Capacity 16. 13-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on March 12, 2026, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a high weighted citation in a pattern/trend category on March 5, 2026. Specifically, the operation was cited for standard 748.2101(1) Medication Storage- Medication in a locked container. During an investigation, a child in care took medication out of a staff's bag and attempted to ingest it. The medication was not stored in a locked container. Emergency services were contacted. Compliance was met on March 9, 2025. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with Texas Human Resources Code Sec. 42.078. The maximum daily penalty for your operation is $100. |
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| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
During the investigation, serious incident reports were reviewed, and it was observed the documentation was lacking required information such as the operation's physical address and the treating physician's name, finding, and treatment. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During this investigation, it was discovered during interviews children in care have been making out with each other in their beds and bedrooms. Five of the five children interviewed girls have played kissing games. Two of the five girls reported making out in the bed together in their bedroom. Four of the seven collateral adults interviewed reported visiting the operation several times a week and observing concerns regarding supervision. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During an abuse/neglect investigation it was noted that while a staff was playing with a child in care, the staff in a non-disciplinary manner, touched the child on her bottom, making a comment to the effect that the staff was bad. This was confirmed by another staff in a written incident report. Two collateral children were interviewed indicating this staff previously "touched or smacked" one of the two residents on the bottom. |
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| 2 | — |
748.949(b)(4) - Annual Training Documentation-Includes the trainer's name and qualifications, or the source of the training for self-instructional training
A training titled "Felt Safety" was signed by A. Aaron, but no qualifications were on the certificate. |
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| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
During the inspection it was found that one admission assessment was not completed within in 30 days after the child was placed. This is the policy of Hope Haven. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the inspection, I observed a child's prescription Iron Supplement was not refilled in a timely fashion, resulting in the child missing a dose of her medication on 10/14/24. The Administrator confirmed the responsible staff admitted to failing to pick the prescription up before the medication ran out. |
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| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A preliminary service plan was completed, signed and dated after the 72-hour required time frame. |
— |
| 3 | — |
748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care
We were only able to check one of the vans, but the first aid kit was missing several items, such as: cotton, a first aid guide, rubble gloves, scissors, and tweezers. |
— |
| 4 | — |
748.125(f)(2)(A) - Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.
During the investigation weekly screenings for the first thirty days were requested; however, they were not provided. After discussion with the administrator, it was reported the screenings were not in the operation's online records. Therefore, the administrator inquired if the screenings had been completed; however, there has not been a response provided. |
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| 3 | — |
748.831(a) - Orientation-Each caregiver or employee must have orientation prior to beginning job duties or having contact with children in care
One of the four employee records reviewed did not contain orientation training. |
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| 5 | — |
748.3301(a) - Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free
There was a large strip of trim missing from one of the staff/therapy doors, and it has been broken since April. Also noted were several small holes in one of the doors in the hallway, It appears that a work order is now in. Please send any documented efforts to get these things fixed. |
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| 3 | — |
748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill
While reviewing the severe weather drills, it was noted that only one drill had been conducted this year. The drill was conducted in January 2023, and there has not been a follow up drill completed. Staff reported the severe weather and fire drill were both completed at the same time in January 2023. |
— |
| 2 | — |
748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves
The first aid kit in the Hope Haven Hilander was missing waterproof gloves, a thermometer, and tweezers. A case manager added the missing items during the monitoring inspection. |
Yes |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During the inspection, it was discovered in the kitchen freezer an uncovered cup with lemon drink and an uncovered bowl of ice cream. The house manager removed and disposed of these items during the inspection. |
Yes |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the investigation, it was discovered that a caregiver playfully spanked a child on the bottom making the child feel weird about the situation. |
— |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
During the investigation, it was observed that the operation did not notify the parent about the child's serious injury, which resulted in seeking medical attention, until the following day and not directly after ensuring the child was safe. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
The administrator confirmed he would not be providing RCCR with a schedule showing his presence at the operation under advisement of his supervisor. The operation has not yet offered correction for this standard, and the administrator noted the standard is currently in Administrative Review with a hearing upcoming. As such, compliance for this standard has not yet been met. |
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| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Two children in care reported witnessing a caregiver was sleep while being the only staff on duty. One of the two children reported witnessing the caregiver with headphones on and asleep. The caregiver admitted to falling asleep while on duty. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the inspection, it was discovered that one of the four child medication records reviewed indicated a child had missed a dose on four days. |
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| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
The first aid kits in the vans did not have thermometers, and this is a requirement per minimum standards. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
A direct care staff was yelling and shaking her finger in the face of a child in care. |
— |
| 4 | — |
748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.
