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Appendix 3.1 Intake Screening Results Case Summaries

RCCI Intake Reports

Intakes Received in May 2020
1. Case ID: 48233832
Intake ID: 73551806
Sample File: May 2020
Summary of Intake Allegations: A DFPS caseworker reported that a child (age 10) currently on her caseload
told her that while at a previous placement in a foster home, she and her two foster siblings (ages 8 and 10)
had been physically abused by three other unrelated foster children (between the ages of 7 and 10) in the home.
The foster mother allegedly pretended she was not aware of the abuse; however, the child said the foster mother
was aware because when the incidents occurred, she would cry, and the foster mother was at home. The child
alleged that the other foster children repeatedly punched her in the stomach, stepped on her head with their
feet and pulled her hair. The reporter did not know whether there were marks, bruises, or injuries as a result.
The child was placed in this home between January 2019 and September 2019. The reporter did not know
whether the other children were still at the placement where the allegations occurred. The child also stated that
when she was removed from her previous foster home by the previous caseworker, she asked that caseworker
whether she would have to go back to the home where the abuse and neglect occurred. The child stated that
the caseworker told her that “as long as she was good” she would not have to go back to that placement.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN and closed without an investigation.

RCCI reason given for downgrade: “Staffing completed with Screener Supervisor. The intake report clearly
reflects that there is no alleged abuse or neglect or violation of law or minimum standards to investigate. The
allegations that [the foster parent] did not provide adequate supervision to children in care is very concerning.
However, the [foster parent’s] home was closed on 12/31/2019 and there are currently no children at risk.
Permission given to administratively close this intake.”
“Screener Final Assessment/Conclusion. An intake was received on 05/27/2020 with primary allegations of
Neglectful Supervision. Allegations state that [the alleged victim] said she was physically abused by three
other kids while in the home. [Two other children] were also abused by these three. [The alleged victim] said
that the foster parent pretended not to be aware but she was aware of the abuse.”
“Per LPPH 6221.5, the supervisor or designee determines that an intake report will be closed without an
investigation if the information in the report clearly reflects that there is no alleged abuse or neglect or violation
of law or minimum standards to investigate. The allegations that [foster parent] did not provide adequate
supervision to children in care is very concerning. However, the [foster parent’s] home was closed on
12/31/2019 and there are currently no children at risk. Therefore, based on the information obtained, this intake
will be administratively closed.”
Monitors’ Review: This allegation that a child (age 10) was being physically harmed by other foster children
in a foster home, allegedly with the knowledge of the foster mother, should have been investigated for
Neglectful Supervision. The reason noted for the downgrade by RCCI is that the foster home is no longer

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operational (the placement voluntarily closed as of December 31, 2019), 1 however, this allegation meets the
threshold for a Neglectful Supervision investigation based upon:

Placing a child in or failing to remove him from a situation that a reasonable member of that profession,
reasonable caregiver, or reasonable person should realize requires judgment or actions beyond the child's level
of maturity, physical condition, or mental abilities, by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559(3).

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Administrative Closure. No investigation was conducted.

2. Case ID: 48230961

Intake ID: 73544140
Sample File: May 2020
Summary of Intake Allegations: A staff member at Helping Hand Home for Children, a GRO, submitted an
e-report stating that a child (age 11) hit his head on a wall while being non-compliant that morning. When the
reporter arrived on the unit where the child resides to administer regular medications, another staff member
informed the reporter that the child was unusually tired and was having difficulty staying awake. The reporter
went to speak with the child who reported feeling nauseated and stated that he had not informed any staff
members before then. The child stated his symptoms started after he hit his head in the morning. The child's
pupils were responsive to light and a normal size. The child's memory and balance seemed to be intact,
although he complained of being dizzy. Because of the child's history of concussions and the fact that he was
demonstrating symptoms consistent with a concussion, staff member(s) took the child to the hospital. Doctors
said the child probably had a concussion and instructed staff member(s) to monitor the child for pain, persistent
vomiting, dehydration, neck pain or stiffness, and extreme sleepiness or irritability. The facility staff members
were also instructed to follow up with the concussion clinic and were advised that the child should avoid
strenuous physical or mental activity until cleared by a doctor.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.

RCCI reason given for downgrade: “The concerns appear to be related to minimum standards and this will
be forwarded to HHSC for evaluation of minimum standards.”
“The facility noticed the [alleged victim] was not acting as he would usually do and proceeded to seek medical
attention.”
“Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report received by SWI to a non-
abuse or neglect report when the information in the report suggest [sic] a minimum standard was violated, but
not that a child was abuse [sic] or neglected; or indicates that there is some risk to children, but the information
is too vague to determine that a child was abused or neglected.”

1
Moreover, pursuant to DFPS’ analysis about whether closure negates the need for investigation, “the fact that the outcry
came out after ... the foster home was closed should not matter as the allegations themselves warrant an investigation.”
See TEX. DEPT OF FAMILY & PROTECTIVE SERVS, QA Report from FY2020 Quarter 3 Review of Residential Child Care
Intakes Reclassified as PN (Priority None), (July 31, 2020) (on file with the Monitors and DFPS).

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Monitors’ Review: This allegation that a child (age 11) struck his head on a wall hard enough to cause a
concussion sometime in the morning but that staff members did not take the child for medical care until late
that afternoon should have been investigated for Medical Neglect and Neglectful Supervision. The child’s
history, as noted in the intake report, included ADHD, chronic PTSD, and DMDD. His records indicated that
he regularly self-harmed by hitting his head on floors, windows, and walls forcefully and that this behavior
has previously caused concussions. The child’s level of care was Intense Plus, and he required one-to-one
support from staff to perform activities of daily living. This allegation meets the threshold for investigation for
both Medical Neglect and Neglectful Supervision based upon:

Failure to seek, to obtain, or to follow through with medical care for a child, by a person working under the
auspices of an operation that causes or may cause substantial emotional harm or substantial physical injury to
a child. 40 TAC §745.8559(5); and

Failure to take an action that a reasonable member of that profession, reasonable caregiver, or reasonable
person should take in the same situation, by a person working under the auspices of an operation that causes
or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC §745.8559(1).

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.

"On 5/23/20, a standards investigation intake was received alleging that a child in care hit their own head on a
wall while non-compliant and may have sustained a concussion from it. The child was later taken to the
hospital. There is enough preponderance of evidence showing minimum standards were violated. A citation
will be issued for standard 748.1531(a)(2) relating to Medical Care. After conducting the investigation, it was
found that on 5/23/20, child in care (11 y/o), at the [child’s unit] was involved in an incident where he hit his
head forcefully on a window in the inner yard at approx. 9:00 am while non-compliant. The injury was self-
inflicted. When [health care staff] arrived for her shift on the Longhorn home where [the alleged victim] resides
to administer 3:00 pm medications, PM staff informed her that [the alleged victim] was unusually tired and
was having difficulty staying awake. She went to speak with [the alleged victim], and he reported feeling
nauseated as well, but stated he hadn't told staff. [The alleged victim] reported the symptoms started after he
hit his head in the morning. It was reported that his pupils were responsive to light and of normal size. It was
reported that [the alleged victim’s] memory and balance also seemed to be intact, although he complained of
being “dizzy.” Due to his history of concussion and symptoms similar to concussion, staff took [the alleged
victim] to [the] ER to get checked out. The doctors said he probably had a concussion and instructed staff to
monitor for pain, persistent vomiting, dehydration, neck pain/stiffness, and extreme sleepiness/irritability.
They also instructed staff to follow up with the concussion clinic and to keep [the alleged victim] from
strenuous physical or mental activity until cleared by a doctor. Collaterals reported that [the alleged victim]
was not evaluated by a health care staff between the time he banged his head at about 8:30 am to between 2:15
pm and 3:00 pm when [health care staff] evaluated him.”

3. Case ID: 48206072

Intake ID: 73475475
Sample File: May 2020
Summary of Intake Allegations: A DFPS caseworker reported that during a treatment team meeting, a staff
member at Freedom Place, a GRO, stated that a youth (Youth A, age 15) reported that she awoke to her female
roommate (Youth B, age 14) touching her on her chest on top of her clothes and kissing her on the cheek.
According to the reporter, Youth B has a history of sexually acting out in relation to her siblings. This incident

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occurred on April 28, 2020; no one from the GRO notified Youth A’s DFPS caseworker until April 30, 2020.
The DFPS worker reported the allegations to SWI.
When the DFPS caseworker asked a staff member why its staff failed to report the incident to SWI, the staff
member stated that it "is not a reportable event." The DFPS worker told the staff member that it is reportable
and therefore, called SWI. The reporter stated that the staff member informed her that the girls were
immediately placed in different rooms in different housing units of the facility.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI reason given for downgrade: “Staffing completed with Program Administrator. The intake report does
not contain an allegation of abuse or neglect. Both [alleged victims] are victims of sexual abuse. Since being
placed at Freedom Place, this is the first incident that has occurred for [the alleged victims] per LPS Worker.
Although the incident was inappropriate, there was no touching underneath the clothing nor penetration. The
operation acted immediately and appropriately by separating [the alleged victims]. Permission given to
downgrade to a Non A/N investigation.”
“05/01/2020 – I made a call to the Local Permanency Specialist. [Local Permanency Specialist] reported that
she is the LPS worker for both [alleged victims]. [Local Permanency Specialist] reported that she is not aware
of any previous incidents while both [alleged victims] have been placed at Freedom Place. [Local Permanency
Specialist] reported that the operation has separated both girls and placed them with new roommates.”
“Per LPPH 6222.2 this intake report does not contain an allegation of abuse or neglect. Both [alleged victims]
are victims of sexual abuse. Since being placed at Freedom Place, this is the first incident that has occurred for
[either alleged victim] per LPS Worker. Although the incident was inappropriate, there was no touching
underneath the clothing nor penetration. The operation acted immediately and appropriately by separating [the
alleged victims]. Therefore, based on the information obtained this intake will downgraded to a Non A/N
investigation.”
Monitors’ Review: The allegation that Youth B reportedly touched her roommate’s chest over clothing and
kissed her cheek while she was asleep should have been investigated for Neglectful Supervision after Youth
A was awakened by the occurrence and reported the event to staff. Freedom Place staff members did not report
the event to SWI nor to the caseworker, indicating it was not “a reportable event.” The GRO is listed in CLASS
as having special capacity to care for young women who have been victims of sex trafficking. DFPS has
confirmed both Youth A and Youth B as victims of prior sexual abuse. This allegation meets the threshold for
a Neglectful Supervision investigation based upon:
Failure to make reasonable effort to prevent sexual conduct to a child, by someone working under the auspices
of an operation that causes or may cause emotional harm or physical injury to, or the death of, a child that the
operation serves. 40 TAC §745.8557(7).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.
The minimum standards investigation found that the physical contact by Youth A and Youth B was under the
clothing and more extensive than initially reported. The GRO received citations and the record stated that:
“Based on the preponderance of evidence gathered during the course of this investigation it has been
determined that there were violation [sic] of the minimum standards as it pertains to reporting serious incident,
maintaining accurate records, and invalidating previous employees in the background check system.”

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4. Case ID: 48232406

Intake ID: 73547892
Sample File: May 2020
Summary of Intake Allegations: The future adoptive mother of a child (age 10) reported the following
detailed concerns regarding the child’s treatment at Embracing Destiny Foundation, a GRO: 1) The child
disciplined by a staff member “who regularly punished the youth by making him lay face down on his bed
with his arms touching his sides ‘like a soldier’.” The child did not complain of being short of breath while in
this position; 2) When the child was not responding to the directions of the staff member, the staff member
reportedly told the boy, who is in the process of being adopted by the reporter, “see that is the kind of behavior
right there that is going to make [the future adoptive parents] not want you.” The staff member also stated that
the boy was not going to live with the future adoptive family, and they were “not going to love” the boy. The
boy became upset and said, “well then f*#k the [adoptive parents].” The child tearfully admitted this to his
future adoptive parents and insisted he did not mean it. The future adoptive mother spoke with the child and
told him that she was disappointed in his behavior but still committed to adopting him and reassured him that
they were not going to give up on him, which calmed him; 3) Shortly after the reporter calmed the child, an
unknown staff member at the GRO started yelling at the child while he was still on the phone with his future
adoptive mother. The staff member was heard screaming “you better get on the phone and tell [the future
adoptive father] what you said. This is the kind of behavior that is going to make them not love you.” The
reporter heard this statement herself through the phone. The future adoptive mother tried to talk to the child
but reported that he was completely shut down at that point. The future adoptive father then tried to speak with
the child and he would only reply ‘yes, sir, yes, sir’ and seemed to be “emotionally broken” by the staff
member’s comments; 4) The reporter stated that the GRO was currently prohibiting the scheduled calls
between the child and the reporter as if the calls were a privilege that can be withheld as punishment; and that
after being prohibited from speaking with his future adoptive parents for a day, the child was very happy to
speak with them and said he was scared that the future adoptive mother “was never going to call again.” She
also stated that staff members regularly monitor calls between the child and the reporter; and 5) Finally, the
reporter stated that the director of the GRO stated to the future adoptive mother that she “had no business
adopting biracial children.” The director also told her that the child was “not adoptable” because he “did not
even know how to love himself.” It is unknown whether the child overheard the director say this, nor whether
the director had told the child this directly.
Downgrade: SWI assigned this case as a Priority Two investigation for Emotional Abuse. RCCI downgraded
to a PN minimum standards investigation.

RCCI reason given for downgrade: “Staffing completed with Screener Supervisor. This intake report does
not contain an allegation of abuse or neglect. The allegations in this intake are concerning due to staff not
allowing [the alleged victim] to make or receive phone calls and staff yelling at [the alleged victim]. Staff
member also told [the alleged victim] that [foster parents] would not adopt him because of his behaviors.
Another staff, the director informed [foster mother] that she had no business adopting biracial [the alleged
victim], because she is white. The director also told [foster mother] that [the alleged victim] was ‘not
adoptable.’ Although this [sic] allegations are concerning, they do not rise to the level of A/N but concerns for
possible minimum standards violations. Permission given to downgrade to a Non-Abuse and Neglect
investigation.”
“An intake was received on 05/26/2020 with primary allegations of Emotional Abuse. Allegations stated [the
alleged victim] reported that due to getting into trouble he was not able to speak with his adoptive mother.
[The foster mother] also reported that she heard another staff in the background yelling at [the alleged victim].
Per LPPH 6222.2 this intake report does not contain an allegation of abuse or neglect”

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Monitors’ Review: The allegations that a child (age 10) who was being treated for anxiety, mood disorder
and ADHD and was under the care of a psychiatrist was repeatedly subjected to persistent verbal bullying by
staff who withheld phone calls with his future adoptive parents as a punishment which resulted in the child
seeming “emotionally broken,” per the reporter, should have been investigated for Emotional Abuse. This
allegation meets the threshold for an Emotional Abuse investigation based upon:

In its discussion of the substantive due process rights of PMC children, the Fifth Circuit stated, “egregious
intrusions on a child’s emotional well-being—such as, for example, persistent threats of bodily harm or
aggressive verbal bullying—are constitutionally cognizable.” 2

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Three – Minor violation of the law or minimum standards that involve low risk
to children.

HHSC determined there was a violation of minimum standards: “Based on the preponderance of evidence
gathered, there will be a citation given for inappropriate discipline. I interviewed five residents and four
caregivers. Four of the residents informed me that if they talk too much while eating at the table, they will
have to throw their food away. Three residents and three caregivers stated that they have not heard anyone tell
a resident that they will not be adopted due to their behavior.”

