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TLW Transformation Center

Name: TLW Transformation Center
Address: TX, US

Child care center · , TX · License 1746886

0Compliance score
Poor

Capacity 88. 6-17

Violation history (500)

Severity	Date	Standard / narrative	Corrected
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Based on the preponderance of evidence in this investigation, staff used inappropriate discipline towards a child in care which results in a deficiency of 748.2307(1)	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form Four out of four employee files reviewed had Affidavit for Employment forms that were not notarized.	—
2	—	748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission One of three child files reviewed did not have a completed initial service plan.	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form Two out of three employees did not have an affidavit for employment completed in their files reviewed.	—
2	—	748.3351(3) - Interior Space-Provide 40 sq feet of indoor activity space per child, including adult residents and children of caregivers residing at the operation Three common areas are over capacity per the square footage allowed.	—
4	—	748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean Two bathrooms were observed, and one had a clogged sink and the other a broken toilet handle.	—
3	—	748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission The unauthorized absence log report did not have the age of the child, date of admission, gender of child, and the staff that was present during the unauthorized absence.	—
3	—	748.4553(2)(A) - Policies and Procedures- Employee protocols and procedures to include internal and external system addressing emergency situations Policy does not state their internal and external communication system for emergency situations.	—
4	—	748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child Staff intimidated children in care using profane language in order to increase personal space. Staff baited a child to strike them so law enforcement could be called.	—
2	—	748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children Water throughout the facility did not get hot.	—
2	—	748.119(1) - Volunteer policy - Include job descriptions and/or responsibilities for the volunteers Policy does not have the job description.	—
4	—	748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean Restrooms were observed with dirty sinks and bathtubs had a black residue in the tile grout. Trash and dirty towels were present in tub.	—
4	—	748.2755(a)(1) - Simultaneous Interventions-May use emergency medication with mechanical restraint only if allowed by operation's policies Not indicated in EBI policy	—
1	—	748.1217(b)(15) - Admission Assessment-At admission, must include child's understanding of the placement Two out of three youth files reviewed did not include the child's understanding of the placement in the admission assessment.	Yes
4	—	748.2751(a)(1) - Successive Interventions-Caregiver may successively use emergency behavior interventions on a child only if allowed by operation's policies Not indicated in EBI policy	—
2	—	748.1101(b)(6)(C) - Children's rights-to confidential care/treatment, include keep medical & operation records private. Discussing them only when it's about child's care A child's personal information was not properly secured, resulting in another child being able to read sensitive information.	—
4	—	748.3301(h) - Physical Site-The building must be free of rodents and insects During the inspection, multiple gnats were observed around the facility.	—
3	—	748.115(5) - Discipline policy - Include a statement that discipline of any type is not allowable for infants Discipline policy doesn't indicate discipline for infants or indicates how caregivers will promptly meet the needs.	—
4	—	748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container During the walkthrough of the medication room the medication cabinet was observed to be unlocked. Two children's medication boxes were observed to have Scheduled II substances in them.	Yes
5	—	748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting A youth in care obtained bruising by being pushed to the ground by a caregiver.	—
4	—	748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply Based on two incident reports, it was determined that staff used EBI to get the child to comply with getting back downstairs and to get back on task at school.	—
1	—	748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event Three out of four child files reviewed did not contain required documentation is the files within 30 days.	—
2	—	748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission During the inspection, one out of 4 children's service plans reviewed was completed past the 45-day requirement.	—
2	—	748.117 - Transitional living policy - For operations who offer a transitional living program, you must develop policies No policy	—
3	—	748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded Two incident reports indicate a restraint occurred but does not have the length of time. Two incident reports did not include the de-escalation attempts before or during the restraint. Two incident reports do not indicate that staff attempted to explain to the child what was required to be released from the hold.	—
3	—	748.111(2) - Child-care Policy - Child's right to correspond by mail, including electronic messages Policy does not state electronic mail correspondence. The policy also does not address children receiving gift or any restrictions of gifts. Also does not address if staff are able to take children for overnight visitations.	—
