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

raw_content: Children in care were left at the operation for over one hour due to staff not communicating with one another and not having knowledge; therefore, children were alone at the operation.

Correction Narrative:
On 10/06/22, compliance plan was received by email from operation staff. Connections conducted their own investigation and discovered the cause of the miscommunication between the staff members on shift. While we found miscommunication to be the cause of the youth being left behind, leadership and the other staff on shift had done their due diligence to ensure youth were properly supervised. Both the second staff on shift and the Residential Supervisor had instructed the staff in question to do visual checks before leaving for the outing. The supervisor also directed staff in question to take children for the outing, so staff had no excuse for leaving anyone behind. The staff member that left the youth unsupervised in the shelter is no longer with our agency. Action items include:
1)	On 9/1/2022, staff member was relieved from duty by Supervisor after leaving youth unaccompanied.
2)	On 9/2/2022, the Chief HR Officer, Chief Residential Officer, and Program manager met with the staff involved to administer a Job in Jeopardy plan and discussed proper supervision of youth, importance of headcounts/checks, and the safety plan put in place through the completion of the investigation.
i.	Safety plan included minimizing time involved staff member would be sole caregiver (no more than 30 minutes and only for assisting with transportation for outings/work/etc.), staff will verify they have assigned youth by phone with supervisor prior to leaving facility, increased unannounced observations/camera audits, and additional trainings to be completed in supervision sessions regarding Prudent Parenting standard, procedure for physically checking on youth in accordance with service plans, and the importance of knowing assigned youths' whereabouts at all times.
3)	The involved staff member resigned the following day and did not work any shifts after being relieved on the 1st.


state: TX

facility_name: Connections

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

raw_content: During the investigation it was determined a caregiver did not demonstrate self-control when they cursed in front of children and made inappropriate comments to them.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: Connections staff was retrained, and staff member involved resigned shortly after incident.


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

raw_content: Supervision was not appropriate when a staff member did not physically check on a child during the night.  The child was in another child's bedroom for approximately 6.5 hours without the staff member knowledge.

Standard Risk Level: High

Correction Narrative: Program Manager conducted retraining on overnight checks, changed documentation form to ensure more random checks, and put in a safety plan during the investigation.


summary: 748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations

raw_content: In reviewing the medication record, it was observed that a child was given the wrong medication on two prescriptions. A healthcare professional was not contacted regarding the incident and how to respond.

Correction Narrative: On 5/18/22, the administrator emailed a response to the citation and corrective steps being taken to come to compliance. These steps included increased medication audits from shelter leadership and additional training for staff covering the finding. Compliance has been met at this time.


raw_content: Interview with staff concludes the child was not checked on within timeframe specified in Service Plan. The child's Service Plan states the child should have checks every 30 minutes. The Service Plan also states the child has high risk behaviors to include history of running away and suicidal behaviors.

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

Correction Narrative: The following compliance plan was received via email: Both staff from this incident received disciplinary action, one of them was terminated from employment later in May due to ongoing issues. The Whereabouts Form we use to assist staff in documenting supervision of youth was updated. Active Supervision is interacting with youth and frequently and randomly checking on all assigned youth to ensure their whereabouts are known by staff. If a staff cannot tell us exactly where a youth is, it is their duty to do another check, even if a check had already been conducted in accordance with their level of supervision per their service plan. Leadership has made this a continuous training topic in staff meetings to include meetings on 4/26/22, 5/19/22, 6/2/2022, 6/16/22, and 6/30/22. Leadership also conducts random check-ins with staff both in person and via camera to ensure supervision is happening according to our policy.


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: One child's medication administration record documented that on two days medication was not given as prescribed. One day the PM medication dose was missed. On the second day, the AM medication dose was missed.

Correction Narrative:
On 3/24/2022, the administrator sent the following corrective actions that the operation will be taking: 1)The Supervisor has resumed Daily Medication Audits. 2)The LCCA has resumed Weekly Medication Audits with the assistance of the Program Manager and Counselor. 3)Shelter Leadership held a staff training on 3/23 and covered the citation, the 5 Rights of Medication, prescription instructions, reading psychiatric appointment notes, and medication audits.

On 4/8/22, a follow-up inspection was completed. Medication logs were in compliance and included documentation of audits being completed.


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

raw_content: During the inspection, a psychotropic medication on one child's medication log was not documented as administered or refused, no med count was completed, and staff's signature was missing on 9/26.

Standard Risk Level: Medium

Correction Narrative: An email was received from the administrator in response to the citation. The employee that did not update the medical record as required has subsequently been terminated. In addition, the operation will continue implementing a thorough medication administration process including daily medication audits by a supervisor, more frequent medication administration trainings, and medication administration review by a second staff on shift completed within an hour of the administration.


facility_name: Roy Maas Youth Alternative - Girlsville/Junction

summary: 748.191(2) - Required Postings-Post Licensing notice Keeping Children Safe in prominent and publicly accessible place where others may easily view it at all times

raw_content: During a walkthrough of the cabin, the "Keeping Children Safe" poster was not posted. It was posted after the walkthrough.

Standard Risk Level: Medium Low

Corrected at Inspection: Yes


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

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

During a review conducted on 12/22/2024 it was determined that:

-the Administrator failed to ensure compliance with the current HM Plan; and

-12 months had elapsed since the effective date of the plan

The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the 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 the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the administrators failure to ensure compliance include the following:

-Operation failed to satisfy the conditions of the plan

-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, including having an open investigation.

Correction Narrative: An HM extension was approved effective 12/22/2025.  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 6/24/2026.


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

raw_content: A report was not document for a medication error within 24 hours of the operation, becoming aware of a child in care receiving another child's inhaler to take on an outing.

Correction Narrative: Follow-up completed by inspection. Staff interviewed and documentation obtained.


raw_content: A child's prescribed medication was not reorder in a timely manner, resulting in the child going without 3 required doses.

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

Correction Narrative: Followed up with the Director on medication refill procedures and obtained related staff training sign-in sheet.


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

During a review conducted on 6/18/2024 it was determined that:

-the Administrator failed to ensure compliance with the current HM Plan; and

-12 months had elapsed since the effective date of the plan.

The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the 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 the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the administrators failure to ensure compliance include the following:

-Operation failed to satisfy the conditions of the plan

-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, including having an open investigation.

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

Correction Narrative: An HM extension was approved effective 6/19/2025.  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 12/20/2025.


raw_content: Staff had  knowledge a  child in care had vape pen and did not remove from possession immediately.

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:
5/12/2025- a follow-up inspection (#4056143) was completed; a copy of meeting sign-in sheet and tobacco policy was received.

4/27/2025 email received from operation reads:
RMYA's objective is to ensure the health, safety, and well-being of all our youth. The staff that had knowledge of the vape pen is no longer with the Agency. We will discuss the importance of being transparent and not keeping secrets with our staff. This citation will be discussed during the week of May 5th-9th.


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

raw_content: Staff was aware of the vape being on campus and did not say anything.

Correction Narrative:
5/12/2025- a follow-up inspection (#4056143) was completed; a copy of meeting sign-in sheet and tobacco policy was received.

