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

raw_content: The CLASS system shows the operation has not their people list since 05-02-2025 as of 08-04-2025.

Correction Narrative: 08-25-2025. The assigned inspector emailed the operation and asked if they already sent a compliance response. The operation replied; ": The Talent Onboarding Specialist received documented re-training on August 25, 2025 (attached to this email) and will ensure the RCCL Background Check Portal for Clementine Houston is updated on a regular basis. To maintain ongoing compliance, the Quality and Compliance Manager will monitor the completion of updates for the next 90 days."


state: TX

facility_name: Clementine The Woodlands

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

raw_content: An employee, was hired on September 12, 2023, and was missing their Pre-Employment Affidavit.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: Received a corrective action plan from the administrator with a new Pre-Employment Affidavit for the employee who was hired on September 12, 2023. Clementine will now ensure that employees hired after September 2023 have their Form 2912 included in their file.


summary: 748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility

raw_content: One of two employee records reviewed did not contain a TB test.

Standard Risk Level: Medium Low

Correction Narrative: The operation was able to provide a TB test for the caregiver.


summary: 748.363(4) - Personnel records-Personnel records-Include current job description.

raw_content: One of two employee records reviewed did not contain a job description.

Category: Reports and Record Keeping

Correction Narrative: The operation provided a copy of the job description.


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

raw_content: Three of three first aid kits did not have cotton balls or a thermometer.

Category: Safety and Emergency Practices

Corrected at Inspection: Yes


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: Two of two child records did not include the education, medical, or dental information. The treatment plans does not address the side effects of medication listed.

Category: Admission, Service Planning, Discharge

Correction Narrative:
The following corrective action plan was provided by the operation:
a.	The action(s) taken to correct each finding of non-compliance:

Additional questions were added to the preliminary service plan were the following items  questions to ask about the most recent medical exam and dental exam. If the child does not have a medical physician or a dentist, the treatment team will provide support to find a provider(s) and set up an appointment post discharge.

Educational needs will be indicated in the preliminary treatment plan next to the educational domain. If the educational needs are not known at the time of the completion of the preliminary service plan, the teacher will consult with the child's educational institution for needs.

Side effects of medications, question will be asked up on admission by the admitting nurse and will be indicated on the preliminary treatment plan by the clinical team. Follow up will be included in our bi-weekly updates if any side effects should be experienced by the child.

b.	The anticipated or requested time frame for completion of each corrective action not yet complete at the time of POC submission to the Division:
Update and change was completed on 12/03/2021.

c.	A plan for quality assurance activities intended to ensure ongoing compliance:
The clinical director will assess each plan when signing all documentation and will report during the next quarterly performance improvement committee meeting on compliance with this item. They will audit ten charts from the previous quarter and report back the percentage of compliance. This will remain an item until the compliance remains at 100% for two quarters in a row.

d.	The name(s) of each individual responsible for ensuring the implementation of each corrective action:
Clinical Director.


summary: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

raw_content: Two of two records reviewed did not contain an immunization record.

Standard Risk Level: Medium High

Correction Narrative:
The following corrective action plan was provided by the operation:
a.	The action(s) taken to correct each finding of non-compliance:
Nurse Manager notified of finding. An additional checklist was added to the electronic medical record, called Admission Diagnostics, Documents, and Attempts to Obtain, which will signal for the admitting nurse to collect the immunization records for each client.

b.	The anticipated or requested time frame for completion of each corrective action not yet complete at the time of POC submission to the Division:
Update and change was completed on 12/03/2021.

c.	A plan for quality assurance activities intended to ensure ongoing compliance:
Nurse Manager will report during the next quarterly performance improvement committee meeting on compliance with this item. They will audit ten charts from the previous quarter and report back the percentage of compliance. This will remain an item until the compliance remains at 100% for two quarters in a row.

d.	The name(s) of each individual responsible for ensuring the implementation of each corrective action:
Nurse Manager.


facility_name: Open Arms Open Hearts Foundation, LLC

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

raw_content: A child in care that needs to be supervised closely with a history of eloping/AWOL was able to get Open Arms Open Hearts Foundations roof of the house.

Correction Narrative: The agency submitted corrections via email. In response to the citation, Administrator retrained all direct care staff on supervision and how to recognize and redirect childhood aggression to ensure the safety of all children and staff involved.


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: A child in care had access and consumed raw foods from Open Arms Open Hearts Foundation refrigerator.

Correction Narrative: The agency submitted corrections via email. In response to the citation, Administrator gave all direct care staff a refresher training on storing raw foods to prevent contamination for the safety of the children. Staff has a log that has to be signed each time on the refrigerator on who cleans and stores all the raw foods in the home.


summary: 748.3367(1) - Bedding-Triple-deck beds are not allowed

raw_content: One bedroom was observed with a triple decker bunk bed.

Category: Physical Site

Correction Narrative: The operation removed the third bed from the bunkbed, resulting in a standard double-decker bunk bed.


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

raw_content: Evacuation diagram doesn t have the designated shelter in place nor the meeting place outside locations.

Correction Narrative: The Inspection was completed, and the operation was in compliance with the minimum standard


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: One bedroom was observed with five beds.

Correction Narrative: The operation had moved the additional bed in bedroom four back to its proper place in room two


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

raw_content:
 The first aid kits were observed to be  missing adhesive tape, scissors, thermometer, and tweezers.

Staff place thermometer and scissor in first aid kit.


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

raw_content:
A package of thawing meat was observed in the refrigerator without any plastic bag.

The meat was removed from the refrigerator and prepared for dinner.


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 does not have an updated fire inspection.

Correction Narrative: The operation emailed an updated copy of their fire inspection.


summary: 748.881(2) - General pre-service training curriculum-Includes measures to prevent, identify, treat, report suspicion of child abuse, neglect, and exploitation

raw_content: 3 of the 3 staff files reviewed did not include the required abuse and neglect training.

Category: Training and Professional Development


summary: 748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being

raw_content: children in care were not being properly supervised as they were allowed into a body of water to fish for crawfish and horseplay around the body of water.

Correction Narrative: The operation acknowledges the lack of supervision for our caregivers during weekend hours and has hired two caregivers supervisors to help support and enfore OAHA policies all seven days of the week.


raw_content: During inspection, it was noticed that 4 of 4 of the reviewed records were without medication side effects in their 72 hr prelimary service plan.

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

Correction Narrative: OAOH acknowledges the deficiency and has implemented corrective action to avoid probability of repeat findings. Case Manager B. Brydson will ensure at admission that each individual child's 72-hour preliminary service plan will list all medication side effects associated with their specific medications.


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 has not reported EBI quarter 2  April through June.

Correction Narrative: The operation submitted EBI quarter 2 and will make sure that EBI will be reported in a timely manner.


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

raw_content: A staff member initiated a restraint (by placing her hands on the child in care and began pulling him out of the car) for non-compliance which led to a nosebleed.

Correction Narrative: Open Arms Hearts will retrain the staff member in EBI de-escalation techniques. The staff member will be on a safety plan for the next 30 days. After speaking with the staff member regarding the restraint and being placed on a safety plan. The staff member declined to return to work.


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: During inspection of staff files it was noted that 1 out of 4 staff files reviewed did not have report abuse and neglect form.

Correction Narrative:
Email from Sherry Mullen Program Director:

AOH Acknowledges the importance of having this form completed by each staff member. We have
collected all signed forms from our current staff
and have implemented it into our new hire paperwork for future staff to complete during their
first week of training.


summary: 748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility

raw_content: It was noted that 3 out of 4 child records did not  have TB test result in their file.

