summary: 748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level

raw_content: 2/2 child files reviewed did not have documentation that orientation was provided.

Correction Narrative:
Conversation with operation owner. A new caseworker and LCCA were hired at the operation with start date of 6/16/25. These new employees will be in charge of ensuring all documents are completed correctly and timely.

Corrections submitted via email 6/19/25:

Completed orientations packets for all 5 children submitted for review. Additionally, caseworker will review files on a regular basis to ensure all required documentation is competed and placed in file within required timeframes.


state: TX

facility_name: Royal Heritage RTC, LLC

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

raw_content: A child in care was not administered medication timely, for a duration of time.

Category: Individual Standards Evaluated

Standard Risk Level: Medium High

Corrected at Inspection: No

Correction Narrative:
unannounced physical follow up conducted 9/2/25. Discussion with administrator revealed that several "reminder" posters have been placed at the operation in an effort to ensure calls are made to hot line when required and documentation is completed in a timely manner. Administrator also submitted documentation that trainings that were submitted as part of the corrections were in fact completed.

The Corrective Action Plan detailed preventive measures:
-	All staff responsible for medication administration will complete refresher training on:
o	Reading and following prescription labels and medical orders.
o	Documenting each administration immediately after giving medication.
o	Verifying the Five Rights of medication administration (right child, right medication, right dose, right time, right route).
-	A double-check system will be implemented, requiring two trained staff members to verify medication and dosage before administration.
-	Updated medication procedures will be posted in the medication storage area as a quick-reference guide.
-	Only trained and authorized staff will be permitted to handle and administer medications.

Admin staff will be responsible for enforcement and follow ups.

During the investigation inspection, it was observed that the medication had begun being administered at the appropriate time.


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 on 1:1 did not have a staff present at all times.

Standard Risk Level: High

Correction Narrative:
unannounced physical follow up conducted 9/2/25. Discussion with administrator revealed that several "reminder" posters have been placed at the operation in an effort to ensure calls are made to hot line when required and documentation is completed in a timely manner. Administrator also submitted documentation that trainings that were submitted as part of the corrections were in fact completed.

The Corrective Action Plan detailed preventive measures:
-	All caregivers/Direct Care staff will receive refresher training on supervision standards, including:
o	Always maintaining visual and auditory awareness of children.
o	Avoiding distractions (personal phone use, side conversations, etc.) while supervising.
o	Proper positioning to always ensure full visibility of all children in their care.
-	A Supervision Zone Chart will be posted in all program areas to clarify coverage responsibilities.
-	Ratios and supervision assignments will be verified at every shift change.
-	Supervisors will perform random spot checks throughout each shift to ensure adequate supervision is being maintained.
-	Administrator will make frequent and random visits to the facility to ensure proper supervision.

Admin staff will be responsible for enforcement and follow ups.


summary: 748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom

raw_content: A bedroom had to cross an "activity room" in order to access a bathroom.

Category: Physical Site

Standard Risk Level: Low

Correction Narrative: Caregiver no longer plans to use loft space as an activity room. The room will have no purpose and will be a "dead space."


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

raw_content:
748.125 (c)(1)(B)(i-iv)-748.125(c)(1)(C)(i-iii): The operations policy indicates that staff will be required to take the AS+K training which only addresses the curriculum components for the risk factors, protective factors, and warning signs of suicide. Training must also address safety planning (748.125 (c)(1)(B)(i-iv) and screening for risk (748.125(c)(1)(C)(i-iii). Training on these specific curriculum requirements will have to be tailored for each operation as training will have to based on an operations own safety planning practices and the specific screening tool the operation will use to screen for risk.
The operation will need to include training to address these two areas, the AS+K Gatekeeper training does not provide for these areas within the training.

748.125(c)(2): The operations policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate.
Will volunteers and non-employees be required to complete training, if yes or no the operation should include it within the policy.

748.125(d)(5): The operations policy does not address how the operation will conduct screening in a manner that protects the childs privacy.
Where will the screening take place? In a private area/office where the child being screened can not be heard.

Category: Organization and Administration

Correction Narrative: Corrections submitted via email 12/17/2024. Suicide policies were updated to include the changes needed.  Definitions were added and curriculum was addressed. Policies were added to the handbook.


summary: 748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention

raw_content: EBI policies are not complete and must be more detailed in order to meet compliance.

Correction Narrative: Corrections submitted via email 12/17/2024. Policies were submitted via email with corrections made. Policies were more detailed and no longer copied and pasted form the Minimum Standards handbook.


summary: 748.105(10) - Personnel Policies- Must include either the model drug testing policy or a written policy that meets or exceeds the criteria in the model policy.

raw_content: Policies submitted for review did not include a drug testing policy.

Correction Narrative: Corrections submitted via email 12/17/2024. Policies state the process for hiring. Corrections were made to the personnel policies and the handbook has been updated.


summary: 748.103(b)(12) - Policies and procedures to submit - Weapons, firearms, explosive materials and projectiles

raw_content: There were no policies regarding weapons, firearms, explosive materials and projectiles.

Correction Narrative: Corrections submitted via email 12/17/2024. Policies and procedures for weapons was uploaded and stated they are not allowed. Policies have been added to the handbook.


summary: 748.123(6) - Vaccine preventable policy - prohibit discrimination or retaliatory action against exempt employee, except use of protective

raw_content: There is no statement in vaccine preventable policy prohibiting discrimination or retaliatory action against exempt employee.

Standard Risk Level: Medium Low

Correction Narrative: Email corrections submitted via email 12/17/2024. Updated policies state that discrimination or retaliation will not be allowed in the workplace for those employees exempt from vaccines.


summary: 748.105(3) - Personnel Policies - Include procedures for screening applicants to determine suitability.

raw_content: There is no procedures included in the policies regarding how the operation would screen applicants to determine suitability for work.

Standard Risk Level: Medium

Correction Narrative: Corrections submitted via email 12/17/2024. Corrections included procedures for screening applicants was detailed and added to the policies handbook.


facility_name: APC House LLC

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

raw_content: The operation did not complete a discharge summary for a child in care.

Category: Admission, Service Planning, Discharge

Correction Narrative: An email from the director stated that they would ensure that all staff are aware of the requirements that for a discharge summary.  The administrator or assigned designee will sign off on the discharge summary and review for accuracy and completion.


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

raw_content: Reason for prescribed medications was not documented on medication logs.

Correction Narrative: An email was received from the operation director. It stated that staff have been retrained regarding the requirements for medication records. The administrator or designee will review all medication logs on a weekly basis to ensure that all required information is included.


facility_name: New Future Residential Treatment Center, LLC

summary: 749.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: A training record for an active staff was altered.

Correction Narrative: 02-27-2026. The operation submitted a compliance response indicating "Training records will be submitted to and maintained by the Administrator only for quality and accurate purposes."


summary: 748.3237(c) - Safety Practices-Children must be able to open emergency exit doors easily from inside, unless written approval on file from fire inspector

raw_content: Both front and back door are locked from the inside of the operation. No one is able to get in/out of the operation without staff opening with their key.

Correction Narrative: The operation sent the following correction: both front and back door locks have been changed to a single cylinder deadbolt.  Anyone has access to get out of the facility at any time.  During the inspection it was observed that both front and back locks have been changed. With the new locks, access from the inside is accessible.


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

raw_content: Resident medication log and medication count wasn't the same.

Correction Narrative: 02-10-2026. The operation emailed the assigned inspector a compliance response indicating "Medication storage has been cleaned new bins were bought to separate each client's medication."


summary: 748.2003(a) - Administration of prescription medication-inform medical consenter of benefits/risks/side effects/treatment/consequences of refusing them

raw_content: Child in care files had no documentation showing a managing conservator signed off on information about medications.

