summary: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting

raw_content: In observing video footage, the staff slaps the child's hand.


state: TX

facility_name: New Life Childrens Treatment Center

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: The incident was witnessed by two staff members and not reported by either. One staff interviewed states a supervisor and manager were also made aware of the incident on the day it occurred. An incident report was not completed at the time of the incident.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No


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

raw_content: A child was restrained by plugging of the nose by one staff while the nurse held the child in place in an attempt to have the child swallow their medication.


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

raw_content: A child's nose was plugged by staff which restricted the child's breathing.

Standard Risk Level: High


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

raw_content: From witness interviews and video footage, a staff states, "it works on dogs to hold their nose closed." after plugging a child's nose.


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

raw_content: A child's service plan was not followed when the child self-harmed and a safety plan was not put in place. The child's service plan states due to the child's high risk of self-harming behaviors a safety plan should be implemented following this type of incident.

Standard Risk Level: Medium


summary: 748.685(c)(5) - Caregiver responsibility - ensure continuity of care by sharing information concerning each child with incoming caregivers

raw_content: Caregivers and Medical staff were unaware of child's self-harming incident reported on 5/3/23 per interviews. Medical information was not shared from shift to shift according to interviews with nursing staff and caregivers. This information was also not documented in shift communication or progress notes observed.


summary: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

raw_content: A child in care was restrained and caseworker was not notified in a timely manner.

Correction Narrative: The administrator informed the Senior Management Team, to include Executive Director, Clinical Director, Program Director, Program Manager, Manager-on-Duty, and Clinical Manager will review Minimum Standard code 748.2857(a) and include the updated information on the agenda of their next department meeting, clinical and program side respectively. This information will be disseminated to all employees on the clinical and program side to implement.


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

raw_content: One staff member fell asleep while counted in ratio. Video footage shows the staff's alarm sounding and children waking her. The incident was confirmed in child interviews.

Correction Narrative: The operation informed that the staff involved was terminated. All remaining overnight staff will be required to attend an additional training on 24-hour Supervision, that includes sleeping restrictions, room checks, etc.


raw_content: The child was not supervised in the staff only area allowing access to a craft knife which was later used for self-harming.

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


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

raw_content: Two staff interviewed made statements that the staff to child ratio exceeded 1:5 during the incident. One staff said there were eight children. Another said there were at least six children. Interviews confirm two staff were present, however, one staff was in observations and not counted into ratio on the day of the incident. Management confirms the staff was not counted into ratio during their interview.


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

raw_content: Medication was prepared four hours before time of administration.

Correction Narrative: On 1/20, the administrator provided a response that the staff that prepared the medication early will receive a refresher training that will cover all medication management protocols and procedures.


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

raw_content: After reviewing video footage, EBI curriculum, and staff statements, Emergency Behavioral Intervention training was not utilized on the aggressive child as required by the extent of possible physical injury. The child's hair was pulled twice, and she was kicked four times prior to the caregiver pulling out phone to call for assistance. The decision was made not to restrain the aggressive child without assistance despite the behaviors needing further management.

Correction Narrative: Staff member involved will attend a refresher training on Active Listening and Crisis Co-regulation. The incident tape recording will be reviewed with the staff. A discussion on what can be done to improve will be held.


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

raw_content: In video footage reviewed, the caregiver exhibits a lack of urgency and fails to protect the child from harm. Body positioning was not positioned to protect the child from injury. The aggressive child was not restrained, and the targeted child was not removed.


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

raw_content: Shower was dirty and coming apart from wall.

Correction Narrative: Bathrooms were observed clean and in good repair to include Olsen Left. There are additional improvements in progress for the bathroom such as new mirrors.


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

raw_content: Staff member used profanity and yelled at children in care.

Correction Narrative: Management emailed to inform the staff member was suspended after the incident and terminated after the results of the investigation were released. The staff's training record and the operation's zero tolerance policy were provided.


summary: 748.3233(b)(4)(B) - Evacuation-Emergency evacuation & relocation diagram includes at least 2 exit routes that are not blocked in any way

raw_content: During the walk through a wooden picnic table was seen blocking the side door.

Corrected at Inspection: Yes


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

raw_content:
During a review conducted on August 5, 2022, it was determined that:

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

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

As you know, the heightened monitoring plans for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original planned end date necessitating previous extension.

Furthermore, due to your recent citations issued on July 20, 2022, your operations planned end date must now be revised again, and the period of heightened monitoring must be extended again.

Further details of the failure of your operations administrator to ensure compliance include the following:
The operation received a medium and medium-high weighted citation in a pattern/trend category on July 20, 2022. Specifically, the operation was cited for 748.2151(c)(6) and 748.2151(d) related to medication documentation. The operation met compliance on July 25, 2022.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

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

Correction Narrative:
Corrective Action:
Administrator will place systems in place to ensure and support compliance to the current HM Plans including reassigning of personnel and duty responsibilities to specific tasks that are highlighted by HM as areas of need,
adding the position of Quality Control Manager to support documentation oversight, creating a new An HM extension was approved effective 08/05/2022.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2).  The HM deadline for your operation has been extended by 6 months and the new deadline is 02/06/2023.


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

raw_content: 1 out of 3 child s medication record reviewed it was discovered that a psychotropic medication count was  documented incorrectly on the medication log.

Correction Narrative: Staff members demonstrating a deficiency in medication documentation are required to attend a three-hour medication documentation observation/training


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

raw_content: During the review of three child medication records if was noticed that two staff who administered medication to a child in care had not written their name and/or signature in the section provided on the bottom of the medication log to identify their initials.

Correction Narrative: Staff members demonstrating a deficiency in medication documentation are required to attend a three-hour medication documentation observation/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: Two of the three child records reviewed did not have the child s TB test results located in the child s records. However the operation was able to request one child's TB test results  and placed it in the child's file.

Standard Risk Level: Medium Low


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

raw_content: One of the three child records reviewed did not have an up to date TB test.

Correction Narrative: Executive Director, Clinical Director, and Program Director will review and provide refresher trainings on TB test requirement listed in Minimum Standards 748.1583(a).


summary: 748.935(a)(1) - Annual Training Timeline-Each person must complete the required annual training within 12 months from the date of hire

raw_content: During the review of employee records, it was discovered that two direct care staff  had not completed their required annual trainings.

Correction Narrative:
The direct care staff member will meet with the Program Manager and Program Trainer to review and discuss
Minimum Standards and Upbring's Policy & Procedures that specifically addresses training requirements.


raw_content: During the review of a child's medication record it was discovered that a psychotropic medication count was documented incorrectly on the medication log.

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


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

raw_content: One prescription medication was not documented as administered within the two hour timeframe.


raw_content: A youth in care was left alone in the unit unsupervised.

Correction Narrative: Administration sent a compliance plan on 01/06/2022 to the licensing representative. The plan was received by the inspector on 01/13/2022. The administrator provided a corrective action plan and New Life will review, with the staff member involved, Upbring's Policy & Procedures that specifically addresses responsibilities of our caregivers and supervision of a child (specifically our Caregiver policy # 1217).


raw_content: A resident was on a safety plan and staff did not check on resident while showering.  Resident got ahold of her hygiene and ingested her bottle of shampoo.

