summary: 748.915(a) - Document the caregivers completion of each training with cert or letter of completion in the appropriate FH or personnel record

raw_content: Three of four employee records reviewed were observed to be missing recent training certificates.

Correction Narrative: The following corrective action was received: SHYR Admin Assistant failed to maintain current, true, accurate, and complete records for each employee, as required by the job description. As immediate corrective action, this employee was reprimanded for deficiency on March 12, 2025. Moving forward, the Admin Assistant will conduct monthly audits of each employee's personnel record, with any deficiencies documented in a report shared with the LCCA by the 5th of the following month. To ensure all employee records are current, true, accurate, and complete, Safe Haven will conduct a full audit of each employee's electronic record beginning Monday, March 17, 2025, until completion, under the direct oversight of the CEO.


state: TX

facility_name: Safe Haven Youth Ranch

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: Medical attention was sought for a child in care after a restraint was administered. Child reported of having stomach pains and was taken to the doctor the next day. Serious incident occurred on 2.11.2025, but was not called into RCCR.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative: The following corrective action was emailed by Owner, Eric Fields: Safe Haven will report all serious incidents involving injury or illness that require treatment by a medical professional or hospitalization within 24 hours.


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

raw_content: During the review of files, services plans were not signed by all parties involved.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Low

Correction Narrative:
The following corrective action was received: Under the previous LCCA, who abruptly resigned in November 2024, the initial service plans completed by the LCCA and the previous Treatment Director did not maintain complete records of the signed signature pages. The previous Treatment Director was replaced as of March 1, 2025.
As of March 3, 2025, SHYR has hired a new Treatment Director who has begun preservice training, which includes instruction on the 14-Day Invitation process for participation in the ISP meeting. This includes sending the invitation to the DFPS worker, parents (if applicable), and other members of the youth's treatment team, as well as documenting any responses from parents. The training also covers the facilitation of the ISP meeting, sharing the ISP with all participants within 10 days of the meeting, and ensuring that all required documentation is properly maintained.
Following the ISP meeting, the 14-Day Invitation email, the ISP including all participant signatures, and the email confirmation of the ISP being shared will be uploaded into the youth's electronic record in Extended Reach by the Case Manager no later than the 5th of the following month. This process will be monitored by the current LCCA to ensure full compliance each month.


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

raw_content: One of four records revewed observed EBI was not completed; last completion was 07/23/2024.

Category: Training and Professional Development

Correction Narrative: The following corrective action was received: Safe Haven Admin Assistant will be entering and monitoring each employee's training records in "Extended Reach." The Admin Assistant will provide the LCCA with a monthly report listing employees whose training is set to expire within the next 30 to 60 days. Additionally, the Admin Assistant will send reminder emails and make follow-up phone calls to ensure employees schedule and complete their training on time. This process will be monitored by the current LCCA to ensure full compliance each month. If a staff member is found to be late or delinquent in completing required training, they will be removed from the active work schedule or duty until the training is completed.


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

raw_content: Children's records reviewed did not have current service plans completed in the file.

Standard Risk Level: Medium Low

Correction Narrative: The following corrective action was received: Under the previous LCCA, who abruptly resigned in November 2024, the 90-Day Service Plans completed by the LCCA and the previous Treatment Director were not properly maintained in the youth's electronic records. The previous Treatment Director was replaced as of March 1, 2025. As of March 3, 2025, SHYR has hired a new Treatment Director who has begun preservice training, which includes instruction on the 14-Day Invitation process for participation in the ISP meeting. This includes sending the invitation to the DFPS worker, parents (if applicable), and other members of the youth's treatment team, as well as documenting any responses from parents. The training also covers the facilitation of the ISP meeting, sharing the ISP with all participants within 10 days of the meeting, and ensuring that all required documentation is properly maintained. Following the ISP meeting, the 14-Day Invitation email, the ISP including all participant signatures, and the email confirmation of the ISP being shared will be uploaded into the youth's electronic record in Extended Reach by the Case Manager no later than the 5th of the following month. This process will be monitored by the current LCCA to ensure full compliance each month.


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

raw_content: During the review of four employee records, it was noted that two of them lacked documentation verifying the completion of reference checks.

Correction Narrative:
The following corrective action was received: SHYR Admin Assistant failed to maintain current, true, accurate, and complete records for each employee, as required by the job description. As immediate corrective action, this employee was reprimanded for deficiency on March 12, 2025. Moving forward, the Admin Assistant will use the New Hire Checklist to audit each new employee's personnel record, ensuring Pre-Employment Screening is completed. This process will be monitored by the current LCCA to ensure full compliance each month.
To ensure all employee records are current, true, accurate, and complete, Safe Haven will conduct a full audit of each employee's electronic record beginning Monday, March 17, 2025, and continuing until completion, under the direct oversight of the CEO.


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

raw_content: Children's records reviewed did not have an immunization record in the file.

Correction Narrative: The following corrective action was received: As of February 24, 2025, SHYR hired a new case manager who has begun preservice training, including instruction on the Extended Reach electronic record-keeping system and the record management protocol. This protocol requires all youth records to be updated no later than the 5th of the following month, with compliance monitored by the current LCCA on an ongoing basis. Safe Haven will contact Texas Imtrac to register the Admin Assistant access to research and obtain access to the youth's immunization records to be uploaded into the youth's electronic record within 72 hours of admission. Safe Haven will conduct audits of youth electronic records throughout April to ensure consistency and compliance as the record maintenance and uploads are completed.


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

raw_content: Children's records reviewed did not have documentation that the service plan meeting letter was sent to all parties.

Correction Narrative: The following corrective action was received: Under the previous LCCA, who abruptly resigned in November 2024, the initial and 90 Day Service Plans completed by the LCCA and the previous Treatment Director did not maintain complete records of the 14-Day Invitation process for participation in the ISP meeting. The previous Treatment Director was replaced as of March 1, 2025. As of March 3, 2025, SHYR has hired a new Treatment Director who has begun preservice training, which includes instruction on the 14-Day Invitation process for participation in the ISP meeting. This includes sending the invitation to the DFPS worker, parents (if applicable), and other members of the youth's treatment team, as well as documenting any responses from parents. The training also covers the facilitation of the ISP meeting, sharing the ISP with all participants within 10 days of the meeting, and ensuring that all required documentation is properly maintained. Following the ISP meeting, the 14-Day Invitation email, the ISP including all participant signatures, and the email confirmation of the ISP being shared will be uploaded into the youth's electronic record in Extended Reach by the Case Manager no later than the 5th of the following month. This process will be monitored by the current LCCA to ensure full compliance each month.


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 child in care suffered pain to the face as a result of a staff member horseplaying with the child.

Standard Risk Level: High


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

raw_content: Staff described physically picking up a child in care and placing him in his bedroom after an altercation with another child.


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


summary: 748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication


summary: 748.751(a)(2) - Pre-Employment Screening-You must contact the employer to verify if the applicant was employed as described in the applicant's employment history.

raw_content: It was observed in one of four employee files reviewed that the operation did not contact each employer included in the five-year employment history.

Category: Personnel

Standard Risk Level: Medium

Correction Narrative: The Administrative Assistant will ensure all Applicants' Employment histories are contacted. If the Employer is no longer in business or unreachable, the Administrative Assistant will document that on the Employee Reference form.


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

raw_content: The person list in the portal shows 8 active employees that are not documented on the employee list provided by the operation.

Correction Narrative:
The Administrative Assistant will scan the portal two times a week to ensure all employees that are no longer employed or applicants that are active and never worked with SHYR are deactivated in the portal immediately.

The Administrative Assistant will update the Employee staff list on each Friday after all new employees have been orientated.


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

raw_content: Three serious incidents for one child in care indicated suicide ideations and/or attempts. Neither of the three incidents were reported to Licensing.

