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

raw_content: While reviewing the investigation multiple people stated that the child was moved due to refusing to go to their room.  It was seen in the video that the child was grabbed by the shoulders and moved to the room after refusing.

Correction Narrative: The Administrator and Supervisor met with the involved staff and discussed ways that the incident could have been handled differently/better.   The Administrator also spoke to the other 3 staff that were present and discussed with them what they could have done to help with the situation.  Due to having a lot of new staff the Administration will be discussing with all staff the appropriate times to do a restraint/escort and stress that it can never be done for compliance, but only in emergency situations when there is an immediate danger to self and others.  The Administrator will also refresh staff on the terminology of what constitutes the definition of a restraint.  They will also retrain on escorts, including when they should be done and how they should be done correctly and go over body positioning with staff to clarify what that entails.  The re-trainings will be as follows: Shift 1 at our June 23rd training, and Shift 2 at our July 21st training.


state: TX

facility_name: Bluebonnet Haven, LLC

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

raw_content: While reviewing service plans on 3 children's files, the signatures of the children did not match other documents signed by the children.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Corrected at Inspection: No

Correction Narrative: The Administrator met with the Case Managers and Treatment Director.  It was explained to them that there is no excuse for the children to not sign the service plan since the client is in their offices for the meetings.  The Administrator stated that next week they will be calling each child up to sign their treatment plans, and then they have ensured me that they will have each child sign their service plan while she is in their offices for the meeting, unless they refuse to attend or sign.


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

raw_content: Video was observed of a child being lifted off their feet and thrown to the ground during a restraint.

Category: Individual Standards Evaluated

Standard Risk Level: High

Correction Narrative: The staff member involved is no longer employed at the operation.  All other staff members will be receiving their SAMA refresher in May  Shift 1 on 5/6 and Shift 2 on 5/26.  The trainer will again review proper SAMA techniques with staff members.


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

raw_content: During the course of the investigation, one staff admitted to sleeping during their night shifts, one staff admitted to dozing off during their shifts, and another staff admitted to falling asleep one time during an unexpected double shift.

Standard Risk Level: Medium

Correction Narrative: An email was received that stated refresher trainings are being completed on April 8th and April 28th for each shift regarding sleeping.   Staff were reminded of the importance of being awake at all times for the safety of the clients and themselves and other staff.  They were reminded to get up and walk around, get a drink, snack, etc. anytime they felt sleepy at all.  Training certificates will be observed at the follow up inspection on 4/13/2022 and after the 4/28/2022 training.


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: Two staff members admitted to using their vaporizers in the staff room of the children's houses and multiple children stated that staff vape around them.

Standard Risk Level: Medium High

Correction Narrative: An email was received that stated refresher trainings are being completed on April 8th and April 28th for each shift regarding the policies on vaping.   The operations policies were updated to state  3.  An adult may only smoke or use tobacco products (includes cigarettes and chewing/dipping), e-cigarettes, or vaporizers on our premises at a safe distance from the children's living quarters, which will be only outside of our fences, and not near any children. Outside the fences and not near any children, was added to the policy.  During the follow up inspection on 4/13/2022 no staff were observed using any of the products.  Training certificates were for the completed training and  will be requested after the 4/28/2022 training.


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

raw_content: A child in care was escorted into the house for refusing to comply.

Correction Narrative: Email received from Administrator, inappropriate restraint was discussed with staff and a disciplinary notice was given.  Documentation was provided at inspection, signed and dated for 8/18/2021.  Additional training for all staff will be given in September regarding restraints being only emergency situations and not for compliance.  Training took place on 9/16/2021 and an additional training will take place 9/272021.


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

raw_content: A child in care went on a 4 day home visit and medication was not sent.

Correction Narrative: We did additional training on transporting clients with their medications to/from home visits on 6/8, 6/28, and 7/2.  We reminded staff that it is the duty of the staff that is packing up the child as well as the transporter to check that meds are packed.  These should also be checked on the visitation form.  Staff was reminded again to store medications in the locked black boxes in the vehicles for transportation.


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

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

Correction Narrative: An email was received on May 17, 2020 and an inspection was completed on 5/19/2021.  The email contained sign in sheets from updated medication administration training and stated that an additional staff has been hired to help the Nurse with some parts of her job duties so that it frees up more of her time to stay on top of the medication administration and counts.


raw_content: A child was restrained by staff for not listening to staff.

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


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

raw_content: A staff admitted to cussing around the children in care and multiple children in care stated that staff have cussed, called names and been rude to them.

Correction Narrative: On June 22, 2021 theAdministrator reposnded and stated that the individual staff will be spoken to regarding the report.  They stated that they will also include this on their upcoming training on June 28 for shift 1 and individually with shift 2 since they don't return till later and their next training is not until July. Copies of the staff notes or training records will be reviewed.


facility_name: Have Haven Inc.

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

raw_content: It was observed in the children bathroom that the water in the sink had low pressure and it took a long period of time before the water get hot. This deficiency was corrected at inspection.

Corrected at Inspection: Yes


summary: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

raw_content:
Van -29 the left tail light is not functioning properly (while braking, turn signal and hazard light) and there's exposed metal seat frame.
Van -00 the backdoor and side door do not open.

Category: Transportation

Correction Narrative: The operation sent photos of the vehicle with the updated light and fixed seat. They also discontinued the use of van - 00


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

raw_content: The staff was not in the room when two foster children had a physical altercation.  One child's service plan documented the child is to have visual and audio at all times.

Correction Narrative: The agency provided the following: They understand that a conjunction word "or" was missing in a child's service plan when a phrase indicated the child will be " within hearing and visual range".  That statement will now read "the child will be within vision and or hearing range".


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

raw_content: A Staff member who was allegedly responsible for searching the child in care when he returned from school did not appear to know it was their responsibility, therefore a BB gun was brought into the facility by a youth in care.

Correction Narrative: The caregiver involved in this investigation is no longer associated with Have Haven Residential Treatment Center. All current staff have been trained and reminded of the importance of their staff duties and responsibilities. All staff are required to sign and date position descriptions/duties/responsibilities during the hiring process. All staff are given an employee handbook with facility rules, policies, and procedures during the hiring process.


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

raw_content: multiple caregivers took their annual trainings late.

Correction Narrative: Agency Response: All current staff have been reminded and trained on the importance of their job responsibilities which includes taking required training in a timely manner.


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

raw_content:
3 children
records did not
have a trigger
review as a result
of their
continuous
AWOL

Correction Narrative: Staff that served as case manager during reviewed period is no longer employed with the agency. All current staff have been trained that a triggered review must take place no later than 30 days after the child's third unauthorized absence within a 60-day timeframe.


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

raw_content: The operation failed to report two different run away incidents timely.

Correction Narrative: All current staff have been reminded and trained on the importance of their job responsibilities which includes reporting all serious incidents and unauthorized absence of a child no later than 6 hours after determining unauthorized absence of a child 13 years or older.


summary: 748.3395(b)(4) - Hand-washing-Provide hand-washing sinks equipped with soap & a personal towel, single-use disposable towels, or hot air hand dryers

raw_content: There was no hand soap in none of the children bathrooms during the walk through.


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

raw_content: A staff member admitted to threatening to physically assault a child in care after the child in care threatened to physically assault him.

Correction Narrative: A follow up was conducted during inspection #3966449. Children were interviewed regarding children's rights and there were no concerns.


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

raw_content: Caregiver failed to intervene during a physical altercation.