5. Case ID: 48210987

Intake ID: 73489262
Sample File: May 2020
Summary: A staff member providing mental health services at The Settlement Club Home, a GRO, reported
that a youth (age 15) expressed suicidal ideation and crafted a noose with the intent to hang herself. The
reporter stated that the staff members immediately intervened and stopped the youth from engaging in self-
harm and suicidal behaviors. A staff member then called law enforcement and a mental health officer (MHO)
to assist and assess the youth. The MHO and EMS responded. The MHO recommended psychiatric
hospitalization and the EMS personnel medically cleared the youth and reported no injuries. Law enforcement
personnel transported the youth to a psychiatric hospital. The reporter also stated that the youth was recently
discharged from a psychiatric hospital and had been struggling to adjust to her new medication.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI Reason given for downgrade: “Due to additional calls made. Doesn’t appear to involve abuse or
neglect. Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report received by SWI to
a non-abuse or neglect report when the information in the report in [sic] suggest a minimum standard was
violated, but not that a child was abuse [sic] or neglected; or indicates that there is some risk to children, but
the information is too vague to determine that a child was abused or neglected. The concerns appear to be
related to minimum standards and this will be forwarded to HHSC for evaluation of minimum standards.”
Monitors’ Review: The above allegations that a youth (age 15) engaged in self-harming behavior with the
intent to hang herself meet the threshold for investigation for Neglectful Supervision to determine whether the
youth was subject to appropriate supervision at the time of the incident. Further, during its secondary screening
process, RCCI learned through additional calls to the GRO that the youth had displayed escalating behaviors

2
M.D. by Stukenberg v. Abbott, 907 F.3d 237, 251 (2018).

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and was in the shower when she attempted to self-harm. They learned that she allegedly used a shower curtain
and a bed sheet to self-harm. The director of the GRO reported to the RCCI screener that the youth’s
supervision level required “fifteen-minute checks” at the time of the incident. The additional calls did not yield
information about the duration of time the youth was in the shower before staff members checked on her and
intervened. The allegations should have been investigated and meet the threshold for Neglectful Supervision
based upon:
Any other act or omission that is a breach of a duty by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559.
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Administrative Closure. No investigation was conducted.

6. Case ID: 48219291

Intake ID: 73512187
Sample File: May 2020
Summary: A DFPS case worker reported that a youth (age 15) at Children’s Hope Residential Services, an
RTC, vomited her dinner and subsequently ran to her room and attempted to self-harm with a pen cap. The
reporter stated that a staff member called the “crisis line” instead of 911. The crisis line personnel advised the
staff member to bring the youth to a psychiatric facility for admission; however, the RTC took no action at
that time. The following morning, the RTC director contacted the youth’s CPS worker to notify her of the
incident and advised her of the RTC’s ongoing efforts to have the youth admitted to a psychiatric hospital. The
CPS worker inquired about the reason the youth had not already been admitted. The director replied that the
staff members at the RTC were unable to transport the youth to the hospital because the staff-to-youth ratios
would have been affected if a staff member left the RTC to transport the youth. The reporter stated that the
CPS worker arranged transportation for the youth to the psychiatric hospital and that it was two days after the
self-harming incident. The reporter did not know whether the youth attempted to self-harm again after the
initial incident.
Downgrade: SWI assigned this case as a Priority Two investigation for Medical Neglect. RCCI downgraded
to a PN minimum standards investigation.
RCCI Reason given for downgrade: “Closed and reclassified. Per LPPH 6222.2 this intake report does not
contain an allegation of abuse or neglect. [The youth], 15yo ate dinner and threw up her dinner. [The youth]
also attempted to self-harm with a pen cap. A review of [the youth’s] history was conducted and there are no
documented incidents for [the youth] while being placed at Children’s Hope. Although these allegations are
concerning and staff member called the crisis line and not 911, it does not appear that staff was neglectful in
making sure that medical treatment was provided to [the youth]. Therefore, based on the information obtained
this intake will be downgraded to a Non-Abuse/Neglect.”
Monitors’ Review: The above allegation that a youth (age 15) self-harmed at a RTC and did not receive
immediate medical attention meets the threshold for a Medical Neglect investigation based upon:

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Failure to seek, to obtain, or to follow through with medical care for a child, by a person working under the
auspices of an operation that causes or may cause substantial emotional harm or substantial physical injury to
a child. 40 TAC §745.8559(5).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Five – Desk Review.
“Based on the preponderance of evidence gathered throughout this investigation, there is insufficient evidence
to substantiate the allegations. It is alleged a child in care was able to access an object and self-harm with it. It
is alleged a child went to the hospital and a hotline report was not reported within 24 hours.

Documents were provide [sic] by Children’s Hope were reviewed. These documents are stored in the media
share portal. Interviews conducted revealed that the therapist on staff accessed [sic] the situation, implemented
a safety plan, and followed the protocol for suicidal situation. The crisis hotline was able to secure a location
for the victim, and transport the victim to the approved hospital. Once the victim left the operation by
ambulance the staff made the hotline report. The report was made within the regulated time frames and
circumstances. The staff on duty was the victim's therapist. She reported that she did not transport the victim
because this would have put the operation out of compliance with ratio, and put the other children at risk. The
operation has since been closed and is no longer operating.

After conducting a thorough investigation and analyzing the information closely for risk, standards
748.303(a)(2)(A),748.303(a)(11)(A), and 748.683(1) were found to be compliant. No deficiencies were cited
for this investigation. Recommended Action: No Action.”

7. Case ID: 48211091

Intake ID: 73489557
Sample File: May 2020
Summary: A law enforcement officer reported that staff members at Williams House, a GRO that
subsequently closed, were allegedly mistreating a child (age 12) who resided there. The child stated that staff
members were rude and verbally abusive to her and told her they were going to cut off her hair. The officer
reported that staff members allegedly told the child that she would not be able to return home to live with her
grandmother because “she can’t behave.” The reporter stated that the child was agitated due to the alleged
verbal abuse, opened her second story bedroom window, and began yelling out of the window. A police
department is located across the street from the GRO; therefore, upon hearing the child yelling out the window,
an officer went to the GRO. The officer stated that the child was not attempting to jump from the window. The
reporter alleged that a GRO staff member restrained the child to get her out of the window and the child then
stated her wrist hurt after the restraint.
During secondary screening, RCCI staff made a collateral call to the child’s CVS caseworker. The caseworker
stated that the GRO staff members allegedly called the child "stupid" and "dumb" and told her that her parents
did not want her due to these characteristics. The caseworker also stated that the child had a history of self-
harming and mental health diagnoses. The caseworker further confirmed that staff members told the child they
would cut her hair while she was asleep and that during a restraint, a staff member told the child if she did not
stop screaming, the staff member would pull her arm up higher on her back. Finally, the documentation at
secondary screening stated that the child reported to the CVS worker that she did not feel safe at the GRO and
did not want to reside there.

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Downgrade: SWI assigned this case as a Priority Two investigation for Emotional Abuse. RCCI downgraded
to a PN minimum standards investigation.
RCCI Reason given for downgrade: “Due to additional calls made. An intake was received alleging the
Emotional Abuse of [a child] by [three GRO staff members]. The intake stated that on 5/5/2020, [three GRO
staff members] were being “rude” to [the child], making comments about how she ended up at the facility and
saying that they would cut her hair, a [sic] well as telling her that she was not going home due to how she
behaves. [The child] ultimately opened up the window to her second story bedroom and began yelling out the
window. It was reported that [the child] was agitated due to what was being said to her and was restrained by
staff to get her out of the window, with subsequent report that her wrist was hurting. The intake stated that it
is unknown if [the child] was suicidal.
Although the reported behaviors are of concern, there has not been sufficient information provided to meet the
defined level of Emotional Abuse as there has not been substantial indication that [the child] was attempting
to self-harm. At this time, further review of the situation as a Standards compliance matter is more appropriate
as opposed to an abuse/neglect investigation. If there are concerns for abuse/neglect identified throughout the
course of the case, an additional intake can be called in to generate an abuse/neglect investigation.”
“Doesn’t appear to involve abuse, neglect or risk. Per CCIH 6242.2, a supervisor may downgrade an abuse or
neglect intake report received by SWI to a non-abuse or neglect report when the information in the report in
[sic] suggest a minimum standard was violated, but not that a child was abused or neglected; or indicates that
there is some risk to children, but the information is too vague to determine that a child was abused or
neglected. The concerns appear to be related to minimum standards and this will be forwarded to HHSC for
evaluation of minimum standards.”
Monitors’ Review: The allegation that a child (age 12) was verbally and emotionally mistreated by GRO staff
members meets the threshold for an Emotional Abuse investigation based upon:
The Fifth Circuit’s prohibition of egregious intrusions on a child’s emotional well-being. In its discussion of
the substantive due process rights of the PMC children, the Fifth Circuit stated, “egregious intrusions on a
child’s emotional well-being—such as, for example, persistent threats of bodily harm or aggressive verbal
bullying—are constitutionally cognizable.” 3

Moreover, it meets the threshold for investigation under the Texas Family Code, defining Emotional Abuse
as:

Mental or emotional injury to a child that results in an observable and material impairment in the child's
growth, development, or psychological functioning; and causing or permitting the child to be in a situation in
which the child sustains a mental or emotional injury that results in an observable and material impairment in
the child's growth, development, or psychological functioning. Tex. Fam. Code §261.001(1)(A),(B). 4

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Three – minor violations of the law or minimum standards that involve low
risk to children.

"Based off the preponderance of the evidence, the standards evaluated are being found compliant at this time.
Other children that witnessed the incident did not indicate staff twisted or grabbed [the child]’s hands or arms

3
M.D. by Stukenberg v. Abbott, 907 F.3d 237, 251 (2018).
4
At the time of this incident, the Administrative Code did not have an independent section defining Emotional Abuse in
RCCI investigations. A new section took effect on July 15, 2020.

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in anyway. [The child] was trying to jump out of a second-story window when staff pulled her out of the
window in a bear hug. Staff did not indicate that [the child] had any injuries at the time. Other residents
indicated that [the child] did not have any pain and was using her hand and arm normally. They did not indicate
that [the child] was harmed in anyway. [The child] was hitting walls and destroying property, and it is possible
she injured her hand, if it was injured, during that incident. There is not enough information to support that
staff caused any injury to [the child] at this time and the restraint was justified. Recommended Action: Routine
monitoring."

8. Case ID: 48229146

Intake ID: 73538940
Sample File: May 2020
Summary: A CPS adoption worker reported allegations to SWI that she learned from the foster mother of a
child (Child A, age 10) in a pre-adoptive home. The foster mother observed Child A “humping” another child
(Child B, age 4) in the home on the home security cameras. The reporter stated that: “The children [were]
laying on the floor in the spooning position and [Child A] [began] to hump [Child B] from behind." When the
foster mother spoke to Child A about the incident, Child A stated that he was having the same feeling that he
had when he had "sex dreams" after he watched movies at his previous placement, Independence Farm, an
RTC. Child A named some of the movies that the children at the RTC watched and reported that the movies
had sex in them. In addition, Child A named two boys at the RTC who “hump[ed] things.” Child A stated that
when he resided at the RTC, every night they either watched movies with sex in them or “they [would] have
to go to bed."
Downgrade: SWI assigned this case as a Priority Two Investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI Reason given for downgrade: “This intake report does not contain an allegation of abuse or neglect.
The allegations in this intake are concerning because two children were able to engage in inappropriate
behaviors by humping others or things as well as watching movies that had inappropriate sexual content. CPS
Adoption Caseworker reported that the operation may not have been aware of the boys humping or watching
shows that had inappropriate content. This does not rise to the level of A/N but concerns for possible minimum
standards violations.”
“Per LPPH 6222.2 this intake report does not contain an allegation of abuse or neglect."
Monitors’ Review: A child (age 10) reported that staff members encouraged him to watch “sex movies” at
his previous RTC. He also named two residents at the RTC who “humped things.” These allegations meet the
threshold for a Neglectful Supervision investigation based upon:
Any other act or omission that is a breach of a duty by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559.
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.
“It is alleged that children in care is [sic] inappropriately supervised by caregivers. Interviews were conducted
with the alleged victim by RCCI and all collaterals were interviewed by RCCR Inspector. The agency currently

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has 5 children in care and all 5 were interviewed privately by Zoom video. All the children denied the
allegations of watching inappropriate movies and that all caregivers are always with them and watching movies
with them. Interviews were conducted with the CPS/Reporter who stated that she had no concerns about the
foster child and that he has ADHD and Anxiety but not sexual aggression. She stated that she saw the actual
video and the foster child was wrestling the other boy and did not see anything inappropriate. The service plan
did not mention that [the child] had any sexual aggression and had to be closely supervised only due to his
age. Based on the information provided there is no preponderance of evidence that the agency did not provide
adequate supervision. No deficiencies will be cited.”

Intakes Received in June 2020

9. Case ID: 48258630

Intake ID: 73619958
Sample File: June 2020
Summary: A mental health professional reported that a child (Child A, age 12) stated that she was sexually
abused once but that the child did not provide any further information. While the reporter was not entirely
clear what happened to Child A, the child told the reporter that an unidentified individual forced her to do
something [sexual] and that she had engaged in inappropriate behavior with her cousin. The reporter stated
that both incidents allegedly occurred prior to Child A’s placement into the care of DFPS and were previously
investigated by DFPS. However, Child A also told the reporter that another child (Child B, age unknown) in
her current foster home wanted Child A to do something [sexually] inappropriate. Child B reported to the
caregiver that Child A was sexually hurting her and “making her do dirty things.” Child A reported that Child
B “lied about her.”
Downgrade: SWI assigned this case a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI Reason given for downgrade: “Inconsistent with documented risk.”
“Although [Child A] reported that the current child [Child B] in her foster home asked her to do something
inappropriate, there is no outcry that the children had inappropriate contact. Reporter stated that she reported
the incident about [Child A] and the other child in the home to the child placing agency case manager. The
allegations do not rise to the level of Abuse and Neglect and will be sent to HHSC for further investigation.
Permission given to downgrade to a Non A/N investigation.”
Monitors’ Review: The above allegation that Child A (age 12), with a documented history as a sexual abuse
victim, was potentially engaging in inappropriate sexual contact with another child in the foster home meets
the threshold for a Neglectful Supervision investigation based upon:
Any other act or omission that is a breach of a duty by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559.
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.

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“Based on the information obtained through the course of the investigation it was determined that there was
no violation of minimum standards found. There was not sufficient evidence to support the lack of supervision
allegation.
On 06/18/2020 a report was made alleging another child in the home wanted [Child A] to do something
inappropriate, however, the caregiver was told that it was [Child A] who was making her do dirty things not
the other child. In reviewing [Child A], she denied any sexual abuse or inappropriate behaviors occurred in
her current foster home. She admitted sexual abuse did occur with a cousin when she was 7 or 8 years old,
who was sent to jail. She recalled an investigation took place. [Child A] did not voice any concerns regarding
her placement in the foster home. However, she did report foster parents would take their own children to the
stores/outing and leave her and her brother behind with one foster parent. [Child A] and sibling confirmed
being permitted to have snacks when household chores were done. They can choose between a snack or
computer time. In interviewing foster parents, no concerns were noted regarding observing inappropriate
behaviors between [Child A] and other children in the home. During the investigation, it was reported that
[Child A] voiced suicidal ideations during a CANS assessment. She wanted to bang her head on the wall as a
suicidal attempt. In interviewing foster parents, [Child A] had not displayed any behaviors or voiced any
concerns of harming herself. Agency and foster parents implemented a safety plan. Also, during investigation,
[Child A] and another child in the home ran away from foster home in attempt to see [Child A’s] grandmother.
Children were returned to the home the same day by law enforcement. The home was equipped with alarms
on doors and windows; however, [Child A] was aware of how to disarm alarms. No safety plan was
implemented. A verbal concern will be addressed with agency as a safety plan was not implemented, [Child
A] knows how to disarm alarms. As a result of the investigation, technical assistance will be issued for foster
children having to do chores in order to get snacks.”

