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

raw_content: A child went on a walk around 5pm and didn't return during the typical 1 hour timeframe. The unauthorized absence was not reported until 4:15am.

Correction Narrative: An email was received from the Hemple Shelter stating that all employees have been retrained on Reporting Serious Incidents with emphasis on Unauthorized Absence of a Child in Care. If a child has a runaway history the report will be made within 2 hours. All other reports will be made according to minimum standards. The steps below will be followed: 1. Call local law enforcement 2. Call the DFPS Hotline 3. The case manager will notify the case worker and placement agency 4. The administrator will notify The Hemple Shelter Licensing Representative. The administrative team to include the LCCA Ms. Chidinma Ndukwe and Case Manager Erma Harper will ensure that compliance is met


state: TX

facility_name: The Hemple Shelter LLC

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

raw_content: During the inspection, it was discovered that a former employee has not been employed at the operation for three months, but has yet to be inactivated.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: Inspector contacted operation via email and telephone. Operation inactivated the subject who was no longer employed on 5/4/2023, the same day of the citation. The operation is in compliance via background checks. A designated operation staff member will be in charge of inactivating subjects who are no longer employed within 3 days of their departure. The operation's plan is to not wait 7 days to inactivate unemployed subjects, thus the operation will inactivate the subjects within 3 days to ensure compliance will always be met via background check in the future.


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

raw_content: The medication logs are pre-filled with the date, time, amount given and amount remaining, when it should be a cumulative record written as medication is given. The medication log was not updated within two hours of the scheduled dose, after a child was admitted to the hospital.

Standard Risk Level: Medium High

Correction Narrative:
The Hemple Shelter Licensed Administrator submitted a revised copy of the child's medication log providing a specific narrative related to why the child was not administered medication reflecting on medication log. The child's medication log now provides a reason of the child not being administered medication due to being hospitalized on the indicated dates.
Additionally, LCCA submitted a revised copy of the operation's medication log in which a time change column was added to the medication log to ensure if the child's medication was not administered at the pre-filled time on the log, the pharmacy technician can adjust the time when the medication was actually administered to the child.
LCCA reported the operation has a pharmacy technician who specifically frequents the operation to administer medication at certain times of the day which times of medication administration is indicated on medication log.

LCCA reported she will continue to ensure that medications are properly administered to children in care.  In addition, LCCA reported she will review medication logs to ensure the pharmacy technician documents the reason a child has not been administered medication, such as, due to hospitalization.


summary: 748.1101(b)(5)(B) - Child rights-participate in service plan within child's ability to manage info and have copy of plan Child 14 yo or older right to review/sign plan

raw_content: The child's service plan is not signed by the child, nor is there notes advising the child's desire/inability to not sign.

Correction Narrative:
Licensed Administrator submitted a revised copy of the child's service plan indicating the child's inability to sign the service plan.
Administrator reported that moving forward if a child in care is unable to sign the ISP, the reason will be indicated on the service plan.  Administrator reported she will oversee this process by doublechecking to ensure signatures for each person is reflected on the service plan.


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

raw_content: Staff file show that staff took medication and trauma informed care trainings late.

Correction Narrative:
Licensed Administrator reported she will implement mandatory training for all staff will commence at the same time in January every year regardless of the hire date.  LCCA reported she will oversee this process.
Additionally, LCCA reported the operation utilizes the recently launched DFPS training hub in which each employee is notified via email for upcoming trainings.


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

raw_content: One of one child records reviewed found that a child was admitted to care on 05/12/22, but a 72 hour service plan was not completed until 05/16/22.

Standard Risk Level: Medium Low

Correction Narrative: Corrective Action    Since, we are now RTC, we will schedule placement to where it falls within 72 hours during the weekdays, but if the 72 hours of admission approaches into the weekend, a backup person will be available to complete it. Also, the LCCA will oversee this process.


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

raw_content: The toilet seat in the bathroom upstairs was broken.  There was a hole in the laundry room door.  There was a missing smoke detector in the upstairs bedroom.

Category: Physical Site

Correction Narrative: Photographs of the repaired toilet seat, repaired door, and smoke detector were provided.  Photographs are uploaded in the digital storage.


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

raw_content: Two out of three child's files reviewed did not have an initial service plan in their files.

Category: Admission, Service Planning, Discharge

Correction Narrative: The two child's updated service plans were provided via email.  The service plans will be uploaded into the digital storage.


facility_name: Royal Oaks Residential Treatment Center LLC

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

raw_content: One out of three employee files reviewed included documentation for a prior TB skin test that was indicated as expired and was not completed while the employee worked for a regulated child-care operation within the previous 12 months.

Correction Narrative: An email was sent on 12/15/23 with a current TB-Skin test for the staff


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

raw_content: A child in care was allowed to carry their own medication outside of the operation. The child has attempted to administer more medication than needed before they administered too medication to themselves.

Correction Narrative: An interview was conducted with direct care staff who was directly involved in the incident who explained the administration of medication process.


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

raw_content: Both child admission assessments were missing the child's religion.

Corrected at Inspection: Yes


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

raw_content: During the review the count of medication was missing.

Category: Medication

Correction Narrative: The operation provided the corrected information.


summary: 748.1331(b)(1) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate treatment and care needs

raw_content: The preliminary service plan is missing needs of treatment and care. childs immediate educational, medical, and dental needs, including possible side effects of medications or treatment prescribed to the child. A description of how you will meet the childs needs, including any necessary increased supervision or follow-up actions of possible side effects of medication or treatment provided to the child. The identification of any issues or concerns the child may have that could escalate a childs behavior. A designation of who will be responsible for meeting each of the childs needs.


summary: 748.115(5) - Discipline policy - Include a statement that discipline of any type is not allowable for infants

raw_content: During the review the policy was missing.

Category: Organization and Administration


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

raw_content: Policy is missing the age range of the children.


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

raw_content: The report is missing location information.

Category: Reports and Record Keeping


summary: 748.1209(b)(1) - Child Orientation-Include policies on visitation, including family visitation & overnight visitation

raw_content: Orientation is missing information about gifts and discipline. How to make complaints to outside agencies (Abuse Neglect Hotline, Ombudsman) and contact parties to a childs case (i.e. caseworker, attorney ad litem, guardian ad litem, CASA worker, etc.).


summary: 748.119(1) - Volunteer policy - Include job descriptions and/or responsibilities for the volunteers

raw_content: Policy is missing job description, responsibilities, qualifications, screening, orientation, training, supervision and contact with children.


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

raw_content: Admission Assessment is missing the initial evaluation of the appropriate placement for a child. Description of the childs behavior, including appropriate and maladaptive behavior, and any high-risk behavior. Any history of trauma.


summary: 748.1217(c)(3) - Admission Assessment-Prior to initial service plan, add child's birth and neonatal history

raw_content: Admission Assessment is missing birth and neonatal history. The services you plan to provide to the child, including long-range goals of placement. Recommendations for any further assessments and testing. A recommended behavior management plan.  A determination of whether and how you can meet the needs of the child based on an evaluation of the childs special strengths and needs.

Standard Risk Level: Low


summary: 748.115(1) - Discipline policy - Guide caregivers and employees in the methods used for discipline of children

raw_content: Reviewed files, things are missing.

Deficiency Narrative: Reviewed files, things are missing.


summary: 748.453(a)(4) - Unauthorized AbsenceAnnual summary log must include name of caregiver responsible for child at time absence discovered

raw_content: Log is missing a place for the name of caregiver responsible for child at time absence discovered.


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

raw_content: Log is missing debriefing form.

