summary: 748.1111(a)(2) - Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP

raw_content: The policies and procedure documented on page 29 state that a child's phone calls may be screened with a notification only.

Correction Narrative:
Policies were updated to include: a.	Youth may make phone calls to their families and friends on a regular basis.
i.	Phone calls made by youth to their families and friends will last for a standard determination of time to ensure all youth in care have the opportunity to make calls.
ii.	Some limitations may be placed on the frequency and duration of family telephone calls in order to allow for fair use of the telephone by all youth in the program.
iii.	If a family situation requires more frequent contacts, the case manager or designee, facilitates the contacts.
b.	In order to verify approved contacts, and update families on the youth's progress, each phone call begins and ends with staff speaking to the party the youth has called. Staff members do not listen to telephone conversations (please see the policy titled Child Rights for further information).


state: TX

facility_name: MiOwn Home, LLC

summary: 745.903(1) - Controlling Person - Submit a Controlling Person Form to the local Licensing office when applying for a permit. See TAC 745.901

raw_content: The Administrator will require a controlling person's form.

Category: Individual Standards Evaluated

Standard Risk Level: High

Corrected at Inspection: No

Correction Narrative: The operation submitted appropriate controlling persons forms.


summary: 748.101(2)(B) - Plans to submit - Fiscal plan - documentation to reserve funds or available credit at least equal to operating costs for first 3 months

raw_content: The purpose of this rule is to ensure that your operation is financially in the position to care for children without immediate reimbursements. Documentation to support adequate funds was last generated 02/2021. It is recommended that statements represent the most current statement period.

Category: Organization and Administration

Standard Risk Level: Medium

Correction Narrative: The operation submitted an updated budget and verification of funds.


summary: 748.101(1) - Plans to submit - Operation plan

raw_content: The operation plan does not include names for the governing body members.

Standard Risk Level: Low

Correction Narrative: Updates were included to add the governing body's names and it corresponds with the controlling persons forms submitted.


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

raw_content: The fire inspection documents violations that require corrections. It also indicates that the inspection was completed for a foster home.

Category: Safety and Emergency Practices

Standard Risk Level: Medium High

Correction Narrative: An approved fire inspection was completed on 07/09/2021.


summary: 748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers

raw_content: The Administrator does not live in the area. The Administrator will be present 30 hours a week. The staffing plan should support how this will be accomplished.

Correction Narrative: The staffing plan was updated to explain how the rule will be met, by 3 days a week, 10 hours a day. It is in compliance with standards.


summary: 748.115(4) - Discipline policy - Include the importance of nurturing behavior, stimulation, and promptly meeting the child's needs

raw_content: This standards is not addressed in the policies and procedures.

Correction Narrative:
Updates were made to state that: h.	In order to avoid escalating situations in which disciplinary measures have to be taken, it is important for staff to nurture and stimulate the youth in care and promptly respond to and meet their needs. Youth who are stimulated by a structured and organized environment, and are encourages and supported, are less likely to engage in behaviors that require consequences.
i.	To create a nurturing environment, staff should: always be present, both verbally and non-verbally, in each interaction with a child; provide comfort and support when/if needed and in a timely manner; provide a safe physical, mental, and social environment; and promote healthy boundaries and relationships with peers and adults. j.To provide stimulation, it is important for staff to follow the program schedule at all times. This allows youth to develop a routine and provides a structured, organized environment to allow the youth to thrive. The program schedule also provides youth with ample opportunities for activity and stimulation on a daily basis.


summary: 748.903(c)(9) - Pre-service training for emergency behavior intervention-Includes drawings, photographs, videos of each personal or mechanical restraint

raw_content: EBI ciriculum was submitted. There were no visual representation of the holds.

Category: Training and Professional Development

Correction Narrative: The operation submitted photographs of EBI techniques which will be used at the operation. All are in compliance with standards.


summary: 745.243 - Complete Application

raw_content: The application states that protective and supportive devices will be used. It was explained that this is not being offered as a part of the restraint process.

Standard Number / Description: 745.243 - Complete Application

Corrected at Inspection: Yes


summary: 748.3601(1) - Swimming Pool-At least two life-saving devices must be available, such as a reach pole or buoy

raw_content: The operation has 1 life saving device. An additional one should be purchased.

Category: Physical Site

Correction Narrative: The operation submitted receipts and photographs of a rescue pole.


summary: 748.107(1) - Conflict of interest policies - Code of conduct on the relationship between owners, employees, contractors, children, & families

raw_content: The policy has a statement for youth served but does not have a policy for conflict of interest for childrens families found on page 14.

Correction Narrative:
Policies were updated to state that I.	All employees (and owners, contractors and volunteers, if applicable) are prohibited from having contact or any form of relationship with a youth and/or their family outside of their scope of responsibilities at MiOWN Home, including when a youth is no longer in our care.
a.   Staff are prohibited from doing personal favors for youth and/or their families.
b.   If a staff member knows a youth and/or their family or has a pre-existing       personal relationship with the youth and/or their family prior to the youth and       family's involvement with MiOWN Home, the employee must immediately disclose this information so that the appropriate steps can be
taken to mitigate a potential conflict of interest or the appearance of a conflict of interest. This notification must be in writing to the child care administrator.


facility_name: Victorious Residential Care LLC

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

raw_content: A youth in care sustained an injury on 1/15/2026 and did not receive medical attention until 1/18/2026.

Correction Narrative: The operation ensured that the child received the necessary medical attention. Additionally, the administrator of the operation held a meeting with the team and case manager to discuss the protocol to follow when a child has a medical issue or injury. The protocol establishes that the supervisor, LCCA, and case manager must be contacted immediately so that the youth could be transported to receive medical attention.


summary: 748.1101(b)(7) - Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously

raw_content: A staff member declined a child's request to contact the ombudsman to file a complaint.

Correction Narrative:
On January 26, 2026, the operation's administrator stated that they conducted an impromptu meeting with the staff to discuss the protocol for facilitating phone calls to the Ombudsman. The protocol stipulates that all staff must ensure that all youth are permitted to make phone calls on request to make a report.

RCCR conducted an on-site follow-up, during which operation staff were interviewed and confirmed that staff received training on reporting to the Ombudsman. All employees signed a statement of understanding that all children have the right to call the Ombudsman when requested. The RCCR Inspector reviewed the training sign-in sheet and the signed employee statement of understanding. During the site visit, the phone numbers for making complaints were clearly posted in a prominent location. Furthermore, a child was interviewed and confirmed that they are informed of their right to call Ombudsman or the hotline to file a report.


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

raw_content: It is important to have all food products off of the floor to ensure the health of the children in care.

Correction Narrative:
Email: On 11/04/2025 the operation provided a compliance response stating that moving forward all staff will ensure that food is stored off the floor and is safe and sanitary.
Operation corrected concern during inspection. Email follow-up approved by RCCR Program Director.


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

Correction Narrative:
"Victorious Residential Care LCCA had a team meeting with staff on 11/21/2025 at 11am to discuss team responsibilites and included that all staff should work as a team in the workplace and use their better or good judgement when working with our youth and refrain from using cellphones and laptops when a youth is in a crisis. Victorious Residential Care also asked that all staff sign the employee expectations acknowledging that each employee must:
In the absence of a more specific rule requirement, demonstrate competency, prudent judgment,
and self- control in the presence of children and when performing assigned responsibilities."


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: A children's file was missing a TB test.

Category: Child Care

Correction Narrative: Operation provided a compliance plan by email stating that they will ensure that all persons over the age 1 has a TB skin test completed. The child missing the TB test had one completed on 08/08/2025.