Correction Narrative:
New Life staff members involved will review Upbring's Policy & Procedures that specifically addresses youth safety (Youth Safety Status & Precaution / Restriction Policy # 1282).

Interview with Program Manager - staff reviewed and trained on residents on a safety plan.
Staff will stand in doorway with door open and will be within hearing range of the resident.
Staff will not let resident be by themselves alone in bathroom, while on safety plan.


raw_content: There was only one caregiver for 9 children for 30 minutes during the morning shift. The other staff memeber that was supposed to be on the unit had called in, and a replacement for the staff was not sent to the unit.

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

Correction Narrative: 8/25/21- An email was received from the administrator. The Administrator stated in the email that the staff that were involved with their unit being out of ratio, will be required to attend a review training that will cover child/caregiver ratio and internal operational responses to callouts, including notifications, resource allocation, and order of operations that will help prevent a reoccurrence of situation that lead to the deficiency.


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

raw_content: The operation staff discouraged children in care from writing grievances.

Correction Narrative: New Life staff member involved will review Upbring's Policy & Procedures that specifically addresses child rights (Children's Rights Policy # 1227 and Client Grievances Policy #1207).


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:
Last health inspection was completed on
4/30/2019. Therefore, operation did not complete the annual required health inspection.

Category: Safety and Emergency Practices

Correction Narrative: New Life provided a letter from the Texas Department of State Health Services to the monitors on the day of their visit.  This letter, dated 5/11/21, stated that DSHS PHR 8 had suspended regulatory inspections until further notice due COVID-19.  This letter also stated that DSHS PHR 8 would be in contact with us when inspections resume to complete the mandatory Health Inspection.  New Life has continued to reach out to DSHS in attempts to get a health inspection completed.


raw_content: The med log in the Olsen unit did not have staff's initials who administered meds for the PM shift on 7/6/21.

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

Correction Narrative: An email was sent by Executive Director, Jonathon Stanford in response to the citation. They are taking corrective action by requiring those who administer medication to take the DFPS online psychotropic medication training and/or attend a medication administration training. In addition, during the inspection, the Program Director, Yolanda Cantu stated they would discuss the error with the assigned staff and make corrections.


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: Resident was standing on a table and staff moved the table causing resident to fall onto the ground, resulting in a fractured shoulder.

Correction Narrative: Email received from Michael Holder, Director.  At the townhall meeting the program trainer scheduled two trainings for 9/18/21.  This time it is children's rights and a review of the Repair process based on the outcome of this investigation.


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

raw_content: A light fixture wires were hanging down where residents could reach and pull down and a light bulb was broken.


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

raw_content:
Operation staff left a resident at the cottage by herself when staff and residents went on outing.
Resident was by herself for two hours.

Correction Narrative: he staff members responsible for leaving the youth on cottage received disciplinary actions.  All program staff were required to review our 24-hr. Awake Supervision of Youth policy and procedure, with a special emphasis on the During Transitions' section.  An assessment over this specific section was also completed.


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: Staff did not give resident appropriate space and resident became more dysregulated.  Verbal de-escalation techniques were also not used.

Correction Narrative: The staff responsible for the citation for 748.1101(b)(1)(B) was immediately suspended and terminated.  The staff initiating the restraint attended a Therapeutic Crisis Intervention (EBI) refresher training on June 11th.  Staff also reviewed the videos, including this specific incident, that have been investigated and/or citations given.   This review included discussion of antecedents and actual behaviors (including staff's) that led to restraint and/or incident.


raw_content: Staff threw a water bottle and struck resident in the face.

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


summary: 748.303(a)(11)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: Investigation documentation reveals operation staff had a note from a child in care expressing intention to commit suicide and shortly after the child in care was seen with a jacket around their neck and would not remove the jacket until staff threatened to cut the jacket off with scissors. The operation admits they did not count this as a suicide attempt and didn't report it.

Correction Narrative:
New Life will review Minimum Standard 748.305  What constitutes a suicide attempt by a child?
A suicide attempt is a child's attempt to take his own life using means or methods for causing his death, including any act a child commits intending to cause his death, but excluding suicidal gestures where it is clear that the act was unlikely to cause death. Suicidal thoughts are not reportable as a suicide attempt


summary: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting

raw_content: A staff member shoved a resident in between restraints.

Correction Narrative: New Life will review our Therapeutic Crisis Intervention curriculum.  Specifically, we will review the Managing the Crisis' module.


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

raw_content: Staff supervise all children in care when calls are made, resulting in calls not remaining private.

Correction Narrative: An email was received from the administrator stating New Life will review Minimum Standard 748.1101(b)(7) with all clinical staff and those program staff who are able to provide phone calls for the youth.  It will be emphasized that any phone calls made to the DFPS Texas Abuse/Neglect Hotline or the Ombudsman by youth are to be private, unless youth is currently on any Safety Precautions.


raw_content: Staff pushed resident with both hands with force back into her room, isolating her in her room with the door closed.

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

Correction Narrative:
The staff member responsible for these citations was immediately suspended and terminated.
Staff also reviewed the videos, including this specific incident, that have been investigated and/or citations given.   This review included discussion of antecedents and actual behaviors (including staff's) that led to restraint and/or incident.


raw_content: Staff pushed resident down on the ground, causing bruising.


raw_content:
Staff failed to properly maintain control of resident while attempting to de-escalate a situation.
Staff struck child in the face with her fist.

Correction Narrative:
New Life will continue to hold multiple Emergency Behavior Intervention trainings per month to help staff in maintaining proper control of an escalated youth.  Any staff observed needing additional training will be required to attend one of the trainings, not to exceed 30 days.
New Life also terminated employment with the staff responsible for this incident.


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

raw_content: Medication records, a professional medical collateral, medical care staff, direct care staff and child in care interviews together confirm a child in care missed one dose on one evening of a medication causing the child in care to feel upset and tired.

Correction Narrative: Medications will remain in the Medication Carts where they are typically stored until the youth leaves for the pass.  When staff go to pick up the youth from their cottage/dorm, they will then pick up their medications as well, if needed.


facility_name: Brotherhood Academy

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

raw_content: Five of seven records reviewed shows missing affidavit for employment affidavit for employment.

Category: Personnel

Correction Narrative:
The Executive Director, Julie Jones, has sent email containing an update of the New Hire Documents Checklist. The checklist required new employees to submit their Pre-Employment Affidavit and Employment Affidavit.  The employee must sign and date the checklist acknowledging that both forms were tuned in, and the Administrator must sign and date the checklist acknowledging the forms were received and reviewed.

The Director stated an administrative Review would not be requested.


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

raw_content: It was determined that a child in care in care was treated in an unnecessary manner and harsh manner when a caregiver pushed them.


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

raw_content: It was determined that a caregiver cursed at a child in care.


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

raw_content: During the inspection, it was found that the reference checks were not completed fully and missing minimum standard requirements.