Deficiency Narrative: Log is missing debriefing form.


summary: 748.1205(a)(2) - Admission Documentation-Includes court orders establishing who is the managing conservator for the child, if applicable

raw_content: Admission is missing the primary caregivers for the child, any person with whom the child is allowed to leave the operation, and any other individual who has the legal authority to consent to the childs medical care. The names, addresses, and telephone numbers of siblings. The childs immunization record (a spot that it was received). Chronic health conditions. Known contraindications to the use of restraint.  Identification of the childs high-risk behaviors, if applicable, and the safety plan staff and caregivers will implement related to the behaviors.


summary: 748.1205(a)(13) - Include any risk factors/warning signs and safety plan staff/caregivers will implement related to the risk factors and warning signs

raw_content:
Admission is missing information about risk factors/warning signs and safety plans. If a suicide risk screening is required at admission and the child is screened as having a high or potential risk of suicide: (A)The identification of any risk factors or warning signs of suicide, if
applicable (B)The safety plan staff and caregivers will implement related to the risk factors and warning signs. The results of the suicide screening at admission, if required.

Standard Risk Level: High


facility_name: In His Hands Children Home

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 and weather drill forms include the date, type, and length of evacuation, but no actual time that the drills took place.

Category: Safety and Emergency Practices


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

raw_content: During the inspection, I observed one of four childrens medication records reflected the operation failed to administer the second dose of a medication prescribed for administration twice daily.

Correction Narrative: All staff members were retrained on the importance of accurate medication documentation. All staff signatures for this training were obtained and included in the corrections received.


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: Upon review of 2 employees files it was found that both employees completed the required TB test after their start date with the operation.

Category: Personnel

Correction Narrative: Administrator is now aware of the TB tests need to be completed prior to staff being around children.  Their personnel files have been updated, and IHH will do better moving forward with TB testing.


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

raw_content: One child's medication record did not include the reason for prescribing the medication.


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

raw_content: During the inspection, we observed 4 of 4 job descriptions that lacked documentation of position-required qualifications.

Correction Narrative: Candice Roberts, administrator, has updated all job descriptions to include Position-required qualifications.  See document library for new descriptions added.


summary: 748.363(9) - Personnel records - Include a statement signed and dated by the employee that he has read a copy of the operational policies.

raw_content: During the inspection, I observed 4 of 4 employee records reviewed lacked a statement signed by the employee acknowledging having read the operation Policies and Procedures.

Correction Narrative: All employees at In His Hands have now read and signed acknowledgement of reading and understanding the policies and procedures at this operation.


summary: 748.1439(b)(4) - Discharge Documentation-Send copy of assessments and/or evaluations you performed to next placement/caregiver within 15 days

raw_content: No assessments or evaluations were given to the worker when the child was discharged.

Correction Narrative: The form reviewed was completed, and new guidelines were entered into a new form for the operation to complete each time a child is discharged.  This will be in effect moving forward.  See document library.


summary: 748.1439(b)(2) - Discharge Documentation-Send copy of child's background info, including progress notes for past 60 days, to next placement/caregiver within 15 days

raw_content: No background information or progress notes were given to the worker at discharged (or no documentation of it.


summary: 748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge

raw_content: No services, accomplishments, or assessments were included in discharge paperwork


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

raw_content: A child was injured at school and taken to er the following day with a fracture.  This should have been called into SWI

Correction Narrative: An overall Serious Incident Reporting form was compiled and reviewed with staff - all incidents requiring a SWI report were reviewed and questions were taken. See document library.


summary: 748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing

raw_content: The fire extinguishers need to be serviced annually.

Correction Narrative: On this date, pictures of all fire extinguishers were sent in, as the fire Marshall was able to service all the overdue extinguishers.


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

raw_content: A child's medication record was missing pill counts for three days. Counts need to be entered within 2 hours after administration.

Correction Narrative: A training with all staff on the afternoon of this Monitoring inspection was conducted with a thorough review on medication counts, that all blanks on the for need to be filled out entirely, etc. Bullet points are in document library.


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

raw_content: During the inspection, I observed two of four employee files showed TB test completed outside the 30 day window from date of employment or starting to volunteer at the operation.

Correction Narrative: The operation offered a written plan stating that the hiring/training process now requires proof of TB test being provided within the first two weeks of the process.  This brings this standard into compliance.


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

raw_content: During the walkthrough, I observed three over the counter medication logs lacked the time the medicine was administered.

Correction Narrative: The operation provided proof that the medication log was updated to more clearly express the intent that date and time both be recorded, and staff received training with regards to this expectation. This brings this standard into compliance.


summary: 748.363(1) - Personnel records-Include date of employment

raw_content: During the inspection, I observed that three of the four employee files reviewed lacked documentation showing the date of employment for the individual.

Correction Narrative: The operation provided pictures demonstrating that the dates of employment were added to existing files.  They have added a start date field to the front page of their employee records to record this information for future hires.   This brings this standard into compliance.


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

raw_content: During the walkthrough, I witnessed a child in care holding an applicator of over-the-counter medication she spilled on her blanket with no caregiver within auditory or visual range of the child.


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

raw_content: The administrator's license expired on 12/14/23, and his renewal packet was submitted on 12/16/23, bringing the standard back into compliance on that date.

Correction Narrative: The operation emailed me on 12/16/23 indicating that the renewal packet had been submitted.  This was verified with the appropriate licensing representative.


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

raw_content: During the inspection, I observed that one of the four employee records reviewed lacked a copy of the employees' proof of educational level or equivalency.

Correction Narrative: On 11/20/23, the operation provided photographic proof of obtaining the missing educational record and noted that the document would be entered into the employee's file today.  This brings this standard into compliance.


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

raw_content: During the walkthrough, I observed cleaning chemicals and lice treatments stored in an unlocked cabinet in the kitchen, accessible to children. The operation relocated these chemicals to a secured location.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location

raw_content: During the inspection, I observed that three of the four records reviewed did not have allergy information clearly identified in the file or on the outside of the record.

Correction Narrative: During the exit, the operation indicated that they would be updating their files to place the data sheet containing allergy information on the outside of the files.  On 10/24/23, the operation provided a picture of the updated allergy sheets now attached to the outside of the file. This picture is located in Document Library.


summary: 748.153(3)(C) - Notification - Remove controlling person

raw_content: During the inspection, the operation identified three individuals that ceased to be controlling persons on 10/17/23 that were not reported to licensing within the timeframe.

Correction Narrative: On 10/24/23, the operation emailed the RCCR representative notifying licensing that they removed the identified individuals from the controlling persons list.  This brings this standard into compliance.


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content: During the inspection, I observed that the administrator was not present and does maintain daily supervision and oversight of the operation.

Correction Narrative: The operation issued the following statement regarding this standard via email: Please note that in regard to the administrator responsibility standard, we will be requesting an administrative review. Dr. Steward will continue with administrative oversight; his oversight includes days and overnights and weekends as we are a 24-hour facility so is his supervision. I staffed this with my supervisor, and was advised to accept this statement as compliant.


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

raw_content: During the walkthrough, I observed that the med log for the only child taking prescription medications did not record the name of the prescribing doctor nor the reason for the prescription.

Correction Narrative: On 10/24/23, the operation sent photographs of the corrected medication log that now includes the reason for prescription and the prescribing doctor.  This picture has been uploaded to Document Library.  This brings this standard into compliance.


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: During the inspection, I observed that one of the records reviewed did not have record of the Child's rights form in the file.

Category: Children's Rights

Correction Narrative: The operation provided an emailed copy of the located Child's Right's form in question and included it in the child's file.  This brings this standard into compliance.


summary: 748.533(a)(5) - Child-care administrator-Can be administrator for two operations if the Operations are contiguous

raw_content: In review of the operation records, I observed that the administrator for the operation is also the administrator for another non-contiguous General Residential Operation in another region.