4/27/2025 email received from operation reads:

RMYA's objective is to ensure the health, safety, and well-being of all our youth. The staff that had knowledge of the vape pen possibly being on campus is no longer with the Agency. We will discuss the importance of being transparent and not keeping secrets with our staff. This citation will be discussed during the week of May 5th-9th.


raw_content:
During a review conducted on 12/18/2024 it was determined that:

-the Administrator failed to ensure compliance with the current HM Plan; and

-12 months had elapsed since the effective date of the plan.

The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the 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 the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.  Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.

Further details of the administrators failure to ensure compliance include the following:

-Operation failed to satisfy the conditions of the plan

-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, including having an open investigation.

Correction Narrative: An HM extension was approved effective 12/18/2024.  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 6/12/2024.


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 with history of self-harming behaviors were given unsupervised access to scissors.

Correction Narrative:
1/14/2025- the operation has put a system in place to inform caregivers of high-risk behaviors.

12/30/2024 email received from operation listed the following compliance response:
"In the shift change report at Girlsville, a section will be added named high risk behaviors. Each employee will read this information at shift change and ensure that they sign it. This will be discussed during staff meetings the week of January 12th, 2025."


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: Child in care was given restrictions for completing an activity that was authorized by a staff member.

Correction Narrative:
1/14/2025- Restriction must be approved by a supervisor and/or campus administrator.

12/30/2024 email received from operation listed the following compliance response:
"On call Supervisor will be notified of all consequences given on each shift. The on-call supervisor or Campus Administrator will approve the consequences or modify the consequences if needed. This change will be discussed in the next program staff meetings during the week of January 12th, 2025."


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

raw_content: it was discovered that staff did not conduct night checks within the appropriate 10-15minute time frames.

Correction Narrative:
10/29/2024 meeting information and attendance sheet received. The operation went over the citation issued and administrators response regarding safety plans and supervision.

10/18/2024 email received from operation
Our goal is to ensure that our children are constantly supervised. We view this as one of our main priorities. Our staff will ensure that they are adequately supervising the residents and that they are following the resident's service                           plans. This will be addressed agency-wide in staff meetings during the week of October 23rd.


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

raw_content: During the review of medication record, there were two (2) prescribed medication with incorrect pill counts documented on the med logs.


summary: 748.2851(d) - EBI Follow-Up-Supervisor(s) of caregivers involved in an EBI must review the use of the emergency behavior intervention within 72 hours

raw_content: Reviewed two EBI reports. One report is missing supervisors/administrative signature indicating the EBI report was reviewed. The second report was signed by the employee involved in the restraint not their supervisor.

Correction Narrative:
The operation seeks to provide services for youth that are of the highest professional quality, to include accurate documentation. The Operation's programming staff will perform the following:
1.A report will be generated from the operation's CMS every Thursday showing what signatures are needed on incident reports.
2.The report will be emailed to Program Administrators along with the Senior Director of Program Leadership along with the Senior Director of Regulatory Compliance.
3.Signatures will be completed by the end of day the following Monday.


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 the course of an investigation the doors to the medication room were seen opened and unattended by staff, leaving psychotropic mediations only single-locked.

Correction Narrative:
Response received from operation:
: We've hired two medication technicians who will be responsible for giving out the resident's medications. In addition, we will be moving our psychotropic medications to our nurse's office so that the medications are centrally located. This should be in effect by the end of January 2024. The staff will be notified in staff meetings during the week of January 10th.


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

raw_content:
During the course of an investigation the child in care reported not receiving medical attention after reporting to staff of possibly having a concussion and needing to go to the hospital to be check after being restraint.

There was no evidence to support the child had a concussion or that staff cause the child to hit their head during the implementation of a restraint.

Correction Narrative:
Received via email:
We strive to ensure that our children's health and safety is a priority. Our staff will be notified that they are to communicate any possible injuries to our campus nurse for direction and to ensure our children's health. This will be addressed agency-wide in staff meetings during the week of January 10th.


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: Incident occurred on 8/28 and was reported to the hotline on 9/21.

Correction Narrative:
11/03/23-Operation Response: :  It is our staff's intention to ensure transparency and that licensing is aware of all significant incidents and report them within the allotted time limit.  In making the decision as to whether to call the incident into the Hotline, staff utilized standard 748.303 (When must I report and document a serious incident) which states Sexual abuse committed against another child. It goes on to state that sexual abuse is conduct harmful to a child's mental, emotional, or physical welfare, including nonconsensual sexual activity between children of any age , and consensual activity between children with more than 24 months difference in age or when there is a significant difference in the developmental level of the children.
We will ensure that our on-call and back-up administrators will follow up with our staff to ensure compliance. This will be addressed agency-wide in staff meetings during the week of November 6th.


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

raw_content: It was confirmed through interviews, staff members did not ensure child made it to school from medical evaluations regardless of runaway risk in child's service plan.

Correction Narrative: On 09/20/22, email was received from operation with following action plan: It is our staff's mission to protect the health, safety, and well-being of our children by ensuring adequate care and supervision of our children. Additionally, our goal is to provide services that are of the highest in professional quality. All staff will ensure that our kids are supervised and within sight when on campus. Crisis and Trauma Team (CATT) and other administrative or support staff will assist during medication evaluations to ensure compliance. This will be discussed Agency wide during staff meetings September 27-29th.


summary: 748.3601(9) - Swimming Pool-swimming area rules & emergency procedures must be posted at the swimming area & explained to the children

raw_content: Emergency procedures were not posted in swimming pool area.

Category: Physical Site

Correction Narrative: An email was received from the administrator stating that even though there were swimming rules posted, it is the Agencies' responsibility to ensure that the emergency procedures are posted as well. The Agency has purchased posters that include emergency procedures, which will be posted in the swimming pool area on 7/1/22. This will be reviewed and discussed Agency wide in staff meetings during the week of July 11 -13th. A photo was received confirming the signage.


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

raw_content: The following was observed that a faucet was loose, tiles were missing in the shower, there was a hole in the wall and a sink drain was clogged.

Correction Narrative: An email was received from the administrator stating that staff are tasked with ensuring that the bathing facilities are in good working condition to reduce the risk of harm to children in care. The facilities department was able to tighten the faucets, unclog the drain, and fix the hole in the wall at the Pool house. The missing tiles in the shower were not missing. It had previously been covered with concrete.  Staff will also ensure that maintenance tickets are completed in a timely manner. Pictures were also received confirming the repairs.


summary: 748.3471(4) - Safety Requirements-Equipment must not have protrusions or openings that can entangle something around a child's neck or a child's clothing

raw_content: It was observed that the playground equipment had protruding screws.

Correction Narrative: An email was received from the administrator stating that the purpose of this rule is to ensure the safety of children using playground equipment. All of the playground equipment has been fixed by facilities. The maintenance department will inspect the playground equipment once a month to ensure the resident's safety. A photo was also received confirming the repair.


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

raw_content: The time was missing on 2 children's medication records.

Correction Narrative: Staff will ensure that they are double checking the resident's medications and will enlist a second staff to double count the medications. Staff will also make sure that they are completing the prescription drug forms and that all areas are filled out. In addition, the campus nurse will conduct a monthly audit of the medication forms and report the findings to the Sr. Director of Clinical & Medical Services and the LCCA. This was discussed Agency wide during staff meetings between April 26-28th.


raw_content: According to video footage, a staff member left children in care unattended for approximately 9 minutes and in addition, did not complete their 30 minute checks on the children.

