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

raw_content: It was determine the background checks were alidated however no staff was put on inactive status after 7 days of departing the operation.

Correction Narrative: Staff is adding quarterly remainder to their outlook and desk top calendar. Staff also added a To do list on outlook.


state: TX

facility_name: HAID LLC

summary: 748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.

raw_content: Two staff files were missing reference check, and one staff file is missing the pre-employment screening assessment.

Category: Personnel

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: To ensure that reference check forms and pre-employment screening assessments are included in the employee binder on time, the LCCA will establish a clear timeline that aligns with the hiring process.  The LCCA will be responsible for compiling the reference check document and the pre-employment screening assessments conducting check-ins to monitor the progress. Additionally, HAID LLC will implement a checklist to track the completion of each document, ensuring nothing is overlooked before the onboarding date.


facility_name: Youthful Haven

summary: 748.103(b)(14) - Policies and procedures to submit - A suicide prevention, intervention, and postvention policy consistent with §748.124 of this division.

raw_content: In a review of the suicide policies, it was determined that it did not meet the criteria outlined in 748.124.

Category: Individual Standards Evaluated

Correction Narrative: The operation provided an updated suicide policy that meets standards.


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

raw_content: The operation did not have a preliminary service plan for the child.

Standard Risk Level: Medium Low

Correction Narrative: Operation staff dropped off a preliminary service plan that is sufficient and up to standard for documents used at the operation.


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 operation did not have a completed admission assessment for the child.

Correction Narrative: Operation staff drop off a professional level service provider that is sufficient and up to standard for documents used at the operation.


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

raw_content: Upon review of the child's Preliminary Service Plan it was discovered the plan did not include (b)(3),(4),(5).

Category: Admission, Service Planning, Discharge

Correction Narrative:
The operation reviewed all current children's records and ensured that a Preliminary Service Plan was completed for each child within 72 hours of admission.

The Program Director, Treatment Director, or designated case management staff is responsible for initiating and completing the Preliminary Service Plan upon admission. A PSP completion requirement has been added to the admission checklist to ensure the plan is completed and reviewed before the deadline. Case Management and lead staff have been trained on the requirements of MS 748.1331(a), timelines for PSP, and required components of a compliant PSP.

The Program Director or designee will review new admissions weekly to verify timely completion of PSPs, and child records will be audited monthly to ensure continued compliance.


summary: 748.153(3)(A) - Notification - Change in child-care administrator

raw_content: The operation failed to notify RCCR in the allotted timeframe the operation's administrator position became vacant.

Correction Narrative: The operation was sent an assessment letter reminding the operation has 60 days to hire an administrator. After 60 days if an Administrator has not been employed, the operation will receive a deficiency. The operation is encouraged to diligently seek an Administrator to carry on the daily duties of the operation. The purpose of this rule is to ensure that the operation is managed so that the health, safety, and well-being of children in care are assured.


summary: 748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights

raw_content: Upon review of the child's folder it was determined the operation failed to present documentation indicating the chid had been notified and provided a written copy of the child's rights.

Category: Children's Rights

Standard Risk Level: Medium

Correction Narrative:
The operation has implemented a written procedure requiring that children and parents/legal representatives be informed of rights at admission.

A Rights Acknowledgement Form is now required, signed and dated by the child, parent or legal representative, in the child's primary or preferred language, and the form is maintained in the child's record.

All Direct Care and admissions staff have been trained on MS 748.1103(a) requirements, how to explain the rights in a developmentally appropriate manner, and documentation requirements for informing children and parents of their rights.

Confirmation of rights notification has been added to the admission checklist and must be completed prior to or immediately upon admission with a signed copy sent to the case worker.

The Program Director or Case Manager will review admission records within 24 hours to ensure rights documentation is complete.

Children's records will be audited monthly by the administrator to ensure ongoing compliance.


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

raw_content: Upon review of one child's medication log it was found that the medication log did not have the reason for medication listed on the log.

Category: Medication

Correction Narrative:
The operation has reviewed all current medication administration records and updated them to include the medical reason/diagnosis for each prescribed medication. A standardized medication administration record form has been revised to ensure the appropriate information is included.

Medication form updated, all direct care and supervisory staff have been trained on MS 748.2151(c)(3) requirements, proper completion of medication records, and verifying prescription information before administration.

The Program Director or designee will review medication records weekly to ensure compliance and completeness. Medication records will be audited monthly as part of the operation's compliance monitoring process.


summary: 748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth

raw_content: Upon review of the child's Admission's Assessment it was discovered the Admission's Assessment was missing several components noted in the standards. The operation provided a draft of bullet points and did not utilize their previously approved Admission's Assessment template.

Correction Narrative:
A standardized Admission Documentation Checklist has been implemented and must be completed at the time of admission for every child.

The Program Director or designated admissions staff is responsible for ensuring all required admission documentation is completed and filed before or immediately upon admission.

Admissions and supervisory staff have been trained on: MS 748.1205(a)(1) requirements, required documentation at the time of admission, and proper record-keeping and verification procedures.

The Program Director or designee will review each new admission record within 24 hours to confirm all required documentation is present.

Children's records will be reviewed monthly to ensure continued compliance with admission documentation requirements.


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: While reviewing personnel records, it was discovered 1 of the 2 records reviewed did not include two reference checks.

Correction Narrative: The operation will create a mandatory reference check process requiring a minimum of two professional references completed prior to the applicant's start date. The prevention plan is to maintain a reference check checklist in every personnel file. Require all applicants to provide at least four reference contacts to ensure two successful returns. Conduct quarterly refresher training on hiring compliance. Review and update hiring policies annually to align with current minimum standards.


facility_name: Peaceful Pathways Residential Treatment Center, LLC

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

raw_content: During the review of three of the medications logs, it was noted that the information from the prescribing healthcare professional was not included in any of the logs. The administrator corrected this by adding the missing information to all of the medication logs.

Corrected at Inspection: Yes


facility_name: Amir's House

summary: 748.1337(b)(1)(H)(ii) - Initial Service Plan-child w/ high risk behaviors, include specific safety contract developed btwn child & staff to ensure safety

raw_content: Two of two charts reviewed determined both children had severe high risk behaviors, but these were not addressed and a plan was not put in place to help ensure a child did not act on their behaviors and harm themselves or others.

Standard Risk Level: High

Correction Narrative: Amirs House has corrected the Initial Service Plan deficiency by creating a safety plan for the children with high-risk behaviors. Staff will receive information on documentation and safety plans. The staff will review safety plans and adjust as needed.


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

raw_content: During a unnanounced initial inspection a staff drug test record was found to be incorrectly completed.

Category: Organization and Administration


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

raw_content: The child's input and/or staff documentation is blank for preferred de-escalation techniques that caregivers can use to assist the child in the de-escalation process.

Correction Narrative: Operation submitted a response stating that the Administrator will be responsible for the following: Ensure that all admission documentation is properly filled out including the Youth's input and staff documentation for preferred de-escalation techniques that caregivers can use to assist the child in the de-escalation process.


raw_content: Several of the daily progress notes are missing information and another operation's name is on the progress notes.

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

Correction Narrative:
Operation provided attendance log for staff retraining on resident progress notes dated April 7, 2025. Operation provided a response stating daily progress notes are currently being reviewed for accuracy, and the form has also been changed to implement a better format (e.g., reflecting the Amir's House name only) making it easier to use.  Operation submitted a corrected response stating that Administrator will be responsible for the following:
1.  Daily process notes will be reviewed for accuracy.
2.  Staff will be re-trained on proper documentation of progress notes.
3.  New Staff will also be trained on proper documentation of the progress notes.


summary: 748.63(1) - Types of services-Operation must only provide services listed on permit

raw_content: Several documents evaluated confirms that a child in care has a diagnosis for which the operation is not licensed to provide services.