Correction Narrative: On8/25/23, the administrator provided a copy of the email sent to his RCCR rep for the second GRO over which he was the administrator notifying them that he was no longer the administrator of that operation effective 8/21/23 and identifying the new administrator.  This results in the administrator only being the LCCA at this single operation and brings this standard into compliance.


raw_content: During the inspection, I observed that three of the fire extinguishers in the operation have not been inspected or serviced by a fire marshall or qualified entity within the past twelve months.

Standard Number / Description: 748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing

Correction Narrative: On 7/31/23, the operation provided photographic proof of the fire extinguishers in the operation having been serviced in July of 2023.  This brings this standard into compliance.  This follow-up method is labeled email to reflect the digital transmission method and copies of the photos are available in digital storage.


raw_content: During the inspection, I observed that one of four employee files lacked proof of Tuberculosis screening completed within 30 days of initiating employment.

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

Correction Narrative: On 4/28/23, the operation provided a copy of the TB test missing from the employee file via text message.  The follow-up method for this standard is shown as email to reflect the digital transmission method.  This brings this standard into compliance.


summary: 748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy

raw_content: During the inspection, I observed three bedrooms that lacked curtains over the windows allowing shade for rest.

Correction Narrative: On 4/28/23, the operation provided photos via text showing the properly installed curtains in the bedrooms that adequately provide privacy and shade for rest.  This follow-up method is being shown as email to reflect the digital transmission method.  These corrections bring this standard into compliance.


summary: 748.343(2)(B) - Records protection policies - Clarify persons outside operation authorized by law to access records

raw_content: In reviewing the policies and procedures, I observed that the policies do not specify the individuals outside of the operation with access to records.

Correction Narrative: On 2/21/23, the operation provided, via email, an updated policy manual including this information.  This brings this standard into compliance.


summary: 748.345(5) - Electronic records policies - Limit access to persons within operation authorized to view specific information in file

raw_content: In reviewing the policies and procedures, I observed the lack of a policy limiting access to the operation's files to persons within the operation authorized to access and see specific information in an electronic file.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including this information.  This brings this standard into compliance.


summary: 748.3273(7) - First Aid Kits-Each one must contain sterile gauze pads

raw_content: During the inspection, I observed that the first aid kits lacked scissors, adhesive tape, and thermometers.

Correction Narrative: On 2/10/23, the operation emailed photos of the first aid kits containing the missing contents.  This brings this standard into compliance.


summary: 748.113(9)(A) - A person for filing a complaint, presenting grievance, or providing information relating to the misuse of EBI at the operation

raw_content: In reviewing the policies and procedures, I observed that the EBI policies lack a prohibition against retaliation toward an individual for filing a complaint, presenting a grievance, or otherwise providing information about the misuse of emergency behavior interventions at the operation.


summary: 748.113(2) - EBI policy - the specific techniques that caregivers can use

raw_content: In reviewing the policies and procedures, I observed that the EBI policies do not list specific techniques approved for use by caregivers and the general descriptions do not match what was identified on the application.


summary: 748.109(1) - Admission Policies - Include program's goals and services provided, including whether emergency admissions accepted

raw_content: In reviewing the policies and procedures, I observed that the admission policies do not specify whether the operation accepts emergency placements.  The document states they will accept placement as needs arise for children.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including an explicit statement that the operation will accept emergency placements.  This brings this standard into compliance.


summary: 748.343(2)(A) - Records protection policies - Clarify persons within operation authorized to access records

raw_content: In reviewing the policies and procedures, I observed that the policies do not specify the individuals within the operation with access to records.


summary: 748.111(1) - Child-care policy - Describes visitation

raw_content: In reviewing the policies and procedures, I observed that the visitation rights policies do not include policies for visitation between the children and friends.  Dating is covered, but visitation with friends is absent.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including additions pertaining to friend visitation and the parameters for those visits.  This brings this standard into compliance.


summary: 748.345(1) - Electronic records policies - What records must be in external paper file and those that can be stored in electronic file

raw_content: In reviewing the policies and procedures, I observed the lack of a policy specifying which records must be in external paper files and those that can be stored electronically.


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

raw_content: In reviewing the policies and procedures, I observed that the admission policies state they will admit without regard to sex; however, the operation is only applying to provide services for girls.  The policies and procedures include parameters for Primary Medical Needs children, but the operation is not applying to provide such services.  The admission policies do not state that they do not take Primary Medical Needs or emotional disturbance.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including specific clarification that the operation will only serve girls under the current parameters.  This brings this standard into compliance.


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, it was observed that a refrigerator in the kitchen lacked a thermometer.

Correction Narrative: On 2/15/23, the operation provided, via email, photos of the thermometers in all refrigerator units in the facility.  The follow-up method is being shown as email due to the digital conveyance of the documentation.  This brings this standard into compliance.


summary: 748.111(13) - Child-care policy - Types and frequency of reports to parents

raw_content: In reviewing the policies and procedures, I observed the frequency of reports to parents is not specified.  The policy mentions regular reports but does not specify frequency.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including a statement that these reports will be provided at least monthly.  This brings this standard into compliance.


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: During the inspection, I observed that three of the four employee files reviewed lacked proof of TB test.

Correction Narrative: On 2/15/23, the operation provided, via email, a copy of the negative TB tests for the reviewed files.  This brings this standard into compliance.


summary: 748.113(3) - EBI policy - the qualifications for caregivers who assume the responsibility for EBI implementation

raw_content: In reviewing the policies and procedures, I observed that the EBI policies state that only qualified caregivers can administer EBI, but the policy does not specify the training requirements or criteria by which a caregiver is deemed qualified.


summary: 748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements

raw_content: In reviewing the policies and procedures, I observed that the background check policies do not specify the types of background checks applicable to the various positions employed by the facility.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including clarification of background check expectations with specific reference to the required types of background checks applicable.  This brings this standard into compliance.


summary: 748.113(9)(B) - EBI policy - A child/adult client/resident because someone on behalf of the client files a complaint, provides information relating to misuse of EBI

raw_content: In reviewing the policies and procedures, I observed that the EBI policies do not include a prohibition against retaliating against an individual for filing a complaint, grievance, or providing good-faith information regarding the misuse of emergency behavior intervention on behalf of another individual.


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

raw_content: During the walkthrough, I observed the window in the kitchen that would be used to ventilate in case of smoke not having a screen.

Correction Narrative: On 2/10/23, the operation provided, via email, photos of the window with a proper screen installed. The follow up method is listed as email to account for the digital, point to point, conveyance of the images.   This brings this standard into compliance.


summary: 748.113(6) - EBI Policy - Post EBIs permitted at your operation viewable to children/clients and provide them with a personal copy of EBI policies

raw_content: In reviewing the policies and procedures, I observed a lack of policies specifying the posting of EBI practices where they can be viewed by children and adults or policies related to providing the clients with copies of the operation's emergency behavior intervention policies.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including a statement that EBI information will be posted.  This brings this standard into compliance.


summary: 748.3271(3) - First Aid Kits-Each one must be in good condition and not have expired medications or supplies

raw_content: During the inspection, I observed that the first aide kits reviewed contained several expired medications or supplies.

Correction Narrative: On 2/10/23, the operation provided images of the expiration dates within the first aid kits via text and these were in date.  She reported that the expired first aid kits thrown away.  The follow up method is listed as email to account for the digital, point to point, conveyance of the images.  This brings this standard into compliance.


summary: 748.113(8) - EBI policy - Training for emergency behavior intervention

raw_content: In reviewing the policies and procedures, I observed a lack of policies specifying the Emergency Behavior Intervention training requirements, the curriculum that will be utilized, the amount and type of training required, training content, and how the training will be delivered.


summary: 748.363(3) - Personnel records-Include current job description

raw_content: During the inspection, I observed two of the four personnel records lacking current job descriptions.

