Royal Heritage RTC, LLC

Psychotropic medication trainings were not provided by a health-care professional.

Resolution: Corrected: 2025-11-24

Three employee files reviewed did not have Form 2912 completed.

Resolution: Corrected: 2025-11-24

Three employee files reviewed did not have Form 2912 completed.

Resolution: Corrected: 2025-11-24

Psychotropic medication trainings were not provided by a health-care professional.

Resolution: Corrected: 2025-11-24

Three employee files reviewed did not have Form 2912 completed.

Resolution: Corrected: 2025-11-24

Three employee files reviewed did not have Form 2912 completed.

Resolution: Corrected: 2025-11-24

Psychotropic medication trainings were not provided by a health-care professional.

Resolution: Corrected: 2025-11-24

Psychotropic medication trainings were not provided by a health-care professional.

Resolution: Corrected: 2025-11-24

The training logs for two staff members were received and reviewed. Both training logs reviewed stated that the employees did not require 40 hours of supervision prior to being counted in ratio. Documentation of this supervised child-care experience was not provided.

Resolution: Corrected: 2025-11-18

Staff members at Royal Heritage RTC failed to adequately supervise a child in care while the child was on the roof of the operation, in addition the child was left alone on the roof.

Resolution: Corrected: 2025-11-18

The owner of the operation was listed as an instructor of EBI training for a staff member. The owner failed to provide documentation on how he meets the requirements to train this subject matter.

Resolution: Corrected: 2025-11-18

The training logs for two staff members were received and reviewed. Both training logs reviewed stated that the employees did not require 40 hours of supervision prior to being counted in ratio. Documentation of this supervised child-care experience was not provided.

Resolution: Corrected: 2025-11-18

The owner of the operation was listed as an instructor of EBI training for a staff member. The owner failed to provide documentation on how he meets the requirements to train this subject matter.

Resolution: Corrected: 2025-11-18

Staff members at Royal Heritage RTC failed to adequately supervise a child in care while the child was on the roof of the operation, in addition the child was left alone on the roof.

Resolution: Corrected: 2025-11-18

The training logs for two staff members were received and reviewed. Both training logs reviewed stated that the employees did not require 40 hours of supervision prior to being counted in ratio. Documentation of this supervised child-care experience was not provided.

Resolution: Corrected: 2025-11-18

The owner of the operation was listed as an instructor of EBI training for a staff member. The owner failed to provide documentation on how he meets the requirements to train this subject matter.

Resolution: Corrected: 2025-11-18

The owner of the operation was listed as an instructor of EBI training for a staff member. The owner failed to provide documentation on how he meets the requirements to train this subject matter.

Resolution: Corrected: 2025-11-18

Staff members at Royal Heritage RTC failed to adequately supervise a child in care while the child was on the roof of the operation, in addition the child was left alone on the roof.

Resolution: Corrected: 2025-11-18

Staff members at Royal Heritage RTC failed to adequately supervise a child in care while the child was on the roof of the operation, in addition the child was left alone on the roof.

Resolution: Corrected: 2025-11-18

The training logs for two staff members were received and reviewed. Both training logs reviewed stated that the employees did not require 40 hours of supervision prior to being counted in ratio. Documentation of this supervised child-care experience was not provided.

Resolution: Corrected: 2025-11-18

Operation did not submit staff trainings for investigation purposes.

Resolution: Corrected: 2025-12-18

Operation did not submit staff trainings for investigation purposes.

Resolution: Corrected: 2025-12-18

Operation did not submit staff trainings for investigation purposes.

Resolution: Corrected: 2025-12-18

Operation did not submit staff trainings for investigation purposes.

Resolution: Corrected: 2025-12-18

Staff file reviewed did not have all the required documentation in the required time frame.

Resolution: Corrected: 2025-10-15

Staff file reviewed did not have all the required documentation in the required time frame.

Resolution: Corrected: 2025-10-15

Staff file reviewed did not have all the required documentation in the required time frame.