Correction Narrative:
7/12/22 Physical follow up at operation conducted by Aaliyah Fontenot. Inspector reported no concerns, stating the children did not voice concerns regarding supervision or caregivers failing to intervene. Inspector reported victim child was present at the operation but refused to be interviewed.

6/24/22 The caregiver involved in this investigation is no longer associated with Have Haven Residential Treatment Center. All current staff have been reminded the importance of intervening during all incidents, and fully aware that it is their responsibility/duty to do so. All staff is required to complete eight hours of emergency behavior intervention annually, and at least four hours of emergency behavior intervention training every six months as a refresher course


raw_content: A child voiced suicidal ideations and fled from the operation, which warrants an emergency situation, and staff did not attempt to restrain the child.

Correction Narrative: Agency Response: Staff that voiced fear of being in danger herself, is no longer employed with the agency. All current agency staff understand per our policy that restraints and/ or appropriate interventions to deescalate situations will have to be implemented in accordance with the CPI training they took on their own and presented before employment. They understand that they are working with children that at times are volatile, dangerous to self and others, homicidal, suicidal, have explosive behaviors and outburst and that they might get hurt. Current staff also understand that restraints are used when a child is endangering self or others including property destruction.


summary: 748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment

raw_content: A child in care was denied water as a form of punishment.

Correction Narrative:
Corrections:
In this situation it was alleged that a staff member refused child water at the time he had asked her for it.  Water will be available and accessible to children at all times.  It will be made where it is reachable without having to go through any restricted permission and where permissions for water will not be required.  The said staff was trained on the minimum standards above, advised and counseled that any child cannot be denied water, sleep, bathroom use, mail, or family visits as punishments.


summary: 748.1301(a)(4) - Education-Advocate that school-age child receives educational and related services to which he is entitled under federal and state law/regulations

raw_content: A child in care required a 504/special education evaluation that the operation did not request from his school.

Standard Risk Level: Medium Low

Correction Narrative: Corrections:  This was corrected immediately - the school was contacted and informed about the child's 504 need, and was referred for appropriate evaluation.


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

raw_content: medication logs were observed with missing signatures.

Correction Narrative: Corrections: The agency logs all the medication record for appropriate signatures much more frequently during the week, and again reviewed at the end of the month before filing.  Any random checking that presents non-compliance will be addressed by the medication administrate ring staff for correction


raw_content: Medication logs were observed with inaccurate medication counts.

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

Correction Narrative: Corrections: The agency has implemented a system where the medication count is checked randomly during each week to ensure accuracy.  Any discrepancy noted, will be addressed for the correction and or documentation of medication error form.


raw_content: Two of three children's medication records observed were not given as instructed by medical professionals.

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

Category: Medication

Correction Narrative:
The operation will modify their medical documents and ensure that the instructions are clear. The medical log will be double checked.
The Admin Penalty has been paid


summary: 748.3273(9) - First Aid Kits-Each one must contain tweezers

raw_content: Three out of the five first aid kits observed were missing the tweezers.

Category: Safety and Emergency Practices


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

raw_content:
All of the medication records observed in the three client files did not document the year the medication was given.
One of the clients medical records were missing the times the medication was given.

Correction Narrative: Our medication administration system has been revised and a check and balance system has been implemented to ensure continued compliance.


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

raw_content:
In all the children records reviewed there were medication logs observed not documented in but the medication was given.
PRN medication was given but documented.
Medication was suppose to be given 3x a day but only documented for twice.


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

raw_content: One of the vans observed does not have a current registration sticker.

Correction Narrative: Registration sticker has been placed in the van. A photo of the registration sticker was sent


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

raw_content: The small deep freezer was observed without a thermometer.

Category: Physical Site


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 out of three children's medication records reviewed had errors in the medication count documentation.


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: Two light fixtures in the (dining area & quiet area)and two exit signs (front and back door) were observer hanging from their electrical wires not flushed to the ceiling.

Correction Narrative: Light fixtures and exit signs have been repaired. See attached (photo).


summary: 748.3365(b)(1) - Bedding-must provide each child with a clean and comfortable mattress

raw_content: A mattress in bedroom 2 was observed in very poor conditions with very strong urine stains that seeped through the rips in the mattress protector.

Correction Narrative: A new mattress and vinyl cover have been purchased and replaced previous ones. See attached attachment (photo).


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

raw_content: Three of the five first aid kit observed did not contain scissors. (including first aid kits in the vans)


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

raw_content: A serious incident report was observed and the reportable incident was not reported to licensing.

Correction Narrative: The agency will be sure to report it to licensing whenever law enforcement is called out to the facility in response to alleged incident.


summary: 748.3233(b)(4)(A) - Evacuation-Emergency evacuation & relocation diagram includes at least 2 exit routes that are located in distant parts of building & lead to outside

raw_content: The Emergency diagram observed only indicated 1 exit route.

Correction Narrative: Emergency plans indicating two (2) egress rounds and meeting areas have been posted. See attached photo.


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

raw_content: There were large white rocks located in the backyard near one of the children's room. A plastic bag, trash, and cups were found scattered in the back yard. There was also clothing covered in dirt in the backyard.


raw_content: In one of the children's bedrooms there was a dresser drawer located under the bed, it that was detached from the sliding mechanism. There is a green hard plastic bench in the backyard that had the seating slanted because of a broken part located underneath the table. Photos were taken.

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


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

raw_content: A broken window was observed in a bathroom assessible to the children in care.

Correction Narrative: The window has been repaired.


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: The operation failed to inactivate a person who was deemed ineligible to be at the facility in the allotted time frame.

Correction Narrative: The individual was made inactive.


raw_content: Several medication records reviewed did not include the name or signature of the individual that administered the medication; instead only the initials.

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

Correction Narrative:
The agency will transition from the use of electronic medication administration forms and start utilizing paper medication administration forms. The medication forms will have a legend that clearly describes the type of activity that took place when medications are given to the child. The legend is listed below. In addition, the medication form will also have the names and initials of all staff that are trained to administer medication clearly listed on the form. Specifically, all medication prescribed to the child will have the side effects listed, and the reason the medication was prescribed on each form. The facility will also discontinue the use of medication recording in pencil. If an error is made on the form, staff will use a simple strikethrough then complete a medication error report detailing the error. The error report will be reviewed and acknowledged by the administrator and then placed with the medication administration form to be filed at the end of every month.

For children taken medications at school, we will require the nurses to send the child's medication forms to the facility monthly to ensure the child is taking the medications as prescribed.  The school's medication record will be attached to the facility's medication record to cross reference and check for accuracy. Monthly, when medications are given to the school for a child, the nurse will be required to sign our form taking possession of the medications. The number of pills given to the nurse will be listed on the medication administration record and the medication transfer form attached for reference. Furthermore, when kids have medications transferred to the schools or sent home for visits, a legend code of TF meaning transfer to family, or TS meaning transfer to school will be written on the medication form with the number of pills transferred.

The administrator and case managers will audit all kids' medications weekly to ensure they are administered and accounted for correctly. When a physician makes changes to a child's medications, the administrator will ensure the changes are implemented and documented accurately on the medication forms.

 All staff have been retrained on this medication procedure as of 4-22-21.

Legend:
H=Child Hospitalized
S=Child was administered medication at school
A=Child absent without approval during medication time
M=Medication withheld with physicians' approval
DC=Medication discontinued by physician
TF=Medication transferred to family for visit
TS=Medication transferred to school for child
F=Child on family visit
R=Child refused Medication
DC=Medication Discontinued by physician

A follow up inspection was conducted during investigation inspection #3829344


facility_name: Connections Individual and Family Services, Inc.

summary: 748.1531(a)(1) - Medical care-A child in care must receive medical care initially according to the requirements in 748.1223

raw_content: A child in care did not receive annual medical appointment within the required timeframe according to minimum standards.