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: Children's orientations were not completed.

Category: Admission, Service Planning, Discharge

Standard Risk Level: Medium Low

Correction Narrative: The operation provided a compliance plan by email. Operation states that they have completed an orientation packet for all residents. The orientation packet was reviewed with all residents and all residents have signed the orientation packet. Moving forward, the operation will complete an orientation packet with the resident within 7 days of the date the resident have been admitted.


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: Caregiver's form pre-employment affidavit was not completed.

Correction Narrative: The operation provided a compliance plan by email. Operation states that they have completed Form 2912 with all current employees and moving forward all new employee will complete the Form 2912 before hire.


summary: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force

raw_content: A caregiver used unnecessary force when she refused to walk away and restraint a child while the child was being aggressive.

Correction Narrative: Operation provided a corrective plan stating on 4/21/2025 at 12:00 PM Victorious Residential Care staff will receive additional training regarding EBI use. Caregivers  will learn preventive and additional de-escalation strategies to help them work through situations, emergencies and crisis. In the training an outline on who to call when there is an emergency and appropriate procedures to deal with a crisis and de-escalate situations.


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

raw_content: The first aid kit was missing scissors including a few other items.

Correction Narrative:
Victorious Residential Care has purchased a
new first aid-kit that includes scissors, tweezers,
Q-tips, and other items needed in the first aid
kit.


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

raw_content: There is no documentation of a weather drill.

Correction Narrative:
Victorious Residential Care completed a
weather drill on July 7, 2024 at 1:00pm and has
completed the necessary documentation for it
that includes the drill type, date, type of drill,
length, and time of evacuation and relocation.


summary: 748.311(10) - Serious Incident Documentation-Includes resolution of the incident

raw_content: One of 10 incident reports reviewed did not contain a resolution to an incident. Another report reviewed was missing information.

Correction Narrative: The operation provided a new incident report form that has it outlined to include the resolution.


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

raw_content: One of three child records did not contain a copy of the child rights. One of three records reviewed had a copy of the child rights with a late signature.

Category: Children's Rights

Correction Narrative: The operation stated that they will ensure that all child rights are signed within 7 days of child's arrival.


summary: 748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs

raw_content: Three of three records reviewed did not contain the possible side effects of medication.

Correction Narrative: The operation emailed the preliminary service plan that contained the required information for medication side effects.


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

raw_content: Preliminary plan does not address supervision requirements  for child in care.

Correction Narrative: Agency provided updated preliminary service plan to include supervision requirements as well as for future use.


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

raw_content: The fire inspection is out of date for the operation which poses a safety concern for children in care.

Correction Narrative: The operations fire inspection was completed on October 25, 2023, and they received the completed inspection report on October 31, 2023. The operation has also provided a corrective action plan on how they plan to prevent this issue from taking place again in the near future.


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

raw_content: Facility failed to notify licensing timely about the Administrator's resignation.

Correction Narrative:
The operation submitted the following corrective action plan:
The agency is taking the proper steps in hiring a new hiree for the LCCA position after resignation of the previous LCCA's short notice of termination. The Executive Director meets with a potential LCCA hiree on 09/26/2023 at 1:30pm who is willing to work full-time with at the agency. Victorious Residential Care will take the initiative and proper steps moving forward to ensure that licensing is notified within 30 days of a change in child-care administrators and ensure that the LCCA signs a contract asking that they provide a 30 day notice of termination.


summary: 748.363(7) - Personnel records - Include statement signed and dated by the employee that he has read a copy of the operational policies

raw_content: While inspecting the personnel file, the record was missing required documentation.

Category: Reports and Record Keeping


facility_name: Pathways 3H Youth Ranch

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

Correction Narrative: All staff were retrained on child's rights; sign sheet and agenda were provided.


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

raw_content: Incident report was not consistent with interviews conducted.

Correction Narrative: All staff were retrained on completing accurate records. Sign in sheet and agenda were provided.


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

raw_content: Staff smacked the glasses off the face of a child in care.


facility_name: Harmony Therapy and Treatment Center LLC

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

raw_content: The operation did not have an annual summary log of unauthorized absences for review.

Correction Narrative:
The operation sent the following corrective action plan on 04/29/2026:

The operation took the following steps to enter compliance:
   -Created a standardized Unauthorized Absence Annual Summary Log.
   -The Program Director will review all incident reports (SIRs) for the current year and enter all applicable unauthorized absence incidents into the log.
   -The log will be placed in a designated compliance binder for immediate access.
   -All direct care staff and supervisors will receive training on the definition of unauthorized absence and use of the annual summary log. Training will be completed by: 04/30/2026

Compliance Assurance
   -The Administrator will conduct quarterly compliance reviews. Any discrepancies will result in immediate corrective action and additional staff training if patterns are identified.

An annual unauthorized absence summary log template was received from the operation. There were no concerns for violations of Minimum Standards.


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

raw_content: Caregiver did not provide adequate supervision to child who was suspected to be under the influence in a potentially dangerous environment.

Correction Narrative:
Email form operation 4/14/26 stating that staff was provided with refresher supervision training 3/18/26.

Corrections submitted via email 3/16/26:
1. Transportation Safety Protocol
Facility has implemented additional transportation safety procedures when youth are being transported for medical or behavioral emergencies. These procedures include:  When risk factors are present, two staff members will transport youth for emergency medical evaluations whenever possible. Or call 911 for emergency transport
2. Supervision Refresher Training
Staff will receive refresher training on Minimum Standard 748.685(b)(4) and the importance of assessing supervision levels based on environmental risks, youth behavior, and safety concerns.
3. Administrative Monitoring
For the next 60 days, the Program Director will review incidents involving supervision to ensure staff follow the updated procedures and supervision expectations.
4. Person Responsible
Program Director
5. Date of Completion
All corrective actions and training will be completed by March 19, 2026.


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

raw_content: Two of three employee records did not state the date of hire.

Correction Narrative:
Dates of hire were verified and added to all affected employee records.
Personnel records were reviewed for completeness.
Preventive Measures
Personnel file checklist updated to include required employment dates.
Administrator will verify documentation prior to finalizing personnel files.


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: There were no severe weather drills to review at the operation.  This was cited in November of 2025, and it was reported a drill was completed on 11/6/25, but staff could not locate the drill.

Correction Narrative:
Drill was located and placed in the emergency preparedness file. Also in document library.
Preventive Measures
Emergency drill calendar established.
Administrator will review drill logs quarterly.


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 of the three personnel files were missing documentation regarding contact with previous employers prior to hire.

Category: Personnel

Correction Narrative:
All current personnel files were audited.
Missing employer contact documentation was located for affected staff.
Documentation was placed in each employees personnel file.
Preventive Measures
A Pre-Employment Screening Checklist has been implemented and must be completed prior to the first day of employment.


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

raw_content: Both the refrigerator and freezer had thermometers, but neither were showing appropriate temperatures of 40 degrees (showed 48 degrees) or 0 degrees (30 degrees) or below.

Correction Narrative:
Refrigerator and freezer temperatures were immediately adjusted. Pictures in document library.
Daily temperature checks were initiated.
Preventive Measures
Temperature logs are now completed and reviewed daily.
House Manager reviews logs weekly.


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

raw_content: The serious incident reports did not contain the operations physical address or phone number.

Correction Narrative:
On 02/10/2026, the Case Manager submitted a formal support ticket to NewOrg requesting modification of the incident report template to include:
Physical Address
Telephone Number
Documentation of the support ticket has been retained.
Effective immediately, Harmony Therapy and Treatment Center began utilizing DFPS Form 2991, which includes the operation name, number, address, and required identifying information, to ensure full compliance pending the New Org system update.