3	—	748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights Not in mock child file.	—
4	—	748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly. Based on interviews conducted, the operation is confirmed to bring out a cleaning cart with cleaning supplies daily into areas accessible to children in care who cannot use chemicals responsibly.	—
5	—	748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting A staff member threatened a child in care with corporal punishment.	—
2	—	748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission Not in mock child file.	—
3	—	748.3357(b)(2) - Bedroom Space-Must have at least 60 square feet of space for each occupant & no more than 4 occupants per bedroom unless certain exemptions met Seventeen bedrooms was over capacity per square footage allowed.	—
4	—	748.911(b)(3)(A) - One caregiver in ratio must have certificate of training with an expiration or renewal date in Pedi/Adult CPR if serving children 0 to 17. One out of three employee files reviewed only contained a pediatric CPR/first-aid training certificate to indicate completion of the training and not an adult training.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records Several documents reviewed were not completely filled in with dates and signatures missing.	—
2	—	748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged One out of one youth discharged file reviewed does not include contact information for the person the youth was discharged to nor did it include the child's reaction to the discharge.	—
2	—	748.4551(1) - Policies and Procedures- Policies must be written and describe the variety of activites offered to develop skills and independence Policy does not state what activities they will use for children to develop their personal identity and life skills for 14yo or older. Also does not state information about the mentor services or information about how they will prevent or discourage children from running away from the facility.	—
3	—	748.311(8) - Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions It was found, during the course of this investigation that the serious incident report did not include the medical interventions made. The child was hospitalized due to complications of a seizure.	—
2	—	748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level Not in child mock file.	—
3	—	748.123 - Vaccine preventable policy - develop and implement written policy for vaccine-preventable diseases Policy does not specify required employee vaccines or exemptions. Policy also does not state how they will verify compliance or verify exemptions. Policy also does not state a procedure to protect children for exempt employees. Policy also does not state how they will maintain records or any disciplinary actions for employees who do not comply.	—
4	—	748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint Not in mock child file.	—
4	—	748.113(3) - EBI policy - the qualifications for caregivers who assume the responsibility for EBI implementation no qualifications for caregiver in policy, no orientation for the child in the EBI policy, no EBI policy indicating informing the child and parents of EBI utilization, no training of EBI policy, no policy of not retaliating after misuse of EBI reported	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language 1 staff member and 3 children in care stated that staff have used profane language in the presence of children in care.	—
3	—	748.2205(1) - Medication label error-Report medication label errors to the pharmacist It's suggested a designee is assigned to audit all medication immediately upon receiving from the pharmacy to ensure all medication labels are correct before administering. If a medication label has an error, the pharmacy should be notified immediately to have it corrected. This will ensure the youth in care is being administered medication per a health professional's orders.	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. All bathtubs need bleach and new caulking. rm 220- hole in ceiling of bathroom rm 221- hole in ceiling of bathroom rm 222- wallpaper coming off under sink, broken tile in the shower and sink was clogged. rm 214- wallpaper in bedroom coming off rm 228- broken tiles in bathroom rm 211- wallpaper coming off in bathroom rm 210- air vent in bedroom needs screwed in	—
2	—	748.1207(a)(1) - Placement agreement-Must include authorization permitting operation to care for the child Not in mock child file.	—
2	—	748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer. Four out of four employee files reviewed did not contain documentation of reference checks and employment history checks completed.	—
4	—	748.2307(4) - Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse During an incident where a child was described as non-compliant and aggressive, staff member asked 15 yo child in care if they needed a hug.	—
3	—	748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules There was no policy regarding background check.	—
3	—	748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services Two out of three child files reviewed included a service plan that was signed by someone other than the Treatment Director or PLSP.	—
3	—	748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved The incident reports reviewed were missing the child's date of admission, the child's gender, the staff's role, the operation's phone number, the circumstances surrounding the incident, the events leading up to the incident, and the resolution of the incident.	—