Correction Narrative: On 2/10/23, the operation emailed me current job descriptions for the two personnel records lacking them during the inspection.  This brings this standard into compliance.


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

raw_content: During the inspection, I observed that two of the four personnel files reviewed lacked drug testing results in accordance with the operation's policies.

Correction Narrative: On 2/10/23, the operation texted me images of the clear drug tests for the two files cited missing at the inspection.  The follow up method is shown as email to account for the digital transmission of the information.  This brings this standard into compliance.


summary: 748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees

raw_content: In reviewing the policies and procedures, I observed that the personnel policies do not contain policies specifying the training requirements for employees and caregivers.


summary: 748.345(3) - Electronic records policies - Requirements for routine back-up of data

raw_content: In reviewing the policies and procedures, I observed that the lack of a policy addressing the requirements for routine back-up of data.


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

raw_content: In reviewing the policies and procedures, I observed that the EBI policies list a number of EBI procedures that do not match the EBI procedures listed on the application.  The EBI description is not specific to the EBI system used.


summary: 748.105(1) - Personnel Policies - Develop a written organizational chart showing administrative/professional/staffing structures and lines of authority

raw_content: In reviewing the policies and procedures, I observed that the organizational chart does not label and specify the supervisory relationships between each tier of employee.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including a clarified flow-chart specifying the supervisory relationship of the positions at the facility.  This brings this standard into compliance.


summary: 748.343(1) - Records protection policies - how paper and electronic records will be protected from destruction and loss

raw_content: In reviewing the policies and procedures, I observed the lack of a policy specifying plans for protection of paper or electronic records from destruction or loss.


summary: 748.101(3) - Plans to submit - sketch of operation's floor plan

raw_content: In reviewing the policies and procedures, I observed that the floor plan provided identifies rooms marked as bedrooms, but does not specify where caregivers and children will be sleeping respectively.

Correction Narrative: On 2/9/23, the operation emailed me a copy of the updated floor plan clearly identifying which rooms are intended to be resident rooms versus caregiver quarters.  This brings this standard into compliance.


summary: 748.119(3) - Volunteer policy - Address orientation and training programs for the volunteers

raw_content: In reviewing the policies and procedures, I observed that the volunteer policies do not specify the training requirements for volunteers.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including clarification on the training expectations for volunteers.  This brings this standard into compliance.


summary: 748.345(4) - Electronic records policies - Anti-virus protection systems

raw_content: In reviewing the documentation, I observed the lack of a policy addressing anti-virus protection systems.

Correction Narrative: On 2/15/23, the operation provided, via email, an updated policy manual including this information.  This brings this standard into compliance.


summary: 748.113(5)(A) - EBI policy - For orientation, explain and document to a child in a manner that the child can understand

raw_content: In reviewing the policies and procedures, I observed that the policies do not include an orientation discussion with the child regarding the Emergency Behavior Intervention policies required in 748.113(5)(A)(i-ix).

Correction Narrative: On 2/21/23, the operation provided, via email, an updated policy manual including this information.  This brings this standard into compliance.


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

raw_content: In reviewing the policies and procedures, I observed that the discipline policies do not detail how Trauma Informed Care is integrated into the care of the children.


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

raw_content: During the inspection, it was observed that four of the four personnel records reviewed lacked documentation of proof of education level for the employee.

Correction Narrative: On 2/15/23, the operation provided, via email, copies of the proof of education for each of the personnel files reviewed.  This brings this standard into compliance.


summary: 748.345(2) - Electronic records policies - Computer security systems, including confidentiality, passwords, and employee procedures

raw_content: In reviewing the policies and procedures, I observed the lack of a policy pertaining computer security systems addressing confidentiality, password protection parameters, and network access.


summary: 748.3563(c) - Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material

raw_content: During the inspection, I observed the protective surface fill to be at least two inches below the nine inch measuring mark on the equipment.

Correction Narrative: On 2/15/23, the operation provided, via email, photos verifying that additional loose fill has been added to the playground area beneath the playground equipment, and the level reaches the 9 inch demarcation points on all of the equipment.  The follow-up method is being shown as email due to the digital conveyance of the documentation.  This brings this standard into compliance.


facility_name: Boys to Men RTC

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

raw_content: An operation employee attempted to pass off a six month unauthorized absences  evaluation dated for 6/30/25 as if it had been completed on 6-30-25. Evidenced was collected to prove that the form was not completed on 6-30-25.

Correction Narrative: On 12-19-25 the director submitted a CAP for the deficiency. Management shall retrain and/or re-orient staff on preserving the integrity of documents by ensuring each document's accuracy and completeness. Management shall likewise cross-check documents to ensure completeness and accuracy before filing the same


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

raw_content: On 12-17-25 a monitoring inspection was conducted at the operation. The director restated that an Administrator has not been hired.


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

raw_content: The operation did not complite a six month anauthorized absence evaluation in June 2025.

Correction Narrative: On 12-19-25 the director submitted a CAP for the deficiency. Unauthorized Absence Evaluation meetings will be conducted and completed within a 6-months time interval, and thereafter. Said meetings shall be aptly dated and documented with each participant signing thereof.


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

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


summary: 748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation

raw_content: During the inspection, the operation's emergency evacuation diagram did not include an escape route, a meeting location outside, or a shelter in place location inside the home.

Correction Narrative: On 8/8/2025, the operation's Administrator provided an updated emergency diagram for the non-contiguous property. On 8/11/2025, the operation's Administrator provided an updated emergency diagram for the primary property.


summary: 748.3319(a) - Required Postings-Residential Treatment Center's must have "No Trespassing Signs" posted.

raw_content: During the inspection, the rtc did not have the required no trespassing signs.

Correction Narrative: On 8/11/2025, the operation's Administrator advised the "No Trespassing Signs were ordered on 08/08/2025 via the HHSCCR website.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location

raw_content: Two child records reviewed did not include documentation of known or unknown allergies on the exterior of records or in a clearly visible location.

Correction Narrative: On 7/11/2025, the operation's Administrator provided corrections via email: Moving forward, known allergies will be added to the client information placed on the front of the client binder.


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

raw_content: Schedule II psychotropic medications were observed stored in a locked cabinet inside the laundry room, which is located off the living room. This makes the medications accessible when the laundry room is in use, creating a potential safety risk.

Correction Narrative: The schedule II medication was observed behind a locked door and the second lock is in a locked file cabinet.


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

raw_content: One of the child records reviewed found the initial service plan was not completed within 45 days of placement. Additionally, service plan was not dated and signed by child, parent, caregivers, and 2 PLSP as required.

Correction Narrative: On 7/11/2025, the operation's Administrator provided corrections via email: Staff will ensure that the initial service plan is completed within 45 days of placement, as well as dated and signed by the child, caregivers, and PLSP as required.


summary: 748.125(d)(4)(C) - Suicide Screening- Must be administered every 30 days after admission for children 10 years of age or older in a residential treatment center.

raw_content: One of the child records reviewed found the suicide screening was not administered for March of 2025 as required.

Correction Narrative: On 7/11/2025, the operation's Administrator provided corrections via email: All monthly suicide screenings will be posted on the calendar and conducted on the same day of each month. Screenings will be filed ASAP.


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

raw_content: One of the child's records reviewed showed discrepancies in the medical appointment dates, with several forms listing dates that did not match the date signed by the medical provider.