Category: Reports and Record Keeping

Correction Narrative:
The following corrective action was emailed:
Upon awareness of any suicide ideation or attempt by a child, staff must immediately notify both their direct supervisor and Ms. Edwards.
The incident must be reported to HHSC Licensing within 24 hours of awareness to ensure compliance with the regulation.


summary: 748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.

raw_content: There were three serious incidents involving one child in care exhibiting suicidal ideations. There were no documented suicide screenings for neither incident.

Correction Narrative:
The following corrective action was emailed:
Any Youth exhibiting warning signs of suicidal ideation must be immediately removed from any group activity or situation and a suicide screening must be conducted within 2 hours.
Annual refresher courses and periodic competency checks will be conducted to ensure staff are well-equipped to respond to suicidal warning signs and follow correct screening procedures.
Screenings will be logged in Extended Reach to ensure they are properly tracked and reported.


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 of four employee files reviewed was observed to be missing notarization on the Licensing Affidavit for Applicants for Employment form.

Correction Narrative: Administrative Assistant will ensure all Affidavits are notarized prior to caregivers being responsible for any youth in our care.


summary: 748.931(b)(1) - Annual Training- Administrators, PLSP's, treatment directors and case managers who do not hold a prof. license must have 2 hrs trauma informed care.

raw_content: It was determined that two trainings were over a year old.

Correction Narrative: The operation sent the following for follow-up/corrections to the citation:	Administrator completed all outstanding trainings July of 2024. Extended Reach tracking system will generate automatic reminders for upcoming trainings 45 days in advance. A monthly audit will be conducted by the Administrative Assistant to ensure all required training is up to date. Any non-compliance will be flagged, and immediate corrective actions will be taken.


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

raw_content: A caregiver sought assistance from other children in care to restrain a child.


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

raw_content: Children in care reported that staff were asleep on shift, staff were observed unresponsive with their eyes closed shut.


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 was not administered prescribed medication for one month. A second child in care received two more milligrams of medication than what was prescribed.

Correction Narrative:
On 08/15/24 Inspector followed up with both victims at the operation regarding medication. Both reported receiving all medications as prescribed and made no further outcries of abuse or neglect.
The operation emailed the following corrective action on 08/21/24: 	All managers received refresher training on medication administration.
	All managers were coached on the importance of properly administering medication.
	The administrator spoke with all youth about the importance of self-advocation, and the importance of knowing the medications they are prescribed and the quantity of medication they take.


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

raw_content: One of the child files reviewed was observed to have an inaccurate count of two medications documented on the medication log.

Category: Medication

Correction Narrative:
	Administrator conducted a Medication Audit on June 26, 2024, to ensure accurate documentation and administration. (All findings reported)
	All managers received refresher training on medication administration (Please see attached certificates for topics covered).


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

raw_content: Staff and residents interviewed stated a staff member called a resident a derogatory name.


raw_content: Caregiver did not provide the 1:1 supervision required for a youth in care.

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

Correction Narrative:
An unannounced visit was conducted on 02/20/24. Victim, Aydian, was observed to be on one-on one supervision and was being properly supervised by staff supervisor, Bianca B. Collateral children in care interviewed confirmed that staff maintain one on one supervision for those who are placed on heightened supervision until they are discharged from the facility.

The agency submitted corrections via email. In response to the citation, the employee responsible for the 1:1 supervision is no longer employed.
with SHYR effective 2/16/24. In response to the specific case, we have conducted a thorough review of our current supervision protocols.
All caregivers will undergo additional training facilitated by the Director.
of Residential Services on the importance of 1:1 supervision,
recognizing potential issues, and responding effectively by Wednesday,
February 28, 2024. In the event of non-compliance with current supervision protocols, individual corrective action plans will be developed for the involved staff, including additional training and supervision. Non-compliance could also lead to termination of employment. We are committed to maintaining the highest standards of care for the youth under our supervision. This corrective action plan reflects our dedication to addressing the cited issue promptly and implementing preventive measures to avoid similar deficiencies in the future.


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

raw_content: It was determined a staff member made inappropriate comments to a child in care regarding family and also engaged in an unnecessary power struggle with a child in care.

Correction Narrative:
An unannounced visit was conducted on 02/20/24. Children in care interviewed denied that there is any inappropriate discipline such as inappropriate comments or physical discipline by staff; stating that discipline is only consisting of loss of privileges.

An email was received from Administrator Marquitta Edwards stating that due to the department's findings, and concerns with Staff Ms. Ebony's inability to set appropriate boundaries with youth, Ms. Ebony's employment will be terminated effective 2/16/2024.


summary: 748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded

raw_content: Several incident reports do not document the length of time a child was restrained.


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

raw_content: Staff have fallen asleep when supervising children in care.


summary: 748.1205(a)(8) - Admission Documentation-Includes allergies (food, medication, sting, and skin allergies)

raw_content: Admission Assessments does not include known allergies.

Correction Narrative: Admission Assessment was updated to reflect youth allergies, if any.


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

raw_content: Admission Assessments reviewed did not include any known contraindications to restraints.

Correction Narrative: Admission Assessment was updated to reflect any contraindications to restraints.


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

raw_content: Log shows that smoke detectors were not tested in May 2023.

Category: Safety and Emergency Practices

Correction Narrative: Administrator or designee will ensure all smoke detectors are tested monthly in compliance with Minimum Standards


summary: 748.1205(a)(6) - Admission Documentation-Includes medication the child is taking

raw_content: Admission Assessments did not include medications the children were taking.

Correction Narrative: Admission Assessment was updated to reflect any medications the youth is taking at the time of admission.


summary: 748.1205(a)(3) - Admission Documentation-Include names, addresses, phone numbers of bio or adoptive parents, unless parental rights terminated

raw_content: Admission Assessments did not include information for parents.

Correction Narrative: Admission Assessment was updated to include contact information for parents whose parental rights aren't terminated.


summary: 748.4003(1)(C) - General requirements-When transporting a child the operation must ensure each driver has a current driver's license for the type of vehicle used

raw_content: It was observed that an employee transported children in care with an expired driver's license.

Category: Transportation

Correction Narrative: Employee Ebony Peavy is prohibited from transporting any youth at our operation until a renewed license is furnished and on file.


raw_content: Video camera footage, captured by the facility, showed a staff using her forearm to push a child back into his room, forcing him to comply to directives for quiet, calm down time.

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


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

raw_content: During the course of the investigation, it was found that the medication error happened on 1-9-23 and it was not documented until 1-20-23.


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

raw_content: While conducting the investigation of the facility it was found that the medication error was found on 1-18-23 and the child had still not received any medical attention as of 2-2-23 when the investigation was initiated.


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

raw_content: Staff performed a personal restraint on a child in care without there being an emergency situation.

Correction Narrative:
An unannounced follow-up visit was conducted. Two children interviewed stated that they are only being restrained for attempting harming themselves or others.
Employee Andre Ross is no longer employed with SHYR

All employees were trained on the appropriate use of EBI.  Our policy is clear on the justifiable reasons to utilize EBI:

1. A youth exhibits:
      a. self-injurious behavior that caused or is likely to cause injury;
      b. behavior which is likely to result in danger to self or others; and/or
      c. aggressive behavior that is likely to cause injury to others; and/or

2. A youth attempts to run away and may be a danger to self.

All employees are expected to adhere to the above policy. Failure to do so will result in Disciplinary Action.


raw_content: A child was inappropriately touched by another child while outside and under the supervision of staff.

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

Correction Narrative:
Employee is no longer employed at SHYR as of November 15, 2022.

All employees are trained on Youth Supervision:

1.	Knowing which youth they are responsible for
2.	Being aware of and accountable for each youth on-going activity
3.	Providing the level of supervision necessary to ensure each youth's safety and well-being including auditory and/visual awareness of each youth's on going activity as appropriate

All employees are expected to adhere to these responsibilities.  Failure to do so will result in disciplinary action, up to and including termination of employment


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

raw_content: The reportable incident occurred on 10.15.22 and it was not reported by the operation to licensing until 10.19.22

Correction Narrative:
On 12/19/22, email was received with the following compliance plan from operation in regard to citation issued.

