Capacity 21. 5-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 5 | — |
748.2003(a) - Administration of prescription medication-inform medical consenter of benefits/risks/side effects/treatment/consequences of refusing them
The operation's medication administration policy does not fully address the requirements in informing the person legally authorized to give medical consent. |
— |
| 3 | — |
748.2103(b) - Medication Destruction-Discontinued or expired meds & meds left at facility destroyed by health-care professional/pharmacist or LCCA & adult witness
The operation's medication policy does not address how discontinued or expired medications are to be destroyed. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During an incident between a staff member and a resident, another staff member was present but did not intervene and assist the staff member. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
A caregiver pulled on a child's hair multiple times as a means to get the child under control. |
— |
| 3 | — |
748.3231(b)(2) - Evacuation-Plan requires person in charge during emergency to make an employee responsible for securing medical consents & medications
The operation's disaster and emergency plan does not designate an employee responsible for securing children?s emergency numbers, emergency medical authorizations, and medications during the emergency. |
— |
| 3 | — |
745.651(2)(A) - Background Check Validation ? Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list
The requirement of validating the people list hasn't been met. |
Yes |
| 3 | — |
748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position
-Employee job descriptions are not consistent with 748.505 minimum qualification requirements and 748.507 general responsibilities requirements. -There is not a job description for the required position of a Professional Level Service Provider. -The administrator's job description is not consistent with 748.535-responsibilities of administrator. Chapter 748 SC E-Child Care Administrator responsibilities have been updated as of April 2022. |
— |
| 5 | — |
748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements
The operation's background check policy is not consistent with TAC Chapter 745, to include, but not limited to: -requirements for when to submit for an initial background check that is consistent with 745.621 -determinations regarding background checks consistent with 745.641 and 745.651 -745.673 pertaining to subject of BGC at operation is under investigation for child abuse or neglect -745.681 pertaining to risk evaluations |
— |
| 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
An employee no longer associated with the operation background check hasn't been inactivated after the seven day requirement. |
Yes |
| 4 | — |
748.3369(d) - Bedding-A bunk bed must be equipped with a securely attached ladder capable of supporting the child using the bed and an employee
The bunk beds for children do not include securely attached ladders as required. |
— |
| 3 | — |
748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded
The EBI incident form does not include requirement for staff to document the length of time a child was restrained. The EBI incident form does not include requirement for staff to document a child's condition following the release from an EBI as required under 748.2855(a)(11). |
— |
| 1 | — |
748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days
Five children receiving emergency care services have been in care longer than the maximum 15 days allowed. The operation has not submitted placement extensions. |
— |
| 4 | — |
748.4009(a) - General requirements-Driver & caregivers must have clear instructions in handling transportation emergencies
The operation's policy and procedures does not include plans for handling transportation emergencies that is consistent with 748.4009 (a) thru (c). |
— |
| 5 | — |
748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child
In a review of the investigation, it was found that a caregiver pushed down on a child's face. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
The medication administration and documentation policy does not provide clear instructions to staff regarding the required timeframe for recording medication administration. |
— |
| 2 | — |
748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children
During the inspection of bathrooms and kitchen, it was observed that none of the hot water faucets produced sufficient hot water. After a further inspection of the hot water heater, it was determined that the pilot light was out and cannot be readily reset. |
— |
| 3 | — |
748.103(b)(5) - Policies and procedures to submit - Child-care