One of the four employee records reviewed had a transportation training that was at least three weeks late. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During an investigation, 2 children indicated that staff had given them vapes while in care at the operation. |
— |
| 4 | — |
748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.
One of the four employee records reviewed included a normalcy training that was over a month late. |
— |
| 4 | — |
748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional
A child was referred to follow up in one month for allergies, blood pressure, and to get a flu shot. The operation was not able to provide documentation to reflect the follow-up visit was completed. |
— |
| 3 | — |
748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights
One of the four records reviewed failed to have a child's signature indicating the child's rights had been reviewed. There was no signature nor was there an explanation of why the child did not sign. The agency provided another copy of the child's right form for this child that indicated the form was signed eleven months later. |
— |
| 3 | — |
748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill
During the inspection it was found that out of the seven fire drills reviewed not all fire drills were six months or less. |
— |
| 5 | — |
748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers
During an investigation, it was determined that children in care were using vapes. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A direct care staff had sexually inappropriate web searches on her phone (accessible to the kids) and used adult/inappropriate language while driving three girls in the operation's van. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
When reviewing medication records, two of the children's logs did not include the reason the medication was prescribed. |
— |
| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
During the inspection, I observed the facility first aid kit to be lacking a pair of tweezers. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A follow-up inspection was conducted at the operation regarding an ANE investigation in which this standard was cited. The operation reported as a correction that a training had been conducted on 10/6/2023. The administrator reported the training had been conducted, however, there was no sign-in sheet to provide evidence the training had actually took place. The administrator stated the staff that led the training is no longer employed with the operation, and he was not aware if a sign-in sheet was completed. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
The name and signature of of each staff administering medicaitons was not present. One staff's signature was illegible, and several medication counts were prefilled (without initials or signatures). |
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| 4 | — |
748.125(d)(4)(E) - Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
A suicide screening was not completed the day of the incident even though a child in care had exhibited three warning signs. |
— |
| 4 | — |
748.1501(d) - Dental Care-must obtain follow-up dental work recommended by the dentist
A child was referred to periodontics for gingival recession during a dental visit in October 2024. At the time of the investigation initial visit in March 2025, the child had yet to complete the periodontic visit. The operation reported issues with the referral and insurance, however, were not able to provide documentation to reflect continued efforts to get the child's referral completed in a timely manner. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the course of the investigation, two children in care reported staff grabbed a child by the arm and snatched a hot pocket out of the child's hand. The child and the staff began to argue, with the child telling staff not to touch her, which escalated the child and as a result the child destroyed the kitchen. There is video footage that supports the staff grabbed the child's arm. There was a previous incident before with this child and staff in which the child was cooking and staff grabbed the child's arm stating the staff wanted to show the child something. The child told staff at that time not to touch the child, and the child didn't want to be touched. |
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| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
This standard was evaluated in follow-up to Investigation #3121194, and the agency has not yet conducted an EBI refresher course including the restraint positions identified in the policies and procedures. |
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| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the inspection, it was discovered a toilet would not flush in one of the bathrooms in which three girls share. There is a do not use sign on the toilet. There is a work order for this toilet dated 6/8/2024, which appears to have been ample time for this toilet to have been fixed. |
— |
| 1 | — |
748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents
Three of the four records did not include documentation in the child's record indicating the child's parent had been notified of the service plan meeting. |
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| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the investigation inspection, medication records were reviewed and one record did not include the name of staff who administered the medication. |
