Capacity 8. 12-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 1 | — |
748.1433(a)(2) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one PLSP involved in child's service planning
3 of 3 discharge summaries reviewed did not contain PLSP (Treatment Director) involvement in the discharge planning. |
— |
| 3 | — |
748.603(a)(1) - Treatment director-responsible for the overall treatment program and therapeutic interventions
A review of the treatment plans of the 2 youth who ran away from the facility identified significant required information missing. One youth's service plan review was overdue and had not been completed. One youth's service plan review did not describe the trauma history or known triggers; identified the youth as a victim of or at risk of being victim of human trafficking, however, did not identify high risk behaviors or plans to address any; did not identify any progress/efforts made by the provider towards achieving the permanency goal; did not address transitioning to successful adulthood or life skills strengths/challenges; and describes that the youth receives 24/7 supervision. |
— |
| 2 | — |
748.2309(b) - Restrictions of activities-restrictions of activities imposed for more than 14 days must have prior approval
A youth's activities were restricted for 30 days. There is no documentation in the youth's record showing approval by a PLSP nor the Treatment Director. |
— |
| 3 | — |
748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826
During the review of documentation, it was found that a pet's vaccine was expired. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
One child's service plan reviewed,supervision requirements addressed/ stated, at no time should the child be alone with younger children. It was founded that the child was sharing a bedroom with a younger child. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk-through of the inspection, one bed did not have a mattress protector. This was corrected at inspection by a staff member adding a mattress protector to the bed. |
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
Based on interviews conducted and records reviewed, it was determined the unauthorized absence debriefing for the 2 youth was not conducted timely. |
— |
| 4 | — |
748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work
Based on interviews conducted and records reviewed, it was determined a caregiver who was in ratio, was pulled away from the group of children to the hallway by the treatment director to discuss a youth, allowing 2 youth the opportunity to runaway from the operation. At the time of the unauthorized absence of the 2 youth, there were 6 children in care (5 treatment services) with 2 caregivers assigned to ratio, as well as the office manager and administrator who were both engaged in administrative duties (not counted in ratio). The youth remained gone until the following day. |
— |
| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
During the walk-through of the inspection, hot dog buns were seen on the floor of the pantry. This was corrected at inspection by a staff member picking the hot dog buns off the floor of the pantry. |
Yes |
| 3 | — |
748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy
During the walk-through of the inspection, it was noticed that there was no shower curtain in one of the bathrooms. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During an inspection a wardrobe cabinet was observed to be severly damaged. Thier was blinds in one of the bedrooms that were observed to be damaged. Their were 2 holes observed in 2 different child's bedroom walls and one of the bedroom doors would not close where the hole was present. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Based on information obtained in interviews and records reviewed, it was founded that there were seven children in care at the operation, all of which were located in the t.v. room and two direct care staff present at the operation, both staff were putting away the children's medications located in the hallway of the facility. While both direct care staff were in the hallway, a fight started between two youth in the t.v. room where the children were located. Based on the layout of the facility the t.v. room can not be seen while a person is in the hallway and there is also a door located in the t.v. room. |
— |
| 1 | — |
748.1433(e) - Discharge-If child receiving tx svcs, tell him of planned discharge/transfer 4 days in advance, unless qualified professional justifies not doing so
2 of 3 non-emergency discharge summaries were observed to have provided 2 days advance notice of planned discharge. There was no documented justification for not meeting the 4 days notice requirement. |
— |
| 2 | — |
748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs
A child's service plan review did not document high risk behavior history of self harm and substance abuse, nor any plans to address. The service plan review did not address treatment services for emotional disorders nor any services to address substance abuse. The review plan did not include information from the recent psychological completed, did not include trauma history and triggers, did not include therapy information, nor any progress summary. The review plan did not identify/document efforts to transition to a lesser restrictive setting (plans for discharge). |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A child's preliminary service did not include the child's supervision requirements. |
— |
| 4 | — |
748.863(a)(4) - Pre-Service Training-Caregiver for tx svcs (not PMN) must have 16 hrs EBI training or 8 hrs if EBI prohibited, 1/2 pre-service & rest within 90 days
After a review of the staff training records, it was found that one staff caregiver did not have the required EBI training. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
A direct care staff with a hire date of 8/2/21, does not have an active background check. |
— |
| 2 | — |
748.1001(a) - Children's rights-A child's rights are cumulative of any other rights granted by law or other Licensing rules
Youth are being subjected to random drug testing conducted at the operation by the operation staff. |
