# REFUGE HOUSE, INC.

| Procedure Information | Details |
| :---- | :---- |
| **PROCEDURE NAME** | Serious Incident Reporting Procedure |
| **PROCEDURE NUMBER** | FC-SIR-01.1 |
| **RELATED POLICY** | FC-SIR-01 Serious Incident Reporting Policy |
| **EFFECTIVE DATE** | 5/15/25 |
| **REVISION DATE** | 6/18/26 |
| **LAST UPDATED** | 5/15/2026 |
| **LAST APPROVED** | 5/22/2026 |

| APPLICABLE T3C PACKAGES: | APPLICABLE T3C ADD-ON SERVICES: |
| :---- | :---- |
| ☒ T3C Basic Foster Family Home | ☒ Transition Support Services for Youth & Young Adults |
| ☒ Substance Use Support Services | ☒ Kinship Caregiver Support Services |
| ☒ Short-Term Assessment | ☒ Pregnant & Parenting Youth or Young Adult |
| ☒ Mental & Behavioral Health |  |
| ☒ Sexual Aggression/Sex Offender |  |
| ☒ Complex Medical Needs or Medically Fragile |  |
| ☒ Human Trafficking Victim/Survivor |  |
| ☒ Intellectual or Developmental Disability (IDD)/Autism Spectrum Disorder |  |
| ☒ T3C Treatment Foster Family Care |  |

## PURPOSE:

To operationalize the Serious Incident Reporting Policy (FC-SIR-01) by detailing the reporting workflow, timeframe matrix, report content, and review process. The strictest applicable timeframe always controls, and reporting through one channel does not eliminate the obligation to report to others.

## MANDATORY DIRECT REPORTING (TAC §749.509):

Foster parents and personnel must report any suspicion of abuse, neglect, or exploitation — and any serious incident involving a child in their care — **directly to the Texas Abuse and Neglect Hotline (1-800-252-5400 or txabusehotline.org)**, in addition to reporting to Refuge House. From the hotline call, obtain and record: the **reference number**, the **name/ID of the hotline representative**, and the **time of the call**.

## SERIOUS INCIDENT REPORTING MATRIX (strictest timeframes — TAC §749.503):

| Serious Incident | To CCR | To Parents | To Law Enforcement |
| :---- | :---- | :---- | :---- |
| Child dies while in care | ≤ 2 hours | ≤ 2 hours | **Immediately, ≤ 1 hour** |
| Substantial physical injury / critical illness needing treatment or hospitalization | ≤ 24 hours | Immediately after ensuring safety | N/A |
| Allegations of abuse, neglect, or exploitation | As soon as aware | Immediately after ensuring safety | **Abuse Hotline 1-800-252-5400** |
| Physical abuse — child against another child | As soon as aware | Immediately after ensuring safety | N/A |
| Sexual abuse — child against another child | As soon as aware | Immediately after ensuring safety | N/A |
| Child indicted, charged, or arrested; or LE responds to an incident | ≤ 24 hours | As soon as aware | N/A |
| Child issued a ticket/citation at school (no detention) | N/A | ≤ 24 hours | N/A |
| Unauthorized absence — child under 6 | Within 2 hrs of notifying LE | Within 2 hrs of notifying LE | **Immediately** upon determining child missing |
| Unauthorized absence — child 6–12 | Within 2 hrs (if still missing) | Within 2 hrs | Within 2 hrs |
| Unauthorized absence — child 13+ | ≤ 6 hrs (immediately if trafficking/abduction/no intent to return) | ≤ 6 hrs (same) | ≤ 6 hrs (same) |
| Communicable disease reportable under 25 TAC 97 | ≤ 24 hours | ≤ 24 hours | N/A |
| Suicide attempt by a child | As soon as aware | Immediately after ensuring safety | N/A |
| Incident rendering a home unsafe/unsanitary (fire, flood) | ≤ 24 hours | ≤ 24 hours | N/A |
| Disaster/emergency requiring a foster home to close | ≤ 24 hours | ≤ 24 hours | N/A |
| Adult with access to a child contracts a reportable communicable disease | ≤ 24 hours | As soon as aware | N/A |
| Allegation an adult caregiver abused drugs within past 7 days | ≤ 24 hours | N/A | N/A |
| Investigation of an adult (employee, foster parent, contractor, volunteer) by an entity other than CCR | ≤ 24 hours | N/A | N/A |
| Arrest/indictment/warrant against an adult affecting ability to be present | As soon as aware | N/A | N/A |
| Search warrant executed at the CPA or a foster home | As soon as aware | N/A | N/A |

Events that may **not** rise to the serious-incident level but are relevant to the child's care are reported to the CPS/SSCC caseworker within 24 hours (**Texas Family Code §264.018; DFPS 24-Hr RCC §1410**).