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

Correction Narrative: Received an email stating : It is the staff's responsibility to protect the health, safety, and well-being of our children by ensuring that they adequately cared for and supervised at all times. The staff was placed on a safety plan and was written up and placed on administrative leave. In addition our staff will not leave the program unless they have another staff present to replace them. The staff were reminded of supervision and our policy regarding checking the children every 30 minutes during bedtimes. This will be discussed Agency wide during staff meetings on March 1-3rd.


raw_content: A child in care was able to crawl passed the window of the office area without staff noticing. During the walk-thru of the cabin it was found when staff are in the office they do not have a clear view of outside of the office. The video of the incident also shows that the staff did not have a clear view of the outside area.

Correction Narrative: Staff will continue to do bed checks every 15 minutes once the childern in care are in their rooms preparing for bedtime. The bed checks will be increased whenever the level of supervision increases. There will only be one staff in the office during leisure and room times, while the remaining staff will be in the common areas. This will be addressed agency-wide during the week of December 7-8th during staff meeting.


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: A child in care requested to call the Texas Abuse Hotline but was not allowed to do so.

Correction Narrative: Staff will allow residents to communicate with their Attorney, Ombudsman, Caseworker, and the Abuse Hotline/Licensing whenever they request. There will be modifications given if the child or party on the other line wants a private conversation.  This will be addressed agency-wide during the week of September 21-22nd during staff meetings.


summary: 748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair

raw_content: One top bunk bedrailing was damaged posing a risk to the health and safety of a child in care

Correction Narrative: An email was received from Administrator Julian Bell. A photograph of the upper level bunk bed was attached. Administrator stated that walkthrough will be conducted to ensure work orders are completed.


facility_name: Hill Country Youth Ranch

summary: HRC 42.049(a) - Operational Responsibilities- Maintain liability insurance coverage in the amount of $100,000 for each occurrence of negligence

raw_content: Liability insurance information provided expired 1/28/26- operation does not have current liability insurance.

Correction Narrative: Follow up information provided by operation stating: We have updated our insurance as of 01/28/26 and it is valid thru 01/28/27. We have a designated person to ensure this does not lapse. Copy uploaded to document library.


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

raw_content: Children's bathrooms were observed to be missing soap, towels and trashcans.  Trash cans were also observed to be overflowing needed to be emptied.  Staff were notified of missing items and replaced them during inspection.


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

raw_content: During a monitoring inspection, it was found that the operation is reporting Emergency Behavior Intervention (EBI) data to include EBI performed at the Residential Treatment Center (RTC). This is inaccurate record keeping as the data must only include data from the GRO.

Correction Narrative: Operation provided the following follow up information: We will continue to monitor and improve on reports in order to maintain accurate and clear information. We will also ensure that reports are separated by program.


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

raw_content: The last background check validation was completed 07/03/25, as of today 12/09/25 operation has not completed backcheck validation which is over a month past due.

Correction Narrative: Background checks were updated in Class and administrator stated that background checks were assigned to staff member to ensure they were completed timely.


raw_content: During an investigation it was determined a direct care staff did not intervene when two children in care engaged in a physical altercation leading to one child sustaining injuries.

Correction Narrative: Two children interviewed stated that they feel safe at the operation, they are always supervised and staff always intervene and protect all children.  Two staff members interviewed stated there were no concerns with supervision or staff intervention to protect children and staff stated that they review supervision and intervening when necessary at weekly staff meetings.


summary: 748.3719(b) - All-Terrain Vehicles-Only a child 16 years or older may ride on or operate a four-wheel all-terrain vehicle

raw_content: Children under the age of 16 have been routinely riding on All Terrain Vehicles at the operation.

Correction Narrative:
According to documentation and interviews with staff and children- children of all ages are now prohibited from
riding or being transported in ATV'/UTV's at the operation.

administrator sent email 12/11/25 stating A new policy prohibits children from riding in UTVs/ATVs. Staff are no longer allowed to bring or use personally owned UTVs/ATVs on the property.


summary: 748.3309(2) - Communication-Operation must have communication system to allow employees to contact other employees in the operation as needed

raw_content: It was noted that both on and off campus communication is not reliable at the operation, there was information that you cant call on or off the campus. There were problems with staff communication and ability to contact Emergency Care Services when a child and staff member were involved in an ATV accident.

Correction Narrative:
The Director provided documentation that the operation has started the process to acquire equipment for radio
system and instillation of repeater that includes 2 channels on a radio tower system to provide better communication at the operation.

administrator sent email 12/11/25 stating A communication issue is currently being evaluated. At this time, access to certain areas of the ranch is being restricted due to unreliable communication in those locations. We are in the process of implementing a formal check-in system. This is an ongoing and complex issue, and efforts to identify a long-term solution are underway.


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

raw_content:
Operation did not report within two hours to licensing timely when four residents ran from the operation. The residents were under age 13.
Incident report indicates the residents ran at 4:45 pm and reported to hot line at 9:02 pm.

Correction Narrative: In the future Hill Country Youth Ranch will report serious incidents to residential child care licensing within two hours of notifying law enforcement. Staff involved in the incident have been counseled regarding the time-frames for reporting.


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

raw_content: While reviewing the incident report it was found that the names of all adults involved, their role in relation to the child and the circumstances surrounding the incident were not documented.

Correction Narrative: The operation provided the following Compliance Plan via email: In order to assure serious incidents are documented in a written report that provides all of the information and details in accordance with minimum standards the form in Extended Reach is being assessed and training will be done for all staff charged with writing serious incidents.


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

raw_content: A child in care was not immediately taken to be evaluated by medical professionals following an assault by two peers. The Incident Report noted the caregiver finding "pooled blood" on the floor of the room where the assault took place, and the child sustained a knot on their head, a bloody nose, as well as bruising. Due to injuries and severity of assault, the child should have been evaluated for a concussion and broken bones.

Correction Narrative: In person follow up conducted at operation. Two staff members were interviewed and verified first aid training as well as a review of policies and procedures pertaining to medical care.


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: A report of abuse, neglect and/or exploitation of a child in care was not made following an incident of a child being pulled off of a couch, having their pants pulled down, and an inappropriate image was drawn on their face. Images of the child's face were shared with peers and staff before an intervention was made.

Correction Narrative: Operation provided Compliance Plan via email. Operation reported Staff present at the time of the incident will be given training in reportable serious incidents.


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

raw_content: Caregivers did not report to their administrative staff a serious incident in which a child was assaulted by two other children in care.  In addition, the caregivers allowed a child in care to go to the annex and be in the presence of other children who had assaulted them two days prior. In a separate incident, a volunteer/frequent visitor to the operation aggressively approached and verbally assaulted a child in care at an outside location.

Correction Narrative:
Compliance Plan was provided by the operation via email on 8/21/2024.
The plan noted staff involved will be given training in reportable serious incidents and discussions will be held with staff and administrative staff regarding interaction between residents following conflict. Administrative staff spoke with a person (visitor) who was reported to have approached a child from the Ranch in an aggressive manner regarding the inappropriateness of the approach and she has committed to exercise better self-regulation in the future when dealing with Ranch children.


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

raw_content: Caregivers did not provide a level of supervision necessary to ensure a child's safety and to intervene when a child was assaulted in the annex of the cabin away from the main house..

