child in care about a MP3 player to have the child return a MP3 player.


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

raw_content: Interviews with children and staff yielded consistent and corroborated statements that a staff member used profanity while on duty in the presence of children in care.


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

raw_content: A staff member used emergency behavior intervention to get a child in care to return a missing MP3 player.


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

raw_content: A staff member was observed attempting to intimidate and/or encourage a child in care to engage in a physical altercation with her.

Correction Narrative:
The operation's owner stated that each employee will receive re-training on Children's Rights, by way of a presentation no later than September 30th.
An in-person follow-up was conducted on 09/13/25 with the victim and staff supervisor; there were no further outcries of abuse or neglect.


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

raw_content: A staff member allowed children in care to pick fleas off dogs belonging to the staff member while on an outing.

Correction Narrative: This standard was found to be in compliance during a follow-up visit.


raw_content: A staff member directed profanity towards children in care.

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


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

raw_content: The incident that lead to the report and subsequent investigation was not documented accurately and correctly. The incident report is missing the child's age, date of admission, name of child witness, and staff signature.

Correction Narrative: On 8-18-25 the operation submitted their corrective action plan which is to provide refresher training on how to thoroughly complete SIR reports. The training is to be completed with all staff by 8-20-25. On 8-28-28 The training certificates were submitted and uploaded to document library. End.


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

raw_content: Based on the interviews with residents and staff, there is only one staff member supervising up to 8 children on Side B between 5am, when the children wake up, and 6:20am, when they leave for bus stop.

Correction Narrative: Corrections originally sent on 6/10/25 but not uploaded. Resent correction plan for an additional staff to be present at 5am to meet ratio standard on 7/18/25. Currently meeting ratio standard.


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

raw_content: Out of 4 children files reviewed for compliance, 2 child records are missing the child's signature on their admission assessment.

Correction Narrative: Inspiratonal hop house will conduct an audit of the resident files within 3 days of admission, to ensure the admission assessment is signed by the resident.


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

raw_content: The operation did not report quarterly EBI information within 15 days following the end of the quarter.

Correction Narrative: The administrative team discussed the findings and will calendar the deadline for the quarterly EBI report, as well as set reminders prior to the deadline.- Charlotte Lynn


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

raw_content: A staff member made inappropriate comments and showed unsuitable videos to children in care.

Correction Narrative: Ms. Figaro sent corrections including the perpetrating staff is no longer employed by the operation.  All remaining staff have been retrained, and a managerial meeting was held with all employees.


summary: 748.705(b)(2) - Reasonable & prudent parent standard-must consider the child's cognitive, social, emotional and physical development level

raw_content: A 12-year-old child in care was allowed to watch a rated R movie, which contained strong violence, language, and disturbing imagery.  This child reported nightmares and hallucinations after viewing this movie.

Correction Narrative: We completed a staffing and posted the expectations for appropriate things for the youth to watch.  The staff were informed only PG and PG-13 were to be watched.  They would also need to be monitoring the content and killing, sexual content and any content that can cause the clients to have a therapeutic negative response is not allowed.  This was communicated on 7/14/24 initially.  It was also communicated on 9/25/27 and 9/27/24 in trainings with the staff and posted on our communication thread.  To make sure leadership was also taking ownership the Lead staff had a meeting and this outcome was also discussed, this will be included in all onboarding.


summary: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

raw_content: During the inspection it was observed that two bathroom showers contained mold.

Category: Physical Site

Correction Narrative: During the inspection it was observed that the operation's showers are free of mold and in good repair


summary: 748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean

raw_content: During the inspection it was found that one bathroom sink had a broken knob. It was also found in another bathroom that the sink was backed up and not draining properly.

Correction Narrative: During the inspection it was observed that the bathroom sinks are in good repair and draining properly


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

raw_content: The investigator was unable to review some of the incident reports on the children, as they were illegible.

Correction Narrative: The staff was re-educated on penmanship and the importance of writing legibly.  We have discussed this with the case manager to ensure the documentation is completed each time.


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

raw_content: Multiple medication logs reviewed did not contain the year the medication was administered. One child's medication log did not contain the time the medication was administered. One child's medication log reviewed did not contain the signature of the staff member who administered it.

Category: Medication

Correction Narrative: The operation sent a statement saying staff will be trained on medication by May 17th 2024 and the training certificates will be placed in the staff's binders. They also stated the medication logs will be evaluated weekly to ensure compliance.


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: Multiple medication logs reviewed contained the incorrect pill count.

Correction Narrative: The operation conducts medication audits multiple times throughout the week. The operation stated a staff meeting will be conducted in order to discuss medication and pill counts.


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

raw_content: Upon review of a service plan there was inaccurate information regarding the child's recent behaviors.

Correction Narrative: The operation updated the service plan in question and placed the updated service plan in the child's file.


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: There are 3 previous employees still listed as active in CLASS.

Correction Narrative: The operation e-mailed a corrective action that stated the background checks were inactivated while staff were still conducting the inspection. The plan also stated all administrative staff were reminded terminated staff background checks must be made inactive within 7 days of their departure.


summary: 748.191(3) - Required Postings-Post emergency and evacuation relocation plans in each building and living quarters used by children where all may view them

raw_content: There was only one evacuation posting posted downstairs in the whole operation.

Correction Narrative: The operation stated the evacuation/relocation plans/diagrams have been posted in all required areas. The plan also stated the girls practiced following the plan over the weekend.


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

raw_content: The operation does not have any documented weather drills.

Category: Safety and Emergency Practices

Correction Narrative: The operations corrective action plan stated they practiced severe weather drills over the weekend and will continue to practice them regularly in the future.


raw_content: It was observed staff was arguing with residents and staff was also arguing amongst each other in front of the residents.

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

Correction Narrative: An in-person follow-up was conducted on 11/08/2023. Please see inspection #3975077.The operation e-mailed a statement saying the staff members involved in arguing with residents as well as other staff are no longer employed at IHH. The operations corrective action plan for this citation also stated staff members will be taking a training titled Interpersonal Relation Skills and Communication on October 19th and any new staff members will be required to take the training as well.


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

raw_content: One staff member with a condition on her background check stating she cannot be left in charge at the operation was the only staff member present with the children upon my arrival.

Correction Narrative: The operation stated there are multiple direct care staff candidates they are in the process of hiring so this occurrence does not happen again in the future. The operation stated they are going to hire both full time and PRN staff to ensure they have adequate staff in case someone calls in or has to leave due to an emergency. Furthermore,	The Program Director and the Administrator will work hand in hand with each other to see to it that the facility meets Minimum Standards. If at any time of a call-in from one of the Direct Care Staff members (unforeseen circumstance), the Program Director will notify the Administrator and the two will alternate reporting to the facility to ensure that there is a second staff member in the facility.


raw_content: Upon my arrival to the operation there was one staff member present with eight children who are receiving treatment services.

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


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

raw_content: Children in care were not appropriately supervised. There were multiple children both upstairs and downstairs in different areas of the operation with one staff member present downstairs cooking upon my arrival.