Category: Child Care

Correction Narrative: RCCR Inspector Olympia Diaz received a correction plan from Program Manager Ashley Wendel via email indicating that to ensure future compliance, they have implemented corrective measures that include assigning a designated staff member to review client files monthly and conducting quarterly management audits of medical records. These actions strengthen accountability and oversight, ensuring all youth in care receive timely medical services as required. The youth was seen by the provider on Saturday, September 13, 2025, and completed the Texas Health Steps Annual Visit that was overdue.


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

raw_content: During the inspection, observation of the boys bathroom revealed a broken tile off the wall at the bottom outside of the shower

Correction Narrative: Completed a walk through of operation to include the scene of incident, the wall has been patched back together with no further issues to the physical site of the operation.


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

raw_content: Several areas of the fence were found to be in disrepair and multiple discarded office, furniture, and other miscellaneous objects were observed throughout the property.

Correction Narrative: Operation provided a work order with scheduled maintenance date.


raw_content: Dryer vent was observed to be cut and lint was observed to have accumulated on the walls and behind the appliances in the laundry room. In addition, clothing items was observed to be stockpiled behind the appliances in the laundry and laying against the water heater.

Correction Narrative: The operation had the dryer vent repaired, and the lint was cleaned in the laundry room.  Clothing was removed from behind the appliances in the laundry.


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

raw_content: A staff documented on a supervision log that a child was present at the operation, but video footage showed the child was not present for two hours.

Correction Narrative:
11/27/23 Assigned Inspector was sent and reviewed the proof of re-training done with all staff on 11/7/23 regarding supervision policy, procedures, & review of supervision forms. Operation also stated that they would not be requesting an Administrative Review for this citation.

11/22/23 Assigned Inspector was sent staff's safety plan and the documentation of the coaching done. It was confirmed that the coaching occurred on 10/19/23.

11/22/23 Assigned Inspector received an email from the operation stating that all residential staff were re-trained in active supervision, documentation, and accurate record keeping on 11/7 and 11/21. The staff member involved in the incident was placed on a safety plan and received written coaching from the supervisor on 10/19 which entailed the review of the policy, review of the safety plan, and completing 1:1 training on supervision of youth with Program Manager. Supervisors will complete a random weekly audit of supervision forms and video surveillance until 1/31/24. Audits will include calling staff to request their location of specific youth randomly and having staff send a picture of their whereabouts form to the Program Manager conducting the audit.


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

raw_content: While reviewing the child's initial service plan it was found to not include medical diagnosis in the health section.

Correction Narrative:
03/31/2023 Inspector attempted phone contact to discuss the review of service plans with Director. A text was also sent to prompt a response. Inspector received a phone call from operation staff confirming that a review of service plans was done and now the CRO will be reviewing all service plans after they have been done by Director.
03/24/2023 Operation emailed assigned Inspector that an Administrative Review was not requested for this citation. Inspector attempted phone contact to discuss the review of the service plans with the Director.
03/16/2023 Operation emailed assigned Inspector that the Chief Residential Officer and the Director of the TLP met to review services plans. Going forward the CRO will review the service plans after they are done by the Director. The service plan in question was corrected but the youth discharged before the plan was scheduled for review. 03/02/2023 Operation emailed assigned Inspector that the child's preliminary and initial service plans will be updated. The child's medical condition was in their electronic case file but needs to be added to the service plan. There is a service plan due 03/17/2023. Chief Residential Officer will review the plan of service template with Program Manager by 3/17/2023 as additional training.


summary: 748.1021(d) - Transitional living program supervision-Document supervision evaluation & approval in child's record; review/update during service planning meetings

raw_content: Supervision evaluations were not available on any of the 10 records reviewed.

Correction Narrative:
Response from Operation:
Response: Connections' service plans, both preliminary and initial, have sections carved out to discuss each youth's supervision needs and what activities the DFPS worker will allow/will not allow based on supervision requirements. We had a change in leadership, and I believe the investigator was not given the proper documents as staff under our previous administration were not properly trained on where youth's supervision documentation was kept in service plans.
Corrective Actions:
1)	Chief Residential Officer with assist Program Manager with developing a training for TLP's next staff meeting to ensure all direct care staff know how to understand and utilize a youth's service plan. This training will take place on the 18th.


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

raw_content: Three severe weather drills were reviewed, the last drill conducted was on 3/7/2022. The operation has now exceeded the six month time frame for the most recent drill.

Correction Narrative: 09/20/22 Compliance response received through email from operation stating: Operation has a policy in place to conduct the drills every 6 months; the audit occurred after a switch in leadership and previous management records were not kept correctly. AR has been requested. Program supervisor will work with staff to conduct the drills every 6 months & Chief Residential Officer will update operation's electronic document system to send email reminder to program supervisor of the drill due dates.


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

raw_content: Documentation of monthly checks of smoke detectors were requested, there was no documentation that these checks occurred within the last 12 months.

Correction Narrative: 09/20/22 Compliance response received by email to include: operation policies and forms are in place for the smoke detector tests; documentation was not filed properly by previous management and the new Program Manager is addressing the issue. Operation will assess current form to ensure compliance with Minimum Standards. And the Program Manager will complete the form regularly & upload to operation's electronic system Extended Reach.


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

raw_content: A witness indicated the staff waited "45 minutes to an hour" before calling 911. The care giver wasn't sure when the care giver called 911. A medical collateral indicated the care giver should've called right away in such a circumstance.

Correction Narrative:
Response from operation: Response: Connections has procedures in place to ensure safety of children in care. The youth involved in this investigation has ongoing diabetic needs with a plan in place to regulate her blood sugar based on her Dexcom readings. Medical professionals have discouraged us from calling EMS immediately and instead administering juice or insulin to regulate her levels and then calling EMS if that is unsuccessful. Youth was not unconscious and was able to self-administer juice in the moment.
Corrective Actions:
1) Program Manager will request a diabetic action plan from pediatric endocrinologist for additional documentation at her appoint scheduled for 10/4/2022.
2) Staff will continue to administer juice/snack/insulin as needed per her Dexcom readings whenever she is outside of her normal levels but still conscious.
i. In the event that this youth does become unconscious or unresponsive, we immediately call 911.


raw_content: Severe weather drills have not been completed at the operation within the last 12 months.

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

Correction Narrative: 10/13/2021 Email from Administrator stated that a severe weather drill was conducted on 10/08/2021. All staff will be retrained in the standard cited on or before 10/30/2021. A Outlook calendar invite will be set up starting 10/15/2021 and shared with supervisors, Program Director, and Residential Services Administrator during the months of October - December. On or before 11/15/2021 Program Director and Residential Services Administrator will audit records to ensure drills were done.


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

raw_content: Two of four youth did not have a documented TB test and results on file. One of four youth did not have a documented hearing test completed.

Correction Narrative: 10/13/2021 Email from Administrator stated: All staff will be retrained on medical and dental requirements & how to properly complete the proper form on or before 10/30/2021. Medical forms will be reviewed by supervisor within 2 business days after medical appointment. All youth files will be audited to ensure TB tests are completed and read by 10/30/2021. If the youth have not had the TB test then it will be completed by 10/30/2021. An intake checklist will be completed during intake and reviewed by program director on or before 10/30/2021. A spreadsheet to track medical dates and TB exam and results will be added and audited monthly by program director.