Category: Medication

Correction Narrative:
01-14-2026. I received and reviewed the form via email which shows where the CPS worker can sign off acknowledging awareness of benefits, risks and side effects of medications.

01-14-2026. IMPACT shows no children in care placed since the 12-17-2025 inspection. I telephoned the operation and verified this. The operation also agreed to email me the form they'll use going forward for medical consenters. The operation plans to use this form even for meds the arriving child in care is already taking and when there's a medication review or change in prescription or dosage.

01-13-2026. RCCR management gave approval to follow up to the compliance response via documentation review and phone conversations with CPS case workers.

01-13-2026. The inspector replied and requested a copy of the form.

01-12-2026. The assigned inspector emailed the operation and requested a compliance response. The operation replied: "Form created that gives the side effects of each medication and signed by the staff administering, that they are aware of the side effects.  Form placed in the clients binder."


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

raw_content: Extension granted due to window having to be measured and personnel stated it will take a couple of days to cut to fit the frame of the door.

Correction Narrative:
11-17-2025. The operation emailed the assigned inspector photographs of the fully replaced door.

11-12-2025. The assigned inspector received a photograph of the boarded-up door with no apparent damaged glass from the inspector who conducted the follow up inspection on 11-10-2025.


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

raw_content: The suicide screening had not been completed at admission for both files reviewed.


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

raw_content: A desk in a childs bedroom is broken on the edge and falling apart. The front door needs to have glass replaced.


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

raw_content: One staff file reviewed was missing the 4 hours of EBI that was due in September 2025.

Category: Training and Professional Development


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: As of 10-16-2025 there is no quarterly report for emergency behavior interventions between July to September 2025.

Correction Narrative:
11-03-2025. The assigned inspector observed the report completed in CLASS.

10-16-2025. The operation emailed the assigned inspector and indicated the report is done.


raw_content: A window was observed with broken glass during an inspection.

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


summary: 748.363(5) - Personnel records-Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position.

raw_content: Staff files reviewed were missing evidence of certifications for the positions evaluated.

Category: Reports and Record Keeping


summary: 748.363(13) - Personnel records-Include record of training and training hours.

raw_content: Staff files reviewed were missing record of training hours.


summary: 748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code §42.0563

raw_content: Staff files reviewed were missing the pre-employment affidavit.


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

raw_content: Staff files reviewed were missing job description documentation.


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

raw_content: Staff files reviewed were missing the documentation stating the staff will report any suspected child abuse or neglect immediately.


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

raw_content: Staff files reviewed and the pre-employment screening was not completed.

Category: Personnel


raw_content: As of 07-23-2025 there is no quarterly report for emergency behavior interventions between April and June 2025.

Standard Number / Description: 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.

Correction Narrative:
The operation submitted a compliance response indicating "On the first business day of each month, the designated staff will log in to the DFPS portal to document: (1) total number of restraints from the previous month, and (2) total number of serious incidents. All entries will be completed no later than the 5th business day of the month.

Quarterly Internal Review: The Compliance Coordinator will conduct a quarterly audit of DFPS reporting logs to verify timely report submission and ensure accuracy through cross-referencing with internal reports. Any discrepancies will be corrected within 5 business days."


summary: 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)

raw_content: Licensing observed the incident report to be without the names of staff involved.

Correction Narrative: The operation emailed the assigned inspector a compliance response indicating "The New Future RTC will retrain staff on how to properly document incident reports in their entirety."


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

raw_content: The operation's 30-day service plan only included information about the child in care's behavior and not the other elements of an initial service plan.


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

raw_content: Residential Child Care Regulation observed a child in care's admission assessment to be without many of the items in this section.

Correction Narrative: The operation submitted a compliance response indicating "The New Future RTC will require that each child's admission assessment include an initial evaluation of the appropriate placement and ensure that the necessary information is obtained to facilitate service planning."


summary: 748.3001(b) - Sanitation Inspection-Each inspection must meet regulations of the local health department ordinances

raw_content: Residential Child Care Regulation observed the operation has an expired health inspection.

Category: Safety and Emergency Practices

Correction Narrative:
07-24-2025. The operation submitted their approved health inspection.

07-21-2025. The operation submitted a compliance response with no specifics on how they'll acquire health inspections.


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

raw_content: Two employees, with a hire date of March 21, 2025 and March 22, 2025, do not have records of pre-employment reference checks.

Correction Narrative:
On 5/13/25, compliance plan submitted via email regarding the following citation.

748.753(d)(1): Each reference's name, relationship, and date of contact will be documented and added to the employee file by Friday, May 16.

On 05/14/2025, additional email sent to address the ongoing changes.

As part of the revised hiring protocol, documentation of references will be tracked through a centralized database. This will include automated alerts for missing information. Monthly reviews will be conducted by the NFRTC Administrator to monitor adherence to this protocol.


summary: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

raw_content: One employee file includes the name and contact information of two references: however, none of the files evaluated include a documentation of the conversation with the references.

Correction Narrative:
On 5/13/25, compliance plan received via email for the following citation.

748.753(a)(2): The two required reference verifications for pre-employment screening will be completed by Friday, May 16.

On 05/14/2025, additional email sent to address the ongoing changes.

A standardized reference verification form has been created and will be used during all hiring processes. CEO or designee will review hiring files monthly for completion of references.


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

raw_content: Employee files evaluated does not include drug screening results.

Correction Narrative:
On 5/13/25, compliance plan was received via email for the following citation.

745.4151(c)(4)(A): The employee who is currently missing a drug screening has been temporarily placed on hold pending the receipt of a negative drug screening result.

On 5/14/25, additional response submitted to address on-going changes implemented.

Moving forward, we will implement a pre-employment compliance checklist that includes verification of completed drug screenings prior to start dates. This will be reviewed and signed off by NFRTC Administrator. In addition, monthly internal audits will be conducted by the NFRTC Administrator to ensure all files remain up to date.


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

raw_content: Employee records evaluated does not include Form 2912.

Correction Narrative:
On 5/13/25, compliance plan received via email for the following citation.

748.505(b)(5): The employee is missing the pre-employment affidavit and Form 2912. This documentation will be added to the employee's file by Friday, May 16. The employee will not be permitted to work until this requirement has been fulfilled.

On 5/14/25, additional response submitted to address ongoing changes.

A revised onboarding checklist will now require the completion of all licensing documents prior to orientation. NFRTC Administrator will perform a monthly audit to confirm compliance will be notified of any missing documents to prevent employees from beginning work without proper documentation.


summary: 748.361(a) - Personnel records - All active records maintained at the operation

raw_content: Employee hired on 12/18/2024 does not have an employee file and operation stated they were not aware this should be completed.

Correction Narrative: The operation sent the following response via email: All employee personnel records will be held at the facility onsite uniformed in binders. Pre-employment documents will be completed on or before the hire date.  Documents will be submitted to the licensing rep. The LCCA will be responsible for ensuring this task is completed.


facility_name: The Origin Home for Children LLC

raw_content: Two of two personnel files had only one Reference check completed and the standard requires that two reference checks be completed.

Standard Number / Description: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

Correction Narrative:
On 1-24-26 the Administrator submitted a CAP for the deficiency. A Reference Verification Checklist is placed in each employees personnel binder upon application; The Administrator or Program Director is responsible for completing and signing the checklist, two professional references are contacted and documented before orientation, Verification includes suitability to work with children, reliability, and professional conduct, and Completed checklists are filed in the personnel record.
Incomplete files result in suspension of onboarding.
Staff may not assume unsupervised duties until verification is complete.
Additional staff training is provided if documentation errors occur.


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

raw_content: One of two employee files was found to have an incomplete Affidavit of Employment.


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

raw_content: One of two employee files does not have a record of employment checks prior to hire.