Category: Child Care

Correction Narrative:
Email from Sherry Mullen Program Director:

All current residents that did not have a TB test
performed in the mandated timeframe have now been completed and we have added the TB mandate in our
admissions checklist as a quality, assurance to  make sure this is done in a timely
manner moving forward.


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: upon review of records it was notice that medication was not administered on the date prescribed by the doctor on Aug 11th. Medication was administered on Aug 17th after it was delivered to the operation on Aug 13th. The delivery is according to medication documentation from pharmacy.

Correction Narrative: I, Kerah Jones RCCR inspector received email correction from operation to have a designated person responsible for late night med drop offs


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

raw_content: Upon review of admission assessment it was noticed the signature page was incorrect with dates signed. The cover page of the assessment had an incorrect date of admission for child

Standard Risk Level: Low

Correction Narrative: inspector reviewed admission assessment of resident's file. File was corrected as well as a corrective action was sent via email.


summary: 748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child

raw_content: Time of restraint is missing

Deficiency Narrative: Time of restraint is missing

Correction Narrative: I, Kerah Jones RCCL inspector received an email from Sherry Mullen <smullen@openarmsopenhearts.org> on July 2nd with corrective action plan and updated restraint form.


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

raw_content: Missing telephone number, physical address , age, gender, admission date, resolution of the incident, names of witnesses.

Correction Narrative: I, Kerah Jones RCCL inspector, received email from Sherry Mullen <smullen@openarmsopenhearts.org>  on July 2nd. A corrective action plan and updated restraint form with requested information was correctly documented.


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

raw_content: A damaged pill was included in the count of the medication administered to a child.

Correction Narrative: inspector reviewed medication and medication logs. These logs have been corrected A corrective action plan was also emailed.


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

raw_content: A child's medication record was not in the medication binder for 3 days and the administered medication was not recorded.


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

raw_content: Two medication records were observed without a treating physicians name and one did not include what the medication was prescribed for.


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

raw_content:
A child's medication was not increased as per the
psychological, for a month.


facility_name: Unique Avenue

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

raw_content: Residential Child Care Regulation observed and photographed the operation's posted emergency evacuation plan to be without an exterior meet up location.

Correction Narrative: The administrator sent an email attachment with an emergency evacuation & relocation diagram illustrating the exterior designated meeting place(s).


summary: 748.3065(b) - Gas Inspection-Must keep most recent inspection report at operation to verify inspection date & findings

raw_content: During the inspection it was discovered that the Gas inspection is expired

Correction Narrative: The operation emailed an updated Gas inspection


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

raw_content: Three children in care stated that they have observed a caregiver asleep during overnight supervision.

Standard Risk Level: High

Correction Narrative: Child to caregiver ratio will be 1 to 10 during sleeping hours. Night caregivers will be continuously present awake and position themselves where they are able to hear and observe children sleeping throughout the night. Additional training will take place in reference to awake supervision with all staff. ***Staff will conduct an overnight inspection by March 10th to ensure that this is being followed.


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

raw_content: One out of the four service plan reviews were outside of the 90 day time frame. Additionally, one initial service plan was completed outside of the 45 day time frame.

Correction Narrative: The MDT will create and review a calendar to ensure treatment plans are completed within a 90 day time frame.


raw_content: One medication record did not have the amount administered for three days.

Standard Number / Description: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

Category: Medication

Correction Narrative: Staff will receive additional training on recording medication administered to residents


summary: 748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation

raw_content: Medication was being prepared a day in advance for administration.

Correction Narrative: The operation will provide staff with additional training on medication administration procedures.


raw_content:
Medication for two children was discontinued on 2/26/21 but was administered up until 3/7/21 and 3/9/21.
One childs medication was increased to twice a day on 2/26/21, however the child continued to have the medication administered once a day until 3/9/21; two of the childs medications dosage was increased on 2/26/21, but the child continued to get the lower dose until 3/1/21 and 3/2/21
On childs medication was given twice a day instead of once of day from 2/1/21 to 3/2/21; one of her medications was given QAM instead of QHS
From 2/1/21 to 2/20/21 one child received medication once a day instead of twice a day; from 2/26-21 to 3/9/21 the child received 4mg instead of 2mg of a medication.

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


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: The operation was opened in November 2020 but does not have all medication logs prior to February 2021. The operation admitted to shredding the documents.

Correction Narrative: We will maintain a child's complete record from admittance to discharge for two years from the date of discharge, or until the resolution of any investigation involving the child, whichever is longer.


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

raw_content: It was determined that a caregiver yelled in a child's face.

Correction Narrative: The operation will train staff again on proper discipline.


summary: 748.1101(b)(3)(A) - Children's rights-communicate in language or other means understandable to child; have at least one person at all times who can communicate with child

raw_content: It was determined that two residents are not allowed to speak their native language.

Correction Narrative: The operation has spoken with staff about the importance of residents being able to speak in their native language.


raw_content: It was determined that a caregiver did not provide adequate overnight supervision to the children in care.

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: Staff will be trained again on proper protocol when supervising residents.


facility_name: Saint Francis Ministries - Residential Texas

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

raw_content: One out of ten child right's was not signed at the time of admission.  An additional child refused to sign the rights of children and additional attempts to have the document signed have not been completed.

Correction Narrative: Operation administrator stated that all records were reviewed and they ensured that residents had signed rights of children in care.


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

raw_content: One out of three service plans reviewed did not contain updated information related to psychotropic medication appointments.

Correction Narrative: this standard is complaint.


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

raw_content: The operation failed to obtain timely medical care for a child after they ingested over the counter medication during an unauthorized departure.

Correction Narrative: This standard is now compliant.


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

raw_content: The operation provided two incident reports documenting separate incidents occurring on separate dates but included identical information regarding the circumstances.

Correction Narrative: This is compliant


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

raw_content: A caregiver yelled profanities at a child in care.  A caregiver also ridiculed a child in care's appearance.

Correction Narrative:
The caregiver directly involved in this incident was required to complete the Mandatory Reporting training and coaching session according to HR policies for personnel disciplinary procedures.

Additionally, it was reported that all caregivers had completed mandatory training on program regulations and minimum standards on November 13, 2024. Caregivers who were not available for the face-to-face training concluded the training virtually. The facility inspection did not reveal any areas of concern.


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

raw_content: The operation failed to ensure appropriate medication count for a prescription medication.

Correction Narrative: Standard is now compliant


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

raw_content: A caregiver failed to demonstrate employee responsibilities when he participated in aggressive horseplay with a child in care, pushing the child down two times.


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

raw_content: A caregiver used an inappropriate form of EBI when a child in care was drug by her feet in a supine position.

Correction Narrative:
During a follow-up inspection at the facility, four caregivers stated on October 16, 2024, that a mandatory training session was held to educate them on various techniques to use when de-escalating behaviors in individuals. It was also noted that supervision and additional education minimum standards and restraint methods were discussed during the meeting.

Caregiver directly responsible in this incident has been terminated from employment as of 8/27/2024.


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

raw_content: A caregiver used an unapproved form of EBI as a means for a child to comply with an instruction.


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: Two caregivers were present and aware that a staff was utilizing an unapproved form of EBI and did not report or intervene for the safety and well-being of a child in care.


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

raw_content: A caregiver at the operation failed to follow operation policies when overnight bed checks were not conducted as required every 10 minutes.