All employees are trained on Reporting reportable incidents to the Texas abuse and neglect hotline and their responsibilities as mandated reporters:

1.	Report suspected abuse, neglect, and exploitation to the Child Abuse Hotline and to the designated employee or administrator

2.	Report Incident as soon as possible, but no later than 24 hours after they become aware of the incident.

3.	All employees will be retrained on Reporting reportable incidents to the Texas abuse and neglect hotline and their responsibilities as mandated reporters Wednesday 12/21/22.

All employees are expected to adhere to these responsibilities.  Failure to do so will result in disciplinary action, up to and including termination of employment.


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

raw_content: 2 children in care were given one extra dosage of medication.

Correction Narrative: Two children in care were interviewed, both indicated that there has not been any issues regarding medication; receiving more than they are supposed to or not receiving it when they are supposed to. Two employees interviewed indicated that they have all been provided with additional medication training.


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: Two staff members administered an additional prescription medication dosage to a child in care.

Correction Narrative:
The operation submitted a Corrective Action Plan that stated:
1. All Employees were required to retrain in psychotropic medication for children in Texas Foster Care.
2. Our medication binder was updated with Tabs for afternoon medications as an addition to our Tabs for AM and PM medications.  Prior to this adjustment Afternoon medication logs were under the PM Tab, however, we certainly realize how this could be confusing for employees.  We hope to prevent further violations of this standard with the corrective actions implemented.

During a physical follow up on 10/12/22, Two children in care were interviewed, both indicated that there has not been any issues regarding medication; receiving more than they are supposed to or not receiving it when they are supposed to. Two employees interviewed indicated that they have all been provided with additional medication training.


raw_content: A child in care was administered an incorrect dosage of medication.

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

Correction Narrative:
The operation submitted the following corrections: SHYR Correction Action Implemented 1. All Employees were required to retrain in psychotropic medication for children in Texas Foster Care.

2.Our medication binder was updated with Tabs for afternoon medications as an addition to our Tabs for AM and PM medications.  Prior to this adjustment Afternoon medication logs were under the PM Tab, however, we certainly realize how this could be confusing for employees.  We hope to prevent further violations of this standard with the corrective actions implemented.

A follow-up visit to the operation was conducted on 10/13/22. Two children in care were interviewed, one including the victim child to this investigation, stated that there have not been any further concerns with medication. Two staff members interviewed stated that they have been provided additional medication training.


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

Deficiency Narrative: 2 children in care were given one extra dosage of medication.


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: Four of the four child records reviewed were observed to be missing immunization records.

Correction Narrative: Immunization Records were requested from all youth in our care Caseworkers.  Moving forward, SHYR Management will ensure Immunization records are obtained prior or during the intake meeting with all youth placed at SHYR.


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

raw_content: In one of the four employee files reviewed, it was observed that an employee who began 01/24/22 did not have a notarized Affidavit for Applicants until 06/13/22.

Correction Narrative: SHYR Management will ensure an affidavit is completed, signed and notarized for all New Hires during New Hire Orientation Training and prior to being in direct contact with the youth at SHYR.


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: One of the four employee files reviewed was observed to be missing a high school diploma. The employee has been working at the operation since 01/24/22.

Correction Narrative: Employee in question will be removed from SHYR's schedule effective 6/23/22 until they are able to provide employer with proof of a HS diploma or GED from program recognized by TEA, TPSAC, other state or documentation of equivalency from home schooling.  SHYR's Management will ensure all employees furnish a HS diploma or GED from program recognized by TEA, TPSAC, other state or documentation of equivalency from home schooling before or during New Hire Orientation Training and prior to being in direct contact with the youth at SHYR.


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: On the date of the incident the agency was not in ratio.

Correction Narrative: SHYR Correction Action Implemented 	Safe Haven Youth Ranch will ensure the program is in ratio at all times in compliance with minimum standards and our policy and procedures.  If an unforeseen incident occurs involving a youth having to receive medical attention off campus grounds, and the incident could potentially cause the program to fall out of ratio, SHYR's management team will ensure emergency coverage is obtained to maintain our staff to youth ratio.


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

raw_content: During the walk through it was observed that one building had a door with a board over the window.   Photos taken.

Correction Narrative:
The operation provided a photo showing this correction.
The window was replaced on Saturday March 5, 2022.


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

raw_content: During the inspection it was observed that the operation had expired food in the pantry and not stored properly. There were two open food boxes in the pantry..mash potatoes, pancakes (photos taken).

Correction Narrative:
The administrator provided a checklist that the operation will use going forward.

Expired food was discarded on Wednesday, March 2, 2022.  A Safety Food Checklist was implemented on March 9, 2022 to avoid further violation of this standard.


summary: 748.1013(a) - Child/caregiver ratio-A caregiver must be awake when caring for a child needing constant supervision

raw_content: It was reported that a staff member was asleep while providing supervision to children in care.

Correction Narrative: The operation's administrator provided signed documentation that staff member, Alfred Martin, signed after he was given a "coaching" regarding the allegations of being asleep while supervising children in care. It was also noted that the Mr. Martin is no longer employed at the operation; his last date of employment was 02/12/2022.


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

raw_content: It was determined that a child in care was restrained for walking/not listening.


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

raw_content: Operation does not have documented report of serious incident that occurred.

Correction Narrative: Administrator emailed a copy of the incident report.


summary: 748.1699(a) - Nutrition-must offer a child a meal or snack, but may not force the child to eat

raw_content: Children in care reported that a staff member would force a child in care to eat food that he did not want to eat.

Correction Narrative: Employee, Cherelle Hubbard, is no longer employed at the operation. The Residential Staff Manager will meet with each current residential direct care staff to address and ensure staff must offer a child meal or snack, but may not force the child to eat. Each residential direct care staff will sign their individual coaching and development note. The Residential Staff Manager will provide a copy of the individual coaching and development note via email and a hard copy will be placed in their individual employee file. During new hire residential direct care staff orientation, the facilitator will address the CPS Rights of the Children and Youth in Foster Care (form 2530) with the newly hired employees.


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

raw_content: Children in care reported that a staff member would make derogatory remarks in reference to the sexuality of a child in care.

Correction Narrative: Employee, Cherelle Hubbard, is no longer employed at the operation. The residential staff manager will meet with each current residential direct-care staff to address the use of any harsh, cruel, unusual, unnecessary demeaning, or humiliating discipline/punishment towards youth in care. Each residential direct care staff will sign their individual coaching and development note. The residential Staff Manager will provide a copy of the individual coaching development note via email and a hard copy will be placed in their individual employee file. During new hire residential direct care staff orientation, the facilitator will address the CPS Rights of the Children and Youth in Foster Care (form 2530) with the newly hired employees.


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

raw_content: Four out of five children interviewed reported to hearing profane language being used to redirect the children.  Three out of five staff interviewed acknowledged being aware of profane language being used to redirect the children.

Correction Narrative:
Staff members Brioni Davis and Cherelle Hubbard are no longer employed at the operation due to said allegations. Residential Staff member will meet with all current staff to address the use of profane language while directing/re-directing youth in care. Each residential direct care staff will sign their individual coaching and development note. The Residential Staff Manager will provide a copy of the individual coaching and development note via email and a hard copy will be placed in their individual employee file.

During new hire residential direct care staff orientation, the facilitator will address the CPS Rights of the Children and Youth in Foster Care (form 2530) with the newly hired employees.


summary: 748.3273(4) - First Aid Kits-Each one must contain cotton balls

raw_content: Observed First Aid Kit did not contain (4) cotton balls or (6) scissors.

Correction Narrative: Cotton balls and scissors were added to First Aid Kit


raw_content: One child's record did not include an Immunization Record.

Standard Number / Description: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

Category: Child Care

Correction Narrative: Immunization record placed in child's record.