Correction Narrative: In person follow up conducted. Two staff members were interviewed and confirmed review of supervision policies and procedures.


raw_content: Incident Reports contained conflicting date and time reporting. An incident report for the assault of a child selected "Yes" to the question "Was child taken to medical professional," but the next response noted the child "will be medically examined tomorrow." Additionally, an Incident Report labeled "type" as Verbal Aggression when the child was the victim of an assault by peers. In other Incident Reports, the type of incident includes that the child is the victim.

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

Correction Narrative: A Compliance Plan was provided via email from the operation on 8/21/2024. The plan noted all staff involved in this incident will receive remedial training in record keeping in order to maintains true and accurate records so that information correctly notes when an incident took place, specific details, the nature of the incident, and so children's records remains up to date.


raw_content: It was confirmed by the operation that a staff member fell asleep while providing supervision to children in care.

Correction Narrative: The operation provided a compliance response. Operation states that staff that are found to be sleeping during nighttime hours will be subject to suspension or termination or additional training will be provided. Operation program directors will monitor video surveillance to ensure that night staff are awake. Cabins are called randomly two times per night and unannounced cabin checks are also completed at least one time per months. These calls and unannounced checks are documented. Corrections have been made at the operation as the incident occurred in January 2024. Staff was provided additional trainings and put on a corrective action plan.


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

raw_content: The operation failed to provide the Annual Summary Log of Unauthorized Absences after it was requested.

Correction Narrative: The operation provided a compliance response on 01/08/2024. Operation states that they will begin to log information regarding unauthorized absences including name, age, gender and date of admission of child who eloped. They are currently working on having the information generated through the Extended Reach system but in the meantime, they will manually log the required information.


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

raw_content: The operation did not have abuse and neglect policy available for review.

Category: Organization and Administration

Correction Narrative: The operation provided a response stating that they  already had policies in place regarding preventing, recognizing and responding to abuse. They recognize, however, that these policies were not codified into a singular document. The operation provided an updated policy for preventing, recognizing and responding to abuse and neglect of children which meets standard 748.121.


summary: 748.4001(b) - General requirements-must ensure the safety of all children during any transportation that the operation provides

raw_content: During walkthrough for Cannon House, Van 33 a seatbelt was found cut, unable to use by a child in care. In addition, a van was found with open rips at the time of inspection and this van was being utilized for transportation purposes of children in care.

Category: Transportation

Correction Narrative: During in person inspection van related to citation is not in use. Work orders were provided at the time of inspection and van is currently in repair. Documents and compliance plan were received through email.


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

raw_content: It was confirmed that service plans for children receiving treatment services for emotional disorders were not updated within 90 days.

Correction Narrative: The service plan of a child in care receiving treatment services was reviewed and found to be in compliance with the standard. The required documentation was also noted during the review.


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

raw_content: It was confirmed that the operation did not complete documentation of medication errors within 24 hours.

Correction Narrative: An unannounced walkthrough was completed of the cabin with citations, 2 binders were reviewed and found to be completed per the standard. Medication information was documented in its entirety.


raw_content: It was confirmed that a staff member failed to demonstrate prudent judgement when they exchanged personal text messages with a child in care.

Correction Narrative: In response to the case findings, the operation has taken actions to address staff concerns. The steps being taken by the operation were discussed with the administrator during inspection #3937841. Additionally, an email was received from the operation on 04/13/2023 regarding their compliance plan. The operation has increased monitoring of cameras in all cabins. Operation is reviewing and updating their policies regarding staff engagement with children and youth on social media. The operation recognizes the importance of maintaining safe and appropriate relationship with children and will review these polices with all employees.


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

raw_content: A child sustained injury that required medical attention and incident was not called in until months after.

Correction Narrative: The operation provided a follow-up regarding the deficient standard stating that effective immediately all non-scheduled routine medical visits will be reported to Licensing within 24 hours. The operation will be requesting an administrative review.


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

raw_content: Food in a freezer was found to be open.

Deficiency Narrative: Food in a freezer was found to be open.

Correction Narrative: Food in a freezer was found to be open.


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

raw_content: Two ovens and one sink  were observed to be dirty.


summary: 748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times

raw_content: Two toilets were observed with no toilet paper.


raw_content: Two refrigerators, a dishwasher, two ovens, one sink, and two bathrooms  were observed to be dirty or not in good repair.

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


raw_content: Food in a refridgerator was found to be expired.

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


summary: 748.3001(C)(2) - Sanitation inspection- inspection unavailable must maintain documentation at operation and make available to us

raw_content: Yearly updated documentation showing inspections are unavailable at the operation has not been provided.

Correction Narrative: The operation provided a response to the citation stating that they continue to have difficulties getting a health inspection completed at their operation. They are outside the city limits and the county does not provide this service. The operation states that they are able to conduct quarterly inhouse inspections using TDFPS form 2932: Environmental Checklist until an alternative can be found.


raw_content: Children in care engaged in inappropriate activity due to improper supervision by staff. One staff member supervising the children at the time of incident had knowledge of the children's high risks behaviors but did not convey this information to the other staff member present.

Correction Narrative: The operation provided a follow up plan in response to the citation. Moving forward the operation will inform all employees in the administration building of which children are present inside. Additionally supervision plans will be communicated to all those staff members in the building. Youth will not be permitted to leave their assigned areas unless with administrator or designee present. 10/04/22, inspection follow-up was completed at the operation through full walk through and FTF contact with Administrator and front office staff involved. Staff will receive additional training and informing staff of purpose for children waiting in front area. No date has been provided for upcoming training.


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

raw_content: Three fire extinguishers observed have not been inspected since April 2022.

Correction Narrative: The operation provided a corrective action plan in response to the citation. Operation states that the staff member responsible for inspecting the fire extinguishers on a monthly basis understands that this must be completed by the last Friday of every month. The executive director of the operation will assign a designee to ensure that this is completed.


summary: 748.3443(a)(5) - Food Preparation-Food items must be refrigerated immediately after use & after meals, if the food requires refrigeration

raw_content: A plate of fish was observed left out on the kitchen counter at cannon cottage.  A dish of meat and noodles was obsevered uncovered in the refrigerator and food was observed on the floor in the pantry at meadow cottage.  An open containter of raw meat was observed in the refrigerator at mabee cottage.


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

raw_content: A medical incident involving a child that did not rise to the level of a serious incident was not documented in the same manner as a serious incident report.

Correction Narrative: A compliance plan was received from the operation. In response to the standards deficiency the operation stated that a staffing was completed with staff regarding the deficiency and the circumstances in which a serious incident report needs to be documented.


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

raw_content: Children in care were yelled at by a caregiver.

Correction Narrative: The operation responded with a corrective action plan by stating that the staff member that yelled at children completed additional compassion fatigue training on 03/10/2022. Supervision of direct care staff and children by supervisors will continue in order to ensure safety and wellbeing of children.


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

raw_content: A restraint was used on a child in care during a situation which was not considered an emergency.

Correction Narrative: Operation responded with a corrective action plan stating that the staff member that restrained the child is no longer employed at the operation. The operation will continue to receive training on proper EBI techniques and procedures.


summary: 748.723(a) - Volunteers and Contractors-if the person performs an employee function, he must meet the same requirements as an employee who performs that function

raw_content: A volunteer did not have all the required trainings to be a caregiver for children and supervised 8 residents with a staff.

Correction Narrative: The operation will ensure that volunteers or contractors who perform employee functions meet the required qualifications, by being careful not to mix RTC and Basic Care participants in activities unless necessary. If it is necessary to mix RTC and Basic Care Program kids together in an activity, the operation will ensure that qualified supervision ratio will be present by discussing beforehand the necessary qualified staff that will be needed to meet the ratio requirements.