Correction Narrative: On 1-24-26 the Administrator submitted a CAP for the deficiency. A Reference Verification Checklist is placed in each employees personnel binder upon application; The Administrator or Program Director is responsible for completing and signing the checklist, two professional references are contacted and documented before orientation, Verification includes suitability to work with children, reliability, and professional conduct, and Completed checklists are filed in the personnel record.


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

raw_content: The incident report provided during the CCI investigation does not describe what type of EBI was performed on the child.

Correction Narrative: The administrator submitted a CAP addressing the documentation of EBI reports. All staff will receive refresher training. The administrator or designee will review the reports for compliance and audits will be done monthly.


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

raw_content: A medication log provided to CCI during the investigation does not have the name of the medication or the medical professional who prescribed the medication.

Correction Narrative: The administrator submitted a CAP addressing the medication logs. The provider will ensure all medication administration records are completed accurately and in full compliance with DFPS Minimum Standards. Effective immediately, all medication logs will include the medication name, dosage, administration time, and prescribing medical professional. Staff will receive refresher training on medication documentation requirements, and supervisory review will occur prior to record filing.The Program Director or designee will conduct weekly reviews of medication administration records and complete monthly audits to ensure accuracy and compliance. Any documentation deficiencies will be corrected immediately and addressed through staff retraining as needed.


facility_name: Cherokee Home For Children

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

raw_content: Missing the contraidications in the admission assessment.

Correction Narrative:
RCCR received an email with an updated version of the admission assessment to include the following section to help ensure this is not missed in future assessments. "Describe child's current/past health concerns. (be sure to include any known
contraindications to the use of restraint)"


summary: 748.1207(a)(3) - Placement agreement-Must include the reason for placement & anticipated length of time in care

raw_content: Missing time and reason for placement in the admission assessment for two of two child records.

Correction Narrative: RCCR received an email from the operation including additional information in the placement agreement for why the child was placed and estimated length of stay to ensure that this section is not missed on future placement agreements.


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: It was observed during a walk through that a electrical outlet did not have a wall cover.

Correction Narrative: An unannounced inspection was conducted on 2/8/24, observed the electrical outlet was covered and in compliance. To ensure this will continue to be in compliance in the future the campus director will inspect buildiings, especially after contract work is done.


summary: 748.3273(3) - First Aid Kits-Each one must contain antiseptic solution or wipes

raw_content: Multiple First Aide Kits were observed to be expired in both the cottage home and in the vehicles used to transport the children in care.

Correction Narrative: An unannounced inspection was conducted on 2/8/24, all first aid kits in the homes and transporation were  in compliance.  In the furture administrator will do monthly walk throughs of the vans and homes conducting spot checks for first aid kits remaining in compliance.


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

raw_content: Food was observed to be expired in pantry, and left out exposed in cottage kitchen area as it was not properly stored.

Correction Narrative: An unannounced inspection was conducted on 2/8/24, all food in the pantry and house was in compliance and not expired.  In the furture administrator will do monthy walk throughs of the pantry and homes conducting spot checks for expired items.


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

raw_content: It was discovered in review of two child records that a service plan was not created within 45 days of admission.

Correction Narrative: Received email from Director of Social Services stating: I have shortened the time for our due date alert email from 45 days to 40 days prior to the due date. This should give plenty of time to complete the initial service plan by the due date.


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: It was discovered that the suicide risk assessment was not conducted in one of two child records.

Correction Narrative: Received email from Director of social services stating: I created a new form in Extended Reach for the house parents to complete the screening at placement and then again every 90 days. However, since Christian was not present to complete the screening with me, I had the house parent complete the screening as soon as possible. A copy of the screening is attached.  The suicide screening for the child in question was also attached.


summary: 748.2203(c)(2) - Medication Error-Document the medication error

raw_content: In reviewing medication logs for two youth, it was observed that several medication errors were not documented accordingly.  Medication errors were observed on various logs in relation to missed/skipped medications, medications given at the incorrect time, and relating to wrong dosage given.

Correction Narrative: The operation's Director of Social Services, Israel Valdez, provided a response letter to the deficiencies listed on 06.09.22. All violations were discovered by the operation prior to investigation and written reprimand was issues to the caregivers.


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

raw_content: It was observed while reviewing medical record documentation and medication administration reports that the cumulative records for both children was not updated with the date of administration, time of administration and the signature of who administered the medication within the time frame required by minimum standards.


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

raw_content: It was observed while reviewing the medication records for both children, that a time was not included on the documentation of when the medication was administered.


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

raw_content: Concerta Medication Log (date ranges 04/28/21-07/18/21) did not include the reason the medication was prescribed.

Correction Narrative: Email received from Mr. Valdez stating the caregivers simply failed to list the reason on the medication log and corrections were made to the logs to reflect the reason for the medication. These corrected logs will be kept on file, attached to original logs.


summary: 748.1349(a)(1) - Initial Service Plan-Give copy or summary of plan to child, when appropriate.  At minimum must give copy to child 14 years and older

raw_content: During the review of the Initial Service plan, it was found parent and child signature was missing. There was also no documentation to show the parent, caregiver, and child received the plan.

Correction Narrative: The agency has reviewed their policy. They have also created a document that will go in each child's folder that will require signatures to show the child and parents received their copies. MLayton


summary: 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings

raw_content: During the walk through of the cottages, the evacuation plans were not posted that children were able to see where to go in an emergency.

Correction Narrative: Received pictures of Evacuation plans hung through the cottages. MLayton


facility_name: Lee and Beulah Moor Children's Home

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: Medication for discharged children was found amongst current medication for children in care.


summary: 748.1381(1) - Service Plan Review-If child not receiving treatment services, review at least 180 days from date of last service plan

raw_content: Service Plans reviews were conducted after 180 days.

Correction Narrative: Action Plan: A meeting was held on May 29, 2024 with caseworkers and quality assurance worker regarding Service Plan  Review of Content and Deadline. Besides the database the agency uses to calculate the deadline for the service plan review, the quality assurance worker will use Excel and the caseworkers will calculate the days the service plan is due as well to make sure the plan of service review is completed within the 180 days.


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

raw_content: During the walkthrough, there was one cottage with several bee hives in the corners of the roof.

Corrected at Inspection: Yes


summary: 748.361(a) - Personnel records - All active records maintained at the operation

raw_content: Staff files were not available at the moment of the inspection, and are located in a third party facility.


facility_name: New Horizons Ranch Residential Treatment Center

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

raw_content: A child in care received a serious physical injury during a restraint.

Correction Narrative: The alleged caregiver was written up for the inappropriate EBI. Children and staff were interviewed regarding EBI's and no concerns were noted in the interviews. Staff were up to date on their trainings.


summary: 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

raw_content: A child in care was restrained for only being verbally aggressive.

Correction Narrative: 748.2551(b)(2) EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention	The Administrator reviewed Subchapter N of the minimum standards with the EBI Trainers to ensure understanding of the standards in which restraints can be utilized. All staff were also re-trained in EBI Implementation on 5/20/25 during an all-staff training. The training focused on the circumstances in which EBI can be utilized, de-escalation strategies, and how to properly implement EBI.


summary: 748.2907(5) - Triggered Reviews-Must include a written plan for reducing the need for emergency behavior intervention

raw_content: The triggered review completed did not contain information required throughout standard 748.2907.

Correction Narrative: An email was received from the Administrator on 5.27.25 via email. It was explained the Administrator and Placement Director, supervisor of case managers, reviewed the required standards for 748.2907.


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 medication count for a child in care was did not have an accurate count of the prescribed medication.


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

raw_content: An investigation determined a child should have received medical attention on 8/18/24, but was not seen until 8/19/24.


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

raw_content: A staff member used emergency behavior intervention on a child in care for a non-emergency situation.