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

raw_content: Three of four children's record showed that there was medication corrections without the required documentation to follow with a total 4 errors.

Correction Narrative:
Effective Immediately. SHYR will ensure that any medication errors are documented within 24 hours in the youth's cumulative medication record.
SHYR Residential Staff who administers medication completion of administering of medication training was completed on May 10, 2021. See attached training certificates.
SHYR Nurse Consultant will continue to provide oversight of medication administration and documentation on a weekly basis. The Nurse will provide weekly progress reviews of the medication count, medication logs, scheduling refill ordering, monitoring medication errors reporting, evaluating youth for possible side effect and providing additional training to residential staff. The SHYR LCCA and Nurse will conduct weekly staffing to review/discuss each youth's medication/health status and the residential staff administration of medication.


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

raw_content: One of four children's records does not document the dosage of the medication.

Correction Narrative:
Effective Immediately. SHYR will ensure that each youth's medication record include medication name, strength and dosage.
SHYR Residential Staff who administers medication completion of administering of medication training was completed on May 10, 2021. See attached training certificates.
SHYR Nurse Consultant will continue to provide oversight of medication administration and documentation on a weekly basis. The Nurse will provide weekly progress reviews of the medication count, medication logs, scheduling refill ordering, monitoring medication errors reporting, evaluating youth for possible side effect and providing additional training to residential staff. The SHYR LCCA and Nurse will conduct weekly staffing to review/discuss each youth's medication/health status and the residential staff administration of medication.


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

raw_content: Four of four children's medication log showed that the children did not get their medication as prescribed, Out of the four children records it was seen 18 times that medication was missed.

Correction Narrative:
Effective Immediately. SHYR will ensure that each youth has taken each medications as prescribed.
SHYR Residential Staff who administers medication completion of administering of medication training was completed on May 10, 2021. See attached training certificates.
SHYR Nurse Consultant will continue to provide oversight of medication administration and documentation on a weekly basis. The Nurse will provide weekly progress reviews of the medication count, medication logs, scheduling refill ordering, monitoring medication errors reporting, evaluating youth for possible side effect and providing additional training to residential staff. The SHYR LCCA and Nurse will conduct weekly staffing to review/discuss each youth's medication/health status and the residential staff administration of medication.


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

raw_content: Four of four Children's recorders had errors based on the cumulative medication count with a total of 16 times.

Correction Narrative:
Effective Immediately. SHYR will ensure that each youth's medication record is updated cumulatively within 2 hours of administering medication.
SHYR Residential Staff who administers medication completion of administering of medication training was completed on May 10, 2021. See attached training certificates.
SHYR Nurse Consultant will continue to provide oversight of medication administration and documentation on a weekly basis. The Nurse will provide weekly progress reviews of the medication count, medication logs, scheduling refill ordering, monitoring medication errors reporting, evaluating youth for possible side effect and providing additional training to residential staff. The SHYR LCCA and Nurse will conduct weekly staffing to review/discuss each youth's medication/health status and the residential staff administration of medication.


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

raw_content: Three of four children's record did not have the signature of staff that administrated the medication, with a total of 4 errors.

Correction Narrative:
Effective Immediately. SHYR will ensure that each youth's medication record include name & signature of person who administered each medication.
SHYR Residential Staff who administers medication completion of administering of medication training was completed on May 10, 2021. See attached training certificates.
SHYR Nurse Consultant will continue to provide oversight of medication administration and documentation on a weekly basis. The Nurse will provide weekly progress reviews of the medication count, medication logs, scheduling refill ordering, monitoring medication errors reporting, evaluating youth for possible side effect and providing additional training to residential staff. The SHYR LCCA and Nurse will conduct weekly staffing to review/discuss each youth's medication/health status and the residential staff administration of medication.


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

raw_content: Three of Four Children's medication record indicated no reason for prescription with a total of 16 logs without a reason.

Correction Narrative:
Effective Immediately. SHYR will ensure that each youth's medication record include reason medication was prescribed, for prescription medication.
SHYR Residential Staff who administers medication completion of administering of medication training was completed on May 10, 2021. See attached training certificates.
SHYR Nurse Consultant will continue to provide oversight of medication administration and documentation on a weekly basis. The Nurse will provide weekly progress reviews of the medication count, medication logs, scheduling refill ordering, monitoring medication errors reporting, evaluating youth for possible side effect and providing additional training to residential staff. The SHYR LCCA and Nurse will conduct weekly staffing to review/discuss each youth's medication/health status and the residential staff administration of medication.


facility_name: Trinity Guidance Residential Treatment Center

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

raw_content: While reviewing serious incidents related to the investigation, it was noted that pertinent information was missing from the report such as time, date, person making the report, and the name of child.

Correction Narrative:
Trinity Guidance will ensure that its Licensed Child Care Administrator henceforth thoroughly
reviews and signs off on Serious Incident Reports to ensure that they are complete and accurate
and not missing pertinent information.


raw_content: While reviewing the medication log it was noted the name and signature of the person who administered the medication was not present on the log.

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

Correction Narrative:
Trinity Guidance will regularly audit the medication log to ensure all information is accurately
noted appropriately, as well as re-train staff on minimum standards protocol for keeping
medication records. This training will be held once a month, starting today (April 14th 2026)


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: While reviewing records at the facility a serious incident report was received by staff detailing an incident on 3/11/2026 that a child did not receive his AM medication as prescribed by a physician due to the pharmacy not being able to fill the prescription timely.

Correction Narrative:
Trinity Guidance, under direct supervision of its Licensed Child Care Administrator, will ensure
that all medication quantities are regularly monitored and audited and refills sent out at least 2
(two) weeks prior to depletion of medication supply.


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

raw_content: The operation is not approved to provide treatment services for autism spectrum disorder, however during an investigation it was found that treatment services for autism spectrum disorder are being provided.

Correction Narrative:
Follow up by email on 3/30/26 with policies to add ASD and IDD services.
An extension was approved on 3/30/26 by RCCR supervisor Martina Beltran. The original compliance date has been extended from 3/30/26 to 4/7/26.
Additional services have been approved and added to the permit.


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 review of the intake, serious incident report, and the medical records indicated that Licensing was notified outside the 24-hour time frame.

Correction Narrative: On 4/16/2026, the Administrator of Trinity Guidance Residential Treatment Center, stated that they had implemented a Policy requiring staff to follow protocol when a serious incident occurs, including injuries or illnesses that warrant treatment by a medical professional. As part of the protocol, the incident is to be reported to DFPS licensing and the caseworker no later than 24 hours.


summary: 748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.

raw_content: Case workers of the victim were not notified in a timely manner of medical treatment received by children.

Correction Narrative: On 4/16/2026 the Administrator of Trinity Guidance Residential Treatment Center, stated that they had implemented a Policy requiring staff to follow protocol when a serious incident occurs, including injuries or illnesses that warrant treatment by a medical professional. As part of the protocol, the incident is to be reported to DFPS licensing and the caseworker no later than 24 hours.


raw_content: The medication log reviewed and staff interviewed confirmed a medication was not administered to a child as prescribed.

Correction Narrative: Interview with staff state that staff will sign med sheet when resident has received medication. Resident did not receive his medication and was in med line.


raw_content: The medication log reviewed did not have a name and signature of the person who administered the medication.

Correction Narrative: Staff confirm that child was sent home before medication could be administered. Staff confirm that medication was administered at operation. Operation follows what doctor and caseworker recommend.


facility_name: Angelic House of Hope

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

raw_content: During the follow-up inspection, it was noticed that substitutions were still missing from the menu.

Correction Narrative: The operation emailed a full menu schedule that included substitutions.


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

raw_content: Fire drill log was missing length of time for the evacuation or relocation to take place.

Corrected at Inspection: Yes


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: During the review of employee files, it was noted that the required notarized employment affidavits were missing from one employee file at the time of the inspection.