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

raw_content: A staff member provided children in care with vaporizer pens on multiple occasions.

Correction Narrative: The operation provided a compliance response stating that the staff member was immediately terminated and vacated the premises. Program Supervisors will continue to perform unannounced visits and monitor the cabins daily. All staff receive training regarding Professional Boundaries and other trauma focused childcare training. Ratio was increased in the boy's cabin to provide additional supervision for the children.


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 admitted to smoking in the children's living quarters.


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: Medications were observed in a child's bedroom.

Correction Narrative: Direct care staff will continue with annual medications policy and procedures training. The medical coordinator will complete random and unannounced inspections.


summary: 748.4005(1) - General requirements-child in care may transport other children in care if the child has a valid drivers license

raw_content: Operation staff allowed two children in care to transport other children in care, who are not licensed drivers.

Correction Narrative: The staff member that allowed the children to drive the vehicle was fired. Direct care staff will continue to be required to complete transportation training. Residents are not allowed to drive vehicles.


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

raw_content: Operation did not provide adequate oversight and a caregiver provided children with illegal substances, alcoholic beverages and acted inappropriately with children while employed at the operation.

Correction Narrative: The operation provided a corrective action plan stating that in response to the deficiency they terminated the staff member's employment. The operation will be installing a electronic check system to improve supervision. Camera systems will also be installed in common areas of the homes and program supervisors will review footage.


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

raw_content: Staff member was inappropriate with children and provided illegal substances to minors.

Correction Narrative: The operation provided a compliance response stating that the employee named in the incident had their employment terminated and does not have access to children in care. The operation will continue to monitor and supervise children daily. The operation will continue to evaluate supervision practices and monitor staff compliance of  Personnel Policies and Procedures and HHSC Minimum Standards. Disciplinary action, up to termination may result if staff are found in noncompliance. A new night electronic monitoring system will be implemented by January 31, 2022. The operation is also contracting with an external agency to conduct an organization risk assessment to review policies and procedures. Ratio has been increased in the boy's cabin to provide additional supervision by staff. Mentor visits are no longer allowed to take place in private and must be held in a communal area.


summary: 748.507(2) - Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator

raw_content: Three staff members were made aware of allegations of abuse toward children in care, yet failed to report as per timeframes.

Correction Narrative: The operation provided a compliance response stating that additional risk and reporting training was completed with all staff. The operation is also contracting with an external agency to conduct an organization risk assessment to review policies and procedures. Program Supervisors will continue to perform unannounced visits and monitor the cabins daily.


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

raw_content: A staff member employed by the operation provided illegal substances to children while charged with caring for them. A staff member was made aware of these allegations of abuse against a staff member and failed to act in protecting children in care.

Correction Narrative: The operation provided a compliance response stating that the employee named in the incident had their employment terminated and does not have access to children in care. Direct care staff received risk management training to include reporting and serious incidents. Program Supervisors will continue to perform unannounced visits and monitor the cabins daily. A new night electronic monitoring system will be implemented by January 31, 2022. The operation is exploring prevention training opportunities with other partners in addition to the training we currently offer.


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: Evidence and information gathered support that a staff member inappropriately touched, provided substances to and inadequately supervised children in care.

Correction Narrative: The operation will be implementing a night electronic check system to enhance supervision during sleep hours. Camera systems will be installed in common areas to ensure residents' safety. Program Supervisors will monitor and review. The operation will be conducting a policy and procedure review. New hires and new volunteers will undergo additional safety screening.


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

raw_content: Throughout the operation there were a total of 7 missing thermometers in the refridgerators.


summary: 748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease

raw_content: Operation did not report awareness of communicable disease timely.

Correction Narrative:
Compliance plan received from Executive Director via email.

Operation will ensure that a report is made to licensing within twenty-four hours along with notifying the child's guardian of all children in care who contract a reportable communicable disease.


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 operation did not report to Licensing concerns of an inappropriate relationship between a child in care and a staff member for possible sexual abuse.

Correction Narrative: HCYR will continue to abide by Serious Incident Report timelines as defined by HHSC Minimum Licensing Standards.


raw_content: A child in care was sexually abused by a staff member.

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

Correction Narrative: The employee named in the alleged incident was terminated immediately and does not have access to children in care. HCYR Supervisors will continue to monitor and supervise children daily.


raw_content: The operation was made aware of concerns of an inappropriate relationship between a child in care and a staff member and failed to take action to protect the child. The child in care was sexually abused by the staff member.

Correction Narrative: Issues brought to the attention of HCYR were addressed by the Program Director. HCYR will ensure that any issues and/or concerns are appropriately addressed and noted in the personnel file. HCYR will continue to evaluate supervision practices and monitor staff compliance of HCYR Personnel Policies and Procedures and HHSC Minimum Standards. Disciplinary action, up to termination may result if staff are found in noncompliance.


raw_content: Two children in care engaged in sexual behaviors due to neglectful supervision of a staff member.

Correction Narrative:
On 09/13/21, email was received from operation with the following compliance plan:

Upon receiving the report regarding the two youth involved, the employee responsible for supervising the resident was terminated. HCYR ensures that all employees are adequately trained and understand their job responsibilities. In this incident, the employee's lapse in judgment and failure to report the incident were cause for termination.

HCYR will continue to provide support, training, and supervision to ensure children are appropriately monitored.

Staff has been terminated and no longer present at this operation.


facility_name: AMIkids Rio Grande Valley

summary: 748.1111(a)(2) - Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP

raw_content: Staff member overheard child's phone conversation.

Correction Narrative: There is no risk present at the operation. There are no placements at the operation. The operation has voluntarily closed and is not operating.


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

raw_content: A child in care with a history of diabetes was not properly supervised during an outing, where the child was able to purchase an item that may have caused potential harm to the child when consuming it.

Correction Narrative: There is no risk present at the operation. There are no placements at the operation. The operation has closed down and is not operating.


summary: 748.125(e)(1)(B) - You must not leave a child alone until a MH professional assesses the child if suicide risk screening finds child to be at a high risk for suicide.

raw_content: Specific actions required in the event the operation finds a child to be high risk for suicide were not documented on suicide prevention policy.

Correction Narrative: Revised suicide policy was submitted. AMIkids RGV requests a written response from TX DFPS by July 1, 2023 advising the approval or if additional revisions are needed to aforementioned policy.


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

raw_content: Operation's suicide prevention training curriculum does not meet requierments on minimum standards such as understanding safety planning.

Correction Narrative: All Staff will complete Safety Planning Training Annually.  Current Staff will complete training by 06/30/23.  Exemption to staff who have completed training in 2023. All Staff will complete Suicide Awareness, Participants Training Annually.  Current Staff will complete training by 06/30/23.  Exemption to staff who have completed training in 2023.


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

raw_content: One employee file was missing the suicide prevention, intervention, and postvention training.


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

raw_content: Medication logs reviewed for two children were missing dates and accurate times (AM or PM) medication was given. In addition, medication count was not accurate.

Correction Narrative: AMIkids RGV Nurse will be conducted medication dispensing training with all program staff and maintaining current, true accurate and complete records by June 19, 2023


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

raw_content: Preliminary service plan for one child out of three reviewed was not completed/ signed within the 72 hour time frame.