Correction Narrative: On 7/11/2025, the operation's Administrator provided corrections via email: Documentation from medical appointments will be obtained on the same day. If not available the same day, a letter will be requested from the doctor's office to place in the client's file.


summary: 748.1531(a)(3) - Medical care-A child in care must receive medical care as needed for ongoing maintenance of medical health

raw_content: One of the child records reviewed did not containt documentation of a completed hearing checkup since the child's placement on 12/11/24. Additionally, the most recent vision checkup was completed in April 2025, making it two months overdue.

Category: Child Care

Correction Narrative: On 7/11/2025, the operation's Administrator provided corrections via email: Moving forward, staff have been instructed to ensure the hearing test is done at the three-day medical appointment and make sure the doctor has checked the box as well as provided feedback.


summary: 748.1217(b)(13) - Admission Assessment-At admission, must include immediate goals of placement

raw_content: One of the child records reviewed found the admission assessment and 72 hours service plan were completed 6 days after placement. Additionally, the following information was found missing from the admission assessment: -Immediate goals of placement -The child s understanding of the placement  -The parent s expectations for placement -The child s social history -A description of the child s home environment and family functioning  -The child s birth and neonatal history -The child s mental health and substance abuse history -The child s history of any other placements outside the child s home -The child s skills and special interests -The child s criminal history, if applicable

Correction Narrative: On 7/11/2025, the operation's Administrator provided corrections via email: Admission Assessment and 72 hour treatment plan will be conducted no more than 72 hours after the resident's admission by a case manager or case aid.


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

raw_content: During the ANE investigation, it was determined that a caregiver got into a physical altercation with a child in care resulting in the child receiving injuries to his face and body.

Correction Narrative: 3 of 6 children were interviewed and denied any corporal punishment or physical discipline.


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: The allegation is related to a DFPS abuse/neglect investigation.

Correction Narrative: On 7/16/2025, the operation's Director provided the following corrections via email: In response to the situation, the staff member involved was promptly removed from the facility and subsequently terminated from his direct care position. This action was taken due to his failure to adhere to the established protocols mandated by the Evidence-Based Intervention (EBI) training that he completed upon his hiring. Furthermore, Boys to Men has scheduled a comprehensive retraining session for all staff members on EBI, which will take place on July 15, 2025. In hopes of reinforcing our commitment to maintaining the highest standards of care and ensuring that all staff are fully equipped to adhere to necessary protocols.


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

raw_content: Child victim's preliminary service plan indicates he may not share a bedroom with another resident. Information obtained throughout the investigation indicates the child victim was sharing a bedroom on the day of the incident.

Correction Narrative: On 8/4/2025, the operation's Director provided the following corrections via email: The resident was relocated to a private bedroom on the same day this issue was confirmed. Effective immediately, the Administrator must review all Preliminary Service Plans before finalizing room assignments during intake. The Case Manager will now verify bedroom requirements for each resident to ensure continued compliance with service plan directives.


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

raw_content: No serious incident report regarding the incident in question was provided during the investigation.

Correction Narrative: On 8/4/2025, the operation's Director provided the following corrections via email: As of June 3, 2025, all staff were retrained on the requirements for reporting and documenting serious incidents. Updated the Serious Incident Reporting Policy to clearly define what constitutes a serious incident and the required timeline for documentation. All serious incidents must be documented using the official Serious Incident Report Form within 4 hours of the occurrence and submitted to administration the same day. Incident report audits will be conducted weekly by the Administrator to ensure full compliance. Failure to report incidents as outlined will result in progressive disciplinary action, including written warnings and potential termination.


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: Agency has not submitted their EBI data for the 1st quarter of 2025.

Correction Narrative:
Citation: Failure to Submit EBI Data by Quarterly Deadline
Facility: Boys to Men Treatment Center
Date: 4/23/25

Issue:
EBI data was not submitted to the HHSC portal by the required quarterly deadline (15th of the month), resulting in a citation.

Cause:
The requirement was misunderstood as being tied to training records.

Immediate Action:
Two staff members our Director of Operations and Administrative Assistant-are now jointly responsible for ensuring EBI data is submitted on time each quarter.

Prevention Plan:
	Deadlines added to our compliance calendar.
	Email reminders set for the 1st and 10th of each due month.
	Submissions will be verified and archived by the Director of Operations.

Responsible Staff:
	Constance Phillips, Director of Operations
	Viola Lewis, Administrative Assistant
	Oversight: Dannon Henderson, Executive Director

Monitoring:
Submission confirmations will be saved. Compliance will be reviewed during monthly administrative meetings.

Dannon Henderson
Executive Director
Boys to Men Treatment Center
3171 Roe Drive, Houston, TX 77087


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

raw_content: A child in care was given the wrong medication and there is no documentation of the medication error.

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


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

raw_content: A child in care was given the wrong medication and there is no evidence to show a health care professional was contacted.


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

raw_content: Two staff record reviewed indicated staff did not receive and/or meet the exemption of pre-service experience training.

Category: Training and Professional Development

Correction Narrative: All staff must complete all onboarding training before being placed in ratio. Also, staff being hired must have at least 40 hours of experience in an RTC setting that provides the same services.


raw_content: Scheduled II psychotropic medications were observed in an unlocked cabinet during the visit.

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


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: One staff record reviewed indicated staff did not have a cleared TB screening prior to having contact with children in care.

Correction Narrative: All new employees will be required to have their TB test completed prior to starting the shadowing and training processes.


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: One staff record reviewed indicated that thestaff member did not complet the required 8 hours of EBI training before being included in the ratio.

Correction Narrative: Moving forward, all staff will be trained in Emergency Behavioral Intervention prior to being placed in ratio.


summary: 745.509 - Licensed Operations Required Fees

raw_content: Background check fee was delinquent as of inspection date. It was due on or before 12/31/24.

Correction Narrative:
The administrator confirmed that the background check fee was paid on 12/21/24. This information was also verified online.
Corrective action plan stating that going forward, the invoice will be paid online on a monthly basis


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

raw_content: One of four child medication records reviewed was missing documentation for a medication that was given to a child for one day/date.

Correction Narrative:
A corrective action plan was sent to rccr on 05/03/2024 stating the following:
The corrective action plan for the medication error is as follows:
1. Staff Training on Medication Documentation
2. Medication Audit to be conducted weekly and turned in to LCCA for monitoring.

Staff Training sign-in sheet was obtained.


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

raw_content: A staff allowed children to violate the operation's rules by allowing the children access into one another's bedroom closet with the closet door closed. It was founded that while the children were located inside the closet the children attempted to use a vape.

Correction Narrative: An inspection was conducted at the operation on 04/23/2024, insp #3998777. In order to meet compliance the operation posted signs stating no room visiting allowed. The alleged staff is no longer employed at the operation. The director stated the staff have been instructed to conduct supervision checks every 10 minutes instead every 15 minutes. The director stated a supervision training is being held with staff on this date, 04/23/2024.


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

raw_content: Three staff records reviewed did not contain accurate/completed pre-employment screenings. (2 were missing the screenings and 1 was not completed correctly)

Correction Narrative: An email was sent to rccr from the operation staff with the required completed pre-employment screenings documents.


summary: 748.1501(d) - Dental Care-must obtain follow-up dental work recommended by the dentist

raw_content: Child in care, Aidan M., on October 3, was referred by Galaxia Dental to see an endodontist for a root canal to be completed on teeth #31 and #18. Per the recommendations, Aidan was to be prepped for the crown on the same teeth once the root canals were completed. No documentation shows that the root canals or crowns have been completed per the dentist's recommendation.