Category: Definitions and Services

Correction Narrative:
Operation provided the following compliance response: 1.  On April 2, 2025, an updated form 2960 to include Autism, form 2960 C and an updated policies and procedures that includes services for Autism was emailed.
2.  The Administrator will refer to the license to affirm which services can be provided by the facility when admitting a youth.
3. The Administrator will thoroughly review the intake paperwork to ensure that the Amir's House is authorized provide the youth's needed services.


facility_name: Sherwood-Myrtie Foster Home FO

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

raw_content: The operation did not have a current gas inspection completed, the last gas inspection was completed 1/29/24.

Category: Safety and Emergency Practices

Correction Narrative: An inspection was conducted at the operation, the Vice President/Program Director provided the gas inspection that was completed on 3/12/26.


summary: 748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event

raw_content: The documentation for two staff records did not have the required education verification documents filed in the record, this documentation was provided at the inspection but it was beyond the 30 day occurrence.

Standard Risk Level: Low

Correction Narrative: An email was received from the Administrator and Vice President with compliance. The operation has updated their new employee checklist to include Education. Also, the Treatment Director is auditing all current employee files and will update as necessary.


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: A child's car seat was not properly installed in the vehicle which led to the car seat falling over with the child strapped into the seat while the vehicle was in motion.

Correction Narrative: The caregivers have been terminated and all remaining caregivers have been retrained.


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

raw_content: The caregivers did not follow the operations requirements related to an additional household member; which resulted in two separate incidents that put children in care at risk.

Correction Narrative: The caregivers have been terminated.


summary: 748.1217(b)(6) - Admission Assessment-At admission, must include current medical & dental status, including available results of medical/dental exams

raw_content: Two of two admission assessments reviewed did not include the results of the children's medical and dental exams.

Correction Narrative: An email was received from the Vice President of the operation. The operation has implemented a new checklist for their admission assessments. The operation created a standardized email that will be sent to the placing party before the child is admitted. The email will request all required information from the placing party, and any information that isn't provided will be requested again at five and ten days if there is no response.


summary: 748.363(7) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: One staff member did not have a signed and notarized affidavit in their file.

Category: Reports and Record Keeping


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

raw_content: A bathroom wall in home 11 was observed with 2 holes. The outside porch in home 13 was cluttered and had hazards to children such as a weed eatter and tools. Home 9 had a toilet that was dirty with water/mold stains.

Correction Narrative: This deficiency has been corrected. The operation provided pictures of the corrections. Several homes were visited during the inspection. The homes now have storage cabinets to use for the back porches. The holes in the wall in home 11 were patched up. Case managers visit the homes monthly and complete walk throughs.


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: Several laundry room chemicals were observed on the counters and on the floor, where children could access them.

Correction Narrative: This deficiency has been corrected. The laundry room was observed and had chemicals stored in a high up cabinet with a magnetic lock on the cabinet. The foster parents were spoken to and know to store the chemicals out of reach of children.


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

raw_content: Medication was observed unlocked in both homes that were inspected today.

Correction Narrative: This deficiency was corrected. Medication storage was reviewed in 8 homes during a walk through and all medications were locked and stored appropriately. One home had the medication unlocked for a scheduled walk through from their case manager and no children were at the home. Medication logs for 6 children in care were reviewed with no errors. Medication records were reviewed for the destruction of expired medications. No children self administer medications. Two staff records were reviewed and had current medication trainings.


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 caregivers did not supervisor two children in care which resulted inappropriate behavior.

Correction Narrative: This deficiency has been corrected. The operation provided a corrective action plan outlining the increased supervision the house parents will be adhering to. The plan includes: following service plans, allowing only one child into bathrooms and bedrooms at a time, parents staying in hallways and common areas, parents being actively engaged with children, and administration checking on the home at least once per week. The plan was signed by both house parents and VP of Children Services. The plan was added to digital storage.The house parents were spoken to about the plan and were aware of the terms. The house has an alarm system and the bedroom doors have alarms as well. Administration visited the home with the inspector as one of the weekly checks outlined in the plan. Administration is also checking the home for medications and they were locked at the time of inspection.


summary: 748.1207(a)(2) - Placement agreement-Must include a medical consent form signed by a person legally authorized by Texas Family Code to provide consent

raw_content: Three medical consenter forms designated the house parents from the operation.

Correction Narrative:
A follow up inspection was conducted on 5/22/24, inspection #4003061. The operation was provided the Medical Care Job Aide from DFPS and it was discussed with the administrator and case managers. They are aware of the changes and will work on changing the medical consent forms as soon as possible. The extension date will be 6/7/24, so they have time to reach out to all children's CVS workers.

On 6/7/24, the operation sent updated medical consent forms for all children, as well as copies of emails that werer sent to the SSCC for their region explaining the change moving forward. This was added to document library.


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

raw_content: A caregiver yelled at a child in care.

Deficiency Narrative: A caregiver yelled at a child in care.

Correction Narrative: This deficiency has been corrected. The house parents were spoken to about discipline and they typically use loss of privleges. They know what is allowed and not. They have no had previous issues with discipline. The administrator reported no problems with discipline. The home's case manager was observed meeting with the parents and was spoken to as well, and had no concerns for the home.


summary: 748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate

raw_content: A baseboard with nails protruding out was observed on the back porch of one home and the house parent removed the nails. An exacto knife/box opener knife was observed in one child's bathroom, was removed and given to the house parent. Dog stakes with sharp ends that drill into the ground were observed on one front porch and the house parent stored these away.


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: Two homes have not completed weather drills within the 6 month time frame.

Correction Narrative:
The inspector received an email from the VP of children's services on 9/20/23:
748.3239(b) and 748.3239(a)-Foster's Home has developed a system where an administration assistant monitors fire drills and weather drills.  Each home that did not have a current weather drill was notified and required to perform a weather drill.
Home 2  7/6/23;  Home 7  7/6/23; Home 8  6/13/23; Home 9  8/1/23; Home 10 6/13/23; Home 11  6/30/23; Home 12  9/18/23;  Home 13  9/7/23; Home 14 9/12/23;  Home 15  6/13/23; Home 16  9/12/23.  Fire Drill dates are Home 2  7/6/23; Home 7  8/7/23; Home 8  6/19/23; Home 9  8/1/23;  Home 10  6/13/23;  Home 11  /7/23; Home 12  6/28/23; Home 13  7/6/23; Home 14  9/12/23; Home 15  6/19/23; Home 16  9/14/23


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

raw_content: One home has not completed a fire drill within the 6 month time frame.


raw_content: 2 homes had cleaning supplies stored where young children in the home could reach them.

Standard Number / Description:
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.

Correction Narrative: The inspector received an email and pictures from the VP of children's service on 9/20/23. There were pictures of homes 14 and 15 with cleaning supplies put away and stored appropriately, out of reach of young children. Pictures were added to document library.


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: Three bathroom sinks were observed without hand towels for children. One of the hand washing sinks was observed unclean.

Correction Narrative: he inspector received pictures via email from the VP of Children's Services on 3/14/23. The pictures were of the corrections made to the homes- several bathroom sinks are pictured to be clean with hand soap and a towel or paper towel for handwashing. The operation also has an online maintenance/repair request form that the homes can fill out if anything needs repair. They have maintenance workers on staff. JG


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: A few furniture/home items were observed to be in need of repair. One light bulb was out in a bathroom. Two bathroom rails for towels were off the walls. One window blind in a bedroom was broken.

