Capacity 12. 5-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child in care with sex trafficking history was allowed outside without supervision. The service plan specifically documents the child requires "visual and auditory" supervision while at the operation. Additionally, it documents the child has a "history as a victim of sex trafficking", which "makes her more susceptible to elopement and unsafe sexual activities." |
— |
| 4 | — |
748.941(c)(3)(A) - Training Criteria- Training must require each participant to demonstrate knowledge and competency of the EBI training material in writing.
The operation's administrator stated the records for EBI written test gets shredded and that the operation does not keep record of them, therefore, there is no record showing the staff member took a written test. |
— |
| 4 | — |
748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint
Two out Three childrens records reviewed were missing several policy components to include the emergency behavior interventions. |
— |
| 5 | — |
745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
A staff member of the operation did not have a pre-employment drug screening. |
— |
| 5 | — |
748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment
Five children interviewed stated that a caregiver threatened that a child/children could not eat dinner unless the child/children took a shower. |
— |
| 1 | — |
748.1433(a)(1) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one of the child's current caregivers
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 4 | — |
748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child
Three children's records did not have a parent orientation. |
— |
| 4 | — |
748.2151(c)(4) - Medication record - must include medication name, strength and dosage
The medication log for a child is missing the medication dosage and time administered. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
All four incident Reports reviewed did not include the telephone number of the operation. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care who had recently been discharged from an inpatient mental institution due to self-harming behaviors was permitted access to a bedroom with a known safety hazard. The bedroom door had a broken doorknob that locked when closed, preventing staff from gaining immediate access to the room. While staff were locked out and unable to supervise or intervene, the child self-harmed. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
It took the operation eight days to provide requested documentation. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
Insulin was found unsecured in the refridgerator. |
Yes |
| 4 | — |
748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Records/Documentation was requested 2 times by an investigator and 1 time by a licensing supervisor. It was initially requested on the October 27th, and it was not sent until November 14th at approximately 10:51 PM. |
— |
| 3 | — |
748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation
A child in care who was admitted to the operation despite being outside of the licensed age range. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Records were requested on 7/3, 8/2, 8/3, and 8/4. Partial records were received on 8/3. An inspection to the operation was conducted on 8/18 where 4 service plans were obtained; however incident reports being requested were not in the child's files. Licensing was informed that incident reports may have been scanned into the operation's electronic system. Those incident reports were requested to be sent to Licensing by end of the day on 8/18. The incident reports were never received. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 3 | — |
748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.
During a records review two staff records did not have a copy of a TB test on file. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
A Direct Care Staff is currently working at the operation without an approved background check. The staff's background check was ran on 7.26.24. The staff was present during an incident on 7.27.24. The background check has not been completed as of 8.15.24. Additionally, it was found the staff worked 8.11.24 and is scheduled for 8.16.24. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation was not able to provide the emergency drill records during the inspection. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The information documented in the serious incident report did not align with the information gathered from interviews with children and staff. |
— |
| 4 | — |
748.1661(c) - Tobacco Products-Adult may only smoke tobacco products, e-cigarettes, or vaporizers on premises at a safe distance from child living area
A nighttime direct care staff member admitted stepping outside the front door of the children's living area to use a vaporizer while the children are asleep. |
— |
| 3 | — |
748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return
The documentation did not include the time and date when the children's parents and the relevant law enforcement agency were notified. Furthermore, there was no record of the names of the individuals contacted. |
— |
| 4 | — |
748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 3 | — |
748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment
Multiple children in care reported staff threatening to send children to a "mental hospital" even when there were times where a child's behaviors did not warrant such hospitalization. |
— |
| 5 | — |
745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone
Background checks for two employees were not conducted by the operation. |
— |
| 1 | — |
748.1433(a)(1) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one of the child's current caregivers
The discharge summary record for a child was not filled out. It was also missing singnatures for all parties that should of been involved. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A direct care staff was found asleep and admitted to being asleep at night with the home unlocked. |
— |
| 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.
This operation did not report the 1st Quarter (January-March) EBI numbers as required despite several reminders by the RCCR Inspector via email to the operation on 4/18/23, 5/1/23 and 5/2/23. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
The follow up was not provided by the original compliance date of 7/12/2024. |
— |
| 3 | — |
748.303(a)(10)(B) - Serious Incident-Report to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older.
The parent of a child with sex trafficking history was not made aware immediately of the child's unauthorized absence. The child eloped at 6:19PM and the parent was not notified until 7:31PM. |
— |
| 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
During the inspection three serious incident reports were found not to have been reported to licensing. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the review of records 2 staff records did not have the pre-employment affidavit and the pre-employment screening assessment was not filled out. |
— |
| 2 | — |
748.1117 - Documentation of searches-Caregiver documents searches in the child's record
A child's room was searched, however, there was no documentation completed. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
On 11/03/2023, during the in-person investigation records were requested but told that they would be provided via email and sent to the RCCL Inspector. On 11/15/2023, an email was sent to the operation requesting records and that they needed by the end of the day on 11/17/2023. On 11/16/2023, due to not receiving a reply from my previous document request a reminder email was sent requesting that the document be provided by the end of the day on 11/17/2023. On 11/17/2023, another email was sent to the operation stating that documents had not yet been received and for them to be provided. On 11/20/2023, documents were provided by the operation. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation failed to submit a corrective action plan addressing compliance for not submitting records to RCCR until five days after the original request date, despite RCCR sending multiple reminders. |
— |
| 3 | — |
748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
It is found after the review of the incident report that the incident occurred on 08/08/23 and the child in care left the operation at 7:27pm. It was reported to licensing on 8/09/23 at 12:01pm. This reporting to licensing is not in the required time frame. |
— |
| 3 | — |
748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.