3	—	748.453(a)(4) - Unauthorized Absence?Annual summary log must include name of caregiver responsible for child at time absence discovered The unauthorized absence log reviewed did not include the staff responsible for supervision at the time of the occurrence.	—
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(4) - Personnel records-Personnel records-Include current job description. Three out of three employee files reviewed did not contain a job description.	—
3	—	748.105(5) - Personnel Policies - Develop written policies on whether caregivers may take children away for day/overnight visits, ensure policy meets requirements Policy does not address if staff are able to take children for overnight visitations. Policy also does not address reporting serious incidents.	—
3	—	748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number Four out of four serious incident reports reviewed didn't include at least one of the following: information about operation and time of incident.	—
3	—	748.363(1) - Personnel records-Include date of employment 4 of 4 staff files were reviewed and all were missing most of the information needed.	—
3	—	748.311(9) - Serious Incident Documentation-Includes treating licensed health-care professional's name, findings, and treatment, if any It was found, during the course of this investigation that the serious incident report did not include the health care professionals name, the finding, or the treatment of the hospitalization.	—
3	—	748.1101(b)(2) - Children's rights-Family contacts: maintaining regular contact with parents and siblings, unless restrictions needed because of child's best interest Multiple children in care and staff stated that personal phone calls are taken as a consequence.	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication The name and signature of the person who administered the medication were missing. Photos of the missing staff signature were taken. The staff names and signatures of those who administered the medication log were updated to correct the deficiency.	Yes
4	—	748.1823(1) - Pregnant child-health-care professional must document whether any type of emergency behavior intervention is inadvisable Not indicated in policy.	—
3	—	748.363(3) - Personnel records-Include current job description Two out of three employee files reviewed did not include at least one of the following: a job description, TB skin test, drug test, affidavit for employment, nor signed acknowledgment of the operational policies and the acknowledgment of reporting abuse/neglect.	—
1	—	748.1211(a)(1) - Parent Orientation - Provide fee policies Missing from policy.	—
4	—	748.2451(a)(1) - Emergency Behavior Intervention-Use short personal restraint only If policies permit and requirements of this subchapter are met Policy did not indicate restraints will be used but mentioned staff will escort youth if need be.	—
2	—	748.119(5) - Volunteer policy - Address volunteer contact with children in care Volunteer policy doesn't indicate contact with children in care.	—
3	—	748.2151(c)(2) - Medication record - must include prescribing health-care professional's name Three out of three medication records reviewed did not include the prescribing health care physician's name.	—
3	—	748.115(5) - Discipline policy - Include a statement that discipline of any type is not allowable for infants Discipline policy doesn't indicate discipline for infants or indicates how caregivers will promptly meet the needs.	—
2	—	748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission Not in mock child file.	—
3	—	748.3357(b)(2) - Bedroom Space-Must have at least 60 square feet of space for each occupant & no more than 4 occupants per bedroom unless certain exemptions met Seventeen bedrooms was over capacity per square footage allowed.	—
3	—	748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded Two incident reports indicate a restraint occurred but does not have the length of time. Two incident reports did not include the de-escalation attempts before or during the restraint. Two incident reports do not indicate that staff attempted to explain to the child what was required to be released from the hold.	—
3	—	748.363(3) - Personnel records-Include current job description Two out of three employee files reviewed did not include at least one of the following: a job description, TB skin test, drug test, affidavit for employment, nor signed acknowledgment of the operational policies and the acknowledgment of reporting abuse/neglect.	—
3	—	748.111(2) - Child-care Policy - Child's right to correspond by mail, including electronic messages Policy does not state electronic mail correspondence. The policy also does not address children receiving gift or any restrictions of gifts. Also does not address if staff are able to take children for overnight visitations.	—
4	—	748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply Based on two incident reports, it was determined that staff used EBI to get the child to comply with getting back downstairs and to get back on task at school.	—
3	—	748.2151(c)(2) - Medication record - must include prescribing health-care professional's name Three out of three medication records reviewed did not include the prescribing health care physician's name.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records Several documents reviewed were not completely filled in with dates and signatures missing.	—
2	—	748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children Water throughout the facility did not get hot.	—
4	—	748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean Two bathrooms were observed, and one had a clogged sink and the other a broken toilet handle.	—