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

raw_content: One youth continued to receive medication for 14 days after doctor had discontinued medication.

Correction Narrative:
10/7/21 Unannounced inspection was conducted at the operation. 7 of 15 staff have been re-trained in medication administration; medication binder was observed with a transition log and updated psychiatric report.
10/4/21 Administrator emailed stating that staff were retrained on administering medications on 10/31/21. When a med is discontinued the supervisor will ensure that the information is passed on to the staff through the use of Transition Logs. Transition log was revised to ensure that medication changes are addressed during transition meeting with staff. The psychiatric report that notes medication changes was added to the mediation binder. During the daily audit the supervisor will ensure the medication changes have been noted in the medication administration record and the staff are administering medication as prescribed.


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: During the inspection, it was discussed that six children in care contracted covid-19. Three of the covid positive cases were not reported to licensing.

Correction Narrative:
On 8/10, a citation response letter was emailed from the Director. The following Corrective Actions have been/are being taken by the operation:
1.	The youth not reported to the DFPS Hotline were called 8/9/21.
2.	Staff will be retrained on the reportable incidents outlined in DFPS Minimum Standards on or before August 25, 2021.
3.	All reportable incidents will be discussed with the LCCA or designee to ensure these incidents are reported to the DFPS Hotline within the time frames outlined in DFPS Minimum Standards

Compliance has been met.


facility_name: Hope for Tomorrow DBA Bridge to Hope

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

raw_content: A child was dropped off at an appointment without staff ensuring there was someone there, resulting in the child waiting outside unsupervised for about 45 minutes.

Correction Narrative: This deficiency has been corrected. The operation implemented a new drop-off supervision procedure for all staff and children. All staff were trained on the new procedure and form to fill out. The specific staff was put on a corrective action plan and will be closely monitored.


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

raw_content: Medication polices regarding administering medications in the staff office and locking medications/storage were not being followed.

Correction Narrative: RCCR inspector conducted a follow up inspection on 6/26/25. 2 staff were interviewed, no children in care were present at the time of inspection. The operation has a new medication administration policy and all staff were retrained in medication administration and new policy. Supervision was increased with new supervision plan at general; times and while medication is being administered.


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

raw_content: Several children mentioned supervision concerns during the investigation. Children were able to obtain, crush, and snort medications with no staff being aware. A child was able to go outside, cut their arms, be found by another child, and brought inside and cleaned up with minimal staff intervention.


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

raw_content: A child in care brought inside and cleaned up another child's wounds with minimal staff intervention.


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: It was determined that children's medications were being crushed when administered.


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

raw_content: It was found no medication error documentation was completed/provided for four children's medication errors.


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

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

Correction Narrative: This deficiency has been corrected. A new storage cabinet with lock/key was purchased and is at the operation in use. Staff were given an additional 1 hour training on medication storage and procedures. Two staff at the operation were spoken to about medication storage and procedures.


raw_content: 6 children interviewed stated a night staff does not complete night checks, and 3 of those children stated they have seen the night staff asleep. Per the operation's policies and procedures, staff should be awake, provide 24 hour supervision, and conduct checks every 15-20 minutes.

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

Correction Narrative: The inspector received an email from the ED on 3/14/25. Staff completed an additional supervision training and the sign in sheet was attached. The operation ordered 3 cameras to put in the office, front stairs, and back stairs to ensure staff are going upstairs and downstairs to complete night checks. The operation is also reviewing their night policies and will let the inspector know if they make any changes. Documents were added to the document library.


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

raw_content: Two first aid kits reviewed did not have all the required supplies needed.

Correction Narrative: The inspector received an email from the Director on 12/17/24. Attached were pictures of the first aid kit with the required supplies. The operation has bought 4 new first aid kits as well. The operation added first aid kit check to the fire drill logs, so they will be checked frequently and refilled as needed. The operation is not admin reviewing. Documents were added to the document library.


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: The child went to the emergency room on 10/31/24, and the incident was reported to licensing on 11/6/24.

Correction Narrative: This deficiency has been corrected. The PLSP and case manager completed an additional training on reporting and documenting serious incident reports.


raw_content: Five children stated they cheeked medication and were able to crush and snort the medication.

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

Correction Narrative: This deficiency has been corrected. The operation has implemented medication procedure changes. The staff recieved additional medication training. Four children's medication logs were reviewed. Medication storage was observed to be compliant.


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

raw_content: Multiple children reported staff driving recklessly- speeding, going off the road, and almost hitting a barrier.

Correction Narrative: This deficiency has been corrected. The staff directly involved is no longer allowed to drive at the operation. Three staff were spoken to and confirmed the staff does not drive.


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 took a child to a road and behind the vehicle, out of sight from other staff and children, while the child was elevated.

Correction Narrative: This deficiency has been corrected. Staff recieved a training on chlid's rights, prudent judgment, and privacy. Three staff were spoken to about this and were consistent. The staff directly involved has been terminated.


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

raw_content: A child was given the wrong dosage of medication for a month, after a change in medication from a medication review. No staff administering medication caught the error. It does not seem the medication change was communicated to staff appropriately.

Correction Narrative: This deficiency has been corrected. The operation corrected the dosage after meeting with a physican. THe child's medication logs for August were reviewed, as well as 4 other children in care. The operation has implemented new medication procedures. The 2 staff present at the time of inspection were spoken to and were aware of the new procedures.


raw_content: A child was administered a 20mg and 30mg medication, equaling 50mg, instead of the prescribed 30mg, as noted in the medication reviewed from the prescribing physician. This is stopped on the day the operation was made aware of the error and the operation met with the physician to see how to continue.


raw_content: 4 children in care were made uncomfortable by an employee pulling at their clothing and pulling them by the arms.

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: This defiecincy has been corrected. All staff were retrained in EBI Handle with Care and Prudent Judgement.


summary: 748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back

raw_content: An employee pulled two children's arms behind their back, pretending to arrest them.


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

raw_content: An employee was alone with a child when the child's high risk behaviors in their service plan cautions against being alone with the child. The administrator and staff of the operation stated this individual was not to be alone with residents at the operation.

Correction Narrative:
The inspector received the following email from the CFO on 12/13/23:
1. The staff's employment with Bridge to Hope was terminated on December 5, 2023.

2.  All staff received training on 12/6/2023 on Handle With Care Basic Program PRT and Take Down and Prohibited Personal Restraints, Children's Service Plans, and Employee General Responsibilities.

3.  Moving forward all caregivers will review and sign each child's service plan to ensure they are familiar with the child's individual needs so that they can be aware of important information such as past trauma that may be triggered by certain situations that the child may experience. These documents were added to digital storage.

A follow up inspection was conducted on 12/28/23, see inspection #3976926.


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

raw_content: A child in care was pulled out of the shower and restrained, which was not an emergency situation.

Correction Narrative:
Inspector received an email from the program director on 1/8/24 with the following follow up plan:
-All staff received additional training on de-escalation techniques, emergency situations that can warrant a restraint, Handle With Care Primary Restraint Technique and Take Down, escorts, and protecting a child's privacy on 11/29/2023 and 12/6/2023, for a total of 4 additional training hours.
-The inspector completed follow up inspection #3984997 on 1/24/24. Two staff and two children were spoken to about restraints and there has not been once since. The staff involved is still on leave. There were no walk through concerns.


summary: 748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers

raw_content: Several children in care stated they saw the situation occur.


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: During the DFPS ANE investigation, this standard was found to be deficient. A child in care was pulled out of the shower and restrained in a non-emergency situation.