Correction Narrative: The inspector received pictures via email from the VP of Children's Services on 3/14/23. The pictures were of the corrections made to the homes- a fixed light bulb, fixed bathroom towel rails, and an order receipt from new blinds that have been ordered to replace the older blinds. The operation also has an online maintenance/repair request form that the homes can fill out if anything needs repair. They have maintenance workers on staff. JG


summary: 748.831(a)(2) - Orientation-Orientation must include facility's philosophy, organizational structure, policies, and a description of the services and programs offered

raw_content: There was a staff person that did not have verification that she reviewed the agencies policies.

Correction Narrative:
The inspector received an email and spoke on the phone with VP of Children's Services on 4/20/23.
Attached please find the document that acknowledges that all employees are advised of the agency's philosophy, organizational structure, and a description of the services and programs offered.  An organization chart will be given to all new employees and was sent to current staff on 4/20/23, as well as being located in their online forms and foster parents having access to this.  Vice President of Children's Services will include this form in staff's orientation checklist.  Attached please also find the form that indicates that all employees are made aware of the policy for using a child's photo. This will also be added to the orientation check list of the Vice President of Children's Services. There will be a yearly acknowledgement of policies, especially any changes to policies in the past year.


summary: 748.1101(b)(3)(M) - Children's rights-consent in writing before taking part in publicity/fund raising for operation, including the use of the child's photo

raw_content: Several children that were interviewed indicated that they did not know their pictures were being taken or posted on social media.

Correction Narrative:
The inspector received an email and spoke on the phone with VP of Children's Services on 4/20/23.
Attached please find the copy of Child's Rights that is signed at intake by both the child (if age appropriate) and the placing party as well as the Our Community/Our Kids form that the placing party initials and signs that includes permission to participate in publicity and fundraising. Vice President of Children's Services will ensure that placing party and child are aware that this permission is a blanket agreement to participate. Foster's Home Case Manager will initial beside the line in Child's Rights where this is indicated. Children will be made aware of the use of pictures before they are used in publications and/or social media.  If children or parents choose not to participate or have pictures taken, that is their choice. Staff and foster parents will be made aware. Vice President and staff will also communicate more with the staff who runs the social media cite to ensure children are only posted if it is approved.


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

raw_content: A caregiver did not follow the agencies policies regarding posting a child's photo publicly.


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

raw_content: The discharge summary did not indicate the time or date the child was informed of the discharge.

Correction Narrative: The inspector received an email and spoke on the phone with VP of Children's Services on 4/20/23. She attached the discharge summary that is included in Casebook, the documentation software. The forms are made to meet minimum standard requirements. Vice President of Children's Services will ensure that this Casebook form is completed in it's entirety, including the circumstances surrounding the child being informed of the discharge, before signing off on the document. The child involved went to live with an employee at Foster's Home so things were a little atypical with the discharge paperwork.


summary: 748.1211(b)(2)(C) - Parent Orientation-Must review & provide written materials on involvement of child in any publicity and/or fund raising activity for operation

raw_content: The agency did not receive written permission from the children in care's parent to post pictures on social media.

Correction Narrative:
The inspector received an email and spoke on the phone with VP of Children's Services on 4/20/23.
Attached please find the form that is signed by all placing parties at intake in regards to the use of pictures in media publications. This is in addition to the signature of the placing party on receiving Child's Rights and the Our Community  Our Kids form that the placing party initials and signs.  If there are current placements that do not have this form on file, Case Managers will make sure that the form is signed and included in each child's files.  If children or parents chose not to participate, that is their choice. Staff and foster parents will be made aware.

Also attached is the signed paperwork that both the child and placing party signed at intake indicating their approval to be used in media by Foster's Home.


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 spanked a two-year-old child in care.

Correction Narrative: According to administrator, agency has fired the caregivers responsible for this.  She verified via email.  Additional training for "constructive discipline" will now be added as part of the agency's annual training.  Also, President will visit with all children monthly regarding discipline.


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

raw_content: Two staff were terminated before 11/16/2022. As of 12/22/2022 their background checks are still active.

Correction Narrative: The background checks of the two staff members have been inactivated.


raw_content: Two staff members yelled at children in care.

Standard Number / Description: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child


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

raw_content: Relief parents did not bathe or place the children in clean clothes while being in the home.

Correction Narrative: I, RCCR Tommie Moore received an email from the administrator. The administrator stated that foster's home will conduct a training each calendar year to all employees in ratio on the proper hygiene, cleanliness, dress and outward care for each child in care. In addition, each employee in ratio will be required to sign the attached attestation that they will understand the necessity of making sure the children in our care are clean and dress appropriately for current weather conditions. The attachment sign in sheet can be found in the share drive.


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

raw_content: Two holes were found in a bedroom wall of House 11. The operation was made aware of the damage over five months ago but the repairs have not been completed.

Category: Physical Site

Correction Narrative: A follow up inspection was conducted on 10/6/2022 during an investigation inspection. The holes have been repaired and were found to be complaint.


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

raw_content: A child in care did not receive medical treatment until two days after sustaining a fracture from a fall and complaining of increasing pain level.

Correction Narrative: The VP of Children's Services and all case managers have reviewed minimum standard requirements for 748.1531(a)(2) that states that a child in care must receive medical care as needed for injury, illness, and pain.  Case Managers will now visibly assess injuries to help the caregivers make an assessment for treatment needed.  The minimum standard requirements were also reviewed with the Medical Coordinator so when they facilitate making medical appointments, they understand the urgency of an injury being seen in a timely manner.


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 operation did not report a serious injury to licensing after a child in care sustained a fracture after a fall.

Correction Narrative: The VP of Children's Services and all case managers reviewed minimum standard requirements for 748.303(a)(2)(A). The VP of Children's Services will directly follow up with all reports of any injuries within 24 hours to ensure that all reports are filed to all appropriate parties in a timely fashion.


summary: 748.863(a)(4) - Pre-Service Training-Caregiver for tx svcs (not PMN) must have 16 hrs EBI training or 8 hrs if EBI prohibited, 1/2 pre-service & rest within 90 days

raw_content: Several awake night staff did not have required trainings including EBI, Normalcy, Trauma Informed Care, and Reporting Suspected A/N.

Correction Narrative: The operation has provided the required trainings to their awake night staff. Documentation for the completed trainings were provided to licensing for review. All documents have been reviewed and there are no concerns.


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: Personnel records for five awake night staff are missing several items including tb results, job descriptions, Licensing affidavits, and signed statements regarding reporting and operational policies.

Correction Narrative: The operation has updated the employee files and provided copies of the missing documents to licensing for review. All documents were reviewed with no concerns.


summary: 748.2151(b)(2) - Medication record - update cumulative record within 24 hours of administering medication if operate on a cottage home model

raw_content: One home had not filled out medication logs in more than 24 hours.  One house had an incorrect medication count.

Correction Narrative: Standard was found to be complaint.


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

raw_content: Bed bugs were found in two bedrooms of one cottage during a walkthorugh of the operation.

Correction Narrative: Standard was found to be complaint


raw_content: Caregiver spanked a child in care as result of toileting issues.

Standard Number / Description: 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

Correction Narrative:
An extension was granted until 10/27/2021 due to not being able to conduct the exit conference until 10/26/2021.

Children were interviewed privately during inspection #3848384, none disclosed being yelled at or any other inapprpirate discipline.

Further the agency has conducted training with the foster parents, training certificates were received from the Director.

The home has put in their 2 weeks notice, agency has a plan to ensure future compliance.


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

raw_content: A caregiver yelled at children in care due to behaviors.


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 had previous inappropriate touching history, and was required to be on "eye sight" supervision.  The child was able to act out inappropriately with another child after the caregiver did not provide appropriate supervision by checking all rooms after the door alarm was set off.