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: Multiple children in care were neglectfully supervised.

Correction Narrative: An in person follow-up was conducted. Please see inspection #3975077. The operation sent the e-mailed the following corrective action plan: Staff member was immediately terminated after the incident. Staff members conduct night time checks of the residents every 5-10 minutes. Administrative staff members do random unannounced night visits to ensure staff are not sleeping. Administrative staff also monitor the cameras at night periodically to ensure staff members are not sleeping. The staff members are also instructed to switch sides at the operation every 15 minutes in order to stay moving.


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

raw_content: Staff members were not providing the level of supervision required per their service plans.

Correction Narrative: An in-person follow-up inspection was conducted. Please see inspection #3975077. The operation e-mailed a statement saying staff members conduct night time checks of the residents every 5-10 minutes. Administrative staff members do random unannounced night visits to ensure staff are not sleeping. Administrative staff also monitor the cameras at night periodically to ensure staff members are not sleeping. The staff members are also instructed to switch sides at the operation every 15 minutes in order to stay moving.


raw_content: A staff member at the operation was not providing adequate supervision to children in care due to sleeping.

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

Correction Narrative: Please see inspection number 3988837. Staff member involved was terminated in July of 2023. Staff members conduct night time checks of the residents every 5-10 minutes. Administrative staff members do random unannounced night visits to ensure staff are not sleeping. Administrative staff also monitor the cameras at night periodically to ensure staff members are not sleeping. The staff members are also instructed to switch sides at the operation every 15 minutes in order to stay moving. The allegations for sleeping staff in this investigation occurred in July of 2023. The residents have since been interviewed in regards to sleeping staff and there were no concerns.


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

raw_content: One child receiving treatment services service plan did not contain any signatures.

Correction Narrative: The operation sent a statement saying how both the Administrator and the Treatment Director will proof read service plan for accuracy and signatures. The service plan was signed by the appropriate individuals and placed in the child's file.


summary: 748.453(b) - Unauthorized Absence - Maintain each annual summary log for five years

raw_content: Upon review of documents received from IHH, Unauthorized log was not maintained for the month of March for child in care

Correction Narrative: The operation sent a corrective action plan stating how the unauthorized absence log, as well as all other documents, will be kept updated in the future.


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

raw_content: One staff's file reviewed did not contain a signed statement saying they have read a copy of the operational policies.

Correction Narrative: The LCCA sent a statement stating in the future, all employees files will be reviewed to ensure all required documentation is in the file. For the staff's file in question, she stated all required documentation will be in the staff's file for review.


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 child's file reviewed did not contain the child's right's documentation.

Category: Children's Rights

Correction Narrative: The LCCA sent a statement saying that all child files will contain required documentation. For the child file in question, the child right's form was signed by the child on 05/23/2023.


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

raw_content: Child in care was not taking medication as prescribed.

Correction Narrative: The operation sent a copy of a new form they are going to use to document when medication is picked up from the pharmacy in order to prevent medication errors in the future. The operation also sent a statement saying the program director and the administrator will both frequently conduct medication audits.


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

raw_content: Service plan did not have medication listed for a child in care.

Correction Narrative: The operation sent the updated service plan to include the child's medications.


summary: 748.3421(1) - Poisons-The operation must ensure that poisonous or flammable materials are stored in their original, labeled containers

raw_content: The laundry room where cleaning supplies was stored was not locked.

Corrected at Inspection: Yes


raw_content: Documentation received from the operation contained inaccurate information and incomplete forms.

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

Correction Narrative:
The operation e-mailed the following response: The errors in the assessment document in investigation #2990492 has been corrected and the following corrective action has been taken.

The Staff Treatment team has implemented the following Quality Control measures to ensure accuracy in all documents.

The Hope House LCCA, Mary Reece will review all assessments for completion and accuracy.
The Hope House Case Manager will review the assessments in  addition to the Treatment Director and LCCA for completion and accuracy.
At the completion of the Treatment Team review files will be placed as a permanent record in the client file.


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

raw_content: Two out of three child files reviewed contained preliminary service plans that were not signed.

Correction Narrative: The operation has hired a Treatment Director and stated they would ensure this issue does not occur in the future. The signed Preliminary Service Plans will be in the children's files for review.


raw_content: One staff member's file showed conflicting information regarding their high school education. One staff members high school diploma was believed to be unauthentic.

Correction Narrative: The operation stated they were unaware the staff member provided a fraudulent high school diploma. They stated the staff was taken off of the schedule and if they cannot provide proof of education they will be terminated. On 04/21, the operation e-mailed a copy of the staff members high school transcript.


summary: 748.113(5)(A)(vii) - EBI policy - for orientation, explain and document to a child the way to report an inappropriate EBI

raw_content: Policy did not include how the operation will explain to a child in care the way to report an inappropriate EBI.

Correction Narrative: The operation e-mailed an updated policy to include how a child can make a report to both the operations staff and to licensing.


summary: 748.1219(2)(D) - Treatment Services Admission-ID: Admission assessment must include reason(s) for choosing treatment services for child

raw_content: Form is missing a place for reasons for choosing.

Correction Narrative: The operation e-mailed an updated form which contained the missing criteria.


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

raw_content: There is no inventory form for discontinued or expired meds.

Correction Narrative: The operation e-mailed an inventory form in which they will use for expired or discontinued medication.


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

raw_content: Form is missing a place for an initial evaluation of the placement. A place for the child's understanding and a place for whether and how they will meet the needs.

Correction Narrative: The operation e-mailed an updated admission assessment form which included the missing criteria.


summary: 748.115(3) - Discipline policy - Include measures for positive responses to appropriate behavior

raw_content: Discipline policy did not include positive measures for positive responses to appropriate behaviors. Does not include the importance of nurturing behavior, stimulation, and promptly meeting the childs needs.

Correction Narrative: The operation e-mailed an updated discipline policy that included the missing criteria.


summary: 748.1209(b)(12) - Child Orientation-Include general daily schedule for routine activities

raw_content: Form is missing that a general daily schedule will be reviewed.

Correction Narrative: The operation e-mailed an updated child orientation task list to include that a daily schedule will be reviewed.


summary: 748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration

raw_content: The operation needs a small medication fridge or a lock for the large fridge to store cold medications.

Correction Narrative: The operation sent a picture of a small medication refrigerator with a lock.


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

raw_content: The operation does not currently have a designated administrator.

Correction Narrative: The operation appointed an administrator.


summary: 748.1205(a)(14) - Admission Documentation- Includes the results of the suicide screening at admission, if required.

raw_content: Form is missing a section regarding suicide screening and safety plans if needed.

Correction Narrative: The operation e-mailed an updated admission assessment that included a section for the results of a suicide screening.


summary: 748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs

raw_content: Form is missing a place for how they would meet immediate needs.

Correction Narrative: An updated preliminary service plan form was e-mailed and included the plans to meet the child's needs.


facility_name: Houston's House of Hope

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

raw_content: Three of the medication's logs reviewed has a different prescribing doctor than, the doctor found on the medication pill back does.