An incident involving a child being arrested was not reported to licensing. |
Yes |
| 3 | — |
748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any
No witness children were noted in the incident report. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
This standard was found deficient as part of a DFPS Investigation. |
— |
| 3 | — |
748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
During a records review, two staff files reviewed did not have the notarized Licensing Affidavit for Applicants for Employment form. |
— |
| 3 | — |
748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation
At the time the case was called in, the operation had 5 girls in placement and was only licensed to take boys. The operation now has a new permit allowing placement of both boys and girls. |
Yes |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
RCI had to request documents multiple times within a three-week period before receiving documents. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The incident report was not consistent with the interviews of staff regarding the incident that occurred. |
— |
| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
Caregiver responsibilities were not met when the operation was unaware they left a child?s only inhaler at the school for an unknown amount of time. The child is diagnosed with asthma and this specific need must always be readily available to the child in case of an emergency. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Documentation was requested 3 times within a 3-week period from the operation. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation was given a deadline for sending records by 12/20/2024 at 5PM. Records were not sent and received until 12/23/2024. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The information documented in the serious incident report did not align with the information gathered from interviews with children and staff. |
— |
| 4 | — |
748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Records/Documentation was requested 2 times by an investigator and 1 time by a licensing supervisor. It was initially requested on the October 27th, and it was not sent until November 14th at approximately 10:51 PM. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation was given a deadline for sending records by 12/20/2024 at 5PM. Records were not sent and received until 12/23/2024. |
— |
| 3 | — |
748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any
No witness children were noted in the incident report. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child in care with sex trafficking history was allowed outside without supervision. The service plan specifically documents the child requires "visual and auditory" supervision while at the operation. Additionally, it documents the child has a "history as a victim of sex trafficking", which "makes her more susceptible to elopement and unsafe sexual activities." |
— |
| 3 | — |
748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.
During a records review two staff records did not have a copy of a TB test on file. |
— |
| 2 | — |
748.1117 - Documentation of searches-Caregiver documents searches in the child's record
A child's room was searched, however, there was no documentation completed. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care who had recently been discharged from an inpatient mental institution due to self-harming behaviors was permitted access to a bedroom with a known safety hazard. The bedroom door had a broken doorknob that locked when closed, preventing staff from gaining immediate access to the room. While staff were locked out and unable to supervise or intervene, the child self-harmed. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
Insulin was found unsecured in the refridgerator. |
Yes |
| 3 | — |
748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation
At the time the case was called in, the operation had 5 girls in placement and was only licensed to take boys. The operation now has a new permit allowing placement of both boys and girls. |
Yes |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
A Direct Care Staff is currently working at the operation without an approved background check. The staff's background check was ran on 7.26.24. The staff was present during an incident on 7.27.24. The background check has not been completed as of 8.15.24. Additionally, it was found the staff worked 8.11.24 and is scheduled for 8.16.24. |
— |
| 3 | — |
748.1101(b)(4)(A)(vi) - Children's rights- To be free from being threatened with the loss of placement or shelter as punishment
Multiple children in care reported staff threatening to send children to a "mental hospital" even when there were times where a child's behaviors did not warrant such hospitalization. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
It took the operation eight days to provide requested documentation. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The incident report was not consistent with the interviews of staff regarding the incident that occurred. |
— |
| 4 | — |
748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision
Caregiver responsibilities were not met when the operation was unaware they left a child?s only inhaler at the school for an unknown amount of time. The child is diagnosed with asthma and this specific need must always be readily available to the child in case of an emergency. |
— |
| 3 | — |
748.303(a)(10)(B) - Serious Incident-Report to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older.
The parent of a child with sex trafficking history was not made aware immediately of the child's unauthorized absence. The child eloped at 6:19PM and the parent was not notified until 7:31PM. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation failed to submit a corrective action plan addressing compliance for not submitting records to RCCR until five days after the original request date, despite RCCR sending multiple reminders. |
— |
| 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
During the inspection three serious incident reports were found not to have been reported to licensing. |
— |
| 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.