Correction Narrative: Foster parents were interviewed and appeared to understand their supervision requirements.  Changes have been made to the alarm system and it is now louder.  Training has been scheduled for the foster parents.


facility_name: New Encounters Residential Treatment

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

raw_content: When reviewing the medication logs, it was discovered that the date for multiple medication administrations were documented for the next day.

Correction Narrative: The medication logs were reviewed, staff were trained on medication, and certificates were received. Compliance has been met.


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

raw_content: A child's medication count did not match what was documented on the medication log.


summary: 748.3105(b) - Fire Inspection-Must comply with local code & all corrections, restrictions, or conditions specified by inspector in fire inspection report

raw_content: Operation failed to comply with all requirements to pass fire inspection.

Correction Narrative: The compliance was met when the administrator sent the fire inspection which is noted as "pass".


raw_content: Caregiver admitted to falling asleep while caring for youth.

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


raw_content: The caregiver displayed a lack of sound judgment by reporting to work despite not feeling well and taking medication during working hours that cause them to become sleepy.

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


summary: 748.507(3) - Employee general responsibilities-Know and comply with rules of Chapter 748 and any other rules and laws relevant to person's duties

raw_content: Staff member did not follow operation's policy.


raw_content: Four children were observed playing basketball outside unsupervised.

Correction Narrative: This standard was evaluation and found to be in compliance.


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

raw_content: There were three medication records that did not show medication was given but the medication bottle showed medication was missing.  The operation adminstrator provided  an updated copy of the medicaiton log.


facility_name: L'Amor Village RTC

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: Three of the children's restrooms were not equipped with handsoap.

Correction Narrative: Operation submitted photos of the restrooms containing handsoap.


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

raw_content: Several children and a passerby heard staff use profane language around children in care.  The staff admitted to "exchanging words" with a child.

Correction Narrative: The staff member denied using profanity with the resident before the investigation was initiated. The staff member was removed from the schedule and assigned to complete Development Training with the Treatment Team Case Manager and Therapist. This staff member is not allowed to return as an employee to L'Amor Village RTC. All current staff members have been assigned to attend Staff Development Training on the harmful effects of using profane or abusive language towards or in the presence of a child who resides at LVRTC.


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 it was discovered that the fire inspection certificate was expired.

Correction Narrative: The operation emailed RCCR Inspector Ibrahim Fye a copy of the newly completed fire inspection. See document library.


summary: 748.311(6) - Serious Incident Documentation-Includes nature of the incident

raw_content: During the inspection it was observed that multiple serious incident reports were missing information like the nature of the incident, and the names of witnesses, residents, & staff involved.

Correction Narrative: The Document has been corrected by adding word prompts for staff members to better describe the incident's nature, cause, techniques used to deescalate, and the outcome and solutions. Also, an area has been added to include the names of individuals that witnessed the incident. Please see attached document.


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

raw_content: A staff member admitted to preparing and administering medication for the evening and following morning for five out of six kids.

Correction Narrative: The staff involved has been discipline and retrained on appropriate medication preparation and administration. The staff member also completed a DFPS Psychotropic Medication training and was taken off the schedule as a disciplinary action.


summary: 748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights

raw_content: One of the four files did not include the copy of child's rights.

Correction Narrative: The child's right document will be obtained and signed during the admission and orientation process. During the biweekly to monthly folder checks the documents presence will be checked by the assistant director and LCCA.


raw_content: Five out of six child medication counts were not accurate due to being predated.

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: During the follow up inspection the medication pill count was accurate and not prepped hours in advance. The medication log was observed to not be filled out in advance.


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

raw_content: The staff list provided included names that are no longer employed at the operation.

Correction Narrative: The staff list and background check list will be updated as staff member is hired or no longer present on the work schedule. These lists will be routinely checked by assistant director and LCCA.


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

raw_content:
Both first aid kits did not include a thermometer.

This standard was corrected by putting working thermometers in the kit.


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

raw_content: An urinalysis strip was observed to be expired in August of 2023.   This was corrected during the inspection by discarding it immediately.


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

raw_content: Based on the training certificates reviewed it was discovered that some of the staff did not complete required annual trainings within the allowed subsequent 12-month period. These trainings include Psychotropic Medication for Children in Texas Foster Care Training and Preventing and Recognizing Sexual Abuse and Victimization of Youth in Foster Care Training.

Correction Narrative: A training checklist has been created by the administrator containing the trainings required to fulfill minimum standards annually. The training checklist will be placed in each staff members folder by the administrator and a copy in a Master Folder titled Annual Training. The date of each staff members current training will be documented, along with the annual due date. These dates will also be documented and displayed on a Training Calendar in the main business office.  Administrator and Lead Supervisor will be responsible for checking each staff member's filed checklist on a monthly basis for staff members who will need to complete their trainings for the current month.  A memo will also be given to staff members who need to complete training for the month at least 2 weeks prior to their due date.


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

raw_content: When reviewing the EBI policy, it stated that a personal restraint may not exceed one hour.

Correction Narrative: An email was received from the operation's administrator that included a response to the citation which stated that each staff was counseled with and informed of the correct maximum time for a resident to be in a restraint and signed a document indicating they are aware of the change. The EBI policy was corrected to state " The maximum length of time for a personal restraint for child of any age is 30 minutes".


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

raw_content: A child in care sustained an injury that required treatment by a medical professional and the operation failed to report the incident to statewide intake.

Correction Narrative: An email was received from administrator Demeteria Tezeno stating it will be the responsibility of Demeteria Tezeno to report all serious medical care administered to residence to licensing with in 24 hours.


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

raw_content: A bottle of what appears to be laundry detergent or fabric softener and an aerosol can of disinfectant/air freshener was observed to be in a resident's bedroom and accessible to all children in care.


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

raw_content: The operation's staff did not follow their written policies and procedures regarding hazardous chemicals use and storage when two cleaning/laundry products were observed to be unsecured and easily accessible to children in care.


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

raw_content: All posted evacuation diagrams were modified and included a designated place written however did not match with the area distinctly marked with a star in the emergency evacuation diagram. The diagrams are inconsistent and inaccurate.

Correction Narrative: All posted evacuation diagrams were modified and are in compliance.


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: Licensing was not notified of children's unauthorized absence until nearly 12hours after the children left the operation without permission.

Correction Narrative: This task of reporting or making notifications is no longer staff's responsibility, it will be Administrative staff's responsibility.


summary: 748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse

raw_content: Three out of three youth interviewed stated a caregiver makes smart alleck statements toward them.

Correction Narrative: Children interviewed reported that staff do not use sarcastic, rude humor or say anything innapropriate or hurtful towards children in care.


raw_content: All posted evacuation diagrams should have a designated place written or outlined in the emergency evacuation diagram.

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


raw_content: All posted evacuation diagrams were observed and a supervisor confirmed that there was no idenified for sheltering inside.


summary: 748.393(b)(5) - Active child record - Ensure record is kept confidential as required by law

raw_content: 2 of 2 binders containing medication records were observed on a desk in the common areas.

Correction Narrative: The records were observed to be stored and kept confidential in a locked office.


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

raw_content: An electrical outlet cover was observed in the boys house in the bedroom to the right to be missing on an outlet actively being used by children in care to charge electronics.

Correction Narrative: An electrical outlet cover was observed, and the building was in good repair.


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

raw_content: 2 of 7 children's file reviewed were observed without a signed copy of child's rights.


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: 4 of 4 bathrooms accessible to children were observed without soap near the handwashing sink. 1 of 4 bathrooms accessible to children were observed without toliet paper.


raw_content: 2 serious incident reports were observed with inaccurate dates of birth of children in care.

Correction Narrative: The documentation was corrected.