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

raw_content: Staff files were observed to not have the required affidavits required by the minimum standards (Form 2912 & Form 2985)

Correction Narrative: The operation has come into compliance with this standard.


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

raw_content: It was observed that the medication count documented on the medication log was not accurate.


summary: 748.751(a)(1) - Pre-Employment Screening- You must obtain in writing an applicant's employment history for the last five years before hiring.

raw_content: Staff file was observed not to have documentation of the employees last 5 years of employment.


raw_content: Medication logs were observed with inaccurate information such as the directions.

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


raw_content: A child did not take their medication as indicated in the directions.


raw_content: The medication records remaining amount does not match the amount of pills left in the pill packs.


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

raw_content: An incident report advises that a doctors appointment was made for a child who required medical attention, however there is no documentation of a medical appointment being completed.


facility_name: East Texas Open Door Inc

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: Of the four child's records reviewed, one was missing a signed child's rights.

Category: Children's Rights

Correction Narrative: On 4/7/2026, the Administrator provided corrections via email stating child rights will be completed in the Casebook system at intake and a hard copy will be kept in the physical file.


raw_content: Two of four medication records reviewed, did not have an accurate medication count.

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: On 4/7/2026, the Administrator provided corrections via email stating all medication count will be maintained within the Casebook system. Casebook maintains the count each time a medication is administered. The medical liaison will check for an accurate medication count each day.


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

raw_content: During the inspection, I observed the siding of the house was rotted out in several locations on both buildings, a bench in the back yard was used as an anchor for the volleyball net with a metal stake being stuck through the bench slats to bear the weight while being exposed in a way a child could injure themselves on it, the paint in the upstairs room of the kitchen building was cracked above a window,  and the paint on the outside rear face of the house as incomplete.

Category: Physical Site

Correction Narrative: On 4/1/2026, the operation's Administrator requested a variance to complete physical site corrections.


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

raw_content: One of four child's records did not have a completed admissions assessment.

Correction Narrative: On 4/7/2026, the Administrator provided corrections via email stating admission assessments are now completed in the Casebook system. Each assessment will be completed timely according to the standard and according to the type of intake (emergency or planned).


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

raw_content: During the inspection, I observed the refrigerator in the kitchen lacked a thermometer, one freezer thermometer read ten degrees Fahrenheit, the other freezer thermometer read four degrees Fahrenheit, and the deep freezer in the other building read fifteen degrees Fahrenheit.

Correction Narrative: On 4/7/2026, the Administrator provided corrections via email stating the operation purchased new digital thermometers. They have a countertop or wall-mounted display that shows the temperature of the fridge and the freezer and has an alarm that goes off if the temperature goes above or below a preset temp. This will assist us in ensuring that the temperature remains at the appropriate level. Dietician and cooks will monitor these thermometers. Any worker who sees or hears an alarm going off will notify administration who will rectify the situation.


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: During the inspection, I observed an unsecured and unattended gas can, containing gasoline, in the yard of one of the houses.


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

raw_content: While reviewing the serious incident report provided, it was determined the documentation did not include the names of the children/adults involved in the incident. There were three children involved in the incident; however, the report only named one child. The incident occurred at the operation, and the staff present that witnessed the incident were not included on the report.

Correction Narrative: A staff meeting will be held to discuss and go over proper documentation procedures relating to serious incidents. This will include what to document, on which form, and what to include.


facility_name: MiOwn Home, LLC

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

raw_content:
During a review conducted on 3/10/2026 it was determined that:

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

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

The heightened monitoring plan for this operation included a specific planned end date at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring.

Furthermore, the operations planned end date must now be revised, and the period of heightened monitoring must be extended.

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

-Operation failed to satisfy the conditions of the plan

-Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and

-Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

Correction Narrative: An HM extension was approved effective 3/12/2026.  In conjunction with this extension, a new deadline was established by which all requirements must be completed by your GRO in order for the operation to be released from its HM plan and move to the Post-plan Monitoring Stage of HM.  Because the extended deadline is now effective, HHSC has determined that the operation is compliant with the requirements of 26 TAC 748.535(2). The HM deadline for your operation has been extended by 6 months and the new deadline is 9/13/2026.


summary: 745.8411(b)(4) - Responsibilities - Not delay or prevent inspection or investigation

raw_content: During a DFPS investigation, documentation was not sent timely after several requests.

Correction Narrative: The operation has a 72 reminder on all  on all documentation requests that pops up.  This is entered at the time the email is seen to help ensure all documents are being sent quickly.


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

raw_content: During an investigation, residents and collaterals indicated concerns for the way staff spoke to children in care which caused children in care to escalate in behavior.

Correction Narrative: Additional training was done on 02/02/26.  This is now also being addressed weekly to ensure staff are aware of the risks of escalating children in care.


summary: 748.1009(2) - Child/caregiver ratio-Must employ adequate number of caregivers to meet their responsibilities regarding supervision of children in 748.685

raw_content: During an investigation, interviews and a work schedule indicate that 1 staff was working with 3 children in care when one of the children was supposed to be 1:1.  There is concern 1:1 ratio is not being met at all times as required.

Correction Narrative: The operation completed a ratio training on 01/12/2026.  The operation is also checking with staff on Monday calls to ensure and address any concerns about ratio that staff might have and ensuring that this is met at all times.


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

raw_content: Operation staff transported two children in care to an activity away from the operation and left them unattended resulting in both children eloping. Both children have a documented history of running away and require supervision when away from the operation.

Correction Narrative: The operation conducted a supervision training on 01/12/2026.  The operation is holding weekly meetings now on Mondays to discuss supervision and levels of supervision needed for events and general operation.


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 agency did not report to the Hotline within 24 hours when a child needed treatment by a medical professional for a possible drug overdose.

Correction Narrative: On 12/26/25, the operation provided training to all staff in regard to Serious Incident Reporting.  A staff sign-in sheet was created, and all staff were emailed minimum standards and additional helpful tips for Serious Incident Reporting.


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

raw_content: A caregiver locked a child in care out of the operation, which resulted in the child kicking the door and breaking it.

Correction Narrative:
3.	Policy Review and Update (Completed 10/28/2025):
o	MIOWN Home updated the Supervision & Safety Policy to explicitly prohibit any appearance or act that could be perceived as locking a youth out of the facility, even momentarily.
4.	Safety Check Procedures (Implemented 10/29/2025):
o	Daily safety checks confirming that all entry/exit doors are operational and free from damage or tampering.
o	Maintenance repairs for the front door were completed immediately following the incident.
5.	Staff Training (Scheduled 11/12/2025):
o	All Direct Care staff will attend a Safety Refresher, facilitated by the Direct Care Supervisor and Executive Director.
o	Training includes:
	Trauma-Informed De-escalation
	Maintaining Emotional Safety During Behavioral Outbursts
	Proper Use of Boundaries Without Isolation or Exclusion
	Crisis Documentation and Communication Protocols
________________________________________
4. Preventive Measures
	Increased Administrative Oversight: Supervisors will conduct random shift observations twice monthly to monitor caregiveryouth interactions and ensure compliance with supervision standards.
	Youth Feedback Loop: The Program Director will conduct weekly youth check-ins to assess their sense of safety and address any concerns directly.
________________________________________
5. Person(s) Responsible
	Rachel Wyatt, Executive Director  Oversight, training verification, and compliance documentation.
	T. Weatherspoon, Direct Care Supervisor  Staff retraining, shift observations, and documentation review.

Inspection #

The operation provided a schedule consisting of how staff supervise children throughout the day. Staff have been informed to keep watch of children that are outside calming down, and to not take any action that could be perceived as locking children outside.


summary: 745.8411(b)(3) - Responsibilities - Provides access to all records

raw_content: Fiscal documentation related to the operations heightened monitoring plan was requested on 8/29/2025 and 9/3/2025 and not provided as of 9/9/2025.

Correction Narrative: Operation provided requested documents pertaining to their HM plan Task 11.