10. Case ID: 48257538

Intake ID: 73617243
Sample File: June 2020
Summary: A staff member at Hector Garza Residential Treatment Center, an RTC where DFPS subsequently
stopped placing children, reported that a child (age 13) stated to her therapist that she spat on another staff
member during a physical intervention on June 15, 2020 at approximately 11:30 p.m. The child stated that the
staff member retaliated against her by immediately spitting back at her. The staff member denied spitting on
the child or engaging in any unprofessional conduct toward her. The staff member later indicated that she did
make a gesture of threatening to spit on the child in response to the child spitting on her. It was reported that
the staff member would be placed on administrative leave pending the conclusion of an internal investigation
into an allegation of unprofessional conduct.
Downgrade: SWI assigned this case as a Priority Two investigation for Physical Abuse. RCCI downgraded
to a PN minimum standards investigation.
RCCI Reason given for downgrade: “Staffing with Screener Supervisor: The information was reviewed and
permission to downgrade to PN was granted.
Completed assessment to determine prioritization of an intake which was designated as a Priority Two for
Physical Abuse by Statewide Intake. It was reported that a 12 year-old child stated that spat on a staff member
during a physical intervention on 06/15/2020. The child said that the staff member retaliated against her by
immediately spitting back at the child. The staff member denied spitting on the child or engaging in any

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unprofessional conduct towards the child. The staff member later indicated that she did not make a gesture of
threatening to spit on the child in response to the child spitting on the staff member and denied actually spitting
on the child.
Based on the information provided, a 12 year old child made an outcry of spitting on a staff member and
alleging that the staff member retaliated and spit on the child. A second staff member whom [sic] assisted in
the restraint of the child was interviewed and stated that the other staff member did not spit on the child. The
staff member denied the allegation but has been placed on administrative leave pending an internal
investigation. Although the behavior is of concern, there has not been sufficient indication that the staff
member's actions placed the child in a situation of substantial risk of significant physical harm and does not
rise to the level of abuse/neglect. The allegations regarding the staff member threatening to spit on the child is
inappropriate and will be referred to HHSC for review of minimum standards.
Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report received by SWI to a non-
abuse or neglect report when the information in the report suggests a minimum standard was violated, but not
that a child was abused or neglected; or indicates that there is some risk to children, but the information is too
vague to determine that a child was abused or neglected. The concerns appear to be related to minimum
standards and this will be forwarded to HHSC for evaluation of minimum standards.”
Monitors’ Review: The allegation that a staff member at an RTC spat on a child (age 13) meets the threshold
for a Physical Abuse investigation based upon:
Any act such as striking, shoving, shaking, or hitting a child, whether intended as discipline or not, by someone
working under the auspices of an operation that causes or may cause emotional harm or physical injury to, or
the death of, a child that the operation serves. 40 TAC §745.8557(1).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.
“Based on the information received through interviews and documents reviewed, it was determined that there
was preponderance of evidence to support the allegations. The child and a staff member, who was present
during the incident, both stated that another staff spit on the child after the child spit on them. An additional
staff member who was nearby the incident, stated that although, they did not see the staff spit on the child,
they heard the child yell out that staff had spit on them. The staff in question refused to speak with me but was
terminated from employment shortly after this incident citing "unbecoming conduct" and is not eligible for re-
hire. A citation will be issued for this incident. In addition, technical assistance will be provided regarding
another staff, as that staff stated that the child threatened to spit on them and they replied, ‘I guess we will both
be spitting.’"

11. Case ID: 48254817

Intake ID: 73609737
Sample File: June 2020
Summary: A DFPS staff member reported concerns that administrators at The Tree House Center, a GRO,
were not following protocols to ensure youth and staff safety related to COVID-19. During a virtual visit, a
caseworker observed a child (age 14), who tested positive for COVID-19, spending time with other residents
at a park unmasked. The following day, the caseworker observed a virtual medication appointment, and
observed the child who was COVID-19 positive in a small room with other children. The children were again

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not wearing masks and the room was too small for social distancing. The reporter expressed concern for the
safety and health of the children and staff at the GRO.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI Reason given for downgrade: “Screener spoke with inspector, she had no concerns about the facility.
She stated she was notified a child at the facility test positive for Covid-19 and they were following the proper
guidelines. She stated there were some emails she was CC’D in regarding Covid-19 but she was unsure who
was the person requesting the children to be tested again.
Screener spoke to CPS regional nurse consultant. She stated the concerns they [sic] are the lack of precaution
the facility took in regards to COVID-19 and she stated she wanted the information to be relayed to HHSC.
She stated they are continuing to go through there precautions to help the facility out but she stated she also
wanted HHSC to look at the facility as well.
Completed assessment to determine prioritization of an intake which was designated as a Priority 2 for
Neglectful Supervision by Statewide Intake. The [child] is 13 years old and resides at [the GRO].
The report reads on 5/15/20- [Doctor] emailed [director] to let her know [caseworker] would be visiting the
girls in person this month & to ask if any of the children or staff had been experiencing any symptoms. She
also asked if any girls were currently hospitalized. 5/15/20- [Director] responded back that no one is currently
running a fever, but a few girls who have allergies are having cold like symptoms. She also sent a list of girls
currently hospitalized. 5/18/20- [Director] sent another email that [the child] tested positive for COVID-19.
The girls were all at the park during the FTFs. None were wearing masks, and [the child] was there with the
other girls. We don’t know if they were transported together or not. 5/27/20- [Doctor] participated in virtual
psychiatric medication appointments. There is a small room at the facility where medication appointments take
place, there is a Telemedicine machine in this room where there [sic] doctor sees them virtually. There is no
way to social distance in this small room. No one was wearing masks. (The first half of the appointment was
virtual, and the 2nd half [doctor] had to participate by phone because the facility started having technical
difficulties). She does not remember what order she saw the girls in.
The concerns appear to be related to minimum standards and this will be forwarded to HHSC for evaluation
of minimum standards.
The reporter (CPS regional nurse consultant) stated the concerns are the lack of precaution the facility took in
regards to COVID-19 and she stated she wanted the information to be relayed to HHSC. She stated they are
continuing to go through there [sic] precautions to help the facility out but she stated she also wanted HHSC
to look at the facility as well. The facility notified HHSC through SWI on 5/19/20 that a child tested positive
for COVID-19. It is believed the [child] contracted COVID-19 while being hospitalized at [a] Psychiatric
Hospital. According to the email provided by the HHSC inspector; the facility tested the [child] again a 3rd
time after being sequestered for two weeks and was asymptomatic at all times. The Doctor states that the
second nasal test was probably showing dead COVID cells. The third time, which was a blood draw test,
resulted in antibodies of COVID. She will probably show COVID for the next two years. As we are following
the protocol and directions of our Doctors and CDC we hope that this addresses your concerns. We have no
intention of testing another 48 people. We are remaining on lockdown as the number of COVID cases is
increasing 30 to 72 cases per day in [the] County. Until our cases flatten or decrease we will remain on lock
down. We hope that this email addresses your concerns. I have directed all of our staff to direct your questions
to me. Please feel free to call me for any further information for you or your staff.

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Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report received by SWI to a non-
abuse or neglect report when the information in the report in suggest a minimum standard was violated, but
not that a child was abuse or neglected; or indicates that there is some risk to children, but the information is
too vague to determine that a child was abused or neglected.”
Monitors’ Review: The allegation that either GRO staff or administration failed to properly quarantine a child
(age 14) who tested positive for COVID-19 meets the threshold for a Neglectful Supervision investigation
based upon:
Any other act or omission that is a breach of a duty by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559.
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Two – Serious Supervision Problems.
“After completing my investigation for The Tree House Center using both interviews and documentation,
there is a preponderance of evidence that indicates staff members did not use prudent judgement [sic] when
allowing a child who tested positive for the Covid-19 virus to interact with the other residents at the facility. 6
out of 6 staff members I interviewed stated that [the child], who tested positive for the Covid-19 virus on May
16th 2020, was not isolated from the rest of the residents for the full recommended time. I received
documentation from [the child]’s LPS worker which stated that she conducted a virtual face-to-face with [the
child] on May 26th 2020. At the time of this virtual visit, [the child] was at the park with the rest of the
residents, not wearing a mask and at the time still positive for the Covid-19 virus. I received documentation
that showed [the child] tested positive for the Covid-19 virus again on May 29th 2020. 6 out of the 6 staff
members I interviewed stated the administrators from The Tree House Center never formally notified the staff
that [the child] tested positive for the Covid-19 virus. The staff members stated they found out about [the
child’s] positive Covid-19 test by either word of mouth from other staff members, [the child] herself or were
contacted by the medical facility that performed the Covid-19 test. Two citations were issued for this
investigation for standards 748.507(1) and 748.705(b)(7).”

12. Case ID: 48245439

Intake ID: 73583431
Sample File: June 2020
Summary: A staff member from a CPA reported that a child (age 11) stated that he had some bad experiences
at a previous placement when he was around three years old, and those experiences were making him nervous
about future placements. He said he was playing with his foster mother and accidentally hurt her while they
were playing. When the foster father found out, he left the room to get a belt buckle. The child said the foster
father threw him on the bed and beat him so badly that he had “bruises on his butt for a while.” The child also
said he had to sleep in a closet for a week. The reporter had a follow-up conversation with the child, and he
shared that he was in that placement when he was approximately three years old, and the placement only lasted
for “like a month.”
Downgrade: SWI assigned this case as a Priority Two investigation for Physical Abuse. RCCI downgraded
to a PN minimum standards investigation.

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RCCI Reason given for downgrade: “Completed assessment to determine prioritization of an intake which
was designated as a P2 for Physical Abuse by Statewide Intake. It was reported that an 11 year old child that
[sic] he had some bad experiences at a previous placement that is making him nervous about future placements.
The [sic] said he was playing with his mom and accidentally hurt her while they were playing and when the
dad found out, he left the room to get a belt buckle to beat him with. The child said that he threw him on the
bed and started to beat him, and he beat him so badly that he had bruises on his butt for a while. The child said
that he had to sleep in the closet for a week after that. Later that day, a follow-up conversation was had with
the 11 year old and he shared that the placement was when he was about 3 years old and it only lasted for ‘like
a month’.
Based on the information provided, an 11 year old child has made an outcry of physical abuse while previously
residing in a foster home back in 2013 when the child was 3 years old. The foster home has been closed since
01/25/2018 and there do not appear to be any CPS children residing in the foster home. The 11 year old has
not had any contact with the foster parent since leaving the home back on 10/14/2013. Although the allegations
made by the child are serious in nature, RCCI does not have jurisdiction to investigate these claims; therefore
the intake will be closed without investigation.
Per CCIH 6221.5, Intake reports to be closed without investigation; The supervisor or designee determines
that an intake report will be closed without an investigation if the information in the report clearly reflects that
there is no alleged abuse or neglect or violation of law or minimum standards to investigate, clearly reflects
that another DFPS division, another state agency, or law enforcement has investigative jurisdiction, or has
already been investigated in a closed investigation.”
Monitors’ Review: The allegations that a foster father physically abused a child (currently age 11; age 3 when
the allegations occurred) and caused “bruises on [the child’s] butt for a while” and that the foster parents forced
him to sleep in a closet for a week warrants an investigation even if the foster home is no longer operational. 5
Therefore, these allegations meet the threshold for a Physical Abuse investigation based upon:
Any act such as striking, shoving, shaking, or hitting a child, whether intended as discipline or not, by someone
working under the auspices of an operation that causes or may cause emotional harm or physical injury to, or
the death of, a child that the operation serves. 40 TAC §745.8557(1).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Administrative Closure. No investigation was conducted.

5
Moreover, pursuant to DFPS’ analysis about whether closure negates the need for investigation, “the fact that the outcry
came out after ... the foster home was closed should not matter as the allegations themselves warrant an investigation.”
See TEX. DEPT OF FAMILY & PROTECTIVE SERVS, QA Report from FY2020 Quarter 3 Review of Residential Child Care
Intakes Reclassified as PN (Priority None), (July 31, 2020) (on file with the Monitors and DFPS).

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13. Case ID: 48253928

Intake ID: 73607130
Sample File: June 2020
Summary of Intake Allegations: A staff member at Freedom Place, an RTC, reported that one of its residents
(Youth A, age 17) ran away from the facility after a sexual encounter with another resident (Youth B, age 15).
Youth A called the staff person from a gas station after running away, explaining that she was concerned that
she would be labelled as a “sexual predator” because she had "fingered" Youth B while on the couch in the
front of the house the night before. After the sexual incident, Youth A asked Youth B how old she was, and
Youth B told her she was fifteen. Neither youth reported that the incident was forced. The staff person believed
the incident occurred between 9:30 p.m. and midnight. Youth A returned to the facility at 4:00 a.m. the
following day.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI reason given for downgrade:
“Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report received by SWI to a non-
abuse or neglect report when the information in [sic] the report suggest [sic] a minimum standard was violated,
but not that a child was abuse or neglected; or indicates that there is some risk to children, but the information
is too vague to determine that a child was abused or neglected.”
“Closed and Reclassified. The concerns appear to be related to minimum standards and this will be forwarded
to HHSC for evaluation of minimum standards. The [alleged victim] ran away [from the] facility because she
had a sexual encounter with [a] 15 year old in fear that she would be considered a child predator. According
to the intake the child has returned to the facility and the two children have been separated. Neither girls has
[sic] made an outcry that the sexual encounter was forced. Also according to the intake the facility was
completing room checks every 15 minutes.”
Monitors’ Review: The allegation that Youth A (age 17) reported that she engaged in a sexual encounter with
Youth B (age 15) in the facility warrants an investigation to determine whether the youth were subject to
appropriate supervision at the time of the incident. Due to both youth having a history of sexual abuse and/or
sexualized behavior, an assessment of supervision at the time of the alleged incident is particularly necessary.
This allegation meets the threshold for a Neglectful Supervision investigation based upon:
Placing a child in or failing to remove the child from a situation in which a reasonable member of that
profession, reasonable caregiver, or reasonable person should know exposes the child to the risk of sexual
conduct. 40 TAC §745.8559.
Any other act or omission that is a breach of a duty by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559.
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Two – serious supervision problems.
HHSC determined there was a violation of minimum standards: “Based on a preponderance of information,
there is evidence to conclude that children in care were not adequately supervised, resulting in children having
inappropriate contact with each other. Children in care, as well as video proves that staff member was present

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at the time of the incident but was not actually supervising the children. It also shows that staff member did
not redirect the children as she stated, she allowed the 3 children to sleep on the couch together with the lights
out stating she underestimated what the girls would do.

Violations cited: 748.685(b)(4): Staff did not adequately supervise children in care, resulting in them having
inappropriate contact with each other.