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

raw_content: None of the windows used for ventilation at the operation had screens. There were two broken windows in the facility that have not been fixed--even though a work order was requested three months prior.

Correction Narrative:
Screens were installed on all windows. Pictures in document library.
Preventive Measures
Administrator will verify completion of all work orders.


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: Two of the three employee files did not have documentation showing the references were contacted.

Correction Narrative:
Written reference verification forms were added to each personnel record.
Preventive Measures
A Reference Verification Form is required for all applicants.
Applicants will not be cleared to work until both references are verified and documented.


facility_name: A Positive Change RTC LLC

summary: 748.311(10) - Serious Incident Documentation-Includes resolution of the incident

raw_content: Two serious incident report reviewed and both did not have interventions or resoluution to incident.

Correction Narrative: Owner sent in compliance plan reflecting staff will be retrained on SIR documentation requirements, SIR's will be reviewed by a supervisor within 24 hours to ensure compliance, and the facility will conduct weekly audits for 60 days. Any staff who do not complete documentation accurately will get training or if necessary disciplinary action.


facility_name: Caring Companions LLC

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

raw_content: During the investigation inspection, the electrical socket was observed cracked, granting access to wires, the carpet on the second floor was ripped in one of the residents bedrooms, one of the window blinds had several broken panels, front of the dish washer is missing, paint needs to be replaced in one of the residents bedrooms on the second floor and a urine stained mattress was observed in the closet of one of the residents.

Correction Narrative:
During unannounced inspection, the carpet was was replaced, front of dishwasher was replaced, mattress was not present at operation, walls were painted on hallway and bedrooms, electrical socket replaced.

One window had blinds missing, but a work order was provided.


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

raw_content: The medication storage cabinet was observed unlocked during the investigation inspection.

Correction Narrative: During unannounced inspection, the medication room and medication storage cabinet was locked.


facility_name: Brooklow's House LLC

summary: 748.2151(g) - Medication record-medication records of prescription & non-prescription medication dispensed to the child must be incorporated into child's record

raw_content: Two medication logs for 2  seperate children in care contained medication logs for 2 other individuals.

Category: Medication

Correction Narrative:
The operation submitted the following corrective action plan response:
A training was held on 05/13/25, to discuss the standard and ensure all staff were aware of the appropriate documentation and storage requirements.


facility_name: Amor Purus LLC

summary: 748.2853(1) - EBI Documentation-Date and time the caregiver offered the post discussion to the child

raw_content: The caregiver did not document the date and time the child was offered the post EBI discussion.

Correction Narrative:
The operation updated procedure and electronic system for documentation. Updated incident report templates now include mandatory fields that require staff to document the specific restraint technique utilized, precipitating factors, duration of the intervention, and the exact date and time a post-EBI discussion offered to the child. Reports cannot be finalized unless all required fields are completed, ensuring completeness and accountability.

Supervisory oversight has been significantly increased to reinforce compliance. Shift leads are now responsible for verifying that all incident documentation is completed prior to the end of each shift. In addition, the LCCA and Executive Director conduct routine audits of EBI documentation a minimum of three times per week to ensure accuracy, completeness, and timeliness. Any discrepancies identified are addressed immediately, and corrective action is implemented within 24 hours.

Staff were completed EBI retraining on 03/02/2026.


summary: 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

raw_content: The parent of a child in care was not informed in writing after a personal restraint was implemented.

Correction Narrative:
The operation updated policy and procedure to ensure the parent is notified of EBI implementation timely. Moving forward written parent notification will now be initiated on the same day of the incident. Documentation of the notification includes the date, time, method of communication, and staff responsible. Leadership reviews notifications daily to ensure all communication is completed well within the 72-hour requirement outlined by DFPS Minimum Standards.

Staff were completed EBI retraining on 03/02/2026.


summary: 748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention

raw_content: The caregiver did not document the specific restraint technique used timely.


facility_name: TRELS Home For Children

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

Correction Narrative: TRELS Home for Children Administrator will ensure compliance of all reasons medications are being administered, as well as audit new medications being added to the system to ensure their reason is listed.


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

raw_content: Carrots were found in the refrigerator with an expiration date of June 24th, 2025.


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: Operation failed to report quarterly EBI numbers for 1st quarter January-March 2025.

Correction Narrative: Moving forward the operation has agreed to make sure all EBI numbers are reported before the 15th of every quarter.


raw_content: The physical interior of the operation was observed with bugs/insects in the window seals of the children's bedrooms & the ceiling and the exist sign had spider webs and a clusters of insect debris.

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


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

raw_content: During the investigation it was found that a child was not supervised according to the special needs addressed in the service plan

Correction Narrative: Inspector interviewed four children in care and two staff members, and no concerns were noted.  Inspector observed the interactions between the staff and children and observed ratio and all children were observed to be appropriately supervised, and interactions were respectful and encouraging.  Inspector conducted a walkthrough of the operation and no risks to children were identified. Inspector reviewed one child's service plan regarding supervision requirements. Operation  is also changing window alarms to ensure the safety of children of care.


raw_content: During the walkthrough, it was observed in the living area wires exposed beneath the TV console, a broken switch cover in upstairs bathroom, damaged door upstairs, and no blinds or privacy screen on living room window. Also, during the inv walkthrough it was observed and cited for physical site concerns for living area wires exposed beneath the TV console, a broken switch cover in upstairs bathroom, damaged door upstairs, and no blinds or privacy screen on living room window the same monitoring concerns back in 8/20/24.

Correction Narrative: All physical site concerns has been brought into compliance observed by inspector during inspection.


summary: 748.2103(b) - Medication Destruction-Discontinued or expired meds & meds left at facility destroyed by health-care professional/pharmacist or LCCA & adult witness

raw_content: During the investigation it was found that discontinued medication was not destroyed

Correction Narrative:
An email was received from the operation's Administrator Da'Neisha Graham with the following corrections:

Staff will maintain the upkeep of the medications by checking medications and destructing medications when there is a new medications we will remove the medications and destruct medications.


summary: 748.683(2) - Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately

raw_content: Staff failed to properly de escalated an incident due not being properly trained.


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

raw_content: During the walk through of the property, one of the children's window had broken blinds.

Correction Narrative: Trels consistently conducts ongoing monitoring of the facility to identify any potential damage and promptly reports all concerns to the maintenance department. Although the reported item has been repaired, the investigator failed to request the corresponding maintenance record. An administrative review will be initiated to address this oversight.


summary: 748.2101(6) - Medication storage & destruction-remove discontinued medication immediately & destroy it in a way that ensures children do not have access to it

raw_content: A medication prescribed to a child in care was discontinued on January 12, 2024 and as of January 17, 2024 the operation had not discarded of it.


summary: 748.125(f)(2)(C) - Post hospitalization protocols must include removing harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt.

raw_content: A child in care had access to a razor after returning from the hospital.

Correction Narrative: Trels staff will follow protocol for youths that are coming from the hospital. Staff will follow safety plan regarding each youth in the home.


summary: 748.125(f)(3) - The operation must alert any persons responsible for the childs care or supervision of the new protocols and new or updated safety plan.

raw_content: A child in care was upstairs alone and was to be in the line of sight. The child was then able to self-harm.

Correction Narrative: Trels will make sure everyone is well aware of the safety plan and everyone is following supervision protocols.


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

raw_content: During the review of a child in care service plan another child was referenced.

Correction Narrative: Operation reported the error was system generated, the administrator and case manager will double checking CPOS to make sure there are accurate information/Name provided on CPOS.