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: A caregiver utilized tobacco products during shift when job responsibilities included providing supervision for children in care.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: Caregivers failed to ensure the safety and supervision of a child in care when she left the operation without permission 4 separate times during a 12 hour period of time.


raw_content: Caregivers aware of a child's frequent elopements left the child unsupervised for at least 8-10 minutes allowing the child ample time to leave without permission.

Standard Number / Description: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

Correction Narrative:
on 09/18/2024 an email received from Administrator with a Program Improvement Plan for compliance. The whiteboard with information about youth stabilization and safety plans will be moved to the staff office from the breakroom making it more visible and the information more readily available for direct care staff to review daily when they come on shift.
Therapist received e-mail communication with reminders about the importance of completing stabilization/safety plans in a timely manner, sending out the appropriate notifications when they are implemented and/or changed, and ensuring a copy is placed next to the whiteboard for easy access to direct care staff.
On September 16, 2024, the administrative team began participating in Daily Stand-Up Meetings where information is shared regarding children from incidents from the day before, off campus, sick bed, truant, one-on-one, shadowing, stabilization, off campus appointments and admissions and discharges. In relation to youths with high instances of runs, during the meeting supervisors communicate about incidents from the day before and therapist discussed current stabilization/safety plans. After the meeting, supervised ensure direct care staff are made aware of the current and updated stabilization plans to ensure they are aware of which youth are under sight and sounds supervision plans or more stringent supervision plans.
Follow up inspection completed on 09/24/2024. Per interviews with staff, meetings are held in the mornings with administrative team then supervisors ensure BHT are aware of any special supervision need and another meeting is held at shift change with BHT's.


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

raw_content: The child's service plans reviewed did not include high risk behaviors.

Correction Narrative:
Inspection Number 4019850 on 09/18/2024
Reviewed training attendance sheet regarding service plans. Training was provided on September 12, 2024. Discussed with administrator the importance of completing thorough service plans. Administrator indicates new systems in place to complete and review service plans routinely for accurate information and updates.


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

raw_content: A child in care was absent from the operation for more than 6 hours before it the incident was reported to law enforcement.

Correction Narrative:
Inspection Number 4019850 on 09/18/2024
Reviewed training attendance sheet regarding reporting serious incidents. Training was provided on September 12, 2024. Discussed with administrator reporting criteria. Administrator indicates new systems in place to guide and track reporting for staff on duty at the time of incident.


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

raw_content: A child in care was absent from the operation for more than 6 hours before it the incident was reported to the parent.


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

raw_content: The operation did not report the absence of a child in care for more than six hours to the hotline.


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

raw_content: The child's service plan was not updated with correct information regarding runaway prevention.


summary: 748.303(a)(9)(A) - Serious Incident-Report to CCL within 2 hours of notifying LE the absence of a child developmentally/chronologically 6 to 12 years old.

raw_content: The operation did not report the absence of a child in care to the hotline within two hours of notifying law enforcement.

Correction Narrative: Director held a training with assistant director and supervisors to go over minimum standards and reporting requirements. In the training they discussed reporting early instead of waiting to ensure time frames are not missed. A folder was also put together with guidelines for reporting and when to report.


summary: 748.303(a)(9)(C) - Serious Incident-Report to law enforcement w/in 2 hrs of determining absence of a child developmentally/chronologically 6 to 12yrs.

raw_content: A child in care was absent from the operation for more than 2 hours before it the incident was reported to law enforcement.


summary: 748.303(a)(9)(B) - Serious Incident- Report to parents within 2 hours of determining absence of a child developmentally/chronologically 6 to 12yrs.

raw_content: A child in care was absent from the operation for more than 2 hours before it the incident was reported to the parent.


summary: 748.1337(b)(1)(A)(vi)(I) - Initial Service Plan - Normalcy - Include plans for social, extracurricular, recreation, and leisure activities

raw_content: Three out of three service plans reviewed did not contain specific information related to normalcy activities at the operation.

Correction Narrative: The opeation has reviewed the documentation for service plans in order to ensure that it includes all required information.  This information has been revieweed with case management staff in order to enusre they are aware of the requirements.


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

raw_content: Multiple medication errors were not approprpiately documented.

Correction Narrative: The operation has developed a plan to ensure that any medication errors are documented in a timely and consise manner.  They have spoke with all staff and put in place a second person to review medications on a daily basis in order to ensure all medications have been appropriately dispensed.


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

raw_content: Two staff conducting routing visual supervision of a child in care failed to intervene when the child had attempted self-harm by tying a plastic bag around their neck.


summary: 748.2551(b)(1) - EBI Implementation-The caregiver must consider the characteristics of the immediate physical environment

raw_content: A caregiver implemented a personal restraint in a public venue, in view of onlookers to intervene in an unauthorized absence after the child had left the facility and law enforcement had been notified.  There was no immediate danger to the child.

Correction Narrative: According to the Operations Director, an all-staff meeting was held on May 3, 2024, to address the appropriate use of restraints with youth. Staff were advised during the meeting to only use restraints on children if they present a danger to themselves or others. Additionally, caregivers were instructed to keep a close watch on children who try to leave the facility so that law enforcement can be informed of their whereabouts if necessary. For the safety of the children in care, caregivers will no longer restrain them in public unless there is a threat to their well-being. The sign-in sheet from the meeting will be added to the document library for reference.


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: A caregiver at the operation with restricted duties was providing sole supervision for a child in care.

Correction Narrative:
An operation walkthrough was completed without any issues. Following a discussion with the administrator, it was confirmed that there are no current employees with provisional status working around children.

The inspector was informed via email by the operations Executive Director that any changes in an employee's background status will prompt the organization to receive a provisional status notification. In the case that the employee holds a client-facing role, a provisional status will lead to termination. Re-application for a vacant position will be allowed if the provision is cleared. Employees in non-client-facing roles must undergo a risk evaluation process to transition from provisional to eligible or conditional status. Failure to meet the eligibility criteria will result in termination.


summary: 748.1117 - Documentation of searches-Caregiver documents searches in the child's record

raw_content: A child in care returned from runaway status and the search conducted by staff was not documented in the child record.

Correction Narrative: An email was received from the operation administrator.  It stated that they have updated documentation regarding searches of both youth's person and bedroom.  This new form has been uploaded into the operation's online electronic record system.  The administrator will ensure that all staff are aware of the documentation requirements and the information that must be documented on the search form.


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

raw_content: A caregiver failed to use prudent judgement when she allowed a child in care to put lotion on her ankles and feet and failed to use appropriate language after being provoked by a child in care.

Correction Narrative: An inspection was completed at the operation on 2/26/24. The staff member involved in the incident is no longer employed at the operation and this was verified during the inspection.  Administrator will have discussion with all direct care staff regarding professional boundaries, including the need for "huddles" when appropriate.  Staff members will sign documentation that they are aware of the policy.


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

raw_content: Operation staff failed to follow policy regarding cell phone and social media usage while on duty and in the presence of children in care.

Correction Narrative: Follow up was completed at the operation on 2/26/24.  Inspector spoke with the operation Administrator.  She reported that all staff have reviewed the policy and signed that they will abide by the cell phone procedures. On going staff training will discuss cell phone policies and procedures for when working with the children in care. No staff were observed with cell phones present on the unit during inspection.


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 caregiver failed to provide appropriate supervision and a child in care was able to use outside objects to climb on the roof of the operation.