Standard Number / Description: 745.8411(b)(3) - Responsibilities - Provides access to all records

Deficiency Narrative: Fiscal documentation related to the operations heightened monitoring plan was requested on 8/29/2025 and 9/3/2025 and not provided as of 9/9/2025.


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

raw_content: A child in care did not have a completed service plan.

Correction Narrative: The operation completed service plan training with staff on 10/27/25.  Service plans reviewed are being completed correctly at this time.


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

raw_content: Foster children interviewed stated that staff have refused to let them call their caseworker.

Correction Narrative: The operation had a meeting on 11/04/2025 about contacts with caseworkers and that these need to be documented to ensure that no calls are being denied and this can be checked.


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

raw_content: This standard was part of an investigation.  The suicide screening was not conducted on the day of admission, but five days later.

Correction Narrative:
2. §748.125(d)(4)(A)  Suicide Screening
Deficiency:
The required suicide screening was not conducted on the day of admission, but rather five days later.
Root Cause Analysis:
The delay was due to incomplete handoff during weekend admissions and the lack of a secondary verification system ensuring that all required screenings were conducted on the day of intake.
Corrective Action:
	The Suicide Screening Tool (Columbia Suicide Severity Rating Scale or equivalent) will now be completed immediately upon admission for all youth age 10 and older.
	A Suicide Screening Verification Form has been added to the admission checklist, requiring both the admitting staff and on-call supervisor signatures.
	All Direct Care Supervisors and Admissions Coordinators have received retraining on suicide screening timelines and documentation procedures.
Preventive Measures:
	The Compliance Analyst will review all admission packets within 24 hours of entry to verify the presence of the suicide screening.
	Implemented an electronic admission checklist in Extended Reach that will not allow admission closure until the suicide screening field is marked complete.
Responsible Party: Hali Shofner, LCCA / Damara Johnson, Compliance Analyst
Completion Date: [Insert Completion Date]

Inspection #4085340

The suicide screening was completed the day of admission for the reviewed foster child.


summary: 748.1217(b)(15) - Admission Assessment-At admission, must include child's understanding of the placement

raw_content: There was no documentation indicating the child understand the placement in the admission assessment.

Correction Narrative:
3. §748.1217(b)(15)  Admission Assessment
Deficiency:
The admission assessment lacked documentation confirming the childs understanding of the placement.
Root Cause Analysis:
Staff conducting admissions did not document the youths verbal acknowledgment of understanding due to omission on the intake form.
Corrective Action:
	Admission Assessment forms have been revised to include a mandatory narrative section titled Childs Understanding of Placement.
	During intake, staff must now document the youths own words regarding:
o	Their reason for placement.
o	Understanding of rules and expectations.
o	Awareness of treatment goals.
	Admission staff trained on trauma-informed communication to ensure this discussion is developmentally appropriate.
Preventive Measures:
	Monthly review of three randomly selected Admission Assessments to verify compliance.
	Refresher training every six months on engaging youth in the admission process.
Responsible Party: Rachel Wyatt, Executive Director / Admissions Staff

Inspection #4085340

A narrative section was added to the Admission Assessment for children to indicate their understanding of placement. This was observed in a new foster child's admission assessment.


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

raw_content: The admission assessment did not include the additional information required for treatment services.

Correction Narrative:
4. §748.1219(1)(A)  Treatment Services Admission
Deficiency:
The admission assessment did not include a dated and signed psychiatric or psychological assessment with diagnoses.
Root Cause Analysis:
The psychiatric assessment was pending due to scheduling delays with the contracted mental health provider and was not uploaded prior to documentation submission.
Corrective Action:
	MIOWN Home has implemented a 72-hour requirement for obtaining and uploading the psychiatric or psychological evaluation for all treatment admissions.
	The Admissions Coordinator will now cross-verify with Great Hope Psychiatry or the assigned provider to ensure the evaluation is completed and signed before the service plan finalization.
	The admission packet checklist has been updated to include a verification field for psychiatric documentation.
Preventive Measures:
	Ongoing compliance audits will review all treatment-level admissions to confirm inclusion of psychiatric/psychological assessments.
	Service Planning will not proceed until the evaluation is completed, except in emergency placements, which will be flagged and followed within three business days.
Responsible Party: Hali Shofner, LCCA / Rachel Wyatt, Executive Director

Inspection #4085340

The admission assessment for a child requiring treatment services had information related to the psychological and their diagnoses. It also included supervision and behavioral requirements.


summary: 748.1331(b)(4) - Preliminary Service Plan-For child receiving treatment services, identify any issues or concerns child may have that could escalate child's behavior

raw_content:
(4) The preliminary service plan did not include information regarding the escalation of the child's behavior.
(3) The preliminary service plan did not include information on increased supervision of the child.
(2) The preliminary service plan did not include any information regarding the child's medication including side effects or treatments prescribed.

Correction Narrative:
1. §748.1331(b)(4)  Preliminary Service Plan
Deficiency:
The preliminary service plan did not include information regarding (1) escalation of the childs behavior, (2) increased supervision of the child, or (3) the childs medication, including side effects or prescribed treatments.
Root Cause Analysis:
Staff completing the preliminary service plan failed to utilize the full behavioral and medical intake information available at admission. There was a lack of cross-departmental communication between admissions, case management, and medical designees, resulting in incomplete behavioral and medication documentation within the plan.
Corrective Action:
	Case Managers and Admissions Staff have been retrained on the requirements of §748.1331(b)(4) to ensure the following are included in all Preliminary Service Plans:
o	Known behavioral triggers and escalation indicators (e.g., defiance, verbal aggression, withdrawal).
o	Any special supervision requirements, including 1:1 or line-of-sight precautions.
o	A summary of current medications, their purpose, and potential side effects as provided by the medical provider or intake documentation.
	Updated Preliminary Service Plan Template to include dedicated sections for:
o	Behavioral Escalation Risks
o	Supervision Needs
o	Medication Overview and Side Effects
	The Treatment Director or LCCA must review and sign off on all Preliminary Service Plans within 24 hours of completion to ensure completeness.
Preventive Measures:
	Added a Preliminary Service Plan Review Checklist to the Admissions Packet.
	Monthly Compliance Audits of new admissions by the Compliance Analyst to ensure behavioral and medical documentation are included.
	All staff responsible for service planning will receive quarterly refresher training on §748.1331 requirements.
Responsible Party: Rachel Wyatt, Executive Director / Hali Shofner, LCCA
Completion Date: [Insert Completion Date, e.g., November 1, 2025]

Inspection #4085340

The preliminary service plan included information about the foster child's diagnoses and how these impact supervision and behaviors.


summary: 748.1351 - Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting

raw_content: A service plan did not have team member signatures and did not have a date of implementation.

Correction Narrative:
Corrective Actions to immediately address the deficiencies:
Service Plan Correction (Completed August 29, 2025):
The plan for Daviyone was corrected to include accurate completion/implementation dates, verified child identifiers, and signature lines for all service team members.

Audit of All Current Service Plans (By September 2, 2025):
Case Management and QA staff are auditing all active youth service plans for missing dates, signatures, or errors.
Any discrepancies are being corrected, and corrected plans re-uploaded into Extended Reach.

Staff Retraining (By September 2, 2025):
Case managers and program staff involved in service planning are being retrained on §748.1351 requirements.
A Service Plan Checklist (newly implemented) must be used prior to finalizing each plan. This checklist requires verification of:
Completion date and implementation date.
All required signatures and dates.
Correct youth identifiers throughout the plan.


raw_content: The operation did not pick up detained foster children in a timely manner. The operation keeps foster children's belongings locked up.

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: 748.2953(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: Quarter 2 Emergency Behavior Intervention numbers were not submitted to licensing timely.

Correction Narrative:
1.Tracking Enhancement:
Extended Reach calendar reminders have been updated to automatically flag upcoming EBI quarterly due dates 30 days and 7 days in advance.

A compliance tracking spreadsheet will also be maintained by the Executive Director as a secondary safeguard.