TA: The purpose of this rule is to protect the health, safety, and well-being of children by ensuring adequate
care and supervision of children.

According to the American Academy of Pediatrics, “Supervision is basic to the prevention of harm. …. To be
available for supervision or rescue in an emergency, an adult must be able to hear and see the children. In
addition to hearing and seeing the children, an adult must be able to gauge a situation and decide how close
children need to be supervised. Recommended Action: Routine monitoring.”

14. Case ID: 48238692

Intake ID: 73565030
Sample File: June 2020
Summary of Intake Allegations: A staff member at Roy Maas Youth Alternative, an RTC, reported that a
youth (Youth A, age 16) presented with a hickey on her neck. The youth initially said it was a bug bite but
eventually admitted that it was a hickey and that it was "done to her by another resident." According to the
staff member, the staff suspects that the hickey was given to the child by another female resident (Child B, age
12). The staff member stated that the staff did not know when the interaction happened; however, it did happen
outdoors on the grounds where there are no cameras. The staff were not able to find any video footage of the
interaction after reviewing the indoor footage.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI reason given for downgrade: “Inconsistent w/ doc risk. Based on the information provided, a 16 year
old child stated that she had a hickey on her neck. It is believed that the hickey was given by another resident
at the facility. The reporter nor the CVS worker were able to be contacted at this time. Given the information
provided in the intake, there was no mention of seduction, coercion, or force; therefore, the situation does not
meet the criteria for child sexual aggression. There [sic] also no mention of penetration or the child being
fearful of anyone at the facility. The child has not been placed in a situation that would expose her to sexual
conduct harmful to the child and the situation does not rise to the level of abuse/neglect. There may be a
concern for the overall supervision of the child and the intake will be referred to HHSC.”
“Other Agency/Out-of-State. Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report
received by SWI to a non-abuse or neglect report when the information in the report suggests a minimum
standard was violated, but not that a child was abuse or neglected; or indicates that there is some risk to
children, but the information is too vague to determine that a child was abused or neglected. The concerns
appear to be related to minimum standards and this will be forwarded to HHSC for evaluation of minimum
standards.”

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Monitors’ Review: This allegation that Youth A (age 16) reported that Child B (age 12) gave her a hickey on
the neck while in care meets the threshold for a Neglectful Supervision investigation based upon:
Any other act or omission that is a breach of a duty by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559.
The SWI intake specialist did not sufficiently probe for more relevant details about the alleged incident with
the reporter that would have informed the decision about whether to investigate these allegations, and
specifically, did not confirm whether the interaction was deemed consensual, although that appears to be the
assumption that the intake specialist made when discussing the allegations with the supervisor. Subsequently,
the CCI screening staff attempted but were not able to gather any collateral contact information; they appeared
to make the PN downgrade based solely on the limited information provided in the report.
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three – minor violations of the law or minimum standards that involve low
risk to children.

“Based on the information gathered through documentation and interviews, there will be no citations on
minimum standards. A child in care gave another child in care a hickey. Neither child was under any special
level of supervision, nor had a history of sexualized behavior or poor boundaries with peers. Additionally, a
safety plan was put in place to keep both children away from each other. Technical assistance was provided
with regards to supervising the children when they are outside, to prevent children from engaging in
inappropriate behaviors. Recommended Action: Routine Monitoring.”

15. Case ID: 48256838

Intake ID: 73615303
Sample File: June 2020
Summary of Intake Allegations: A DFPS caseworker stated in an e-report that while she was at the foster
home to place a youth (Youth A, age unidentified), she observed another youth (Youth B, age 15) in the home
who was swinging a broom handle. Next, she observed Youth B getting a bottle of bleach and start yelling at
the foster mother to video her so it could be placed on YouTube. Youth B started dumping bleach into the
flower beds near the front entry walkway and then returned inside the home with the bleach. She then attempted
to go into the foster mother's room with it. The foster mother took the bleach away from her at that time. The
reporter left the home to pick up prescriptions for Youth A and when she returned, Youth A told the reporter
that while she was gone, Youth B picked up a “chain saw” and started swinging it. Youth A was visibly upset,
crying, and shaking. Youth B continued with her behavior and then walked out of the house, proceeding down
the street and out of sight. About ten minutes later, the foster mother came outside and took the car to go look
for the youth. When the foster mother and Youth B returned to the home, Youth B exited the vehicle with a
metal object, walked over to a car and hit the car twice with the metal object. Throughout the entire time that
Youth B was acting out, she allegedly expressed indecision about whether she wanted to go to the hospital or
to respite care. The reporter stated that she did not believe that Youth B went to either place following the
event. Youth A was removed from the home and taken to respite care, as she was not comfortable staying at
the home. The reporter later notified Youth B’s caseworker about her observations while at the foster home
and learned that Youth B’s caseworker was not previously aware of the incident.

Downgrade: SWI assigned this case as a Priority One investigation for Neglectful Supervision and Medical
Neglect. RCCI downgraded to a PN minimum standards investigation.

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RCCI reason given for downgrade: RCCI documented extensive notes confirming the information submitted
by the reporter, a DFPS caseworker, and verifying that Youth A, who witnessed the event, was taken to respite
care following the incident. The foster mother called MHMR (Mobile Crisis) and the agency case manager
for Youth B; however, they said that she would not qualify for their services and suggested that they try taking
her to the hospital. There is no indication that the foster mother or DFPS brought Youth B to the hospital. 6

“Intake staffed with [other staff]. Intake downgraded to PN as it does not rise to the level of abuse or neglect.
Victim was not harmed or injured. She was in fact destructive toward property but was adequately supervised.
Safety plan was implemented.” It should be noted that the safety plan that was implemented was for Youth A,
not for Youth B, the girl who had the outburst.

Monitors’ Review: Youth B (age 15) has an extensive history of demonstrating difficulties regulating her
moods and emotions and has a history of suicidal ideation, homicidal ideation, physical aggression, and self-
injurious behaviors. The allegation indicate that she had access to bleach, a metal instrument to strike the
caseworker’s car, and a chain saw. Youth B’s medical history combined with the access to dangerous
instruments meet the threshold for an investigation of Neglectful Supervision. As of May 20, 2020, Youth B’s
Common Application stated that she had been hospitalized twice in 2020 for suicidal/homicidal ideations and
physical aggression toward others; moreover, she had a service plan that called for “constant” supervision
because of violent behaviors. Furthermore, following an episode that included aggressive behavior that was
potentially dangerous to herself or others, it appears that the foster mother failed to secure mental health
support for her once the Mobile Crisis Unit was unable to provide assistance. These allegations meet the
threshold for Neglectful Supervision and Medical Neglect investigations based upon:

Placing a child in or failing to remove him from a situation that a reasonable member of that profession,
reasonable caregiver, or reasonable person should realize requires judgment or actions beyond the child's level
of maturity, physical condition, or mental abilities, by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559(3).

Failure to seek, to obtain, or to follow through with medical care for a child, by a person working under the
auspices of an operation that causes or may cause substantial emotional harm or substantial physical injury to
a child. 40 TAC §745.8559(5).

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.

HHSC determined there was a violation of minimum standards: “During this investigation all principles were
interviewed documentation was read as well. It was discovered bleach and a bush trimmer were left out, which
the child picked up and threatened household members and poured bleach around the home. The child's service
plan called for ‘constant’ supervision because of violent behaviors. The foster parent by leaving these items
out violated not only physical site standards but also following service plan requirements. Citations were issued
for both.”

6
Monitors summarized this portion of the RCCI downgrade documentation due to its length.

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16. Case ID: 48269302

Intake ID: 73649890
Sample File: June 2020
Summary of Intake Allegations: A case manager at Whataburger Center for Children, a GRO, stated that a
youth (age 15) was in her room using the restroom while on one-to-one staff supervision. The staff member
waited for her outside of the bathroom door. The staff member reportedly asked the youth if she was okay, and
she said that she was. She then asked whether the youth wanted pizza and the youth replied that she did. The
staff member did not notice the youth carrying any materials on her person after she came out of the restroom,
but the youth informed the staff member that she was scared. The staff member reassured her that she was
safe, and they were not going to permit anything to happen to her.
A few minutes later, the youth informed staff members that she had self-harmed using the wire spring from
inside the toilet paper holder in the bathroom. The youth self-harmed in her breast area. Staff members then
transported her to [a psychiatric facility] but once they arrived there, the youth ran away from staff. She then
picked up a glass bottle from a construction site to self-harm again. A staff member contacted law enforcement
to assist, and the youth was admitted into a psychiatric hospital.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.

RCCI reason given for downgrade: No collateral contacts were successfully made. “Staffed with RCI
Screener Supervisor. Doesn't appear to involve abuse, neglect or risk”.
Monitors’ Review: Although the reporter stated that the youth (age 15) with an extensive history of self-
harming was subject to one-to-one supervision at the time the incident occurred, an investigation was necessary
to determine the duration of time she had been in the bathroom unsupervised while she self-harmed. According
to the youth’s Common Application that was completed five days prior to this incident, she was hospitalized
seven times in 2020 (in excess of seventy-five days) for self-harming and suicidal ideation. Therefore, this
allegation meets the threshold for a Neglectful Supervision investigation based upon:

Any other act or omission that is a breach of a duty by a person working under the auspices of an operation
that causes or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC
§745.8559.

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.

“Based on the information gathered through interviews with the victim, 2 residents, 3 staff case workers, and
external documentation there are no minimum standard violations. [The alleged victim] was on one-to-one
supervision and the staff responsible for her was [staff member A]. [Staff member A] was with [the alleged
victim] at all times and provided adequate supervision. With staff's permission, [the alleged victim] went to
use the restroom located in her bedroom while staff member was outside the door waiting for her. After [the
alleged victim] came out of the restroom, her and [staff member A] went to the dining room to get something
so she could get something to eat. [Staff member A] stated that [the alleged victim] appeared anxious and she
asked her if she was ok. Initially, [the alleged victim] told [staff member A] that she was ok and then disclosed
that she had self-harmed while she was in the restroom. [the alleged victim] told staff that she self-harmed on
her chest and used a wire spring that was inside the toilet paper dispenser. The cuts were superficial and did
not require medical attention. Staff transported [the alleged victim] to [a] psychiatric hospital for further

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evaluation. After they arrived at [the hospital], [the alleged victim] attempted to run away. [Staff member B]
followed [the alleged victim] and contacted the police. [the alleged victim] was within eyesight of [staff
member B] until she went a nearby construction site and found a piece of glass. [The alleged victim] self-
harmed with the piece of glass. [Staff member B] had continued to follow [the alleged victim] and stated that
she did not see her for about a minute and caught up to her. The police arrived and then took her back to [the
hospital] where she was admitted. The case worker and licensing was [sic] notified of the incidents.”

Intakes Received in July 2020

17. Case ID: 48281965

Intake ID: 73685524
Sample File: July 2020
Summary: A CPA case manager reported that a child (age 12) reported that she was raped in a previous foster
home by a foster parent. The reporter was unable to identify the CPA responsible for the previous placement,
nor did she report additional details about the identity of the alleged perpetrator and timeframe. The child
previously made an outcry to her therapist (named in the report) and the CPS case worker. The reporter stated
that the child told other foster children in her current foster placement that she was raped by a previous foster
parent.
Downgrade: SWI assigned this case as a Priority Two investigation for Sexual Abuse. RCCI downgraded to
a PN minimum standards investigation.
RCCI Reason given for downgrade: “Collateral Contact: 2:40pm – Spoke with reporter. [Therapist] stated
she had no additional details regarding the outcry. She stated [the child] told other children that she had been
raped by her foster father in a previous foster home. There was no information obtained as to the identity of
the AP or what foster home or child placing agency the home was licensed by. She stated the CVS worker was
aware of the incident. I asked if the worker was aware of it in that [the child] made the outcry or there was a
previous allegation. [Therapist] reported she thought the incident had been previously reported. 3:40pm –
Attempted to contact CVS caseworker A message was left requesting a return call. Additional Allegations:
N/A Safety Concerns: N/A Staffing: Intake and screening information staffed with RCI Screener Supervisor.
Screener Final Assessment /Conclusion: A report was received indicating 12 year old [child] had reported to
other foster children in her current foster home that she had been raped by her foster father in a previous foster
home. There was no information given to identify an AP or when this alleged incident took place. Reporter
was contacted. [Therapist] stated she had no additional details regarding the outcry. She stated that [the child]
told other children that she had been raped by her foster father in a previous foster home. There was no
information obtained as to the identity of the AP or what foster home or child placing agency the home was
licensed by. She stated the CVS worker was aware of the incident. I ask if the worker was aware of it in that
[the child] made the outcry or there was a previous allegation. [Therapist] reported she thought the incident
had been previously reported. An attempt to contact [the child’s] CVS caseworker for possible additional
information was unsuccessful. [The child] has an extensive placement history and has been in several foster
homes, basic care facilities, RTCs, and psychiatric hospitals. Investigation records show a previous
investigation (RC - 44133014- 12/1/15) where “alleged victim” made an allegation of being raped by her foster
father. During the investigation three of eight children interviewed indicated [the child] had told them [previous
foster parent] came to her room at night and touched her inappropriately. [The child] was interviewed three
times and each time denied any sexual abuse by [previous foster parent]. An additional reported regarding an

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allegation of [the child] being raped by her foster father was received 7/2/20. [The child] was interviewed she
reported [previous foster parent] came into her room at night and touched her vaginal area. She stated she told
her sister, who told other children in the home, and they in turn told the foster mother. The [previous foster
home] is no longer operating/providing care for children. Per CCIH 6221.5 an intake can be closed without
an investigation. The intake will be admin closed. Based on the available information is appears the allegation
has been previously investigated in RC inv 44133014 (12/1/15) and again reviewed in intake # 48275172
(7/2/20). [The child] has made allegations of being inappropriately touched by [previous foster parent]. She
has also denied any inappropriate touching by [previous foster parent] when interviewed as well. The foster
home is no longer open or providing care to children. Per CCIH 6221.5 an intake can be closed without an
investigation. The intake will be admin closed.”
Monitors’ Review: A child (age 12) made an outcry of sexual abuse in a prior foster home. While the child's
outcry did not include specific identification about the perpetrator or the timeframe, the reporter stated that
both the child’s therapist and CPS caseworker may have additional information regarding the outcry. Because
it is unclear whether this was a previously reported allegation or a new outcry, this allegation meets the
threshold for a Sexual Abuse investigation based upon:
Sexual conduct that constitutes the offense of indecency with a child as defined under Penal Code, §21.11,
sexual assault as defined under Penal Code, §22.011, or aggravated sexual assault as defined under Penal Code,
§22.021, by someone working under the auspices of an operation that causes or may cause emotional harm or
physical injury to, or the death of, a child that the operation serves. 40 TAC §745.8557(5).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Administrative Closure. No investigation was conducted.