This operation did not report the 1st Quarter (January-March) EBI numbers as required despite several reminders by the RCCR Inspector via email to the operation on 4/18/23, 5/1/23 and 5/2/23. |
— |
| 3 | — |
748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return
The documentation did not include the time and date when the children's parents and the relevant law enforcement agency were notified. Furthermore, there was no record of the names of the individuals contacted. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Documentation was requested 3 times within a 3-week period from the operation. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
RCI had to request documents multiple times within a three-week period before receiving documents. |
— |
| 3 | — |
748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation
A child in care who was admitted to the operation despite being outside of the licensed age range. |
— |
| 1 | — |
748.1433(a)(1) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one of the child's current caregivers
The discharge summary record for a child was not filled out. It was also missing singnatures for all parties that should of been involved. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the review of records 2 staff records did not have the pre-employment affidavit and the pre-employment screening assessment was not filled out. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
The operation was not able to provide the emergency drill records during the inspection. |
— |
| 5 | — |
748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment
Five children interviewed stated that a caregiver threatened that a child/children could not eat dinner unless the child/children took a shower. |
— |
| 4 | — |
748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 3 | — |
748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond.
An incident involving a child being arrested was not reported to licensing. |
Yes |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Records were requested on 7/3, 8/2, 8/3, and 8/4. Partial records were received on 8/3. An inspection to the operation was conducted on 8/18 where 4 service plans were obtained; however incident reports being requested were not in the child's files. Licensing was informed that incident reports may have been scanned into the operation's electronic system. Those incident reports were requested to be sent to Licensing by end of the day on 8/18. The incident reports were never received. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
On 11/03/2023, during the in-person investigation records were requested but told that they would be provided via email and sent to the RCCL Inspector. On 11/15/2023, an email was sent to the operation requesting records and that they needed by the end of the day on 11/17/2023. On 11/16/2023, due to not receiving a reply from my previous document request a reminder email was sent requesting that the document be provided by the end of the day on 11/17/2023. On 11/17/2023, another email was sent to the operation stating that documents had not yet been received and for them to be provided. On 11/20/2023, documents were provided by the operation. |
— |
| 5 | — |
745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone
Background checks for two employees were not conducted by the operation. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
All four incident Reports reviewed did not include the telephone number of the operation. |
— |
| 4 | — |
748.2151(c)(4) - Medication record - must include medication name, strength and dosage
The medication log for a child is missing the medication dosage and time administered. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
This standard was found deficient as part of a DFPS Investigation. |
— |
| 4 | — |
748.1211(a) - Parent Orientation - At admission you must provide certain policies to the parent placing the child
Three children's records did not have a parent orientation. |
— |
| 1 | — |
748.1433(a)(1) - Discharge-Involve in planning child's non-emergency discharge or transfer at least one of the child's current caregivers
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 4 | — |
748.941(c)(3)(A) - Training Criteria- Training must require each participant to demonstrate knowledge and competency of the EBI training material in writing.
The operation's administrator stated the records for EBI written test gets shredded and that the operation does not keep record of them, therefore, there is no record showing the staff member took a written test. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A direct care staff was found asleep and admitted to being asleep at night with the home unlocked. |
— |
| 5 | — |
745.4151(c)(4)(A) - Mandatory drug testing-all applicants intended to be hired are subject to pre-employment testing, must have results prior to child access
A staff member of the operation did not have a pre-employment drug screening. |
— |
| 3 | — |
748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older.
It is found after the review of the incident report that the incident occurred on 08/08/23 and the child in care left the operation at 7:27pm. It was reported to licensing on 8/09/23 at 12:01pm. This reporting to licensing is not in the required time frame. |
— |
| 4 | — |
748.1661(c) - Tobacco Products-Adult may only smoke tobacco products, e-cigarettes, or vaporizers on premises at a safe distance from child living area
A nighttime direct care staff member admitted stepping outside the front door of the children's living area to use a vaporizer while the children are asleep. |
— |
| 3 | — |
748.363(7) - Personnel records- Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
During a records review, two staff files reviewed did not have the notarized Licensing Affidavit for Applicants for Employment form. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
The follow up was not provided by the original compliance date of 7/12/2024. |
— |
| 4 | — |
748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint
Two out Three childrens records reviewed were missing several policy components to include the emergency behavior interventions. |
— |
| 5 | — |
748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment
Five children interviewed stated that a caregiver threatened that a child/children could not eat dinner unless the child/children took a shower. |
— |
| 3 | — |
748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return
The documentation did not include the time and date when the children's parents and the relevant law enforcement agency were notified. Furthermore, there was no record of the names of the individuals contacted. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The incident report was not consistent with the interviews of staff regarding the incident that occurred. |
— |
| 3 | — |
748.303(a)(10)(B) - Serious Incident-Report to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older.
The parent of a child with sex trafficking history was not made aware immediately of the child's unauthorized absence. The child eloped at 6:19PM and the parent was not notified until 7:31PM. |
— |
| 4 | — |
748.1209(b)(6) - Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint
Follow up was not provided by the original compliance of 7/12/2024. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care who had recently been discharged from an inpatient mental institution due to self-harming behaviors was permitted access to a bedroom with a known safety hazard. The bedroom door had a broken doorknob that locked when closed, preventing staff from gaining immediate access to the room. While staff were locked out and unable to supervise or intervene, the child self-harmed. |
— |
192 inspection record(s) on file from TX-HHSC.