Texas › Alvin › Make A Way Residential Treatment Center

Make A Way Residential Treatment Center

Child care center · 6245 COUNTY ROAD 169, Alvin, TX 77511-4768 · License 1724502

0Compliance score
Poor

Capacity 16. 6-17

Violation history (128)

Severity	Date	Standard / narrative	Corrected
3	—	748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly During a review of the records I found that EBI had not been reported for the first quarter of 2022.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During the course of the investigation it was determined that kids are subjected to profanity by staff.	—
5	—	748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children. At the time of inspection, numerous walls and ceilings were observed with missing dry wall yet coved with transparent plastic pending repair. However, the closet in room 8 had exposed electrical wires, sprinkler lines, and fire alarm lines exposed and accessible to children in care.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety One staff member admitted to falling asleep while counted in ratio. A physical altercation occurred between three residents. The incident was confirmed in child interviews.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone Background check was not submitted for a caregiver at the time of hire for the corresponding operation.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Children and staff reported a child was upset when staff held a child so birthday cake could be smashed in the child?s face.	—
4	—	748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather Policies didn't include diagram designating location inside operation to shelter from threatening weather.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication At the time of inspection, prescription medication documentation for 5 children's med log were observed to have been administered but not documented and 2 child med logs did not have the pill count documented.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During an investigation children reported staff use profanity towards them. A staff member admitted to using profanity towards children when directing the children to sit down.	—
5	—	748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child During the course of the investigation it was determined kids in care were subjected to painful restraints administered by staff.	—
4	—	748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation Policies did not include directions for egress	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Child in care was restrained with arms behind the back.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the inspection, 2 of 4 children's files were missing dental records.	Yes
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back A staff voiced restraining a child with the child's arms behind his back; the child also verified that this occurred.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair At the time of inspection, a bed in bedroom 6 was observed broken and unsafe for a child to use.	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old At the time of inspection, 1 prescription medication for a child in care was administered but not documented.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back A staff voiced restraining a child with the child's arms behind his back; the child also verified that this occurred.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication At the time of inspection, prescription medication documentation for 5 children's med log were observed to have been administered but not documented and 2 child med logs did not have the pill count documented.	—
3	—	748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly During a review of the records I found that EBI had not been reported for the first quarter of 2022.	—
5	—	748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child During the course of the investigation it was determined kids in care were subjected to painful restraints administered by staff.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair At the time of inspection, a bed in bedroom 6 was observed broken and unsafe for a child to use.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During an investigation children reported staff use profanity towards them. A staff member admitted to using profanity towards children when directing the children to sit down.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the inspection, 2 of 4 children's files were missing dental records.	Yes
4	—	748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation Policies did not include directions for egress	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old At the time of inspection, 1 prescription medication for a child in care was administered but not documented.	—
5	—	748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children. At the time of inspection, numerous walls and ceilings were observed with missing dry wall yet coved with transparent plastic pending repair. However, the closet in room 8 had exposed electrical wires, sprinkler lines, and fire alarm lines exposed and accessible to children in care.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone Background check was not submitted for a caregiver at the time of hire for the corresponding operation.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety One staff member admitted to falling asleep while counted in ratio. A physical altercation occurred between three residents. The incident was confirmed in child interviews.	—
4	—	748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather Policies didn't include diagram designating location inside operation to shelter from threatening weather.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Child in care was restrained with arms behind the back.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During the course of the investigation it was determined that kids are subjected to profanity by staff.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Children and staff reported a child was upset when staff held a child so birthday cake could be smashed in the child?s face.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety One staff member admitted to falling asleep while counted in ratio. A physical altercation occurred between three residents. The incident was confirmed in child interviews.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the inspection, 2 of 4 children's files were missing dental records.	Yes
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair At the time of inspection, a bed in bedroom 6 was observed broken and unsafe for a child to use.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During the course of the investigation it was determined that kids are subjected to profanity by staff.	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old At the time of inspection, 1 prescription medication for a child in care was administered but not documented.	—
5	—	748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child During the course of the investigation it was determined kids in care were subjected to painful restraints administered by staff.	—
4	—	748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather Policies didn't include diagram designating location inside operation to shelter from threatening weather.	—
4	—	748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation Policies did not include directions for egress	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back A staff voiced restraining a child with the child's arms behind his back; the child also verified that this occurred.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During an investigation children reported staff use profanity towards them. A staff member admitted to using profanity towards children when directing the children to sit down.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication At the time of inspection, prescription medication documentation for 5 children's med log were observed to have been administered but not documented and 2 child med logs did not have the pill count documented.	—
5	—	748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children. At the time of inspection, numerous walls and ceilings were observed with missing dry wall yet coved with transparent plastic pending repair. However, the closet in room 8 had exposed electrical wires, sprinkler lines, and fire alarm lines exposed and accessible to children in care.	—