Correction Narrative:
An email was received from operation administrator which indicated that the following policies were reviewed with the staff member, which included procedures for the treatment program, interventions for residents, active treatment for all groups during activities as well as supervision requirements.  This information was reviewed individually and will be reviewed with all staff members.

An inspection was completed on 1/12/2024 and staff were observed to be providing appropriate supervision during mealtime.  No concerns were noted.


raw_content: A caregiver failed to use reasonable judgement when a child in care obtained access to the caregiver's cell phone and viewed inappropriate pictures.

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 email received from the operation Executive Director stated that they have provided all staff with additional information related to cell phone use on the unit.  Additional education and training was provided to staff member.  Cell phone use is also restricted to areas not occupied by youth and appropriate measures are taken to ensure cell phones and their content are not accessible to youth.


raw_content: Overnight caregivers did not conduct bed checks during sleeping hours according to operation policies.

Standard Number / Description: 748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures

Correction Narrative: An emailed was received from the Executive Director which stated that all staff will review the policy regarding overnight checks.  Administrative staff will review video footage to ensure that checks are being completed and documented appropriately.


summary: 748.125(d)(6) - Suicide Screening- Must be documented.

raw_content: An operation staff reported that the initial suicide prevention screening was completed but not documented.

Correction Narrative: An email received from operation Executive Director reports that the previous suicide screening was completed but did not properly save due to a new software program.  The operation will ensure that when complete the suicide screening that is saves appropriately.  Records will be audited to ensure that all appropriate screenings are completed and documented in the child's record within the required time frames.


raw_content: A caregiver had possession of a vape on the unit.  The vape fell out of her pocket and became accessible to children in care.

Correction Narrative: An email was received from the Executive Director which stated that the operation does not allow any vapes or tobacco products on the campus.  All staff members are provided with the operation policy regarding tobacco products at the time of employment.  The staff member involved in this incident is no longer employed by the operation.


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

raw_content: Agency staff did not intervene immediately when a suicidal child ran out of the facility and self-harmed with glass.

Correction Narrative: An inspection was completed at the operation and I spoke with the Executive Director regarding this citation.  She stated that they had done individual coaching with the staff member involved in the incident which discussed early intervention, verbal de-escalation and utilizing MAB when it becomes necessary.  She stated that the staff member will be provided with one on one training regarding the MAB holds, specifically on how to safely remove an object from someone's hand, as well as personal safety of the staff.  She stated that she hopes that the additional training will increase the comfort level of the staff member.


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

raw_content: Three out of three child records reviewed did not contain information related to previous dental status or upcoming dental appointments that have been scheduled.

Correction Narrative: The operation director submitted an email which stated that the information related to the prior dental and vision exams will be added to the service plans.  The program improvement plan includes having additional training provided to case management staff, as well as the Clinical Director reviewing the completed service plans to verify accuracy.


summary: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction

raw_content: The operation was unable to access the employee training records for licensing immediate review.


summary: 748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation

raw_content: The operation did not have appropriate documentation related to fire and severe weather drills.

Correction Narrative: The Executive Director for the operation has developed a system to ensure that all emergency drills are easily accessible.  Drills will be reviewed on a monthly basis in order to ensure records are current and complete.


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

raw_content: A child in care intervened in a physical altercation between two other children in care by restraining the aggressing child and escorting the aggressing child away from the victim.

Correction Narrative:
On June 26,2023 the Executive Director provided a corrective action plan via email indicating all staff would be retrained in EBI policy and procedures.

On June 29, 2023 unannounced inspection 3955540 verified the following information:

The staff who allowed a child to perform an EBI restraint and escort is no longer employed by the operation and was not present.  The people list for the operation reflects the staff as inactive.

An interview with the Executive Director confirms the EBI training has been updated to focus on early detection and warning signs of emergency behaviors as well as early de-escalation and intervention by staff to prevent children and untrained persons from performing any interventions.  Training for active staff is underway and all staff will receive the updated training within 30 days.


raw_content: A suicide risk screening conducted verbally on May 7, 2023 was not documented until June 2, 2023.

Standard Number / Description: 748.125(d)(6) - Suicide Screening- Must be documented.

Correction Narrative: Per an email from the Executive Director on July 14, 2023, the Executive Director, Clinical Director, and or Therapist will conduct reviews of all incident reports and documentation to ensure Suicide Risk Screenings have been documented timely.  All Clinical Staff will be provide Suicide Screening policies for review and signature acknowlegment by July 28 2023.


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

raw_content: Three records reviewed did not have an admission assessment was not completed prior to admission. The professional level service provider must sign and date the admission assessment prior to admission.

Correction Narrative: An email from the Executive Director for the operation has emailed an updated admission assessment which includes all the information as required by the standard.  The form will be reviewed by both the Clinical Director as well as the Executive Director for the operation.


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

Correction Narrative:
Medication logs did not contain accurate medication count for prescription medication.

5.30.2023 Medication logs were reviewed and found compliant with all criteria of 748.2151.


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: One record reviewed did not contain detailed information regarding the emergency discharge of a child in care.

Correction Narrative: An email was received from Executive Director for the operation.  The discharge summary was updated to include all information as required by the Minimum Standards.  This will be reviewed by both the Executive Director, as well as the Clinical Director.


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

raw_content: A medication record showed that a child in care did not receive a prescribed medication for 4 consecutive days.

Correction Narrative: An emailed was received from the Executive Director for the operation.  A copy of the MAR, as well as bubble pack, showed that the medication was administered appropriately on the night of 5/8/23.  The operation will be retraining staff regarding medication administration.  Clinical staff will conduct 2 medication audits per month.  The operation will also have the nurse observe medication administration for all staff to ensure it is being completed appropriately without error.


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

raw_content: Two of two admission assessments reviewed lacked the legal status, current medical status, dental status, mental health status, substance abuse history, developmental function, education needs, services that will be provided, goals of placement, parents expectations of placement, and/or the child's understanding of placement as required under subsection b of this standard.

Correction Narrative: Per an email from the Executive Director, the admission assessment template has been updated to include prompts for all required information.  A copy of the updated format will be uploaded to the SharePoint.  An unannounced inspection (#3954563) conducted on June 22, 2023 found that no new admissions have been completed since the form was updated.  An interview with the Administrator confirmed the CPMS staff have been provided additional coaching for completing admission assessments and all assessments will be subjected to a secondary review, approval, and signature by the Administrator prior to admission of each child.


summary: 748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks

raw_content: Two children with histories of elopement and suspected of planning an elopement were allowed to participate in outdoor activities from which they eloped on two separate dates.  Caregivers failed to consider the risk of allowing the children to participate in the activities.

Correction Narrative: Per an email from the Executive Director, staff have been provided supplemental training regarding supervision and recognizing risks of elopements.   An unannounced inspection (#3954563) confirmed training has been deployed and management has released staff who were not a strong fit for providing supervision to meet the needs of the children served by this type of facility.


facility_name: AT LAST!, Inc.

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: Operation did not submit EBI information for quarter 3.

Correction Narrative: The operation submitted EBI data for the third quarter. The operation set automatic calendar reminders to go off two days before the due dates to ensure the data is submitted timely. The operation emailed screen shots of the calendar to verify.


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

raw_content: Three staff files were reviewed, and one staff file did not include TB test results.

Category: Personnel

Correction Narrative: The staff completed a new TB test that includes the results. These documents were reviewed by RCCR Inspector.


summary: 748.915(b)(4) - Pediatric CPR training documentation must include the trainer's name and qualifications.

raw_content: Two of three staff CPR certificates reviewed did not include the trainer's qualifications. The certificates also did not include the length of the training.