Correction Narrative: Follow-up was completed with the individual staff member involved in the incident which included 1:1 EBI training. In addition, an EBI training focused on de-escalation was held on 9/10/24 for all direct care staff.


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 restrained a child without attempting de-escalation.


raw_content: 1 child's service plan contained the name of two other individuals. Additionally, the unauthorized absence log contained the wrong staff member's name responsible for a child who ran away.

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

Correction Narrative: The operation is conducting a complete review of all services plans for the children actively there now and spoke with case managers about ensuring copy and paste issues are not occurring moving forward.


summary: 748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return

raw_content: 3 serious incident reports regarding an unauthorized absence did not have the time and/or date of the notification to the case worker and/or law enforcement officer and the names of those they spoke to.


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

raw_content: During the course of the investigation, it was determined that a hazardous item was left in reach of a child.

Correction Narrative: Four children and two staff were interviewed regarding accessibility to sharp objects. One child reported obtaining another sharp object from the study area; however other children and staff deny sharp objects are accessible. Additionally a walk through of the unit was conducted and it was observed that sharp objects were locked in a safe. The staff leaving the object accessible has received training.


summary: 748.2463(1) - Emergency Behavior Intervention-Never used as punishment

raw_content: It was noted during an investigation that a child in care was being restrained which resulted in a child being restrained inappropriately as the child in care resisted.


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

raw_content: It was noted that during an investigation, a child was not properly restrained.


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

raw_content: It was noted during the investigation that profane language was used during an incident that had escalated on a child in care.

Correction Narrative: The operation has had 4 seperate trainings in regards to use of profane langauge and the effects it can have on children in care since this incident,


summary: 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

raw_content: It was noted in this investigation that a child in care was grabbed by the front of the shirt.

Correction Narrative: The operation has retrained the employee in deescalation practices and placed the employee on an action plan at this time,


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

raw_content: Records were requested on 12/4/23 (by email), on 12/7/23 (by email), and on 12/18 (by email & by phone). Records were provided by the operation on 12/18/23.

Correction Narrative: The operation indicated that one of the email addresses on the Child-Care Regulation account page was no longer active which caused the correspondence not to be received. The account page has now been updated in an effort to prevent this from happening again.


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

raw_content: The suicide screening indicates it was done 13 days late.

Correction Narrative: The suicide screening was completed immediately, but this was unable to be shown due to the agency's migration to a new electronic health record when the incident occurred. The migration has been completed so this should not occur in the future.


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

raw_content: A staff member allowed children to go to an unauthorized outdoor area. As a result, the children ran away and committed inappropriate physical contact with each other.

Correction Narrative: The staff member involved in this incident was a newly hired staff. The staff member was provided with 1:1 training by Ranch Director, David Long, and was immediately transferred to work with a younger group of children as she was not a fit to work with teenage girls due to her lack of experience.


raw_content: Three children and two staff stated that staff will use curse words around children. Staff said they will repeat what children say as a way to have them rethink their own words.

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

Correction Narrative: A meeting was held on 9/12/23 in the house in which this was reported as occurring. During the meeting, it was reviewed that language with and around kids should always be appropriate.


raw_content: Four children described examples of being restrained for not following directions or situations that were not an emergency.

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

Correction Narrative: The deficiency has been corrected.  A follow up inspection was completed at the operation. The administrator and program director were spoken to about the recent EBI trainings given to staff. Staff training documentation was obtained for de-escalation techniques and appropriate holds. 5 children were spoken to about restraints as well.


raw_content: Four children described excessive force being used during restraints, such as being slammed against a wall or floor, arms twisting back, and being bent over.

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


raw_content: Upon reviewing letters and pictures from a caregiver it was determined that the caregiver has maintained an inappropriate relationship with a child in care.

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:
Received compliance from administrator via email on 5/22 in response to the citation. 748.507(1):

"All staff were required to review and sign New Horizons professional ethics policy which is outlined in New Horizons' Employee Handbook. The professional ethics policy includes the following areas: confidentiality, conflict of interest, relationship boundaries. The signed document will be filed in each current employee's HR file.

The administrator met with the staff involved multiple times about this incident. There has not been any contact with the child since prior to when the investigation was initiated. They followed up with the staff in the past two weeks and confirmed that there had been no other contact between staff and the child.

In terms of boundaries, many of our staff maintain contact with kids after they leave. From what I have been able to gather through conversation with them, they are offering encouraging words to the kids and giving them good advice about choices. Our goal is to develop healthy relationships with kids so that the kids can transfer those relationships to other trusted adults in their lives. Given this, I have not specifically told the staff that they cannot have contact with kids after they leave because that would be contrary to what we have always done. However, I have asked that if they plan any in-person visits, I would like to be notified if/when these occur so that I can follow up after the visit and also monitor the frequency.

I have worked with this staff for more than seven years. In that time, we have not had any incidents that were similar to this one, and they have maintained relationships with other kids that have left the program during that time. I also reviewed their HR file, and there is nothing documented prior to that time regarding any similar type of concerns related to boundaries. "

An unannounced follow up inspection #3954422 was completed on 6/23/23. The deficiency has been corrected. Several staff were observed supervising and interacting with children appropriately. The staff involved was spoken to about their role and responsibilities. The staff has no other incidents or history of concerns. The administrator expressed confidence in the staff.


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: 7 previous staff members who are no longer employed at the operation were not inactivated within 7 days of unemployment. The administrator inactivated these staff during the inspection.


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

raw_content: A child with high-risk behaviors noted did not have a plan to address these behaviors in their service plan.

Correction Narrative: Inspector received an email from the administrator on 2/22/23 stating "Training was completed with all clinical staff responsible for writing service plans on February 22, 2023. This training included both case managers and therapists as well as administrative staff. Areas of the service plan that were reviewed were the high-risk behaviors, behavior management, therapeutic goals, and supervision." A phone call was made on 2/23/23 to the administrator to confirm that the child's service plan was updated to reflect the high-risk behaviors. The administrator said they updated it yesterday with an addendum and will send that to me. This will be uploaded to digital storage.


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 child did not have a TB test documented in their record. The child was at a doctor's appointment and recieved a test today. The results will be done in 48 hours.

Category: Child Care


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

raw_content: 4 out of 10 medication logs did not have the required signature of the person who administered the dose.

Correction Narrative:
Administrator emailed the following to Inspector on 7/28/22:
All of the medication logs were revised on 7/13 and 7/14 to include a box for staff to initial that they had administered the medication. Previously, the form did not specify causing some instances for staff to not initial at each administration. The medication logs are being checked 2-3 times per week by the Lead Case Manager who oversees medications. Part of the check is to ensure that the required initials are present on the form.


summary: 748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being

raw_content: A child in care assisted staff by monitoring a restraint conducted on another child in care.

Correction Narrative: RCCR Supervisor Leslie Perkins received an email from Administrator Brandi Batten with the following compliance plan: The staff members involved in this incident are no longer employed by New Horizons Ranch & Center. Both were terminated in April 2022. The child who was involved in this incident was provided with education from this therapist regarding our policies and procedures regarding restraints and who to talk to if these procedures are not followed. The other child who was involved in the restraint was previously discharged and could not be addressed. Staff will continue to be trained as required on all minimum standards as well as New Horizons policies and procedures regarding restraints.


raw_content: 2 children's service plans noted high-risk behaviors but did not include specific plans that address these behaviors.