3	—	748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly During a review of the records I found that EBI had not been reported for the first quarter of 2022.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Children and staff reported a child was upset when staff held a child so birthday cake could be smashed in the child?s face.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Child in care was restrained with arms behind the back.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone Background check was not submitted for a caregiver at the time of hire for the corresponding operation.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Children and staff reported a child was upset when staff held a child so birthday cake could be smashed in the child?s face.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back A staff voiced restraining a child with the child's arms behind his back; the child also verified that this occurred.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Child in care was restrained with arms behind the back.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety One staff member admitted to falling asleep while counted in ratio. A physical altercation occurred between three residents. The incident was confirmed in child interviews.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair At the time of inspection, a bed in bedroom 6 was observed broken and unsafe for a child to use.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication At the time of inspection, prescription medication documentation for 5 children's med log were observed to have been administered but not documented and 2 child med logs did not have the pill count documented.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During the course of the investigation it was determined that kids are subjected to profanity by staff.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone Background check was not submitted for a caregiver at the time of hire for the corresponding operation.	—
4	—	748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather Policies didn't include diagram designating location inside operation to shelter from threatening weather.	—
4	—	748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation Policies did not include directions for egress	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During an investigation children reported staff use profanity towards them. A staff member admitted to using profanity towards children when directing the children to sit down.	—
5	—	748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child During the course of the investigation it was determined kids in care were subjected to painful restraints administered by staff.	—
5	—	748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children. At the time of inspection, numerous walls and ceilings were observed with missing dry wall yet coved with transparent plastic pending repair. However, the closet in room 8 had exposed electrical wires, sprinkler lines, and fire alarm lines exposed and accessible to children in care.	—
3	—	748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly During a review of the records I found that EBI had not been reported for the first quarter of 2022.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the inspection, 2 of 4 children's files were missing dental records.	Yes
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old At the time of inspection, 1 prescription medication for a child in care was administered but not documented.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During the course of the investigation it was determined that kids are subjected to profanity by staff.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the inspection, 2 of 4 children's files were missing dental records.	Yes
4	—	748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather Policies didn't include diagram designating location inside operation to shelter from threatening weather.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone Background check was not submitted for a caregiver at the time of hire for the corresponding operation.	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old At the time of inspection, 1 prescription medication for a child in care was administered but not documented.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Children and staff reported a child was upset when staff held a child so birthday cake could be smashed in the child?s face.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety One staff member admitted to falling asleep while counted in ratio. A physical altercation occurred between three residents. The incident was confirmed in child interviews.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Child in care was restrained with arms behind the back.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair At the time of inspection, a bed in bedroom 6 was observed broken and unsafe for a child to use.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication At the time of inspection, prescription medication documentation for 5 children's med log were observed to have been administered but not documented and 2 child med logs did not have the pill count documented.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back A staff voiced restraining a child with the child's arms behind his back; the child also verified that this occurred.	—
5	—	748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child During the course of the investigation it was determined kids in care were subjected to painful restraints administered by staff.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During an investigation children reported staff use profanity towards them. A staff member admitted to using profanity towards children when directing the children to sit down.	—
4	—	748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation Policies did not include directions for egress	—
3	—	748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly During a review of the records I found that EBI had not been reported for the first quarter of 2022.	—
5	—	748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children. At the time of inspection, numerous walls and ceilings were observed with missing dry wall yet coved with transparent plastic pending repair. However, the closet in room 8 had exposed electrical wires, sprinkler lines, and fire alarm lines exposed and accessible to children in care.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Children and staff reported a child was upset when staff held a child so birthday cake could be smashed in the child?s face.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication At the time of inspection, prescription medication documentation for 5 children's med log were observed to have been administered but not documented and 2 child med logs did not have the pill count documented.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During the course of the investigation it was determined that kids are subjected to profanity by staff.	—
5	—	748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child During the course of the investigation it was determined kids in care were subjected to painful restraints administered by staff.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair At the time of inspection, a bed in bedroom 6 was observed broken and unsafe for a child to use.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the inspection, 2 of 4 children's files were missing dental records.	Yes
3	—	748.2953(b) - Evaluation-Operation's quarterly data on emergency behavior interventions must be reported to Licensing quarterly During a review of the records I found that EBI had not been reported for the first quarter of 2022.	—
5	—	748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children. At the time of inspection, numerous walls and ceilings were observed with missing dry wall yet coved with transparent plastic pending repair. However, the closet in room 8 had exposed electrical wires, sprinkler lines, and fire alarm lines exposed and accessible to children in care.	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old At the time of inspection, 1 prescription medication for a child in care was administered but not documented.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety One staff member admitted to falling asleep while counted in ratio. A physical altercation occurred between three residents. The incident was confirmed in child interviews.	—
4	—	748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather Policies didn't include diagram designating location inside operation to shelter from threatening weather.	—
4	—	748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation Policies did not include directions for egress	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Child in care was restrained with arms behind the back.	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During an investigation children reported staff use profanity towards them. A staff member admitted to using profanity towards children when directing the children to sit down.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone Background check was not submitted for a caregiver at the time of hire for the corresponding operation.	—
5	—	748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back A staff voiced restraining a child with the child's arms behind his back; the child also verified that this occurred.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone Background check was not submitted for a caregiver at the time of hire for the corresponding operation.	—
4	—	748.3233(a) - Evacuation-Must have written emergency evacuation & relocation diagram specifying directions for egress on file at operation Policies did not include directions for egress	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language During the course of the investigation it was determined that kids are subjected to profanity by staff.	—
4	—	748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather Policies didn't include diagram designating location inside operation to shelter from threatening weather.	—

Severity 5 = most serious. Source: official state record.

Inspections (80)

80 inspection record(s) on file from TX-HHSC.

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