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| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Interviews with staff and children indicate three children were allowed unsupervised access to a personal laptop, with one child requiring increased supervision due to recent behaviors. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
The direct care staff member used poor judgment by bringing vape pens for a child to use while at the facility. She also purchased two vape pens for two residents. |
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| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During the inspection it was found that a package of potato's were rotten. The treatment director disposed of the potato's on site. |
Yes |
| 3 | — |
748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest
A staff member was told to stand in the restroom and turn around while a child used the restroom. This made both the child and the caregiver uncomfortable. |
Yes |
| 3 | — |
748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling
Three of the staff records read had no proof of a high school or equivalency certificate. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
During the investigation, it was discovered that the operation did not follow their plans to restrict medication administration by a staff member after a medication error. |
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| 3 | — |
748.1547(2) - Vision and hearing examination-If a child in care needs an examination, ensure the professional and medical recommendations are carried out
A child was seen by medical personnel for an annual physical and referred to an optometrist in September 2024. The child was seen by an optometrist in October 2024; glasses were ordered and ready for pick-up within 3 weeks, however, operation staff did not pick-up the glasses until nearly 5 months later in March 2025. |
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| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
While reviewing the three victim child plans, it was discovered two of the three victim child plans had inaccurate information regarding another child in the plan. |
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| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
There were two missing staff signatures (initials) on a medication record for a specific medication. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During the monitoring inspection, one child's medication record had an inaccurate medication count. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the course of the investigation, a child in care was observed by staff picking up a marijuana roach. The staff told the child multiple times to drop the roach; however, the child did not. The staff witnessed the child walk around to multiple people at the park asking for a lighter; as well as asking the staff. The staff had the children load the van, because the child would not dispose of the roach. The child pretended to throw the roach out the window; and the staff believed she did. After returning to the operation, it was discovered that the child had not disposed of the roach as she was attempting to light it. The staff failed to obtain possession of the roach to ensure it was disposed of. The staff failed to check to see if the child actually disposed the roach. |
— |
| 3 | — |
748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate
Children at the operation were sleeping on mattresses placed directly on the floor. |
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| 2 | — |
748.1101(b)(6)(C) - Children's rights-to confidential care/treatment, include keep medical & operation records private. Discussing them only when it's about child's care
During the investigation, it was discovered through child and staff interviews that a staff member was not confidential in discussing with a child in care's skin checks with the child in front of other children. The child asked the staff to speak with her privately as it shocked her that the staff would discuss this with her in front of her peers. |
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| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
Completed supervision check forms were reviewed for HHS Investigation 3128973, and it was observed the operation was not following supervision checks per the child's safety plan; the operation failed to check on the child every 15 minutes on multiple occasions on 11/18/2024 and 11/19/2024. The child was interviewed and corroborated the discrepancy. The operation was cited on 12/12/2024 and provided a comply by date of 12/18/2024. The operation failed to show compliance, timely. |
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| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
During the investigation, a child reported the operation was not following supervision checks per the safety plan. A review of the completed supervision check forms corroborated the child's allegations. The operation failed to check on the child every 15 minutes multiple times on 11/18/2024 and 11/19/2024. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the inspection, I observed the adminstrator was not present at the operation during the inspection, interviews with staff and children indicate he is only present at the operation once or twice a week for meetings. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
A caregiver failed to follow the operation's approved policies and procedures. According to the operation's electronic and social media policy only authorized staff can handle these concerns. An off duty, unauthorized staff member provided a child with a history of social media abuse the password to social media. |
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| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