The operation's child care policies do not address a child?s right to correspond by phone and mail with family members and friends, how a child obtains clothing, does not address how teenagers are provided reasonable opportunities to select clothing, nor policies regarding mail restrictions and receipt of electronic messages and mail. The operation's child care policies do not address care for pregnant teens that is consistent with 748.111(15). **The operation's admission policy does not indicate that this population of youth are accepted or excluded from admission. The child care policies do not address nutrition and hydration for children in care that is consistent with 748.1691, 748.1693, 748.1697, 748.1699, 748.1701, and 748.1703. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
The serious incident form does not include requirements for documentation that is consistent with 748.313(3)(B thru E) and 748.313(4). |
— |
| 4 | — |
748.103(b)(10) - Policies and procedures to submit - Abuse and neglect
The operation's abuse and neglect policy reviewed is not consistent with 748.121. The policy does not address the following: -Methods for increasing employee awareness of issues regarding child abuse and neglect -Strategies for coordination between the operation and appropriate community organizations -Methods for increasing employee awareness of prevention techniques for child abuse and neglect -Actions that the parent of a child who is a victim of abuse or neglect should take to obtain assistance and intervention. |
— |
| 4 | — |
748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention
The operation's EBI policy contained on pages 85-92 were reviewed. The EBI policy: -does not provide a complete description of the EBI caregivers may use, only names the curriculum. -does not identify the specific techniques the caregivers can use, only names the two types of EBI allowed to use. -does not include the determination of the basis for the EBI; does not address instructions for caregivers on attempting less restrictive behavior interventions that prove to be ineffective at defusing the situation; does not address requirements under 748.2551; does not address requirements under 748.2553(2), 748.2601, 748.2603, 748.2801(2), and 748.2805(2). -does not address the caregiver's responsibility for documentation following use of EBI as required by 748.2853 and 748.2855(a). -does not address notifications to the managing conservator when EBI is used with a child. -does not address triggered review requirements of EBI for a specific child 748.2901 (Personal Restraints), 748.2903, 748.2905, 748.2907, and 748.2909. -does not include the operation's requirement to conduct quarterly EBI data collection. -does not include the operation's requirement to conduct an annual operation evaluation of EBI. |
— |
| 5 | — |
748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard
Children's bunk beds are not equipped with required bedrails. |
Yes |
| 4 | — |
748.3709(1) - Higher Risk Activity-There must be a person that is responsible for and supervises a higher risk recreational activity
The operation's recreation policy describes camping, hiking, fishing, and building construction as recreation activity opportunities offered and planned. However, the recreation policy does not address requirements for when children participate in higher risk recreational activity. The operation's recreation policy must meet or exceed 748.3709 thru 748.3713 and 748.3841 thru 748.3861, as applicable. |
— |
| 2 | — |
748.111(9) - Child-care policy - Plans for meeting educational needs of each child
The operation's education policy does not address requirements in 748.1303. |
— |
| 3 | — |
748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees
The operation's staff training policy was reviewed. The policy does not include the following for general pre-service training: -location and use of fire extinguishers and first aid equipment -curriculum components for pre-service training in normalcy -curriculum components for pre-service training in administering psychotropic medication -requirement that training on administering psychotropic medication must be instructor led training and the instructor must be a health care professional or a pharmacist The policy does not include the following for annual training: -curriculum components for normalcy -curriculum components for administering psychotropic medication -psychotropic medication instructor led training requirement |
— |
| 3 | — |
748.103(b)(7) - Policies and procedures to submit - discipline
The operation's discipline policy does not address: -who may discipline a child -explanation to staff what is considered "unproductive work" -restriction of child's activities as a behavior management tool consistent with 748.2309 |
— |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
There were multiple children present during the inappropriate restraint. There were two staff members present during the altercation, and one staff member did not remove the other children present. |
— |
| 3 | — |
748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.