Correction Narrative:
	Houston's House of Hope's Licensed Child Care Administrator and Program Director will ensure that the prescribing physicians name is corrected on each medication form for each child.

	Houston's House of Hope's Licensed Child Care Administrator and Program Director will also notate on the medication form the new prescribing physicians name if the child is prescribed a refill for the same medication.

Houston's House of Hope's Licensed Child Care Administrator and Program Director
	will complete weekly audits to ensure that the medication forms having the correct information and the correct prescribers name.


facility_name: The Lullaby House

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

raw_content: The gas inspection has not been completed within the required time frame.

Correction Narrative: An email was received from the Executive Director and the Administrator with the completed gas inspection. The gas inspection has been uploaded to the document library.


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

raw_content: A health inspection has not been completed within the required time frame.

Correction Narrative: An email was received from the Executive Director and the Administrator with the completed health inspection. The health inspection has been uploaded to the document library.


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

Deficiency Narrative: A health inspection has not been completed within the required time frame.


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

Deficiency Narrative: The gas inspection has not been completed within the required time frame.


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

raw_content: A window on the front porch is broken and has tape over it.

Correction Narrative: An email was received from the Administrator and the Executive Director to request a voluntary suspension to conduct the necessary repairs to the operation. In order for the window to be repaired the foundation has to be repaired first. The operation is requesting a voluntary suspension from 8/7/25 to 8/7/26 to complete all repairs. An inspection will be completed prior to the operation reopening.


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

raw_content: During Walkthrough inspeciton, it was discovered that poison was left out on the dinning table. This was corrected at inspection as staff immediately put the poision in locked storage.


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

raw_content: The vehicle registration sticker expired 10/2024.

Category: Transportation

Correction Narrative:
An email was received from the Administrator of the operation with a picture of the updated registration sticker. The picture has been uploaded to the document library.

It was discussed over the phone with the Administrator, that the agency will set calendar reminders 2 months prior to registration due dates.


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

raw_content: The operation has not had a fire inspection conducted in over 12 months; the last passing fire inspection was completed 2/22/23.

Correction Narrative:
Several emails were received and phone calls conducted with the Administrator and Director to discuss the status of the fire inspection.

The original fire inspection was conducted on 6/3/24, corrections were needed, and a reinspection was conducted on 11/15/24 and 11/29/24. The receipt was provided showing that the permit effective date is 6/3/24 and expires 6/3/25. All documents have been uploaded to the document library.


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

Deficiency Narrative: The operation has not had a fire inspection conducted in over 12 months; the last passing fire inspection was completed 2/22/23.


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

raw_content: A child in care had COVID and it was not reported to licensing.

Correction Narrative:
An email was received from the Administrator on 8/15/24 that the incident has been reported to the hotline, this was verified in CLASS as an intake.

The updated serious incident report form was provided by email on 8/27/24. The Administrator reviewed reporting requirements with staff and the updated form during the staffing meeting conducted on 8/17/24.


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

raw_content: An unauthorized absence was not documented on a log or form.

Correction Narrative: An email was received from the Administrator on 8/27/24 with an updated unauthorized absence form, which included the debriefing for a child. The Administrator reviewed unauthorized absence reporting and documentation requirements, with staff and reviewed the updated form during the staffing meeting conducted on 8/17/24.


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

raw_content: A serious incident report did not document the childs age, gender or date of admission.

Correction Narrative: An email was received from the Administrator on 8/27/24 with an updated serious incident report form. The Administrator reviewed reporting requirements, including documentation, with staff and reviewed the updated form during the staffing meeting conducted on 8/17/24.


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

raw_content: Staff records were missing a drug test result, TB test result and their education documentation.

Correction Narrative: An email was received from the Administrator on 8/27/24 stating that a quarterly audit on staff records is scheduled (calendar reminders are set) in a 3-month rotation, to ensure all required documentation is in the record.


raw_content: The operation has not had a fire inspection conducted in over 12 months; the last fire inspection was completed 2/22/23.


Deficiency Narrative: The operation has not had a fire inspection conducted in over 12 months; the last fire inspection was completed 2/22/23.


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 of the two employee files that were reviewed did not have the TB test in the file.

Correction Narrative:
An email was received from the Administrator with a copy of the TB results for the staff member.

The agency has created a new hire checklist that will be placed in each staff record to ensure all required documents are filed prior to the staff member caring for children.


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

raw_content: There were four staff who do not have documentation for first aid training.

Correction Narrative:
An email was received from the Administrator of the operation on 7/11/23 with details of the CPR training class that includes hands on practice scheduled for 7/13/23.

During the unannounced follow up inspection conducted on 7/25/23 (documented on monitoring inspection #3959583) the training certificate completed on 7/13/23 was in the staff records.


summary: 748.949(b)(2) - Annual Training Documentation-Includes date of the training

raw_content: There was a training for TIC that did not have a date and two trainings for psychotropic medications that did not have dates.

Correction Narrative:
An email was received from the Administrator of the operation on 7/11/23 with details of how the operation will comply moving forward by printing the training certificate off as well as the training transcript to show the date the training was completed.

During the unannounced follow up inspection conducted on 7/25/23 (documented on monitoring inspection #3959583) the training certificates along with the training transcripts were in the staff records.


summary: 748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.

raw_content: There was one staff who did not have documented psychotropic medication training. There were also two staff who were late taking their annual psychotropic medication training.

Correction Narrative:
An email was received from the Administrator of the operation on 7/11/23 with details of how the operation will comply moving forward by sending out 30-day notifications to staff members for all trainings coming due as well as printing the training certificate off along with the training transcript to show the date the training was completed.

During the unannounced follow up inspection conducted on 7/25/23 (documented on monitoring inspection #3959583) the training certificates along with the training transcripts were in the staff records.


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: There were seven staff who took online CPR class and did not include hands on practice according to the foster parent.


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

raw_content: A child in care was left unsupervised at the hospital when the infant was admitted and received treatment.

Correction Narrative:
An email was received from the Administrator of the operation on 7/11/23 with details of how the operation will comply moving forward by requiring a staff member to remain at the hospital while a child in care is receiving treatment.

During the unannounced follow up inspection conducted on 7/25/23 (documented on monitoring inspection #3959583) a staff member was interviewed and stated this has been discussed at the last staff meeting this month.


summary: 748.1757(a)(1) - Prohibited equipment for infants-Must not use baby walkers

raw_content: An infant was observed using a baby walker.

Correction Narrative: An unannounced follow up inspection was conducted at the operation. The baby equipment was observed and found to be compliant with the minimum standards, pictures were taken and uploaded to digital storage.


summary: 748.1753(a)(2)(A) - Play yard requirements- Firm, flat mattress snugly fits sides of crib and is designed for crib; mattress not supplemented w/additional foam/pads

raw_content: A play yard was supplemented with blankets for padding.


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

raw_content: One of the two medication logs reviewed did not document the physicians name.

Correction Narrative: An unannounced follow up inspection was conducted at the operation. The current medication logs were reviewed for February and found to be compliant with the physician's name filled out, pictures were taken and uploaded to digital storage.