A child was placed at the operation on 5/23/2024. According to the Common App, the child was prescribed Abilify/Aripiprazole on 5/6/2025, prior to placement. According to documents provided by the operation and interviews, the child was never administered Abilify, in error. The operation was not able to provide medication records to reflect the child was administered the prescribed medication. |
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| 5 | — |
748.1661(a) - Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the investigation inspection, the administrator was not present at the operation. The administrator has not been present at the operation the last few times Licensing has been to the operation. |
— |
| 3 | — |
748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill
While reviewing the fire drills, it was noted that only one drill had been conducted this year. The drill was conducted in January 2023, and there has not been a follow up drill completed. Staff reported the severe weather and fire drill were both completed at the same time in January 2023. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Children in care and staff reported that children were allowed to possess and utilize personal sexual stimulators at the operation. A child in care admitted to using a personal sexual stimulator on another child while at the operation. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the investigation, it was discovered through interviews the staff on duty failed to intervene during the incident allowing two residents to witness, control, and de-escalate a traumatic incident with a peer, while staff was instructed by residents to remain outside the bathroom. A child was allowed to have a prohibited item listed on the child's safety plan, after the staff found a plan written by the child to harm oneself with the prohibited item. |
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| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
It was discovered while conducting interviews, the operation failed to include a child's name on the incident report that witnessed and was involved in the incident. Staff and child interviews indicated the child that name was not included witnessed the incident and refused to get out of the car when staff left to follow the victim child who had walked away from the operation. |
— |
| 4 | — |
748.1007(b)(1) - Child/caregiver ratio-Awake caregiver may care for 15 children if any child in group requires treatment services
Interviews, staff schedule and director confirm that they have not followed the required ratio of 8:1 when residents wake up at all times. Director stated this was done outside of normal plan as some staff needed to use leave. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
The operation has not yet met compliance with this standard as a refresher course in their EBI system has not yet been conducted with staff. The administrator confirmed it has not yet been completed, and the operation is seeking an instructor to meet this need. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
Serious incident reports were reviewed for HHS Investigation 3128973, and it was observed the documentation was lacking required information such as the operation's physical address, telephone number, and the treating physician's name, findings, and treatment. The operation was cited on 12/12/2024 and provided a comply by date of 12/18/2024. The operation failed to show compliance, timely. |
— |
| 5 | — |
748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment.
During the investigation, it was discovered that a caregiver was yelling, screaming, and/or cursing at the children, |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
During the investigation it was discovered during interviews and documentation, the victim child was on increased supervision and could not be with two residents without staff presence. Three residents reported staff was not present to intervene when the incident occurred. The staff reported two residents went to the victim's aid, while the staff put up chemicals. One of the residents that went to check on the victim was listed on the victim's safety plan, as to not be with this peer without staff supervision. |
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| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
During the investigation, it was discovered that a caregiver was leaving staff keys accessible to children and leaving the staff office door and medication closet opened and accessible to children. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
During the inspection, three of the four child medication records reviewed were missing the reason the medication was prescribed. This was corrected at inspection. |
Yes |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the inspection, I observed the adminstrator was not present at the operation during the inspection, exhibits a historical pattern of not being present at the operation, and interviews indicate he is present at the operation only for staff meetings. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
During the investigation, I confirmed two staff members did not receive EBI training within six months of their previous training. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
Two of the four child records reviewed were missing service plan reviews. One of the records had the initial service plan only. Another record was missing one service plan review. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
One of the beds in room 1 was missing a mattress protector, and the child refused to put one on her bed. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.
