Capacity 16. 0-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 5 | — |
745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions
It found that one staff was on provisional status as of 8/10/21 with conditions to include not to administer medications to children in care, however on 8/20/21 this staff person administered a psychotropic prescription medication to one child in care. |
— |
| 3 | — |
748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident
It was found that the incident on 10/23/21 involving two children in care/siblings getting into two physical altercations where law enforcement (LE) responded at the operation, was not reported to the A/N Hotline until 11/1/21 once one of the two children was arrested by the local police dept. for this incident. However, this incident should have been reported to the A/N Hotline within 24 hours of LE responding to the alleged incidences between the two children in care. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
After conducting the investigation and reviewing records, it was found that 3 of 4 children in care were not properly administered prescription psychotropic medication(s) and other prescription medication(s) on different days as instructed by the label or as ordered by their health care professional. |
— |
| 5 | — |
745.4151(c)(5)(B) - Drug testing procedures-Drug testing will use one of these drug-testing methods: certified lab, appropriate testing kit or other comparable method
Drug testing kit was expired, and drug kit manual does not have proven rates that false positive results are below 2 percent, and false negative results are below 8 percent as required by policy. |
— |
| 5 | — |
745.4151(c)(5)(D) - Drug testing procedures-Preserve the privacy and rights of the person tested
The operation does not have the drug test results for hired employees as this is only documented on a log, actual results are not located in staff file. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
It was determined that 2 children's initial service plans were completed 126 days late. |
— |
| 4 | — |
748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs
5 medication errors were not documented as required within the 24 hour period. |
— |
| 3 | — |
748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request.
The operation had not been completing an annual summary log of unauthorized absences as required by standards prior to this incident. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the insp., both knobs on the showers in the girls bathrooms were observed to be broken off or not attached. These should be repaired or replaced. |
— |
| 4 | — |
748.2259(a) - Psychotropic medication documentation-Maintain a daily record of the child's use of psychotropic medication according to requirements in 748.2151
After conducting the investigation and reviewing records, it was found that medication errors such as missed psychotropic medication and other prescription medications were either not documented on 3 of the 4 children's medication records and/or not properly documented according to minimum standards. From July 2021 to September 2021, when several children either refused prescription psychotropic medications and/or other prescription medications or missed their meds, staff did not document the refusal and/or the reason the medication(s) were missed or skipped. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the inspection three medication logs were reviewed and two of the logs were missing signatures next to the over the counter medication. |
— |
64 inspection record(s) on file from TX-HHSC.