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: The 2 staff records reviewed did not have a notarized Affidavit for Applicants for Employment form.

Correction Narrative: An email was received from the Administrator of the operation. The notarized Affidavit for Applicants for Employment form was received for the 2 staff members. Moving forward affidavits have been added to all new hires onboarding process to be completed and uploaded during the new hire paperwork.


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: The child's rights form was not signed by the child in care.

Correction Narrative: An email was received from the administrator with an updated child's rights form that has been signed by the child in care.


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

raw_content: There was tree limbs, wooden deck planks, rolled up rug and electrical wire laying in the backyard.

Correction Narrative: An email was received from the administrator with pictures of the backyard that show the debris removed from the backyard.


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

raw_content: The child in care did not have an initial service plan completed.

Correction Narrative:
An email was received from the administrator that the service plan meeting is being held on 10/31/22.

A second email was received that the service plan has been completed for the child in care and moving forward the preliminary service plan is to be filled out within 72 hours of admitting the resident into the program. The initial and review service plans will then be scheduled with an agreed upon date with all parties involved.


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: Operational Policies did not discuss the use of car seats/booster seats for children in care.

Correction Narrative: Email corrections received 1/19/22. Updated policies detailing information regarding use of car and booster seats.


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

raw_content: Fire extinguishers were last serviced on Novermber 2020.

Correction Narrative: Email corrections received 1/19/22 Picture showing fire extinguisher had been serviced jan 2022.


summary: 748.3061(1) - Gas Inspection-Operation inspected before initial permit issued

raw_content: Operation did not have a current gas inspection on file at the time of inspection.

Correction Narrative: Email corrections recived 1/19/22. Invoice stating gas inspection had been successfully performed 1/13/22.


summary: 748.3001(a)(1) - Sanitation Inspection-Sanitation official must conduct a sanitation inspection before initial permit issued

raw_content: Operation did not have a current health inspection.

Correction Narrative: Health inspection performed and passed.


summary: 748.111(13) - Child-care policy - Types and frequency of reports to parents

raw_content: Operational Policy did not include the types of frequency of reports to parents.

Correction Narrative: Email corrections received 1/19/22. Policies updated to reflect frequency of report to parents in the policy handbook.


summary: 748.3357(b)(2) - Bedroom Space-Must have at least 60 square feet of space for each occupant & no more than 4 occupants per bedroom unless certain exemptions met

raw_content: Operation wishes to be licensed with a capacity of 15; however, there is only capacity for 8.

Correction Narrative: Email corrections received 1/19/22. New application form with capacity for 8 marked.


facility_name: Divine Integrity Group Home

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 was able to leave the facility and be out of sight and earshot for at least 10minutes and brought back alcohol without being noticed by staff.

Correction Narrative: Kesha Picknei   Director  and Mara Scott - Employee Operations Manager HR stated the staff involved in the incident were given a write up in January 2026 and were provided with trianing regarding supervision. It was also stated that in February 2026 there was a quaterly meeting that covered supervision issues and ratio. Signing sheet, training and write ups were provided during this follow up inspection.


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

raw_content: Staff allowed children to play truth or dare, and the dares were inappropriate for the age group.

Correction Narrative: Six out of six children interviewed stated that no truth or dare games have been played at the home since the incident that triggered this investigation. Three out of three staff interviewed denied truth or dare games are played with children in care. The staff stated they attended a staff meeting where every staff was instructed to refrain from playing truth or dare games with children in care. The operation provided the meeting agenda and staff signatures which confirmed staff understood the subjects discussed and signed. Email: On 09/25/2025 the operation provided a written compliance response. Operation states that a mandatory meeting was completed with all operation staff. During the meeting, staff were informed of the immediate prohibition of the game Truth or Dare and were reminded of their responsibility to uphold safe, structured, and developmentally appropriate activities. The discussion included reviewing the risks associated with Truth or Dare and similar peer-led activities, reinforcing proper supervision expectations, guidance on redirecting youth to safe, approved activities, reminders regarding prudent judgment, self-control, and professional boundaries.


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

raw_content: It was determined the wall in room 5 needed to be repaired as there was a hole in the wall and door frame in room 4 was broken with a piece of wood sticking out. Worker order could not be provided by staff.

Correction Narrative:
Licensing conducted a physical follow-up at the operation and conducted a walkthrough with Administration.  All repairs were observed to be completed, and no physical site concerns were observed. The hole in room 5 was repaired and no other holes in the walls in any area of the operation were observed.  Additionally, room 4 door frame was repaired, and no other door frames were observed to be in need of repair. No safety concerns nor risks to children were observed. Licensing also interviewed two staff members who both stated that the operation is conducting weekly walkthroughs and submitting work orders to ensure repairs are corrected timely.

The operation provided a compliance plan by email on August 20, 2024. Operation states that tape has been applied to door frame to minimize any risk of injuries. Work orders have been placed to make the needed repairs. Operation has implemented a new task in which staff complete daily walkthroughs of the premises to verify home is in compliance.


summary: 748.3301(a)(3) - Physical Site- Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes.

raw_content: It was determined a wall electrical cover is broken and needs to be replaced.

Correction Narrative:
Licensing conducted a physical follow-up at the operation and conducted a walkthrough with Administration.  All repairs were observed to be completed, and no physical site concerns were observed. All electrical covers were observed to be in good repair. No safety concerns nor risks to children were observed. Licensing also interviewed two staff members who both stated that the operation is conducting weekly walkthroughs and submitting work orders to ensure repairs are corrected timely.

The operation provided a compliance plan by email on August 20, 2025. Operation states that the electrical light cover has been repaired. Operation has implemented a new task in which staff complete daily walkthroughs of the premises to verify home is in compliance.


summary: 748.2307(3) - Other Prohibited Punishments-threatening with the loss of placement as discipline or punishment

raw_content: During the investigation through child and staff interviews, it has been heard that consequences for bad behavior or disruption of placement. Three of the three children admitted to hearing staff saying children will be discharged with bad behavior. Staff admitted to consequences of bad behavior is discharge.

Correction Narrative:
The facility responded: I am writing in response to the concerns raised regarding a youth's claim of being threatened with discharge from Divine Integrity Group Home. We take such concerns very seriously and would like to clarify our position and the structured approach we take to ensure the well-being and safety of every youth in our care.
Divine Integrity Group Home is committed to providing a safe, nurturing, and structured environment where female youth can heal, grow, and thrive. Our program is designed to offer a world-class experience, equipping youth with essential life skills while promoting emotional and social development. Our caregivers are trained to provide compassionate guidance and support while maintaining a positive and structured living environment.
To clarify, Divine Integrity Group Home does not arbitrarily discharge youth from our program. However, youth who engage in behaviors that significantly disrupt the program's flow, including persistent disrespect toward caregivers and bullying of other residents, jeopardize their permanency. Our primary responsibility is to create a secure and supportive setting for all individuals in our care. When a youth's actions threaten the safety or well-being of others, we are obligated to address these concerns appropriately and in accordance with DFPS regulations and best practices.
We implement a tiered intervention approach, which includes behavioral redirection, counseling, and individualized support plans, before considering any changes to a youth's placement. Discharge is considered only as a last resort and is done in collaboration with DFPS and all relevant stakeholders to ensure the youth's needs are met in the most appropriate setting.