The operation's policy on reporting serious incidents is missing significant policies and procedures for reporting serious incidents and other occurrences. The policy is missing notification requirements as applicable in 748.317 and 748.319. The operation must use form 7266 "Notification of Abuse/Neglect/Exploitation Deficiency" to notify parents of the deficiency. These changes to the minimum standards were in effect April 2021. The policies must be consistent with Subchapter D, Div 1- Reporting Serious Incidents and Other Occurrences. Serious incident reporting requirements were updated in minimum standards effective April 2022. |
— |
| 4 | — |
748.537(a) - On Call Staff-A person designated to handle emergencies must be on call and accessible to caregivers
The operation's professional staffing plan does address plans for handling emergencies. The professional staffing does not address a designated person must be on call and accessible to caregivers and that all caregivers (and CCR) are informed of emergency system and how to contact the person on call. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
During inspection of the children's bedrooms, the beds were observed to have splinters and exposed pieces of wood (newly built beds and ladders) that could cause injuries. Slats of some of the beds were found to not have been properly secured to the bed frame. One slat was observed on the floor under the bed. |
— |
| 3 | — |
748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded
The EBI incident form does not include requirement for staff to document the length of time a child was restrained. The EBI incident form does not include requirement for staff to document a child's condition following the release from an EBI as required under 748.2855(a)(11). |
— |
| 2 | — |
748.111(9) - Child-care policy - Plans for meeting educational needs of each child
The operation's education policy does not address requirements in 748.1303. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During an incident between a staff member and a resident, another staff member was present but did not intervene and assist the staff member. |
— |
| 3 | — |
748.3231(b)(2) - Evacuation-Plan requires person in charge during emergency to make an employee responsible for securing medical consents & medications
The operation's disaster and emergency plan does not designate an employee responsible for securing children?s emergency numbers, emergency medical authorizations, and medications during the emergency. |
— |
| 3 | — |
745.651(2)(A) - Background Check Validation ? Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list
The requirement of validating the people list hasn't been met. |
Yes |
| 4 | — |
748.3709(1) - Higher Risk Activity-There must be a person that is responsible for and supervises a higher risk recreational activity
The operation's recreation policy describes camping, hiking, fishing, and building construction as recreation activity opportunities offered and planned. However, the recreation policy does not address requirements for when children participate in higher risk recreational activity. The operation's recreation policy must meet or exceed 748.3709 thru 748.3713 and 748.3841 thru 748.3861, as applicable. |
— |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
There were multiple children present during the inappropriate restraint. There were two staff members present during the altercation, and one staff member did not remove the other children present. |
— |
| 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
An employee no longer associated with the operation background check hasn't been inactivated after the seven day requirement. |
Yes |
| 3 | — |
748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.
The operation's policy on reporting serious incidents is missing significant policies and procedures for reporting serious incidents and other occurrences. The policy is missing notification requirements as applicable in 748.317 and 748.319. The operation must use form 7266 "Notification of Abuse/Neglect/Exploitation Deficiency" to notify parents of the deficiency. These changes to the minimum standards were in effect April 2021. The policies must be consistent with Subchapter D, Div 1- Reporting Serious Incidents and Other Occurrences. Serious incident reporting requirements were updated in minimum standards effective April 2022. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the walkthrough of the inspection, it was noticed that the back refrigerator and freezer were missing a thermometer. |
— |
| 4 | — |
748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention
The operation's EBI policy contained on pages 85-92 were reviewed. The EBI policy: -does not provide a complete description of the EBI caregivers may use, only names the curriculum. -does not identify the specific techniques the caregivers can use, only names the two types of EBI allowed to use. -does not include the determination of the basis for the EBI; does not address instructions for caregivers on attempting less restrictive behavior interventions that prove to be ineffective at defusing the situation; does not address requirements under 748.2551; does not address requirements under 748.2553(2), 748.2601, 748.2603, 748.2801(2), and 748.2805(2). -does not address the caregiver's responsibility for documentation following use of EBI as required by 748.2853 and 748.2855(a). -does not address notifications to the managing conservator when EBI is used with a child. -does not address triggered review requirements of EBI for a specific child 748.2901 (Personal Restraints), 748.2903, 748.2905, 748.2907, and 748.2909. -does not include the operation's requirement to conduct quarterly EBI data collection. -does not include the operation's requirement to conduct an annual operation evaluation of EBI. |
— |
| 4 | — |
748.537(a) - On Call Staff-A person designated to handle emergencies must be on call and accessible to caregivers
