Capacity 16. 12-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 4 | — |
748.2451(a)(4)(A) - Seclusion-Only for child with ED or PDD when 25+ children with ED or PDD or >30% of children with ED or PDD; not allowed for child in therapeutic camp
A child was in their bedroom and a staff member blocked the door by using their foot, preventing the child from opening or leaving the bedroom. |
— |
| 2 | — |
748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth
Child files reviewed, two out of two files were missing the child's religion or religious preference. |
— |
| 4 | — |
748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
The administrator did not ensure compliance with a safety plan when a staff person who was limited in contact with a child was able to interact with the child. |
— |
| 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
Loose medication was observed in the medication drawer. |
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 time of review a child was woken up during nighttime hours to help assist with another child in care that was being unmanageable when 3 staff/caregivers were present. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
One of the children underwent surgery on 1/5/26 and this was not reported into the statewide hotline. |
— |
| 5 | — |
748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child
A staff member secluded a child in their room by blocking the door with their foot and body. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The thermometer was observed to be at a temperature of twenty degrees fahrenheit. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
Two out of three child medication logs reviewed did not have the accurate count for two medications they were taking. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the walkthough, 1 out 3 freezers were observed to be at 20 degrees Fahrenheit. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
The people list was reviewed, and background checks for two employees were inactivated a few months after they were no longer associated with the operation. In addition, the administrator did not have their background check inactivated within seven days of leaving the operation. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
It was noted that staff members did not attempt to deescalate the behavior of a child before performing a restraint on them. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One out of two child medication logs reviewed did not have a record of administration of the medication as prescribed. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A staff member scrolled through a cell phone during an altercation. While the staff member viewed their phone, children in care engaged in a verbal altercation. A child in care was left in the room for 1 minute. While alone and in the hearing of staff members, the child expressed suicidal ideations. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
During the Investigaton it was discovered that a staff member was unfamiliar with the agency's operational policies. |
— |
| 3 | — |
748.1699(c) - Nutrition-if meal or snack not appropriate to meet a child's individual needs, then must offer an appropriate nutritional substitute
A child that was diagnoses with high cholesterol is not being offered a nutritional substitute for meals and snacks. |
— |
| 1 | — |
748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves
The menu did not list the snacks that are provided to the children in care. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
7 child medication logs were reviewed. Of the 7 logs reviewed, 5 child files documented a medical professional who was not the actual physical listed on the medication label. |
Yes |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
One of the bathrooms in unit B was found to have water on the floor and was not draining the water properly in addition to having peeling paint below the mirror on the sink and on the toilet. Two other bathrooms in unit B were found to have peeling paint on the soap dispensers and on the toilets and in one of these, there was dirty water observed on the railing under the sink. Three of the bathrooms in unit A were found to have peeling paint on the soap dispensers, on the toilets and below the mirrors above the sink. |
— |
| 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 in care did not recieve their morning medications. An administrative penalty in the amount of 100% of the daily maximum, per HRC 42.078(a-2) will be recommended as a result of this citation. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
The service plan indicates that the child should be learning how to cook healthy meals for themselves. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
A youth care specialist admitted to using profanity towards a child in care. |
— |
| 3 | — |
748.531(b) - Child-care administrator-If acting as administrator for two operations, split full-time schedule per professional staffing plan for each operation
The LCCA is the administrator for two operations however a written staffing plan was not completed. |
— |
| 3 | — |
748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services
One of the preliminary service plans reviewed did not have a signature from the treatment director or PLSP. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Caretakers at the operation did not provide proper supervision to a child in care allowing for the child to cause a self injury to themselves requiring hospitalization |
— |
| 3 | — |
748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean
The sink in the classroom near unit A was found to have rust while the sink in the classroom near unit B was found to have a broken handle. |
— |
| 4 | — |
748.153(3)(A) - Notification - Change in child-care administrator
Leadership failed to notify licensing of a change in controlling persons within the two day time frame. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
A caregiver had a verbal altercation with a child in care during which they yelled at the child and made inappropriate comments. |
— |
| 4 | — |
748.2203(c)(1) - Medication Error-Document the time & date of the error
The medication logs for four children do not document the medication error including the time and dates the children were without medications. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
A bathroom in unit B was found to have water on the floor and was not draining the water properly. The shower head was also not in proper working condition. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A child was able to obtain a pair of scissors and use to cut their own hair. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
Management staff did not instruct direct care staff on what was the supervision requirements for a child with known self-harming behaviors. |
— |
| 3 | — |
748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan
Staff responsible for the supervision of a child in care did not provide the level of supervision indicated on the preliminary service plan. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