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

raw_content: During the walkthrough it was discovered that at the bottom of the shower curtain, in bathroom 2, contained mold. Soap scrum was present as well on the walls.  While at the facility, staff changed the shower curtains out with a new curtain and clean the shower stalls.


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

raw_content: During the inspection it was found that one of the child's records reviewed were missing the required 14 day notification to the child's parent.

Correction Narrative: The operation sent email stating that the operation will use outlook calendar to track staffing dates and notification of service plans. Operation is administratively reviewing this citation.


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

raw_content: During the inspection it was learned that a child in care ran out of her medication 3 days prior to the inspection. The child's appointment is not until 2/6/2024. The child will be without her medication for a total of 6 days.

Correction Narrative: The operation is requesting an administrative review and did not provide corrections. Once the citation was upheld the operation sent corrections stating they would ensure the children appointments are scheduled prior to the time the prescriptions are due.


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

raw_content: During the inspection it was found that several  windows did not have protective screens attached.

Correction Narrative: Operation sent email with photos of the screens that are attached to the windows.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: A child in care was subjected to a restraint that was inappropriate and was only let go once the child expressed that she should not be in a choke hold.

Correction Narrative:
Email sent for correction:

STANDARD/RULE

748.507(1)

Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

DEFICIENCY

An employee did not use prudent judgment or self-control when a comment was mase which triggered a child to fight another child in care.

CORRECTION

All staff members successfully completed a refresher EBI (Crisis Prevention, De-Escalation, and Crisis Intervention training course), which addressed proper use of verbiage and restraints. Completion date: 3-21-23

STANDARD/RULE

748.2551(b)(2)

EBI Implementation The caregiver must consider the permitted types of emergency behavior intervention.

DECIFIEENCY

A child in care was subject to a restraint that was inappropriate and was only let once the child expressed that she should not be in a choke hold.

CORRECTION

All staff members successfully completed a refresher EBI (Crisis Prevention, De-Escalation, and Crisis Intervention training course), which addressed proper use of verbiage and restraints. Completion date: 3-21-23


raw_content: An employee did not use prudent judgement or self-control when a comment was made which triggered a child to fight another child in care.

Correction Narrative:
Email for correction:

STANDARD/RULE

748.507(1)

Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

DEFICIENCY

An employee did not use prudent judgment or self-control when a comment was mase which triggered a child to fight another child in care.

CORRECTION

All staff members successfully completed a refresher EBI (Crisis Prevention, De-Escalation, and Crisis Intervention training course), which addressed proper use of verbiage and restraints. Completion date: 3-21-23

STANDARD/RULE

748.2551(b)(2)

EBI Implementation The caregiver must consider the permitted types of emergency behavior intervention.

DECIFIEENCY

A child in care was subject to a restraint that was inappropriate and was only let once the child expressed that she should not be in a choke hold.

CORRECTION

All staff members successfully completed a refresher EBI (Crisis Prevention, De-Escalation, and Crisis Intervention training course), which addressed proper use of verbiage and restraints. Completion date: 3-21-23


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: During inspection it was noted that the medication record for multiple children in care was not accurately recorded with date, count and signature.

Correction Narrative: Medications were reviewing during Inspection #3918124. Operation is in compliance.


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

raw_content: During the inspection of children's records it was noticed that  2 out of 8 records did not have an initial service plan at the 45 day mark

Correction Narrative:
Inspector received email from administrator stating:

We will develop and implement a service plan schedule that will chart service plan deadlines for all youth in our care. The chart will be reviewed weekly by Divine Integrity administration weekly.
Service plan meetings will be scheduled no later than 30 days after admission to ensure that there is enough time for review, quality control measures and implementation not to exceed 45 days


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

raw_content: One of two child records reviewed did not contain discharge summaries to include all required information.

Correction Narrative: LCCA submitted a discharge summary template to be utilized for all discharges from the operation.


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

raw_content: Four of four children's admission assessment did not document known contraindications to the use of restraints

Correction Narrative: Admissions Form has been modified to include known contradictions to the use of restraints. Moving forward, the updated form will be used. Revised admissions form was submitted.


summary: 748.4231(a)(5)(A) - Admission assessment for emergency and respite care services-must include reason for emergency placement

raw_content: One of four child records reviewed did not document the reason for emergency placement.

Correction Narrative: LCCA submitted a revised admissions intake form and admissions assessment form that captures all required information.


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

raw_content: Two of four staff records did not contact proof of education.

Category: Personnel

Correction Narrative: LCCA submitted proof of education for one of the employees. The other employee is no longer employed at the operation.


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

raw_content: Four of four child records reviewed of children in program over 15 days, did not contain a written discharge plan.

Correction Narrative:
LCCA submitted an extension request/discharge planning template for use at the operation.
Administration will submit request for extension / Discharge plan update to the child's caseworker in a timely manner.


summary: 748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days

raw_content: Four children have remained in program  over the maximum amount of time allowed and have not had an approved placement extension.

Correction Narrative: Administration was unaware of the requirement to submit a request for variance concerning the request for extension beyond 15 days. Moving forward, Administration will receive a request for extension from the youths caseworker on the 15th day and place it in the child's record no later than the 16th day. Administration will submit a request for variance via provider portal on or prior to the 15th day if it is anticipated that the youth will reside at the facility beyond 15 days. LCCA submitted an extension request/discharge planning template for use at the operation.


summary: 748.303(c) - Serious Incident- Doc unauthorized absence that does not meet the reporting time reqs defined in subsection (a)(8)-(10) of this section in 24 hrs

raw_content: A child's two unauthorized absences were not documented as serious incident to include required information.

Correction Narrative: LCCA submitted a revised incident report template that captures required information.


summary: 748.1207(a)(3) - Placement agreement-Must include the reason for placement & anticipated length of time in care

raw_content: One of four children's placement agreement did not document reason for placement nor anticipated length of time in program.

Correction Narrative: Staff will ensure that the caseworker completes the required information at intake, to include, reason for emergency placement and anticipated length of stay. LCCA submitted a revised admission assessment intake form to capture required admission documentation.


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

raw_content: It was noticed during the walkthrough that the fence surrounding the operation in the backyard was not in good repair.

Correction Narrative: I, Kerah Jones RCCL, inspector received emailed corrections from operation.


summary: 748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard

raw_content: In bedroom #2 the top of safety guardrails is not at least five inches above the top of the mattress.


facility_name: Greater San Marcos Youth Council

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

raw_content: During the inspection three medication logs  were reviewed and two of the logs were missing signatures next to the over the counter medication.