The operation's professional staffing plan does address plans for handling emergencies. The professional staffing does not address a designated person must be on call and accessible to caregivers and that all caregivers (and CCR) are informed of emergency system and how to contact the person on call. |
— |
| 3 | — |
748.103(b)(7) - Policies and procedures to submit - discipline
The operation's discipline policy does not address: -who may discipline a child -explanation to staff what is considered "unproductive work" -restriction of child's activities as a behavior management tool consistent with 748.2309 |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
A caregiver pulled on a child's hair multiple times as a means to get the child under control. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
The serious incident form does not include requirements for documentation that is consistent with 748.313(3)(B thru E) and 748.313(4). |
— |
| 3 | — |
748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees
The operation's staff training policy was reviewed. The policy does not include the following for general pre-service training: -location and use of fire extinguishers and first aid equipment -curriculum components for pre-service training in normalcy -curriculum components for pre-service training in administering psychotropic medication -requirement that training on administering psychotropic medication must be instructor led training and the instructor must be a health care professional or a pharmacist The policy does not include the following for annual training: -curriculum components for normalcy -curriculum components for administering psychotropic medication -psychotropic medication instructor led training requirement |
— |
| 5 | — |
748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard
Children's bunk beds are not equipped with required bedrails. |
Yes |
| 5 | — |
748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child
In a review of the investigation, it was found that a caregiver pushed down on a child's face. |
— |
| 4 | — |
748.3369(d) - Bedding-A bunk bed must be equipped with a securely attached ladder capable of supporting the child using the bed and an employee
The bunk beds for children do not include securely attached ladders as required. |
— |
| 5 | — |
748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements
The operation's background check policy is not consistent with TAC Chapter 745, to include, but not limited to: -requirements for when to submit for an initial background check that is consistent with 745.621 -determinations regarding background checks consistent with 745.641 and 745.651 -745.673 pertaining to subject of BGC at operation is under investigation for child abuse or neglect -745.681 pertaining to risk evaluations |
— |
| 2 | — |
748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children
During the inspection of bathrooms and kitchen, it was observed that none of the hot water faucets produced sufficient hot water. After a further inspection of the hot water heater, it was determined that the pilot light was out and cannot be readily reset. |
— |
| 3 | — |
748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position
-Employee job descriptions are not consistent with 748.505 minimum qualification requirements and 748.507 general responsibilities requirements. -There is not a job description for the required position of a Professional Level Service Provider. -The administrator's job description is not consistent with 748.535-responsibilities of administrator. Chapter 748 SC E-Child Care Administrator responsibilities have been updated as of April 2022. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
The medication administration and documentation policy does not provide clear instructions to staff regarding the required timeframe for recording medication administration. |
— |
| 4 | — |
748.103(b)(10) - Policies and procedures to submit - Abuse and neglect
The operation's abuse and neglect policy reviewed is not consistent with 748.121. The policy does not address the following: -Methods for increasing employee awareness of issues regarding child abuse and neglect -Strategies for coordination between the operation and appropriate community organizations -Methods for increasing employee awareness of prevention techniques for child abuse and neglect -Actions that the parent of a child who is a victim of abuse or neglect should take to obtain assistance and intervention. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
During inspection of the children's bedrooms, the beds were observed to have splinters and exposed pieces of wood (newly built beds and ladders) that could cause injuries. Slats of some of the beds were found to not have been properly secured to the bed frame. One slat was observed on the floor under the bed. |
— |
| 3 | — |
748.103(b)(5) - Policies and procedures to submit - Child-care
The operation's child care policies do not address a child?s right to correspond by phone and mail with family members and friends, how a child obtains clothing, does not address how teenagers are provided reasonable opportunities to select clothing, nor policies regarding mail restrictions and receipt of electronic messages and mail. The operation's child care policies do not address care for pregnant teens that is consistent with 748.111(15). **The operation's admission policy does not indicate that this population of youth are accepted or excluded from admission. The child care policies do not address nutrition and hydration for children in care that is consistent with 748.1691, 748.1693, 748.1697, 748.1699, 748.1701, and 748.1703. |
— |
| 1 | — |
748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days
Five children receiving emergency care services have been in care longer than the maximum 15 days allowed. The operation has not submitted placement extensions. |
— |
| 4 | — |
748.4009(a) - General requirements-Driver & caregivers must have clear instructions in handling transportation emergencies
The operation's policy and procedures does not include plans for handling transportation emergencies that is consistent with 748.4009 (a) thru (c). |