Correction Narrative:
Inspector received an email from the program director on 1/8/24 with the following follow up plan:
-All staff received additional training on de-escalation techniques, emergency situations that can warrant a restraint, Handle With Care Primary Restraint Technique and Take Down, escorts, and protecting a child's privacy on 11/29/2023 and 12/6/2023, for a total of 4 additional training hours.
-After receiving a Reason to Believe for ANE, the staff involved was placed on unpaid administrative leave while we await the results of an administrative review. Once the results of the administrative review are received BTH will determine next steps for the staff. At this time, we anticipate they will be moved to a Housekeeper/Cook position which will remove them from being in a direct care role and in ratio.
-The victim child was discharged from BTH on 11/16/23.
-The inspector completed follow up inspection #3984997 on 1/24/24. Two staff and two children were spoken to about restraints and there has not been once since. The staff involved is still on leave. There were no walk through concerns.


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

raw_content: A child was pulled out of the shower and restrained. The child was restrained again on the porch. Staff had their weight on the child and a few collaterals stated it was done incorrectly. The child in care said she was hurt and had to spit after the restraint.


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

raw_content: A staff member did not report a child's suicide attempt to the appropriate operation supervisors or to the Hotline.

Correction Narrative:
The inspector received the following email from the Administrator on 11/30/23:

The staff member involved will be terminated from Bridge to Hope. We will be meeting on 12/4/23 to officially do this.

All staff received additional 1 hour training on 11/29/23 on Suicide Prevention and Intervention.  This included how to talk to kids about suicide and review of BTH's policy on suicide prevention, intervention, and postvention. A training log for this was added to the document library.

The child involved was also discharged from BTH on 11/16/23, due to escalating behaviors and refusing to follow the implemented safety plan.


raw_content: A staff caregiver put their hands on a child's forehead and pushed their head back. A staff caregiver engaged in banter with a child during this incident.

Correction Narrative:
The inspector received the following email from the administrator on 10/11/23:
The staff received a corrective action write up regarding the incident. The staff continued to work during the investigation under the supervision of the administrator while children were at school and not present in the home. Once the investigation was completed, all staff received a 1 hour additional training on reasonable and prudent parenting on 10/4/23. There is an attached sign in log. The staff returned to their regular duties on 10/4/23.
The inspector conducted a night inspection at the operation on 10.9.23 and observed the staff supervising the children in the living room/kitchen area of the home. They were interacting appropriately and within ratio.
Documentation was added to the document library.


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

raw_content: The service plan of a child in care with high-risk behaviors does not have a plan to address the behavior and minimize risk.

Correction Narrative: The inspector received an updated service plan for the child on 7/5/23 via email. A service plan review was held on 7/5/23 and included the child, caregiver, case worker, therapist, and administrator. Plans to address high risk behaviors were added and included: weekly therapy, monthly medication monitoring, suicide risk screenings as indicated, locking up/removing harmful objects, increased supervision as needed, using coping skills, and encouragement to share emotions. The service plan was added to digital storage.


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

raw_content: Fire extinguishers in the home were recently out of date and need to be serviced.

Correction Narrative: The inspector received an email with a picture of the fire extinguisher updated and marked May 2023. This will be good for a year. The picture is added to digital storage. The administrator stated this was a mistake and they thought the fire marshal checked the extinguishers when they were at the home in February.


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

raw_content: Two of the operation's vans did not have current inspection stickers.

Correction Narrative: The inspector received an email from the Administrator with documents/pictures showing the new inspection and inspection sticker. The administrator stated "Attached you will find proof that the big van now has a current inspection.  The little van is not currently being used because staff hit a deer (no children were in the van when the accident happened) and we are waiting for repairs, scheduled for February. Once it is back in operation, we will have it inspected and will forward those documents." The documents were added to digital storage.


summary: 748.401 - Archived child record-kept safe from damage and available for Licensing review within 48 hours.

raw_content:
Documentation had to requested on multiple occasions from the operation.
Documentation was initially requested in person on 10.27.22 during the inspection. It was requested again to be sent via email on 11.3.22 by 5PM. Part of the documentation was received on 11.4.22. The remainder of the documentation was requested by EOBD via email on 11.8.22. Another email had to be sent on 11.10.22 for the remainder of the documentation to be obtained. All requested documentation was received on 11.10.22.

Correction Narrative: The inspector received an email from the Administrator on 12/13/22. The operation created a House Supervisor role that will help with quality assurance, trainings, etc. A current staff has moved into this role. The operation is also in the process of hiring a case manager. These two new roles will help the Administrator with their duties and will be able to provide documents and meet deadlines more timely. As well, the administrator will include her supervisor in documentation request emails, so they are also aware.


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

raw_content: A child in care was left without staff supervision at a store for about 45 minutes. Although the staff and children stated that staff did count the children, the child was still left, and the others were able to go to another store until noticing.

Correction Narrative: The inspector received a follow up email by the administrator on 1/26/23. All employees have received additional supervision and transportation trainings. A laminated seating chart for the van was created and attached. Staff will indicate which children are in the van and will count on each outing. BTH has ordered supplies to make bracelets that have the staff phone numbers. Each bracelet will be numbered, and all children will be given one for outings. They will return the bracelet when entering the van to ensure all children are accounted for. The phone numbers provide and extra layer of security in allowing children to call staff if they are separated. The children in the home also received training on the importance of staying with the group and getting in the can when instructed to do so. Pictures of the seating chart and bracelets were added to digital storage. JG


summary: 748.2301(c) - Disciplinary Measures-goal must be to teach a child acceptable behavior and self-control; caregiver must explain reason for discipline when imposed

raw_content: 5 of the 7 children interviewed described negative interactions with staff such as being called demeaning names, being treated unfairly, and staff assuming children are misbehaving.

Correction Narrative:
On 7/22/22 an extension was granted due to the operation needing more time to complete face to face training with staff. The compliance was extended until 8/24/22 so the operation can have all current employees trained. LPerkins

On 8/24/22, an email from the administrator was received and the follow up plan was stated: Since this investigation was completed, three of Bridge to Hope's House Parents have resigned. Remaining staff and new hires received an additional training on 8/19/22, titled Power of Words and Positive Parenting. The training log with details will be uploaded to digital storage.
As well, staff will receive on-going training specific to administering disciplinary measures in a positive way and focusing on learning from the situation. It is understood that children in our care do not always know why some behaviors are unacceptable and in addition to simply implementing consequences for behavioral issues staff should also be offering guidance. Being harsh or demeaning to children is not acceptable as a form of discipline.


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

raw_content: It was found that a child in care was given double the amount of their medication due to an oversight in checking the medication log.

Correction Narrative: The operation sent a document with detailed instructions for administering medications and updated medication logs for easier use which also include areas to document errors and what to do in the case an error occurs. They also attached a document that shows a 1 hour medication training occurred  on 8/25/21 given by a pharmacist to house parents, staff, and administration and it is signed by the participants. They have also attached the corrective action plan which states that a medication error occurred and that the solution was that the staff member who gave the extra medication attended the medication training on the importance of giving medication correctly as well as creating a new medication log which was also reviewed by the staff member. These documents are uploaded to digital storage in the folder for this investigation.


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

raw_content: A staff currently on duty did not have results of the pre-employment test before having access to children in care.


summary: 748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint

raw_content: Orientation for 3 out of 4  children in care did not have deescalation techniques documented that the child prefers.