Correction Narrative:
3. Corrective Actions:
A. Staff Training and Acknowledgment
To be completed NO LATER THAN November 12, 2025
	All staff will receive training on the proper procedure for documenting OTC medication administration.
	Training will include when and how to complete the medication log, and the importance of signing each entry.
	Staff will sign a Training Acknowledgment Form confirming they understand and will comply with this policy.
B. Shift-Level Review
	The Shift Supervisor or Lead Staff will review the medication log at the end of each shift to ensure all entries are complete and signed.
	Any missing information or signatures will be corrected before the shift ends.
C. Administrative Oversight
	The Program Director or Designee will review all medication logs daily to verify compliance.
	Any discrepancies will be immediately addressed with staff, and corrective coaching will be provided as needed.
D. Ongoing Monitoring and Accountability
	Weekly audits will be conducted by the Administrative Team to confirm continued compliance.
	Repeated failure to follow documentation procedures will result in formal corrective action as outlined in agency policy.
E. Documentation and Recordkeeping
	All medication logs and training acknowledgments will be maintained in agency records.
	Documentation will be reviewed during internal audits and future Licensing visits to demonstrate sustained compliance.
4. Implementation Date:
Effective Immediately (upon Licensing approval)
5. Responsible Parties:
	Program Director: [Insert Name]
	Shift Supervisors / Lead Staff
	All Direct Care Staff
6. Verification of Compliance:
	Daily reviews will confirm all medication entries include the date, time, name, and signature of the person administering medication.

On 11-12-2025, the operation administrator provided the staff sign-in sheet acknowledging presence and completion of the Over-the-Counter Medication Log training conducted on 11-10, 11-11, and 11-12-2025. The document was provided to RCCR Representative by E-mail.


summary: 745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method

raw_content: Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy.

Correction Narrative:
On 12/12/24, the operation submitted their compliance plan by email:

Drug Testing-The agency is aware of the Texas Administrative Code for drug testing. There are two companies that the agency has contacted to confirm the false positive and false negative percentage the TAC states. Correspondence between the agency and the companies is attached, along with one of the drug testing inserts. Moving forward, the agency will ensure that there is proper documentation stored in an employee's personal file that is not accessible by other staff. Documentation will also provide proof of the results that were documented.  This will be done by taking a picture of the results along with providing identifying information of the employee to ensure accuracy. The agency will also require the Residential Program Director to ensure that all results are properly filed in each employee's file.


summary: 745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested

raw_content: The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file.

Correction Narrative:
On 12/12/24, the operation submitted the following compliance plan by email:

Drug Testing-The agency is aware of the Texas Administrative Code for drug testing. There are two companies that the agency has contacted to confirm the false positive and false negative percentage the TAC states. Correspondence between the agency and the companies is attached, along with one of the drug testing inserts. Moving forward, the agency will ensure that there is proper documentation stored in an employee's personal file that is not accessible by other staff. Documentation will also provide proof of the results that were documented.  This will be done by taking a picture of the results along with providing identifying information of the employee to ensure accuracy. The agency will also require the Residential Program Director to ensure that all results are properly filed in each employee's file.


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

raw_content: The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident.


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

raw_content: 5 medication errors were not documented as required within the 24 hour period.

Correction Narrative: An email was received from the operation on 12.8.23. Attached to the email was a new form the operation is implementing to recording medication errors.


summary: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

raw_content: During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced.

Correction Narrative: The operation provided a work order / invoice from a plumbing company dated 11/8/21 to show the two shower knobs repaired/replaced in the female restroom. The oper. also provided photos of both the fixed shower knobs.


summary: 748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident

raw_content: It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care.

Correction Narrative: The operation reported the Residential Program Director will include in training a detailed explanation of a Serious Incident Report and when to report based on the Serious Incident chart. Current staff have all been addressed as of 12/27/2021 and informed that Law Enforcement involvement at the facility due to residents requires reporting for a serious incident.


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

raw_content: It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care.

Correction Narrative: The operation has identified employees for each shift to administer and document prescribed medications rather than allowing all employees to do so. The operation has attempted to only employ individuals who can obtain eligibility without conditions and will continue to do so.


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: After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional.

Correction Narrative: A child in care was without a prescribed medication that would not be paid for by Medicaid without a physician's prior authorization. The provider paid for the prescription rather than allow the child to wait any longer for pre-authorization. Moving forward, documentation will be obtained and included in child(s) records.


summary: 748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151

raw_content: After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped.

Correction Narrative: The operation acknowledged that employees failed to properly document refusal by children to take prescribed medication(s). The Residential Program Director has identified individual employees on each shift who is responsible for proper administration and documentation of prescribed medications for children in care. These employees also received additional training on the reasons for proper documentation. Each child's progress notes will detail specifics of refusal to take prescribed medications.


summary: 748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification

raw_content: It was found that a staff member did not receive their CPR training within 90 days of employment. Employment start was on 12/14/2020. Variance was not requested within these 90 days, it was requested on 04/09/2021.

Correction Narrative: On 06/02/2021, the operation emailed the following: "In an effort to prevent this from happening again, an agency employee became certified to train First Aid/CPR in-house. The Program Director shared with staff the importance of submitting necessary variances in a timely manner and adjusted staffing patterns to help ensure it happens consistently." In addition, the employee has been CPR trained as of 04/19/2021.


facility_name: Bluebonnet Haven, LLC

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

raw_content: During the review of the operations background checks three persons where not inactivated within 7 days of leaving the operation.


raw_content: During a walkthrough of the facility it was observed bathroom  tubs in each home had mildew in the corners and along the edges of the tubs.

Standard Number / Description: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

Correction Narrative:
RCCR staff received an email from Bluebonnet stating that staff will clean affected areas using a vinegar solution to remove any visible mildew. If vinegar is not effective, a diluted bleach solution will be used as an alternative treatment. Our maintenance technician will re caulk areas as needed, ensuring that only 100% waterproof silicone caulkmold-free or mildew-resistant with a 10-year ratingis applied.
Additionally, staff will instruct the residents to run ventilation fans for 1520 minutes after showers and to keep bathroom doors open to improve air circulation. The LCCA will conduct routine inspections to monitor for any signs of mildew and ensure continued compliance. Photos were also sent showing clean tubs.


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: During the course of a review of serious incident reports it was discovered that 1 incident report of abuse/neglect was not reported as soon as the operation became aware as required by minimum standards.

Correction Narrative: RCCR received an email from the operation indicating they will retrain all staff at the November monthly staff trainings. The Executive Director and LCCA will ensure that all Serious Incidents are reported to the hotline in a timely manner.


summary: 748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan

raw_content: During the course of the investigation, it was determined that a child in care required supervision with close proximity. However, staff did not verify the child's location, which resulted in the child being able to elope during an outing.

Correction Narrative: RCCR received an email from the operation indicating that retraining during our Decembers monthly staff meeting will be helping to ensure all staff members understand and maintain appropriate supervision for the girls at all times, including during off-campus activities. This specific situation will be reviewed to retrain on how it should have been handled using best practices. The December training is to be held on Shift 1: 12/16/25 and Shift 2: 12/4/25.


summary: 748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator

raw_content: During the unannounced walk through of the operation food was observed uncovered and not secured appropriately in the refrigerator.