Correction Narrative: On 10/10/24, the operation Executive Director emailed their assigned licensing representative and provided two attachments (1.) an updated reference check form; (2.) their own Verification of Employment form for references as part of their follow up response. The operation reported that after the last inspection the assigned licensing representative conducted, they updated their reference check form template and added to it the question, "How would they be working with children?" for the interviewer to ask the reference person(s). The Executive Director reported they will also add to the template a place for documenting when a reference person(s) is unreachable and/or if the operation is unsuccessful in completing the interview and the reason for this. They reported that if the reference person(s) is permanently unreachable, then they will include their assessment of the prospective employee's suitability to work with or around children. They also reported they will add to the form the attempts that were made to reach the reference person(s) and an explanation of the reason the reference person was unreachable.


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 inspection one child file was evaluated. It was found that one child has been administered medication for sleep that was discontinued by the health care professional as of 6/29/24.

Category: Medication

Correction Narrative: During the inspection one child file was evaluated. It was observed that prescription medication instructions were followed accurately.


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

raw_content: During the inspection, one staff file reviewed was missing the signed/dated statement for immediately reporting abuse/neglect, exploitation to the A/N hotline.

Correction Narrative: On 2/2/24, the operation sent an email to licensing stating that the employee signed and dated a statement confirming the requirement that they must immediately report suspected child abuse, neglect, or exploitation on January 25, 2024. This signed and dated statement is filed in the employee's personnel record.


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

raw_content: During the inspection, one staff file reviewed was missing the Affidavit of Employment.

Correction Narrative: On 2/2/24, the operation sent an email to licensing stating that the employee signed the Licensing Affidavit for Applicants for Employment form on January 31, 2024.  The signed and notarized affidavit is filed in the employee's personnel record.


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

raw_content: During the inspection, it was found that the non-prescription cabinet for medications was unlocked. This was corrected at inspection.


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

raw_content: During the inspection, it was found that the staff file didn't have documentation to show that the staff obtained a high school diploma or a GED or documentation for home schooling, if applicable.

Correction Narrative: On 2/2/24, the operation sent an email to licensing stating that a copy of the employee's high school diploma was provided to Brotherhood Academy on January 26, 2024. This documentation is filed in the employee's personnel record.


facility_name: Home of Joseph Foundation

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

raw_content: During a walkthrough inspection two items were found to be expired.

Category: Physical Site


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

raw_content: During a walkthrough inspection one matress  was found to not have a matress protector.


summary: 748.2255(1)(A) - Operation does not employ professional who prescribes psychotropic meds-Operation must give consenter nature of child's condition before consent given

raw_content: Residential Child Care Regulation observed two children in care's medication logs to contain psychotropic medications which were prescibed after placement at the operation. The operation emailed the managing conservators upon prescrption of the medications and before administration, however the information for consent was only general and did not elaborate on the specific items in this standard.

Correction Narrative: 11-11-2024. The operation emailed a compliance response: "Although we provide the K-905-2403 form, stating the medication and what the medication is prescribed for, from the psychiatrist to each child's managing conservator for consent prior to filling each prescription; the consent request doesn't elaborate on the specific items in the standards. HOJF will now use form K-905-4526 in addition to form K-905-2403 to ensure medical consent requests sent to each child's managing conservator meets this standard."


summary: 748.3301(e) - Physical Site-Outdoor areas must be well drained

raw_content:
Licensing observed and photographed a bucket of standing water in the side yard, which staff indicated had been there for two days.

The inspector observed the director drain the bucket during the inspection.


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: As of 07-16-2024 the data for restraints between April and June 2024 has not yet been reported to Licensing.

Correction Narrative: 08-09-2024. The assigned inspector met wtih the operation director and learned the operation set a permanent reminder in outlook for the EBI reporting.


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

raw_content: Residential Child Care Regulation observed a child in care's file to be without documenation of known contraindication to the use of restraint.

Category: Admission, Service Planning, Discharge

Correction Narrative:
06-05-2024. The assigned inspector observed the photo provided of the cover to the child in care's file which now has known contraindication to the use of restraint.

05-31-2024. The assigned inspector requested documentation of the compliance response.

05-17-2024. The operation submitted a compliance response: "748.1205(a)(10) - Home of Joseph Foundation has added a section for known contraindications to use of restraints to the Admission Assessment, 72-hour Treatment Plan and Child's Binder Cover Page. (This is complete and ready for review)."


summary: 748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child

raw_content: Residential Child Care Regulation observed the child in care's file is without the policy notification documentation for the managing conservator.

Correction Narrative:
06-05-2024. The assigned inspector reviewed the policy acknowledgement form signed by the CPS case worker.

05-31-2024. The assigned inspector requested documentation of the compliance response.

05-17-2024. The operation submitted a compliance response: "748.1211 - Home of Joseph Foundation will provide, and obtain evidence, that parents/conservators were notified of our fee policies, EBI policies, discipline policies and any other policies required upon parent request. (Complete, please note we have evidence of the receipt of our resident handbook from child's conservator, which documents the required information."


summary: 745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access

raw_content: Residential Child Care Regulation observed four staff files to be without pre employment drug testing documentation. The operation indicated they don't perform such tests.

Correction Narrative:
06-05-2024. The assigned inspector reviewed all drug test results emailed by the operation and telephoned the operation to ask about the four employees in CLASS people list who don't have tests. The operation indicated they are being considered for employment and are not yet at the drug test phase of the hiring process. The inspector also telephoned two employees who verified they had drug tests.

05-31-2024. The assigned inspector requested documentation of the compliance response.

05-17-2024. The operation submitted a compliance response: "745.4151 - Home of Joseph Foundation will perform mandatory drug testing on all applicants intended to be hired for employment in accordance with Rule 745.4151. All staff at Home of Joseph Foundation will complete drug testing by 5/22/24. (Complete, please note all employees have been tested and supporting documentation can be provided upon request)."


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

raw_content: Residential Child Care Regulation observed a child in care's 72 hour service plan to be without a plan for medication side effects.

Correction Narrative:
06-05-2024. The assigned inspector reviewed the addendum with the new section related to medication side effects.

05-31-2024. The assigned inspector requested documentation of the compliance response.

05-30-2024. The assigned inspector acquired RCCR supervisory approval to follow up for compliance without an onsite inspection.

05-17-2024. The operation submitted a compliance response: "748.1331(b)(3) - Home of Joseph Foundation has added a section to the 72-hour Treatment Plan regarding a plan for medication side effects. (Complete, we have added an addendum for your review)."


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

raw_content: The operation does not yet have a licensed child care administartor.

Category: Organization and Administration

Correction Narrative:
12-06-2023. I telephoned the LCPA and learned the LCPA will operate from Houston and Victoria. Payroll, hiring staff, disciplinary training, picking the children for placement, handling incidents and investigations with RCCR and administrative actions. The LCCA was an administrator at another GRO.

12-01-2023. The assigned inspector emailed RCCR management and requested to follow up and verify compliance in the form of a phone interview with the administrator.

11-27-2023. The operation submitted the form 2760 for their newly hired administrator. RCCR completed an AARS check with no matches, updated the administrator section of the governing body page and CLASS and added the administrator in the controlling persons page.


facility_name: TRELS Home LLC

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

raw_content: The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room.

Correction Narrative: Staff was retrained during the weekly meeting on 03/31/2025 and ensure the program director understands minimum standards requirements on proper ways to fill out documentation. Administrator will conduct monthly audits to ensure all required minimum standards and Texas law documentation is completed with accurate and current information.


summary: 748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: A pre-screening was not completed prior to hiring in one of two employees' files.