2.Staff Training:
All clinical and case management staff have been retrained on the requirement that all EBI reviews must be completed at least once every 90 days per youth.

Training emphasizes documentation requirements, clinical review content, and signature protocols.

Quarter 2 EBI numbers have been uploaded to CLASS.


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

raw_content: Staff used inappropriate language to refer to a foster child's behavior.

Correction Narrative:
Corrective Actions
To immediately address this deficiency:

Staff Involved (Completed August 20, 2025):
The staff member was counseled and issued a corrective action notice.
Incident was documented in personnel records.

Training (To be completed by August 26, 2025):
All direct care staff are required to complete a refresher training on Respectful Communication and Trauma-Informed Care, including emphasis on §748.1101(b)(4)(A)(v).

Follow up inspection conducted on 9/16/25. See inspection id #4075961.


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

raw_content: Documentation pertaining to the investigations were requested on multiple occasions and never received in a timely manner.

Correction Narrative:
Training (Scheduled for August 30, 2025):

Case managers, direct care supervisors, and administrative staff will complete a refresher training on Documentation Standards and Compliance with §748.399(a).


summary: 748.2853(2) - EBI Documentation-Child's reaction to the opportunity for post discussion

raw_content: An Emergency Behavior Intervention report was reviewed and there was no documentation that a discussion with the foster child was attempted.

Category: Emergency Behavior Intervention

Correction Narrative: The operation has not had a second EBI since the first EBI report. The operation has added a segment to their online form for employees to include whether a post-EBI discussion has occurred.


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

raw_content: During walkthrough, the operation had several holes in the wall due to an altercation that occured recently

Correction Narrative: A walkthrough of the home was completed, and all holes were noted to be completely covered.


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

raw_content: During Walkthrough Inspection, expired food were found in th e freezer and fridge

Correction Narrative: During walkthrough, no expired foods or items were observed. Multiple freeze-by dates were noted to be compliant.


summary: 748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves

raw_content: During walkthrough, there were no menus posted for the operation.

Correction Narrative: During walkthrough, I asked staff to show me the May calendar for food. The calendar was observed to be compliant with standards.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: A direct care staff did not have pre-service emergency behavior intervention training.

Correction Narrative: The direct care staff observed during the inspection was compliant with EBI training requirements. Operation understands that caregivers are not in ratio without 4 hours.


summary: 748.1337(b)(2)(B) - Initial Service Plan-For treatment services, include description of the emotional, behavioral, & physical conditions that require treatment services

raw_content: Compliance plan to mitigate risk has not been submitted for this citation. A child in care's service plan does not have a description for how the operation will address treatment.


summary: 748.303(a)(7)(B) - Serious Incident- Report to parent as soon as possible, but no later than 24 hours after you become aware of child receiving ticket or citation.

raw_content: Compliance plan to mitigate risk has not been submitted for this citation. Operation did not notify CVS worker of a citation provided to a child in care.


raw_content: A child in care's service plan does not have a description for how the operation will address treatment.

Standard Number / Description: 748.1337(b)(2)(B) - Initial Service Plan-For treatment services, include description of the emotional, behavioral, & physical conditions that require treatment services


raw_content: Operation did not notify CVS worker of a citation provided to a child in care.

Standard Number / Description: 748.303(a)(7)(B) - Serious Incident- Report to parent as soon as possible, but no later than 24 hours after you become aware of child receiving ticket or citation.


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.


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: An inspection of the operation was completed. The operation did not provide documentation on how the home complies with this standard.

Correction Narrative: The operation provided documentation of completed Fire Inspections. Both homes were inspected on 1/24/2025 and both homes passed. The Fire Inspection documentation will be uploaded to the document library.


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

Deficiency Narrative: An inspection of the operation was completed. The operation did not provide documentation on how the home complies with this standard.


raw_content:
On 7/19/2024, a fire inspection was completed with the following concerns:
1. Check electrical permit for service to storage building- will check during R-4 inspection
Media closet door not accessible- complete
Occupant of the home must verify fire alarm coverage, have current codes and be the contact for alarm company.
2. Fire alarm is scheduled to be inspected the week of July 22-26.
Note for future R-4 occupancy use:
Fire alarm/ Sprinkler system will need to be upgraded to R-4 requirements if housing more than 5 residents. Sprinkler and fire
alarm plans will need to be submitted to the town for R-4 occupancy.

An extension will be provided until 9/20/2024 to allow the operation to obtain a fire inspection without corrections.


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

raw_content: A child's Initial Service Plan did not document plans to meet their medical needs.

Correction Narrative: RCCR received documentation to support medical plans are included in a child's service plan such as a plan for medical, dental, hearing and TB exams.


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

raw_content: An Initial Service Plan was not signed by the child, and there was no documentation of a refusal.

Correction Narrative: RCCR received documentation to support a initial signed service plan by the child.


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

raw_content: A Preliminary Service Plan did not address immediate supervision needs.

Correction Narrative: RCCR received documentation to support supervision needs were included in a child's preliminary service plan by stating the child will have 1:2 supervision ratio.


summary: 748.3001(a) - Sanitation Inspection-State or local sanitation official must conduct a sanitation inspection

raw_content: Health Inspection was not completed at the operation's new location.

Correction Narrative: RCCR received documentation via email to support a sanitation health inspection was completed at the operation on 7/5/2024.


raw_content: On 06/28/2024 a fire inspection was performed.  3 violations were noted, and the inspection failed due to 1. not having 7 or fewer children, 2. access to water heater blocked. 3. fire extinguishers are not mounted 4. fire escape plan not written 5. electric systems not in good condition 6. garage storage is not in compliance.


summary: 748.3603(d) - Swimming-Outdoor pools must be enclosed with a 6-foot fence/wall that prevents children's access to the pool

raw_content: The operation's pool is not enclosed.

Deficiency Narrative: The operation's pool is not enclosed.

Correction Narrative: Operation has a 6ft fence enclosing the pool. There are sand bags holding the fence down on the inside/outisde of fence and a lock on the fence to prevent access to the pool.


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

raw_content: Documentation was received to support a fire inspection was requested, however the fire inspections are delayed per the fire department.

Correction Narrative: The operation received a fire inspection. Fire inspection documentation was received.


summary: 748.3603(i) - Swimming-When a fence is made of horizontal & vertical slats, the horizontal slats must be located on the swimming pool side of the fence

raw_content: This standard was not in compliance during the inspection.

Correction Narrative: The operation has purchased a 6ft fence and it is currently installed.


summary: 748.3603(j) - Doors from operation leading to pool area must have lock that can only be opened by adult unless lock violates fire code and documentation is on file

raw_content: The door leading to the pool from the dining room can be opened by a teen and the sensor was not on.

Correction Narrative: The operation provided a documentation from the fire department stating the back exit door can not have a lock or be blocked.


Standard Number / Description: 748.3603(j) - Doors from operation leading to pool area must have lock that can only be opened by adult unless lock violates fire code and documentation is on file

Deficiency Narrative: The door leading to the pool from the dining room can be opened by a teen and the sensor was not on.


raw_content: The inspection form was not provided upon inspection.

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


Standard Number / Description: 748.3603(i) - Swimming-When a fence is made of horizontal & vertical slats, the horizontal slats must be located on the swimming pool side of the fence

Deficiency Narrative: This standard was not in compliance during the inspection.


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

Deficiency Narrative: The inspection form was not provided upon inspection.

Correction Narrative: A gas inspection was completed on March 5, 2024. At that time a gas leak was identified and an estimate to correct the leak was provided.


Standard Number / Description: 748.3603(d) - Swimming-Outdoor pools must be enclosed with a 6-foot fence/wall that prevents children's access to the pool


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

raw_content: The admission assessment does not document the known contraindications for the child in care.

Correction Narrative: A compliance plan was not received by the compliance date. An email was sent to the administrator to send compliance plan by the end of the day, 4/15/2024. The operation submitted documentation with "N/A" listed for known contraindications.