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

raw_content: Meet-up locations inside the operation were not identified on the emergency evacuation map.

Correction Narrative: Trels Home For Children has added emergency evacuation on the map(s). TRELS Home For Children will always make sure there is an inside meet up location on the evacuation map.


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

raw_content: Water-Well observed outside without a lock device to prevent child access.  In addition, the attic in the home was observed without a lock to prevent child access.

Correction Narrative: There is a lock on the water well. The well also has an internal safety feature, an internal net, that prevents anyone from falling inside. TRELS Home For Children will ensure there is a lock on the well to prevent child access.


facility_name: TRELS Home for Children

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

raw_content: The operation has failed to designate a full-time administrator for this operation via the provider portal.

Correction Narrative: Staffed with supervisor and we agreed to mark it compliance since an approved variance is in place for the administrator.


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 staff member was sleeping during their work shift.

Correction Narrative: Deficiency has been corrected.


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

raw_content: A child in care missed a dose of medication due to it running out and the medication not being available on time in order to prevent the child from missing a dose.

Correction Narrative: The operation sent its correction via email. In its correction, the operation stated that on 1/13/25, a backup pharmacy protocol was established to address any future supply delays. The psychiatrist now has an assistant who will write prescriptions in her absence


raw_content: Medication administration record for a child in care was out of a prescription medication, for a chronic health condition, for several days before it was reordered.

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


summary: 748.2001(a) - Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications

raw_content: A child in care was given medication without consent of the parent/guardian/medical consenter, and communication regarding the operation to youth was minimal.


facility_name: A Better Choice ABC LLC

summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: The operation failed to self-report when a child in care was arrested.

Correction Narrative: Compliance was met when the administrator sent their serious incident template and an explanation of the incident that occurred.


summary: 748.949(b)(2) - Annual Training Documentation-Includes date of the training

raw_content: All training certificate submitted did not include the date of the training or the length of the training on the certificates.

Correction Narrative: The compliance was met when the administrator sent an audit check list.


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

raw_content: The admission assessments submitted did not include all the required information.

Correction Narrative: Compliance was met when the administrator sent a blank copy of the template.


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

raw_content: The preliminary service plans submitted by the operation were not signed by the PLSP.

Correction Narrative: The compliance was met when the administrator sent the updated template.


raw_content: There were multiple documents that contained inaccurate information.

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

Correction Narrative: Compliance was met when the administrator sent an audit check list.


facility_name: Jamsteld West Community Living - Ellie's House

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

raw_content: Cleaning supplies found under the kitchen cabinet.


facility_name: Hearthstone Support LLC

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

raw_content: Three children in care voiced witnessing the same staff sleeping.


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

raw_content: Child in care left the operation without staff being aware.


facility_name: Epiphany Soul

summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: Review of the child record did not show the allergies of the child printed on the outside of the cover.


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

raw_content: A review of the serious incident report was completed. The report was missing the complete address an phone number of operation.

Correction Narrative: Ms. Kimberly Tatum sent in a corrected incident report. It now contains the missing items such as address, phone number, and name of RTC on report.


facility_name: Concho Valley Home For Girls

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

raw_content: Both children and one staff reported a staff being demeaning, instigating, escalating situations and putting the children down.

Correction Narrative: RCCR inspector received a compliance email on 11/13/2025, from the operations director. Discussions with staff were held on 10/27/25 and 11/13/25, to include strategies to prevent power struggles and handle situations more constructively. Additionally, staff participated in a 4-hour TBRI training on 10/15/2025.


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

raw_content: Both children and one staffed stated a staff uses their cell phone to call and text constantly for personal reasons, while actively supervising on duty.

Correction Narrative: RCCR inspector received a compliance email on 11/13/2025, from the operations director. Discussions with staff were held on 10/27/25 and 11/13/25, to include strategies to prevent power struggles and handle situations more constructively and supervisory skills and limiting phone use during scheduled shifts. Additionally, random and unannounced checks will be conducted at the operation by the director for 90 days to ensure that staff are not using their phones excessively while on shift.


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: During the inspection, it was found that the operations last health inspection was last completed on 6/05/24, and an updated health inspection has not been scheduled.

Correction Narrative: A follow-up email was received by the Director on 7/21/25, with the attached health inspection report that was conducted on 7/14/25.


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

raw_content: During the inspection, it was found that 3 employees have only received an online training of administering psychotropic medications, and not an instructor led training in administering psychotropic medications.

Correction Narrative: An email was received from Concho Valley Home for Girls director on 8/01/25, with a memo for compliance of instructor led psychotropic medication training scheduled for 8/28/25.


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

raw_content: During the inspection, it was found that the operations last fire inspection was conducted on 4/25/24, and an updated fire inspection has not been completed.

Correction Narrative: A follow-up email was sent by the Director on 7/21/25, with the attached fire inspection report that was conducted on 7/14/25.


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

raw_content: During the inspection, there were 3 employee files that were missing documentation of educational requirements such as GED, High School diploma, and/or transcripts.

Correction Narrative: An email was received from Concho Valley Home for Girls director on 8/01/25, with compliance documentation of educational records for caregivers.


summary: 748.3065(b) - Gas Inspection-Must keep most recent inspection report at operation to verify inspection date & findings

Correction Narrative: An email was received from Concho Valley Home for Girls with a copy of the gas inspection.


summary: 748.3003 - Sanitation Inspection-Must keep most recent sanitation inspection report at operation; report must include name & phone number of inspector

Correction Narrative: On 6/10/24 I received an email from the operation with an attached health inspection form that was completed on 6/5/2024.


raw_content: All children interviewed reported staff yelling and cussing at children.  One staff admitted to yelling, cussing, and slamming their hand down on a table in anger.  Three children in care reported that one staff instigates and makes them angry on purpose to get a reaction from them. One staff reported a staff does instigate and escalate situations with the children in care.

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

Correction Narrative: Program Director emailed the follow up compliance plan to RCCR inspector on 5/15/24. One staff member was met with on 2/26/24 and 5/7/24. This staff member was re directed, counseled with extra teaching and training on how to not get into power struggles with residents, how to create better relationships with residents and learning to call for assistance when needed. The Program Director stated there have been no further issues regarding yelling, cussing or intimidation. The full compliance plan will be uploaded to the document library.


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

raw_content: One childs initial service plan was not signed by the child in care or service plan team

Correction Narrative: Program director provided the service plan signatures of child in care and service planning team.


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 in their records

Correction Narrative: Program Director provided the child in care's TB test and negative results.


summary: 748.1209(d) - Child Orientation-document in child's record when orientation occurred, any required information omitted, reason for any omissions

raw_content: The orientation in 2 childrens records were missing additional information regarding the operations policies

Correction Narrative: Program Director provided orientation packet that included all required minimum standards regarding the operations policies and procedures.


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

raw_content: There was no documentation on both initial and updated service plan that the CPS caseworker had participated or that a copy of the service had been provided.

Correction Narrative: Received the following response from Brittney Jones regarding the regulatory standard 748.1341(b). Ms. Jones stated in the future they will ensure that all e-mails requesting signatures are printed and put in the child's file immediately for documentation purposes. If they speak to the CPS caseworker via phone call, they will send a follow-up email for documentation purposes that will also be added to the child's file immediately. When caseworkers do not immediately sign the service plan, they will make sure to send follow-up requests to obtain the signature every 2-3 weeks and print those e-mails and add them to the child's file for documentation purposes. If they are unable to obtain the signature prior to the child's discharge from our facility, they will ensure that the caseworker signs the service plan before the child leaves our facility.


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 plan review was not completed timely.