Correction Narrative: The staff file was added and named refnow reference in extended reach.


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: While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain.

Category: Child Care

Correction Narrative: Administrator provided a copy the Tuberculous results to RCCR Inspector. Administrator will conduct monthly audits to ensure all requested documentations are in the child in cares records in a timely manner.


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

raw_content: While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing.

Correction Narrative: The operation removed the borken door and replaced them. All holes on the wall were covered.


summary: 748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged

raw_content: The address, and relationship of person is missing on the discharge summary of one of the child's file.

Correction Narrative: The operation added the required information to the summary and is in extendedreach.


summary: 748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed

raw_content: The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file.

Correction Narrative: The operation added a section in extendedreach to ensure the requirement was added.


summary: 748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules

raw_content: The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency.

Correction Narrative: The operations rewrote the policies and procedures to reflect the type of services the operation provides. The operation will ensure all staff sign and date documentation stating they read and understand all the policies.  RCCR reviewed polices and policy, they are in compliance.


facility_name: Youth Health Associates Glenn Heights Academy

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

raw_content: 2 of 2 case files did not contain support that references were contacted.

Correction Narrative: 2 of 2 staff files reviewed for a follow-up had the appropriate documentation.


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: 2 of 2 files did not contain this document .

Category: Reports and Record Keeping


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

raw_content: During medical review, it is indicated that a child medicaiton was not documented.

Correction Narrative: The operation will be hiring a full time registered nurse to handle all medical logs and working on onboarding 2 LVNs to fill in the gaps. An inspection was conducted on 03/09/2026 and validated compliance was met.


summary: 748.1101(b)(3)(G) - Children's rights-comfortable clothing suitable to age/size/similar to peers in community. Teenagers have reasonable chance to select clothing

raw_content: A youth in care was observed to not have enough clothing at the operation.


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

raw_content: The medications logs reviewed did not include the prescribing health-care professional name.

Correction Narrative: An inspection to the operation occurred to review medication compliance. This standards has been bought to compliance.


summary: 748.2151(c)(8) - Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years

raw_content: In review of the medication logs, an as needed psychotropic medication was given on three dates in early December without the specific reason.

Correction Narrative: An Inspection was completed to the operation on 01/12/2026 and medical records were reviewed. The operation plans to hire an Registered Nurse and LVN to handle their medical records error.


raw_content: Supervision is not addressed in the preliminary service plan.

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

Correction Narrative: A review of child files indicates that this standards has been bought to compliance.


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: The possible side effects of medications were not listed in the preliminary service plan.


summary: 748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours

raw_content: Three of six staff EBI training certificates reviewed did not have the length of time documented.

Correction Narrative: The operation provided certificates with hours. The operation plans to write in hours into the main certificate, when they receive certificates without hours


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

raw_content: Six of six staff EBI training reviewed was not completed every six months.  The training had been completed ever 10-12 months.

Correction Narrative: A follow up was completed at operation. The operation's plan to ensure that staff complete training timely by using sources such as outlook calendar to complete training in May and November of each year.


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

raw_content: The medication logs reviewed did not include the name and signature of the person administering the medication.

Correction Narrative: An Inspection was completed to the operation. The Child's medical records were reviewed and this particular standard for medication was found to be in compliance.


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: In review of the medication logs, seven prescription medications had lacking documentation showing doses were or were not given, given the wrong number of doses in a day, or given at the wrong time of day.

Correction Narrative: An Inspection was completed to the operation to review the medical records. The operation plans to hire RN nurse and LVN to correct future errors.


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

raw_content: For medication logs reviewed, two of nine prescription medication did not have documentation of the reason the medication was prescribed.

Correction Narrative: An On site Inspection was completed on 01/12/2026, the medication logs were reviewed and found to be in compliance. The operation plans on hiring Registered Nurse and 2 LVN to help support their errors in Medication management.


raw_content: 4 children in care were not provided medications appropriately. As well as 5 prescriptions were not found in the child's medication box.

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


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

Deficiency Narrative: 2 of 2 files did not contain this document .


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

Deficiency Narrative: 2 of 2 case files did not contain support that references were contacted.


summary: 748.363(15) - Personnel records-Include date and reason for the person's separation, if applicable.

raw_content: 1 employee is no longer working with the operation.  The case file does not represent the termination-


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: It was discovered that staff members were monitoring children's phone calls without providing restrictions in the children's service plans.

Correction Narrative: An onsite Inspection was completed and a discussion was completed with administrator. The operation will include changes which will have staff remain within eye sight of the child but still maintaining  distance where privacy will not be disrupted.


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

raw_content: There was a hole in the wall and pieces of dry wall was on the floor. The toilets were dirty. The doorknob to the Eagle's room is loose.


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

raw_content: Children in care were subjected to profane language.

Correction Narrative: Compliance was send by email, operation has provided the response that staff will retrained on verbal De-escalation and trauma informed will be emphasized  during monthly meetings.


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

raw_content: The operation had a loose tile, and a child was able to use that tile to cause harm to self. A loose tile is against the city's ordinance.

Correction Narrative: An Inspection was conducted to the operation on 10/23/2025, the flooring concerning the incident was observed to be in compliance. On 10/10/2025, Administrator send photos of the fixed floor.


summary: 748.455(a)(1) - Unauthorized Absence - The debriefing should include the circumstances that led to the unauthorized absence

raw_content: The debriefing form did not have documentation including the child's response for leaving the facility.

Correction Narrative: An email was received from administrator providing debrief forms with each child response. The debrief form can be found in the document library.


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

raw_content: The operation did not follow 3/3 children in care service plans due to supervision.

Correction Narrative: An email was received from the administrator. It is recommended that a child is placed on 1 to 1 supervision that plan will be followed without reserve.


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

raw_content: The operation did not provide a debrief form for one child in care.

Correction Narrative: operation send a form including the debriefing that was conducted with the child at a follow up date.


summary: 748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care

raw_content: When reviewing a child's admission assessment, it was observed multiple required information needed at the time of admission wasn't documented on the admission assessment.

Correction Narrative: The child involved was discharged on September 9, 2025, so updates to the case files cannot be made. The operation submitted an corrective action plan which outlined how they will avoid this deficiency in the future. See document library for more information.


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

raw_content: Staff member failed to use self-control meanwhile trying to de-escalate a situation by resorting to making inappropriate comments to child in care about their family.

Correction Narrative: YHA determined that after review of this investigation the employee in question was taken off administrative leave and terminated.


summary: 748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute.

raw_content: Staff completed a prone personal restrain that lasted more than one minute.

Correction Narrative: YHA determined that after review of this investigation the employee in question was taken off administrative leave and terminated. Additional training was provided that reviewed: Enhancing Direct Care Staff leadership by increasing from having two Supervisors to having four Supervisors. Thus, there will be increased support for coaching and guiding staff in their compliance of the standards. Enhancing our EBI "Handle With Care" staff trainer from having only one Trainer to increasing that to have two staff Trainers. This will support staff for further coaching and guiding in their compliance of the standards since the Trainers are frequently present in the houses. Creating a poster to put by the time clock which indicates the rules of EBI related to restraints


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

raw_content: Three children in care reported that force was used during a restraint.