Correction Narrative: An Appointments Follow up Dates sheet has been created to ensure the operation keeps track of current and future Medical, Dental, Vision, Mental, appointments/follow-ups. For the specific case of minor a specialist has been contacted and scheduled a follow up appointment for 2/1/2024.


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: The operation office is being used to store medication for a child in care who was discharged from the operation back around November 1 or 2. The medication was found in an unlocked closet and unlocked office, which provides access and accessibility to the medication, including other children in care.

Correction Narrative: Effective immediately, a lock was installed to the closet door. In addition, BEMAG Pharmacy has been contacted to verify the pickup date for discarded medicine. They confirmed the pickup will be by the end of the month, since is the end of the quarter.


summary: 748.393(b)(4) - Active child record - Ensure record is locked and kept in a safe location or locations

raw_content: The office where active child records are stored was unlocked and provided access for anyone to enter the property and gain access to confidential information.

Correction Narrative: Effective immediately, all active staff have been instructed to keep the main doors (upstairs office and facility door) always locked when leaving the premises of the facility. A check Log has been implemented to record the times when staff check and verify the doors are locked.


summary: 748.3365(c)(1) - Bedding-must provide each child with pillow/bed linens appropriate for temperature including pillowcase, top sheet, fitted or bottom sheet

raw_content: Eight beds were observed to be missing top sheets, and two beds were missing mattress pads.


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

raw_content: The job description in one workers personnel file has the name of an employee that is not employed or listed on the person's list of the operation.

Correction Narrative: Job description with wrong name has been removed from file and the correct one has been added. All active employee files have been inspected to ensure that proper documents are filed and in compliance.


summary: 748.3109(b) - Smoke Detector-Batteries must be changed annually or sooner, as required to maintain operable smoke detector units

raw_content: The smoke detector in room 4 is flashing red and beeping.


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

raw_content: One worker is missing a job description from their personnel file.

Correction Narrative: Missing job description has been added to the employee file. All current employee files have been reviewed to ensure proper documentation is on file.


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

raw_content: Three employee's personnel files have no documentation showing their completion of the annual training.

Correction Narrative: All employees (active and onboarding) completed suicide prevention training on 11/8/2023. The training certificates were provided.


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

raw_content: The operations vehicle (Chrysler Town and Country) has expired temporary tags and no inspection sticker.

Correction Narrative: Car dealer was contacted to request a current/accurate temporary tag. Current temporary tag has been issued and properly placed on the corresponding vehicle.


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

raw_content: During an inspection at the operation it was discovered that 15 year old biological daughter of an owner of the operation resides at the operation without an initial background check being submitted.

Correction Narrative: I conducted a walkthrough of the operation. The 15-year-old biological daughter of the executive director was not observed on the operation grounds and the apartment/office on the property has been vacated by operation staff that was living in the property.


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

Category: Transportation

Deficiency Narrative: The operations vehicle (Chrysler Town and Country) has expired temporary tags and no inspection sticker.

Correction Narrative:
The Dealership has extended the
temporary registration and tags until
the permanent plates are ready for pick
up.


summary: 748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826

raw_content: Two dogs were observed on the property; however, the animal's vaccination records were not available for review.

Correction Narrative:
Documentation for rabies vaccination
for the service animals was provided.


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

raw_content: The grounds of the operations were observed to have tall grass in the front yard and multiple bags of trash were observed in front of the apartment door.

Correction Narrative:
Boys to Men has purchased additional
garbage cans to supplement for any
trash overages. A follow up inspection was conducted on 9/22/23 to confirm compliance with this standard.


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

raw_content: The deeper freezer in the kitchen does no have a thermometer to verify food is at the appropriate temperature.

Correction Narrative: The back up deep freezer immediately was given a thermometer to verify food is at the appropriate temperature. This was confirmed during a follow up inspection at the operation on 9/22/23.


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

raw_content: Insects were observed in the living quarters of children in care and around the door frame of the backdoor.

Correction Narrative:
Boys to Men has sprayed for all insects,
and has created a buildings and
grounds checklist to ensure the facility
is free of insects daily. This was confirmed during a follow up inspection at the operation on 9/22/23.


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

raw_content: In bedroom room one, the bottom bunk did not have a mattress protector. A bed skirt was being used as a mattress protector.


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

raw_content: Three out of three children records were observed to be missing.

Correction Narrative:
Boys to Men RTC administration
team has placed a checklist in place
to ensure that all residents are
provided the child's rights upon
arrival and must sign a statement
indicating that the child has read and
understands these rights. A copy of a
timely signed CPS Rights of Children
and Youth in Foster Care will meet
this standard. This signed form must
then be put in the child's record.


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

raw_content: Operation staff made changes to the operations floor plan without providing notification. The second living room is now being utilized as an office space that children in care do not have access to.

Correction Narrative:
Boys to Men will give a 15day notice in
the future of any floor plan adjustments.
Boys to Men has since changed the floor
plan back to the original plan. This was confirmed during a follow up inspection at the operation on 9/22/23.


raw_content: The operation's policies include an address unrelated to this operation. The operation's policies state the children will attend a school district that is not in the area of the operation.

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

Correction Narrative: The operation updated their address and advised that the children in care will attend school at a school district in the area of the operation.


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

raw_content: The operation does not have a full-tine administrator.

Correction Narrative: The operation hired a suitable administrator, thus compliance is now met.


summary: 748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care

raw_content: Employee record is missing the TB test, job description, and the performance evaluation.

Correction Narrative: The operation provided updated TB screening for employee and is therefore now compliant with this standard.


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

raw_content: During the inspection, it was determined that the operation's vehicle did not start properly and did not appear ready to transport children.

Correction Narrative: The operation purchased an alternate vehicle and satisfied all automobile requirements according to minimum standards. Compliance has now been met.


summary: 748.1331(b)(1) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate treatment and care needs

raw_content: The plan did not include the immediate treatment and care needs, as well as a designation of who will be responsible for the child.

Correction Narrative: The operation updated their preliminary service plan and revised all necessary portions according to minimum standards; thus compliance is now met.


summary: 748.453(a)(5) - Unauthorized AbsenceAnnual summary log must include the intake report number, if report was made to CCR or DFPS

raw_content: The form was missing a spot for reporting to Licensing. The form was also missing a spot for gender and DOA.

Correction Narrative: The operation updated their annual summary log and revised all necessary portions according to minimum standards; thus compliance is now met.


raw_content: During the inspection, it was observed that the operation's vehicle did not have a required inspection or proper vehicle registration.


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

raw_content: The policies submitted should follow the guidelines of minimum standards, but it should also be tailored to your operational needs/wants.

Correction Narrative: The operation updated their policies and procedures and revised all necessary portions according to minimum standards; thus compliance is now met.


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

raw_content: The assessment did not have a space for trauma, immediate goals, determination of how the operation will meet the needs, maladaptive behavior, birth/neonatal history, or criminal history. Also, did not see a spot for the services that will be provided to child.

Correction Narrative: The operation thoroughly updated their admission assessment and included all missing information. Compliance is now met.


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

raw_content: During the inspection, it was determined that the serious incident report did not include the address and phone number of the operation.

Correction Narrative: The operation updated their serious incident documentation forms and revised all necessary portions according to minimum standards; thus compliance is now met.


facility_name: Option House Es

summary: 748.3191 - Carbon Monoxide-Must have operable carbon monoxide detector-system if operation has gas appliances

raw_content: The Inspector conducted a walkthrough of the facility during a monitor inspection, and discovered the facility did not have a carbon monoxide detector system installed.

Correction Narrative: On 6/16/2025 the facility found to be  in compliance. A walkthrough was conducted. The facility had an operational Carbon monoxide unit installed.