## REPORTABLE (SERIOUS) INCIDENT WORKFLOW:

| Who | Action | Timeframe |
| :---- | :---- | :---- |
| Foster Parent / On-Call Worker | Ensure the child's safety; report to the Abuse Hotline and/or law enforcement per the matrix; notify Refuge House | Per matrix (strictest) |
| Refuge House Case Manager | Submit the Serious Incident Report via **Texas Provider Gateway (TPG)** (auto-notifies the SSCC) **and** notify the Residential Contract Manager, CPS/SSCC caseworker, and chain of command | Within **24 hours** of discovery (Contract §1411) |
| Refuge House Case Manager | Complete a Reportable Incident Report Form in the child's binder — de-identified, complete, proofread — with the §749.511 content | Within 24 hours |
| Case Manager → Treatment Manager / Administrator / Treatment Director / Director of Quality Development | Notify of the completed report by email | Upon completion |
| Treatment Manager / Director(s) | Review for approval; provide feedback or sign off | Within 1 business day each |
| Last approver | File the completed report in the Serious Incident Report Binder (report is not complete until all parties sign off) | Next business day after approvals |

## SSCC-SPECIFIC NOTIFICATIONS:

**SSCC-2INGAGE — addition start** *(provider-specific requirement; remove this block if the 2INgage contract ends)*

For children placed through **2INgage**, the following notifications apply **in addition to** the Texas Provider Gateway (TPG) report and the standard channels above:

- Within **24 hours** of knowledge, Refuge House reports to 2INgage at **cmd@2INgage.org** any critical incident, **licensing investigation, licensure-board report or investigation, and suspected fraud or fraud investigation**, as well as any violation occurring within Refuge House's business. *(2INgage Provider Manual Rev. 1.2026 §11, pp.46–47)*
- For a **psychiatric hospitalization**, Refuge House notifies 2INgage at **cmd@2INgage.org** no later than **12 hours** after admission, in addition to the serious-incident report submitted through TPG within 24 hours. *(2INgage Provider Manual Rev. 1.2026 §6, pp.37–38)*
- For a **runaway/missing child**, Refuge House sends the completed Runaway Prevention Plan to the 2INgage Missing Children (cmd@2INgage.org) and Special Investigator mailboxes; a 14-day disruption notice may be submitted once a child has been missing 24 hours. *(2INgage Provider Manual Rev. 1.2026 §6, p.41)*

**SSCC-2INGAGE — addition end**

**SSCC-EMPOWER — addition start** *(provider-specific; remove this block if the EMPOWER contract ends)*

For children placed through **EMPOWER**, in addition to the Texas Provider Gateway report: within **24 hours** of knowledge, Refuge House reports to **placement@3empower.org** any critical incident, licensing investigation, licensure-board report or investigation, and suspected fraud or fraud investigation *(EMPOWER Provider Manual Rev. 1.2026 §11, p.48)*; for a psychiatric hospitalization, Refuge House emails **placement@3empower.org** no later than **12 hours** after admission (plus the Gateway report within 24 hours) *(EMPOWER Provider Manual Rev. 1.2026 §6, p.39)*; for a runaway/missing child, the completed Runaway Prevention Plan (Form K-902-2882) is sent to **placement@3empower.org** and the Special Investigator mailbox **sirequestregion03@dfps.texas.gov**, with a 14-day disruption notice available once the child has been missing 24 hours *(EMPOWER Provider Manual Rev. 1.2026 §6, p.42)*.

**SSCC-EMPOWER — addition end**

**SSCC-OCOK — addition start** *(provider-specific; remove this block if the OCOK contract ends)*

For children placed through **OCOK**, Refuge House submits serious/critical incident reports via the **Texas Provider Gateway (TPG)** within **24 hours** (OCOK's enumerated categories — including death, abuse/neglect, suicidal/homicidal behavior, sexual-abuse disclosure, restraint use, runaway, and medication errors) and reports **all Emergency Behavior Interventions/restraints as serious incidents** with required documentation *(OCOK Network Management Operations Manual Rev. 7-1-2025 §4.10, pp.81–87)*. For a psychiatric hospitalization, Refuge House emails **psychhospitalization@oc-ok.org** (cc the OCOK Therapeutic Services Coordinator) no later than **12 hours** after admission, in addition to the TPG report within 24 hours *(OCOK Network Management Operations Manual Rev. 7-1-2025 §5.05, pp.117–118)*. Runaway/missing-child notifications follow OCOK's age-tiered timeframes and are reported immediately to DFPS *(OCOK Network Management Operations Manual Rev. 7-1-2025 §4.10, pp.84–85)*.

**SSCC-OCOK — addition end**

**SSCC-4KIDS — addition start** *(provider-specific; remove this block if the 4Kids4Families contract ends)*

For children placed through **4Kids4Families**, Refuge House reports critical/serious incidents — including licensing incidents, board reports/investigations, suspected fraud, and contract/Minimum-Standards violations — to the SSCC within **24 hours**, in addition to DFPS Statewide Intake (1-800-252-5400) and the chain of command *(4Kids4Families Subcontractor Agreement Art. XV–XVI)*. Psychiatric hospitalizations and missing children are reported to 4Kids (care@4kids4families.org), with missing-child notification no later than **8 hours** after learning the child is missing *(4Kids4Families Joint Operations Manual, pp.63, 83)*.