Correction Narrative: A follow-up inspection was completed on 10-23. The administrator was spoken to about EBI. The administrator stated that all staff, including himself, will receive a refresher course in EBI. He stated that an additional technique "verbal judo" is being added to the training. In addition, the program director is conducting weekly staff meetings with staff members to ensure that are following the rules as it relates to restraints.


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

raw_content: Review of the medication administration log revealed discrepancies in the medication count; as no medication errors or refusals were documented.

Correction Narrative: A follow up inspection was conducted at the operation on 10-23. The administrator was spoken to about Medication Documentation. He stated that the operation's program director is conducting weekly staff meetings with staff members to ensure that are following the rules as it relates to medication documentation/administration.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

raw_content: It was noted that a medication error occurred, but it was not documented.


summary: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

raw_content: Three children report that a youth in care expressed discomfort and was not released.


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: 2 out of 2 trainings  files reviewed for staff did not have training on pyschotrophic medication by a Health Care professional.

Category: Training and Professional Development

Correction Narrative: The agency send an email with trainings for the staff which showed that staff was trained by a health care professional on medication management on 07/07/2025


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

raw_content: Two unauthorized absences were not documented timely.


raw_content: The Unauthorized Absence debriefing was missing the following information: the circumstances that led to the childs unauthorized absence, the trauma informed strategies the child can use to avoid future unauthorized absences and how the operation can support those strategies, the childs condition, what occurred while the child was away from the operation (including where the child went, who was with the child, the childs activities, and any other information that may be relevant to the childs health and safety), and including any routine activity that would be inappropriate for the child to return to and the explanation for why the activity is inappropriate.

Standard Number / Description: 748.455(a)(1) - Unauthorized Absence - The debriefing should include the circumstances that led to the unauthorized absence

Correction Narrative: The operation send a compliance regarding debriefing


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

raw_content: The Unauthorized Absence Log was missing the following information: gender, the time the unauthorized absence was discovered, the name of the caregiver responsible for the child at the time the child's absence was discovered, the intake report number (if a report was made to Licensing or the Department of Family and Protective Services), and whether law enforcement was contacted (including the name of any law enforcement agency that was contacted and the number of the police report, if applicable).

Correction Narrative: The compliance was met, the agency send appropriate documentation


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

raw_content: During a review of records for Emergency Behavior Intervention. Serious Incident report was reviewed and found to not have the information on who conducted a restraint on a child

Correction Narrative: Administrator send over compliance documentation


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: During Inspeciton, serious incident report was reviewed. The file reviewed indicated that a child in care had a restraint completed on him. The details of the documentaiton was not in detail. 748.2855(a)- 748.2855(a)(9)

Category: Emergency Behavior Intervention

Correction Narrative: Administrator emailed over documentation to meet compliance.


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 staff member admitted to falling asleep while on duty.

Correction Narrative:
Email received from Administrator stating Lead Staff will make more frequent round to check on the well being of their staff.
Direct Care staff will be encouraged to get appropriate rest before reporting for duty to help eliminate falling asleep during shift.
Supervision will be instructed to be more inter active with staff, offering regular breaks and even providing coffee, water and light snacks to keep staff alert and focused on the assigned tasks.
Practical Implications:
-Constant awareness: The caregiver should know where each child is and what they are doing at all times.
-Age-appropriate supervision: Younger or more vulnerable children require closer supervision.
-Individualized care: Supervision should be adjusted depending on each child's behavior, needs, and known risks.
-Proactive risk management: Caregivers should anticipate potential hazards and intervene before issues arise.
-Active Supervision: All residents will be monitored in intervals not to exceed 15 minutes.


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

raw_content: The child's preliminary service plan states that they will have their own living space, but they were placed in a room with another child in care.

Correction Narrative: An email was received from the Administrator of the agency with compliance. The agency has reviewed and updated their policy in regard to admissions policy. This has been discussed with the intake staff to ensure that we are following any specific instructions on Attachment A. Effective immediately, the agency will ensure that all residents will be assigned their own private room during sleeping hours and will NOT be placed in a room with another child in care.


summary: 748.363(10) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: Three out of three files reviewed indicated that there was no signed statement from the employee that he or she will report suspected child abuse, neglect or exploitation

Correction Narrative: The administrator provided support documentation to ensure compliance.


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

raw_content: The application states that children with emotional disorders will be admitted. However, the admission policies found on pages 118, 124, and 130 conflict.

Correction Narrative: Policies and procedures were updated to include clear information to meet the criteria for admission.


summary: 748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position

raw_content: The minimum qualification for the PLSP, in YHA's plan, is that the person would have a degree in social work or a bachelor's degree. This is not according to minimum standard rule 748.563(a).

Correction Narrative: Policies and procedures were updated to include this information.


summary: 748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules

raw_content: The policies and procedures submitted in certain areas speak to the rights of the guardian only.


summary: 748.111(5) - Child-care policy - How a child obtains clothing

raw_content: The procedures for obtaining clothing indicate that children will have adequate clothing at placement. The budget does not have a line item for how clothing will be purchased or provided.


summary: 748.105(9) - Personnel Policies - Must require those with access to information about a child be informed of their responsibility to maintain confidentiality.

raw_content: The policies and procedures do not specify confidentiality requirements for contractors and volunteers.

Correction Narrative: The operation returned policies and procedures to address this rule.


summary: 748.115(2) - Discipline policy - Integrate trauma informed care into the care, treatment, and management of each child

raw_content: The policies and procedure do not address this rule.


summary: 748.107(2) - Conflict of interest policies-statement that majority of members of the governing body must consist of persons who do not have a conflict of interest

raw_content: Conflict of Interest section did not have a statement which informs that governing body does not have a conflict of interest.

Correction Narrative: Policies and procedures were submitted to support compliance with this rule requirements.


summary: 748.125(d)(1) - Your policy must describe the suicide risk screening tool that you will use and the process for implementing the screenings.

raw_content: On page 253, the specific screening tool and its application is not defined.


summary: 748.119(2) - Volunteer policy - Address qualifications, screening, and selection procedures for the volunteers

raw_content: A description for volunteer responsibilities, the criteria for the selection process, and required training is not explained.

Correction Narrative: The policy was updated to identify that the operation will not accept volunteers.


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

raw_content: The applicant and the designee do not have a background check submitted.

Correction Narrative: Background checks were submitted and pending CBCU processing.


summary: 748.153(2)(C) - Notification - At least 15 days in advance - Adding a swimming pool or other permanent body of water

raw_content: This rule is not addressed in the policies and procedures.


summary: 748.103(b)(12) - Policies and procedures to submit - Weapons, firearms, explosive materials and projectiles

raw_content: In the weapons policy PDF on pg. 242, it states that weapons will be prohibited. However, on page 229 of the YHA policies and procedures it states that children may engage in high-risk activities that include weapons, etc.