Correction Narrative: The operation provided documentation to show the missing information on the training certificates.


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

raw_content: During the inspection three fire extinguishers were observed to have expired in April 2024.

Correction Narrative: Agency sent pictures of the new fire extinguisher tags by email on May 6, 2024. RCCR Inspector reviewed fire extinguisher tags in the email to show they were in compliance. Further during the inspection on June 6, 2024, the fire extinguisher tags were observed to be in compliance.


summary: 748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer.

raw_content: One staff's file contained reference checks that did not include all required information about the reference.

Correction Narrative: Agency Administrator emailed RCCR Inspector a copy of the staff's pre-employment reference check with the needed corrections on May 3, 2024.


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

raw_content: The medication cabinet was unlocked during the inspection. Non-prescription ointments were stored in an unlocked cabinet that was accessible to children.

Correction Narrative: An unannounced follow-up inspection was conducted and the medication cabinet was locked. The ointments were observed to be locked in the Wellness Closet.


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

raw_content: Operation runaway log did not have information for the gender date of admiission or if law enfrocement was contacted.

Correction Narrative: The operation has updated their documentation as per minimum standard.


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

raw_content: Three of the three child files that were reviewed did not document the date the preliminary service plan was completed.

Correction Narrative: The operation has updated their documentation and policies as per minimum standard.


summary: 748.4111(b)(1) - Transportation records-Must maintain the insurance verification in the vehicle

raw_content: Van used to transport children did not have current liability insurance.

Category: Transportation


summary: 748.2051(1) - Medication Self-Administration-The child's parent must give written authorization

raw_content: A child in care was self administering an inhaler and there was no documentation.

Correction Narrative: The operation has updated their policy to allow children with medication to be admitted and the operation will follow all standards regarding self-administrating medication.


summary: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

raw_content: Child admission assessment did not have immunization record and other important information.


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

raw_content: The operations did not have all documentation completed documentation was contractidcing on dates and information.

Category: Organization and Administration

Correction Narrative: The operation has implemented internal audit process to ensure operation records are true and accurate.


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: The operation  allowed a caregiver to have contact with the children in their admission assessment program prior to the caregiver having a TB screening completed.

Correction Narrative: Operation has developed a policy to ensure the operation stays in compliance.


summary: 748.539 - Child-care administrator must designate a licensed child-care administrator responsible for the operation while the administrator is absent

raw_content: The operation had designated a volunteer to be reponsible when the administrator was not at the facility.

Correction Narrative: Operation has hired staff that can occasionally handle administrators' responsibilities when the administrators is absent. A staff member will be at the facility daily (except Friday and Saturday). As children are admitted AT LAST! will begin to operate on a multiple shift schedule.


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

raw_content: Two lighters were located in a drawer in the common living area.


summary: 748.3111(a) - Smoke Detector-Administrator or designee must test battery-operated smoke detectors monthly; date tested & name of employee that did test documented

raw_content: AtLast! policy does not document the information needed when conducting a monthly smoke alarm detecter.


summary: 748.3369(d) - Bedding-A bunk bed must be equipped with a securely attached ladder capable of supporting the child using the bed and an employee

raw_content: Bunkbeds in all bedrooms were missing the ladder.


summary: 748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation

raw_content: At Last! does not have written relocation plan.


summary: 748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate.

raw_content: The operations policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate.


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: At Last! discipline policies does not document that making a child do physical exercise as discipline is prohibited.

Category: Discipline and Punishment


summary: 748.125(c)(1)(B) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes the understanding of safety planning.

raw_content: The operations policy does not indicate which suicide prevention training curriculum staff/volunteers/non-employees will be required to take.


summary: 748.2271(1) - Adopt and Implement a written policy that complies with the unassigned epinephrine auto-injector requirements set by DSHS.

raw_content: At Last! medication policies does not document requirements regarding administering epinephrine auto-injectors


summary: 748.345(5) - Electronic records policies - Limit access to persons within operation authorized to view specific information in file

raw_content: Operation policy did not specified who has acess to the records.


summary: 748.125(g)(1)(B)(i) - Your written action plan must include a communication strategy consistent with 748.125(g)(1)(B)(i)(I)-748.125(g)(1)(B)(i)(VI) of this subsection.

raw_content: The operation's Suicide Prevention, Intervention, and Postvention Policy does not include a detailed plan for Postvention plans and protocol.


summary: 748.724(a) - Volunteer/contractor of organization subject to operation policies/procedures unless org provides screening/training/supervision that protect children

raw_content: At Last! does not have policies and procedures regarding volunteers contracting with other organizations.


summary: 748.3063(a) - Gas Inspection-If operation uses natural gas, licensed plumber or gas company official must conduct gas leak inspection

raw_content: At Last! safety policies does not document who must conduct a gas inspection for the operation.


summary: 748.3237(a) - Safety Practices-Closet door latches must allow children to open door from inside of closet

raw_content: At Last! safety polices does not include these additional safety provisions


summary: 748.3065(a) - Gas Inspection-Gas inspection report must show operation's gas system is free of leaks, must include inspection date & inspector name, phone number

raw_content: At Last! safety policies does not document what documentation is required for gas inspections.


summary: 748.3061 - Gas Inspection-Operation must be inspected for gas leaks

raw_content: At Last! safety policies does not document when the operation needs to be inspected for gas leaks.


summary: 748.125(d)(4)(B)(ii) - Suicide Screening- Must be conducted at admission for children under 10 yrs if parent who admits the child or operation requests a screening.

raw_content: The Suicide Prevention Intervention and Postvention Policy submitted by the operation does not indicate when Suicide Risk Screenings will be completed for specified ages of the children admitted to the operation.


summary: 748.125(g)(2)(E) - You must offer mental health resources for children and staff who have a difficult time coping.

raw_content: The policy does not address all areas of the Addressing Suicide Attempts.


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

raw_content: Childrens bedrooms did have appropritate window covers to provide privacy.


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

raw_content: The operation admission policy did not specify the gender they will provide services for.


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

raw_content: Grass at the facility was overgrown.

Deficiency Narrative: Grass at the facility was overgrown.

Correction Narrative: Grass at the facility was overgrown.


summary: 748.3369(d) - Bedding-A bunk bed must be equipped with a securely attached ladder capable of supporting the child using the bed and an employee

raw_content: Bunkbeds in all bedrooms were missing the ladder.


summary: 748.3351(2) - Interior Space-Provide personal storage space in the child's bedroom for each child's clothing and belongings

raw_content: 4 out 4 Children's bedroom did not have a designated space to store clothing for their belonging.


summary: 748.721(a) - Volunteer personnel record-The operation must maintain a personnel record for each volunteer

raw_content: At Last! policies and procedures does not document that a personnel record will be kept for volunteers for the operations.


summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: The operation does not indicate the ages of the children they will screen. The operations states they will screen quarterly, however, the standards indicate that a child should be screened every 90 days.


summary: 748.2253(a)(5) - Operation employs professional who prescribes psychotropic med-Prescribing professional describe accompanying risks to consenter before consent given

raw_content: At Last! psychotropic medication policies does not include the following information: a description of any accompanying discomforts and risks, including those which could result from long-term use of the medication, and possible side effects, including side effects that are known to frequently occur in persons, side effects to which the child may be predisposed, and the nature and possible occurrence of irreversible symptoms; a statement of whether the medication is habituating in nature; alternative interventions to the use of psychotropic medication that have been  attempted and that have been unsuccessful; other alternative treatments or procedures to the use of the psychotropic medication; risks and benefits of the alternative treatments or procedures; and risks and benefits of not receiving or undergoing a treatment or procedure.


facility_name: Helping Hand Home for Children

summary: 748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment.

raw_content: 3 of 3 files were missing the pre-employment affidavit.