Category: Admission, Service Planning, Discharge

Correction Narrative: AMIkids RGV Executive Director will review Youth Intake Check off list with Case Managers by June 7, 2023to ensure completion of Preliminary Service Plan within 72 hours of completion is included.


summary: 748.125(g)(2)(A) - You must immediately call emergency services and render first aid until professional medical treatment can be given.

raw_content: Specific actions required in the event that there is a suicide attempt are not documented on the suicide policy.


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: Child's record had missing documentation of a unauthorize absence debriefing within the 24 hours of the child's return to the operation. The child's record documentation didn't include the condition of the child, the information of what event occurred while the child was away and any relevant information in regard to the child's health and safety.

Correction Narrative: AMIkids RGV staff will be trained on Youth Unauthorized Absence return procedure.  Training will be completed by June 18, 2023


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

raw_content: Physical altercation occurred after caregiver failed to intervene.

Correction Narrative:
Follow up inspection was completed on 5/10/23 Administrator stated he reviewed the video and did a refresher EBI training with staff.  He stated he has no concern with any staff being able to administer EBI correctly. Mr. Ibarra provided EBI curriculum and sign in sheet of employees who attended the trainings.  He stated one staff present during the incident is no longer employed.  Other female staff present was listed on the sign in sheet.
Administrative review requested 5/1/23.


summary: 748.153(3)(B) - Notification - New controlling person

raw_content: Operation failed to update controlling persons list.

Correction Narrative: Controlling persons form for pending person was submitted via email.


summary: 748.3441(i) - Food Preparation-Food packages must be in good condition & protect the integrity of the contents

raw_content: During walk-throught two ziplock bag in the fridge were observed to be open.  One bag of popcorn in kitchen area was observed to be open.


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

raw_content: During walkthrough, one child bedroom was observed to not be clean.  Clothes, shoes, and personal belongings were observed on the bed and floor.


summary: 748.3301(h) - Physical Site-The building must be free of rodents and insects

raw_content: There was a live scorpion observed in a living area.

Correction Narrative: In regards to deficiencies, AMIkids Rio Grande Valley will contact our exterminator and request pesticide spray specifically for scorpions.  Additional exterminator visits may be required in addition to monthly visit. The program will also install exterior door sweeps to all living area and student classroom doors.  Door sweeps will be purchased at The Home Depot or ordered if not in stock by 6/17/22.  Door threshold to student living areas will be inspected.  If replacement is needed program will contact carpenter request bid for repair and submit repair / replace work order.


raw_content: A caregiver failed to intervene when a youth was displaying risky behavior that placed himself and other youths are risk of slipping or falling on a hard surface.

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

Correction Narrative:
Email from the agency;
Response: To ensure the agency is  complying with Operation's Safety and Supervision guidelines, including staff interventions.  Training scheduled for July 27, 2022 for AMIkids Rio Grande Valley Staff.  Documents for the training requested.


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

raw_content: During a walk through of the operaton, three beds used by the minors in care, were found to be missing mattress protectors.

Correction Narrative:
Corrections received from Operation.  In regards to deficiency AMIkids Rio Grande Valley purchased twelve waterproof mattress pads on June 09, 2022.
AMIkids RGV staff issued new mattress pads to students who were missing them on June 10, 2022.
Program staff will inspect student mattress daily to ensure mattress pads are in place and remind students mattress pads must be on their bunks at all times. Copy of receipt was provided.


summary: 748.931(a)(1)(B)(ii) - Annual Training-Must include 2 hours on normalcy

raw_content: During the inspection two employees were missing normalcy training

Category: Training and Professional Development

Correction Narrative:
TD sent an email with the following information:

I have attached the 2 Normalcy trainings and the 1 CPR/First Aid training that were past due for RV and for Jose LB, for which we were cited.

I have also included a blank Training Tracker which we are using for all staff moving forward so that we remain compliant with required trainings.


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

raw_content: During the inspection one staff members cpr/first aid certification was expired


facility_name: The Gladney Center

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

raw_content: An initial service plan was not signed by the PLSP or the child.

Standard Risk Level: Low

Correction Narrative: Compliance was met when the administrator sent the signatures for the service plan.


raw_content: A serious incident occurred on 1/11/26. The serious incident report that was documented by the operation noted that the incident occurred on 1/12/26 which is not accurate.

Correction Narrative:
All staff involved in writing or reviewing incident reports received same day coaching on proper documentation, including:
o	Accurately verifying the date the incident occurred
o	Accurately verifying the date the report is submitted
o	Understanding the legal and regulatory importance of accuracy in reports
	Staff were required to sign an acknowledgment confirming they were re trained.


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

raw_content: A child was not given her medication as prescribed.

Category: Medication

Correction Narrative: Compliance was met when the director sent documentation to address their plan to ensure this standard is met going forward. They also sent a medication check list that shows their process for administering medication and the requirement to not leave medication unattended.


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

raw_content: A child in care was not properly supervised when they continued to have contact with someone that was noted as a concern.

Correction Narrative:
An unannounced visit was conducted on 11/13/25 to address the follow up. Compliance was met as it was discussed that children are closely monitored when on devices.
On 11/6/25 compliance was met when the operation sent an email advising of a change in their policies regarding cell phone usage. The policy change and agreement was sent as well.


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: Medication is not being administered as prescribed.

Correction Narrative:
An unannounced visit was conducted on 11/13/25 and compliance was met when the new systems for logging medication was observed and explained.

On 11/5/25 compliance was met when the operation sent an email advising of changes to their medication practices. They included a form for children in care to sign after each medication is given.


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

raw_content: The last annual fire inspection was conducted on 02/20/2024.

Correction Narrative: Compliance was met when the Administrator sent the fire inspection document. The fire inspection passed on 6/10/2025.


summary: 748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required

raw_content: The child's service plan is not specific concerning her supervision and addresses her history.

Correction Narrative: Inspector received an email from the director. The operation met with the case managers about the importance of making sure that each residents' service plan reflects the supervision needed for their at-risk behaviors and their needs. Also, the meeting discussed the importance of being specific in these plans in regard to stating minutes between resident checks and what direct supervision looks like.  The case managers will be reviewing and updating all of our service plans to make sure they are in compliance and accurately state the residents' supervision needs. The meeting took place on 3/4/2025. The signed form by both case managers regarding the meeting was provided.


summary: 748.1433(d) - Discharge-If child not receiving tx svcs, tell him of non-emergency discharge/transfer 4 days in advance, unless LCCA or PLSP justifies not doing so

raw_content: A discharge summary documented that the child only had two days of the notification. There was no documentation as to why four days was not provided.

Correction Narrative: RCCR Inspector received documentation from director to address the notification to a child during discharge. There was a reason but not documented. It was also discussed on the phone with the director that the worker completing the form will ensure that any information concerning the discharge will be noted in the summary.


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: A staff member who was released of her duties on 7/29/2024 still have an active background check.

Correction Narrative: RCCR Inspector received documentation from administrator to address inactivate a staff person. HR updated their checklist to include this task. It is noted at Terminate Employee in DFPS Portal.


summary: 748.1433(a)(1) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one of the child's current caregivers

raw_content: The discharge summary did not document who was involved in the planning, such as the current caregivers and the  professional level service provider.