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

raw_content: On June 21 in the girls house in the refrigerator there was a gallon of milk was observed with an expiration date of May 18.


summary: 748.1703(b) - Menus-must document food substitutions on the menu that are of comparable food value

raw_content: All nutrients menus were observed without food substitutions documented on the menus.

Category: Child Care

Correction Narrative: All nutrients menus were observed with food substitutions documented on the menus.


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

raw_content: 3 of 3 child discharge files were observed without documentation confirming when the children were informed of thier discharge or tranfer.


raw_content: A child didn't return home from school at the regularly scheduled time which is approximately 3:46-4:00pm. The unauthorized absence was not reported until 1:41am the following morning.

Standard Number / Description: 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.


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

raw_content: The operation failed to submit quarterly EBI data for the 4th quarter on time.

Correction Narrative: EBI data was submitted. An email with written corrections was received sating: L'Amor Village Residential Treatment Facility will have this deficiency corrected for the next quarters. To remain in compliance the due dates for each Quarterly EBI have been documented on a calendar, an alarm has been set on the main computer, and the DFPS Provider Portal will be monitored daily for needed information.


summary: 748.463(a) - Unauthorized Absence EvaluationMust conduct an eval every 6 mths for unauthorized absences that have occurred during that time period

raw_content: Report was not able to be given at time of inspection.

Correction Narrative: The Unauthorized Absence Evaluation documentation was received. No concerns were found.


raw_content: On 12/5/22 a child received medical treatment at Brazos Urgent Care. This situation was not reported to the hotline as required.

Standard Number / Description: 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

Correction Narrative: The operation reported the incident today to the hotline in order to come into compliance. The operation also acknowledged in an email that they will report any future incidents that meet the requirements of standard 748.303(a)(2)(A).


summary: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.

raw_content: It was noted that Ms. Sweed's EBI training expired on 05/12/22.

Correction Narrative: An email of the certificate of completion for EBI was received for the staff member. No concerns were found.


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

Correction Narrative:
5 children admitted that a staff member uses vulgar language in front of them.

3 children were interviewed today, and there were no concerns with the interviews.


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

raw_content: It was found during the course of the investigation that staff got into a verbal altercation with a child in care's visitor. In addition, it was also found that a staff sometimes yell.

Correction Narrative:
Staff members involved in the verbal altercation with the resident's mother attended a training lead by Case Manager Patrick Oliphant, LMSW. Staff members had to explain how they must be responsible in all situations to ensure and maintain that each child's rights are fulfilled. Topics of Training: Behavior Management Techniques, Styles of Communication, De-Escalation Techniques, and Revisiting Child's Rights.

Signatures of employee attendance were provided. No concerns were found.


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

raw_content: The operation did not have an annual summary log readily available for review.

Correction Narrative:
The operation submitted the following correction: L'Amor Village RTC has added an Unauthorized Absence Log Form to Unauthorized Absence binder that was present the day of the investigation.
The operation provided the cumulative log with all information of their unauthorized absences for the year.


raw_content: Two residents interviewed stated a staff member curses at them. One staff member interviewed stated it has been reported to her that a staff member curses at the residents.

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

Correction Narrative: During the inspection I spoke with several children in care and there were no additional complaints of staff using profanity towards them. On 01/26 Mary Reece, the administrator sent an email stating that the girl's staff members would be taking several trainings biannually to assist with sensitivity towards children in care.


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

raw_content: Two children in care expressed that a staff grabbed a child in care around the neck and threw him onto the couch to stop them from potentially fighting.


summary: 748.931(a)(1)(B)(i) - Annual Training-Must include 2 hours on trauma informed care

raw_content: Direct Care Staff most recent Trauma Informed Care Training was last taken on 10/19/20.

Correction Narrative: Direct Care Staff completed the Trauma Informed Care on 10/25/21.


summary: 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

raw_content: A child received two doses of medication that was not prescribed to them.

Correction Narrative:
Written correction was received by Admin on 10/7/21. This error was due to a staff member allowing a child to rush up to the medication desk and grab medications from the medication box without their permission.
As of 9/28/21, 15 minutes prior to medications being administered at the medication desk, ALL residents will be instructed to return to their bedrooms to wait for further instructions from the staff. All activities are to be stopped until all medications have been administered. Each resident will be called to the medication desk one at a time.


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

raw_content: It was found that the organizational chart was not updated and was missing names of persons under positions listed.

Correction Narrative: An updated organizational chart was sent with the correct information.


facility_name: Jonathan's Place GRO

raw_content: In the GTP cottage 3 bathrooms were out of use due to plumbing issues.  One bathroom observed had a leaking faucet in the shower.

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


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

raw_content: Three out of four freezers did not have a thermostate.  One freezer with food stored inside was observed unplugged in the kitchen area.

Correction Narrative: 4 of 4 freezers were observed to have thermometers.


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

raw_content: Two employee files did not have pre-employment affidavit form 2912 documentation.


summary: 748.915(b)(6) - Pediatric CPR training documentation must include length of the training in hours

raw_content: 2 of 2 CPR training documents did not have length of training in hours.

Category: Training and Professional Development

Correction Narrative: RCCR received the following response from the operation: The Training department will make sure all training certificates have length of training hours.


summary: 748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.

raw_content: 1 of 2 staff files did not have  tuberculosis screening  results documented.

Correction Narrative: RCCR received a copy of an employees tuberculosis screening via email. The operation submitted the following response: H.R. department will audit all new hires files to make sure (the operation) is meeting job requirements before new hires starts on boarding process.


summary: 748.363(7) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: 1 of 2 staff files did not have the Licensed Affidavit notarized.

Correction Narrative: RCCR received a notarized affidavit for the employee involved. The operation submitted the following response: H.R. department will audit all new hires files to make sure (the operation) is meeting job requirements before new hires starts on boarding process.


summary: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position

raw_content: 1 of 2 files did not have education provided to support the employee meets the qualifications.

Correction Narrative: RCCR received education documentation for an employee that matches the employees job description.


summary: 748.455(c) - Unauthorized Absence-debriefing must be documented in childs record, including routine activity that would be inappt for child to return to and why

raw_content: The operation will to retrain staff memebers on debreifing with children.

Correction Narrative:
On 5/3/2024, the operation submitted a sign up sheet with staff members who attended the training. The training does not include documentation to support unauthorized absences training. Follow up is needed with staff members.

Follow-up was completed during the inspection on 5/22/2204. During the inspection 2 staff interviewed indicate staff members were trained on debriefing with children who runaway by asking the child why they ran, what coping skills can be used next time and questions if anything took place while away from the operation.


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

raw_content: 5 of 6 medication logs did not have health-care professionals name.

Correction Narrative: Medications meet the requirement.


raw_content: 1 of 2 files did not have education provided to support the employee meets the qualifications. The file is also missing documentation to support minimum experience with children.

Standard Number / Description: 748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position


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

raw_content: 2 of 2 refrigerators did not have a thermometer

Correction Narrative: Thermometers were observed in refrigerators.


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

raw_content: 5 of 6 medication logs did not display the reason the medication was prescribed.


raw_content: 1 of 2 child files reviewed did not have a debrief with child following a unauthorized absence.

Standard Number / Description: 748.455(c) - Unauthorized Absence-debriefing must be documented in childs record, including routine activity that would be inappt for child to return to and why


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

raw_content: During the walk through, a hole was seen behind a door.

Correction Narrative: During the walk through, a hole was observed to be filled in RESET program.


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

raw_content: During the investigation, it was discovered that the operation does not report any unauthorized absences of children who are private placements.

Correction Narrative: The operation made an intake regarding a run away child. Intake number and documentation was provided.


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

raw_content: One child in care did not recieve their prescribed medication as directed.