— |
| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
During the inspection, it was found that the operation did not have an updated fire inspection completed. |
— |
| 3 | — |
748.721(b) - Volunteer personnel record-Include signed/dated statement that volunteer will report child abuse/neglect to Tx Abuse & Neglect hotline & administrator
Based on information gathered during an evaluation of two volunteer records, it was determined two out two volunteer records reviewed did not contain a statement signed and dated by the volunteer indicating the volunteer must immediately report any suspected incident of abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the operation?s administrator. |
— |
| 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 2nd. Quarter EBI Report has not been submitted to Child Care Regulation. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
2 of 4 youth preliminary service plans were completed past the 72 hour requirement. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly
The 2nd quarter EBI report has not been submitted to Child Care Regulation. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One child's medication logs documentation reviewed for the month of December of 2021 showed the child was not administered one of the required prescribed medications two times. |
— |
| 4 | — |
748.2203(c)(1) - Medication Error-Document the time & date of the error
One child's medication log documentation reviewed showed the child was not administered one of the required prescribed medications two times in the month of December 2021. The medication error was not documented. |
— |
| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
One out of the three child files reviewed showed an admission assessment that was missing information. There were a few pages that were blank with no entered information. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
Based on information obtained in interviews and records reviewed, there was only one staff on shift during the weekday mornings with 7 children in care, 6 of which were treatment services children. |
— |
| 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
Two employees resigned approximately one month ago and the two staff still has active background checks. |
— |
| 3 | — |
748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available
During the review of documentation, the operation did not have documentation to show that the city/county is no longer providing health inspections. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
The follow-up inspection conducted at the operation. the wardrobe in the front bedroom has been dismantled and removed from bedroom, and is located on the front porch away from the front door. One bedroom door is damaged and does not close, which does not allow for privacy. Another bedroom door is warped and separating. The two holes in the walls have been covered with plastic door protector. One set of blinds was observed to have broken slats. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
Three of the three child files did not have the PLSP signatures on the Admission Assessment/Preliminary Service Plan. |
— |
| 2 | — |
748.1439(b)(1)(A) - Discharge Documentation-Discharge summary must include services provided to the child while in your care
3 of 3 discharge summaries evaluated were observed to be missing information as required by 748.1439(b)(1)(A-F). |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
A child complained of pain and was asked to be taken to the doctor by the staff after being punched approximately 10 times in the back of head by another child during an incident at the facility. The child was not taken to the doctor. |
— |
| 3 | — |
748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy
During the walk-through of the inspection, it was noticed that there was no shower curtain in one of the bathrooms. |
— |
| 1 | — |
748.1433(e) - Discharge-If child receiving tx svcs, tell him of planned discharge/transfer 4 days in advance, unless qualified professional justifies not doing so
2 of 3 non-emergency discharge summaries were observed to have provided 2 days advance notice of planned discharge. There was no documented justification for not meeting the 4 days notice requirement. |
— |
| 1 | — |
748.1433(a)(2) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one PLSP involved in child's service planning
3 of 3 discharge summaries reviewed did not contain PLSP (Treatment Director) involvement in the discharge planning. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
One child's service plan reviewed,supervision requirements addressed/ stated, at no time should the child be alone with younger children. It was founded that the child was sharing a bedroom with a younger child. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
2 of 4 youth preliminary service plans were completed past the 72 hour requirement. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly
The 2nd quarter EBI report has not been submitted to Child Care Regulation. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A child's preliminary service did not include the child's supervision requirements. |
— |
| 3 | — |
748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available
During the review of documentation, the operation did not have documentation to show that the city/county is no longer providing health inspections. |
— |
| 4 | — |
748.863(a)(4) - Pre-Service Training-Caregiver for tx svcs (not PMN) must have 16 hrs EBI training or 8 hrs if EBI prohibited, 1/2 pre-service & rest within 90 days
After a review of the staff training records, it was found that one staff caregiver did not have the required EBI training. |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk-through of the inspection, one bed did not have a mattress protector. This was corrected at inspection by a staff member adding a mattress protector to the bed. |
Yes |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
One child's medication logs documentation reviewed for the month of December of 2021 showed the child was not administered one of the required prescribed medications two times. |