18. Case ID: 48273058

Intake ID: 73660367
Sample File: July 2020
Summary of Intake Allegations: A private therapist reported that a child (age 4) disclosed to her that
"mommy got really mad at her and pinched her" after the child had spilled some paint on the carpet at her
foster home. The therapist reported being able to see a bruise on the upper-left inside part of child’s thigh. The
therapist described the bruise as "a couple of little ones" the "size of fingerprints." She indicated that she was
not sure whether there were signs of multiple pinches and that it might have been just one squeeze. She further
stated that she does not feel like the foster parents are horrible or abusive people. The therapist reported that
she had not met the foster mother; but she had been working with the foster father, who participated in weekly
sessions to support the child’s behavioral issues, and that he appeared to want things to get better and to help
the child. The therapist reported that the child’s CVS worker also reported the alleged incident to SWI.
Downgrade: SWI assigned this case as a Priority Two investigation for Physical Abuse. RCCI downgraded
to a PN minimum standards investigation.
RCCI reason given for downgrade: “Other Agency/Out-of-State. Due to add'l calls made. Based on the
information provided, a 4 year old made an outcry to a professional that the foster mom pinched her after the
child spilled paint on the carpet. The pinch resulted in a couple of small bruises to a non-vital part of the
child’s body. The actions of the foster parent appear to be an inappropriate method of discipline which did not
result in substantial harm to the child or the genuine threat of substantial harm; therefore does not rise to the

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level of abuse/neglect. HHSC currently has an active investigation (CLASS #2634161) for this situation which
was reported on 06/30/2020. The intake will be referred to HHSC for concerns of inappropriate discipline used
by the foster parent. Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report received
by SWI to a non-abuse or neglect report when the information in the report suggests a minimum standard was
violated, but not that a child was abused or neglected; or indicates that there is some risk to children, but the
information is too vague to determine that a child was abused or neglected. The concerns appear to be related
to minimum standards and this will be forwarded to HHSC for evaluation of minimum standards.”
Monitors’ Review: This allegation that a child (age 4) had visible bruising caused by her foster mother
pinching her as punishment meets the threshold for investigation for Physical Abuse. Furthermore, an
investigation is consistent with the RCCI Intake Guidelines which state that the following is usually assigned
as an intake: “A child, age 6 or younger, sustains any injuries as a result of physical discipline and/or restraint
by a foster parent/caregiver.” 7 Therefore, this allegation meets the threshold for a Physical Abuse investigation
based upon:
Any act such as striking, shoving, shaking, or hitting a child, whether intended as discipline or not, by someone
working under the auspices of an operation that causes or may cause emotional harm or physical injury to, or
the death of, a child that the operation serves. 40 TAC §745.8557(1).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Two - injury or serious mistreatment of a child.
“Based on the information gathered during the investigation there is not enough evidence to support a citation.
Testimonial and documentary evidence were reviewed and support the finding in the investigation. The victim
was interviewed and denied the allegations. The victim does have a couple of bruises on her legs which are
round. She indicated the new puppy jumps and sometimes lands on her legs which can cause a bruise. I
observed the puppy jumping and playing with the victim and can see where the [puppy’s] paws could cause a
bruise in the area where bruises were observed. Both foster parents denied the allegations.

The victim has been in the home for 2 years and the foster parents said they are planning to adopt her and
would not harm her. The victim seemed very bonded with the foster dad and said she liked the home. The
reporter/therapist stated both of the foster parents seem very committed to the victim and based on her
interactions with them does not think they would pinch or physically harm the victim. The case manager also
stated the family is very committed to the victim. The victim has never made an outcry of physical discipline
or being harmed in any other way. CPS does not have any concerns about the family harming the victim or the
care she is receiving in the home.

The preponderance of evidence in the investigation indicates the allegation in the investigation most likely did
not occur. No citations will be given as a result of this investigation. Recommended Action: Routine
monitoring.”

7
See TEX. DEP’T OF FAMILY & PROTECTIVE SERVS, RCCI Intake Guidelines, (January 2020) (on file with the Monitors
and the State).

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Intakes Received in August 2020

19. Case ID: 48320728

Intake ID: 73793652

Sample File: August 2020
Summary of Intake Allegations: A foster mother reported that her foster child (age 8) stated “out of the blue”
when she picked him up from daycare, "Hey mom, I know why you and Dad don't hit me. It's because you
love me, right?" She added that the child said, "When I get in trouble, I don't get spanked, I get grounded."
The foster mother also stated that the child said that at his prior foster home, the foster mother hit him with a
belt, a back scratcher, and a brush. She stated that the child said the prior foster mother would hit the child
with a brush on his fingers until they were red. She did not know where on his body he was hit with the belt
and back scratcher. The child came to the current foster home in April 2020 and the foster mother stated that
he was living in the foster home where the alleged abuse occurred for two years. She expressed concern that
the prior foster mother might be abusing other children in her care.
Downgrade: SWI assigned this case as a Priority Two investigation for Physical Abuse. RCCI downgraded
to a PN and closed without an investigation.
RCCI reason given for downgrade: “Due to local records. Staffing completed with Screener Supervisor. The
allegations received stated that [the alleged victim] reported he was hit with a belt, a back scratcher, and on
his hand with a brush. In the investigation conducted by HHSC the child was approximately 6 years old and
did not articulate details but generally stated that he was “whooped by the foster parent and they hit him with
a stick” which is assumed to be the backscratcher. According to the disposition given by HHSC there was not
a reason to believe that inappropriate discipline took place while [the alleged victim] was placed in the home.
Based on the information obtained during the screening process and Screener Supervisor’s review of the
CLASS investigation, it was agreed that this intake can be PN-Closed without Investigation.”
“Allegations addressed in previous case. Screener Final Assessment/Conclusion Priority None (Closed without
Investigation). Completed assessment to determine prioritization of an intake which was designated as a P2
for Physical Abuse by Statewide Intake. Allegations state that on 08/12/20, foster mother picked up [the alleged
victim] from daycare. [The alleged victim] told [the foster mother], “I know why you and dad don’t [sic], it’s
because you love me”. [The alleged victim] said he gets grounded when he gets in trouble with foster parents.
[The alleged victim] said at his old home, his former foster parent [CPA] would hit him with a belt and a back
scratcher. [The alleged victim] said that she would hit him with a brush on his hand until his hand was red.”
“Per LPPH 6221.5, the supervisor or designee determines that an intake report will be closed without an
investigation if the information in the report has already been investigated in a closed investigation. After
reviewing [former foster parent’s] history, it was determined that the allegation of inappropriate discipline was
[sic] addressed in HHSC investigation 2435447 (IMPACT Case ID 46686247). During that investigation, [the
alleged victim] stated he gets a 'whoopin' from [former foster parent]. He then stated he didn't know what a
'whoopin' was but he does have to go to his room when he gets in trouble. When asked about an incident that
occurred between him and another child, [the alleged victim] stated that he got a 'whoopin' with a stick. He
stated [former foster parent] hit him and another with a stick on their finger. [The alleged victim] left [former
foster parent]’s home on 4/20/2020. CPS Caseworker stated that the [foster family] never said anything to her
about the behaviors; the [foster family] are old school and [the alleged victim] reported that when he got into
trouble he would go to his room. [Current foster parent] stated that she never seen any indications of bodily

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harm nor any marks or bruises. [Current foster parent] stated that [the alleged victim] was placed with his new
foster family due to the foster parents being adoption motivated. Although the allegations are concerning, it
appears to be more of a minimum standards violation and would have been forwarded to HHSC for further
investigation. Based on the information obtained, it appears that these allegations were already addressed by
HHSC. Therefore, this intake will be closed without investigation.”
Monitors’ Review: This allegation that a prior foster mother hit a child (age 8) with a belt, a back scratcher,
and a brush at a prior foster home meets the threshold for a Physical Abuse investigation based upon:
Physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from
physical injury to the child, including an injury that is at variance with the history or explanation given and
excluding an accident, by a person responsible for a child’s care, custody, or welfare. 40 TAC § 707.789(1).
When downgrading the intake report, RCCI concluded that the allegations of inappropriate discipline were
previously investigated in April 2018 by HHSC (IMPACT Case ID 46686247) and ruled out. The 2018
investigation involved allegations of Neglectful Supervision due to inappropriate sexual behaviors between
the alleged victim and one of his foster siblings, as well as allegations of inappropriate discipline that were
disclosed during the investigation. The Monitors disagree with RCCI’s conclusion that these allegations were
previously investigated given that the original investigation was conducted in 2018, and the child continued to
live at the foster home for an additional two years, during which time these additional allegations potentially
arose.
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Administrative Closure. No investigation was conducted. RCCI downgraded to a PN and closed
without an investigation.

20. Case ID: 48311453

Intake ID: 73767746
Sample File: August 2020
Summary of Intake Allegations: A therapist at Prairie Harbor, an RTC, reported that during a therapy session
with a youth (age 15), who had an unidentified mental health disorder, the therapist noticed some bruising on
the youth’s arms and marks on the youth’s wrists. The reporter asked the youth about the marks, and the youth
said that the marks on her wrists were self-inflicted but stated that the other bruises on her arms occurred when
a Prairie Harbor staff member “put her hands” on the youth. The bruising was on both arms: one was on the
back of her lower right arm which was a half-dollar size and the other was on the youth's left forearm and was
a quarter size. The youth reported that she was “having a meltdown” and went to sit on the floor of the shower.
The RTC staff member attempted to get her off the shower floor (the youth was fully clothed), and the youth
put her hands on the RTC staff member who was reportedly pregnant. When the therapist asked the RTC
supervisor whether the youth had been placed in a restraint by staff, the supervisor stated that no restraint had
been done involving the youth. The therapist stated that the youth is very pale-skinned and she could see why
bruising could show up on this youth if a staff member put her in a restraint, but there was no documentation
of a staff member using a restraint involving this youth. The RTC supervisor said that he saw the youth in the
bathroom when the incident occurred and the RTC staff member never touched the youth. The supervisor did
not say whether the youth had bruises on her arms when he saw her in the bathroom. The therapist stated that
the August 2, 2020 progress notes (the date of the intake report) did indicate that bruises were noted on the
youth, but that it was unclear when the bruises were first observed. The youth also had some scratches on her

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arm. The youth claims that she did some of the scratches to herself, but she also claimed, “the devil did that to
her while she was sleeping” and she woke up with the scratches. None of the scratches were deep, but they
were red. The therapist stated that there is no indication that there have been previous incidents involving this
staff member, but the youth alleges that this staff member has been “picking on her and writing her up.” The
youth claims that the staff member is “racist against white people.” However, the therapist further stated that
there are four other white youth in that section of the RTC who had not reported any similar issues and,
therefore, the therapist did not believe this to be the case.
Downgrade: SWI assigned this case as a Priority Two investigation for Physical Abuse. RCCI downgraded
to a PN minimum standards investigation.
RCCI reason given for downgrade: "The concerns appear to be related to minimum standards and this will
be forwarded to HHSC for evaluation of minimum standards. The child was inappropriately disciplined by a
staff member. As per RULE §707.789, the bruising did not result in physical injury that resulted in substantial
harm to the child, or the genuine threat of substantial harm from physical injury to the child. [The alleged
victim] was observed with a quarter size bruise on her left forearm and a half dollar size bruise on the back of
her upper right arm. [The alleged victim] refused to get up after being directed to do so by a staff member. At
that time is when the staff put her hands on [the alleged victim], in attempt to getting her to stand up. [The
alleged victim’s] bruises were in a non-vital area and according to the intake the location of the bruises are
consistent with being grabbed by the staff member. Per CCIH 6242.2, a supervisor may downgrade an abuse
or neglect intake report received by SWI to a non-abuse or neglect report when the information in the report
in suggest a minimum standard was violated, but not that a child was abuse or neglected; or indicates that there
is some risk to children, but the information is too vague to determine that a child was abused or neglected.
The concerns appear to be related to minimum standards and this will be forwarded to HHSC for evaluation
of minimum standards."
Monitors’ Review: The allegation that a youth (age 15) reported that she was restrained by a Prairie Harbor
staff member and had a half-dollar size bruise on her right arm and a quarter size bruise on her left forearm
meets the threshold for a Physical Abuse investigation based upon:
Physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from
physical injury to the child, including an injury that is at variance with the history or explanation given and
excluding an accident, by a person responsible for a child’s care, custody, or welfare. 40 TAC §707.789(1).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Two – injury or serious mistreatment of a child.
“Based on the evidence gathered there is not a preponderance of evidence a violation of the minimum standard
occurring regarding the original allegation. The following lead to this disposition. An [sic] serious incident
report corroborates what the staff and other collateral residents interviewed stated. No residents stated that [the
staff member] made any racist remarks or was inappropriate with [the alleged victim]. [The alleged victim]
refused to answer questions about the allegation and to be interviewed. The bruises that were reported could
not be seen by the Inspector. CPS Caseworker of [the alleged victim] stated that she had no issues concerning
the facility specifically inappropriate discipline and restraints. Reporter Therapist stated that she was told these
allegations by [the alleged victim]. [The alleged victim] at times would say very awkward things and make
allegations of things. All allegations have been reported to statewide intake. [The alleged victim] stated that
[staff member] was racist. However there are 3 white residents that were housed with [staff member] and [CPS
Caseworker] had never had any complaints. She also states that [the alleged victim] is a self harmer but
everything has been superficial.”

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Minimum Standard Investigation Conclusion: “Based on the evidence gathered there is not a preponderance
of evidence a violation of the minimum standard occurring regarding the original allegation."

21. Case ID: 48311472

Intake ID: 73767838
Sample File: August 2020
Summary of Intake Allegations: A DFPS staff member reported via an e-report that a child (Child A, age 9)
with severe ADHD was sent on two overnight visits with his adoptive family and that his foster mother failed
to send him with his ADHD medication. The first incident occurred on July 22, 2020 and the foster mother
stated that she “forgot” to send the medication with Child A. The second incident occurred on July 31, 2020
when the reporter went to pick up Child A and his two siblings to move them to the adoptive placement. The
reporter asked the foster mother for the children's medication and the foster mother said that Child A had
“flushed his ADHD medication down the toilet” and that his sibling (Child B, age 9) saw him do it. The foster
mother stated, “it was her fault for leaving the medication on the table where he could get it.” The reporter met
with each of the children separately and privately that day and they each denied what the foster mother said.
They stated that Child A did not flush his medication down the toilet and Child B did not see him do it. When
the reporter asked Child A about his medications, he said he did not have any (his last refill was reportedly on
July 10, 2020, twenty-one days prior to the date of the incident). The reporter is unsure whether Child A had
been taking the medication and was not aware of the impact on the child. Child A and his siblings were
removed from the foster home and placed with their adoptive family.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation. RCCI documentation referenced that the report was
coded as a Priority Two for Medical Neglect; however, it was coded by SWI as Priority Two for Neglectful
Supervision.
RCCI reason given for downgrade: “Completed assessment to determine prioritization of an intake which
was designated as a P2 for Medical Neglect by Statewide Intake. The [alleged victim] is 9 years old and is
residing with his adoptive mother. The report reads there was incident on 7-22-20, and the second one which
is the one that worries me the most was on 7-31-20. On 7-22-20, [foster mother] was aware the children
([alleged victim and sibling], 9 years old) had a visit with adoptive family, and [foster mother] didn't send
ADHD medication for the approved overnight visit. She stated that she forgot it. On 7-31-20, [foster mother]
was aware that the children would be moved from her home. When the case worker arrived to pick the children
up, [the foster mother] was asked for the children's medication and she stated [the alleged victim] had flushed
his down the toilet. She added that [victim’s sibling] had watched him do it. Later that day, each of the boys
were spoken to separately and privately and they each denied what [the alleged victim] said. [The alleged
victim] didn't flush his medication and [the victim’s sibling] didn't see him do it. When the case worker asked
[the alleged victim] about his medication, he stated that he didn't have any.
"On 7-31-20, foster mother stated that she put the medication on the table and that was how [alleged victim]
got his hands on it to flush it down to [sic] toilet. It is really concerning because what if [alleged victim] had
instead took all the medication. He could have been a very sick little boy. The concerns appear to be related to
minimum standards and this will be forwarded to HHSC for evaluation of minimum standards. The foster
parent did not provide the required medication for the child’s ADHD medication or properly secure the
medication. RULE §707.801Placing a child in or failing to remove him from a situation that a reasonable
member of that profession, reasonable caregiver, or reasonable person should realize requires judgment or