Resolution: Corrected: 2025-10-15

Staff file reviewed did not have all the required documentation in the required time frame.

Resolution: Corrected: 2025-10-15

Fire inspection was not completed by the expiration date.

Resolution: Corrected: 2025-09-26

Fire inspection was not completed by the expiration date.

Resolution: Corrected: 2025-09-26

Fire inspection was not completed by the expiration date.

Resolution: Corrected: 2025-09-26

Fire inspection was not completed by the expiration date.

Resolution: Corrected: 2025-09-26

Two child files did not have completed service plans within the 45 day time frame.

Resolution: Corrected: 2025-09-08

Two child files did not have completed service plans within the 45 day time frame.

Resolution: Corrected: 2025-09-08

Two child files did not have completed service plans within the 45 day time frame.

Resolution: Corrected: 2025-09-08

Two child files did not have completed service plans within the 45 day time frame.

Resolution: Corrected: 2025-09-08

Caregivers failed to provide adequate supervision resulting in inappropriate behaviors amongst youth in care.

Resolution: Corrected: 2025-08-11

Child was allowed to self-administer medication by staff. Childs service plan did not state child was allowed to self-administer medications.

Resolution: Corrected: 2025-08-11

Caregivers failed to provide adequate supervision resulting in inappropriate behaviors amongst youth in care.

Resolution: Corrected: 2025-08-11

Child was allowed to self-administer medication by staff. Childs service plan did not state child was allowed to self-administer medications.

Resolution: Corrected: 2025-08-11

Caregivers failed to provide adequate supervision resulting in inappropriate behaviors amongst youth in care.

Resolution: Corrected: 2025-08-11

Child was allowed to self-administer medication by staff. Childs service plan did not state child was allowed to self-administer medications.

Resolution: Corrected: 2025-08-11

Child was allowed to self-administer medication by staff. Childs service plan did not state child was allowed to self-administer medications.

Resolution: Corrected: 2025-08-11

Caregivers failed to provide adequate supervision resulting in inappropriate behaviors amongst youth in care.

Resolution: Corrected: 2025-08-11

Child was able to utilize an e-cigarette at operation and staff was unaware.

Resolution: Corrected: 2025-07-29

Youth in care admitted to possession and use of a tobacco e-cigarette at the operation.

Resolution: Corrected: 2025-07-29

Youth in care admitted to possession and use of a tobacco e-cigarette at the operation.

Resolution: Corrected: 2025-07-29

Youth in care admitted to possession and use of a tobacco e-cigarette at the operation.

Resolution: Corrected: 2025-07-29

Child was able to utilize an e-cigarette at operation and staff was unaware.

Resolution: Corrected: 2025-07-29

Youth in care admitted to possession and use of a tobacco e-cigarette at the operation.

Resolution: Corrected: 2025-07-29

Child was able to utilize an e-cigarette at operation and staff was unaware.

Resolution: Corrected: 2025-07-29

Child was able to utilize an e-cigarette at operation and staff was unaware.

Resolution: Corrected: 2025-07-29

Youth care worker transported children in care with a Provisional background. Conditions stated worker was not allowed to transport children in care.

Resolution: Corrected: 2025-07-28

Youth care worker transported children in care with a Provisional background. Conditions stated worker was not allowed to transport children in care.

Resolution: Corrected: 2025-07-28

Youth care worker transported children in care with a Provisional background. Conditions stated worker was not allowed to transport children in care.

Resolution: Corrected: 2025-07-28

Youth care worker transported children in care with a Provisional background. Conditions stated worker was not allowed to transport children in care.