One of the two medication's reviewed did not have the updated count on the medicaiton log. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A video was reviewed showing two caregivers not intervening when a child was harming themself. |
— |
| 3 | — |
748.705(b)(2) - Reasonable & prudent parent standard-must consider the child's cognitive, social, emotional and physical development level
An employee at your operation showed favoritism to one particular child as well as buying inappropriate gifts for this child. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Staff members were observed not intervening when children in care were escalated. |
— |
| 2 | — |
748.191(2) - Required Postings-Post Licensing notice Keeping Children Safe in prominent and publicly accessible place where others may easily view it at all times
The operation did not have the notice of keeping children safe at the operation. |
— |
| 3 | — |
748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
1 of the 2 employment files reviewed did not have "none" written on the notarized affidavit concerning incidents involving children as required. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
It was determined that caregivers were displaying inappropriate behaviors, caregivers were having inappropriate conversations in front of the children and were showing favoritism towards some children. |
— |
| 3 | — |
748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement
Due to the child's history, the safety plan did not implement a plan to ensure the proper protocol to keep a child safe that has a history of self-harm. |
— |
| 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
A caregiver was found to have threaten to hit and physically harm the child. |
— |
| 3 | — |
748.685(a)(1) - Caregiver responsibility - knowing which children they are responsible for
A child in care service plan indicated that she not to be left alone no more than 15 minutes at a time. The caregiver responsible for supervising a child, left the child alone for over 40 minutes unattended, thinking other caregivers were supervising her. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection, on Unit B, in one of the bedrooms, the trim in the corner by the bed was detached from the wall and appeared that it could fall. |
— |
| 4 | — |
748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return
1 child left the operation on 07/18 and returned on 07/18. The serious incident report does not document a debriefing with the child. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
It was determined that a caregiver did not create a safe environment for a child in care when failing to adhere to a safety plan causing the child to be triggered. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff member did not demonstrate prudent judgement when he used his foot and body to block one of the residents in their room and dragged the child while they were on their mattress. |
— |
| 3 | — |
748.303(a)(9)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older
A child in care ran away from the operation on 07/18 and returned on 7/19 and the report was received on 7/23. |
Yes |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
During the time of review a child was being restrained in front of another child and the child that was asked to help was attempting to take off the other child's shirt while 3 caregivers/staff were present. |
— |
| 4 | — |
748.2101(5) - Medication Storage - keep medication storage area(s) clean and orderly
A child's medication was observed to be in another child's drawer. This was corrected at the inspection when staff moved the medication to the correct child's drawer. |
Yes |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff member did not use appropriate de-escalation techniques with a youth in care. The caregiver taunted the child by swinging a mop in the child?s direction as well as mopping a beanbag used by the youth. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
One of the two medication's reviewed did not have the updated count on the medicaiton log. |
— |
| 3 | — |
748.1205(a)(12) - Admission Documentation-Identification of child's high risk behaviors and related safety plan staff and caregivers will implement
Due to the child's history, the safety plan did not implement a plan to ensure the proper protocol to keep a child safe that has a history of self-harm. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
A youth care specialist admitted to using profanity towards a child in care. |
— |
| 3 | — |
748.303(a)(9)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older
A child in care ran away from the operation on 07/18 and returned on 7/19 and the report was received on 7/23. |
Yes |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A child was able to obtain a pair of scissors and use to cut their own hair. |
— |
| 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
A caregiver was found to have threaten to hit and physically harm the child. |
— |
| 4 | — |
748.2451(a)(4)(A) - Seclusion-Only for child with ED or PDD when 25+ children with ED or PDD or >30% of children with ED or PDD; not allowed for child in therapeutic camp
A child was in their bedroom and a staff member blocked the door by using their foot, preventing the child from opening or leaving the bedroom. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During the time of review a child was woken up during nighttime hours to help assist with another child in care that was being unmanageable when 3 staff/caregivers were present. |
— |
| 1 | — |
748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves
The menu did not list the snacks that are provided to the children in care. |
— |
| 3 | — |
748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services
One of the preliminary service plans reviewed did not have a signature from the treatment director or PLSP. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Caretakers at the operation did not provide proper supervision to a child in care allowing for the child to cause a self injury to themselves requiring hospitalization |
— |
| 2 | — |
748.191(2) - Required Postings-Post Licensing notice Keeping Children Safe in prominent and publicly accessible place where others may easily view it at all times
The operation did not have the notice of keeping children safe at the operation. |
— |
| 3 | — |
748.1699(c) - Nutrition-if meal or snack not appropriate to meet a child's individual needs, then must offer an appropriate nutritional substitute
A child that was diagnoses with high cholesterol is not being offered a nutritional substitute for meals and snacks. |
— |
| 4 | — |
748.153(3)(A) - Notification - Change in child-care administrator
Leadership failed to notify licensing of a change in controlling persons within the two day time frame. |
— |
| 4 | — |
748.2203(c)(1) - Medication Error-Document the time & date of the error
The medication logs for four children do not document the medication error including the time and dates the children were without medications. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff member did not demonstrate prudent judgement when he used his foot and body to block one of the residents in their room and dragged the child while they were on their mattress. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