Correction Narrative:
1) The 1st caregiver on duty will administer medications and complete a pill count of the medication and sign the medication log for accuracy.
2) The 2nd caregiver on duty will complete an audit of the pill count for accuracy and sign the Medication of sheet, after the 1st caregiver on duty has completed administering medication.
3) If there is not a 2nd caregiver on duty, the Lead Direct Care staff complete the audit of the pill count for accuracy and sing the Medication log.
4)The Lead Direct Care staff will do a daily audit of the Medication logs for accuracy.
5) The case Managers will complete weekly audit of the medications log sheet.
During Inspection on 10/25/2023 we saw it being applied.


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

raw_content: A caregiver did not use self-control when she snatched a phone out of child's hand, causing the child to escalate grab a fire extinguisher and set it off inside the cottage house.

Correction Narrative:
To achieve improvement, staff will demonstrate the 3 R's, relationship, regulation, and de-escalation. Directors will ensure staff receive a refresher to alter the youth's emotional and physical state when they are exhibiting verbal and or aggressive behaviors.

On 10/25/2023 a follow up inspection was conducted. Documentation was reviewed regarding crisis intervention response training for both staff members. Documentation indicates a meeting was conducted with both staff members related to strategies to de-escalate children verbally. The fire extinguisher was installed in a safer place but still accessible to staff members.


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

raw_content: A caregiver was not paying attention to a child in care, allowing the child to gain access to a fire extinguisher, sit it on the table, figure out how to engage the fire extinguisher and then use it to spray another caregiver without warning.

Correction Narrative:
To achieve improvement, staff will provide active and engaging supervision. Staff must be in close range and have visibility of youth. Staff will ensure youth are in line of sight and provide 1015-minute checks. Directors will ensure staff maintain their Managing Aggressive Behavior training every six months and/or provide refreshers as needed.
During the Inspection on 10/25/2023 during our walk through we saw the form that is being used in the 10-15 minutes check.


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

raw_content: 1 child file reviewed did not include the date the child was notified of the discharge.


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

raw_content: a file that was reviewed did not have an employee s high school diploma or any verification that they completed high school.


summary: 748.4211(a) - Placement Extension-Must document reason for continuing emergency care services in child's record by 16th day that child is in care

raw_content: The operation was not completing the place extension documentation by the timeframe required.

Category: Emergency Care


summary: 748.1209(c)(1) - Child Orientation - Include information on how to make complaints to outside agencies

raw_content: 2 of 2 files did not provide the child with information on making reports to outside agencies.


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

raw_content: A child file was reviewed and did  not have the reason of why the child was placed in emergency care. The file was also missing the child's understanding or need for placement and child feels about crisis situation/operation.


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: Documentation of severe weather drill was not produced during the inspection.


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

raw_content: Caregivers did not follow a child's safety plan requirements. Requirements state the child will remain within line of sight during waking hours and staff will ensure no other residents are down the hall when the child is goes to the bathroom.


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

raw_content: A child's service plan was not signed by the child or any members of the service planning team.

Correction Narrative: Operation director emailed me the service plan signed by all participants in the service planning team.


raw_content: During an outing, four of six children were separated and out of sight of the caregiver which resulted in two children being caught shoplifting and law enforcement being called.

Correction Narrative: A follow-up inspection is planned for 11/10/2022. The caregiver no longer works at the operation as of 11/10/22.


summary: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures

raw_content:
A caregiver did not follow the operation's procedures when they took six children in care on an outing after being told they could only take three.
The operation's management staff provided the caregiver with verbal counseling on 8/2/2022 and a written final warning for not following directions of the management staff and placing children at risk.


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

raw_content:
A caregiver admitted to using profane language in the presence of the children in care. The caregiver was also yelling at a child in care.
The operation's management staff provided the caregiver with verbal counseling on 8/2/2022 and a written final warning for using inappropriate language in the presence of children.

Correction Narrative:
A follow-up inspection is planned for 11/10/2022.

RCCR completed a follow-up inspection on 11/10/22. During the inspection it was learned that a staff member had used inappropriate language with a new group of children in care. After speaking with the operation, it was confirmed that the staff will no longer be working with the operation going forward. A report was called into the abuse hotline on 11/10/22. Report # 76946635. As of 11/10/22, The staff member is not an active employee of the operation.


summary: 748.1337(b)(1)(D) - Initial Service Plan-Include specific goals and strategies to meet the child's needs, including instructions to caregivers

raw_content: Of the three initial service plans reviewed, none of the plans state specific supervision requirements based on the child's age, behaviors, and level of care. The information in all three service plans appear to be copied and pasted. All three service plans are missing signatures from the service plan team and only contain the signatures of the children.

Correction Narrative: At the time the investigation was complete, the children were discharged, and no corrections could be made.


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

raw_content: A child with a history of cutting self harmed 7/16/22 and on 7/31/22. This was after a safety plan was implemented on 7/6/22.


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

raw_content: On 7/31/22 after staff was made aware of the first self harming incident, the child was left unattended and self harmed again with objects in the environment.


summary: 748.1501(b) - Dental care-The child's record must include a written record of each dental examination

raw_content: 4 out of 6 child files reviewed did not have a dental examination record.


summary: 748.1531(b) - Medical care-The child's record must include a written record of each medical examination

raw_content: 2 out of 6 child files reviewed did not have a medical examination record.


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

raw_content: A caregiver slept while counted in the child care ratio.

Correction Narrative: A detailed plan was emailed to RCCR Inspector JerSean Walder. Jonathan's Place is updating the overnight monitoring procedure to include bed check documentation on the electronic monitoring system in extendedReach.


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

raw_content: During the inspection 1 out of 3 cottages homes had an uncovered piece of cake in the freezer.


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

raw_content: Psychotropic medication (Sertraline) was stored in an unlock storage box.  Corrected during inspection.  Pictures were taken.


facility_name: San Marcos Treatment Center

summary: 748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work

raw_content: It was observed during the walk through of the Unit One staff with 7 children and another staff with 3 children.

Correction Narrative: Walkthrough was completed of Gateway Mideast dorm with unit manager. 11 girls were observed in the dorm with 3 staff. Unit manager stated they have implemented more FAO staff to be on site daily to help with ratio if needed and frequently check cameras for ratio. Unit manager stated they also implemented alternative activities to comply with ratio.


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

raw_content: While reviewing staff files it was found that staff are only taking 1 hour of Trauma Informed Care annually.

Correction Narrative:
On 11.6.25 the operation emailed a sampling of training certifications showing that staff have completed the 2 hour normalcy training.

On 10.30.25 the operation emailed the below compliance plan:

Corrective Action: We value the ongoing development of our direct care staff and strive to continue furthering their development to ensure consistent care for all our patients. In addition to the initial two-hour Trauma-informed care training, we will continue that development annually with consistent re-training. As of 10/30/25 all staff will be assigned two hours of annual Trauma Informed Care training and due by 11.30.2025. The records for this training will be kept in staff files and will be available upon request.


raw_content: A child in care was allowed to attend school and be off unit due to a miscommunication from nursing staff to Direct Care staff regarding the child's Safety Plan. This allowed the child to be exposed to contraband and swallowed 2 magnets while off unit.

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

Correction Narrative:
An in person inspection was conducted at the operation. Staff was interviewed regarding how safety plans were documented and communicated to all shifts and all staff. There were no new concerns.

On 10.17.25 the operation emailed the following written compliance :

Corrective Action: The nursing staff from this incident were supervised on the need to review and confirm all patient's special needs and supervisions. Additionally, the unit manager and group therapist will be providing reviews of structures and their implementation on a regular basis. Going forward, we will meet the state licensing standards for caregiver responsibility.


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

raw_content: A child in care tested positive for a communicable disease and it was not reported to the hotline until after the required timeframe.