Correction Narrative: Policies and procedures were updated to stated that weapons are not allowed.


summary: 748.105(8) - Personnel Policies - Ensure employees report serious incidents and suspected abuse/neglect and exploitation directly to DFPS

raw_content: YHA's policy reporting serious incidents do not align with all the requirements found at 748.105 (8) and 748.303(a)


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

raw_content: The staff house is not in an appropriate condition for children in care. The house would need to be cleaned, cleared, and beds added prior to operating. The larger house has several bathroom handles and sink knob that required replacement. Some flooring was soiled. The garage was filled with items to be discarded. The pool house is blocked and in need of repairs/maintenance. The house where the heater is stored is dilapidated and contains discarded items.


summary: 748.153(2)(B) - Notification - At least 15 days in advance - Changes to floor plan

raw_content: This rule was not addressed in the policies and procedures.


facility_name: Glory Home RTC

summary: 748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs

raw_content: During inspection, three staff were reviewed to not have 40 hours of supervised child-care experience at the operation and/or another operation that provides the same treatment services.

Correction Narrative: The operation updated the orientation form to document all OJT hours required for staff with experience and staff without experience.


summary: 748.869(d)(3)(A) - Training on EBI must at the end, require each participant to demonstrate knowledge and competency of the training in writing.

raw_content: During inspection, two staff files did not have EBI post test.

Correction Narrative: The operation requested copies of the EBI post-test and received and filed all post-test copies in the appropriate files.


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

raw_content: Staff ask children in care to intervene between other children fighting/aggressive towards one another.

Correction Narrative: The operation sent a corrective plan on 3-20-26 inciting trainings in professionalism was sent to all staff on 3/19/26. The operation will continue to train on using appropriate communication methods while in the presence of youth and professionalism in the workplace.


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

raw_content: Staff do not have completed annual trainings required by minimum standards.

Correction Narrative:
The operation sent email indicating the following took place on 3-17-26: Staff completed the training and are in the process of uploading into casebook and the dates will be monitored.
To operations plan to implement from this day forward is to make sure and verify dates of earlier dated staff to have notification and completed trainings according to minimum standards.


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

raw_content: Staff use profanity when speaking to one another and staff make negative remarks about/to children in care.

Correction Narrative: The operation provided via email on 3/20/26 a corrective plan where staff were reprimanded for their actions and training was provided on compliance date 3/19/26. The operation will continue to monitor staff and encourage child in care to report any reports where staff interactions make them feel uncomfortable.


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

raw_content: Children in care who should be receiving 1:1 supervision are not being provided the 1:1 supervision as caregivers are leaving their assigned child without direct supervision.

Correction Narrative: A meeting was conducted with all caregivers on 12/15/2025. Supervision training was conducted and 1:1 supervision was explained and operation expectations for appropriate supervision was discussed.


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

raw_content: A child in care was able to lock himself in an upstairs restroom and absconded out restroom window.

Correction Narrative: A follow up inspection was conducted on 12/12/2025. Staff were scheduled for a meeting/training on 12/15/2025 to further discuss appropriate supervision. The meeting was completed and each staff was provided keys to all locks in the operation so that children are unable to lock themselves in restrooms.


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

raw_content: Children in care are being picked up from the armpits and carried to their bedrooms by caregivers.

Correction Narrative: A follow up inspection was conducted on 12/12/2025. Staff were scheduled for a meeting/training on 12/15/2025 to discuss the concern and redirect staff. The meeting was completed.


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

raw_content: Staff told children in care not to report what goes on at the facility. Children in care are placed on room restriction for making statements to police officers at church about the facility.

Correction Narrative: A follow up inspection was conducted on 12/12/2025. Staff were scheduled for a meeting/training on 12/15/2025 to discuss the concern and redirect staff. The meeting was completed. The operation also implemented random surveys of the clients. Management will be conducting random survey and ask children in care questions about staff and how things are going.


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

raw_content: At the time of inspection, 1 employee file did not have a documentation to verify a caregiver had a high school diploma or GED.

Correction Narrative: The operation corrected the deficiency by obtaining the high school diploma. As part of the hiring process at Glory Home RTC, the LCCA will establish a streamlined process to ensure that employee education records are promptly added to the personnel binder. Potential employees will be asked to submit proof of education along with background check information such as driver's license and social security card at the time of interview. The CEO will receive either electronic or physical copies of these documents before background check is requested from CCR. Additionally, administrative assistant will collect and verify all educational documentation, setting specific timelines for submissions and conducting monthly reviews to ensure compliance. Regular communication will be maintained with employees to remind them of their responsibilities regarding record submission, ensuring that the binder remains current and accurate.


summary: 748.125(e)(2)(A) - You must refer a child to a MH professional within 24hrs for a suicide risk assessment if screening finds child to be a potential risk for suicide.

raw_content: At the time of inspection, operation policy did not address procedure if the screening finds a child to have a potential for risk of suicide.

Correction Narrative: The agency responded by updating the operation policies and procedures to address all minimum standards when the operation identifies risk of suicide.


summary: 748.125(f)(2)(A) - Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.

raw_content: At thetime of inspection, operation policy did not address all the areas that are required post hospitalization.

Correction Narrative: The agency responded by updating the operation policies and procedures to address all minimum standards related to post hospitalization.


summary: 748.125(g)(1)(A) - You must create a Postvention Team, Written Action Plan and Protocols.

raw_content: At the time of inspection, the operation policies related to post vention were not adequately and appropriately addressed.

Correction Narrative: The agency responded by updating the operation policies and procedures to address all minimum standards related to postvention.


facility_name: The Children's Shelter

raw_content: There is documented evidence confirming that a caregiver fell asleep while supervising children.

Correction Narrative: Staff members were retrained on the minimum standards for night time supervision and awake policy. Administrator had staff members sign awake policy, acknowledging they understand the minimum standards. Staff member was interviewed and confirmed they were retrained on awake policy.


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

raw_content: A medication administration record was not updated with a dosage that was given to a child in the required timeframe.

Correction Narrative: F/U completed via inspection 4082024 on 10/21. Staff were retrained on medication procedures. Compliance was met.


facility_name: A Journey of Hope

raw_content: Contracted staff personnel did not practice prudent judgement when making an inappropriate/unnecessary comment to a child in care, one of which led to an escalated behavior of an unauthorized absence.

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:
On 12/1/25 the operation emailed a CAP that advises of the following: "In addressing the specifics of this standard rule, The QMHP contract staff in question is no longer with AJOH. Going forward all contractors that will be having contact with AJOH Residents will be trained on appropriate use of prudent parental judgment while communicating with the residents."

On 12/5/25 multiple children were interviewed to assess that compliance with this standard. There were no additional concerns found for staff or skills workers making inappropriate/unnecessary comment to a child in care.


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

raw_content:
Re citation:

The non-emergency admission assessment was not completed, signed, or dated prior to the admission of the child.

Licensing rep has not received a response from the operation.

Operation has not submitted any corrective plans of action.

Operation is non- responsive to attempts to obtain a correction for the citation issued

Standard Risk Level: Low

Correction Narrative:
Operation provided documentation that showed the correction being made, the non-emergency admission has now been signed and it is complying.
Operation provided a corrective plan of action in which they specify that they have put in place a qualitive assurance review, meaning both the PLSP and the LCCA will be ensuring all newly placed residents are in compliance with minimum standards.


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 did not conduct a mandatory Suicide Screening for the child in care.