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

raw_content: The certificate for EBI training does not document the training hours.

Correction Narrative: A compliance plan was not received by the compliance date. An email was sent to the administrator to send compliance plan by the end of the day, 4/15/2024. The operation sent updated EBI record with training hours.


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

raw_content: A child in care did not receive medication as instructed for 2 days.


raw_content: Last approved fire inspection was June 2022.


raw_content: The swimming pool fence has slats towards the opposite side of the pool.


raw_content: The operation's pool is not enclosed by a 6 ft fence.


Deficiency Narrative: The swimming pool fence has slats towards the opposite side of the pool.


Deficiency Narrative: The operation's pool is not enclosed by a 6 ft fence.


Deficiency Narrative: Last approved fire inspection was June 2022.


raw_content: Last approved gas inspection was  04/23/2021.

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


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

raw_content: During inspection, an outlet was found to be missing a cover in the closet located in youth bedroom two.

Correction Narrative: During a follow up inspection the light outlet in bedroom 2 was observed to be covered.


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

raw_content: During a walkthough of the operation, the freezer was found to be missing a thermometer.

Correction Narrative: Thermometer was observed in freezer.


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

raw_content: During the investigation, it was determined that a child in care's discharge medication information was missing information on the reason the medication was prescribed and the dosage of the medication.

Correction Narrative: This standard was found compliant.


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

raw_content: During the investigation, medication logs for a child were requested from the operation on 2/2/2024 and were not provided.

Correction Narrative: The operation sent the requested medication logs via email.


summary: 748.2101(8) - Medication Storage & Destruction-remove medication of discharged/deceased child immediately & destroy in way that ensures children do not have access

raw_content: During the investigation, it was determined that there were two children discharged from the facility who currently had their medications present at MiOwn home.

Correction Narrative: This standard was compliant at inspection.


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

raw_content: The operation does not have an Administrator.

Correction Narrative: Regulations verified through the internal portal that the assigned administrator completed the exam on 10/20/23.


raw_content: Administrator position is vacant.

Standard Number / Description: 748.153(3)(A) - Notification - Change in child-care administrator

Deficiency Narrative: Administrator position is vacant.

Correction Narrative: A person was hired to fill the position.


summary: 748.3603(e) - Swimming-Doors, operable windows, or gates of living quarters must not be part of the pool enclosure for outdoor swimming pools

raw_content: Child bedroom has a door that leads to outdoor pool.

Correction Narrative:
The owner communicated via email the operation is looking for quotes for to add a pool fence. The compliance date has been updated to 8/15/2023. During an inspection on 9/27/23 RCCR observed the bedroom leading to the pool is no longer being used as a bedroom. The room is currently being used as storage.

Contact was made with R.Wyatt on 8/31/2023. Due to a lack of notification or updates pertaining to the installation of pool fence the operation was recited. During the contact it was discussed that a new compliance date will be issued to ensure the operation has mitigated risk. Compliance date is set for 9/15/2023.

A follow up inspection was completed on 9/27/23. During the inspection RCCR observed the bedroom with access to the pool as being locked. The operation has removed all children from the room. The room is currently being used as clothing storage.


summary: 748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059

raw_content: 2 of 2 staff files did not have Licensing Affidavit for Applicants for Employment form.


raw_content:
The fence surrounding the pool is not
in compliance. The slats are facing
outside of the property.


summary: 748.2051(3) - Medication Self-Administration-Must consult health-care professional who prescribed medication and document his/her concerns in child's record

raw_content: The documentation from the child's doctor that was provided expired in 07/16/2020 and the other form that was also provided was dated on 08/22/2022.

Correction Narrative: A compliance plan was received from Rachel Wyatt via email. In regard to standard 748.2051(3) Case Manager's and LCCA at MIOWN HOME will ensure that all documentation will be updated monthly during the audit of clients records.


summary: 748.2051(2) - Medication Self-Administration-Self-medication program must be in the child's service plan & include requirements for caregiver supervision

raw_content: The service plan did not address the requirements for a child that self medicates.

Correction Narrative: A compliance plan was received from Rachel Wyatt via email. In regard to standard 748.2051(2) Case Manager's and LCCA at MIOWN HOME will ensure the administration of self-medication is provide in the service plan for each clients files that qualify.


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

raw_content: There was prescription medication not locked up and assessable to children.  It was locked up at inspection.


raw_content: Copy of the unauthorized absence annual log was requested but never received. Multiple requests were made via phone call and emails.

Standard Number / Description: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction

Correction Narrative: The operation submitted a copy of the annual review log.


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

raw_content: Operation failed to notify Statewide Intake about this incident until four days after the incident had occurred.

Correction Narrative: Please Note: RCCR Inspector, is not requiring follow up as this deficiency is a result of the director failing to follow her own policy that she has instituted at the operation to contact Statewide Intake regarding any serious incidents. Staff at the operation has been trained to call in serious incidents. Director failed to follow proper protocol in reporting incident.


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

raw_content: MiOwn home notified that the Administrator's position was vacant on 12/31/21. On 03/09/2022 a deficiency for the Administrator vacancy was issued. 30 days was provided to obtain compliance. On 04/06/2022 the operation submitted a variance for standard number 748.533(a)(5). On 05/05/2022 the variance was denied. The operation has not obtained an Administrator.

Correction Narrative: Operation has new administrator who meets required qualifications. Administrator has been added to controlling person list and is listed in CLASS as active administrator. Administrator will start on 06/06/2022


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

raw_content: A review of an employee file showed that file did not have required mandatory drug screening.

Correction Narrative: Operation provided a copy of required Drug Screening to bring employee into compliance with required standard


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: A review of an employee file did not have a cleared tuberculosis screening

Correction Narrative: Operation provided a copy of required TB Screening to bring employee in compliance with Standard


raw_content: MiOwn home notified that their Administrator's position was vacant on 12/31/21.

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


raw_content: During a review of an employee file, it was discovered that a contract employee who was then subsequently hired as a regular employee failed to have a required drug test prior to starting to work at the operation

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

Correction Narrative: Operation submitted drug test results for employee to meet compliance.


summary: HRC42.063(a) - Reporting Incidents and Violations that threaten or impair the basic health, safety or well-being of a child

raw_content: During an investigation at your operation it was discovered that a resident was able to get on the roof and no incident report was documented by your operation as required.

Correction Narrative: Follow-up by RCCR Inspector was completed on 1/24/22.  The operation provided signed in sheets as well to verify that they went over reporting incident.  The operation has a policy in place for reporting incidents and forwarded the policy to licensing.  The operation stated that they went over reporting requirements with all staff. All room were moved to the first floor of the facilty


summary: 748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child

raw_content: A review of a EBI incident at the operation did not show documentation of a post discussion with child care staff

Correction Narrative: Operation submitted revised report showing that the post discussing required did not take place due to the OV being placed in police custody.


raw_content: A review of medication indicated that a child in care is able to administer his own medication and keep the medication with him at all times. Documentation from a medical provider is needed

Standard Number / Description: 748.2051(3) - Medication Self-Administration-Must consult health-care professional who prescribed medication and document his/her concerns in child's record

Correction Narrative: Operation submitted updated policy to ensure that any youth who has to take self administered medication will have documentation prior from a health care provider as well as documentation in child file. The child associated to this deficiency was discharge.


summary: 748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded

raw_content: A review of a child file were EBI was administered did not record the length of time child was in the restraint

Correction Narrative: Operation submitted updated EBI report outlining the length of time child was in restraint


summary: 748.103(b)(7) - Policies and procedures to submit - discipline

raw_content: The discipline procedures does not prohibit the use of threatening corporal punishment.

Category: Organization and Administration

Correction Narrative:
Updates were included to add a.	Staff may never use or threaten to use corporal punishment with any youth in care. Corporal punishment is the infliction of physical pain on any part of a
youth's body as a means of controlling or managing the youth's behavior.