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

raw_content: During an unannouced team inspection, Inspectors were unable to gain access to operation records. There was no one on site that had access to the requested records.

Correction Narrative: The Director, Reggie Harrell, stated moving forward, a spare key to the cabinets that contains the staff and children's records would be made accessible to the Option House Youth Advocate, Christain Madsen.


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 contain a date showing when it was completed.

Correction Narrative:
The Director has directed the Youth Care Workers, in writing, to properly perform the future intakes in a more detailed manner. Doing so will ensure the completeness of all intake forms being filled out correctly and, in their entirety, to reflect accurate dates and times in accordance with Minimum Standards as outlined.
The Director has also made an internal change on the form. This change will ensure the form is completed and reviewed within the allotted timeframe by Youth Care Worker performing the intake and reviewed by the Option House Director. This would prevent future occurrences to persist.


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

raw_content: While conducting interviews it was admitted to RCCL Staff that an operation staff member knowingly didn't follow operation procedures by checking to see that full authorization and permission was given for an overnight excursion. Staff member was told by the child in care they had received the proper permissions but failed to follow up with the overnight/ visit forms and ensure all permissions were given.

Correction Narrative: On 10/11/2023, Option House provided RCCL Staff with a letter of counsel for the staff member in question with a write-up and corrective action plan going forward.


summary: 748.3109(a) - Smoke Detector-Smoke detectors installed & maintained according to manufacturer's instructions or in compliance with fire inspector's instructions

raw_content: A smoke alarm in the back bedroom was chirping to indicate a low battery.


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

raw_content: There appeared to be mold in the ceiling and upper parts of the wall in the boys restroom. There was also a broken drawer on the vanity as well as sections of the edging peeled off. Multiple lightbulb were also out. The wall by the shower had multiple areas where the drywall was broken, cracked and peeling away.


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

raw_content: Part of the fence was leaning over and a section was broken and on the ground with numerous nails sticking up. There were also broken fence pieces around and other trash items in the yard area.


summary: 748.3107(a) - Smoke Detector-Must have an operable smoke-detection system that is audible throughout building

raw_content: During the physical site inspection, it was observed the girl's bedroom fire alarm was not operable or audible. The facility administrator put in a maintenance request to have it fixed.

Correction Narrative: this was corrected at this inspection


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

raw_content: An active staff members background was inactivated in 2019.


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: One employee did not have the additional 4 hours of EBI trainings for pre-service within 90 days and two files did not have all required sections of general pre-service.

Correction Narrative: Director met with Supervisor to implement changes for number of houses to be completed during orientation and complete subsequent hours prior to any Youth Care Worker being counted  in ratio.  The remaining four hours of EBI will be scheduled and complete prior to the initial ninety (90) days of employment with CTYS PAPH trainer.  Previously employed staff members will continue to receive semi annual EBI training as scheduled in June and December of each year.  Director will be more attentive in follow up of maintaining training certificates and ensure all training is both accounted for and documented on each employee training sheet.  Director will also ensure that each employee training log is updated, initialed and signed upon completion of pre-service annual 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: During a night inspection, medications showed that a child in care did not receive their three morning medications. The child also reported that they did not get their morning medications.

Correction Narrative: The Director and responsible staff member met to review and go over standards as prescribed in Minimum Standards, Subchapter L, Medications.  Staff members understand the importance of medications and the standards that are expected to be followed.  Staff member was counseled and agreed to be more responsible ensuring medication regimens are carried out and properly documented.


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

raw_content: While reviewing the video, it was observed that staff immediately put a child in a choke hold without attempting a proper restraint.

Correction Narrative: An email was received on May 12, 2022 with the operations plans.   Semiannual staff training on EBI will be held no later than June 3, 2022 for all Option House employees.  Staff members will be instructed on best practices and proper de-escalation techniques.  Emphasis will be placed on body positioning in case a takedown becomes necessary during an incident or physical altercation.  MS will be utilized as a guideline as well as the current PAPH/EBI training to be conducted simultaneously.  The staff involved in the incident is no longer employed.


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

raw_content: While reviewing the video, it was observed that children in care were helping to restrain another child in care.

Correction Narrative: An email was received on May 12, 2022 with the operations plans.  Semiannual staff training on EBI will be held no later than June 3, 2022 for all Option House employees with an emphasis placed on de-escalation and separating residents from any physical altercation.  Removing residents from the area will preclude residents from assisting staff in case a restraint becomes necessary.  Option House staff will also discuss any concerns regarding EBI, de-escalation and caregiver burn out.  There will also b e training conducted on the importance of MS and best practices. The staff involved in the incident is no longer employed.


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

raw_content: While reviewing the video, it was observed that staff initiated an inappropriate restraint prior to an emergency situation occurring.

Correction Narrative: An email was received on May 12, 2022 with the operations plans.   Semiannual staff training on EBI will be held no later than June 3, 2022 for all Option House employees.  Proper verbal de-escalation techniques, review of safety contracts and utilizing restrains as a last resort will be discussed thoroughly to prevent the need for staff member to restrain a resident.  OH does not condone the mistreatment of any resident in our care for any reason.   The staff involved in the incident is no longer employed.


summary: 748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan

raw_content: A child's supervision instructions were not followed by staff.

Correction Narrative:
1. Facility staff will ensure while auditing binders that page 8 of the service plan reflects our agency supervision policy and is also in conjunction with approved supervision guidelines by the CW provided at intake. They will ensure their internal policies are followed and intake and staff are knowledgeable of the resident's service plan. Staff will follow the policy and youth service plan when they have an unaccompanied offsite excursion.

2. Staff members will acknowledge an understanding that they provide line-of-sight supervision to include eyes on the child with appropriate documentation.  This supervision is to be expected on site at the facility, 24 hours a day, and to be included during off-site excursions when accompanied by Staff.

This requirement is in effect immediately and all staff will acknowledge and be trained to ensure compliance by 1 NOV 2021.


facility_name: Camp Worth, LLC

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: 15 year old child in care was left unsupervised in a kitchen with oil heating on in a pan on a stovetop.  A fire started that resulted in evacuation of the home.

Correction Narrative: The owner discussed that there are no staff working at the operation. The operation does not have any children and is not in operation as of 6/21/23. The staff member was fired after the incident.


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

raw_content: A caregiver did not intervene to prevent and remove harmful items a child in care used to pierce her own flesh.

Correction Narrative: The owner discussed that there are no staff working at the operation. The operation does not have any children and is not in operation as of 6/21/23.


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

raw_content: A staff person did not provide the level of supervision required for a child as indicated in the service plan.

Correction Narrative: The owner discussed that there are no staff working at the operation. The operation does not have any children and is not in operation as of 6/21/23. T


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

raw_content: The hallway floors in House 2 and House 3 had were had soft spots and uneven portions posing a trip hazard.   2 bedrooms in House 2 had a square of uneven flooring in the center of the rooms.

Correction Narrative: There are no children in care. The operation has not been in operation since 6/21/23.


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

raw_content: Medication logs observed during the inspection indicated administration of medications for a later time period.  The medications had not been administered to the 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: A child was left unattended with high-risk cooking supplies in the kitchen without staff supervision.

Correction Narrative: There are no children in care. The operation has not been in operation since 6/21/23. The staff member is no longer employed.


raw_content: A staff member ignored a child's numerous verbal requests to be left alone and engaged in discussion and activities that antagonized the child.

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

Correction Narrative: The staff member is no longer employed. There are no children in care. The operation has not been operating since 6/21/23


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

raw_content: The operation did not obtain a current fire inspection by 6/12/23.

