Capacity 18. 5-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.2203(c)(2) - Medication Error-Document the medication error
This was found on the child's medication logs. It was noted on three logs reviewed that there was no dose given to the child on a few dates in the month of August. |
— |
| 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 December 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 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 the heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 1, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a medium-high weighted citation in a pattern/trend category on December 1, 2025. Specifically, the operation was cited for 748.936(1) Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services. The operation met compliance on 12/8/2025. - 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. |
— |
| 4 | — |
748.3443(a)(4) - Food Preparation-Food items must be stored in a container that is protected from insects & rodents
Four chip bags were found to be opened and unprotected from external elements located in the kitchen. Administrator disposed of the open chip bags as well as puchased additional chip clips. |
Yes |
| 5 | — |
745.8417 - Licensing must have access to records
Video footage and documentation was not provided during the investigation. |
— |
| 3 | — |
748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
One of four child records reviewed showed a serious incident report that did not note how the incident was resolved. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
In one child's record, it was found that the child received the wrong dosage of medication on two separate occasions. |
— |
| 5 | — |
748.2001(a) - Administration of Medication-Must obtain a general written consent to administer routine, preventive, & emergency medications
A medical consenter was not notified or made aware of changes to authorize consent of a child in care's medication regimen change. |
— |
| 2 | — |
748.3273(9) - First Aid Kits-Each one must contain tweezers
Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have tweezers. |
Yes |
| 2 | — |
748.941(a)(1) - Training Criteria- Instructor-led/Self-Instructional Training must include specifically stated learning objectives.
In a review of staff files, there was no specifically stated learning objectives noted on the documents that were used to notate annual training. There was no objective listed on the sign in sheets. |
— |
| 4 | — |
748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
One of four child records showed that a child made an allegation of abuse. The serious incident report did not note a report made to the Abuse and Neglect Hotline. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Upon reviewing medication logs and documentation, it is noticed that 2 out of 4 child medical records did not show a diagnosis/reason for prescription medications. Out of the 2 child records on 1 childs; 6 medication logs were missing the reason/diagnosis and on the other childs record, 1 of their mediction log was missing the reason/diagnosis. |
— |
| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
A child in care did not have TB skin test record or result. |
— |
| 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 June 17, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has 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 two medium weighted citations in a pattern/trend category on June 2, 2025. Specifically, the operation was cited for 748.869(a)(3) in the category Required Trainings. The operation came into compliance on June 9, 2025. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
Upon reviewing medication logs and documentation, it is noticed that 1 of 4 childs medication logs was noted to be missing prescribing health care professional information. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
In one of the bedrooms, it was noted that the floor tile was peeling in multiple places. The tile under the legs of the bed, and in a corner against the wall had been torn up. |
— |
| 2 | — |
748.3273(8) - First Aid Kits-Each one must contain thermometer
Upon reviewing first aid kits, it is noticed that 3 out of 3 first aid kits do not have a thermometer. |
Yes |
| 3 | — |
748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059 |
— |
| 3 | — |
748.303(a)(11)(A) - Serious Incident-Report to Licensing no later than 24 hours after awareness that a child contracts reportable communicable disease
In a review of a child's record a positive covid result was found. There was no report made to licensing to notify of the positive result. |
— |
| 4 | — |
748.3301(h) - Physical Site-The building must be free of rodents and insects
The pantry was observed with evidence of rodent droppings. The pantry shelves were observed to be dirty and had sticky substances. |
— |
| 2 | — |
748.721(a) - Volunteer personnel record-The operation must maintain a personnel record for each volunteer
Upon requesting files for volunteers, it is discussed by the administrator that they do not have documentation or personal files for the volunteers. |
— |
| 2 | — |
748.869(a)(3) - Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.