Correction Narrative:
The DCQI will audit all new admission files for required signatures/documentation within 3 business days following a new admission.
Also, during orientation a prompt was added to ask children specifically about de-escalation techniques staff should use on them. This has also been included as a prompt on their Restraint form.


facility_name: A.B.E Residential Services

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

raw_content: Medications were observed not properly stored.

Correction Narrative: An unannounced inspection was conducted on 4/25/2025. Medication is now properly stored in a lock box. Medication and medication logs were reviewed for accuracy, no concerns noted.


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

raw_content: The employee file reviewed did not have reference checks completed.

Correction Narrative:
email received from the operation: "The reference forms will be done before an employee is hired.  Each person that is  hired, will have a reference form in their personnel file that includes:
(1) Documentation of each reference check that includes
(A) The reference's name;
(B) The relation of the reference to the applicant;
(C)The reference's contact information;
(D)The date you completed the check;
(E) Information that was obtained from the reference check is documented and a summary of the interview or a copy of the written information provided by the reference
(F) If ABE conducts the check through an interview, the name of the person who interviewed the reference will also be given

If compliance is not met the administrator will receive proper training from the manager on the expectations and standard for reference checks for a new hire.
The administrator/manager will be responsible for ensuring the reference check has been complete.
An audit will be done by the administrator/manager/supervisor on all employees rehire reference forms paperwork is complete the employee can be fully hired.  This will be put in place so no further citations will be given for this standard and any similar standards."


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

raw_content: The employee file reviewed did not have a signed Reporting Suspectted Abuse and Neglect policy.

Correction Narrative:
Email received from the operation: "ABE will provide the employee a statement that will be signed and dated by the employee indicating the employee must immediately report any suspected incident of child abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and to the operation's administrator or administrator's
designee.

If compliance is not met the employee provider will receive proper training from the administrator/ manager on the expectations and standard for reporting suspected abuse and neglect.
The administrator/manager will be responsible for ensuring the employee has read, understands, signed and dated the form for  suspected incident of child abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and to the operation's administrator
An audit will be done by the administrator/manager/supervisor on all employee paperwork once a month. This will be put in place so no further citations will be given for this standard and any similar standards."


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

Correction Narrative:
Medication storage with controlled substance medications were not double locked.

Medication was viewed to be double locked.


summary: 748.3365(b)(1) - Bedding-must provide each child with a clean and comfortable mattress

raw_content:
During the walkthrough of the facility, one damaged (torn) mattress was observed inside one of the children's rooms which a child sleeps on.

The operation corrected this citation at inspection by removing the torn mattress from the children's room and replacing it with a new mattress and photo of the new mattress was taken upon approval.


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

raw_content: One Lysol chemical and one RID-X septic back-ups solution were observed inside the children restroom cabinet. The operation corrected the citation by removing the Lysol Chemical and RID -X solution and locking it up.


summary: 748.3563(a) - Protective Surfacing-Must have loose-fill surfacing material or unitary surfacing material in the use zones

Correction Narrative:
During the walkthrough of the playground area, no loose-fill was observed in the perimeter around the play structure.

An extension was granted to April 24, 2025.


summary: 748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate

raw_content:
During the walkthrough of the facility, one child's mattress was observed on the floor without a bed.

The operation corrected this citation at inspection by removing the mattress from the floor and placing it on top of a wooded bed.


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

Correction Narrative:
The entrance ramp to one storage building at the backyard was observed to be damaged which posses safety risk to the children while playing at the back yard. We noticed a missing dog door. We also noticed a poorly maintained pond and an uncovered well at the backyard in the children playing area.

The entrance ramp was fixed and in good repair, and the pond was cleaned and filled with fresh water.


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

raw_content: One of the children's records reviewed was missing the Preliminary Service Plan.

Correction Narrative: ABE will ensure that the preliminary service plan includes all the required information, addresses the immediate needs of the child, required by minimum standards and is complete within the 72 hours of placement.


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

raw_content: One of the medication records reviewed was missing reasons for administering the psychotropic medication.

Correction Narrative: ABE will ensure that the medication records are kept with all minimum standards requirements included and documented correctly. Medication records will be reviewed by the supervisor and administrator daily.


Correction Narrative:
A child in care did not receive one of his noon medications for 3/12/25 and 3/13/25.

A child was interviewed regarding medication and no concerns were found.


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

Correction Narrative:
It was observed during the inpsection that: 1-Cabinet door in the kitchen was off the hinge. 2-Peeling paint and od wood boards in one of the children's bedrooms. 3-A large hole on the wall in the front bedroom of the house.

A walkthrough was completed for the operation and the findings were viewed to be in compliance.


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

raw_content: It was observed during the inspection that: 1-the vanity in one of the bathrooms had water damaged causing  a soft hole in the cabinet area of the vanity. 2-Two of the toilet tissue holders were broken.

Correction Narrative:
ABE will ensure that the physical site is walked each day and that any issues will be repaired within 5 days.  There is a duty checklist that has been created and provided to you to show that all staff members are responsible for the physical site walk depending on who is on duty. The administrator or supervisor will be responsible for ensuring the walk has been done and any issues have been documented on the maintenance form and called in for repairs.  The maintenance form will then be signed and documented as completed by the administrator or supervisor. The restrooms will be walked each morning shift and evening shift to ensure the restroom is clean, in good repair and has toilet tissue and paper towels.

Agency provided pictures showing the are under the sink for fixed and the toilet tissue holders were replaced.

A monitoring inspection was conducted on 04/01/25 by HM inspector. Deficiency was found to be in compliance.


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

Correction Narrative:
I observed many lose bricks throughout the backyard; a broken light fixture on the side of the house; door in the backyard has wood that appeared to be rotten with holes; a loose cable cord on the ground that used for the generator was not plugged in; loose cords from the lighting system box that is located near the front door.

During the walkthrough of the operation, the findings were viewed to be in compliance.


summary: 748.3397(d)(1) - Bathing-Provide showers and bathtubs with hot & cold running water under sufficient pressure to meet the demands of children

raw_content: It was observed that one of the shower knobs was broken resulted in hot water not available during shower.

Correction Narrative:
ABE will ensure that the shower and bathtub will have running cold and hot water under sufficient pressure to meet the demands of the children.  If the bathtub or shower is not properly working a maintenance form will be filled out and completed within 5 days.

Agency provided pictures showing the shower knobs were replaced.

A monitoring inspection was conducted on 04/01/25 by HM inspector. Deficiency was found to be in compliance.


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

raw_content: One of the children's admission assessments was not signed and dated by all required members.

Correction Narrative: ABE will ensure that the professional service level provider signs and dates each assessment in the child's records.


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

raw_content: It was determined that a caregiver choked a child to where they couldn't breathe.

Correction Narrative:
ABE staff will only use CPI approved physical holds when necessary. These three holds, (Child, Side, and Team) to ensure a child's airway is never obstructed and his breathing is never impaired during a physical hold. Staff that were on duty at the time of the incident was retrained on October 9th.
All other staff have been retrained as November 25th on CPI holds and will correctly use them when needed.  Any staff that does not adhere to this standard will be terminated immediately.


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

raw_content: There were a few items around the home that need to be repaired.

Correction Narrative: The operation provided pictures of the repaired work.


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

raw_content: It was determined that a child in care was injured but did not receive medical attention.

Correction Narrative: On 8/16/2024, the Administrator provided documentation to verify the child was seen by medical and advised the operation's plan to ensure compliance with this standard, included the Administrator's role in ensuring that any injured child is immediately taken to their doctor or urgent care.


summary: 748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy

raw_content: It was determined that a door connected to the bathroom was broken for over a day and residents were still using it to take a shower.