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

Correction Narrative:
The administrator emailed the following plan of correction on 6/22/22: Additional training and guidance was provided to all staff responsible for writing service plans. The training was focused on ensuring that there is consistency in what is written within the service plan and that needed information is documented in the corresponding section. In addition, it was stressed that any high risk behavior identified needed to have a plan to address that behavior. Training was also provided regarding the need to review the plans each time to ensure that information is updated accordingly. This training was completed on 6/22/22 during a clinical meeting. Meeting notes are attached and show what staff was present during the meeting.
An addendum was added to Isaiah's service plan to address his high risk behaviors on 6/20/22. An addendum was added to youths service plan on 6/20/22, stating that he no longer exhibits his high risk behaviors.


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

raw_content:
A few of The Ranch's policies were not followed regarding this incident.
-Night staff members were sleeping.
-Staff sleeping was not reported, and staff is trained to report this.
-Concerns that hadn't been handled and needed more attention were not relayed to higher-up Supervisors/chain of command.

Correction Narrative:
Administrator emailed the following follow up actions on 6/24/22:
The staff member who was sleeping was terminated immediately upon this being reported to the Administrator. In addition, the staff member who failed to report that a staff member was sleeping was also terminated for failing to report as is outlined in our policies and procedures.
The Ranch Director sent an email to all night staff outlining expectations and procedures for supervising children at night. This included 7 reminders and staff had to reply to acknowledge that they read the email. The operation has a Supervision Training scheduled in August where they will review Supervision procedures.
As well, the operation is working with a tenured staff to move into the night supervisor position.


raw_content: A caregiver was administering medication without having a signature on the medication file.

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

Correction Narrative: The operation sent a plan of correction detailing that medication logs were reviewed to ensure that all required staff signatures were documented. Additionally the administrator and staff member responsible for quality assurance met and did a 1:1 training on staff signatures on medication logs.


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

raw_content: A child in care's prescription label was altered by a staff member. The instructions stated take 1 tablet by mouth every morning but morning was mark through and night was written by pen.

Correction Narrative: Follow up to Inv. #281673. A follow up inspection was conducted at the operation. There are 57 children in care and 16 direct care staff on location. Medication logs for 2 children in the Knights group were reviewed. TA will be given for keeping accurate records, as one medication summary had a discontinued medication and one medication summary did not indicate if medication was "as needed." A walkthrough was conducted at the Knight home and there were no plain cite deficiencies. Bedrooms and bathrooms were clean and had adequate materials for children. Chemicals are stored in locked cabinets in bathrooms. Fire extinguishers are in each room and in the kitchen. Background checks were compliant. Photographs were taken. Exit interview was conducted with Ranch Director Rick Summers.


summary: 748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional

raw_content: It was found that the child in care was not seen for a follow up medical appointment as it was requested by the ER doctor at the time of discharge.

Correction Narrative: Brandi Batten emailed and stated the staff member responsible for scheduling medical appointments was provided with 1:1 training by the Administrator regarding the importance of ensuring that follow-up appointments are scheduled as recommended by the health-care professional.


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

raw_content: A report to licensing that a child contracted a communicable disease was not made within 24 hours.

Correction Narrative: The staff member involved received additional training on the minimum standards for reporting communicable diseases.


summary: 748.685(b)(5) - Caregiver responsibility - when deciding how close to supervise, takes into account the child's physical, mental, emotional, and social needs

raw_content: A child with a history of struggling with medical compliance, was made responsible for monitoring their blood sugar levels. The child was also able to sneak snacks, as other children in care reported.

Correction Narrative:
The administrator emailed the following on 6/30/22:
In addition, while the child remained in placement until her successful discharge, New Horizons made the decision to no longer accept children with Type 1 diabetes. Managing a child with complex medical needs and a significant history of trauma requires a significant level of supervision beyond what the program is designed to provide. If New Horizons changes its policy in the future and decides to accept children with this level of need, our policies and procedures will be updated to ensure that the child is provided with the level of supervision and support that may be needed.


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

raw_content: Staff was unaware of a child's medical needs outlined in the service plan, which resulted in the child's medical needs not being properly met.

Correction Narrative:
The Administrator emailed the following on 6/30/22:
On September 29, 2021, a Diabetic Specialist from Hamilton Healthcare system provide training to the staff members assigned to work with the child who had diabetes. This training was focused on understanding diabetic ketoacidosis, causes of ketoacidosis, types of insulin, and how to develop a sick day plan. In addition, the diabetic child's specific plan was reviewed by the Diabetic Specialist.
The sign in sheet for the training will be uploaded to digital storage.


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 operation/staff failed to provide the level of monitoring and oversight necessary to help ensure a child's compliance with their diabetic treatment regimen. Staff was not aware of the child's supervision needs during blood sugar checks, which directly led to the child being hospitalized.

Correction Narrative: While the child was still in care, the staff was trained by a healthcare professional on how to better provide care to children with diabetes and their medical needs. Once the child was discharged, the operation determined that they will no longer accept children with Type 1 diabetes as they are not equipped to provide the level of care needed. At this time, the operation does not currently have any children with these medical needs in care.


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 investigation it was determined that the caregiver in charge failed to supervised children by falling sleep and not checking on them after waking up. As a result the children ran away from the operation.

Correction Narrative: The staff member involved in this incident was issued formal disciplinary action as a result. This occurred immediately following the incident and prior to the RCCL investigation. The staff member, who was new, was also provided with numerous strategies to ensure that he remained alert throughout his shift to ensure the safety of the children at all times.


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

raw_content: A child's service plan contained inaccurate and outdated information and instructions for supervision

Correction Narrative: On 8/4/2021 I, RCCR Inspector Brody Ratto, reviewed a plan of correction sent by the operation. It details that 1:1 training was done with the staff member who wrote the service plan with her supervision. It also details that supervision instructions and service planning were reviewed with staff members


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: Three children in care were forced to do exercise as discipline

Correction Narrative: On 8/4/2021 I, RCCR Inspector Brody Ratto, reviewed the plan of correction sent by the operation. It details that on 5/17/2021, the ranch administrator and director both met with the staff responsible and reviewed discipline and work project policies. Additional training was also provided for all staff regarding productive vs unproductive work


facility_name: Casa Esperanza Inc DBA Hope House

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: The medication record for a child in care showed 11 doses were taken, but the number of pills remaining was 17 out of 30.

Correction Narrative: On 10/21/25, an email was received from the operation's treatment director. The email stated that all staff will be retrained regarding medication documentation and maintaining accurate medication counts. This training will be completed by 11/15/25. A follow-up email will be sent on that date to confirm the completion of the training.


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

raw_content: It was determined that the operation did not receive consent prior to increasing the dosage of a psychotropic medication for a child in care.

Correction Narrative:
An email was received on 9/10/25 from Treatment Director, Tina Gould, stating the following:
Our program software, extendedReach, sent an email alert to show that the form had been signed. However, it was not the medication consent form, it was the appointment notification form. Hope House has addressed this by changing the notification in the system to make a clear distinction on the medication consent and discontinued the appointment notification.


summary: 748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren)

raw_content: It was found that the serious incident documentation was missing the names of all adults involved and their role in relation to the child.

Correction Narrative: The operation provided a corrected SIR and a corrective action plan that states that Extended Reach now requires the staff and/or residents' names or initials to be added to the incident report. A screenshot of the required fields in Extended Reach was also provided.


summary: 748.881(7) - General pre-service training curriculum-Includes normalcy

raw_content: During a review of training logs, it was found that one staff did not complete the training for Normalcy within the 90 days of the hire date.

Correction Narrative:
A corrective action plan was emailed on 5/16/25. 1. Staff now completes a 3 week training period and all training that is required is completed during this time before being counted in ratio. This is a new requirement since the staff in question did not complete their training.

2. All medication logs have been fixed and all medication is being counted. Also MAR training has been completed to train staff on the new procedure.


summary: 748.881(6) - General pre-service training curriculum-Includes trauma informed care

raw_content: During a review of training logs, it was found that one staff did not complete the training for Trauma informed Care within the 90 days of the hire date.


raw_content: During the interview, a staff stated during a head count of the children it was discovered the victim was missing.