The pre-service training records for one employee are not signed and dated by the instructor. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
Three of the medication logs reviewed did not have a prescribing physician noted on the documentation. |
— |
| 2 | — |
748.2853(2) - EBI Documentation-Child's reaction to the opportunity for post discussion
Upon reviewing EBI documentation, it is noticed that 2 of 3 debriefings did not have childs reaction. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Two of ten beds being used did not have protective mattress covers. This was corrected at inspection by the operation placing mattress covers on the uncovered beds. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
Two sinks in the girl's restroom was not draining properly. One sink in the boy's restroom was not draining properly. Administrator applied drain-o to the sinks to unclog the drains. |
Yes |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
Upon discussion with the administrator, it is noted that the volunteers are coming in contact with children without documention of TB screenings. |
— |
| 4 | — |
748.507(2) - Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
In multiple interviews with staff members, it was found that there were multiple instances where staff should have made a hotline report, but did not. |
— |
| 4 | — |
748.3563(d) - Protective Surfacing-Must ensure 9 inches of the loose-fill materials are maintained at all times
Upon reviewing the playground at the operation, it is noticed that the loose-fill does not reach the required 9 inches of height that it should be, as set by minimum standards. |
— |
| 5 | — |
748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child
Children interviewed stated that they were laid on their back and/or belly during restraints and that it hurt. Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
In a review of a child's file, there is a positive Covid test. There was no incident report for the positive test. Due to no report, there is no documentation showing notification to licensing or the child's parent/managing conservator. |
— |
| 3 | — |
748.3271(6) - First Aid Kits-Each one must be kept out of the reach of children
Two First aid kits were observed in the kitchen in an area accessible to children. This was corrected at inspection by moving them to an area that was kept locked and children not permitted to enter without an adult. |
Yes |
| 3 | — |
748.861(b)(3) - Pre-Service Training - Supervised experience must be documented in personnel record
In one of the records reviewed the documentation for the 40-hour supervised experience is minimum. It does not include the date or if this is the staff's actual 40-hour shadowing experience. |
— |
| 3 | — |
748.1111(a)(2) - Child Rights contact others-Not listen to or screen child's calls without permission from parents, service planning team, treatment director, or PLSP
It was determined that staff were listening in on children's phone calls. |
— |
| 4 | — |
748.2851(d) - EBI Follow-Up-Supervisor(s) of caregivers involved in an EBI must review the use of the emergency behavior intervention within 72 hours
Upon reveiwing EBI documentation, it is noticed that 3 out of 3 EBI reviews did not have supervisory review. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
A child in care did not receive sufficient doses of medication sent by provider for a visit and a child in care's medication was not stopped per a physician's order. |
— |
| 4 | — |
748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional
A child in care did not receive recommended 30 day well child check up follow up care as recommended by the health professional. |
— |
| 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
It was discovered that staff are denying phone calls from children. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
In a review of one child's records, there were six Behavior Observation Reports that were completed by another staff member, but held the name and signature of another. In another child's record, there were service plan reviews found that contained inaccurate and untruthful information. |
— |
| 2 | — |
748.565(3) - Professional level service provider-must review/approve discharge or transfer summaries; sign and date to indicate approval
In a review of one child's discharge summary it was noted that the PLSP did not participate in the discharge preparation, nor did they review and sign the summary. This standard was corrected at inspection. |
Yes |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
Two of the four child records reviewed were late on the completion of the initail service plan. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
Medication logs were filled out incorrectly for a child in care. Child had not been given his PM medication; however, the medication log reflected his PM medication had already been dispensed. |
— |
| 3 | — |
748.2003(b)(4) - Administration of prescription medication-Administer each child's medication within one hour of preparation
During a walkthrough inspection of the medication room, medication was observed outside of the blister pack in a white paper cup labeled with the initials TR. |
— |
| 3 | — |
748.363(10) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months
It was found that two employees had expired drivers licenses. |
— |
| 2 | — |
748.1225(b) - Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file
One of four child records reviewed did not have documentation off a dental appointment. |
— |
| 3 | — |
748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.
It was not noted on the EBI reports nor the serious incident reports when written notice was provided to the parent after a restraint was conducted on a child. |
— |
| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
In a review of four child records, it was noted that the children were missing TB tests. |
— |
| 3 | — |
748.2951(d) - Evaluation-Results of each overall annual evaluation made available to Licensing for review.