Resolution: Corrected: 2025-07-28

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

Resolution: Corrected: 2025-06-20

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

Resolution: Corrected: 2025-06-20

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

Resolution: Corrected: 2025-06-20

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

Resolution: Corrected: 2025-06-20

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2025-08-04

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

Resolution: Corrected: 2024-12-26

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

748.125 (c)(1)(B)(i-iv)-748.125(c)(1)(C)(i-iii): The operation?s policy indicates that staff will be required to take the AS+K training which only addresses the curriculum components for the risk factors, protective factors, and warning signs of suicide. Training must also address safety planning (748.125 (c)(1)(B)(i-iv) and screening for risk (748.125(c)(1)(C)(i-iii). Training on these specific curriculum requirements will have to be tailored for each operation as training will have to based on an operation?s own safety planning practices and the specific screening tool the operation will use to screen for risk. The operation will need to include training to address these two areas, the AS+K Gatekeeper training does not provide for these areas within the training. 748.125(c)(2): The operation?s policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate. Will volunteers and non-employees be required to complete training, if yes or no the operation should include it within the policy. 748.125(d)(5): The operations policy does not address how the operation will conduct screening in a manner that protects the child?s privacy. Where will the screening take place? In a private area/office where the child being screened can not be heard.

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-26

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

748.125 (c)(1)(B)(i-iv)-748.125(c)(1)(C)(i-iii): The operation?s policy indicates that staff will be required to take the AS+K training which only addresses the curriculum components for the risk factors, protective factors, and warning signs of suicide. Training must also address safety planning (748.125 (c)(1)(B)(i-iv) and screening for risk (748.125(c)(1)(C)(i-iii). Training on these specific curriculum requirements will have to be tailored for each operation as training will have to based on an operation?s own safety planning practices and the specific screening tool the operation will use to screen for risk. The operation will need to include training to address these two areas, the AS+K Gatekeeper training does not provide for these areas within the training. 748.125(c)(2): The operation?s policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate. Will volunteers and non-employees be required to complete training, if yes or no the operation should include it within the policy. 748.125(d)(5): The operations policy does not address how the operation will conduct screening in a manner that protects the child?s privacy. Where will the screening take place? In a private area/office where the child being screened can not be heard.

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

748.125 (c)(1)(B)(i-iv)-748.125(c)(1)(C)(i-iii): The operation?s policy indicates that staff will be required to take the AS+K training which only addresses the curriculum components for the risk factors, protective factors, and warning signs of suicide. Training must also address safety planning (748.125 (c)(1)(B)(i-iv) and screening for risk (748.125(c)(1)(C)(i-iii). Training on these specific curriculum requirements will have to be tailored for each operation as training will have to based on an operation?s own safety planning practices and the specific screening tool the operation will use to screen for risk. The operation will need to include training to address these two areas, the AS+K Gatekeeper training does not provide for these areas within the training. 748.125(c)(2): The operation?s policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate. Will volunteers and non-employees be required to complete training, if yes or no the operation should include it within the policy. 748.125(d)(5): The operations policy does not address how the operation will conduct screening in a manner that protects the child?s privacy. Where will the screening take place? In a private area/office where the child being screened can not be heard.

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-26

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-26

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

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

Resolution: Corrected: 2024-12-17

748.125 (c)(1)(B)(i-iv)-748.125(c)(1)(C)(i-iii): The operation?s policy indicates that staff will be required to take the AS+K training which only addresses the curriculum components for the risk factors, protective factors, and warning signs of suicide. Training must also address safety planning (748.125 (c)(1)(B)(i-iv) and screening for risk (748.125(c)(1)(C)(i-iii). Training on these specific curriculum requirements will have to be tailored for each operation as training will have to based on an operation?s own safety planning practices and the specific screening tool the operation will use to screen for risk. The operation will need to include training to address these two areas, the AS+K Gatekeeper training does not provide for these areas within the training. 748.125(c)(2): The operation?s policy does not indicate how they will promote suicide prevention training for non-employees, as appropriate. Will volunteers and non-employees be required to complete training, if yes or no the operation should include it within the policy. 748.125(d)(5): The operations policy does not address how the operation will conduct screening in a manner that protects the child?s privacy. Where will the screening take place? In a private area/office where the child being screened can not be heard.

Resolution: Corrected: 2024-12-17