Correction Narrative: Inspector received an email from the consultant stating that the license was turned in to RCCR. The owner will ensure that the operation is in compliance with the fire inspection and all codes if the operation decides to re-open. There are no children in care and they are not operating.


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

Deficiency Narrative: The operation did not obtain a current fire inspection by 6/12/23.


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

raw_content: Agency policy requires staff not sleep during their shifts; one staff member was found sleeping on their shift.

Correction Narrative: RCCR Inspector received compliance from the operation's attorney. The compliance response documented that the staff member is no longer employed with the operation. The operation no longer has children placed. The operation will ensure that the policy concerning not sleeping on shift will be an emphasis with future staff.


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

raw_content: Several staff allowed another staff member to sleep during their shift.


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

raw_content: Several staff members failed to effectively intervene when three children were involved in a physical altercation which failed to protect the children's safety in the operation.

Correction Narrative: RCCR Inspector received compliance from the operation's attorney. The compliance response documented that the staff are no longer employed with the operation. The operation no longer has children placed. The operation is working on developing and creating new training and practices to identify staff who may be weak in the area of EBI. This will assist to determine in re-training staff or terminating staff. They are also developing practices to identify concerns that staff have about other staff who may not have the ability to perform effective EBI.


summary: 748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children

raw_content: The operational administrative staff failed to ensure that staff in ratio included staff that were capable of providing an appropriate EBI response to manage child behaviors.  The staff at the time of an incident were relying on intervention from a contractor who was not readily available.


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

raw_content: The pill count was off by one pill on two days for two count the ten medication logs reviewed.

Correction Narrative: Inspector was informed that a new nurse has been hired at the operation. Nurse will be creating a new system for Quality assurance for medication count and verification. They will be conducting random checks.


summary: 748.864(d) - Pre-Service Training-Document the completion of each training requirement in the appropriate personnel record.

raw_content: Two of the staff files reviewed did not have the pre-service training documented in the file.

Correction Narrative: The trainings were completed and documented. However, the certificates were not completed. They are updated and in their system. Inspector reviewed the documents.


summary: 745.8641 - Requirements during probation

raw_content:
Condition 1 was not met. The supervision of all the children were not reviewed.
Condition 2 was not met. The minimum number for the unannounced visits were not met. The minimum number of hours per week of observing video were not met.
Condition 3 was not met. One staff did not complete required trauma training.
Condition 4 was not met. All staff and all children did not have a monthly meeting.
Condition 5 was not met. There is no log with the current investigations.
Condition 6 was not met. There was no documentation for the restraint conducted.

Correction Narrative: RCCR Inspector received notification and spoke to director. There were changes conducted at the operation with the LCCA leaving. The operation has a plan in place on who will be responsible for each condition and ensure that they are meeting compliance. The staff will be using tracking tools.


summary: 748.831(b) - Orientation-Document the completion of the orientation in the appropriate personnel record

raw_content: One out of two staff files reviewed did not document the orientation completed.

Correction Narrative: Staff took orientation training on 3/14/23. The certificate was uploaded in the system and sent to Inspector. Inspector reviewed the document.


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: One of the service plans reviewed was not signed by the child.

Correction Narrative: The operation is no longer operating. However, RCCR Inspector received documentation that the operation would begin to have an audit system with reviewing their service plans every six months to ensure all signatures are received.


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

raw_content: A caregiver used an inappropriate technique on a child which caused him to the be thrown on the ground with excessive force.


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

raw_content: A staff member did not use proper de-escalation techniques before attempting to implement the EBI on a child.

Correction Narrative: The owner discussed that there are no staff working at the operation. The operation does not have any children and is not in operation as of 6/21/23. The staff member was fired after the incident occurred.


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

raw_content: A staff member wrapped his arm around a child's neck during a restraint.


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 child's service plan called for the child to be "given distance", along with use of "non-threatening and non verbals", and "avoid overacting by the caregivers".  Staff did not use these techniques on the child prior physical intervention techniques.

Correction Narrative: The owner discussed that there are no staff working at the operation. The operation does not have any children and is not in operation as of 6/21/23. If the operation re-opens, staff will be trained on the importance of following the child's service plan for de-escalation.


summary: 748.1337(b)(1)(D)(vi) - Initial Service Plan-Include instructions to caregivers about behavior intervention techniques

raw_content: One of the child service plan's was assessed and it listed 3 different children's names that were not applicable to the child's service plan that was reviewed.

Correction Narrative: The owner discussed that there are no staff working at the operation. The operation does not have any children and is not in operation as of 6/21/23. If the operation re-opens, staff will be trained on the importance of ensuring service plans are reviewed for accuracy.


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 15 year old child in care was provoked to engage in a physical altercation with a staff person where the child was slammed to the ground and held in an inappropriate hold.

Correction Narrative: The owner discussed that there are no staff working at the operation. The operation does not have any children and is not in operation as of 6/21/23. The staff member was fired after the incident.


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

raw_content: A caregiver engaged in physical contact with the child after escalating the child's behaviors.


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: The fire or the severe weather drill do not document the time of evacuation or relocation.

Correction Narrative: Inspector assessed the new form used for the drills by the operation. It will document the time the drills begin and end in order to document the relocation time. A copy was received by the operation.


raw_content:
Condition 1 was not met. The review before placement for one youth did not address supervision. The admission assessments for two new youths did not document specific information required in the plan for supervision.
Condition 2 was met.
Condition 3 was met.
Condition 4 was not met. Monthly staff documents were missing detailed information.
Condition 5 was met.
Condition 6 was met.

Standard Number / Description: 745.8641 - Requirements during probation

Correction Narrative: The adminstrator sent the updated supervision information for the youth. A binder will be provided for condition 1 moving forward. They will be reviewing the documents for condition 4 to ensure all required information is documented properly.


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

raw_content: Two of the two medical consenter forms designated staff from the operation.

Correction Narrative: The administrator sent updated medical consent forms that did not include staff at the operation. In the future, the operation will ensure only case workers will be included on the form.


summary: 748.4111(b)(1) - Transportation records-Must maintain the insurance verification in the vehicle

raw_content:
There were not copies of the current insurances cards in the two vehicles used for transportation during the inspection.

The insurance cards were obtained during the inspection and placed in the vehicles.


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

raw_content:
There were two bowls of uncovered food and a plate of uncovered burgers in the refrigerator.

The uncovered food was removed during the inspection. The dishes were washed. There was no longer any food left uncovered in the refrigerator.


raw_content:
Condition 1 was met.
Condition 2 was not met. The videos were not reviewed during the week of December 11, 2022.
Condition 3 was met.
Condition 4 was met.
Condition 5 was met.  Feedback was provided.
Condition 6 was met. There were no restraints conducted to review.

Correction Narrative: The administrator sent an email stating that they understand the review period for the reviewing of the videos. They will have all weekly tasks through a spreadsheet on the one drive until all the forms and tasks can be uploaded to Casebook.


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

raw_content: A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child for eight minutes and fifteen seconds.

Correction Narrative: Staff attended training on Dec. 22. They are no longer employed as of today.


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

raw_content: A child was allowed to throw an object at another child who was involved with an incident with a caregiver. A child was also allowed to pick up a broom during the incident. There was a staff member who did not intervene with the child to prevent injury to another child.


summary: 748.2461(b)(1) - Short Personal Restraint-Caregiver may not use a prone or supine restraint

raw_content: A staff member used a supine restraint on a child in care.

Correction Narrative: Staff attended training on Dec. 22. Staff is no longer employed as of today.


summary: 748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective

raw_content: After a staff member made an aggressive gesture by removing his jacket and lanyard, a child in care was escalated. The child was not allowed to continue with his preferred de-escalation method of playing with the Legos.