— |
| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
During the inspection, it was found that the operation did not have an updated fire inspection completed. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Based on information obtained in interviews and records reviewed, it was founded that there were seven children in care at the operation, all of which were located in the t.v. room and two direct care staff present at the operation, both staff were putting away the children's medications located in the hallway of the facility. While both direct care staff were in the hallway, a fight started between two youth in the t.v. room where the children were located. Based on the layout of the facility the t.v. room can not be seen while a person is in the hallway and there is also a door located in the t.v. room. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During an inspection a wardrobe cabinet was observed to be severly damaged. Thier was blinds in one of the bedrooms that were observed to be damaged. Their were 2 holes observed in 2 different child's bedroom walls and one of the bedroom doors would not close where the hole was present. |
— |
| 3 | — |
748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826
During the review of documentation, it was found that a pet's vaccine was expired. |
— |
| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
During the walk-through of the inspection, hot dog buns were seen on the floor of the pantry. This was corrected at inspection by a staff member picking the hot dog buns off the floor of the pantry. |
Yes |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
The follow-up inspection conducted at the operation. the wardrobe in the front bedroom has been dismantled and removed from bedroom, and is located on the front porch away from the front door. One bedroom door is damaged and does not close, which does not allow for privacy. Another bedroom door is warped and separating. The two holes in the walls have been covered with plastic door protector. One set of blinds was observed to have broken slats. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
A child complained of pain and was asked to be taken to the doctor by the staff after being punched approximately 10 times in the back of head by another child during an incident at the facility. The child was not taken to the doctor. |
— |
| 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
Two employees resigned approximately one month ago and the two staff still has active background checks. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
Three of the three child files did not have the PLSP signatures on the Admission Assessment/Preliminary Service Plan. |
— |
| 3 | — |
748.721(b) - Volunteer personnel record-Include signed/dated statement that volunteer will report child abuse/neglect to Tx Abuse & Neglect hotline & administrator
Based on information gathered during an evaluation of two volunteer records, it was determined two out two volunteer records reviewed did not contain a statement signed and dated by the volunteer indicating the volunteer must immediately report any suspected incident of abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the operation?s administrator. |
— |
| 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
Based on interviews conducted and records reviewed, it was determined the unauthorized absence debriefing for the 2 youth was not conducted timely. |
— |
| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
Based on information obtained in interviews and records reviewed, there was only one staff on shift during the weekday mornings with 7 children in care, 6 of which were treatment services children. |
— |
| 3 | — |
748.603(a)(1) - Treatment director-responsible for the overall treatment program and therapeutic interventions
A review of the treatment plans of the 2 youth who ran away from the facility identified significant required information missing. One youth's service plan review was overdue and had not been completed. One youth's service plan review did not describe the trauma history or known triggers; identified the youth as a victim of or at risk of being victim of human trafficking, however, did not identify high risk behaviors or plans to address any; did not identify any progress/efforts made by the provider towards achieving the permanency goal; did not address transitioning to successful adulthood or life skills strengths/challenges; and describes that the youth receives 24/7 supervision. |
— |
| 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 2nd. Quarter EBI Report has not been submitted to Child Care Regulation. |
— |
| 2 | — |
748.1439(b)(1)(A) - Discharge Documentation-Discharge summary must include services provided to the child while in your care
3 of 3 discharge summaries evaluated were observed to be missing information as required by 748.1439(b)(1)(A-F). |
— |
| 4 | — |
748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work
Based on interviews conducted and records reviewed, it was determined a caregiver who was in ratio, was pulled away from the group of children to the hallway by the treatment director to discuss a youth, allowing 2 youth the opportunity to runaway from the operation. At the time of the unauthorized absence of the 2 youth, there were 6 children in care (5 treatment services) with 2 caregivers assigned to ratio, as well as the office manager and administrator who were both engaged in administrative duties (not counted in ratio). The youth remained gone until the following day. |
— |
| 2 | — |
748.1001(a) - Children's rights-A child's rights are cumulative of any other rights granted by law or other Licensing rules
Youth are being subjected to random drug testing conducted at the operation by the operation staff. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
A direct care staff with a hire date of 8/2/21, does not have an active background check. |
— |
| 2 | — |
748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs
A child's service plan review did not document high risk behavior history of self harm and substance abuse, nor any plans to address. The service plan review did not address treatment services for emotional disorders nor any services to address substance abuse. The review plan did not include information from the recent psychological completed, did not include trauma history and triggers, did not include therapy information, nor any progress summary. The review plan did not identify/document efforts to transition to a lesser restrictive setting (plans for discharge). |
— |
| 4 | — |
748.2203(c)(1) - Medication Error-Document the time & date of the error
One child's medication log documentation reviewed showed the child was not administered one of the required prescribed medications two times in the month of December 2021. The medication error was not documented. |
— |
| 2 | — |
748.2309(b) - Restrictions of activities-restrictions of activities imposed for more than 14 days must have prior approval
A youth's activities were restricted for 30 days. There is no documentation in the youth's record showing approval by a PLSP nor the Treatment Director. |
— |
| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
One out of the three child files reviewed showed an admission assessment that was missing information. There were a few pages that were blank with no entered information. |
— |
| 3 | — |
748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly
The 2nd quarter EBI report has not been submitted to Child Care Regulation. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During an inspection a wardrobe cabinet was observed to be severly damaged. Thier was blinds in one of the bedrooms that were observed to be damaged. Their were 2 holes observed in 2 different child's bedroom walls and one of the bedroom doors would not close where the hole was present. |
— |
| 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 2nd. Quarter EBI Report has not been submitted to Child Care Regulation. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
The follow-up inspection conducted at the operation. the wardrobe in the front bedroom has been dismantled and removed from bedroom, and is located on the front porch away from the front door. One bedroom door is damaged and does not close, which does not allow for privacy. Another bedroom door is warped and separating. The two holes in the walls have been covered with plastic door protector. One set of blinds was observed to have broken slats. |
— |
| 2 | — |
748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs
A child's service plan review did not document high risk behavior history of self harm and substance abuse, nor any plans to address. The service plan review did not address treatment services for emotional disorders nor any services to address substance abuse. The review plan did not include information from the recent psychological completed, did not include trauma history and triggers, did not include therapy information, nor any progress summary. The review plan did not identify/document efforts to transition to a lesser restrictive setting (plans for discharge). |
— |
| 3 | — |
748.3443(a)(1) - Food Preparation-Food items must be covered & stored off the floor
During the walk-through of the inspection, hot dog buns were seen on the floor of the pantry. This was corrected at inspection by a staff member picking the hot dog buns off the floor of the pantry. |
Yes |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
2 of 4 youth preliminary service plans were completed past the 72 hour requirement. |
— |
| 4 | — |
748.1005 - Child/caregiver ratio-Each group must have enough caregivers for that group who are not caring for other children or doing administrative work
Based on interviews conducted and records reviewed, it was determined a caregiver who was in ratio, was pulled away from the group of children to the hallway by the treatment director to discuss a youth, allowing 2 youth the opportunity to runaway from the operation. At the time of the unauthorized absence of the 2 youth, there were 6 children in care (5 treatment services) with 2 caregivers assigned to ratio, as well as the office manager and administrator who were both engaged in administrative duties (not counted in ratio). The youth remained gone until the following day. |
— |
| 1 | — |
748.1433(a)(2) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one PLSP involved in child's service planning
3 of 3 discharge summaries reviewed did not contain PLSP (Treatment Director) involvement in the discharge planning. |
— |
| 3 | — |
748.721(b) - Volunteer personnel record-Include signed/dated statement that volunteer will report child abuse/neglect to Tx Abuse & Neglect hotline & administrator
Based on information gathered during an evaluation of two volunteer records, it was determined two out two volunteer records reviewed did not contain a statement signed and dated by the volunteer indicating the volunteer must immediately report any suspected incident of abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the operation?s administrator. |
— |
| 2 | — |
748.2309(b) - Restrictions of activities-restrictions of activities imposed for more than 14 days must have prior approval
A youth's activities were restricted for 30 days. There is no documentation in the youth's record showing approval by a PLSP nor the Treatment Director. |
— |
| 2 | — |
748.1001(a) - Children's rights-A child's rights are cumulative of any other rights granted by law or other Licensing rules
Youth are being subjected to random drug testing conducted at the operation by the operation staff. |
— |
| 3 | — |
748.603(a)(1) - Treatment director-responsible for the overall treatment program and therapeutic interventions
A review of the treatment plans of the 2 youth who ran away from the facility identified significant required information missing. One youth's service plan review was overdue and had not been completed. One youth's service plan review did not describe the trauma history or known triggers; identified the youth as a victim of or at risk of being victim of human trafficking, however, did not identify high risk behaviors or plans to address any; did not identify any progress/efforts made by the provider towards achieving the permanency goal; did not address transitioning to successful adulthood or life skills strengths/challenges; and describes that the youth receives 24/7 supervision. |