4	—	748.1823(1) - Pregnant child-health-care professional must document whether any type of emergency behavior intervention is inadvisable Not indicated in policy.	—
4	—	748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container During the walkthrough of the medication room the medication cabinet was observed to be unlocked. Two children's medication boxes were observed to have Scheduled II substances in them.	Yes
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form Two out of three employees did not have an affidavit for employment completed in their files reviewed.	—
3	—	748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number Four out of four serious incident reports reviewed didn't include at least one of the following: information about operation and time of incident.	—
3	—	748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules There was no policy regarding background check.	—
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	—	748.113(3) - EBI policy - the qualifications for caregivers who assume the responsibility for EBI implementation no qualifications for caregiver in policy, no orientation for the child in the EBI policy, no EBI policy indicating informing the child and parents of EBI utilization, no training of EBI policy, no policy of not retaliating after misuse of EBI reported	—
3	—	748.311(9) - Serious Incident Documentation-Includes treating licensed health-care professional's name, findings, and treatment, if any It was found, during the course of this investigation that the serious incident report did not include the health care professionals name, the finding, or the treatment of the hospitalization.	—
4	—	748.1205(a)(10) - Admission Documentation-Includes known contraindications to the use of restraint Not in mock child file.	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. All bathtubs need bleach and new caulking. rm 220- hole in ceiling of bathroom rm 221- hole in ceiling of bathroom rm 222- wallpaper coming off under sink, broken tile in the shower and sink was clogged. rm 214- wallpaper in bedroom coming off rm 228- broken tiles in bathroom rm 211- wallpaper coming off in bathroom rm 210- air vent in bedroom needs screwed in	—
3	—	748.105(5) - Personnel Policies - Develop written policies on whether caregivers may take children away for day/overnight visits, ensure policy meets requirements Policy does not address if staff are able to take children for overnight visitations. Policy also does not address reporting serious incidents.	—
3	—	748.2205(1) - Medication label error-Report medication label errors to the pharmacist It's suggested a designee is assigned to audit all medication immediately upon receiving from the pharmacy to ensure all medication labels are correct before administering. If a medication label has an error, the pharmacy should be notified immediately to have it corrected. This will ensure the youth in care is being administered medication per a health professional's orders.	—
1	—	748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event Three out of four child files reviewed did not contain required documentation is the files within 30 days.	—
2	—	748.1207(a)(1) - Placement agreement-Must include authorization permitting operation to care for the child Not in mock child file.	—
2	—	748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level Not in child mock file.	—
2	—	748.119(5) - Volunteer policy - Address volunteer contact with children in care Volunteer policy doesn't indicate contact with children in care.	—
2	—	748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission One of three child files reviewed did not have a completed initial service plan.	—
3	—	748.363(4) - Personnel records-Personnel records-Include current job description. Three out of three employee files reviewed did not contain a job description.	—
3	—	748.363(1) - Personnel records-Include date of employment 4 of 4 staff files were reviewed and all were missing most of the information needed.	—
4	—	748.2451(a)(1) - Emergency Behavior Intervention-Use short personal restraint only If policies permit and requirements of this subchapter are met Policy did not indicate restraints will be used but mentioned staff will escort youth if need be.	—
2	—	748.753(d)(1) - Pre-Employment-You must document in the employee record each references name, relation, date completed, info obtained and name of interviewer. Four out of four employee files reviewed did not contain documentation of reference checks and employment history checks completed.	—
2	—	748.119(1) - Volunteer policy - Include job descriptions and/or responsibilities for the volunteers Policy does not have the job description.	—
1	—	748.1217(b)(15) - Admission Assessment-At admission, must include child's understanding of the placement Two out of three youth files reviewed did not include the child's understanding of the placement in the admission assessment.	Yes
2	—	748.1101(b)(6)(C) - Children's rights-to confidential care/treatment, include keep medical & operation records private. Discussing them only when it's about child's care A child's personal information was not properly secured, resulting in another child being able to read sensitive information.	—
3	—	748.4553(2)(A) - Policies and Procedures- Employee protocols and procedures to include internal and external system addressing emergency situations Policy does not state their internal and external communication system for emergency situations.	—

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

Inspections (176)

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

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