Correction Narrative: Received the following email in response to the 748.1381(1) citation from Brittney Jones. Brittney stated in the future they will set reminders on the computer calendar to review service plans within 180 days of the last service plan. They will also make sure that the date is added to the child's file so that it is seen in multiple places when the service plan is due to be reviewed. They will also make sure that the date is added to the child's file so that it is seen in multiple places when the service plan is due to be reviewed.


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

raw_content: A 16 yo child in care participated in the service plan meeting but did not sign the service plan.

Correction Narrative: Received the following response regarding regulatory standard 748.1101(b)(5)(B) from Brittney Jones. Ms. Jones stated in the future they will take extra precaution ensure that all children sign the service plan or indicate if they refused to sign the service plan as soon as they are provided with a copy of the service plan. They will do this by highlighting areas that need to be signed the day the service plan is made and making reminder notes to ensure that the child signs.


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

raw_content: A caregiver was asleep while responsible for caregiving and did not respond to attempts to wake them.

Correction Narrative: The operation sent a letter detailing that the safety plan that was instituted during the investigation has been incorporated into their regular policies and procedures. This includes ensuring that staff do not take medications that cause drowsiness, do not work consecutive shifts so that they can get adequate sleep at home, doing unannounced visits and check ins via phone calls or in person visits to ensure that staff are awake, and discipline procedures for staff that are caught sleeping. The log detailing the check ins was sent as well.


raw_content: The operation's fire inspection is out of date

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

Correction Narrative: The operation sent passed fire inspections to this inspector


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

raw_content: The operation did not keep an annual summary log

Correction Narrative: On 6/10/2021 the operation sent this inspector compliance detailing that that an unauthorized absence log was created and filled in with the required information for unauthorized absences that have occurred.


summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested

raw_content: Police responded to a physical altercation at the operation that was not reported to the hotline

Correction Narrative: On 6/10/2021 the operation sent this inspector compliance detailing that a training was performed with staff that went over reporting and documentation standards related to serious incidents


summary: 748.863(a)(3) - Pre-Service Training-Caregiver for child-care or programmatic services only must have 8 hours EBI training, 4 pre-service & rest within 90 days

raw_content: A caregiver did not receive the 4 hours of EBI training within 90 days after caring for children.

Correction Narrative: On 6/10/2021 the operation sent this inspector compliance detailing that the staff received EBI training to fulfil the full 8 hour requirements and the EBI training certificate was sent to this inspector


summary: 748.4231(a)(5)(B) - Admission assessment for emergency and respite care services-must include child's understanding of the need for emergency care services

raw_content: The admission assessment did not contain the child's unstanding of the need for emergency services.

Category: Emergency Care

Correction Narrative: On 6/10/2021 the operation sent this inspector compliance detailing that the forms for orientation have been updated to ensure that the information in minimum standards is filled out by staff if the child's caseworker does not provide the information


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

raw_content: There was a serious incident regarding an arrest of a child in care that was not documented in a serious incident report


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

raw_content: One child's orientation did not include EBI policies or the child's preferred deescalation techniques.


facility_name: Meridell Achievement Center

summary: 748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.

raw_content: During the course of the investigation, it was determined that the incident resulted in a child being arrested on February 20, 2026. However, the operation did not notify Licensing til the 22nd.

Correction Narrative:
An email was received from the operation on 3.26.26. The following was explained-
Campus Administrator/Facility Risk Manager spoke with the Administrator on Call who made the late report about the situation and referred the staff member back to the provided materials in the AOC binder to reference when a report was necessary to be made to the TDFPS Hotline and the timeframe involved. The AOC made the report late.
Campus Administrator/Facility Risk Manager conducted refresher training with all AOC (Administrators on Call) and clearly reviewed the guidelines, expectations, and timelines about reporting serious incident to the TDFPS Hotline.  This training was held on 3/5/2026.
Training certificates were reviewed.


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

raw_content: Throughout the course of the investigation, it was determined that there are staff using profanity with children in care.

Correction Narrative: Interviews were completed with children in different units regarding discipline and staff professionalism. No concerns were noted. Additionally, corrective actions were reviewed for staff involved.


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

Correction Narrative: A walk through was completed of 4 units and ratio was in compliance. Interviews were completed with children in different units and no concerns were noted.Additionally, corrective actions were reviewed for staff involved.


facility_name: Bayes Achievement Center

summary: 745.8641 - Requirements during probation

raw_content:
Condition #1-Met
Condition #2-Met
Condition #3-Met
Condition #4-Met
Condition #5-Not Met
Condition #6-Met

Correction Narrative: A new calendar was created for observers highlighting the new Pitman schedules and the days that observations must occur for employees on those schedules. In addition, employees with other alternative schedules were identified and observation windows noted.


Standard Number / Description: 745.8641 - Requirements during probation

Deficiency Narrative:
Condition #1-Met
Condition #2-Met
Condition #3-Met
Condition #4-Met
Condition #5-Not Met
Condition #6-Met

Correction Narrative: A log of part-time staff was generated to complete the current month's observations. Moving forward, part-time staff will be included on the log generated by HR at the beginning of the month. Observers were also provided a copy of the part-time employee's schedule with the employees who work during the mandated observation hours highlighted to ensure observations are completed and documented.


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

raw_content: A review of records indicated that documentation of dental examinations for two children in care was not present in their files.

Correction Narrative: Nursing staff scanned the documentation and uploaded it into the children's files. Nursing supervisor reviewed how documents are scanned, named, and uploaded. She updated the list for how documents should be named and changed who will be responsible for scanning documents into files.


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: References for an employee hired on 02/09/26 were not contacted until 02/18/26.

Correction Narrative: HR Administrators indicated that starting in 2026 their practice has been that a new hire cannot begin orientation unless all documentation has been received by the Friday before.


facility_name: Renewed Strength, Inc. East

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, which resulted in a child being injured.

Correction Narrative: The operation will ensure that direct care staff closely monitor residents and implement the required level of supervision needed when on campus and off campus. Staff was trained on supervision levels on 12.08.2023.


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 course of the investigation this standard was found to be deficient due to a child being injured while a caregiver left the children unsupervised.

Correction Narrative: The operation will ensure that direct care staff closely monitor residents and implement the required level of supervision needed when on and off campus. Staff were trained on supervision levels on 12.8.2023.


summary: 748.303(a)(4)(B) - Serious Incident-Report to parents immediately after ensuring the safety of the child.

raw_content: During the investigation this standard was found to be deficient due to the parent not being notified after their child was injured.

Correction Narrative: Parents/Managing Conservator will be notified of any serious incident regarding their operations knowledge of a serious incident. This managing conservator was notified of the incident on July 12, 2023.


raw_content: The caregiver in charge of the children was not aware of the children going into one bedroom closet

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: There was a training regarding supervision. Three children were interviewed and reported there always being two staff members with them, never being left alone and staff checking on them at night every 10 to 15 minutes.


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

raw_content: The operation failed to follow safety plan put in place and allowed two children to be together in one of the bedrooms.

Correction Narrative: During an inspection on 9/12/22, one safety plan which is currently in place was reviewed. The safety plan contained detailed information regarding the child's supervision and limitations child has while in the house.


facility_name: Open Arms Open Hearts Foundation, LLC

summary: 748.3765(a) - Swimming in a body of water-dangers of the body of water & rules of the activity must be explained to children before activity

raw_content: Child in care were able to fish for crawfish in a large ditch in front of the operation. Multiple children in care were horseplaying in a body of water that was not permitted to be in as a water activity. Staff allowed children in care to fish in the ditch.