Correction Narrative:
Provided by Email from LCCA on 10/30/2025: Effective immediately, AJOH Case Manager in collaboration with the Treatment Director will ensure that suicide screenings are completed at the point of placement for all residents that are 10 years of age or older.

The Facility Administration will ensure completion and proper documentation of the screening.


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

raw_content: The operations serious incident form is missing age, gender, and date of admission of the child, operation, physical address, and telephone number.

Correction Narrative: The operation sent the following corrective action: It was provided by Email from LCCA on 10/29/2025: In addressing the specifics of this standard rule. The operation will always document their debriefing reports and serious incident reports in writing separately. All serious incident reports will be provided to the investigator as requested.


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

raw_content: The operation failed to document date and time the child was informed of the discharge.

Correction Narrative: The operation sent the following corrective action: It was provided by Email from LCCA on 10/29/2025: In addressing the specifics of this standard rule, The Case Manager will update AJOH discharge Summary to include the date and time the child was informed of her discharge or transfer. The Facility Administration will ensure proper completion of this document during discharges.


raw_content: Staff left child unsupervised resulting in child involvement in physical altercation.

Correction Narrative:
Operation stated staff were in fact retrained regarding supervision and steps were made to ensure all youth are being cared for by a worker at all times.

Caregiver responsibility-providing the level of supervision necessary to ensure each child's safety and well-being.
In addressing the specifics of this standard rule and to prevent future occurrences, on 7/28/2025 during Monthly staff Meeting/Training, all employees were retrained on the importance of appropriate supervision highlighting three areas of supervision (Sight, Hearing and Proximity)

Secondly, allocation of residents to individual staff members is now being done to ensure appropriate management monitoring of supervision
The shift supervisors will ensure compliance under the supervision of the LCCA.


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

raw_content: During the inspection the carpet was viewed on the stairs, in the upstairs common area, and in the hallways to be heavily soiled, decolorated, and stained.

Correction Narrative: The operation is no longer located at the physical site for which this citation was issued. There are no issues at the current location.


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

raw_content:
Bathroom door does not close properly.
Toilet seat is detached from the toilet base.


raw_content: The non-emergency admission assessment was not completed, signed, or dated prior to the admission of the child.

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


summary: 748.3319(a) - Required Postings-Residential Treatment Center's must have

raw_content: No Trespassing sign was viewed to be created by the facility and does not meet the required guidelines by Minimum Standards.

Correction Narrative: During the follow up inspection, I observed the No Trespassing sign was corrected.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: During a walkthrough of the home, a container of refills of medications for the residents were not found to be double locked.


summary: 748.125(f)(1) - A PLSP must meet with a child within 24 hours of their return to an operation post hospitalization.

raw_content: During the course of the investigation, it was found that the child did not have a postvention meeting upon returning to the facility.

Correction Narrative: During the follow up inspection, it was found that the postvention meeting was conducted.


raw_content: During the walkthrough of the operation, it was observed that the garage had animal droppings on the ground.

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

Correction Narrative: Operation was found to be in compliance with this standard.


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

raw_content: Documents were observed to have the incorrect operation name.


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

raw_content: Staff files requested was not available for immediate review.


raw_content: Staff file reviewed is missing education requirement documentation.

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


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

raw_content: The health operation did not have a health inspection completed.

Correction Narrative: An email was sent with the following letter information from the Harris County Public Health (HCPH) stating please be advised that Harris County Public Health does not conduct environmental health inspections for foster or foster group.  homes.


facility_name: Adaptive Mind Services, LLC

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

raw_content: The operation has been without a licensed Administrator for over 60 days.

Correction Narrative: The operation submitted and hired an Administrator effective 2/23/2026.


raw_content: A hired employee did not have a complete and current record for review.

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

Correction Narrative:
12/23/2025-The operation's Governing Body submitted to Licensing via email a Corrective Action Plan which included documentation demonstrating that the staff member meets all required personnel qualifications.

12/19/2025-The operation's Governing Body submitted to Licensing via email a Corrective Action Plan.  The plan included a statement indicating the CEO immediately printed, gathered all completed onboarding forms missing from the staff file as well as any other needed documents have been added and updated to the staff file effective date 12/16/2025.


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

raw_content: Upon revew of CLASS Person List, it was identified that a former staff member remained active beyond seven days after no longer being associated with the operation, which is not  in compliance with requirements.

Correction Narrative:
12/19/2025-The operation's Governing Body submitted to Licensing via email a Corrective Action Plan.  The plan included a statement indicating the CEO has disassociated all former employees from CLASS and marked inactive from facility effective date 12/16/2025.

12/16/2025-Based on review of the operation's People List, it was observed that the staff member's background check status was inactive effective 12/16/2025.  A citation was issued, and compliance was subsequently demonstrated in accordance with Minimum Standards.


raw_content: During the 3rd. Initial inspection it was found that the Administrator has not been present at the operation.  It was noted that the Administrator is also listed at another operation. Further, in a discussion with the attached administrator, it was found that she has not been working with the Operation since August 2025.

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

Correction Narrative: 12/19/2025-The operation's Governing Body submitted to Licensing via email a Corrective Action Plan.  The plan included a statement indicating the CEO is in the process of interviewing and hiring a new qualified full-time LCCA within the next 60 days or less effective date 12/16/2025.


summary: 748.3395(b)(3) - Hand-washing-Provide hand-washing sinks with hot & cold running water under sufficient pressure to meet the demands of children

raw_content: The operation's sink areas were observed to lack hot water and did not have operable hot water at the time of inspection.

Correction Narrative: During a walk-through of the operation, the functionality of hot water in bathroom areas as well as kitchen area, including sinks, was evaluated and found to be operational.


summary: 745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone

raw_content: A hired employee did not have a ran and cleared background check with the operation.

Correction Narrative: Based on review of the operation's People List, the staff member's background check was completed on 12/17/2025, and the staff member was active as of 12/17/2025, meeting eligibility requirements per Minimum Standards.


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

raw_content: The operation's bathing areas were observed to lack hot water and did not have operable hot water at the time of inspection.

Correction Narrative: During a walk-through of the operation, the functionality of hot water in bathroom areas, including tubs, showers, and sinks, was evaluated and found to be operational.


summary: 748.105(3) - Personnel Policies - Include procedures for screening applicants to determine suitability.

raw_content: There is no policy on screening applicants, nor verifying employment history and conducting reference checks.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the operation has developed as well as implemented a written policy on applicant screening, including steps for employment history verification as well as reference checks within the policy.


summary: 748.105(4)(B) - Personnel policies-develop professional staffing plan that describes qualifications/duties/responsibilities/authority of professional positions.

raw_content: The policy is missing components for authority and frequency of services for staff members.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating the operation has developed a comprehensive written professional staffing plant that includes qualifications, duties, responsibilities, authority, and frequency of services for each role as well as integrated into the official personnel policies.


raw_content:
During the inspection walk-through, it was observed that the shower light in one of the bathrooms on the 2nd floor did not appear to be working.

Also, during the walk-through the fence surrounding the backyard had multiple nails needed to be removed or nailed into the fence properly.