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actions beyond the child's level of maturity, physical condition, or mental abilities. [The alleged victim] was
placed in the foster home of [foster mother] on 07/26/2019 until 07/31/2020. It was reported that [foster
mother] left [the alleged victim’s] ADHD medication in an unsecured location which resulted in [the alleged
victim] flushing the medication down the toilet. Although the reported information is a concern there has not
been sufficient information provided surrounding [the alleged victim] not receiving his ADHD medication to
rise to the level of Medical Neglect. The child is currently residing in his adoptive home. There is currently
one child placed in the foster home [of the foster mother].
“Per CCIH 6242.2, a supervisor may downgrade an abuse or neglect intake report received by SWI to a non-
abuse or neglect report when the information in the report suggests a minimum standard was violated, but not
that a child was abuse or neglected; or indicates that there is some risk to children, but the information is too
vague to determine that a child was abused or neglected. The concerns appear to be related to minimum
standards and this will be forwarded to HHSC for evaluation of minimum standards." RCCI made no collateral
calls prior to the downgrade.
Monitors’ Review: A foster mother reported leaving her foster child’s ADHD medication unsecured, resulting
in the child (age 9) gaining access to it, putting the child at risk. This allegation meets the threshold for a
Neglectful Supervision investigation based upon:
Placing a child in or failing to remove him from a situation that a reasonable member of that profession,
reasonable caregiver, or reasonable person should realize requires judgment or actions beyond the child's level
of maturity, physical condition, or mental abilities. 40 TAC §707.801(1)(C).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three—minor violations of the law or minimum standards that involve low
risk to children.
"When [alleged victim and sibling] were interviewed, both denied touching the medication or flushing it. Their
younger sister was interviewed and denied any knowledge of the incident. The foster mother was interviewed
and stated that she did leave [the alleged victim’s] medication out on their table. She stated that it was always
normally double locked and showed me where medication was normally kept. She told me that on the day of
the incident, the children were going to be moved to their adoptive placement out of region. She said that in
preperation [sic] for their move, she had packed all of their belongings and placed them on the table. She said
the CPS worker was supposed to be there at 2pm but didn't arrive until several hours later. She said she had
also put [the alleged victim’s] medication on the table as well to be taken. She said later she realized they
weren't there and asked the boys about them. She said [victim’s sibling] told her [the alleged victim] had
flushed them and [the alleged victim]' eventually didn't deny it. She said she looked but never found the bottle
or anything else. She said in hindsight she should have waited until the CPS worker was there to unsecure
them. She denied any other issues as the kids have been placed there for about a year. [The other foster parent]
was present and interviewed and denied any other knowledge of the incident. The other child placed in the
home was also interviewed. 'A' has been placed there for several years. She denied any knowledge of the
incident in question. I asked her about her medication as she is a type 1 diabetic and has an insulin pump. She
was able to tell me all about it and also how she self administers her own medication, which is in the fridge. I
observed this medication unsecured but the foster parents reported the insulin is not stored with needles as it
is for [the other child placed in home]’s insulin pump. They reported it was unsecured so she would be able to
access it herself as she is 15 years old and working on independence and taking care of her needs. The CPS
worker was interviewed and expressed concerns about the medication being left out, but also that when she
had asked the boys about what happened, they both denied knowing anything about it. She denied any other
concerns about the home and stated the courtesy worker who saw the kids monthly also did not report any

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concerns. The administrator of the agency was interviewed as she has known this family for her whole time
with Therapeutic Family Life and for years with a different agency. She reported she does have to be more of
a "micromanager" with this home for paperwork and things such as keeping appointments, but as far as care
for the kids, she has no concerns. She said they are the family who will make sure the kids placed feel
welcomed and part of their family. She said they have had former placements come back and stay in contact
with the foster parents because they love them. She acknowledged the foster mother leaving the medication
out and said they would be addresing [sic] it with the family and ensure moving forward, medication for
children leaving the home is taken out last and given directly to the CPS worker. The case manager of the
home was interviewed and reported she did not necessarily believe this story but couldn't say what happened
to the medication. She expressed concern and frustration with the family as not needing to take kids who
required extra appointments as they have had issues in the past following through with them. She said she has
brought this up to the administrator as well. She said she has been the case manager for two years. She denied
any recent issues and said the missed medical appointment was last year and the children named in this
investigation did not miss any appointments. Based on the preponderance of evidence and admission by the
foster mother, it can be determined that medication was not stored as required on the date of this incident. Due
to the situation and the home's compliance history, a deficiency will not be given--instead just technical
assistance. There have not been any recent issues of medication storage and no other concerns were noted.
This home takes children long term and provides normalcy. They also have another child who has been in the
home for several years and have helped her work towards independence by being knowledgable [sic] and
responsible for her health and medical care. Technical assistance is also being given regarding ensuring
medication stored in the fridge is either secured as required or a variance is in place. At this time, this
investigation will be closed."

Intakes Received in September 2020

22. Case ID: 48346333

Intake ID: 73864891
Sample File: September 2020
Summary of Intake Allegations: A DFPS caseworker stated that she received a call from a therapist
employed at a psychiatric hospital advising her that two youth had run away from their prior placement at
Merkabah, an RTC, and were hospitalized after attempting to self-harm while they were on runaway status.
The reporter stated that a child (Child A, age 13) had run away twice, most recently with another child (Child
B, age 12). Both children allegedly attempted suicide by swallowing “a bunch of cold medications” while
away from their RTC. The children allegedly jumped out of a second-floor window at the facility and ran
away, stole over-the-counter medications from a nearby dollar store and ingested them. Child A previously
ran away from the RTC with another youth (Youth C, age 15) and had stolen cough, cold and congestion
medication from a large discount store. Youth C allegedly gave the medications to staff members at the RTC
the first time he stole them. The reporter did not know when Youth C did so nor the quantity of medication.
The reporter is not the primary worker for any of the youth but is the temporary local permanency specialist.
The reporter stated that she advised Child B’s adoption worker of these incidents, that the RTC had not
previously informed Child B’s adoption worker, and that Child A and Child B were still placed at a psychiatric
hospital. The reporter did not know who was supervising Child A and Child B at the time that they ran away,

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nor did she report information about their supervision levels. She stated that the children had a history of drug
use.
The reporter also relayed concerns that there were new RTC staff members, that the RTC is understaffed, and
that residents are running away. The reporter also stated she was concerned about “cold and drug” use.
The SWI intake specialist staffed the call with a supervisor. The supervisor said the report should be assigned
as an abuse/neglect intake as Child A and Child B overdosed and were hospitalized.
Downgrade: SWI assigned this case as a Priority Two investigation for Neglectful Supervision. RCCI
downgraded to a PN minimum standards investigation.
RCCI reason given for downgrade: “Completed assessment to determine prioritization of an intake which
was designated as a P2 for Neglectful Supervision by Statewide Intake. Allegations state that today is 9/2/2020.
Today it was learned that [the two alleged victims] are hospitalized at [a hospital in Houston]. [Child A and
Child B] both attempted suicide by taking a large quantity of cold, congestion and cough medicine. [Child A
and Child B] had gone AWOL from Merkabah Residential Treatment Center by jumping out a second story
window. [Child A and Child B] then stole the cold, congestion and cough medicine from a nearby Dollar Tree
Store. This was the second time that [Child A] had gone AWOL from the facility. [Child A] had disclosed
the first AWOL incident on 8/20/2020. It is not known when the first incident occurred. It is not known who
was supposed to be supervising [Child A and Child B] at the time they went AWOL. [Youth C] had previously
stolen an unknown quantity of cold, congestion and cough medication while he was out with a staff member
from Merkabah Residential Treatment Center. [Youth C] later admitted to the theft and allegedly turned the
medication in. However, there is concern that there still may be a stash of medication somewhere in or outside
of the facility that is accessible to [Youth C] and possibly other residents. Last week, [Youth C] began having
seizures. [Youth C] was taken for medical attention, and the doctor(s) were unable to determine what could be
causing [Youth C’s] seizures. [Youth C] has an appointment next week with a neurologist and a cardiologist
for further evaluation. After [Youth C] started having seizures, [Child A], who sleeps in a separate room,
started going into the room where [Youth C] sleeps. [Child A] slept on the floor of [Youth C’s] room. [Child
A] is very dependent on [Youth C] and tries to do everything [Youth C] does.”
“Per CCIH 6222.2 this intake report does not contain an allegation of abuse or neglect. There are concerns that
residents [Child A] and [Child B] attempted suicide by taking a large quantity of cold, congestion, and cough
medicine. RULE §707.801 regarding neglect, it was reported that while out with staff, [Youth C] stole cold,
congestion, and cough medicine. However [Youth C] admitted to the theft and turned in the medication. When
[Child A] and [Child B] ingested the cough medication, they were not at the operation due to running away.
The medication the [Child A] and [Child B] took was medication that they had stolen from a nearby store.
Although the incident took place away from the operation, there are concerns for supervision and possible
minimum standard violations. There is currently an open HHSC investigation number 2649903 8/31/20 (linked
under investigation 2649914 8/30/20) concerning similar allegations. Therefore, this intake will be
downgraded to a Non Abuse and Neglect investigation and forwarded to HHSC for further investigation.”
Monitors’ Review: This allegation that two children (ages 12 and 13) reportedly ran away from Merkabah
RTC should have been investigated to determine whether the youth were subject to an appropriate level of
supervision at the time of the incident. While on runaway status, the youth stole over-the counter medications
and took those medications to attempt suicide, which led to a subsequent hospitalization. This allegation meets
the threshold for a Neglectful Supervision investigation based upon:

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Failure to take an action that a reasonable member of that profession, reasonable caregiver, or reasonable
person should take in the same situation, by a person working under the auspices of an operation that causes
or may cause substantial emotional harm or substantial physical injury to a child. 40 TAC §745.8559(1).

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Three – Minor violation of the law or minimum standards that involve low risk
to children.
“[Child B] was asked how kids are getting out, the first time and the 2nd time for [Child A]. [Child B] stated
the first time through a window who’s [sic] bars were bent off and was open enough for us to get through.
[Child B] stated staff were not paying attention….
[Child B] was asked about style of supervision from staff. [Child B] stated on a scale of one to 10, he would
say 7.8- 8. Most times when kids run away the kids don’t tell and the staff don’t know about it. If residents
run, staff check on the others. Staff check the kids every ten to fifteen minutes. When residents are in the day
room, they do a head count. Kids that want to run know what they’re doing….
[Child B] was asked how long it before staff realized [Child A and Child B] were gone. [Child B] stated he
does not know, but from what [an RTC staff member] told him, it took almost the entire night before they
realized they were gone. They stuffed their beds. [An RTC staff member] checked all the beds of the kids that
run. He patted the bed and found [Child B’s] bed last. Staff waited 10 minutes for them to come back and then
called the cops….
[Youth C] stated when [Child A and Child B] left, it took staff about forty-five minutes as everyone was
outside playing. [Youth C] stated he went outside to ask where [Child B] was, and that is when staff realized
that they were not there. [Youth C] stated when staff realized they were not there, they notified administration
and called police. [Youth C] stated he doesn’t know what happened after that, as police were asking staff
questions.
[Child A] stated that the second time he ran away with [Child B], and they went store to store stealing. [Child
A] stated that he stole some cough medicine call” Triple C”. [Child A] stated that he tried to overdose on the
cough medicine by drinking the whole bottle. [Child A] stated that he wanted to commit suicide at that time.
[Child A] stated they ended up at the hospital shortly after drinking the medication. [Child A] reported that he
ran away the second time because he wanted to commit suicide. [Child A] stated that staff persons were on
duty at the time. [Child A] stated that the staff would intervene if they were aware that the children were trying
to run away. [Child A] stated that a person would have to be sneaky in order to escape. [Child A] stated that
there was only one time that a staff person was aware and was unable to stop them from running away because
he was an older man. [Child A] stated that they were supervised by one staff member to every five children,
and if there were more than five children there would be two or more staff members supervising. [Child A]
stated that one of the times they ran away they were missing from 4:30pm until 11:00pm. [Child A] stated that
he isn’t sure when the staff realized they were missing. [Child A] stated that [Child B] showed signs of suicide
when they were riding in the emergency truck. [Child A] reported that [Child B] stated that he wanted to die
several times while intoxicated on the “Triple C”. [Child A] stated that he didn’t show previous signs of suicide
and he didn’t tell anyone about his thoughts. [Child A] stated that ‘Papa D’ was the only person he would talk
to. [Child A] did not confirm where the medication taken from the facility was located, and [Child A] stated
that he had taken all of the medication that he and [Child B] had stolen.”
HHSC determined there was a violation of minimum standards: “During the course of the investigation,
interviews were conducted and documentation was reviewed to support the following: 748.685(a)(4) Caregiver
responsibility- providing the level of supervision necessary to ensure each child's safety and well-being. This

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standard was evaluated and determined to be deficient. Six of the seven children interviewed stated that
residents bend or break the burglar bars on the windows and AWOL. The interview with the CPS worker for
one of the victims stated there was not enough staff for the type of kids the operation accepts. Two of the four
staff interviewed stated they knew that the residents were getting out through the windows which had bent or
broken burglar bars.”

23. Case ID: 48362898

Intake ID: 73911339
Sample File: September 2020
Summary of Intake Allegations: A staff member at the child’s current placement reported that the child (age
10) alleges that at a previous placement at The Care Cottage, an RTC, a staff member hit her with a belt, which
resulted in a bruise on her leg. The child also stated that The Care Cottage staff were mean and regularly
threatened the children at the RTC. The child also stated that she “pressed charges against the staff person and
that he was sent to jail.”
Downgrade: SWI assigned this case as a Priority Two investigation for Physical Abuse. RCCI downgraded
to a PN minimum standards investigation.
RCCI reason given for downgrade: “Due to local Records. Completed assessment to determine prioritization
of an intake which was designated as a P2 for Physical Abuse by Statewide Intake. The [alleged victim] is 10
years old and is currently residing at [a residential treatment center]. The report reads today (9/16/20), [the
alleged victim] disclosed that unknown staff member hit [the alleged victim] with a belt at her old placement.
[The alleged victim] sustained a bruise on her leg. It is unclear when this occurred, but it only occurred once.
[The alleged victim] pressed charges against staff member and the staff member went to jail for assault. Other
staff at The Care Cottage threatened to hit other children and were “not nice.” Doesn’t appear to involve abuse,
neglect, or risk.”
“Per LPPH 6221.5 Intake Reports to Be Closed Without an Investigation. [the alleged victim] was placed at
the Care Cottage on 02/01/2018 until 06/27/2018. Although the information in the intake is very concerning,
[the alleged victim] is no longer placed at the facility and the AP no longer has access to her. Also, the operation
where this incident allegedly took place, The Care Cottage is no longer open and was closed. There are no
children at risk of harm. Therefore, based on the information obtained this intake will be closed without
investigation.”
Monitors’ Review: This allegation that a child (age 10) reported that she was hit with a belt by a staff member
at a prior RTC placement, The Care Cottage meets the threshold for a Physical Abuse investigation based
upon:
Physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from
physical injury to the child, including an injury that is at variance with the history or explanation given and
excluding an accident, by a person responsible for a child’s care, custody, or welfare. 40 TAC §707.789(1).
Contrary to CCI’s finding at secondary screening, the Monitors determined that this facility is still open and
operated by the same owners, however, in a new location and under a new name. When the facility changed
names and location, the former residents were moved to the new location.