— |
| 3 | — |
748.2103(b) - Medication Destruction-Discontinued or expired meds & meds left at facility destroyed by health-care professional/pharmacist or LCCA & adult witness
The operation's medication policy does not address how discontinued or expired medications are to be destroyed. |
— |
| 5 | — |
748.2003(a) - Administration of prescription medication-inform medical consenter of benefits/risks/side effects/treatment/consequences of refusing them
The operation's medication administration policy does not fully address the requirements in informing the person legally authorized to give medical consent. |
— |
| 3 | — |
748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing
During the walkthrough, it was noticed that all fire extinguishers were out of date. |
— |
| 5 | — |
748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard
Children's bunk beds are not equipped with required bedrails. |
Yes |
| 3 | — |
748.103(b)(5) - Policies and procedures to submit - Child-care
The operation's child care policies do not address a child?s right to correspond by phone and mail with family members and friends, how a child obtains clothing, does not address how teenagers are provided reasonable opportunities to select clothing, nor policies regarding mail restrictions and receipt of electronic messages and mail. The operation's child care policies do not address care for pregnant teens that is consistent with 748.111(15). **The operation's admission policy does not indicate that this population of youth are accepted or excluded from admission. The child care policies do not address nutrition and hydration for children in care that is consistent with 748.1691, 748.1693, 748.1697, 748.1699, 748.1701, and 748.1703. |
— |
| 3 | — |
748.2103(b) - Medication Destruction-Discontinued or expired meds & meds left at facility destroyed by health-care professional/pharmacist or LCCA & adult witness
The operation's medication policy does not address how discontinued or expired medications are to be destroyed. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the walkthrough of the inspection, it was noticed that the back refrigerator and freezer were missing a thermometer. |
— |
| 5 | — |
748.2003(a) - Administration of prescription medication-inform medical consenter of benefits/risks/side effects/treatment/consequences of refusing them
The operation's medication administration policy does not fully address the requirements in informing the person legally authorized to give medical consent. |
— |
| 3 | — |
745.651(2)(A) - Background Check Validation ? Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list
The requirement of validating the people list hasn't been met. |
Yes |
| 4 | — |
748.3369(d) - Bedding-A bunk bed must be equipped with a securely attached ladder capable of supporting the child using the bed and an employee
The bunk beds for children do not include securely attached ladders as required. |
— |
| 4 | — |
748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication
The medication administration and documentation policy does not provide clear instructions to staff regarding the required timeframe for recording medication administration. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
During an incident between a staff member and a resident, another staff member was present but did not intervene and assist the staff member. |
— |
| 3 | — |
748.103(b)(7) - Policies and procedures to submit - discipline
The operation's discipline policy does not address: -who may discipline a child -explanation to staff what is considered "unproductive work" -restriction of child's activities as a behavior management tool consistent with 748.2309 |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
The serious incident form does not include requirements for documentation that is consistent with 748.313(3)(B thru E) and 748.313(4). |
— |
| 3 | — |
748.2551(d)(1) - EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
There were multiple children present during the inappropriate restraint. There were two staff members present during the altercation, and one staff member did not remove the other children present. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
A caregiver pulled on a child's hair multiple times as a means to get the child under control. |
— |
| 3 | — |
748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position
-Employee job descriptions are not consistent with 748.505 minimum qualification requirements and 748.507 general responsibilities requirements. -There is not a job description for the required position of a Professional Level Service Provider. -The administrator's job description is not consistent with 748.535-responsibilities of administrator. Chapter 748 SC E-Child Care Administrator responsibilities have been updated as of April 2022. |
— |
| 1 | — |
748.4205 - Placement Extension-child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days
Five children receiving emergency care services have been in care longer than the maximum 15 days allowed. The operation has not submitted placement extensions. |
— |
| 5 | — |
748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements
The operation's background check policy is not consistent with TAC Chapter 745, to include, but not limited to: -requirements for when to submit for an initial background check that is consistent with 745.621 -determinations regarding background checks consistent with 745.641 and 745.651 -745.673 pertaining to subject of BGC at operation is under investigation for child abuse or neglect -745.681 pertaining to risk evaluations |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
During inspection of the children's bedrooms, the beds were observed to have splinters and exposed pieces of wood (newly built beds and ladders) that could cause injuries. Slats of some of the beds were found to not have been properly secured to the bed frame. One slat was observed on the floor under the bed. |
— |
| 3 | — |
748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located.