Correction Narrative: The operation provided proof that the light had been replaced and is in working order.


summary: 748.115(2) - Discipline policy - Integrate trauma informed care into the care, treatment, and management of each child

raw_content: The policy does not notate how the operation staff will integrate TIC into the care, treatment, and management of each child.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the operation has drafted as well as adopted a written policy titled Trauma Informed Care in Discipline and Treatment, outlining Trauma Informed Care principles and integration into behavior management.


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

raw_content: During the inspection, in review of the administrators file, it was observed that the required Pre-Employment Affidavit for Applicants for Employment at certain Child Care Operations (form 2912) was missing.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the operation has adopted including downloading as well as completing Form 2912 for the Administrator and any other staff who are missing it in their files.


raw_content: The operation policies included conflicting information. There were instances of other operation names in the policy, conflicting information regarding the services planned to offer.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the operation conducted a full review as well as edited the operation's policy to identify as well as correct inaccurate operation names.


summary: 748.105(8) - Personnel Policies - Ensure employees report serious incidents and suspected abuse/neglect and exploitation directly to DFPS

raw_content: The policy does not include that an employee may not delegate the responsibility to make a report and that you may not require an employee to seek approval to file a report or to notify you that a report was made.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the CEO has updated the personnel policy to include a clear statement that all employees are legally required to report suspected abuse, neglect, or exploitation directly to DFPS and my not delegate this responsibility.


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

raw_content: The medication log form was missing the opportunity for the operation to provide the dosage information.

Correction Narrative: The operation has chosen to adopt and use the HHSC medication administration logs.


summary: 748.105(5) - Personnel Policies - Personnel Policies - Develop written policies on the training requirements for employees.

raw_content: The policy is missing the required general pre-service training components regarding Emergency Behavior Intervention and Normalcy.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the CEO has revised the personnel policies to include mandatory pre-service training topics, specifically EBI as well as Normalcy.


summary: 748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file.

raw_content: During the inspection, in review of the administrators file, it was observed that the documentation results from prior employers were missing.

Correction Narrative: The operation provided a completed pre-employment screening for the administrator.


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

raw_content: During the inspection, in review of the administrators file, it was observed that the reference information was missing.

Correction Narrative: The operation provided documentation to verify that two reference checks were completed as part of the pre-employment screening process.


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

raw_content: The serious incident form was missing an area for the operation to provide the child's age, the child's gender, and the resolution to the incident.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the CEO revised the Serious Incident Report form to include fields for the child's age, gender, and a section for the resolution/outcome.


summary: 748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use

raw_content: The EBI policy is missing a complete description of the types of EBI that they plan to permit for use by the caregivers.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the operation has drafted as well as implemented a detailed EBI policy that describes each permitted intervention (CPI approval holds, verbal de-escalation, transport positions).


summary: 748.121 - Abuse and neglect policy - You must develop policies on preventing, recognizing, and responding to abuse and neglect of children

raw_content:
Regarding standard 748.121(4), the policy does not include strategies of coordination between the operation and appropriate community organizations.

Regarding standard 748.121(5), the policy does not include actions that the parent of the child who is a victim of ANE should take to obtain assistance and intervention.

Correction Narrative: 07/21/2025-The operation's CEO submitted to Licensing via email the corrective action plan indicating that the operation has developed a policy related to abuse and neglect as well as integrated withing the policies and procedures.


facility_name: Perfect Start Homes INC

summary: 748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below

raw_content: During the inspection, the thermometer in the freezer was observed to be missing.

Correction Narrative: The administrator sent an email with a picture of a thermometer in the freezer.


summary: 748.3107(c)(1) - Smoke Detector-Must be equipped with battery back-up

raw_content: The battery in the smoke detector in one of the victims room does not work.


summary: 748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly

raw_content: The fire extinguishers inspection is expired.


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

raw_content: The fire extinguisher in the in the front area of the house was observed to be expired.

Correction Narrative: The fire extinguisher has been serviced by Fireton life safety solution. A inspection tag was placed on the fire extinguisher device.


raw_content: The battery in the smoke detector is expired in one of the residents' bedrooms.

Standard Number / Description: 748.3107(c)(1) - Smoke Detector-Must be equipped with battery back-up

Correction Narrative: The smoke detector battery has been replaced. The operation provided documentation stating that they will log and track battery installation dates.


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

raw_content: Two employees were listed on the people list as active that are not employed at the operation.


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 staff member was observed with a vape at the dining table upon arrival for the inspection.

Correction Narrative: Operation submitted for the staff vaping in the home. The employee was written up.


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

raw_content: In a review of the provided operation schedule, it was found that the Administrator was out on leave for an extended period of time. There was no designated back up provider.

Correction Narrative: An email was received from the operation staff stating the administrator is no longer employed by the operation, therefore an additional assessment/citation was conducted regarding this concern.


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

raw_content: Two child records reviewed were missing required information on both initial service plans.

Correction Narrative:
An email was received from the operation staff on 12/17/2025 stating the following: The service plan for one of the children is completed as of 12/12/25. The other child's plan is coming up as it is due by the 30 days of admission into the facility. We have also adopted form K908-3300 when completing each child's Initial Service Plan-Base.
In response to the corrective action the child's completed service plan was requested.

1/7/2026: Operation submitted completed service plans.


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

raw_content: In a review of Serious Incident Reports, it was found that one child witnessed a sexual act conducted by a child of an opposite gender.

Correction Narrative:
A corrective action was sent to the operation on 12/17/2025 via email stating the following:
Staff have been informed and redirected on the one on one care and issues that were addressed during inspection - The alleged child does not have any electronics in his room - his use of school laptop is permitted at the dining room table and in the common area.  The children have re-reviewed the house rules and rules amongst each other regarding personal space.  Staff have been re-notified that they are able to call the abuse hotline anytime there is a concern they feel should be addressed. The number is posted in the facility.  Aydan has a specific caregiver for his need of one-to-one care.


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:
In a review of children's medication logs, the following issues were noted:
- Two children are noted to have missed the AM dose on 12/7 for multiple medications.
- One child received a half dose on 11/28
- One child received a double dose in the AM on 11/22
- One child missed a dose on 11/29
- One child received a double dose on 11/28 and missed a dose on 11/29.

Correction Narrative:
A corrective action along with an attachment regarding medication errors was sent via email from the operation staff on 12/11/2025 stating the following:
The updated forms have been added to the medication error binder, and staff have been instructed on the proper procedures moving forward with the newly implemented forms. I will also begin assigning specific staff members each shift to administer medications to ensure consistency. I want to note that the children did not receive any double doses or miss any medications  the issue was solely with the forms being filled out incorrectly.


summary: 748.563(c) - Professional level service provider-must meet specific educational and professional qualifications

raw_content: It was found that one staff member does not meet the qualifications of a PLSP with the professional or educational qualifications. This staff member was completing the assessments and the plans for the children.

Correction Narrative: The operation has identified a new PLSP that does meet the qualifications.


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

raw_content: During a review of records, it was found that one of the two children currently placed at the operation meets ED treatment services. The operation does not have a hired treatment director.


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

raw_content: In two child records, the PLSP did not sign and date the assessments.

Correction Narrative: A corrective action was sent via email from the operation staff of 12/12/2025 stating the following: The following forms have been reviewed and signed by the children and also by the case manager. The completed forms were also attached, signed and dated.