**SSCC-4KIDS — addition end**

**SSCC-BELONG — addition start** *(provider-specific; remove this block if the Belong contract ends)*

For children placed through **Belong**, Refuge House submits a written incident report to **incidentsbelong@sjrctexas.org within 24 hours** (and via the TPG portal) *(Belong Stage I & II Provider Manual, pp.49–50)*. A 24-hour discharge request following a youth's psychiatric-hospital admission is submitted within **24 hours of admission** *(Belong Stage I & II Provider Manual, p.15)*.

**SSCC-BELONG — addition end**

**SSCC-STFRANCIS — addition start** *(provider-specific; based on the publicly-sourced July-2020 SFCS manual — confirm against the current SFCS manual; remove this block if the SFCS contract ends)*

For children placed through **SFCS**, a psychiatric hospitalization is reported to SFCS at **TXReg1IR@st-francis.org** no later than **12 hours** after admission (a discharge notice does not substitute for a serious-incident report) *(SFCS Placement Provider Manual, July 2020 §3.1.4.1, p.38)*. *(General SFCS critical-incident reporting protocols fall in the manual's truncated back-half (§4.7) — confirm against the current SFCS manual.)*

**SSCC-STFRANCIS — addition end**

## REQUIRED WRITTEN REPORT CONTENT (TAC §749.511):

Home name/address/phone; date and time of the incident; child name, age, gender, and admission date; all adults involved and their roles; witnesses; nature and circumstances of the incident; interventions during and after (medical, contacts, follow-up); treating health-care professional's name, findings, and treatment; and the resolution.

**Additional documentation (TAC §749.513):** for a child death, substantial injury, or suicide attempt — any EBI implemented within the **48 hours** prior; for substantial injury from a short personal restraint — documentation of that restraint; for an unauthorized absence — efforts to locate, notification dates/times, persons contacted, whether/when the child returned, length of absence, and an addendum if the child returns after 24 hours.

## DE-IDENTIFICATION:

All incident reports are de-identified — include only the first name and last initial for any other children involved.

## NON-REPORTABLE INCIDENTS:

Within 24 hours, complete a Non-Reportable Incident Report Form in the applicable binder (complete, de-identified, proofread), notify the Treatment Manager/Administrator/Treatment Director/Director of Quality Development by email, and route through the same one-business-day review and sign-off chain.

## TRIGGERED REVIEW OF UNAUTHORIZED ABSENCES:

Patterns of unauthorized absence trigger an ISP review and a Runaway Prevention Plan update (cross-reference FC-04 Crisis Management §12 Missing Child/Runaway/Trafficking Response). On a child's return, complete the absence addendum and screen for trafficking/abuse victimization.

## QUALITY ASSURANCE (PQI):

Monthly, the Director of Quality Development reviews all incident reports for patterns and trends and compiles a quarterly report for the Quality Development (PQI) meeting. At least quarterly, trends are reviewed, action plans developed, and presented to the Executive Director.

## REFERENCES:

Same as Policy FC-SIR-01.

**SSCC alignment (FY-26):** 2INgage Provider Manual Rev. 1.2026 — §11 Risk Management & Reporting (pp.46–47) and §6 Services to Children (pp.37–38, 41). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC coverage tracker (`temporary-reference/fy26-sscc-joint-monitoring/sscc-alignment/`).

**SSCC alignment (FY-26) — EMPOWER:** EMPOWER Provider Manual Rev. 1.2026 — §11 (p.48 reporting); §6 (pp.39, 42). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — OCOK:** OCOK Network Management Operations Manual Rev. 7-1-2025 — §4.10 (pp.81–87 incidents/EBI); §5.05 (pp.117–118 psych). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — 4Kids:** 4Kids4Families Joint Operations Manual (Dec 2025) / Subcontractor Agreement — Agreement Art. XV–XVI (24-hr SSCC reporting); Manual pp.63, 83 (psych/missing). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — Belong:** Belong Stage I & II Provider Manual (Aug 2025) / Provider Services Agreement — pp.49–50 incidents; p.15 psych. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — SFCS:** SFCS Placement Provider Manual (July 2020, publicly-sourced — currency unconfirmed) / 2019 Affiliate Provider Agreement — Manual §3.1.4.1 p.38 (psych); general incident reporting needs current manual. Confirm against the current SFCS provider manual. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

## FORMS/ATTACHMENTS:

- Reportable Incident Report Form
- Non-Reportable Incident Report Form
- Responsibilities for Reporting Abuse and Neglect (mandated-reporter acknowledgment)
- Serious Incident Report Binder

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*This procedure operationalizes the principles established in FC-SIR-01 Serious Incident Reporting Policy. While policies require Board approval and remain relatively stable, procedures may be updated by the Executive Director to adapt to regulatory changes or operational improvements without requiring Board approval, provided such changes maintain alignment with the policy's intent.*