The operation failed to report the quarterly EBI data timely. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the inspection, it was discovered a toilet would not flush in one of the bathrooms in which three girls share. There is a do not use sign on the toilet. There is a work order for this toilet dated 6/8/2024, which appears to have been ample time for this toilet to have been fixed. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
While reviewing the three victim child plans, it was discovered two of the three victim child plans had inaccurate information regarding another child in the plan. |
— |
| 3 | — |
748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill
During the inspection it was found that out of the seven fire drills reviewed not all fire drills were six months or less. |
— |
| 2 | — |
748.3273(10) - First Aid Kits-Each one must contain waterproof, disposable gloves
The first aid kit in the Hope Haven Hilander was missing waterproof gloves, a thermometer, and tweezers. A case manager added the missing items during the monitoring inspection. |
Yes |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the course of the investigation, a child in care was observed by staff picking up a marijuana roach. The staff told the child multiple times to drop the roach; however, the child did not. The staff witnessed the child walk around to multiple people at the park asking for a lighter; as well as asking the staff. The staff had the children load the van, because the child would not dispose of the roach. The child pretended to throw the roach out the window; and the staff believed she did. After returning to the operation, it was discovered that the child had not disposed of the roach as she was attempting to light it. The staff failed to obtain possession of the roach to ensure it was disposed of. The staff failed to check to see if the child actually disposed the roach. |
— |
| 3 | — |
748.3239(a) - Evacuation-Must practice unannounced fire drill at least once every 6 months from date of last fire drill
While reviewing the fire drills, it was noted that only one drill had been conducted this year. The drill was conducted in January 2023, and there has not been a follow up drill completed. Staff reported the severe weather and fire drill were both completed at the same time in January 2023. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the inspection, I observed a child's prescription Iron Supplement was not refilled in a timely fashion, resulting in the child missing a dose of her medication on 10/14/24. The Administrator confirmed the responsible staff admitted to failing to pick the prescription up before the medication ran out. |
— |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
During the investigation, it was observed that the operation did not notify the parent about the child's serious injury, which resulted in seeking medical attention, until the following day and not directly after ensuring the child was safe. |
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| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
This standard was evaluated in follow-up to Investigation #3121194, and the agency has not yet conducted an EBI refresher course including the restraint positions identified in the policies and procedures. |
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| 3 | — |
748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care
We were only able to check one of the vans, but the first aid kit was missing several items, such as: cotton, a first aid guide, rubble gloves, scissors, and tweezers. |
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| 4 | — |
748.125(f)(2)(A) - Protocols must include weekly screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer.
During the investigation weekly screenings for the first thirty days were requested; however, they were not provided. After discussion with the administrator, it was reported the screenings were not in the operation's online records. Therefore, the administrator inquired if the screenings had been completed; however, there has not been a response provided. |
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| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
During the investigation, it was discovered that the operation did not follow their plans to restrict medication administration by a staff member after a medication error. |
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| 3 | — |
748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest
A staff member was told to stand in the restroom and turn around while a child used the restroom. This made both the child and the caregiver uncomfortable. |
Yes |
| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
The first aid kits in the vans did not have thermometers, and this is a requirement per minimum standards. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Children in care and staff reported that children were allowed to possess and utilize personal sexual stimulators at the operation. A child in care admitted to using a personal sexual stimulator on another child while at the operation. |
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| 4 | — |
748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional
A child was referred to follow up in one month for allergies, blood pressure, and to get a flu shot. The operation was not able to provide documentation to reflect the follow-up visit was completed. |
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| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
During the investigation, serious incident reports were reviewed, and it was observed the documentation was lacking required information such as the operation's physical address and the treating physician's name, finding, and treatment. |
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| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the course of the investigation, two children in care reported staff grabbed a child by the arm and snatched a hot pocket out of the child's hand. The child and the staff began to argue, with the child telling staff not to touch her, which escalated the child and as a result the child destroyed the kitchen. There is video footage that supports the staff grabbed the child's arm. There was a previous incident before with this child and staff in which the child was cooking and staff grabbed the child's arm stating the staff wanted to show the child something. The child told staff at that time not to touch the child, and the child didn't want to be touched. |
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| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
There were two missing staff signatures (initials) on a medication record for a specific medication. |
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| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Two children in care reported witnessing a caregiver was sleep while being the only staff on duty. One of the two children reported witnessing the caregiver with headphones on and asleep. The caregiver admitted to falling asleep while on duty. |
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| 1 | — |
748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents
Three of the four records did not include documentation in the child's record indicating the child's parent had been notified of the service plan meeting. |
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| 4 | — |
748.1501(d) - Dental Care-must obtain follow-up dental work recommended by the dentist
A child was referred to periodontics for gingival recession during a dental visit in October 2024. At the time of the investigation initial visit in March 2025, the child had yet to complete the periodontic visit. The operation reported issues with the referral and insurance, however, were not able to provide documentation to reflect continued efforts to get the child's referral completed in a timely manner. |
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| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
During the inspection, I observed the facility first aid kit to be lacking a pair of tweezers. |
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406 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.