Correction Narrative:
Licensing received the following corrective action plan from the operation:

San Marcos Treatment Center submits the following corrective action plan for standards deficiencies received on 8/21/25. By submitting this Plan of Correction, the Facility does not admit that it violated the regulations. The facility also reserves the right to amend the Plan of Correction as necessary and to contest the deficiencies, findings, conclusions, and actions of the agency.
Standard Reviewed: 748.303(a)(11)(A): Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease.
Finding: On a Saturday night a child tested positive for covid, and licensing was not notified until Monday morning.
Corrective Action: We met with our nursing team to review our method of communication and the mandated reporting deadline for serious incidents on 8/21/25. Going forward, we will meet the standards for reporting serious incidents to state licensing within the mandated timeframe.


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

raw_content: It was determined through interviews with 4 staff and 3 children that a staff would threaten children with restraints and corporal punishment.

Correction Narrative:
4.8.25 - An unannounced in person follow up inspection was conducted. Interviews with 3 residents and 2 staff were conducted and confirmed that the employee involved in this incident has been placed on leave by the school starting 3.7.25 and has not been employed at the operation since 2.27.25. Residents reported that they have not heard any other staff cursing or using threatening language.

4.18.25 the operation emailed the corrective action plan stating the following :

The PRN staff in question was terminated, on 3/07/25, before the facility was made aware of these allegations and before the investigation was completed.

All caregivers are trained using the Handle with Care approach for physical and verbal interventions.  These techniques prioritize verbal interventions while limiting the use of physical restraints.

San Marcos Treatment Center nurtures a culture of see something, say something amongst all employees.  All employees are trained to report any concerning interactions involving other staff. All caregivers are trained to be mandated reporters of abuse and neglect.

Going forward the facility will continue to promote staff reporting on interactions not aligned with facility policy.  Additionally, the team involved in this incident will be reeducated on our see something, say something culture at their next team meeting, which will be documented in Human Resources by 5/18/25.


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

raw_content: In interviews with 4 staff and 3 children, it was determined that a staff member would curse at and threaten children in care.

Correction Narrative: During an in person follow up visit 3 residents and 2 staff were intterviewed and reported that this employee no longer works at the operaton. Residents and staff stated that they have not heard any staff using foul or threatening language towards children in care.


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: Through interviews it was found that a staff member was left to supervise 11 residents for an hour during awake hours.

Correction Narrative:
4.8.25 - An unannounced follow up inspection was conducted at the operation. A walkthrough of the operation was conducted to evaluate ratio with no concerns. Interviews with residents regarding ratio were also conducted with no concerns.

3.21.25 The operation sent an email with the corrective action plan stating the following:
Facility Administrative Officers (FAOs) review morning, afternoon, and overnight shifts for ratio. If there are any unplanned shortages FAO notifies Unit Manager.
The Unit Manager is the point of contact in the event of any issues with ratio on his or her unit and is responsible for reviewing and adjusting as needed. The facility Unit Director will provide weekly oversight to ensure ratio requirements are met by reviewing the unit schedule for this unit with the assigned Unit Manager.
Additionally, the facility trains nurses, therapists, supervisors, and administrators to be qualified caregivers to step in and help cover the ratio as needed. If these additional caregivers are required, the Unit Manager will be responsible for communicating this to his or her team, as well as updating the FAO and schedule to reflect the coverage plan.


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

raw_content: During an investigation it was determined a staff member failed to review each hygiene box to assure all hygiene items are accounted for, and verify the absence of contraband. Due to this oversight a child was able to use a toothbrush to make a weapon.

Correction Narrative:
The department received an email from Roberto Rodriquez, Director of Risk at the operation with the plan of correction.

All staff members assigned to the Clearview team will be re-educated and re-trained on the facility policy for Procedures on Bathroom Safety which includes staff members reviewing each hygiene box to assure all hygiene items are accounted for and to verify the absence of contraband.
The Clearview Unit Manager will be responsible for having all staff complete the training by 3/31/25.

Director of Human Recourses will be responsible for maintaining all training records which will be available for licensing to review upon request.


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

raw_content: It was determined a child was on 5 minute checks and staff did not check on the child timely allowing the child to self harm.


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

raw_content: When reviewing training records, 5 out of 10 files reviewed did not have normalcy training completed annually and trauma informed training was missing 1/2 an hour annually.

Correction Narrative:
The operation sent an email with the following corrective action:

San Marcos Treatment Center currently provides Normalcy and Trauma Informed Care training to all caregivers during new hire orientation and ongoing as needed. Starting on Sept 6, 2024, the facility will also provide these trainings annually.

The Trauma Informed Care training curriculum will also be revised by Sept 6, 2024, to meet the 2-hour licensing requirement.

San Marcos Treatment Center Human Resourced Director will be responsible for tracking all required training and maintaining compliance to all licensing training standards.


raw_content: During the review of this investigation, interviews reported that a staff member slapped a child in care during a restraint.

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

Correction Narrative: During an inperson inspection, two residents were interviewed regarding EBI and discipline with no additional concerns.


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: An x-ray concluded that a child in care had a fractured finger, and the injury was not reported to the hotline until after the required timeframe.

Correction Narrative:
The department received an email from the operation stating that the following steps were taken to correct and prevent this incident from happening again:

The facility was aware of the reporting delay when the incident occurred and shared the information with licensing when the investigation was initiated.

Although the patient received appropriate medical treatment, all staff involved in the incident have received formal supervision from their supervisors regarding the timelines associated with reporting serious incidents to licensing.

Documentation of the supervision will be kept in employee personnel files and available for licensing to review upon request

12.13.23 RC Insp. Melanie Forsyth staffed with Jessica Keith-Valdez and was approved for email follow-up for this citation.


raw_content: After the review of video footage, it was observed in the common room that there were 12 children to 2 staff members.

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

Correction Narrative:
The staff member was scheduled to receive formal supervision for her recent attendance issues, however she quit without notice soon after the incident, and did not return to work.

On 11.9.23 an in person follow up was conducted. RCCR Inspector Melanie Forsyth conducted an unannounced follow up inspection at the operation. A walk through of the Clearview unit was conducted to observe ratio with no concerns. 2 residents were interviewed regarding ratio and supervision with no concerns. No photos were taken.

San Marcos Treatment Center trains all direct care staff to qualify as caregivers. In addition to training direct care staff, the facility also trains nurses, therapists, supervisors, and administrators to be qualified caregivers as well.

Moving forward, when a staff member is running late and affecting the patient ratio, the facility will utilize additional trained caregivers to help cover and maintain the patient ratio requirement.


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

raw_content: Staff was not properly informed of supervision levels regarding children in care.


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

raw_content: During the course the investigation, it was determined a caregiver failed to intervene timely during an altercation which resulted in minor injuries to a child in care.

Correction Narrative: This Inspector attempted to interview staff involved, however, they were not present. A conversation was had with the Administrator on what was discussed with the staff present during the incident.


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

raw_content: During the investigation, it was found that seven out of seven children reported that different staff have used profane language/multiple curse words towards the children in care in a derogatory way and/or have said inappropriate derogatory comments towards and around children in care. Other collaterals reported staff may use profane language out of reflex or by accident around children in care, but usually not near or away from the children in care.

Correction Narrative: An email was received by the operation on 1/13/23 and an in-person follow up was conducted on 1/24/23 at the operation. The operation explained initial and ongoing training is provided to all caregivers on how to respond to challenging child behaviors, while using supportive language and an additional training will be provided 1.11.23 to provide caregivers appropriate methods of interacting with the children. The operation requested an AR for this citation.


raw_content: 4 children interviewed mentioned that during the incident one staff member directed profane language toward a child in care.