The operation's policy on reporting serious incidents is missing significant policies and procedures for reporting serious incidents and other occurrences. The policy is missing notification requirements as applicable in 748.317 and 748.319. The operation must use form 7266 "Notification of Abuse/Neglect/Exploitation Deficiency" to notify parents of the deficiency. These changes to the minimum standards were in effect April 2021. The policies must be consistent with Subchapter D, Div 1- Reporting Serious Incidents and Other Occurrences. Serious incident reporting requirements were updated in minimum standards effective April 2022. |
— |
| 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
An employee no longer associated with the operation background check hasn't been inactivated after the seven day requirement. |
Yes |
| 3 | — |
748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded
The EBI incident form does not include requirement for staff to document the length of time a child was restrained. The EBI incident form does not include requirement for staff to document a child's condition following the release from an EBI as required under 748.2855(a)(11). |
— |
| 3 | — |
748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing
During the walkthrough, it was noticed that all fire extinguishers were out of date. |
— |
| 4 | — |
748.537(a) - On Call Staff-A person designated to handle emergencies must be on call and accessible to caregivers
The operation's professional staffing plan does address plans for handling emergencies. The professional staffing does not address a designated person must be on call and accessible to caregivers and that all caregivers (and CCR) are informed of emergency system and how to contact the person on call. |
— |
| 5 | — |
748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child
In a review of the investigation, it was found that a caregiver pushed down on a child's face. |
— |
| 4 | — |
748.103(b)(10) - Policies and procedures to submit - Abuse and neglect
The operation's abuse and neglect policy reviewed is not consistent with 748.121. The policy does not address the following: -Methods for increasing employee awareness of issues regarding child abuse and neglect -Strategies for coordination between the operation and appropriate community organizations -Methods for increasing employee awareness of prevention techniques for child abuse and neglect -Actions that the parent of a child who is a victim of abuse or neglect should take to obtain assistance and intervention. |
— |
| 2 | — |
748.3397(d)(2) - Bathing-Provide sufficient hot water to meet the demands of the children
During the inspection of bathrooms and kitchen, it was observed that none of the hot water faucets produced sufficient hot water. After a further inspection of the hot water heater, it was determined that the pilot light was out and cannot be readily reset. |
— |
| 2 | — |
748.111(9) - Child-care policy - Plans for meeting educational needs of each child
The operation's education policy does not address requirements in 748.1303. |
— |
| 4 | — |
748.4009(a) - General requirements-Driver & caregivers must have clear instructions in handling transportation emergencies
The operation's policy and procedures does not include plans for handling transportation emergencies that is consistent with 748.4009 (a) thru (c). |
— |
| 3 | — |
748.3231(b)(2) - Evacuation-Plan requires person in charge during emergency to make an employee responsible for securing medical consents & medications
The operation's disaster and emergency plan does not designate an employee responsible for securing children?s emergency numbers, emergency medical authorizations, and medications during the emergency. |
— |
| 4 | — |
748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention
The operation's EBI policy contained on pages 85-92 were reviewed. The EBI policy: -does not provide a complete description of the EBI caregivers may use, only names the curriculum. -does not identify the specific techniques the caregivers can use, only names the two types of EBI allowed to use. -does not include the determination of the basis for the EBI; does not address instructions for caregivers on attempting less restrictive behavior interventions that prove to be ineffective at defusing the situation; does not address requirements under 748.2551; does not address requirements under 748.2553(2), 748.2601, 748.2603, 748.2801(2), and 748.2805(2). -does not address the caregiver's responsibility for documentation following use of EBI as required by 748.2853 and 748.2855(a). -does not address notifications to the managing conservator when EBI is used with a child. -does not address triggered review requirements of EBI for a specific child 748.2901 (Personal Restraints), 748.2903, 748.2905, 748.2907, and 748.2909. -does not include the operation's requirement to conduct quarterly EBI data collection. -does not include the operation's requirement to conduct an annual operation evaluation of EBI. |