It was determined that caregivers were displaying inappropriate behaviors, caregivers were having inappropriate conversations in front of the children and were showing favoritism towards some children. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the walkthough, 1 out 3 freezers were observed to be at 20 degrees Fahrenheit. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
A caregiver had a verbal altercation with a child in care during which they yelled at the child and made inappropriate comments. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
A bathroom in unit B was found to have water on the floor and was not draining the water properly. The shower head was also not in proper working condition. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection, on Unit B, in one of the bedrooms, the trim in the corner by the bed was detached from the wall and appeared that it could fall. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One out of two child medication logs reviewed did not have a record of administration of the medication as prescribed. |
— |
| 3 | — |
748.531(b) - Child-care administrator-If acting as administrator for two operations, split full-time schedule per professional staffing plan for each operation
The LCCA is the administrator for two operations however a written staffing plan was not completed. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
Two out of three child medication logs reviewed did not have the accurate count for two medications they were taking. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
7 child medication logs were reviewed. Of the 7 logs reviewed, 5 child files documented a medical professional who was not the actual physical listed on the medication label. |
Yes |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Staff members were observed not intervening when children in care were escalated. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
Management staff did not instruct direct care staff on what was the supervision requirements for a child with known self-harming behaviors. |
— |
| 4 | — |
748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
It was noted that staff members did not attempt to deescalate the behavior of a child before performing a restraint on them. |
— |
| 5 | — |
748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child
A staff member secluded a child in their room by blocking the door with their foot and body. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A video was reviewed showing two caregivers not intervening when a child was harming themself. |
— |
| 4 | — |
748.2101(5) - Medication Storage - keep medication storage area(s) clean and orderly
A child's medication was observed to be in another child's drawer. This was corrected at the inspection when staff moved the medication to the correct child's drawer. |
Yes |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
It was determined that a caregiver did not create a safe environment for a child in care when failing to adhere to a safety plan causing the child to be triggered. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
The service plan indicates that the child should be learning how to cook healthy meals for themselves. |
— |
| 3 | — |
748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean
The sink in the classroom near unit A was found to have rust while the sink in the classroom near unit B was found to have a broken handle. |
— |
| 4 | — |
748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
The administrator did not ensure compliance with a safety plan when a staff person who was limited in contact with a child was able to interact with the child. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
During the Investigaton it was discovered that a staff member was unfamiliar with the agency's operational policies. |
— |
| 3 | — |
748.685(a)(1) - Caregiver responsibility - knowing which children they are responsible for
A child in care service plan indicated that she not to be left alone no more than 15 minutes at a time. The caregiver responsible for supervising a child, left the child alone for over 40 minutes unattended, thinking other caregivers were supervising her. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A staff member did not use appropriate de-escalation techniques with a youth in care. The caregiver taunted the child by swinging a mop in the child?s direction as well as mopping a beanbag used by the youth. |
— |
| 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 in care did not recieve their morning medications. An administrative penalty in the amount of 100% of the daily maximum, per HRC 42.078(a-2) will be recommended as a result of this citation. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
One of the children underwent surgery on 1/5/26 and this was not reported into the statewide hotline. |
— |
| 3 | — |
745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving
The people list was reviewed, and background checks for two employees were inactivated a few months after they were no longer associated with the operation. In addition, the administrator did not have their background check inactivated within seven days of leaving the operation. |
— |
| 2 | — |
748.1205(a)(1) - Admission Documentation-Includes child's name, gender, race, religion, date of birth
Child files reviewed, two out of two files were missing the child's religion or religious preference. |
— |
| 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
Loose medication was observed in the medication drawer. |
Yes |
| 4 | — |
748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return
1 child left the operation on 07/18 and returned on 07/18. The serious incident report does not document a debriefing with the child. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The thermometer was observed to be at a temperature of twenty degrees fahrenheit. |
— |
| 3 | — |
748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan
Staff responsible for the supervision of a child in care did not provide the level of supervision indicated on the preliminary service plan. |
— |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
During the time of review a child was being restrained in front of another child and the child that was asked to help was attempting to take off the other child's shirt while 3 caregivers/staff were present. |
— |
| 3 | — |
748.363(6) - Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
1 of the 2 employment files reviewed did not have "none" written on the notarized affidavit concerning incidents involving children as required. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A staff member scrolled through a cell phone during an altercation. While the staff member viewed their phone, children in care engaged in a verbal altercation. A child in care was left in the room for 1 minute. While alone and in the hearing of staff members, the child expressed suicidal ideations. |
— |
240 inspection record(s) on file from TX-HHSC.