Correction Narrative: Staff stated they have a tracking spreadsheet that is used for pre-hire and onboarding of new hires to track required documents and ensure they are being completed. Quarterly audits of personnel files are being conducted to verify completeness of the staff files.


summary: 745.621(a)(1) - Initial background checks submitted - At the time you submit your application

raw_content: It was found a staff member hired in 2024 does not have a background check.

Correction Narrative: Staff stated they have a tracking spreadsheet that is used for pre-hire and onboarding of new hires to track required documents, and background checks, and ensure they are being completed. Quarterly audits of personnel files are being conducted to verify completeness of the staff files.


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

raw_content: Review of the medication logs for two children showed that there were discrepancies in the count of medication.


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

raw_content: Through interviews and documentation reviewed, staff were not following an active safety plan of 1:1 supervision for a child in care.


summary: 748.3475(a)(2) - Safety Requirements-The administrator or designee must inspect the equipment and surfacing material for broken or missing parts

raw_content: It was found that a slide on one of the playgrounds has been broken for 4 months and a child in care was able to play on it, resulting in an injury.

Correction Narrative:
An in person inspection was conducted at the operation. Outdoor play areas were observed. The slide is currently roped off so children do not have access to it. The operation has the new slide on site and it will be installed on 4.4.25 by the manufacturer.

4.8.25 - the operation sent an email reporting that the new slide needed some alterations to fit correctly. A receipt from the manufacturer was submitted to licensing showing that service was paid for and they are waiting on a tech to come out for installation. The receipt can be found in the document library.


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

raw_content: A child's medication log did not have the reason the medication was prescribed.

Correction Narrative: Email received from the operation stating that a new Healthcare Team Member failed to put the necessary information, so she will be supervised to ensure that she follows through on doing so in the future.


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

raw_content: When reviewing documentation, it was determined that a child in care received medical care, and this wasn't reported until 28 hours later.

Correction Narrative: During an in person follow up inspection at the operation, the medical care policies were reviewed with no concerns noted.


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

raw_content: It was found during the investigation an escort and a restraint occurred that were not documented.

Correction Narrative: During an in person follow up inspection at the operation, interviews with the administrator and clinical director were conducted discussing EBI and the EBI policy was reviewed. The operation will retrain and shadow the staff member involved in this incident. The operation has also requested an administrative review of this citation.


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

raw_content: While conducting interviews, one of the staff members stated they escorted a child to their room when the child refused to go.


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

raw_content: It was identified that that a caregiver used EBI that was not warranted.

Correction Narrative:
The operation suspended the staff in question, will hold additional EBI training monthly that will result in staff receiving 8-10 hours of EBI review. Amongst topic that are reviewed are types of containments and justification for containments. Also using switching out with other staff when feeling frustrated. The operation will also have group staff meeting exploring this incident and reviewing how to handle this type of incident.
A follow up inspection #4037255 was conducted at Helping Hand Home on 1/8/25, interviewing 2 children and 2 staff members regarding ratio, Emergency Behavior Interventions, appropriate communication with children, managing frustration with children, and medical protocols, chain of command. No concerns were noted on these topics.


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

raw_content: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401, as a caregiver strained a child's arm after grabbing them by their arm and escorting the child into their room.

Correction Narrative:
The operation suspended the staff in question, will hold additional EBI training monthly that will result in staff recieving 8-10 hours of EBI review. Amongst topic that are reviewed are types of containments and justification for containments. Also using switching out with other staff when feeling frustrated. The operation will also have group staff meeting exploring this incident and reviewing how to handle this type of incident.
A follow up inspection #4037255 was conducted at Helping Hand Home on 1/8/25, interviewing 2 children and 2 staff members regarding ratio, Emergency Behavior Interventions, appropriate communication with children, managing frustration with children, and medical protocols, chain of command. No concerns were noted on these topics.


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

raw_content: It was discovered during the course of this investigation that a caregiver used physical force to get a child to comply and made inappropriate comments to a child in care.


summary: 748.937(c)(4) - Annual training hours-Time spent presenting training to others can not be counted toward annual training requirements

raw_content: A Program Manager who facilitated the EBI training in October 2024 signed off on their own training hours. It was explained the trainers are recertified every 2 years and receive their bi-annual EBI training hours from facilitating trainings.

Correction Narrative:
An email was received on 12.17.24 from the Director of Clinical Services. It was explained the Director of Residential Services would ensure that all staff would receive EBI as required 2 times a year.
A follow up email was received from the Administrator stating that he is a master trainer and will provide the training for the trainers. The goal is to have them trained by the end of Jan. 2025. The administrator said that he is trained by the creator of SAMA every two years.


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 exhibited signs of an injury and did not receive medical care for about 14 hours after the injury occurred.


raw_content: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 after failing to get timely medical care for a child who had dislocated their hip.

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:
The operation indicated that the two staff in question were terminated. They will offer supervision to staff that included when a child is injured that they are to notify any of the following positions if they are on campus to receive guidance and instruction on how to best manage the situation: Health Care Manager, Health Care Coordinator, Program Manager, Director of Clinical Services, and Director of Residential Services. They will provide cell phones for all if these positions are not present. Beginning February 2025 a registered nurse to the staff in order to assess injuries.
A follow up inspection #4037255 was conducted at Helping Hand Home on 1/8/25, interviewing 2 children and 2 staff members regarding ratio, Emergency Behavior Interventions, appropriate communication with children, managing frustration with children, and medical protocols, chain of command. No concerns were noted on these topics.


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

raw_content: During the inspection, a caregiver had contact with children on 10/30/23 but did not have an eligible background check until 11/7/23.

Correction Narrative: The operation has implemented a system for verifying eligibility before allowing new hires to contact children in care.


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

raw_content: During the investigation, a caregiver admitted to utilizing an inappropriate EBI when she pulled a child by the wrists to his room when he dropped to the floor.  There were no injuries.

Correction Narrative: Caregivers was immediately terminated, and staff were provided training by Program Managers regarding appropriate interactions with children in care.


summary: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child

raw_content: During the investigation, it was found that a child's right wrist was strained during a restraint conducted by a staff and the child received medical care for this. It was reported by collaterals that this staff holds too tightly during restraints.


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

raw_content: During the course of this inspection, it was determined that a caregiver used inappropriate language in front of children and used unnecessary force on a child.


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

raw_content: During the investigation, a Service Plan for a child in care had several areas where a different child's name was listed.

Correction Narrative: The operation has implemented a process whereby two staff members review service plans before they are entered into the electronic system.


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

raw_content: One of four child records reviewed showed the child participated in the service plan on 1/10/24 which is after the service plan meeting took place.  The service plan meeting was completed on 1/4/24. The remaining three child records reviewed did not have a date indicating child participation.

Correction Narrative: This starndard is compliant.


summary: 748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents

raw_content: Five of five child records reviewed did not have the 14 day notification to the parent included in the chart record.


summary: 748.363(14) - Personnel records-Include date and reason for the person's separation from the operation, if applicable

raw_content: One of four records reviewed was missing the date and the reason for separation in the personnel record.


raw_content: At the time of the inspection, documentation required to be in the chart was unable to be located in the electronic record.  Some documentation had to be printed from and provided to the inspector as it was also not in the paper file.