Correction Narrative: Picture of fixed door was provided.


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

raw_content: It was determined that the operation was out of ratio in June 9, 2024.

Correction Narrative: The operation will have residents who are 1:1 with their assigned staff. The residents who are in groups that are not 1:1 will be with their staff with appropriate supervision. The operation will also have the schedule reflect which staff has the 1:1 resident. The operation will cover the importance of ratio and close supervision in staff meeting.


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

raw_content: The operation failed to follow the service plans of multiple children in care, as there was observation of multiple child who required lower ratios, left with one staff member.

Correction Narrative: On 8/1/2024, the operation's administrator advised ABE Residential Services will follow the service plans of all children in care. All residents will be supervised by staff according to their correct ratios. Following the standard will allow ABE residential to continue to protect the health, safety, and well-being of the children by giving adequate care and supervision at times and to ensure it is always adequate for each child. ABE staff schedules will comply with the adequate and correct ratios that are required for each resident. If the ratio cannot be met due to an employee not coming to work, the administrator, case manager, or facility manager will fill in to ensure that the adequate amount of employees that are required are at the facility for proper supervision and care of all residents.


summary: 748.1011 - Child/caregiver ratio-Includes only qualified caregivers working directly with a child or group of children

raw_content: A caregiver was caring for two children, where one child required 1:1.


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 safety plan requested CCI Investigator was not implemented immediately and a signed copy was not returned to CCI investigator until approximately two weeks later.

Correction Narrative: Email received 06.03.2024, from the operation to implement a more thorough search of the children and their personal belongs.  They will be searched at the door and in a secluded area for their privacy.  It provides details on how searches will be conducted. Room checks will be completed three times a week at random.  Children will be monitored while interacting with other youth and will not be allowed into other children's rooms.  They will not be allowed to sit next to each other during transport. The administrator will discuss the requirements with all staff upon receipt of approval from the RCCI investigator, ensure receipt of all signatures from all staff within 24 hours of RCCI approval and maintain records of documentation of the implementation of the safety plan from the date of inception until termination of the plan.


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: Two children were using vapes at the operation.

Correction Narrative: Email received 06.03.2024, from the operation to implement a more thorough search of the children and their personal belongs.  They will be searched at the door and in a secluded area for their privacy.  It provides details on how searches will be conducted. Room checks will be completed three times a week at random.  Children will be monitored while interacting with other youth and will not be allowed into other children's rooms.  They will not be allowed to sit next to each other during transport. They have also developed a resident behavior contract that describes the agreement between the operation and the child, the rewards and consequences of not following the agreement.


summary: 748.1217(c)(6) - Admission Assessment-Prior to initial service plan, add child's school history

raw_content: One of two child records reviewed did not contain the child's previous school history. The assessment is also missing dates and discharge reasons from previous placements.

Correction Narrative: The operation stated that although some of the information is hard to obtain, they will put in their best efforts to received it from each child's caseworker.


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: One incident report indicates that a child was injured and transported to the hospital by an ambulance; this was not reported to licensing.

Category: Reports and Record Keeping

Correction Narrative: The operation stated that they will ensure that all staff are aware of certain incidents that need to be called in.


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

raw_content: Two employee records reviewed did not contain reference checks.

Category: Personnel

Correction Narrative: The operation stated that reference checks will be conducted on every employee.


summary: 748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement

raw_content: One of two child records reviewed did not contain an admission assessment.

Correction Narrative: The operation provided a copy of the admission assessment. They stated that moving forward, they will ensure that the assessments are done in the correct timeframe.


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

raw_content: Two employee records reviewed did not contain suicide prevention training.

Category: Organization and Administration

Correction Narrative: The operation provided a copy of each employee's suicide prevention training.


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

raw_content: Two child records reviewed did not contain the suicide screening assessment.

Correction Narrative: The operation provided a copy of the screening and stated that each child will be questioned at admission and if showing any signs.


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

raw_content: One of two employee records reviewed did not contain a statement for reporting ANE.

Correction Narrative: The operation stated that they will ensure that all staff sign the statement at the beginning of employment.


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

raw_content: A child's medication log was missing the reason for four different ones. One log is missing a signature, and another one is missing the time medication was administered.

Correction Narrative: The operation stated that they have been retrained to ensure that everyone is aware of the importance of correctly filling out the med logs.


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

raw_content: Two child records reviewed did not contain a preliminary service plan.

Correction Narrative: The operation provided copies of the service plan stating that moving forward, they will be stored in each child's file within 30 days of completion.


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

raw_content: During the walk-through, it was observed that the flooring in one bedroom was loose and broken. Another room was also observed to have two holes in the wall.

Correction Narrative: The operation provided photos of the completed work.


summary: 748.2853(4) - EBI Documentation-Content of the post discussion, if applicable

raw_content: No post EBI discussion was documented as being held with the child.

Correction Narrative: The operation emailed a new incident form with the EBI post discussion added to their incident report.


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: Of the six initial service plans reviewed, four had not been reviewed and updated within the required 90 days. Additionally, three of the initial service plans did not have the appropriate signatures that are required according to minimum standards 748.1337(b)(1)(N) and 748.1333.

Correction Narrative: The operation provided to licensing a written safety plan that states to ensure that all initial service plans are completed within the first 45 days of placement and updated every 90 days according to minimum standard requirements by the staff supervisor will be responsible for putting the due dates and reminders of all service plans on the calendar. The case manager will be responsible for ensuring all service plans are completed by the due dates.


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

raw_content: Two children in care did not have an initial service plan completed by the operation during their placement. The two children were in care for over 70 days. The initial service plans were completed by another operation prior to the children being placed at this operation.


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

raw_content: One of two overnight caregivers was found to be sleeping which inhibits their ability to respond and assist the second caregiver when needed.

Correction Narrative: The operation provided a written safety plan to licensing stating that the staff member has been removed from the night schedule indefinitely. The staff member will be monitored by a member of management during office hours and unannounced visits. All staff members met with management on the proper protocol as it pertains to 24-hour supervision.


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

raw_content: An overnight caregiver did not follow the operation's 24-Hour Awake Supervision Policy when they were found to be asleep while present at the operation.


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

raw_content: Two incident reports for a restraint do not include documentation of the specific EBI administered or the length of time the child was restrained.

Correction Narrative: Operation director emailed a copy of the corrected incident reports with all required information documented. Staff were also retrained on how to properly complete incident reports. CPMS will also check incident reports once submitted to ensure all required information and necessary sections are filled out completely.


summary: 748.303(a)(5)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child.

raw_content: Based on the investigation, serious incident reports were documented regarding a sexual act between residents.

Correction Narrative: An email was sent by the operation stating that following the deficiency the operation will provide training for staff regarding Serious Incident Reports will be conducted on 9/22/2023. The operation agreed to submit a staff sign in sheet for confirmation.


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

raw_content: A child's preliminary service plan is not signed nor dated by anyone.

Correction Narrative:
All treatment plans have been signed by all required planning team members that were involved in the development of the service plan.  ABE has put a plan in place to ensure all service plans are complete in a timely manner and all required planning team members are invited to the service plan meeting and all the required documents are signed.
The plan is for the treatment coordinator to have meeting dates available two weeks prior to the due date of the service plan so all required attendees can make the meeting and sign the document immediately after the scheduled meeting has occurred. The Case Manager and Administrator for ABE will ensure this process is put in place and that all required signatures are on the service plan.


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

raw_content: There were no thermometers in the refrigerator, the freezer, or the deep freezer.