Upon requesting documents, the operation stated that they do not have an overall operation evaluation review of their Emergency Behavior Intervention. |
— |
| 4 | — |
748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child
During the course of the investigation, it was found that a staff member was threatening a child with harm as a method to gain compliance. |
— |
| 3 | — |
748.705(b)(1) - Reasonable & prudent parent standard-Must consider the child's age and level of maturity
During an inspection, it was reported that operation staff transported three children not in care of the operation on an outing with children in care. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
Upon review of medication records, it was found that after administering the medication, the staff member went up on the count, rather than noting that there was less medication. The count was documented incorrectly, and thus messed up the count going further on the following days. Prior to leaving the operation, the administrator provided documentation stating that the staff member will not be assigned the task of medication administration effectively immediately. Documentation was provided for the inspector. |
Yes |
| 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 December 16, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months has 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 two medium weighted citations in a pattern/trend category on November 19, 2024. Specifically, the operation was cited for 748.363(7) in the category Leadership Responsibilities- Personnel and 748.1333 in the category Service Plans-Preliminary. The operation came into compliance with both deficiencies on November 26, 2024. - Operation failed to satisfy the conditions of the plan. - Operation failed to satisfy the conditions of the plan; and - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
Small freezer in pantry thermometer was reading to be approximately 10 degrees F. The pantry fridge/freezer combo was missing a thermometer in the freezer. The fridge thermometer was broken. The kitchen fridge/freezer combo was missing both thermometers. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff engaged in an inappropriate conversation with children in care; this same staff was later involved in a verbal altercation with another staff in front of children in care, using language and behavior not suitable for children. |
— |
| 3 | — |
748.2851(b) - EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child
Upon review of incident reports, it was found that 1 document informed of an EBI being used. Upon further review, it was found that there was no post intervention discussion conducted with the child. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
It was determined that a staff member at the operation would yell and raise their voice in front of the children. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
In the boys restroom, it was observed that the shower/tub combo was missing a shower head. Administrator installed a new shower head to the shower/tub combo. |
Yes |
| 2 | — |
748.1385(4) - Service Plan Review-Must document reasons for continued placement if review shows no progress towards meeting identified needs
Two out of four children records reviewed showed little progress/updates in their service plan reviews. |
— |
| 2 | — |
748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan
A subsequent service plan for a child did not adress skills for youth 13 and older. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
During an inspection, prescribed medication was found stored in containers with handwritten labels. |
— |
| 3 | — |
748.685(e) - Caregiver responsibility-for a child receiving treatment services for an emotional disorder must maintain daily, signed and dated progress notes
In a review of four children's daily progress notes for the months March through April, none were signed by staff as required. There were also three days missing daily progress notes for one child. |
— |
| 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 found that a child was not given the correct dose of medication on four occassions. |
— |
| 4 | — |
748.2203(c)(2) - Medication Error-Document the medication error
Upon reviewing medical logs and documentation, it is noticed that 2 of 4 children medical records showed an error. On one child's record it was noted a child missed a dose. On 2 other child's records, it appears that the children received a double dose on for approximately 5 days and one for approximately 1 day. There was no documentation of medication errors in the child's records. There was no documentation of current medication review notes to accurately determine appropriate medication administration is being followed. |
— |
| 3 | — |
748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill
Upon request of the severe weather drill documentation, it is noted that the operation does not have documented severe weather drills. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
In a video recording, it was heard that a staff member was using profane language towards children. |
— |
| 5 | — |
745.8411(a) - Responsibilities - Not interfere with an inspection or investigation
A staff member questioned a youth regarding details of allegations being report by the youth to their caseworker. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
In a review of one child's medication logs, it was found that the child missed a dose of medication for two days before getting refilled. |
— |
| 4 | — |
748.507(3) - Employee general responsibilities-Know and comply with rules of Chapter 748 and any other rules and laws relevant to person's duties
An employee failed to comply with requirement to report being under investigation for abuse/neglect. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
In one of the records reviewed the staff record did not have the notarized affidavit available for review in the record. |
— |
| 4 | — |
748.3475(b)(1) - Safety Requirements-Ensure that hazards or defects identified during the playground inspection are removed or repaired promptly
During an inspection of the playground equipment, the slide was found to have several large, open cracks, the grounds of the play area had excessive debris, and multiple boards were missing or broken from the play-structure. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
During an investigation inspection a staff responsible for multiple children in care was found sleeping. The staff member was difficult to rouse and did not have an awareness of the children's ongoing activity. |
— |
| 3 | — |
748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
It was noted that staff did not write EBI documentation in a timely manner. |
— |
| 2 | — |
748.869(a)(3) - Pre-Service Training- Must include a certificate, letter, or a signed and dated statement of successful completion from the training source.
During a review of one employee record, pre-service training certificates were not signed or dated by the instructor. |
— |
| 3 | — |
748.363(12) - Personnel records-Include record of training and training hours.
An employee's file did not have an up to date record of all training and training hours completed. |
— |
| 4 | — |
748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint
In one of four children records reviewed, in the child's Admission Assessment, it was noted to be missing the contraindications to use of restraints. |
— |
| 5 | — |
748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso
Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe. |
— |
| 5 | — |
748.4045 - Safety restraints-only one person may use each child passenger safety seat system or safety belt
During an inspection, it was reported that 3 staff transported 12 children, in an 11 passenger vehicle and multiple children shared seats/safety belts while on an outing. |
— |
| 3 | — |
748.751(a)(1) - Pre-Employment Screening- You must obtain in writing an applicant's employment history for the last five years before hiring.