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


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

raw_content: During the walkthrough of the facility, a corner piece of the wall next to the window had excessive paint peeling and exposed support frame.


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: The health inspection for the operation expired on 07/11/2023.

Correction Narrative: The operation provided the Form 4004 Environmental Health Checklist to bring this standard into compliance.  They have also contacted the local health department and scheduled a health inspection by the Travis County Health Department and will ensure this is completely on an annual basis.


raw_content: It was found that, a child was not taking to direction to an expectation set by staff to go to their room and was restrained on 11/14/23 for approx. 8 minutes from 5:49 pm until 5:57 pm. The child was not harming themselves or others prior to this restraint. Additionally, in an incident on the same day at approx. 3:55 pm, prior to the above incident, it appears staff further escalated the situation to where the child was restrained.

Standard Number / Description: 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply


summary: 748.303(e)(9)(A) - Serious Incident- Report to CCL w/in 24hrs of becoming aware of an allegation of an employee using a prohibited or inappropriate EBI technique.

raw_content: It was found, that a child was restrained to get the child to comply and this was not reported to the A/N hotline.


raw_content: Two of ten bathrooms observed showed significant paint peelings in the paint on the walls above the showers.   This was corrected at the inspection when the maintenance team sealed the area and repainted the ceilings.

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


raw_content: During the course of the investigation, it was determined a caregiver failed to adequately supervise a child in care, who was on a safety plan, which resulted in inappropriate sexual behaviors.

Correction Narrative: This standard was reviewed for compliance.


summary: 748.4013(b) - Out-of-state Overnight Trips-Operation must obtain written permission from each child's parent

raw_content: During the course of the investigation, it was determined that the operation failed to notify a parent or get permission for a child to travel out of the state.

Correction Narrative: A follow up inspection was completed on this date with the operation.  Interviews were conducted and the operation discussed the travel permission expectations with their employees.  This citation is being administratively reviewed and the request was sent in on 10.10.2023.  See chronology for interview information.


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

raw_content: During the investigation, it was found that the child was not administered one of their doses of prescription medication antibiotic suspension for their injury on 8/10/23 as ordered by the doctor for the knee cut.

Correction Narrative:
On 10/27/23, the operation reported they did a counseling supervision with the staff responsible for missing the medication administration. The operation reported the staff knows to follow through with all aspects of the medication part of our program. The operation also reported the Administrator will be checking on additional information pertaining to this and if additional information is obtained, they will get back to licensing.

On 11/15/23, the assigned licensing rep conducted an unannounced in-person follow up inspection at the operation and there were no concerns found on this day regarding administration of medications.


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

raw_content: In reviewing the investigations documentation and interviews verified at the time it was decided to escort the child, it was to get them to go to their room.

Correction Narrative: A follow up inspection was completed on this date.  Staff were interviewed and a sample of EBI reports were reviewed and found compliant.


Deficiency Narrative: In reviewing the investigations documentation and interviews verified at the time it was decided to escort the child, it was to get them to go to their room.


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

raw_content: 24 children medication administration records with their medication inventory form were reviewed for medications administered between 07/29/2022-8/11/2022 and there were times that the reason medication was prescribed was not documented.

Correction Narrative: On 5/24/23 the Administrator sent a copy of the new Medication Log that will be used here forward.


summary: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.

raw_content: During the follow up inspection on 4/18/23 it was found that the facility had not determined a plan to have a qualified medical professional conduct the training.

Correction Narrative: On 4/24/23 received notification from the administrator stating they hired their Psychiatrist to do the training portion of their medication training.


raw_content: Video showed a caregiver grabbed a child by the arm and put the child in the cool down corner.

Correction Narrative: RCCR Inspector  met with the Supervisor and was provided documentation to verify they had met compliance. Staff was on suspension until retrained and counseled. Staff has also been moved to a different shift to allow less interaction with the children. This will be re-evaluated in 30 days.


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

raw_content: Review of the video showed the child was grabbed by the arm in an abrupt manner and put into the corner.


raw_content: In reviewing documentation required areas were missing.

Correction Narrative: An extension was given as training for documenting serious incidents and EBI is scheduled for 4/27/23.


raw_content: During the review of Medication Training it was found the trainer did not have Medical Training.

Standard Number / Description: 748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.


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

raw_content: After reviewing multiple Medication Administration records, Medication Inventory records, and Drug Count Sheets, it was determined that there were multiple errors in the total number of doses remaining.

Correction Narrative: As per the operation's Healthcare Manager, the operation has implemented an updated MAR on Friday, June 2, 2023, that includes the medication count directly on the MAR. The operation has also implemented a check and balance system in which one member of the Healthcare team counts and pulls medications, and a second staff member counts all prescription medication again to ensure all counts match with the documented count. The plan is to meet with our direct contact at the Pharmacy on June 6, 2023, in order to review potential MAR's that the pharmacy would be creating for the operation.


raw_content: Two Medication Administration Records were provided for March 2023. One was provided in April and one in May 2023, which noted altered documentation.

Correction Narrative: As per the operation's Healthcare Manager, if a medication documentation error is identified when Medication Administration Records are being reviewed, the staff member is to correct the error within 24 hours of the medication administration time.


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

raw_content: It was determined that the operation did not seek immediate medical attention for a child in care who had a substantial injury which resulted in a concussion diagnosis days after the incident.

Correction Narrative:
As per the operation's Healthcare Manager, A refresher on operation's Head Injury Protocol (HIP) training was complete for all current staff members at the all staff training in April 2023. An email regarding Head Injury protocol was sent to the Program Managers/Team Leaders, Shift Leaders, and Healthcare staff on the communication breakdown and the process in dealing with a child that hits their head. Communication between all parties mentioned and the Direct Care staff will occur so that proper
medical care is provided for the children at the operation. Attached is the aforementioned email that was send to the parties mentioned as well as our current Head Injury Protocol. (Provided)


summary: 748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given

raw_content: A child in care was administered an OTC, over the counter, antibiotic cream after an injury. The operation did not have any notation and/or medical documentation on when the antibiotic cream was administered or how often.

Correction Narrative:
As per the operation's Healthcare Manager, a standing list of PRN's can be found on the back of the MAR. Each child has a standing PRN list that identifies the correct dosage and frequency of administration based on medication's guidelines. Children over the age of 12 and/or exceeding the recommended weight for Children PRN medications are placed on an Adult PRN list. If any of the standing PRN medications or supplements outside of the standing PRN list are administered, then those medications will be documented in the PRN Medication administered this period section found on the back of the MAR. This section requires the staff member administering non-prescription medications or supplements to input the date, time of administration, name of medication, dose given, staff members initials and the reason for the administration. A Response to the medication will need to be provided stating the child reaction to the medication. When a nonprescription or supplement medication is given on a daily basis, this medication is included at the front of the MAR, and it is signed out by the staff member administering the medication.
Attached is a copy of the back of the MAR that includes the information mentioned above. (Provided) The plan is to meet with our direct contact at the Pharmacy on Tuesday, June 6, 2023, to review updated MAR's that include the standing PRN's listed on the front of the MAR.


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

raw_content: The child's service plan documented the child "must remain in eyesight of staff at all times due to incidents of history..." However, while interviewing staff, it was determined the child was allowed to be in their bedroom with the bedroom door shut. Staff noted to check on the child in their bedroom every 5-10 minutes.