Correction Narrative:
An email was received from the Administrator with the following:
The facility has chosen to appeal the findings due to several patients not being interviewed who were also present when the incident occurred, and also due to six separate staff members who all reported no one cursing at patients when interviewed.
Although the facility does not agree with the findings, San Marcos Treatment Center will continue to provide initial, and ongoing training, focused on treating all patients with dignity and respect. Any confirmed incidents of staff curing at patients will continue to result in re-training or formal supervision, up to and including, termination.


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

raw_content: A direct care staff has been working at the operation without an active background check. This staff's background check was inactivated as of 6/16/22. [The operation was recently cited for background check results on 3/17/22].

Correction Narrative:
On 8/1/22, The Administrator reported through email that he has contacted their Human Resources (HR) Director so they can follow up on the staff's background check. The operation reported they will also identifying how and why the background check lapsed. It was reported that the staff is a PRN employee and has not worked since they received notice that the background check was inactive. The staff will not work again until it is completed and cleared.

On 8/4, the operation reported the current process for monitoring all background checks was evaluated and revised by the facility HR Dir. on 8/1. Revisions to the process included adding electronic reminders to a scheduling and calendar system that will now provide visual prompts for deadlines related to the background check process.

Moving forward, anytime their HR Department does not receive clearance for pending background checks within the 30 day requirement, the staff member will be not be allowed to work or have contact with children, until fully cleared.

The facility HR Dir. will continue to be responsible for monitoring all background check deadlines.

As of 8/10, the staff' background is still showing "inactive."


raw_content: A child was able to obtain staff's prescription medication from a staff member's personal backpack while at the operation.

Correction Narrative:
SMTC Administrator, Robert Rodriguez, sent the corrective action plan for standards deficiencies received on 7/26/22.

The staff member involved was temporarily suspended on 6/28/22 until video review of the incident, conducted with the assigned licensing inspector, verfied that the inciden occurred in between the 15 minute visual check requirement that the staff member was required to perform, while she was distracted, and working with other patients in a classroom. After video review, licensing was supportive of the staff member being reinstated on 7/1/22.

Although the facility and the assigned licensing inspector were able to verify that the staff member did provide adequate supervision while maintaining the 15 minute visual checks, the facility also identified the need to prevent patients from accessing potential dangerous items brought into the facility by staff. In addition, the facility also identified a need to develop a policy that outlines how staff can safely access prescribed medication and other personal items when necessary.

As result of the incident, the facility immediately stopped allowing staff to have personal backpacks in all patient care areas on 6/28/22. The facility also revised an existing policy on 7/7 that outlines safe and secured areas on campus where personal items like prescription medication can be kept. The policy also outlines how staff can safely access these items during their shift.

Training for the new policy was introduced into new hire orientation on 7/18. the same training was also added to the facility online training platform, as a requirement on for all existing employees on 7/18/22.
_____________________________

A follow up inspection, #3899940 was completed on 8.22.22 to ensure compliance. Staff were observed in/out of the unit without personal backpacks/purses. Lockers/cubbies were observed with staff personal items, which are inaccessible to the children. The lockers/cubbies were labeled with each staff name. The Administrator explained all staff had received the new training in regards to storage. The Administrator explained if a staff needs to take medications or grab a personal item, it is arranged between all staff on the unit to ensure supervision is met.


summary: 748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file

raw_content: 1 child's file documented the child had a dental exam 7 months prior to being placed, however, the operation did not have documentation to prove this exam took place.

Correction Narrative:
The following email was received from the operation:
Our Admissions Department will continue to request patient dental records prior to admission. Once obtained, Admissions Department staff will place a copy of the dental record in the patient's medical record.

In addition to copies of the dental record, the Admissions Department will also place a copy of a checklist in the patient's chart that reflects documented attempts to obtain dental records when families are unable to provide them prior to admission.

Copies of dental records along with the checklist will be added to the Medical Record Department auditing process. Any identified deficiencies will forwarded to the Admissions Department Director for correction in a timely manner.

Copies of dental records will also be kept on file in the Admissions Department and on the facility network public drive.


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

raw_content: 2 out of 3 affidavits for employment were completed after the date of hire.

Correction Narrative:
The following was received from the Operation.
Although the two employee affidavits that were reviewed were signed during the new employee orientation process, prior to having contact with patients, moving forward, our Human Resource Department will have all potential employees sign the affidavits and have them notarized during the application process, before participating in orientation.


raw_content: While reviewing the operations background checks, it was observed that a Psychatrist has an inactive background check as of 03/17/20. This Psychatrist  is currently employed with this operation.

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

Correction Narrative:
An email was sent with an attachment showing verification that the background check was completed and the psychiatrist is eligible to be present.
This Inspector checked the background check to ensure and found it to be active and eligible.


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

raw_content: A staff members actions were noted to have presented a genuine threat of substantial harm from physical injury to the child when the staff member placed the child in an inappropriate restraint.

Correction Narrative:
Email from the operation: The staff member involved was suspended immediately after the incident, and then terminated shortly after further review.

All staff at San Marcos Treatment Center receive both initial and continuing education/ training regarding safe and effective patient interventions. We are committed to using the least restrictive intervention when possible, and reserve physical restraints as a last resort in an effort to keep patients and staff safe.

All restraints will continue to be monitored using video within 72 hours, with emphasis on verbal de-escalation attempts, justification, and proper technique. Staff will continue to receive positive feedback and praise for compliance related to restraint standards and facility policy. Staff will also continue to receive additional training, re-education, and formal supervision leading up to and including possible termination, for any non-compliance related to restraint standards and facility policy.

Additionally, RCCR conducted an inspection to the operation on 5/27/22, where 7 children were interviewed which yielded no additional concerns. Walk through of the unit was conducted and ratio was evaluated.


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

raw_content: A staff members actions were noted to have escalated a situation, which ultimately resulted in at least one child in care being inappropriately restrained.

Correction Narrative:
Email from the operation: The staff member involved was suspended immediately after the incident, and then terminated shortly after further review.

All staff at San Marcos Treatment Center receive both initial and continuing education/ training regarding safe and effective patient interventions. We are committed to using the least restrictive intervention when possible, and reserve physical restraints as a last resort in an effort to keep both patients and staff safe.

All circumstances leading up to use of restraint will continue to be monitored by use of video within 72 hours, with emphasis on verbal de-escalation attempts, justification, and proper technique. Staff will continue to receive positive feedback and praise for compliance related to restraint standards and facility policy. Staff will also continue to receive additional training, re-education, and formal supervision leading up to and including possible termination, for any non-compliance to related to restraint standards and facility policy.

Additionally, RCCR conducted an inspection to the operation on 5/27/22 where 7 children were interviewed and no additional concerns were noted. A walk through of the unit was conducted and ratio was evaluated.


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

raw_content: A staff member was noted to have placed a limb (hand and arm) around a childs neck.

Correction Narrative:
Email from the operation: The staff member involved was suspended immediately after the incident, and then terminated shortly after further review.

All staff at San Marcos Treatment Center receive both initial and continuing education/ training regarding safe and effective patient interventions. We are committed to using the least restrictive intervention when possible, and reserve physical restraints as a last resort in an effort to keep patients and staff safe.

All restraints will continue to be monitored using video within 72 hours, with emphasis on verbal de-escalation attempts, justification, and proper technique. Staff will continue to receive positive feedback and praise for compliance related to restraint standards and facility policy. Staff will also continue to receive additional training, re-education, and formal supervision leading up to and including possible termination, for any non-compliance to related to restraint standards and facility policy.

Additionally, RCCR conducted an inspection to the operation on 5/27/22 where 7 children were interviewed and no additional concerns were noted. A walk through of the unit was conducted and ratio was evaluated.