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Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Administrative Closure. No investigation was conducted.

CPI Intake Reports

1. Case ID: 48206799

Intake ID: 73477860
Sample File: May 2020
Summary of Intake Allegations: An adoption caseworker reported that two children (Child A, age 10 and
Child B, age 7) were physically abused in their former kinship foster home and were removed from that
placement two days prior to the call to SWI. The reporter stated there had been ongoing concerns about
physical abuse in the home, including a previous investigation, which prompted the removal of the children.
When the caseworker arrived at the foster home to remove the children, Child A reported that there was
"physical discipline very frequently, using belts, using spatulas, using hands, using whatever was in place."
Child A disclosed being struck "on her bottom, on her legs, on her arms." The caseworker stated that both
children said they had to stay in their rooms all day long and were only able to come out to use the restroom.
The caseworker also stated she was concerned that the foster parent at times put the children to bed without
food (although later would be able to get a sandwich). The children also stated that one of the birth children
(Child C, age 10) in the home received preferential treatment by being permitted to swim in the pool, play on
his tablet, and play games while the foster children had to remain in their room. Child A also reported that the
foster mom ripped apart and threw away a stuffed animal that was given to her by her birth mother when she
was young. The caregiver allegedly did this in front of both foster children. The children also stated that there
is a "lot of cussing and arguments going on in the home." The caseworker stated that one child told her that
sometimes when she got hit with the belt it would be "really, really hard," and sometimes "she couldn't sit
down." The reporter stated that the foster mother was the primary perpetrator of the physical abuse, but the
foster father hit them as well. On the day prior to the report, the foster mother told the case worker that she
had broken a blood vessel in her hand when spanking her birth son.
Closure: SWI assigned this case as a Priority Two investigation for Physical Abuse. CPI downgraded to PN
and closed without an investigation.
CPI Closure Reason: “Due to additional calls made. Doesn’t appear to involve abuse or neglect.”
“I staffed this intake with a PD. The intake was approved for PN as the children have been moved out of this
placement and are no longer at risk of abuse or neglect. Due to the concerns of [foster mother’s] statement of
breaking a blood vessel while spanking her own child, an intake will be called in on [foster mother’s]
household involving her biological children.”
Monitors’ Review: This allegation that two children (ages 10 and 7) were inappropriately physically
disciplined (including being hit with a belt and a spatula and hit on multiple body parts) by their former foster
parents meets the threshold for Physical Abuse based upon:
Physical injury that results in substantial harm to the child by the person, or the genuine threat of substantial
harm from physical injury to the child, including an injury that is at variance with the history or explanation
given and excluding an accident or reasonable discipline by a parent, guardian, or managing or possessory

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conservator that does not expose the child to a substantial risk of harm, by a person responsible for the child's
care, custody, or welfare. 40 TAC §707.455 (1).

2. Case ID: 48273819

Intake ID: 73662360
Sample File: July 2020
Summary of Intake Allegations: A foster mother reported that her foster child (age 12) made outcries of
maltreatment in her former pre-adoptive foster home. The child is deaf and uses sign language to communicate
with caregivers. The child told the foster mother that she is "out of the family" because her prior pre-adoptive
foster family could not handle her and that she was a safety issue for them. The foster mother reported concern
for the children who are still living in the prior home. During a conversation observed by the foster mother
between the alleged victim and her former pre-adoptive sister who was “re-homed,” the child stated there was
"some physical stuff” that the former pre-adoptive foster parents did, including slapping with an open hand.
According to the alleged victim, her pre-adoptive foster parents "shunned" the deaf children, who had to eat
by themselves. The former pre-adoptive foster parents also allegedly instructed the other children in the home
not to speak with the deaf children. The reporter also stated that the child was locked in her room by her former
pre-adoptive foster parents. The former pre-adoptive sister confirmed that she had experienced the same
maltreatment while in the home. The reporter also stated that the child was on very heavy psychiatric
medications – “medications that people who are bipolar or schizophrenic take.” The child also has vision loss
and the foster mother states that the child's former pre-adoptive foster parents have refused to share information
with the child's school about her vision.
Closure: SWI assigned this case as a Priority Two investigation for Physical Abuse. CPI downgraded to a PN
and closed without an investigation.
CPI Closure Reason: “Due to additional calls made. Doesn’t appear to involve abuse, neglect or risk.”
“PN was approved by CPI [worker] and CPS [Supervisor] as there is no likelihood of abuse, neglect, or risk
of [sic]. [The pre-adoptive foster parents] relinquished their rights on June 9, 2020. [Alleged victim] is in the
process of is in the process [sic] of being adopted and there is an adoption staffing scheduled for July 9, 2020.
The child is safe as the parents no longer have access to the child.”
Monitors’ Review: This allegation that a child (age 12) was shunned by her former pre-adoptive foster
parents, forced to eat alone, and locked in her room meets the threshold for Emotional Abuse based upon:
In its discussion of the substantive due process rights of the PMC children, the Fifth Circuit stated,
“egregious intrusions on a child’s emotional well-being—such as, for example, persistent threats of bodily
harm or aggressive verbal bullying—are constitutionally cognizable.” 8

8
M.D. by Stukenberg v. Abbott, 907 F.3d 237, 251 (2018).

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Referrals to HHSC

Intakes Received in November 2020

1. CLASS Intake ID: 2668168
Intake ID: 74085255
Sample File: November 2020
Summary of Intake Allegations: The regional director of a CPA reported that a child (age 12) was having
behavioral problems and the foster mother attempted to de-escalate the situation by placing the child in a
disciplinary hold. During the attempted de-escalation, the child became aggressive, rolled onto the floor and
the foster mother reportedly kicked the child. The foster mother admitted to telling the child, “if I cannot trust
myself to not touch you, you cannot be here.” The reporter did not know where the foster mother kicked the
child and stated that the child did not have any bruises, injuries, or marks. Due to the incident, the reporter
stated that the CPA would move the child to a respite placement.
Monitors’ Review: The allegation that a foster mother kicked a child (age 12) meets the threshold for a
Physical Abuse investigation based upon:
Physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from
physical injury to the child, including an injury that is at variance with the history or explanation given and
excluding an accident, by a person responsible for a child’s care, custody, or welfare. 40 TAC §707.789(a)(1).
Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Two – Injury or serious mistreatment of a child.
“Based on the information obtained through interviews and records reviewed, it is determined there is
sufficient evidence to support the allegations of inappropriate discipline. This is based on the following
information: [The alleged victim] confirmed that he was kicked in the back by foster parent. Although he did
not receive any injury or bruising [sic]. He stated that he was only kicked one time by foster parent. [The foster
parent] did in fact admit to kicking [the alleged victim] in the back while he was on the ground because she
was upset with him. Her story is consistent with what she communicated in the initial incident report. She said
that it did not hurt [the alleged victim] and there was no injury or bruising. The [foster] home has been closed
by the agency due to this investigation."

2. CLASS Intake ID: 2671820

Intake ID: 74119955
Sample File: November 2020
Summary of Intake Allegations: The owner of Adiee Emergency Shelter, a GRO, reported a physical
altercation between three youth. The reporter stated that two youth (Youth A, age 15 and Youth B, age 17) hit
another youth (Youth C, age 16) without provocation in a bedroom area. Following the incident, a GRO staff

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member contacted law enforcement. Staff and law enforcement reported that Youth C did not have any injuries.
Law enforcement cited the two youth who hit Youth C with Class C citations for family violence. The reporter
did not indicate whether any staff members were present at the time of the incident or what the expected level
of supervision was for each of the youth. A staff member contacted Youth C's CPS worker who removed him
from the GRO because he felt unsafe.
Monitors’ Review: The allegation that Youth C (age 16) was hit by two other youth meets the threshold for a
Neglectful Supervision investigation based upon:
Failure to take an action that a reasonable member of that profession, reasonable caregiver, or reasonable
person should take in the same situation. 40 TAC §707.801(b)(1)(A).
Summary of RCCL Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three - Minor violation of the law or minimum standards that involve low risk
to children.
"Based on the preponderance of evidence gathered during the course of this investigation there were any [sic]
violations of minimum standards as it pertains to caregiver responsibility. 748.685(a)(5) Caregiver
responsibility-being able to intervene when necessary to ensure safety. A child in care was physically attacked
by two other children. There was no caregiver available to intervene in the altercation to ensure the safety of
all individuals involved.
Four residents were interviewed and each reported being residents at [the GRO]. [Youth] were each familiar
with the incident that resulted in [Youth C] being physically attacked. [Youth A and Youth B] confirmed that
they were involved in an altercation with [Youth C] upstairs and there was no staff present during the time of
the altercation. [Youth B] reported that he and [Youth A] were paid by [Youth D] to fight [Youth C].
Four staff were interviewed and each of them confirmed currently being affiliated with [the GRO] to some
degree. [Staff] confirmed being on shift during on the day that the altercation took place. [Staff] each confirmed
tat [sic] they were not initially upstairs and did not witness the altercation and therefore were not able to
intervene. [Staff] contends that she was upstairs, but she was not in a position to be aware of what was taking
place and she didn’t know that an altercation had taken place. Each of the staff reported that they were aware
of there being previous issues between [Youth D] and External [sic] documentation reviewed included
incidents [sic] reports, services plans, and video surveillance. The incident report depicts a slightly different
recount than the staff reported during the interviews. The services plans were not initially available upon
request, but later provided via email. The video surveillance revealed that there were no caregivers in a close
proximity or in a position to intervene [sic] deescalate a physical altercation to ensure the safety of all children
in care admitted to Adiee Emergency Shelter.”

3. CLASS Intake ID: 2669991

Intake ID: 74104968
Sample File: November 2020
Summary of Intake Allegations: A counselor at Connections, a GRO, reported that while driving a group of
youth back from an outing, two GRO staff members pulled over to address a conflict among the youth. When
the staff member who was driving pulled the vehicle over, two of the youth ran out of the vehicle and the two
staff members left the vehicle to run after them. One of the youth (age 16) who reportedly remained in the
vehicle, became frustrated and left the vehicle. The reporter stated that the youth called her mother and asked
her to order an Uber to take her back to the GRO. The youth’s mother did not call an Uber, but instead drove
and picked up the youth and took the youth to her own house. The counselor stated that the youth’s mother

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refused to return the youth to the GRO. The GRO staff members reportedly “had assumptions but no
confirmations” that the youth was with her mother. The youth remained at her mother’s home for a week.
Upon her return to the GRO, the youth disclosed to the reporter that at least one “random guy” raped her while
at her mother’s home. She also stated that her mother forced her to take heroin and methamphetamines. The
youth only returned to the GRO after her sister called their mother, heard the youth crying in the background,
picked up the youth from the mother’s home, and contacted CPS.
Monitors’ Review: The allegation that lack of supervision of youth in transport by staff members of a GRO
led a youth (age 16) to leave the area and return to her mother’s home for a week meets the threshold for a
Neglectful Supervision investigation based upon:
Failure to take an action that a reasonable member of that profession, reasonable caregiver, or reasonable
person should take in the same situation. 40 TAC §707.801 (b)(1)(A).
A negligent act or omission by an employee, volunteer, or other individual working under the auspices of a
facility or program, including failure to comply with an individual treatment plan, plan of care, or
individualized services plan that causes or may cause substantial emotional harm or physical injury to, or the
death of, a child served by the facility or program as further described by rule or policy. 40 TAC § 707.801(a).
Summary of RCCL Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three - Minor violations of the law or minimum standards that involve low
risk to children.
“Based on the information gathered throughout the investigation through staff and residents, there are no
minimum standard violations. During the course of the investigation, staff attempted to verbally redirect [a
youth] not [sic] leave from the van. Based on this information, it was found that the staff were attempting to
get [the youth] to remain at the van. Staff did go search for [the youth] at Circle K, but did not find her. Law
enforcement were contacted. Staff made attempts to get [the youth] to remain.”

4. CLASS Intake ID: 2671893

Intake ID: 74120819
Sample File: November 2020
Summary of Intake Allegations: A DFPS staff member reported that a child (age 9) disclosed that a staff
member at Embracing Destiny Foundation, an RTC, physically disciplined him. The child stated that when he
got in trouble, one staff member hit him on the head with a balled fist and another staff member bent his fingers
back. The child further stated that it was “not a tap on the head” and that he did not feel safe at the placement.
The reporter did not observe any new bruises or marks on the child; however, the reporter did observe older
marks on his face, arms, and back. The child denied that he was hurt during the incidents of alleged physical
abuse.
Monitors’ Review: The allegation that a staff member at an RTC hit a child (age 9) on the head with a fist
and that another staff member pulled his fingers back meets the threshold for a Physical Abuse investigation
based upon:
Physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from
physical injury to the child, including an injury that is at variance with the history or explanation given and
excluding an accident, by a person responsible for a child’s care, custody, or welfare. 40 TAC §707.789(a)(1).

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Summary of RCCL Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Two – Injury or serious mistreatment of a child.
“Based on the information gathered during the course of this investigation, there is a preponderance of
evidence to suggest children in care have been inappropriately disciplined, by being yelled at and hit on top of
the head, by caregivers. Five of six children interviewed stated that the staff yell at the children in care.
Furthermore, while standing outside waiting to get her temperature taken when she arrived for the investigation
inspection, this Inspector heard a staff member yelling at the children. Three of the six children stated that they
have been hit on top of their head, by caregivers, when they do something wrong. Each of those three children
described the hit on top of the head in the same way, a hit with two closed fist [sic] in the child’s head. There
was not a preponderance of evidence to suggested that a caregiver bent a child in care’s finger back, as a form
of discipline. There were no supporting interviews from neither children [sic] in care, other than the victim
child, or staff to support this claim.”

5. CLASS Intake ID: 2667984

Intake ID: 74083252
Sample File: November 2020
Summary of Intake Allegations: A staff member at Sheltering Harbour, an RTC, reported that a youth (Youth
A, age 17) punched another youth (Youth B, age 16) in the eye during a physical altercation. Youth B sustained
injuries that required emergency medical attention and at least five stitches under his eye. Youth A did not
sustain any injuries.
Monitors’ Review: The allegation that Youth B punched Youth A in the eye, causing an injury, meets the
threshold for a Neglectful Supervision investigation based upon:
Failure to take an action that a reasonable member of that profession, reasonable caregiver, or reasonable
person should take in the same situation. 40 TAC §707.801(b)(1)(A).
Summary of RCCL Minimum Standards Investigative Findings if Minimum Standards Investigation
Conducted: Assigned Priority Three – Minor violations of the law or minimum standards that involve low
risk to children.
“Based on the information gathered throughout the course of this investigation it was determined that there is
not a preponderance of evidence that any violations of the minimum standards occurred. The following led to
this disposition:
- [Youth A] reported that the boys fight a lot and staff always break it up and put one in time out. Staff are
always able to see and hear them at all times. The incident happened in his bedroom, he used to be roommates
with [Youth B] at that time. The staff was sitting in the living room and they were talking and raising their
voices and staff checked on them and asked what they were talking about, and they told the staff they were
just talking and staff turned around and that is when he punched him in the face because he thought [Youth
B]was going to hit him first, he stated that he is not sure what staff came in and separated them.
- [Youth B] reported that prior to the incident he asked him if he had something against him and he out of no
where [sic] punched him in the eye. The staff was in the doorway when it happened. He stated that the staff
stood there while it happened. He reported that he did not remember what staff was there. He stated he stumbled
out of the room and was in shock, and no one came in to help. He went up to a staff and he asked him what
happened and he ended up taking him to the emergency room, he got his stitches that night and doesn't
remember going back for a follow up, but then he did go back when he got his stitches taken out.