Correction Narrative:
The operation reviewed policies and procedures with the clinical team on Wednesday, April 12, 2023. The clinical team received standards regarding supervision and specific language to be used.

The operation will be asking for an AR.


raw_content: A child in care was administered an OTC, over the counter, topical ointment after an injury. The operation did not have medical documentation on when the ointment was given to the child and how often it was given.

Standard Number / Description: 748.2151(e) - Medication Record-must document non-prescription medication or supplement given to child and how often given

Correction Narrative:
The operation going forward will be documenting the time and date of all medication interventions, including over the counter topical ointments.
The operation will be asking for an AR.


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: When reviewing 4 service plan notifications for 3 children in care, 3 notifications weren't sent timely to notify parents.

Correction Narrative:
An email was received from Micki Marquardt. We have now created a new plan with a back-up for making sure these tasks (to notify CPS workers of scheduled meetings and provide the documentation) are completed in a timely manner.
As of November 17th, 2022, each Therapist/Case Manager will assure that the service plans are completed and provided to the CPS worker by email within the 10 day time frame.  Additionally, the Case Manager will provide an email invitation with the date and time of the next review at the same time so that there is plenty of notice.  Each Therapist/Case Manager is responsible for completing treatment plans as well as providing an invitation and documentation as outlined by 24-Hour RCC Requirements. The Director of Clinical Services or another designated clinical team member will perform these duties as a back-up if needed due to any outages.


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

raw_content: Through interviews with children and staff, it was determined that staff are not giving children in care privacy when making phone calls.

Correction Narrative: An email was received from Micki Marquardt. As of December 2022 the Helping Hand Home for Children policy regarding Mail Gifts & Telephone Contacts, has been updated to more clearly outline procedures for supervising children around the use of the telephone.  This policy describes when children need supervision and support and how staff can safely monitor while also allowing for privacy.  This policy is included along with this management response and additions are highlighted so that changes can clearly be noted. All RTC direct care staff were informed of policy changes to the Mail Gifts & Telephone Contacts, procedures during a training on December 14, 2022.  During this training staff were educated regarding the importance of client's rights and how they can respect the need for privacy while also assuring safe supervision.


raw_content: 2 prescribed PRNs, Ondansetron and Ibuprofen, were not counted daily count, rather only on the days when they were administered to the child.

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

Correction Narrative: This Inspector received an email from the Director of Clinical Services. She explained the operation has updated procedures to ensure a daily count of PRN prescriptions and attached an example. The operation will be ARing this citation.


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

raw_content: During the inspection 2 child charts and 4 staff charts were reviewed and found to have several items not placed in the chart timely.

Correction Narrative: Director stated that the Medical Records Manager was terminated who was responsible for ensuring records were reflecting correctly. The OP was aware this was an issue and has already hired a new replacement who will be reviewing records and ensuring each reflects policy requirements.


summary: 748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form

raw_content: In reviewing 3 of the 4 charts for staff, three did not have the Licensing Affidavit notarized.

Correction Narrative: HR will be creating a process to notarize each affidavit so none are missed. HR is a notary. This will start immediately.


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

raw_content: During the reivew of Backgrounds it was found a staff was inactive but scheduled to work.

Correction Narrative: Director informed that the staff was pulled from rotation as background check will be re-run on Monday 7/18 when the Background Check Personnel returns from vacation. In the meantime, the staff lacking the needed check will not be working.


summary: 748.2855(a)(4) - EBI Documentation-Must include the specific emergency behavior intervention administered

raw_content: The EBI reports for 1/12/22 at 11:00 AM & 12/10/21 at 1:45 pm do not have in the narrative the type of EBI that was used and when the restraint was initiated and ended. The 12/10 report is also missing what each staff was doing during the restraint (i.e. witnessing, monitoring, assisting, etc...) and if a staff was monitoring the restraint.

Correction Narrative: Received email from Chris Janowicz (Administrator) stating they have put a system into place to have a Supervisor review the documentation daily and enter it into their system and then have the Therapist double check to ensure all requirements are in the documentation. This email was sent to RCCR Inspector Sara Foshat. MLayton


summary: 748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.

raw_content: There is sufficient evidence to show that children are being kept in holds in an excess of 30 minutes and sometimes up to an hour.

Correction Narrative:
Operation sent the following email All RTC direct-care staff, supervisors and therapists received updated training regarding the use of EBI interventions with updated information regarding the length of time a child may be held in a physical containment.  That training also emphasized the need for timely and accurate documentation of all EBI procedures.

Updated training was held the week of April 18-22.


summary: 748.2855(a)(2) - EBI Documentation-Must include a description and assessment of the circumstances and specific behaviors that were the basis for EBI

raw_content: Staff failed to document a complete assessment of circumstances that led to a restraint not providing appropriate rational for the restraint.

Correction Narrative: The staff who filled out the original form is no longer with the operation, another staff involved in the restraint completed the form.


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

raw_content: There is sufficient evidence to show that staff on at least three occasions failed to completed the appropriate documentation after a medical error occurred.

Correction Narrative: Operation sent an email stating. All RTC direct care employees, supervisors and therapists are to assure adherence to policy and to DFPS Minimum Standards.  Therapists and Direct-Care supervisors are required to review documentation daily to assure timely and accurate completion of the documentation of EBI reports.


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: After conducting the investigation, it was found that there were two staff with a provisional background check with conditions set by CBCU. The two staff were left alone with children in care during their shifts and also administered medications to children in care during their shift(s). One of the two staff worked on and administered meds to the child involved on 1/11/22 and 1/18/22 and the other staff worked on and administered meds to child involved on 2/4/22. Both staff initials are on the med logs (MAR) provided by the operation.

Correction Narrative: OP personnel informed INSP that they have already informed staff of supervision protocols/requirements when on shift, informed supervisors again of following provisional requirements, that you will not be scheduling the two staff for OVN shifts, and that they've been informed not to administer meds.


raw_content: A direct care staff was in the care of children with a pending background check.

Standard Number / Description: 745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation

Correction Narrative: As part of the new hire process, HR will be using the Checklist for Paperwork to be Completed Prior to Start Date which includes a list of required documents/procedures for each applicant to include the date the background check was received and its result. Human error and/or lack of sufficient staff caused this particular applicant to proceed in the process.


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: During the course of this investigation, seven of seven medication records were found to be incomplete, illustrating lack of information and/or documentation.

Correction Narrative:
The operation has established a new system for how they will be handling medication administration record errors in documentation and/or other corrections. As of 9/27/2021, the healthcare team at the operation will maintain custodianship of each medication administration record needing correction, with a list of staff members who need to complete said corrections. Direct care staff members and their supervisors will be sent an email with details explaining details about the medication administration records needing their attention. Direct care staff will be expected to complete these corrections within two days of receiving the email. Reminder emails will be sent to staff and their supervisors if healthcare staff notice delinquency on corrections. This will continue until medication administration records are completed in full.

Additionally, as of 10/1/2021, all medication count sheets will include a medication rationales page with details explaining the reason the medication has been prescribed, the date the medication was started, and potential side effects to look out for as well as contraindications to the medication(s).

Medication administration records will be reviewed monthly by the healthcare staff for needed revisions, corrections, or other attention to ensure all medication is being administered and documented correctly by direct care staff. Once medication administration records have been deemed complete and ready to file by the healthcare team, they will be given to the client records manager, an individual who does not administer medications, for a second and final review to ensure all medication is being administered and documented correctly by healthcare and direct care staff.