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

raw_content: A staff member was observed yelling and using profane language outside to another staff member outside in the presence of children in care.

Correction Narrative: An email was received on 4.25.25. Attached was the training documentation from 4.25.25 showing the staff involved was retrained on professionalism.


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

raw_content: During the walkthrough of the operaiton the fill surface for the swings were observed having about 4 to 5 inches of loose wood material.

Correction Narrative: Proof of purchase was reviewed of the mulch ordered on April 2, 2025 from Living Earth Pineland.


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

raw_content: The time the medication was administered was not documented on the medication log.

Correction Narrative:
All staff trainings were reviewed to have been completed after the incident occurred on 1.10.25 and 1.30.25.
Interview was completed with the Pharmacy Tech/Nurse Assistant. This staff double counts the medications Monday-Friday. Items are reviewed and corrected, if needed.


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

raw_content: The staff member responsible for the child who eloped was inside the unit while that child and 2 others children were outside the unit. During this time, the two children helped the third child over the operation fence which led to the child eloping the operation.

Correction Narrative:
Inteviews were completed with children and this standard was found to be in compliance.
All staff training and inidividual trainings were reviewed to have been completed 3.19.25.


raw_content: Staff members were using vulgar language around a child speaking of another staff member. The language was later directed at a child for the incident the child had placed themselves in.


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

raw_content: A staff member attempted to kick a child in the head while the child was in handcuffs laying on the ground.


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

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


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

raw_content: Children mentioned staff use profane language at them. 1 staff member admitted to using profane language toward a child.

Correction Narrative:
A disciplinary action was completed with both staff involved in this incident. Staff signed the action. Documentation was received.
Additionally, this will be discussed in the upcoming trainings in January scheduled for 1.10.25 and 1.22.25.


raw_content: Children mentioned staff make fun of a child in care for their physical disability.


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

raw_content: A child was admitted on 12.7.23, however, documentation within their record was dated with the admission date of both 12.7.23 and 12.4.23.

Correction Narrative: An email was received by the operation on 7.8.24. It was explained the admission date was corrected and the corrections were noted within the record. Case Managers were also spoken with about how this occurred and how to prevent this going forward.


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

raw_content: Based on information gathered it was determined that a caregiver belittled the children in care when they made profane remarks about their families.

Correction Narrative: 3 children and 2 staff were spoken to.  The children stated they have not heard staff cussing at or around them.  They said if a staff does slip up they immediately apologize but it is rare and hasn't been recent.  The staff said they are reminded at the monthly meetings about not cussing around the kid and to not allow the kids to cuss.  They said on their shifts they haven't heard staff cussing.


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

raw_content: The operation did not report the serious incident. The child made allegations to a staff member of inappropriate physical contact with another child.

Correction Narrative:
An inspection was completed on 2.21.24. 1 staff member was interviewed and mentioned during the monthly staffing reporting and professionalism was discussed. Training documentation was reviewed for both 2.9.24 and 2.21.24.

The operation retrained staff on 2/9/2024 and on reporting to administration accurate and complete information so they can determine if an event is an incident report correctly.


raw_content: During a power struggle to retrieve a phone back from a child who was attempting to make an unapproved call, a staff member placed their hands on the child's wrist on 2 occasions.

Correction Narrative: Staff meetings completed for February and March were reviewed. SIRs, SAMA post EBI, child's rights, and discipline/TBRI were reviewed. A conversation was had with the Administrator about Satori upcoming training, as well as items from the Plan of Action that are still being implemented to reduce concerns regarding restraints.


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

raw_content: During the course of an investigation, it was found that a caregiver used force to get a child to comply.

Correction Narrative:
The following documentation was provided by the operations' representative.
A follow up inspection was completed on 1.10.24, INS #3983588. Employee files were reviewed and the memo regarding when EBI cannot be used was signed and filed.

An email was sent out to the operation explaining when EBI cannot be used and the appropriate times to use EBI. All staff signed a copy of the memo and it has been placed in their file. A reminder will also be given during the January trainings.


raw_content: A staff member was speaking to a child's parent via phone call with the child present. It was determined the staff was belittling the child during the conversation and being unprofessional with the parent.

Correction Narrative:
An inspection was completed on 2.21.24. 1 staff member was interviewed and mentioned during the monthly staffing reporting and professionalism was discussed. Training documentation was reviewed for both 2.9.24 and 2.21.24.

The Administrator explained the incident was addressed with the staff member directly after occurring. It was explained to the staff, in a situation such as this, to direct the person to the child's legal team. This directive will also be discussed during the all staff training on 2.9.24 and 2.21.24.


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: During a walkthrough of the operation, it was noted in a staff office there was a significant amount of medication that was described as discontinued when seen.  Staff identified it had been there approximately 5-6 months.

Correction Narrative:
An email was received from the operation on 11.28.23. The pharmacy came to pick up medications to be destroyed on 11.28.23, after numerous other failed attempts. The pharmacy denied the operation is allowed to drop them off. The operation asked the pharmacy to put them on a quarterly pick up schedule. In addition, another locked cabinet was purchased for discontinued medications to be placed in until they are able to be picked up by the pharmacy.

During an inspection on 12/11/23 medication stored in the medication closet in House 1 were observed to be locked appropriately.  There were no expired medications observed.


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

raw_content: There were more than 10 beds observed currently being used by children in care that did not contain a mattress protector or cover.

Correction Narrative:
An email was received from the operation on 11.28.23. Mattress covers were purchased on 11.14.23 after the inspection and placed on the beds that needed them. Extra covers are located in the office. A new daily walkthrough checklist was created that includes checking mattress covers.

During an inspection on 12/11/23 observation was made of all the occupied beds in House 1. They were inspected for mattress pads/waterproof liners.  All beds were equipped with the appropriate bedding.


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

raw_content: 1 tablet of a child's Cetrizine 10mg AM was left on the counter top in the medication room. This was  noticied during the walkthrough after 3PM.


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

raw_content: When reviewing documentation, it was observed that the operation did not complete medication error documentation timely.

Correction Narrative:
The department received an email from the operation explaining their compliance plan to reduce risk.

The nurse handling medications at this time is no longer employed at our operation, and we have our former nurse who is more versed in RTC compliance back with us.  Every time there is the weekly Dr. Day when girls are seen via telehealth for their psychiatric visits, the nurse will update the medication changes on each child's Information Sheet.  This will be placed in each child's MAR book so that it can be compared with the MARs and labels each time to ensure accuracy with medications.  Our Treatment Director verifies medication counts and ensures that all medications match and are accurate on the information sheet, MAR, and label.


raw_content: There is sufficient evidence to show that staff failed to document the events occurring during the search of a child.

Correction Narrative:
An in person follow up was completed on 8.21.23. A conversation was had with the Administrator and the training documentation was reviewed for the training which occured on 8.17.23..

An email was received by the Administrator explaining thorough documentation in general would be addressed with all staff in their August trainings, which occur on 8.17.23 and 8.29.23.