Correction Narrative: RCCR Inspector received documentation from director to address who participated in the planning. A copy was provided. It was also discussed on the phone with the director that the operation will ensure that the staff who participate in the planning will be documented properly.


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

raw_content: It was reported a staff member yelled at a child in care.

Correction Narrative: Staff member attended trainings on August 27 and 28 concerning communication.


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

raw_content: Nine out of the thirteen previous medication logs reviewed for the two children in care did not document the reason for the medication administered.

Correction Narrative: The administrator and director updated the medication log to reflect the reason will be documented moving forward on all medication logs. The count will be printed when the medication logs are added to the child's file. All records were updated as well.


summary: 748.535(3)(D) - Child-care administrator responsibilities-Assigning tasks to caregivers that do not conflict/interfere with caregiver responsibilities.

raw_content: A caregiver left children unattended with an intern.

Correction Narrative: Inspector assessed the training requirements that the intern will be required to complete before they will begin volunteering for the operation. The intern involved in the incident is no longer volunteering with the operation. Inspector spoke with Administrator to discuss the policy the volunteers will be following, and staff will be informed. This was known and staff was put on a performance plan for allowing this to occur. Staff will also be attending a meeting on 7/26/23 to remind them of the policy. They were sent an email for immediate reminder. All staff sent a reply to confirm receipt of the email.


summary: 748.863(a)(1) - Pre-Service Training-All caregivers must receive 8 hrs of general pre-service training & 4hrs before being counted in child/caregiver ratio.

raw_content: An intern was counted in ratio prior to completing de-escalation training.


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

raw_content: Four out of four incident reports reviewed did not document the date of admission for the child involved.

Correction Narrative: The director sent an email with a copy of the updated serious incident report. It includes the date of admission for the child or children involved.


summary: 748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected

raw_content: One out of two children files reviewed did not have a hearing test.

Category: Child Care

Correction Narrative: Director sent a copy of the child's hear test completed on 3/10/23.


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

raw_content: A staff member did not have appropriate boundaries with a child in care.

Correction Narrative: The director sent an email stating that boundaries was discussed with all staff. They also had to attend a training about the dangers of young and vaping. Staff member is no longer employed.


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

raw_content: A staff member who is a mandate reporter did not report an incident where a staff allegedly purchased a vape for a minor.

Correction Narrative: The director sent an email stating that boundaries was discussed with all staff. They also had to attend a training about the dangers of young and vaping. They also had to attend a training on reporting incidents. Staff member is no longer employed.


summary: 748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill

raw_content: The operation has not conducted any fire drills since October 2020 or severe weather drills since November 2020.

Category: Safety and Emergency Practices

Correction Narrative: The director sent the updated inspections for the fire and severe weather. The director has set to re-occur in the calendar every 5 months for these drills. The documentation forms have been uploaded into their shared documents and instructions for completing a drill and where to keep the forms once completed have been added to the Gladney Home staff office. Copies of the drills are in the case files.


summary: 748.863(a)(3) - Pre-Service Training-Caregiver for child-care or programmatic services only must have 8 hours EBI training, 4 pre-service & rest within 90 days

raw_content: One out of four staff files reviewed did not have EBI training.

Correction Narrative: The director send a copy of the staff completing the EBI training on 3/24/22. A copy of the certificate is in the case file.


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

raw_content: There were waffles on a plate in the refrigerator uncovered. The staff covered the waffles during the inspection.


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

raw_content: Two medication records did not match the acutal count of medication present.

Correction Narrative: The agency administrator stated that a system will be put into place to have medication counted before midnight to ensure the count is accurate.


facility_name: Athletes For Change

summary: 748.431(b) - Record Retention-Maintain personnel records for a year after last day of employment or until investigation involving employee is resolved

raw_content: Records were purged and unavailable during the investigation.


raw_content: A staff member's background check is listed as active. The staff member was not associated with the operation since April 14, 2024.

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


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

raw_content: The air return vents located next to the dining area (hall) and the one located in the hall upstairs were covered with dust, as well as the ceiling in the Cowboys bedroom had dust on the ceiling as well as the ceiling fan.

Correction Narrative: The operation submitted photos of the air return vents. The vents were clean. The agency has made the cleaning of the vents as part of the chore list, so that it will not be missed in the future.


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

raw_content: One of the two children's medication did not have a document explaining the reason the medication was given on the wrong date.


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

raw_content: Two out of two employee files did not have verification of education. One of the employee verification was received at the time of inspection.

Category: Personnel

Correction Narrative: The operation hired another caregiver to take Latrina Hollands place. She will be able to come back to work after she receives the copy of her diploma. Skyline High School told them that the diploma could possibly be ready by the 5/24/23. The Administrator has tried the online services to get verification but its only for colleges. RCCR Inspector received email from Maureen stating that Skyline High School told the employee that they don't keep copies of diploma on file if they are over five years old. They were able to place it on order, but it could take anywhere from 3 to 6 weeks to get.


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

raw_content: 3 out of 4 children interviewed stated that a caregiver uses profane language and threatened a child in care.

Correction Narrative: An email was received with the re-training for the staff member for verbal de-escalation and restraint techniques. A safety plan was received that will be in affect for 30 days for the staff member for increased supervision by staff supervisor, weekly progress check and the staff member will go through another re-training of handling youth with care.


raw_content: Restroom areas were observed to unclean and rust build up in toliets.

Correction Narrative: A physical follow up to the operation was conducted by RCCR.  Mold in the showers had been removed and re-caulked. The bathrooms were observed to be clean. The rust in toilets' were removed and cleaned.


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: The restroom areas were observed to have mold in both showers.

Correction Narrative:
08/16/2022 A physical follow up to the operation was conducted by RCCR.  Mold in the showers had been removed and re-caulked. The bathrooms were observed to be clean. The rust in toilets' were removed and cleaned. However the showers continue to have what appears to be black mold or dirt on the tiles. +                                         10/17/2022 - pictures of the bathrooms new construction was received. The Eagles (downstairs) bathroom was completely gutted and replaced. The Cowboys upstairs shower had the grout and tile removed and replaced from the lower section of the shower.
A further review of the bathrooms will be conducted November 7th during the semi-annual inspection.
Pictures of both bathrooms were placed in the CCL Digital storage.


raw_content: A caregiver did not use self-control or good judgement when he showed teenage boys in care inappropriate photos and videos.

Correction Narrative:
a. employee general responsibilities training for all AFC employees was conducted on 7/9/22 specifically reviewing the previous serious incident.
b) All AFC employees were trained again on 7/9/22 on the use of cell phones at the facility. No employee cell phones are allowed to be used by residents. No employee shall use their cell phone or any other method to share non-educational or non-therapeutic content with children in care.
c) ongoing- All new AFC employees are trained on our cell phone policy during orientation training.


summary: 748.303(a)(3)(B) - Serious Incident-Report to parents allegations of abuse, neglect, or exploitation of a child directly after ensuring the child's safety.

raw_content: Staff was informed June 26, 2022, that children in care were being given inappropriate material by a caregiver but did not report it to licensing until June 28, 2022.

Correction Narrative: Reporting serious incidents training for all AFC employees was conducted on 7/9/2022 reminding them what is considered to be a serious incident and the reporting timeline requirements.


summary: 745.619 - Background Check Requirements - Submit All Identifying Information

raw_content: An out of state background check was not completed for a caregiver who moved to Texas March 2019 which is less than five years.