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

Correction Narrative: A training log was provided showing staff received additional training in supervision and conducting 15-minute checks. New locks and alarms were placed on all doors leading outside.


summary: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

raw_content: Based on investigation interviews the operation staff and/or management are not reporting suspected allegations of abuse and neglect of a child to the Child Abuse Hotline.

Correction Narrative: A training log was provided showing staff received additional training regarding mandated reporting and time frames for reporting.


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

raw_content: The operation does not currently have a system in place to monitor fire extinguishers monthly to ensure they are maintained properly.


raw_content: It was found that a caregiver dragged a child to the restroom and hit the child repeatedly in the head.

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


raw_content: It was found that a caregiver used corporal punishment with a child in care.

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


raw_content: It was found that one of the child's prescription medications was not administered according to the medical treatment discharge record as of 6/4/24. The health care professional's instructions on the record states to administer this medication three times daily, however, the child's medication log shows that from 6/5/24 to 6/11/24, the child was administered this medication twice daily.

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

Correction Narrative: During the follow-up, two child medication reviews were reviewed and determined to be compliant. A staff member explained the medication administering process during the walkthrough  . The operation is also working with the local pharmacy to ensure MARs reflect accurate medication instruction.


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

raw_content: It was found that the doctor's medication instructions for three of the child's medications as of 6/4/24 were written incorrectly on the child's June 2024 medication log (aka MAR). The medication logs for May and June 2024 were also missing the prescribing doctor's name [2], reason medications were prescribed for the prescription medications (except for one medication that was for anxiety) [3], staff initials were illegible and some did not match the initials on the signature page provided for staff who administered the medications [6], the medication log was missing the reasons for administering the medications (including the specific symptoms/conditions) [8].

Correction Narrative: During the inspection, the operation provided an example of a medication record where the pharmacy would provide instructions about giving the medications and side effects directly on the forms for the operation.  They have also started adding the reason for the medication and the physician's name.  This practice will be in place for all children effective 9/1/24.   A staff member explained the medication administering process during the walkthrough.


summary: 748.311(7) - Serious Incident Documentation-Includes circumstances surrounding the incident

raw_content: It was found that the serious incident documentation was missing information such as names of all adults involved and their role in relation to the child [4], names or other means of identifying witnesses to the incident, if any [5], circumstances surrounding the incident [7], interventions made during and after the incident [8], the treating licensed health-care professionals name, findings, and treatment [9], and the resolution of the incident [10].

Correction Narrative: The operation revised its current SIR to include all pertinent information. They maintain a SIR binder in the office and have ensured that the required standards are included in one document. As data is gathered, it is also included in the Extended Reach program to make it available to all staff timely. During the walkthrough, staff shared when and how to document serious incidents.


summary: 748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection

raw_content: The last health inspection was completed on 07/13/2022 and expired on 07/13/2023.    The DFPS Form 4004 (Environmental Checklist) was submitted on 03/21/2024 by the operation.

Correction Narrative: The operation completed a health inspection on 3/29/2024.


summary: 748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available

raw_content: The operation failed to provide written documentation showing the health inspection could not be completed by the city.

Correction Narrative: The operation was provided documentation from the health department that they have been added to the wait list. This information was provided to Licensing.


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

raw_content: A serious incident report was reviewed and it was found that the following information was not provided in the template: physical address and phone number, age and gender of child, adults involved, names of witnesses, and name of medical personnel treating the child.

Correction Narrative: The operation sent a new SIR template showing all required information will be captured on future reports.


summary: 748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.

raw_content: Several operation caregivers do not have current first aid training documentation.

Correction Narrative: The operation sent a sign-in sheet showing staff names who took the required first aid course.


summary: 748.863(a)(2) - If EBI not allowed, caregivers for childcare prog. or treat. svc must have 8hrs EBI. 4 before counted in ratio, rest w/in 90 days.

raw_content: During the inspection, it was noted 1 out of 4 employees did not have the required 4 hours of pre-service training prior to being counted in ratio.

Correction Narrative: The operation provided this training over two days to this employee:  2 hours on 07.11.2023 and 2 hours on 07.12.2023 for the required 4 hours of preservice EBI training.  The corrective action plan was provided to ensure future occurrences are  avoided.


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: Two outlets in the main sensory room accessible to children were observed to be cracked/broken.

Correction Narrative: The two cracked outlet covers have been repaired.


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

raw_content: Two of two picnic tables on the playgrounds accessible to children present safety risks which included an exposed nail and paint was observed to be peeling on two of the outdoor swing sets.

Correction Narrative: The two picnic tables were observed and have been repaired.


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

raw_content: During the inspection it was determined that the booster seats in use had expiration dates that had expired or dates that had been scratched off and could not be verified. This was corrected prior to Licensing leaving the premise as the operation ordered new seats to replace the expired seats.

Category: Transportation


facility_name: Shiloh Treatment Center

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

raw_content: The details documented in the operational Emergency Personal Restraint Report are inconsistent with the events observed in the operational video recording.


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

raw_content: Two operational staff members completed an EBI transport for a child by dragging the child across the living room area of the home.


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

raw_content: An operational staff member responded to a child in a physically aggressive manner by pushing the child as a means of discipline prior to conducting an inappropriate restraint.


summary: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

raw_content: An operational staff member failed to release a youth from a physical hold, when the youth was no longer displaying behavior that exhibited that the child was a danger to himself or others.


raw_content: The operation failed to complete an incident report related to a non-routine incident concerning aggression and an EBI incident that occurred between a youth and two operational staff members.

Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report


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: Staff did not attempt de-escalation or a lesser intervention prior to utilizing a restraint.


summary: 748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being

raw_content: Two caregivers were involved in a physical restraint of a child, and staff members failed to ensure that signs of distress were monitored appropriately during the restraint.


summary: 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway

raw_content: An operational staff member placed a child in a prone and supine position during a restraint on a couch. The staff member failed to discontinue the restraint when the child verbally indicated that he was having difficulty with breathing.


summary: 748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute.

raw_content: An operational staff member exceeded the required time limit when utilizing prone and supine restraints as required in Minimum Standards.


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

raw_content: During a monitoring inspection, it was found that one out of four staff files reviewed there was no documentation of any contact with the applicant's previous employers.

Correction Narrative:
The operation sent the following corrections:

Shiloh is responsible for conducting Pre-Employment screening for each applicant. If the applicant is hired, documentation of the results of any contact with an applicant's previous employers related to employment verification must be maintained in the applicant's personnel file. The following actions address this deficiency-

 Reviewed the Shiloh policy 1.4 Record of Employment regarding personnel records and identified policy to follow Standard 748.751(b)(2). No additional action is needed regarding the Shiloh policy 1.4 Record of Employment.
 The Shiloh Human Resources Director received a memo regarding the noncompliance related to Standard 748.751(b)(2) and the Shiloh policy 1.4 Record of Employment. The memo included directives regarding the Human Resource Director's role in ensuring documentation of the results of any contact with an applicant's previous employers related to employment verification is maintained in the applicant's personnel file.
 Shiloh will conduct spot-check audits of future-hire employee files to ensure compliance with Standard 748.751(b)(2).


summary: 748.2951(d) - Evaluation-Results of each overall  annual evaluation made available to Licensing for review.

raw_content: The operation did not have an overall annual EBI evaluation for review.