Correction Narrative: The operation now has thermometers for the fridge, freezer, and deep freezer.


summary: 748.565(1) - Professional level service provider-must review/approve admission assessment or other evaluation; sign and date to indicate approval

raw_content: The PLSP did not sign or date the child's admission assessment.

Correction Narrative: All treatment plans have been signed by all required planning team members that were involved in the development of the service plan.  ABE has put a plan in place to ensure all service plans are complete in a timely manner and all required planning team members are invited to the service plan meeting and all the required documents are signed. The plan is for the treatment coordinator to have meeting dates available two weeks prior to the due date of the service plan so all required attendees can make the meeting and sign the document immediately after the scheduled meeting has occurred. The Case Manager and Administrator for ABE will ensure this process is put in place and that all required signatures are on the service plan.


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

raw_content: I observed that the doorway to the garage was unlocked and opens to a commonly used play space.  The garage contained poisonous chemicals that would be accessible to children without the garage door being locked.

Correction Narrative: The poisons were removed and locked out of reach from the children in care.


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

raw_content: All the Evacuation plans were very detailed, but none of them designated a meeting place for caregivers and children to meet in an emergency evacuation.

Correction Narrative: Ms. Franklin emailed me pictures of each exit/evacuation plan, with the correct meeting place added to each hanging diagram.  These were shown to have been sent to Ms. Lodrig on 8/10/23, and Ms. Franklin apologized for not ccing me at that time. Pictures have been uploaded to digital storage.


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

raw_content: There was no thermometer in the operation's first aid kit.

Correction Narrative: The operation sent pictures of two thermometers for the first aid kits.


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

raw_content: Four of the four children receiving treatment services the service plans did not have the signatures from the service planning team (CPS, Therapist, Caregiver, CPMS, or the Child).

Correction Narrative:
The Administrator explained the agency became aware the plans were not signed and fixed the issue before the MSV. The agency provided the information summarized below.

The plan is for the treatment coordinator to have meeting dates available two weeks prior to the due date of the service plan so all required attendees can make the meeting and sign the document immediately after the scheduled meeting has occurred. The Case Manager and Administrator for ABE will ensure this process is put in place and that all required signatures are on the service plan.


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

raw_content: It was observed that the application from one caregiver states that he graduated from Sterling High School in 1999 but his diploma says that he graduated in 1997 from Sharpstown High School.

Correction Narrative: Since the employee was not able to provide accurate documentation of his education, the operation terminated him.


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

raw_content: During the inspection, documents reviewed showed the fire inspection has expired. The last fire inspection was completed 3/10/2022.

Correction Narrative: The operation provided a fire inspection that was conducted on May 8, 2023.


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

raw_content: Three of three records reviewed does not contain an instructor led training for psychotropic medication.

Category: Training and Professional Development

Correction Narrative: The operation provided emails with the training certifications indicating that all employees were trained by an instructor.


summary: 748.2855(a)(3) - EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies

raw_content: Two of two child records reviewed contained an incident report regarding a restraint. The report did not specify about the de-escalation technique used and one report did not contain how long the restraint lasted.

Correction Narrative: The operation provided an updated incident report that includes sections for more details to be added regarding a restraint.


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

raw_content: One of three employees did not have a drug test.

Correction Narrative: The operation provided the drug test results and there were no concerns.


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

raw_content: During the inspection, documents reviewed showed the gas inspection has expired. The last gas inspection was completed 1/8/2021.

Correction Narrative: The operation provided the invoice for a passed gas test that was conducted on April 21, 2023.


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

raw_content: During the inspection, two of three children's records reviewed did not have documentation of a TB skin test.

Correction Narrative: The operation provided a copy of the negative TB test.


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

raw_content: Two shovels were observed outside, with wooden planks, a broken gate, and other loose objects.


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

raw_content: Dead insects and termites were observed in the bathroom drawers. The outside physical site is unkept.


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: It was determined that the former administrator is no longer working at the agency since 2/10/23 but has yet to be inactivated.

Correction Narrative: The operation inactivated the background check for the former administrator.


summary: 748.3445(d) - Food Preparation-Food must be protected from contamination

raw_content: It was observed that two items in the freezer and in the cabinet was not properly stored, and there were expired eggs in the fridge.


summary: 748.1217(b)(5) - Admission Assessment-At admission, must include any history of trauma.

raw_content: One of two records reviewed did not contain the history of trauma, social history or neonatal history. Nor did it contain complete information on the history of previous placements or schools.


summary: 748.1219(1)(A) - Treatment Services Admission-ED or PDD: Admission assessment must include dated, signed psychiatric/psychological assessment with diagnoses

raw_content: Two of two child admission assessments wasn't signed or dated by anyone.


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

raw_content: Two of two staff records contained expired certification in CPR.


raw_content: It was observed that a spring was broken for one bed, there was an unclean shower floor and drawer in the Rockets restroom area. A closet door is off the hinge. Two window areas need to be swept. Windows also does not have screens.

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


raw_content: It was observed that five food items were not properly stored. There were also two expired food items.

Standard Number / Description: 748.3445(d) - Food Preparation-Food must be protected from contamination


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

raw_content: Two of two child records did not contain an initial service plan.


summary: 748.1217(b)(1) - Admission Assessment-At admission, must include child's legal status

raw_content: Two of two records reviewed did not contain the legal status.


raw_content: There were shovels out in the open. There were also a few trip hazards outside that will be shared with the operation via email.

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


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: Two of two child records do not contain an updated service plan from June and July.


summary: 748.685(e) - Caregiver responsibility-for a child receiving treatment services for an emotional disorder must maintain daily, signed and dated progress notes

raw_content: Two of two records reviewed did not contain progress notes.


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

raw_content: The operation has not had an administrator for 100 days.

Correction Narrative: The operation hired a full-time administrator effective 11/10/22. The administrator has been added as a controlling person and has a cleared background check.


raw_content: It was determined that the operation does not have an administrator.

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


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

raw_content: 1 volunteer record reviewed has a TB test from 2011, but there is no recent TB test. There is no documentation of the volunteer having lived, worked, or volunteered at a regulated residential child-care operation within the previous 12 months.

Correction Narrative: The operation provided the volunteer's updated TB test.


summary: 748.721(b) - Volunteer personnel record-Include signed/dated statement that volunteer will report child abuse/neglect to Tx Abuse & Neglect hotline & administrator

raw_content: 1 volunteer record reviewed did not include a signed statement stating the volunteer will report any suspected incidents of abuse and neglect.

Correction Narrative: The operation emailed a signed and dated copy of the statement.


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

raw_content: The employee list received was not current and accurate.

Correction Narrative: The operation provided an updated and accurate employee list.


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

raw_content: 2 of the 5 employee records reviewed did not include a copy of TB test

Correction Narrative: The operation sent an email stating, "Personnel records.  Marcus Harris and Linda Banks have been removed from the schedule until TB test have been completed.  Mr. Harris is scheduled to see his physician December 13 and Ms. Banks is scheduled to see her PCP, December 9.  If either are completed before, I will send the information.  (See revised schedule attached)"


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

raw_content: 1 discharge record was reviewed and is imcomplete. The discharge summary was not completed and is missing a lot of information.

Correction Narrative: The operation sent an email stating," The discharge summary was has been completed and all information provided. (See attached)"


summary: 748.311(2) - Serious Incident Documentation-Includes time and date of incident

raw_content: 1 incident report reviewed is missing the date of the incident. Serveral incident reports were not completed entirely and were missing the DOA.

Correction Narrative: The operation sent the incident reports correctly filled out.