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

raw_content: A caregiver was observed on their cell phone and then working on paperwork when a child in care, who was on eyesight supervision, attempted to commit suicide in the bathroom.

Correction Narrative:
An in person follow up inspection, INV #3966967, was completed on 9.18.23 where this citation was found to be in compliance. The below training/meeting sign in sheet from 8.29.23 was observed and a conversation was had with the Administrator. The Administrator explained the definition of each supervision type was discussed, appropriate cell phone usage and time was discussed, along with explaining to staff they don't need approval before calling 911, you are to call then update the op on what is taking place.

An email was received from the operation on 8.28.23 explaining in the training on 8.29.23 they would add a refresher training for expectations on eyesight and 1 to 1 supervision, other types of supervision, and cell phone usage. The Administrator stated after Shift 1 completed their trainings, Shift 2 could complete this one refreshed for supervision the same day.


raw_content: It was observed in video footage that child in care was able to assault another child in care with multiple staff present. Some employees are observed to not having a reaction to try to stop the altercation.

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


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

raw_content: A child in care had a mark on their neck from wrapping a string around their neck. The child answered yes to all questions on a suicide screening, indicating this was a suicide attempt. This was not self-reported to Licensing.

Correction Narrative: The Administrator has spoken with the treatment team and have reminded everyone that they must self-report anytime that a child has made a true suicide attempt per Minimum Standards.


raw_content: Based on sufficient evidence gathered in an investigation conducted by DFPS, a child in care was abused.

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

Correction Narrative: In person follow up was completed and a discussion was had with the Adminstrator on 11.14.23. Compliance was completed June 2023 when an additional SAMA training course was given to all staff. The Administrator explained restraints are discussed in monthly staff meetings- when to use restraints, what techniques are appropriate, what areas to avoid during the restraint, along with randomly quizing the staff during walkthroughs. The Administrator explained the staff involved in this incident no longer works at operation. The background check was verified to be inactive.


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

raw_content: Based on interviews with children and staff and video footage, a staff placed a child in a chokehold when trying to break up a physical altercation between children in care.

Correction Narrative: In person follow up was completed and a discussion was had with the Adminstrator on 11.14.23. Compliance was completed June 2023 when an additional SAMA training course was given to all staff. The Administrator explained restraints are discussed in monthly staff meetings- when to use restraints, what techniques are appropriate, what areas to avoid during the restraint, along with randomly quizing the staff during walkthroughs.


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 was not seen by a medical professional after an attempted suicide.

Correction Narrative: An email was received on 8/2 stating that all staff are trained in first aid and CPR. The nurse asked all nursing questions and the staff answered. During the inspection on 8/4/2023 staff stated the renewal CPR/First Aid will be in August and they will review again when kids should go to the doctor/ER.


raw_content: During the investigation it was found two staff physically abused two children when completing two separate inappropriate restraints.

Correction Narrative:
An email was received by the operation.
All employees involved had their employment with Bluebonnet terminated.


summary: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back

raw_content: During the investigation it was found a staff member restrained a child placing the childs arms bent behind their back.

Correction Narrative:
An email was received by the operation.
1. All employees involved had their employment with Bluebonnet terminated. This was ensured to be true by inactive background checks, 9.21.23, KW.
2. All staff have been retrained appropriate SAMA techniques since this incident occurred, and will continue to get refresher training every 5 months or more frequent if needed.
3. Administration is completing reviews and staffings with all EBIs that occur on camera.
4. Actual video footage from campus is used in monthly trainings to model correct and incorrect SAMA techniques.


summary: 748.125(d)(4)(C) - Suicide Screening- Must be administered every 30 days after admission for children 10 years of age or older in a residential treatment center.

raw_content: Two suicide screenings were completed late.

Correction Narrative: On May 31, 2023 an email was received stating the Case Managers are now using a date calculator to ensure the date of the CSSRS screening falls within 30 days of the previous one completed.  They will be using the same Sticky Note reminder system on their computers that they use for service plan compliance dates to manage the dates for the CSSRS screenings done every 30 days.


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

raw_content: A child in care was pushed by a caregiver.

Correction Narrative:
An inspection was completed at the operation on 7.26.23. Children and staff were interviewed about staff involved. It was discussed with the operation that they had a meeting with all staff and they were retrained on SAMA and de-escalation in July. An AR will be requested.

An email was received on 7/21 stating staff was met with to discuss this incident. Staff was reminded to walk away from children if they feel they are getting frustrated or upset. This will be discussed with both shifts again.


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

Correction Narrative:
It was found during the investigation a child sustained injuries as the result of an improper restraint.

A training was completed with all staff on May 17, 2023 to go over EBI.  Staff were re-trained in appropriate situations to use restrains and how to properly complete a restraint when necessary.  Another training on practicing physical restraints is being scheduled for June with all staff to practice appropriate restraints.


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

Correction Narrative:
A child in care sustained injuries after being improperly restrained in a non-emergency situation.

A training was completed with all staff on May 17, 2023 to go over EBI.  Staff were re-trained in appropriate situations to use restrains and how to properly complete a restraint when necessary.  Another training on practicing physical restraints is being scheduled for June with all staff to practice appropriate restraints.


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

raw_content: It was noted that on several occasions staff appear to have used curse words at children based off of interviews completed.

Correction Narrative: The staff involved in this incident is no longer working for the operation.  The operation also retrained all staff on 03/22/23 in regards to how to communicate effectively with clients.  This training included not cussing at or around clients, not yelling at clients, and staff walking away when becoming upset to let other staff handle the situation.  Staff were reminded to use TBRI skills and profession, prudent judgement when working with clients.  Additional one on one training with staff is planned in the future as well as having them sign a contract on these matters.


summary: 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment.

raw_content: There is sufficient evidence to show staff have been demeaning children who self harm telling them they are attention seeking, not normal and minimizing the issue. There is also evidence the staff have been yelling and cussing at the children.

Correction Narrative:
Administrator sent an email stating
For all deficiencies noted, we will be speaking to specific staff that you mentioned to me on a 1:1 basis to discuss the findings and our expectations for their job performance, our program model, and expected compliance with Minimum Standards in regards to these deficiencies.  Progressive discipline will be followed for these employees, which can include written warnings, suspensions, and termination if warranted.  We will also re-train on all of these procedures and expectations with all of our staff in our November monthly trainings.
Admin stated they would not be requesting and Admin review.


summary: 748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids

raw_content: There is sufficient evidence to show a staff member is vaping inside the home the children live in.


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

raw_content: Multiple children's medication logs and count logs were reviewed and found to be incorrect in multiple spots and missing required information.

Correction Narrative: We were in a period of turnover in our nursing department.  Staff were responsible for counting meds on a daily basis.  We now have a medical assistant again that is counting meds Mon-Fri to ensure all is being done correctly.  I reviewed all protocols and expectation with her immediately following our contract monitoring visit.  We will also address all medication concerns listed in the findings with all staff in our August trainings this month on 8/18 and 8/30.