Category: Emergency Behavior Intervention

Correction Narrative:
The operation sent over the following corrections:

Shiloh is responsible for conducting and maintaining the Overall Annual EBI Evaluation Review. The following actions address this deficiency-
 Reviewed the Shiloh policy 6.1.1.5 Review of the Behavior Management Program and determined updates were warranted to ensure clarity with Standard 748.2951(d). Shiloh policy 6.1.1.5 Review of the Behavior Management Program was updated.
 Training will be provided to the Director for Quality Improvement regarding the updated Shiloh policy 6.1.1.5 Review of the Behavior Management Program and the development of the overall annual EBI evaluation.
 Shiloh will complete an overall annual EBI evaluation at the end of the 4th quarter and ensure it is available to Licensing upon request.


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

raw_content: During a monitoring inspection staff files reviewed did not include the personnel's job description.

Correction Narrative:
The operation sent the following corrections in addition to the updated job description:

 Reviewed the Shiloh policy 1.4 Record of Employment regarding personnel records and determined updates were warranted to ensure clarity with Standard 748.363(4). Shiloh policy 1.4 Record of Employment was updated.
 The Shiloh Human Resources Director received a memo regarding the noncompliance related to Standard 748.363(4) and the updated Shiloh policy 1.4 Record of Employment. The memo included directives regarding the Human Resources Director's role in ensuring a current job description is included in each current employee's file.
 Shiloh will conduct an audit of current employee personnel records to ensure compliance with this standard.
 Shiloh will conduct spot-check audits of future-hire employee files to ensure compliance with Standard 748.363(4).


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

raw_content: During a monitoring inspection a staff record reviewed did not contain a copy of a high school diploma to indicate that they qualify for their position at the operation.

Correction Narrative:
The operation sent the following corrections:

Reviewed the Shiloh policy 1.3.1.1.6. Employee Qualifications, regarding personnel records and determined policy follow Standard748.363(2). No additional action is needed regarding the Shiloh policy 1.3.1.1.6. Employee Qualifications.
 The Shiloh Human Resources Director received a memo regarding the noncompliance related to Standard 748.363(2) and Shiloh policy 1.3.1.1.6. Employee Qualifications. The memo included directives regarding the Human Resources Director's role in ensuring the appropriate documentation is maintained within the personnel record as part of the applicant screening process for hiring qualified employees.
 Shiloh will conduct an audit of current employee personnel records to ensure compliance with this standard.
 Shiloh will conduct spot-check audits of future-hire employee files to ensure compliance with Standard 748.363(2).


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

raw_content: The unauthorized absence log does not have the required components such as the child's age, gender or date of admission.

Correction Narrative:
The operation sent the following corrections, in addition to sending an updated unauthorized absence log:

Shiloh is responsible for maintaining the Unauthorized Absence Annual Summary Log. The summary log includes name, age, gender, date of admission. The following actions address this deficiency-
 Reviewed the Shiloh policy 6.6 Unauthorized Absence (Runaway) and determined updates were warranted to ensure clarity with Standard 748.453.(a)(1). Shiloh policy 6.6 Unauthorized Absence (Runaway) was updated.
 Training will be provided to the Lead Shift Supervisor, Treatment Director, and Director for Quality Improvement regarding the updated Shiloh policy 6.6 Unauthorized Absence (Runaway) and the revised Unauthorized Absence Annual Summary Log.
 Shiloh will maintain the Unauthorized Absence Annual Summary Log according to the updated Shiloh policy 6.6 Unauthorized Absence (Runaway) and the revised Unauthorized Absence Annual Summary Log.


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: A caregiver aggressively shoved a 13-year-old child in care on three occasions during a struggle over the caregiver's personal items.

Correction Narrative:
As of 8/28/25, the caregiver involved with this investigation is no longer employed by the operation. Shiloh will conduct refresher training with direct care staff regarding policy 6.1 Behavior Management and Treatment Program Established and Appendix A: Behavior
Management Guidelines and Training Modules specifically regarding Crisis Prevention
and Intervention, Treatment Modalities and Intervention and the utilization of De-
Escalation strategies.


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

raw_content: During a DFPS investigation, it was found a 13-year-old child in care was neglectfully supervised when a caregiver repeatedly failed to de-escalate her.

Correction Narrative: As of 8/28/25, the caregiver involved in this RTB is no longer employed at Shiloh Treatment Center.  They will conduct a refresher training with direct care staff regarding Child Rights  to provide clarity regarding the requirement to comply with a child's individual treatment plan and use of de-escalation techniques to prevent neglectful supervision.


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 13-year-old child with documented high-risk behaviors was not adequately supervised, and proper de-escalation techniques were not utilized by direct care staff.

Correction Narrative: The staff involved with this investigation is no longer employed with the operation as of 8/28/2025.  Shiloh will conduct refresher training with direct care staff regarding caregiver responsibility, with a specific focus on adequate supervision and proper de-escalation techniques.


summary: 748.1337(b)(1)(A)(vi)(I) - Initial Service Plan - Normalcy - Include plans for social, extracurricular, recreation, and leisure activities

raw_content: The review of two children records found normalcy was not addressed in the children's service plan.

Correction Narrative: Shiloh is responsible for ensuring that normalcy is addressed with the child within their service plan. Shiloh must include plans for normalcy to include social, extracurricular, recreation, and leisure activities. Shiloh's case managers received a memo of the standard and the requirement to have normalcy addressed within the service plan. Shiloh will conduct spot-check audits of service plans to ensure that normalcy is being addressed.


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

raw_content: One of the children records reviewed found the last service plan review was completed on February 20, 2025.

Correction Narrative: Shiloh is responsible for ensuring that a service plan receives a review at least 90 days from the date of the last service plan. Shiloh's case managers received a memo of the standard and the requirement to complete service plan reviews at least 90 days from the date of the last service plan. Shiloh will conduct spot-check audits of service plans to ensure they are completed at least 90 days from the date of the last service plan.


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

raw_content: The review of two restraint reports showed the basis for EBI was not an emergency situation.

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


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: The review of two children records found that both children who are over the age of 6 did not sign the Child's Rights statement acknowledging they have read and understood the listed rights.

Correction Narrative: Shiloh is responsible for ensuring that the child is informed of their rights and that an acknowledgment form is signed and a copy is filed in the child's record. Within seven days after admission, Shiloh will review the child's rights with the child and provide a copy of the child's rights within the client handbook. Shiloh's intake coordinators received a memo of this standard and the requirement to have the child review and acknowledge in writing of receiving the child's rights. Shiloh will conduct spot-check audits of admission/orientation paperwork to ensure the child receives the child's rights and the acknowledgement form has been signed.


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

raw_content: One staff record reviewed missing proof of education.

Correction Narrative:
Shiloh's Human Resources Director will ensure all employees have proof of education
in their personnel file prior to their hiring date. The HR Director will verify their education
by providing a degree, high school diploma, GED, or transcripts to ensure compliance
with this standard. The HR Director has a checklist in place to ensure all pertinent
documentation is in the personnel file. That checklist is audited through a spreadsheet
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for all employees to ensure no documentation is missing.


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

raw_content: Three children records reviewed were missing TB screening results.

Correction Narrative:
Shiloh will obtain records of a TB exam from the parent/guardian prior to admission. If
Shiloh is unable to obtain the TB exam records within the first 7 days of admission,
Shiloh will administer a TB screening. Shiloh's medical department created a TB
screening consent form to be signed by a parent/guardian at the time of admission.
PPD skin tests will be completed on all admissions with consent from the
parent/guardian starting on 2/20/2025. (See below: Consent for Tuberculin Skin Test.)


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

raw_content: Four staff records reviewed were missing documentation of current CPR/First Aid certificate.

Correction Narrative:
The four staff who were missing documentation of current CPR/First Aid certificates
were removed from duties and not counted in the caregiver ratio for the facility. The four
staff have been scheduled to receive their CPR/First Aid certificate. The Training
Director has a notification system that will alert when a staff's CPR/First Aid certificate
will expire within 30 days. The staff's supervisor will be notified of the upcoming
certificate expiration to ensure completion. If the staff fails to obtain re-certification then
that staff will be removed from duties until a certificate is provided.


summary: 748.125(c)(1)(A) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes risk & protective factors, and warning signs.

raw_content: Documentation of suicidal training that covers the risk factors, protective factors, and warning signs of suicide was missing in three staff records reviewed.