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-Three collateral children reported that staff always intervene when there is a fight between residents.
-Four staff reported that they are trained to immediately intervene to avoid any physical altercations from
happening; however, if it occurs they are trained to immediately intervene and keep the children away from
each other.
- [CVS worker for Youth B] reported that she has no concerns regarding the facility providing appropriate
level of supervision and informed that they did in fact inform her of [Youth B’s] incident and medical care
that he received. (pictures were obtained as she went the very next day after the incident).”

Intakes Received in January and February 2020

6. CLASS Intake ID: 2594570

Intake ID: 73098756
Sample File: January 2020
Summary of Intake Allegations: A teacher reported that since the beginning of the school year through the
date of the report in January, a child (age 4) arrived at school looking “very dirty.” The reporter stated that the
child had dirty hair and dirt on her neck. During a school hygiene lesson, the child told the reporter that she is
not allowed to brush her teeth or take baths. After the school hygiene lesson, the child’s foster mother called
the school to complain to the reporter because she wanted to know why the reporter told the child to wash her
hair. The reporter told the foster mother the conversation was part of a class lesson on hygiene. The foster
mother said she “didn't wash her hair because [the child] gets lice.” The child came to school on one occasion
and told the reporter that she “got to take a bath because she peed in the bed.” The child also “complained
often of being hungry.” During the months of November and December 2019, the child came to school with
shoes that were falling apart. The reporter stated that she “had to duct-tape them together so the child would
not trip on them because the bottoms were falling off.” After about two weeks of wearing the duct-taped shoes,
the child came to school with new shoes. On the day prior to the date of the report, the child said that her foster
sibling did not live with her anymore because "she don't act right." The child also stated, "I'm next because I
punch my sister.” The child often talks about how she will have to leave [her foster home] and she does not
know where she will go. She often has emotional episodes.
Monitors’ Review: The allegations that a child (age 4) repeatedly attended school unbathed and who claimed
she was unable to take a bath or brush her teeth, attended school for two weeks wearing shoes with the soles
coming off, and was reportedly “often” hungry meet the threshold for a Physical Neglect investigation based
upon:

Failure to provide a child with food, clothing, and shelter necessary to sustain the life or health of the child, by
a person working under the auspices of an operation that causes or may cause substantial emotional harm or
substantial physical injury to a child. 40 TAC §745.8559(6).

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Three – Minor violation of the law or minimum standards that involve low risk
to children.

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RCCR Minimum Standards Findings: RCCR conducted a minimum standards investigation that it
announced to the foster mother prior to commencing the investigation. The investigator did not investigate the
allegation that the child was “often hungry.” “It was determined that there was not a preponderance of evidence
to prove the home did not provide adequate hygiene for a child in their care. The child (OV) [child] made
allegations that she does not bathe every day or brush her teeth. [The child] stated that she has never been told
she couldn’t take a bath and that her foster parent places toothpaste on her toothbrush every morning but does
not watch her brush her teeth. [The child] and the other children were all observed to be clean and well
groomed. All of the children were dressed in appropriate and clean clothing. After interviewing the foster
parents it was determined that they allow the (OV) [child] and her sister to bath themselves but have to help
the other children due to their age. Both parents reported that he [sic] OV [child] was sent to their home with
lice and that they had to get it out. The parents also stated that they wash the girl’s hair almost every day out
of fear that the lice will return. In conclusion;[sic] the child receives hygiene on a regular basis but has on
occasion chosen not to properly clean themselves. No violations of minimum standards were found and no
citations will be issued.”

7. CLASS Intake ID: 2602302

Intake ID: 73220212
Sample File: February 2020
Summary of Intake Allegations: The mother of a youth (age 17) reported that her daughter, who had
previously resided at Whataburger Center for Children and Youth, a GRO, told her that a male staff member
restrained and threw the youth to the floor. Her daughter told her that she sustained a bump on the face and a
fractured hand. The mother reported that the youth had behavioral issues, and at the time of the report, the
youth had been admitted into a behavioral health center.
Monitors’ Review: The allegations that a youth (age 17) sustained a bump on the face and a fractured hand
while restrained by a staff member at a GRO meet the threshold for a Physical Abuse investigation based upon:

Any act such as striking, shoving, shaking, or hitting a child, whether intended as discipline or not, by someone
working under the auspices of an operation that causes or may cause emotional harm or physical injury to, or
the death of, a child that the operation serves. 40 TAC §745.8557(1)

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Two – Injury or serious mistreatment of a child.

RCCR Minimum Standards Findings: “Based on the information gathered there will be no citations. The
injuries [sic] the child had did not happen at the facility. The injuries occurred when she was at the hospital.
Caseworker and Case Manager stated the incident did not occur at the Whataburger facility.”

8. CLASS Intake ID: 2607220

Intake ID: 73280700
Sample File: February 2020
Summary of Intake Allegations: The reporter, a DFPS worker, stated that while she was performing a
medication review with a youth (age 14) at Hector Garza Residential Treatment Center, an RTC, she observed
bruising on the youth’s right arm. The youth stated that the bruise was caused during a restraint. The youth did

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not state why or when the restraint occurred. The reporter stated that she observed a circular quarter-sized
bruise that was bluish/greenish and several other bruises on the youth’s forearm. The reporter further stated
that the youth was “difficult to talk to” and that, in general, it is “difficult to get her to talk.”
Monitors’ Review: The allegations that a youth (age 14) had a quarter-sized bruise and several other bruises
on her right arm that allegedly occurred during a restraint meet the threshold for a Physical Abuse investigation
based upon:

Any act such as striking, shoving, shaking, or hitting a child, whether intended as discipline or not, by someone
working under the auspices of an operation that causes or may cause emotional harm or physical injury to, or
the death of, a child that the operation serves. 40 TAC §745.8557(1)

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Assigned Priority Two–Injury or serious mistreatment of a child.

RCCR Minimum Standards Findings: RCCR conducted a minimum standards investigation and, although
the investigator interviewed the youth, the documentation indicated that the youth was not very cooperative or
talkative and did not indicate whether she was restrained nor whether she had concerns about her interactions
with the staff. The investigation documentation noted that the youth’s file included a caution that she has
“experienced abuse and to please take caution if initiating physical intervention.” The documentation further
stated that “there may be times when the use of physical intervention is wired [sic] and appropriate. These
times are strictly limited to those when a resident is demonstrating emergency behaviors as defined by:
‘probable death or substantial bodily harm to self or imminent physical harm to others.’” The youth “had three
physical interventions in the previous two weeks” [the two-week period began approximately two weeks
following the date of this intake]. The investigation findings stated: “After conducting interviews and
reviewing documentation there will be no citations. There is an incident report with the minor involved in a
physical restraint. There is no indication there was an injury. When speaking with the minor she allowed me
to see her arms and there was no bruising observed. I asked for permission to take pictures and they [the youth]
declined. They did not give specifics on how restraints are done.”

9. CLASS Intake ID: 2603524

Intake ID: 73236089
Sample File: February 2020
Summary of Intake Allegations: A law enforcement officer reported that a youth (age 16) ran away from
Children’s Hope Residential Services, an RTC, at approximately 6:30 p.m. About ten minutes later, the officer
found the youth walking in a park a few blocks from the RTC. The youth told the officer that she did not want
to go back to the RTC and threatened that she would harm herself by cutting her wrists if the officer took her
back there. The youth stated that the RTC staff "don't care and don't give help." The youth stated that two
weeks prior, the RTC staff restrained her, and that three bones in her chest "popped." She also stated that her
knee was injured, revealing what looked like a rug burn. The officer stated that the injury looked like it might
be infected, and that it looked like it occurred more recently than two weeks ago. The officer took the youth
back to the RTC and spoke to a staff member about what the youth told him and about her injuries. The officer
suggested to the staff that someone transport the youth to a hospital for a suicide evaluation. The RTC staff
member said she would have to look at their protocols to determine whether to obtain medical attention for the
youth. At that point, the RTC supervisor arrived and spoke to the officer; the officer again recommended that

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that youth be evaluated. The supervisor said that she did not know whether they would be able to comply
because they were short on staff that night. She added that they might call for an ambulance. The officer also
recommended that the RTC staff keep the youth isolated from the other children. The supervisor responded
that they did not have room in the RTC to separate the youth.
Monitors’ Review: The above allegations state that a youth (age 16) ran away from an RTC and when she
encountered a police officer reported that she had suffered untreated injuries during a restraint by RTC staff.
When the officer took the youth back to the RTC, he suggested to staff that she be evaluated for suicidality
and that she be isolated from other residents. Staff did not commit to taking either action and indicated potential
insufficient staffing and space to ensure her safety. The allegations meet the threshold for Physical Abuse and
Medical Neglect investigations based upon:

Any act such as striking, shoving, shaking, or hitting a child, whether intended as discipline or not, by someone
working under the auspices of an operation that causes or may cause emotional harm or physical injury to, or
the death of, a child that the operation serves. 40 TAC §745.8557(1).

Failure to seek, to obtain, or to follow through with medical care for a child, by a person working under the
auspices of an operation that causes or may cause substantial emotional harm or substantial physical injury to
a child. 40 TAC §745.8559(5).

Summary of RCCR Investigative Findings if Minimum Standards Investigation Conducted:

Assigned Priority Two – Injury or serious mistreatment of a child.

RCCR Minimum Standards Findings: “Based on the preponderance of evidence, there is insufficient
evidence to support the allegations. It is alleged that a child ran away from the operation. It is also alleged that
a child was injured during a restraint and did not receive medical attention.

Note: The allegations that a child was injured during a restraint were reported to State Wide [sic] Intake (Intake
#7325862) as it was determined that the restraint was implemented at school by school staff. The school and
its staff are not regulated by RCCL. This allegation will be explored by DFPS Investigators.

Throughout the investigation, seven adults and eleven children were interviewed. Five adults and eleven
children confirmed that the victim ran away from campus by jumping over the fence and walking away from
campus. Three adults did not know if the victim ran away from campus or were not present when the child ran
away from campus. Five adults and eleven children reported that staff called the police immediately after the
victim left campus. The victim was located and returned to campus within approximately one hour. Three
adults and ten children indicated that the victim jumped over a fence and walked away from campus even
though staff was supervising the victim. Four adults and one child did not know if the victim was being
supervised when the victim ran away. Three adults and ten children state the victim made suicidal threats upon
returning to the facility. Four adults and one child did not know if the victim made suicidal threats upon
returning to the facility. Five adults and eleven children report that the victim was assessed and admitted for
inpatient psychiatric care due to the suicidal threats. Two adults did not know if the victim was admitted for
inpatient psychiatric care. Five adults and two children report that the victim has been restrained by the facility
staff at some point during placement without injury. Three children deny that the victim has been restrained
by facility staff. Two adults and three children did not know if the victim has been restrained by facility staff.
The victim denied injury incurred during a restraint implemented by facility staff.

A review of documents returned no documented injuries resulting from restraints implemented by facility staff.
The victim’s service plan indicates the victim has a previous history of self-harming behaviors but no recent
history of suicidal attempts. After conducting a thorough investigation and analyzing the information closely
for risk, standards 748.303(a)(9)(A), 748.685(a)(3), 748.2851(a), 748.2553(1)(A), 748.2551(a),

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748.2551(c)(1), 748.2453, and 748.1531(a)(2) are compliant. All of the parties involved background checks
were compliant with standard 745.621(a)(4).”

10. CLASS Intake ID: 2603564

Intake ID: 73237500
Sample File: February 2020
Summary of Intake Allegations: A staff member at an RTC reported that a youth (who is now an adult and
formerly resided in a foster home) told her that approximately 10 years ago, he witnessed his foster mother
having sex with another foster child in the foster home. This foster mother no longer has an active foster home;
however, the reporter stated that the foster mother currently works at the RTC where the reporter is employed.
Monitors’ Review: The allegations that a former foster youth (who could have been as young as age 17 at the
time of the incident) witnessed his foster mother having sex with another foster child in the foster home and
that foster mother is reportedly still working at an RTC meet the threshold for a Sexual Abuse investigation
based upon:

Sexual conduct that constitutes the offense of indecency with a child as defined under Penal Code, §21.11,
sexual assault as defined under Penal Code, §22.011, or aggravated sexual assault as defined under Penal Code,
§22.021, by someone working under the auspices of an operation that causes or may cause emotional harm or
physical injury to, or the death of, a child that the operation serves. 40 TAC §745.8557(5).

Summary of RCCR Minimum Standards Investigative Findings if Minimum Standards Investigation

Conducted: Administrative Closure.

RCCR Minimum Standards Findings: No investigation was conducted.

11. CLASS Intake ID: 2601903

Intake ID: 73213207
Sample File: February 2020
Summary of Intake Allegations: A DFPS staff member reported that while staff members were completing
a desk monitoring review at City of Hope Missions, a GRO, they observed “several medication errors on the
medication logs” in the records of four youth spanning across a five-month period. The documented errors
included the administration of an “as needed” medication nightly for what appeared to be a three-month period,
failure to dispense the correct dosage of medication after a prescribed increase for four, nine, and in one
instance thirteen days, failure to administer a psychotropic medication for nine days, failure to report
medication changes to CPS, and numerous discrepancies noted in the medication log.
Additionally, the reporter observed several problems with the provision of care as per children’s treatment
plans. These included no documentation of healthcare follow-up or routine preventative care as required,
failure to ensure youth received therapy consistent with service plans and, in at least three instances,
documentation reflecting the receipt of less than 25% of the therapy required by the service plan for a given

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month. In addition, the reporter observed a failure to administer CANS; failure to coordinate with Star Health;
and failure to complete an emergency room visit follow-up.
Monitors’ Review: The above allegations that the medication and treatment records at a GRO indicate that
staff failed to dispense medicines as prescribed, failed to follow-up with services as medically recommended,
and failed to document the provision of therapies as required by youths’ treatment plans meet the criteria for
a Medical Neglect investigation due to:
Failure to seek, to obtain, or to follow through with medical care for a child, by a person working under the
auspices of an operation that causes or may cause substantial emotional harm or substantial physical injury to
a child. 40 TAC §745.8559(5).
Summary of RCCR Investigative Findings: Assigned Priority Three - Minor violation of the law or
minimum standards that involve low risk to children.
RCCR Minimum Standards Findings: “It is clear that there were delays in medication change decisions that
occurred during medication reviews and getting the medication increased or lowered and then administered to
reidents [sic]. These seem to be clustered around psychotropic prescriptions. Email communication between
the operation and pharmacy showed problems getting new prescriptions called in. Residents report that on
medication doctors ordered, such as an antibiotic, these were obtained immediately. To address this, the
operation has changed the psychiatrist they use. No citations issued.”

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