— |
| 1 | — |
748.1433(e) - Discharge-If child receiving tx svcs, tell him of planned discharge/transfer 4 days in advance, unless qualified professional justifies not doing so
2 of 3 non-emergency discharge summaries were observed to have provided 2 days advance notice of planned discharge. There was no documented justification for not meeting the 4 days notice requirement. |
— |
| 2 | — |
748.1439(b)(1)(A) - Discharge Documentation-Discharge summary must include services provided to the child while in your care
3 of 3 discharge summaries evaluated were observed to be missing information as required by 748.1439(b)(1)(A-F). |
— |
| 3 | — |
748.3365(b)(2) - Bedding-must provide each child with a mattress cover or protector unless mattress is waterproof
During the walk-through of the inspection, one bed did not have a mattress protector. This was corrected at inspection by a staff member adding a mattress protector to the bed. |
Yes |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
A child complained of pain and was asked to be taken to the doctor by the staff after being punched approximately 10 times in the back of head by another child during an incident at the facility. The child was not taken to the doctor. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A child's preliminary service did not include the child's supervision requirements. |
— |
| 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
Based on interviews conducted and records reviewed, it was determined the unauthorized absence debriefing for the 2 youth was not conducted timely. |
— |
| 4 | — |
748.2203(c)(1) - Medication Error-Document the time & date of the error
One child's medication log documentation reviewed showed the child was not administered one of the required prescribed medications two times in the month of December 2021. The medication error was not documented. |
— |
| 4 | — |
748.863(a)(4) - Pre-Service Training-Caregiver for tx svcs (not PMN) must have 16 hrs EBI training or 8 hrs if EBI prohibited, 1/2 pre-service & rest within 90 days
After a review of the staff training records, it was found that one staff caregiver did not have the required EBI training. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Based on information obtained in interviews and records reviewed, it was founded that there were seven children in care at the operation, all of which were located in the t.v. room and two direct care staff present at the operation, both staff were putting away the children's medications located in the hallway of the facility. While both direct care staff were in the hallway, a fight started between two youth in the t.v. room where the children were located. Based on the layout of the facility the t.v. room can not be seen while a person is in the hallway and there is also a door located in the t.v. room. |
— |
| 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
Two employees resigned approximately one month ago and the two staff still has active background checks. |
— |
| 3 | — |
748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available
During the review of documentation, the operation did not have documentation to show that the city/county is no longer providing health inspections. |
— |
| 3 | — |
748.3397(a) - Bathing-Bath & shower areas must provide for individual privacy
During the walk-through of the inspection, it was noticed that there was no shower curtain in one of the bathrooms. |
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| 4 | — |
748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children
Based on information obtained in interviews and records reviewed, there was only one staff on shift during the weekday mornings with 7 children in care, 6 of which were treatment services children. |
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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
One child's medication logs documentation reviewed for the month of December of 2021 showed the child was not administered one of the required prescribed medications two times. |
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| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
Three of the three child files did not have the PLSP signatures on the Admission Assessment/Preliminary Service Plan. |
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| 3 | — |
748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826
During the review of documentation, it was found that a pet's vaccine was expired. |
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| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
A direct care staff with a hire date of 8/2/21, does not have an active background check. |
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| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
One out of the three child files reviewed showed an admission assessment that was missing information. There were a few pages that were blank with no entered information. |
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| 4 | — |
748.3101(2) - Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection
During the inspection, it was found that the operation did not have an updated fire inspection completed. |
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| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
One child's service plan reviewed,supervision requirements addressed/ stated, at no time should the child be alone with younger children. It was founded that the child was sharing a bedroom with a younger child. |
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| 3 | — |
748.3001(c)(1) - Sanitation inspection- inspection not available, you must obtain documentation stating inspection not available
During the review of documentation, the operation did not have documentation to show that the city/county is no longer providing health inspections. |
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128 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.