Correction Narrative:
The three staff who were identified as missing the annual suicide training have been
employed for approximately 90 days. All three staff will receive their annual suicide
training within 12 months from their date of hire. Shiloh offers an annual suicide training
through AS+K Basic Gatekeeper Training.


summary: 748.1501(a)(1) - Dental care-Children in care must receive dental care initially  according to the requirements in 748.1225

raw_content: Two children did not received their dental exam within 90 days of admission.

Correction Narrative:
The two clients that were identified as not receiving a dental exam within 90 days of
admission were Nevada clients. Shiloh's medical department contacted several
providers in the area about contracting with Nevada Medicaid. In the meantime, Shiloh
has scheduled dental appointments for the two clients and will pay out of pocket. Clients
that do not have a dental exam within 90 days of admission have been scheduled for an
appointment. Moving forward, Shiloh has a documentation to obtain dental examination
records within the past year from admission as well as a spreadsheet checklist and
calendar reminder to schedule a dental examination to the other clients who require a
dental examination within 90 days of admission.


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

raw_content: Immunization record was missing from one of the children's records reviewed.

Correction Narrative:
Shiloh's medical department provided the admission department with a checklist that
includes Immunization Records needed for admission. After review of the client
immunization records, Shiloh's medical department will obtain parent/guardian consent
and vaccinate clients that are past due for immunizations. Shiloh's medical department
also has a spreadsheet for all current clients to ensure immunization records are either
received or will be administered while in care.


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

raw_content: Two staff records reviewed were missing documentation of the results of any contact with an applicant's previous employers. Two other records did not include results of contact from all previous employers prior to application date.

Correction Narrative:
Shiloh's Human Resources Director will contact each applicant's previous employer
prior to their hire date. The HR Director will document the results including the date of
verification of employment and place the results in their personnel file. The HR Director
4
has a checklist in place to ensure all pertinent documentation is in the personnel file.
That checklist is audited through a spreadsheet for all employees to ensure no
documentation is missing.


summary: 748.861(b)(3) - Pre-Service Training - Supervised experience must be documented in personnel record

raw_content: One staff record reviewed is missing documentation of supervised experience training.

Correction Narrative:
Shiloh's Supervisors are responsible for ensuring that staff have 40 hours of supervised
child-care experience. Once that supervised child-care experience is complete, the
Supervisor will submit that documentation to the Human Resources Director to be
placed in the personnel file. The Training Director will contact the Shift Supervisor within
30 days of the staff's start date to ensure the supervised experience training document
has been completed. Supervisors received notification of the deficiency of missing
documentation of supervised experience training.


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

raw_content: All eleven interviewed children reported that they were not familiar with the administrator's name since their placement. Five of seven direct care staff identified someone else as the administrator. Additionally, all staff reported that staff meetings have been conducted by shift supervisors or trainers. The administrator acknowledged that her school responsibilities may have limited her involvement in her role at the RTC.

Correction Narrative: The agency has designated Mr. Douglas Plaeger to be the administrator of the operation effective upon approval from licensing. Agency will update their governing body/administrator accordingly.


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

raw_content: A staff member did not use prudent judgement and self-control while trying to de-escalate a child having maladaptive behaviors which led to the child being injured.

Correction Narrative:
Director sent email stating the staff member involved has been released from his employment before completing additional training.
Shiloh scheduled a refresher training on Safe Crisis Management (SCM) which included de-escalation techniques and emergency behavior interventions (personal restraints) for staff on both shift 1 and shift 2; the SCM trainer further discussed the use of self-control while attempting to de-escalate a child and, if possible, calling for assistance from another staff or supervisor. The training was completed on 1/13/25. Copy of Training Roster provided to licensing rep during the follow-up monitoring inspection on 1/25/25. Copy uploaded on Document Library.


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: The staff used corporal punishment as a means to get a child to comply.

Correction Narrative:
Staff member was suspended and later released from his employment at the operation. The operation scheduled a refresher training and Safety Crisi Management for all staff.
Shiloh prohibits the use of corporal punishment as a form of discipline or behavior management. Regardless of the interpretation of corporal punishment, a staff member did not use prudent judgement and incorporated furniture during the incident which resulted in injury. As a result, the staff was immediately suspended and later released from the company. Shiloh scheduled a refresher training on Safe Crisis Management (SCM) which included de-escalation techniques and emergency behavior interventions (personal restraints) for staff on both shift 1 and shift 2; the SCM trainer further discussed that the use of furniture during an incident is strictly prohibited.
The training was completed on 1/13/25. Copy of Training Roster provided to licensing rep during the follow-up monitoring inspection on 1/25/25. Copy uploaded on Document Library.


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

raw_content: A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.A child was injured by a staff member after an accident.

Correction Narrative:
Director sent email that staff member was suspended then released from employment. The operation scheduled a refresher course in Safe Crisis Management for additional staff.
Shiloh has a zero-tolerance policy for abuse, neglect, and exploitation of children. Once the supervisor observed that the child sustained serious injury by staff, that staff member was immediately suspended and later released from the company. Shiloh scheduled a refresher training on Safe Crisis Management (SCM) which included de-escalation techniques and emergency behavior interventions (personal restraints) for staff on both shift 1 and shift 2; the SCM trainer further discussed that Shiloh has a zero-tolerance for abuse, neglect, and exploitation of children.
The training was completed on 1/13/25. Copy of Training Roster provided to licensing rep during the follow-up monitoring inspection on 1/25/25. Copy uploaded on Document Library.


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

raw_content: While reviewing staff files, 4 out of 6 staff files did not contain job descriptions.

Correction Narrative:
Shiloh utilizes a Job Description & Performance Appraisal form. This form identifies the job
title, department of service, supervisor, minimum qualifications, and general purpose (description) of the position. This form also identifies elements of performance that will be evaluated during the employee's performance appraisal. All new hires receive this form
and sign a copy for their personnel records. The same form is then used during the performance appraisal. There will be quarterly auditing to ensure that it is in the files.


summary: 748.3395(b)(3) - Hand-washing-Provide hand-washing sinks with hot & cold running water under sufficient pressure to meet the demands of children

raw_content: When conducting a walk through in the girl's unit, it was observed that one of the hand washing sinks did not have sufficient hot water pressure.

Correction Narrative:
Once it was reported that a hand washing sink did not have sufficient hot water pressure,
a Maintenance and Housekeeping Report was filed for the facility manager to address. Hot
water pressure was restored to the hand washing sink in the girls unit. All hand washing
sinks were checked and confirmed to have sufficient hot water pressure.


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

raw_content: While reviewing employee files, it was observed that 1 out of the 6 files reviewed did not conduct reference checks.

Correction Narrative: Shiloh conducts a verification of reference with potential employees. The form is completed and filed within the employee's personnel file.


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

raw_content: One of the two first aid kits did not contain tweezers.

Correction Narrative: Once it was reported that one of the first aid kits did not contain tweezers, facility staff checked all remaining first aid kits. Staff confirmed that tweezers were in each kit, and any kit that did not contain tweezers had a new set placed in the first aid kit. An additional set of tweezers were issued to each teaching home so as to have a set for daily use as well as a set for medical use inside the first aid kit.


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: While conducting a walkthrough of the girls unit, it was observed that the cleaning supplies were accessible and not locked back.


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

raw_content: The last weather drill was not completed within the last six months.

Correction Narrative: The safety director will ensure that the drill is actually conducted, and it not just be a training for the staff.