— |
| 3 | — |
748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees
The operation's staff training policy was reviewed. The policy does not include the following for general pre-service training: -location and use of fire extinguishers and first aid equipment -curriculum components for pre-service training in normalcy -curriculum components for pre-service training in administering psychotropic medication -requirement that training on administering psychotropic medication must be instructor led training and the instructor must be a health care professional or a pharmacist The policy does not include the following for annual training: -curriculum components for normalcy -curriculum components for administering psychotropic medication -psychotropic medication instructor led training requirement |
— |
| 4 | — |
748.3709(1) - Higher Risk Activity-There must be a person that is responsible for and supervises a higher risk recreational activity
The operation's recreation policy describes camping, hiking, fishing, and building construction as recreation activity opportunities offered and planned. However, the recreation policy does not address requirements for when children participate in higher risk recreational activity. The operation's recreation policy must meet or exceed 748.3709 thru 748.3713 and 748.3841 thru 748.3861, as applicable. |
— |
| 3 | — |
748.103(b)(7) - Policies and procedures to submit - discipline
The operation's discipline policy does not address: -who may discipline a child -explanation to staff what is considered "unproductive work" -restriction of child's activities as a behavior management tool consistent with 748.2309 |
— |
| 4 | — |
748.3709(1) - Higher Risk Activity-There must be a person that is responsible for and supervises a higher risk recreational activity
The operation's recreation policy describes camping, hiking, fishing, and building construction as recreation activity opportunities offered and planned. However, the recreation policy does not address requirements for when children participate in higher risk recreational activity. The operation's recreation policy must meet or exceed 748.3709 thru 748.3713 and 748.3841 thru 748.3861, as applicable. |
— |
| 5 | — |
748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment
A caregiver pulled on a child's hair multiple times as a means to get the child under control. |
— |
| 3 | — |
748.3231(b)(2) - Evacuation-Plan requires person in charge during emergency to make an employee responsible for securing medical consents & medications
The operation's disaster and emergency plan does not designate an employee responsible for securing children?s emergency numbers, emergency medical authorizations, and medications during the emergency. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
The serious incident form does not include requirements for documentation that is consistent with 748.313(3)(B thru E) and 748.313(4). |
— |
| 4 | — |
748.537(a) - On Call Staff-A person designated to handle emergencies must be on call and accessible to caregivers
The operation's professional staffing plan does address plans for handling emergencies. The professional staffing does not address a designated person must be on call and accessible to caregivers and that all caregivers (and CCR) are informed of emergency system and how to contact the person on call. |
— |
| 5 | — |
748.3369(e) - Bedding-Bunk bed must have attached bedrails; bedrails & the mattress supports must not be an entrapment hazard
Children's bunk beds are not equipped with required bedrails. |
Yes |
| 5 | — |
748.2003(a) - Administration of prescription medication-inform medical consenter of benefits/risks/side effects/treatment/consequences of refusing them
The operation's medication administration policy does not fully address the requirements in informing the person legally authorized to give medical consent. |
— |
| 3 | — |
745.651(2)(A) - Background Check Validation ? Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list
The requirement of validating the people list hasn't been met. |
Yes |
47 inspection record(s) on file from TX-HHSC.