Correction Narrative: The operation acknowledges the deficiency and has since held a staff meeting where all staffed signed a memorandum acknowledging their understanding of the current standards regarding water activities. This will remain in place for all new hired staff moving forward to ensure no multi-generation issues arise.


facility_name: Unique Avenue

raw_content: Multiple youth are being subjected to profane language by a caregiver.

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

Correction Narrative: Staff will receive additional training on Constructive Guidance and Discipline of Children and Rehashing Traumatic Experiences on July 16, 2025.


facility_name: La Maison, LLC

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

raw_content: It was determined that a child was inappropriately restrained due to the caregiver using too much force.

Correction Narrative:
The operation re-trained all staff on CPI, the operation provided RCCR with the sign in sheet.
RCCR conducted and inspection to the operation and interviewed children in care.  Interviewed where conducted with one child due to the other two victims being temporary placements (interviews are in chrono) IMAPCT placement log shows both boys placements ended on 4/1/2025.


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

raw_content: It was determined that a child was restrained by a caregiver, and the child did not pose any immediate risk to himself or others.


facility_name: New Horizons Audrey Grace House RTC

raw_content: During the DFPS ANE investigation, this standard was found to be deficient. A child in care was slapped by a staff member.

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

Correction Narrative: This deficiency has been corrected. 3 children and 3 staff were spoken to regarding discipline and child's rights with no concerns. Administration had a meeting with the staff's group to discuss expectations regarding discipline and child interaction. The staff member involved has been terminated.


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 staff slapped a child in care.

Deficiency Narrative: A staff slapped a child in care.


facility_name: Hope Haven of East Texas

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

raw_content: A preliminary service plan was completed, signed and dated after the 72-hour required time frame.

Correction Narrative: The operation completed additional training with staff responsible for completing all service plans to ensure all information needed is included and that these are done timely.  The response was sent on 03/20/26.


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

raw_content:
During a review conducted on March 12, 2026, it was determined that:
(1)	your operations administrator failed to ensure compliance with the current HM Plan; and
(2)	12 months had elapsed since the effective date of the plan.
As you know, the heightened monitoring plan for your operation included a specific planned end date at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of post plan monitoring.  As a direct result of the administrators failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operations planned end date must now be revised, and the period of heightened monitoring must be extended.
Further details of the administrators failure to ensure compliance include the following:

Your operation received a high weighted citation in a pattern/trend category on March 5, 2026.  Specifically, the operation was cited for standard 748.2101(1) Medication Storage- Medication in a locked container. During an investigation, a child in care took medication out of a staff's bag and attempted to ingest it. The medication was not stored in a locked container. Emergency services were contacted. Compliance was met on March 9, 2025.
-	Operation failed to satisfy the conditions of the plan.
-	Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and
-	Operation was unable to meet compliance with Medium-High or High weighted licensing citations.
Finding: 748.535(2)  The licensed administrator must ensure the operation complies with current heightened monitoring plan.
An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100.

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


summary: 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: A suicide screening was not completed the day of the incident even though a child in care had exhibited three warning signs.

Correction Narrative: On 01/20/26, the Administrator completed a review on guidance on completing an ASQ, provided guidance on when to perform an ASQ, and how to properly document this with staff.


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

raw_content: It was discovered while conducting interviews, the operation failed to include a child's name on the incident report that witnessed and was involved in the incident. Staff and child interviews indicated the child that name was not included witnessed the incident and refused to get out of the car when staff left to follow the victim child who had walked away from the operation.

Correction Narrative: The operation sent an email indicating the incident report was adjusted to reflect the additional witness to the incident. The operation provided training to staff regarding including pertinent details in incident reports. This meeting was held at a staff meeting on December 8, 2025.


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

raw_content: During an investigation, 2 children indicated that staff had given them vapes while in care at the operation.

Correction Narrative: All staff were spoken with at a staff meeting 2 weeks ago about vaping, e-cigarette use and policy, and that no nicotine was allowed to be given or shared with residents.  This will be addressed again in another upcoming staff meeting to ensure compliance by staff.


summary: 748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers

raw_content: During an investigation, it was determined that children in care were using vapes.

Correction Narrative: The staff involved in this was placed on probation for other issues and terminated.  This staff is no longer employed by the operation.


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

raw_content: During the monitoring inspection, one child's medication record had an inaccurate medication count.

Correction Narrative: The operation is conducting nightly medication counts at this point as well as weekly audits to ensure any errors are caught and corrected.  There is a staff meeting scheduled for 06/23/25 to discuss medication concerns as well.


summary: 748.125(f)(2)(A) - Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.

raw_content: During the investigation weekly screenings for the first thirty days were requested; however, they were not provided. After discussion with the administrator, it was reported the screenings were not in the operation's online records. Therefore, the administrator inquired if the screenings had been completed; however, there has not been a response provided.

Correction Narrative: The operation has designated this task to the Treatment Director to follow up on all ASQ screenings for residents at admission, every 90 days and weekly for 30 days following inpatient stay. The Suicide Prevention policy was discussed on 5/2/2025.  A follow up inspection will be conducted on 5/7/2025. An unannounced follow-up inspection (4056632) was conducted on 5/13/2025. Training sign in logs were provided and two staff and one child interviewed. There were no concerns.


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

raw_content: During the investigation it was discovered during interviews and documentation, the victim child was on increased supervision and could not be with two residents without staff presence. Three residents reported staff was not present to intervene when the incident occurred. The staff reported two residents went to the victim's aid, while the staff put up chemicals. One of the residents that went to check on the victim was listed on the victim's safety plan, as to not be with this peer without staff supervision.

Correction Narrative: On 5/5/2025 Training for all staff Serious Incident Reporting, training for expectations of staff before, during, and after an incident. On 5/12/2025 Hope Haven will provide a training to all staff titled Appropriate Youth De-escalation, Staff Intervention, and Supervision. A follow up inspection will be conducted on 5/7/2025.  A follow up inspection will be conducted on 5/7/2025. An unannounced follow-up inspection (4056632) was conducted on 5/13/2025. Training sign in logs were provided and two staff and one child interviewed. There were no concerns.


raw_content: During the investigation, it was discovered through interviews the staff on duty failed to intervene during the incident allowing two residents to witness, control, and de-escalate a traumatic incident with a peer, while staff was instructed by residents to remain outside the bathroom. A child was allowed to have a prohibited item listed on the child's safety plan, after the staff found a plan written by the child to harm oneself with the prohibited item.

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: On 5/5/2025 Training for all staff Serious Incident Reporting, training for expectations of staff before, during, and after an incident. On 5/12/2025 Hope Haven will provide a training to all staff titled Appropriate Youth De-escalation, Staff Intervention, and Supervision. A follow up inspection will be conducted on 5/7/2025. An unannounced follow-up inspection (4056632) was conducted on 5/13/2025. Training sign in logs were provided and two staff and one child interviewed. There were no concerns.


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

raw_content: During the inspection, it was discovered in the kitchen freezer an uncovered cup with lemon drink and an uncovered bowl of ice cream. The house manager removed and disposed of these items during the inspection.


summary: 748.1547(2) - Vision and hearing examination-If a child in care needs an examination, ensure the professional and medical recommendations are carried out

raw_content: A child was seen by medical personnel for an annual physical and referred to an optometrist in September 2024. The child was seen by an optometrist in October 2024; glasses were ordered and ready for pick-up within 3 weeks, however, operation staff did not pick-up the glasses until nearly 5 months later in March 2025.