In the employee record reviewed there was no documentation made to show the last five years of employment history. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
Upon discussion with the administrator regarding the volunteers, it is noted that the operation has allowed frequent visitors to be present at the operation without a background check. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A professional staff member failed to demonstrate prudent judgment when he used a cell phone to audio and video record a conversation with a youth. |
— |
| 5 | — |
748.3471(5) - Safety Requirements-Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, etc.
Upon reviewing the playground equipment, it is noticed that a swing set is not properly anchored to the ground as well as the tether ball and was noticed that the wooden play structure was just sat on top of the ground, not anchored or built into the ground. |
— |
| 1 | — |
748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals
In a review of one child's service plan, there was no child signature, no caregiver signature, no treatment director signature, nor normalcy signature. In a review of three other service plans, there was no treatment director signatures. |
— |
| 4 | — |
748.936(1) - Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services
A caregiver's Emergency Behavior Intervention training was not renewed timely. |
— |
| 3 | — |
748.1385(5) - Service Plan Review-Must evaluate effectiveness & side effects of psychotropic meds, change in psychotropic meds, child's behaviors and reactions
During a review of the child's service plan review, it was noted that there was no evaluation of the medication's effectiveness, changes in medications, changes in behaviors, or any lab work completed. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
Upon walking through the operation, it is noticed that 2 of the girls beds in one of the rooms was missing a mattress cover or protector. |
Yes |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
Upon review at the inspection, it was found the administrator installed new playground equipment that was not in compliance with minimum standards, was not conducting the required reviews of the playground equipment, allowing volunteers at the operation for tutoring and mentoring without background checks, and not providing oversight of the entire program and staff's duties and responsibilities. |
— |
| 3 | — |
748.463(a) - Unauthorized Absence Evaluation?Must conduct an eval every 6 mths for unauthorized absences that have occurred during that time period
Operation did not have a current six month evaluation of Unauthorized Absence. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
Two of the five freezers inspected did not have a reading of 0* F. One read 8*F and the other read 24*F. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Two of two plans of service reviewed for an investigation had sections that were duplicated specifically in the type of approved contact, why visitation is not allowed, the same family members and supportive adult relationships, and information was inaccurate regarding the grade, school, and target due dates are from prior to the children's placement. |
— |
| 3 | — |
748.363(3) - Personnel records-Include current job description
Upon request of a staff member's current job description, it was found that no new job description was created and signed in the employee's record. |
— |
| 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 prescribed 1/2 dose of medication in AM and 1/2 dose of medication in PM. Child was being given a full dose by one staff member and a 1/2 dose by another staff member. Pill count reflected the discrepancy on the medication logs. |
— |
| 2 | — |
748.1337(b)(1)(A)(iii) - Initial Service Plan-Include intellectual functioning, including any testing and plans for recommended follow-up
The service plan reviewed during the inspection identified the child's level of care as specialized, borderline level of functioning, and the child needed follow up evaluation for autism spectrum disorder; however this was not reflected in any other records reviewed. |
— |
| 4 | — |
748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
In one of the staff records reviewed there was no documentation made to show that the potential staff's references were contacted. The application does list 5 different references, but the operation does not have any documentation to show where contact was made. |
— |
| 2 | — |
748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan
A subsequent service plan for a child did not adress skills for youth 13 and older. |
— |
| 3 | — |
748.941(a)(3) - Training Criteria- Must include an evaluation tool to determine whether the person obtained the information necessary to meet the stated objectives
In a review of staff records and files, there were no evaluation tools to determine if the staff retained the information received in trainings. In staff interviews, none of the staff stated that they had taken an assessment or any other evaluation tool to determine if they obtained or retained the information. |
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| 4 | — |
748.1699(a) - Nutrition-must offer a child a meal or snack, but may not force the child to eat
During the course of the investigation, it was found that staff are forcing children to eat all of their food. |
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| 4 | — |
748.3113(c) - Fire Extinguisher-Fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with equivalent unit
During walk-through of the facility, it was noted that one of the fire extinguishers needed to be recharged. The fire extinguisher was switched out and replaced with one that was still in the "White" |
Yes |
| 5 | — |
748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting
In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner. |
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| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
A child in care was inadequately supervised that resulted in them acting inappropriately with a peer. |
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| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
Food items were observed to be stored on the floor in the kitchen. Food in boxes were observed to have started to rot. Boxes were removed and thrown in dumpster. |
Yes |
| 4 | — |
748.2203(c)(2) - Medication Error-Document the medication error
One of the child records reviewed showed that a child missed two medication doses on two separate dates. This was found on the child's medication logs. |
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394 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.