Correction Narrative:
The Administrator was informed on 1/10/2023 of the DFPS process for reviewing out of stated applicants and how out of state information for applicants that have lived outside of Texas less than five years must be included when submitting a background check.
b) The Administrator is the person that enters the DFPS background check information and conducts a review of the minimum standards/tac on 1/10/2023. If the applicant has been in Texas less than five years, the applicants previous state will be included in the background request.


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

raw_content: A caregiver showed five children in care ages 15 through 16 inappropriate videos and photos.

Correction Narrative:
The employee is no longer working at the operation. He quit on June 26, 2022.
a) All employees reviewed the Children's Rights document on 7/9/22 and we discussed how the previous serious incident would violate those rights and how this incident could have been avoided and will not happen again.
b) Ongoing- All new AFC employees are trained on Childre's Rights during orientation and pre-service training.


raw_content: The bathroom upstairs in the main house was missing the glass covering on the overhead light.

Correction Narrative: The operation submitted a picture of the bathroom light fixture with the new light fixture in place. They are also re-instating the maintenance list and will go over the process with staff to ensure that any repairs are placed on a to do list.


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

raw_content: during a review of children's medical file it was found that there were six children in care that tested positive for Covid-19 and it was not reported to the hotline and no seriious incident report was completed.

Category: Reports and Record Keeping

Correction Narrative: Operation sent copies of the serious incident reports and have implemented a new process to include calling the hotline and DFPS. They will also generate serious incident reports for any positive covid-19.


facility_name: Unity Children's Home - Girls

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

raw_content:
During a review conducted on December 12, 2025, it was determined that:

(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan 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 plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended again.
Further details of the administrators failure to ensure compliance include the following:

Your operation received a medium-high weighted citation in a pattern/trend category on September 25, 2025. Specifically, the operation was cited for standard 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions. The operation met compliance on 9/25/2025.

-	Operation failed to satisfy the conditions of the plan
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having open investigations.

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

An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $150.

Correction Narrative: Unity Children's Home understands the responsibilities a child-care administrator must meet with minimum and heightened monitoring standards. Unity Children's Home Administrator follows the Heightened Monitoring Corrective Actions with newly hiring of Quality Assurance staff. This staff is responsible for tracking elements of the plan to ensure compliance. In addition, the Administrator participates in weekly meetings with supervisors and administrative staff and bi- monthly with Direct Care Staff to review the monitoring plan, assess progress and address barriers. All actions required by the monitoring plan are documented in binders that include evidence of trainings, updated procedures, incident reviews, and checklists. The Administrator is responsible for weekly review of log verifications completed of each monitoring item. Lastly, in place are monthly and bi-monthly checks by DFPS, Contracts and RCCL Representatives to review corrective action status, any new incidents and help with steps taken to prevent recurrence.


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

raw_content: During the review of one child file today, multiple date of birth was noted. The date of birth in the children list is different from the date of birth in the childs behavior managment plan. The date in the children list says 14 while the date in the behavior management plan says 12. Citation was corrected at inspection.


summary: 748.3445(a) - Food Preparation-Food and drinks must be of safe quality, stored, prepared, and served under sanitary & safe conditions

raw_content: Lettuce was observed in the refrigerator that was brown and slimy with a label of 8/3/2025.


summary: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number

raw_content: Several Serious Incident reports did not have the facility address and the telephone number.

Correction Narrative: Operation provided its written correction via email. In its correction, the operation stated that all future incident reports will be reviewed for completeness to ensure the facility name, physical address, and telephone number are documented in accordance with regulatory standards.


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

raw_content: It was determined that a staff members name was forged on a document.

Correction Narrative: Licensed Child Care Administrator conducted a training on December 23, 2024, to review Subchapter C Division 2 of the Minimum Standards for General Residential Operations.  In addition, the organization will review the HM plan to ensure that Administration, Quality Support, Crisis Counselors and Supervisor staff are refreshed on the policies that govern record keeping, and debriefing forms.  The signature page along with certificates for this training will be kept on file for inspectors to review.


raw_content:
During a review conducted on December 9, 2024, it was determined that:

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

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

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

Further details of the failure of your operations administrator to ensure compliance include the following:
Your operation received a Medium-High weighted citation in a pattern/trend category on November 27, 2024. Specifically, the operation was cited for 748.2003(b)(3)-Administration of prescription medication. The operation has not met compliance.

-       Operation failed to satisfy the conditions of the plan
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

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

Correction Narrative: An HM extension was approved effective 12/9/2024.  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 6/10/2025.


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: Child was prescribed 2 medications during her visit with the doctor, operation staff confirmed during interview that he received the medication from the pharmacy but did not administer medications to the child because they were waiting for approval from CVS caseworker

Correction Narrative: Operation provided written correction via email on 12-3-24. In its correction, it stated that the Licensed Child Care Administrator, conduct a training on December 9, 2024, to review Subchapter L Division 1-4 of the Minimum Standards for General Residential Operations.  In addition, the organization will review the HM plan to ensure that employees are refreshed on the policies that govern medications.  The signature page along with certificates for this training will be kept on file for inspectors to review. Follow up by inspection was conducted on 12-20-24 and the operation provided me with sign in sheet for the training conducted on December 9th, 2024, which covers SUB Chapter L


summary: 748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.

raw_content: During the review of one staff file, the last Truama Training taken by staff  was 4-12-23. No Evidence that the Truama training has been taken in 2024 by staff

Correction Narrative: The operation sent its written correction via email. In its correction, it stated that all staff will complete Trauma training online latest 10-11-24.


raw_content: According to information in the Serious Incident report, it stated that victim child did not need any medical care. However, child was taken to HCA ER and was prescribed pain medications to be administered as needed and also recommended to follow up with PCP

Correction Narrative: Operation sent its written correction via email. In its correction, it stated that to alleviate the mistakes the agency will continue to complete a system review regularly, to ensure their accuracy, completeness and relevance. It stated that the review should help to update, correct and delete any records that are no longer valid, useful or necessary. Training was completed on 10-8-24 which addressed the importance of accurate records.


raw_content: During the review of one staff file, different dates of hire was noticed in the staff file. One of the date of hire is 8-14-23 while the other date of hire says 8-28-23. Also, during the review of one childs file, 2 dates of birth was noticed. One of the date says 4-13-24 while the other says 4-13-10. Both errors were corrected at inspection.


raw_content: During the review of one childs file today,  date of birth in the childs initial service plan and pre liminary service plan has it as January 16th while the date of birth for the child in the childs biography cover page has it as January 6th but has same year of birth.

Standard Number / Description: 748.393(b)(3) - Active child record - Ensure record is kept accurate and current


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

raw_content: During the review of one staff file today, the job description for the staff was misssing in the file. Inspector was not able to locate job description in the file. The administrator also reviewed the staff file in presence of the inspector and did not find the staff job description.

Correction Narrative:
Follow up by email was sent on 2-24-24. In the email, the operation stated that Unity Children's Home understands the importance of personnel records having all required information according to minimum standards. The administrative team and quality assurance staff is actively completing an audit of each staff member's file to ensure compliance. The audit is being conducted effective 1/15/2024 through 1/22/2024. Documentation of any missing documents will be noted with a comply by date immediately upon notification.

Follow up by inspection was completed and copy of staff audit completed on 2-15-24, 2-16-24, 2-20-24 and 2-24-24.