Correction Narrative: On 4/25/2025, the operation's Administrator advised they have implemented a new system to ensure that follow-up visits are scheduled and completed in a timely manner. After a medical appointment the Case Manager is required to upload the document within 3 business days. Upon reviewing the document for accuracy, it is the responsibility of the case manager to schedule any necessary follow-up appointments also within 3 business days. We also have a new TEAMS channel where all appointment AVS will be loaded for review for leadership to keep track. It is also a new practice that all efforts to schedule appointments, appointment changes, any issues and necessary communication regarding medical appointments are to be documented in the monthly case manager notes.  If the Case Manager has an issue that cannot be resolved, they must alert their supervisor.


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

raw_content: A child was referred to periodontics for gingival recession during a dental visit in October 2024. At the time of the investigation initial visit in March 2025, the child had yet to complete the periodontic visit. The operation reported issues with the referral and insurance, however, were not able to provide documentation to reflect continued efforts to get the child's referral completed in a timely manner.

Correction Narrative: On 4/25/2025, the operation's Administrator provided documentation to reflect the child completed a routine dental check up on 3/25/2025. The child also completed an orthodontist initial evaluation on 4/1/2025.


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 was placed at the operation on 5/23/2024. According to the Common App, the child was prescribed Abilify/Aripiprazole on 5/6/2025, prior to placement. According to documents provided by the operation and interviews, the child was never administered Abilify, in error. The operation was not able to provide medication records to reflect the child was administered the prescribed medication.

Correction Narrative: On 5/2/2025, the operation's Administrator advised the RN created an entire new medication auditing system and training. This training has been completed for all staff at least once; some have attended twice.


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

raw_content: A child was referred to follow up in one month for allergies, blood pressure, and to get a flu shot. The operation was not able to provide documentation to reflect the follow-up visit was completed.


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

raw_content: During the investigation inspection, medication records were reviewed and one record did not include the name of staff who administered the medication.

Correction Narrative: On 2/24/2025, during an inspection at the operation, the medication record was reviewed, and corrections were observed.


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

raw_content: The operation failed to report the quarterly EBI data timely.

Correction Narrative: The operation reported there were staffing changes to the individual responsible for submitting the EBI quarterly report. The Program Manager now has a login to the provider website and will take over the responsibility of reporting the operation's quarterly EBI.


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

raw_content: Serious incident reports were reviewed for HHS Investigation 3128973, and it was observed the documentation was lacking required information such as the operation's physical address, telephone number, and the treating physician's name, findings, and treatment. The operation was cited on 12/12/2024 and provided a comply by date of 12/18/2024. The operation failed to show compliance, timely.

Correction Narrative: On 1/10/2025, Hope Haven's Program Manager provided the requested corrections: Case Managers were notified of inaccurate information in records and were asked to complete a thorough audit of all records to ensure accuracy in information and make any necessary corrections, case managers were asked to thoroughly review any future documents before submitting the document for review in our electronic records system, which will require a supervisor final approval. Should the supervisor find any inaccurate information the document will be sent back for corrections prior to approval. Furthermore, all documents are currently being reviewed by Hope Haven's Client Service Manager and all documents will be reviewed, and any necessary changes will be completed by 1/17/2025. This will ensure that all documents are accurate and meet requirements moving forward.


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

raw_content: Completed supervision check forms were reviewed for HHS Investigation 3128973, and it was observed the operation was not following supervision checks per the child's safety plan; the operation failed to check on the child every 15 minutes on multiple occasions on 11/18/2024 and 11/19/2024. The child was interviewed and corroborated the discrepancy. The operation was cited on 12/12/2024 and provided a comply by date of 12/18/2024. The operation failed to show compliance, timely.

Correction Narrative: On 1/10/2025, Hope Haven's Program Manager provided the requested corrections: Residential Manager, now sends out all required check forms to staff daily to include all safety and supervision plans for each resident. These checks are also reviewed by the residential manager prior to being loaded into the electronic system. All staff were asked on 1/7/2025 to ensure that these check logs clearly identify if a child is out of the home while on 15-minute checks. Safety and Supervision plans are accessible to find in 3 different areas now, when before it was only 2 places to remind staff the necessary checks. Staff will be reminded of this at the required staff meeting on Monday 1/13/25.


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: The operation has not yet met compliance with this standard as a refresher course in their EBI system has not yet been conducted with staff.  The administrator confirmed it has not yet been completed, and the operation is seeking an instructor to meet this need.


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

raw_content: The administrator confirmed he would not be providing RCCR with a schedule showing his presence at the operation under advisement of his supervisor.  The operation has not yet offered correction for this standard, and the administrator noted the standard is currently in Administrative Review with a hearing upcoming.  As such, compliance for this standard has not yet been met.


summary: 748.1101(b)(6)(C) - Children's rights-to confidential care/treatment, include keep medical & operation records private. Discussing them only when it's about child's care

raw_content: During the investigation, it was discovered through child and staff interviews that a staff member was not confidential in discussing with a child in care's skin checks with the child in front of other children. The child asked the staff to speak with her privately as it shocked her that the staff would discuss this with her in front of her peers.

Correction Narrative: The operation indicated a disciplinary action/write up was given to the staff due to confidentiality breach for the child. The operation provided a copy of the Employee Disciplinary Action Form. A copy of the disciplinary form is uploaded in Document Libaray.


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

raw_content: During the course of the investigation, two children in care reported staff grabbed a child by the arm and snatched a hot pocket out of the child's hand. The child and the staff began to argue, with the child telling staff not to touch her, which escalated the child and as a result the child destroyed the kitchen. There is video footage that supports the staff grabbed the child's arm. There was a previous incident before with this child and staff in which the child was cooking and staff grabbed the child's arm stating the staff wanted to show the child something. The child told staff at that time not to touch the child, and the child didn't want to be touched.

Correction Narrative: The operation will provide a training to all staff on 1/13/2025 title "Understanding the Reasonable and Prudent Parent Standard. An outline of the training was provided. A training will be provided at staff meeting on 1/27/2025 regarding communication and include reminders about body language, tone of voice, expression, etc. RCCR Supervisor gave permission to close this investigation and review training logs for both trainings during a Plan of Action inspection.


raw_content: This standard was evaluated in follow-up to Investigation #3121194, and the agency has not yet conducted an EBI refresher course including the restraint positions identified in the policies and procedures.

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


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

raw_content: While reviewing the three victim child plans, it was discovered two of the three victim child plans had inaccurate information regarding another child in the plan.

Correction Narrative: Case Managers will complete a thorough audit of all records to ensure accuracy in information and make any necessary corrections. Case Managers will thoroughly review any future documents before submitting the document for review in the electronic records system, which will require a supervisor final approval. Should the supervisor find any inaccurate information the document will be sent back for corrections prior to approval.


raw_content: During the investigation, a child reported the operation was not following supervision checks per the safety plan. A review of the completed supervision check forms corroborated the child's allegations. The operation failed to check on the child every 15 minutes multiple times on 11/18/2024 and 11/19/2024.

Standard Number / Description: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures


raw_content: During the investigation, serious incident reports were reviewed, and it was observed the documentation was lacking required information such as the operation's physical address and the treating physician's name, finding, and treatment.

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


raw_content: During the course of the investigation, a child in care was observed by staff picking up a marijuana roach. The staff told the child multiple times to drop the roach; however, the child did not. The staff witnessed the child walk around to multiple people at the park asking for a lighter; as well as asking the staff. The staff had the children load the van, because the child would not dispose of the roach. The child pretended to throw the roach out the window; and the staff believed she did. After returning to the operation, it was discovered that the child had not disposed of the roach as she was attempting to light it. The staff failed to obtain possession of the roach to ensure it was disposed of. The staff failed to check to see if the child actually disposed the roach.

Correction Narrative: The operation conducted a training for staff to review the Reasonable and Prudent Parenting standard with staff and a knowledge test was given. The training also discussed person and room searches reviewing different scenarios and proper documentation. A sign-in sheet of attendees for this training was provided.


raw_content: During the inspection, I observed the adminstrator was not present at the operation during the inspection, exhibits a historical pattern of not being present at the operation, and interviews indicate he is present at the operation only for staff meetings.

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


raw_content: During the inspection, I observed a child's prescription Iron Supplement was not refilled in a timely fashion, resulting in the child missing a dose of her medication on 10/14/24.  The Administrator confirmed the responsible staff admitted to failing to pick the prescription up before the medication ran out.

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 inspection, interviewed the RN on staff for the operation and observed the new system for refills put in place for the operation.  New prescriptions are put in a refill box that is tracked by a specific log.  The day staff picks up refills when available each day.  The RN audits the medication logs every week, and Night staff audits the med logs over night to ensure they remain accurate.  The staff received training on this refill system and medication management in September.


raw_content: During the investigation, I confirmed two staff members did not receive EBI training within six months of their previous training.


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

raw_content: During the inspection, it was discovered a toilet would not flush in one of the bathrooms in which three girls share. There is a do not use sign on the toilet. There is a work order for this toilet dated 6/8/2024, which appears to have been ample time for this toilet to have been fixed.

Correction Narrative: The operation has received multiple quotes for repair but they are unsure of the timeline for the work to be completed. An immediate corrective plan is to not utilize the two rooms that share the adjoining bathroom, until it is repaired. An inspection was conducted on 10/24/2024, and the two rooms are not being utilized.


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

raw_content: During the inspection, three of the four child medication records reviewed were missing the reason the medication was prescribed. This was corrected at inspection.


raw_content: During the inspection, it was discovered that one of the four child medication records reviewed indicated a child had missed a dose on four days.

Correction Narrative: The operation held a medication training on 9/30/2024 and 10/4/2024. A trained staff is conducting weekly audits on medication. An inspection was conducted on 10/24/2024 and two child records were reviewed and found to be compliant.


raw_content: The name and signature of of each staff administering medicaitons was not present.  One staff's signature was illegible, and several medication counts were prefilled (without initials or signatures).

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

Correction Narrative: Trainings were done on medication records and PRN medications. Document Library has the corrections.


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

raw_content: A direct care staff was yelling and shaking her finger in the face of a child in care.

Correction Narrative: Email by Paul Christman stated the staff involved subsequently resigned from Hope Haven, and the operation had a training for all other employees on inappropriate discipline, including yelling and shaming. Sign in sheets have been sent and uploaded.


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 this investigation, it was discovered during interviews children in care have been making out with each other in their beds and bedrooms. Five of the five children interviewed girls have played kissing games. Two of the five girls reported making out in the bed together in their bedroom. Four of the seven collateral adults interviewed reported visiting the operation several times a week and observing concerns regarding supervision.

Correction Narrative: A general training with Direct Care Staff regarding appropriate supervision will be conducted during the work week of August 12, 2024. The training will emphasis the operation's policies regarding routine bed check and the appropriating of increase supervision plans if suspected high risk behavior is possible. They are also reviewing for emergency and disaster management to revise the supervision standards necessary during abnormal operating conditions. The policy will be finalized by August 26, 2024


summary: 748.831(a) - Orientation-Each caregiver or employee must have orientation prior to beginning job duties or having contact with children in care

raw_content: One of the four employee records reviewed did not contain orientation training.

Correction Narrative: The operation came into compliance with this standard by confirming that the staff had completed the training and the operation also reviewed other staff files to ensure nothing was missed with them as well. T


summary: 748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves

raw_content: The first aid kit in the Hope Haven Hilander was missing waterproof gloves, a thermometer, and tweezers.  A case manager added the missing items during the monitoring inspection.


raw_content: A caregiver failed to follow the operation's approved policies and procedures. According to the operation's electronic and social media policy only authorized staff can handle these concerns. An off duty, unauthorized staff member provided a child with a history of social media abuse the password to social media.

Correction Narrative: The individual who violated the policy was suspended from work during the investigation and subsequently terminated as an employee. Training on the Hope Haven Technology Policy has occurred with Direct Care, Supervisory, and Management staff, and they all have been sent an electronic copy of the Hope Haven Technology Policy. A sign in sheet from the training reflecting those that attended.


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

raw_content: During the inspection, I observed the facility first aid kit to be lacking a pair of tweezers.

Correction Narrative: The operation provided a photograph via email showing the added pair of tweezers to the first aid kit.  This brings this standard into compliance.


raw_content: During an abuse/neglect investigation it was noted that while a staff was playing with a child in care, the staff in a non-disciplinary manner, touched the child on her bottom, making a comment to the effect that the staff was bad. This was confirmed by another staff in a written incident report. Two collateral children were interviewed indicating this staff previously "touched or smacked" one of the two residents on the bottom.

Correction Narrative: On 1/5/2024, the staff was retrained on proper and prudent actions to take when supervising children, including that touching on the bottom regardless of the innocent intent of such action is inappropriate. A signed training log for the Boundaries between childcare workers and children in care was provided. The training was an hour long.


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

raw_content: Interviews with staff and children indicate three children were allowed unsupervised access to a personal laptop, with one child requiring increased supervision due to recent behaviors.

Correction Narrative: On 2/14/24, the operation submitted documentation of updated technology policies stating the supervision expectations regarding children's technology use and a parameter to include specific technology allowances and restrictions in the children's service plans.  The operation also presented a training schedule covering this information to be completed before the end of the month.  This establishes proper supervision of children accordant to their specific needs documented in the service plan as well as general expectations and brings this standard into compliance.


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

raw_content: One of the four records reviewed failed to have a child's signature indicating the child's rights had been reviewed. There was no signature nor was there an explanation of why the child did not sign. The agency provided another copy of the child's right form for this child that indicated the form was signed eleven months later.

Correction Narrative: The operation has modified their intake process to verify all forms are in compliance with a standard check list maintained in the electronic records.


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

raw_content: Three of the four records did not include documentation in the child's record indicating the child's parent had been notified of the service plan meeting.

Correction Narrative: The operation has modified their electronic record system to require inclusion notices and service plans. If the task is not completed the records will be flagged with a non-compliance indicator for management review.


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

raw_content: While reviewing the fire drills, it was noted that only one drill had been conducted this year. The drill was conducted in January 2023, and there has not been a follow up drill completed. Staff reported the severe weather and fire drill were both completed at the same time in January 2023.

Correction Narrative: The operation conducted a fire drill with the residents in care on 12/1/2023 and provided a copy of the drill. The operation has modified their electronic records to automatically send the due date for the next required drill.


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: While reviewing the severe weather drills, it was noted that only one drill had been conducted this year. The drill was conducted in January 2023, and there has not been a follow up drill completed. Staff reported the severe weather and fire drill were both completed at the same time in January 2023.

Correction Narrative: The operation completed the weather drill on 11/30/2023, with the children in care. The operation has modified the electronic records to automatically send the due date for the next required drill.


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

raw_content: Two of the four child records reviewed were missing service plan reviews. One of the records had the initial service plan only. Another record was missing one service plan review.

Correction Narrative: The operation modified their Service Plan procedure to require Case Managers to upload service plans and track compliance with electronic records. The operation created a review process by the Legal and Regulatory Manager to approve all Service Plans.


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

raw_content: A staff member was told to stand in the restroom and turn around while a child used the restroom.  This made both the child and the caregiver uncomfortable.