Texas › Manvel › Shiloh Treatment Center

Shiloh Treatment Center

Child care center · 4774 DEL BELLO RD, Manvel, TX 77578-3030 · License 517689

0Compliance score
Poor

Capacity 60. 3-17

Violation history (480)

Severity	Date	Standard / narrative	Corrected
2	—	748.3273(9) - First Aid Kits-Each one must contain tweezers One of the two first aid kits did not contain tweezers.	—
4	—	748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child Operation did not report a child's allegation of abuse by a staff member until four days after the allegations were made.	—
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 The facility is permitted to take children 3-17 years old but has excepted a resident who is 18 years old upon being admitted.	—
5	—	748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain There was a delay in the child receiving medical care.	—
3	—	748.125(c)(1)(A) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes risk & protective factors, and warning signs. Documentation of suicidal training that covers the risk factors, protective factors, and warning signs of suicide was missing in three staff records reviewed.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation During a DFPS investigation, it was found a 13-year-old child in care was neglectfully supervised when a caregiver repeatedly failed to de-escalate her.	—
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. While reviewing employee files, it was observed that 1 out of the 6 files reviewed did not conduct reference checks.	—
4	—	748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification Four staff records reviewed were missing documentation of current CPR/First Aid certificate.	—
3	—	748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record The review of two children records found that both children who are over the age of 6 did not sign the Child's Rights statement acknowledging they have read and understood the listed rights.	—
3	—	748.311 - Serious Incident Documentation-Documented in written report The operation failed to complete an incident report related to a non-routine incident concerning aggression and an EBI incident that occurred between a youth and two operational staff members.	—
4	—	748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered Medication log does not have what time the residence medication is being given.	—
5	—	748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work. The staff used corporal punishment as a means to get a child to comply.	—
5	—	745.4151(a) - Operation must adopt the DFPS drug testing policy or have its own that meets or exceeds criteria for model policy The operations policy advises that the facility administers drug test quarterly but multiple staff have not had drug test in a number of years.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety A staff member recognized another staff members actions were inappropriate and still failed to intervene.	—
3	—	748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill The last weather drill was not completed within the last six months.	—
3	—	748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission The unauthorized absence log does not have the required components such as the child's age, gender or date of admission.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A staff member failed to utilize proper de-escalation techniques when they realized a child was having a crisis and instead of professionally assisting the child, exhibited physical aggression to the child in care.	—
3	—	748.1337(b)(1)(A)(vi)(I) - Initial Service Plan - Normalcy - Include plans for social, extracurricular, recreation, and leisure activities The review of two children records found normalcy was not addressed in the children's service plan.	—
2	—	748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan One of the children records reviewed found the last service plan review was completed on February 20, 2025.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. Two staff records reviewed were missing documentation of the results of any contact with an applicant's previous employers. Two other records did not include results of contact from all previous employers prior to application date.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records A staff member failed to accurately depict the incident when completing the incident report. The staff member did not detail the role they played in the incident or the harm they caused to the child. The staff member falsified records by omitting dragging the child and portraying the child as the aggressor.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures Two operational staff members completed an EBI transport for a child by dragging the child across the living room area of the home.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment An operational staff member responded to a child in a physically aggressive manner by pushing the child as a means of discipline prior to conducting an inappropriate restraint.	—
3	—	748.861(b)(3) - Pre-Service Training - Supervised experience must be documented in personnel record One staff record reviewed is missing documentation of supervised experience training.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The details documented in the operational Emergency Personal Restraint Report are inconsistent with the events observed in the operational video recording.	—
1	—	748.4111(a) - Transportation records-Must maintain on file at the operation the name of each driver and a copy of that person's valid driver's license One staff file lacks an valid drivers license/	Yes
5	—	748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being Two caregivers were involved in a physical restraint of a child, and staff members failed to ensure that signs of distress were monitored appropriately during the restraint.	—
2	—	748.1211(b)(2)(B) - Parent Orientation-Must review & provide written materials on type & frequency of notifications made to parents The parent orientation does not have any information on the frequency of notifications that will be made to parents.	—
5	—	748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child A staff member grabbed a child by the arm and dragged them off a couch and down a hallway. Then the staff member pushed the child into a bedroom.	—
4	—	748.1205(a)(7) - Admission Documentation-Includes child's immunization record Immunization record was missing from one of the children's records reviewed.	—
3	—	748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position While reviewing staff files, 4 out of 6 staff files did not contain job descriptions.	—
2	—	748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility Three children records reviewed were missing TB screening results.	—
3	—	748.1501(a)(1) - Dental care-Children in care must receive dental care initially according to the requirements in 748.1225 Two children did not received their dental exam within 90 days of admission.	—
5	—	748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child A staff member pulled a child by their hair.	—
2	—	748.3395(b)(3) - Hand-washing-Provide hand-washing sinks with hot & cold running water under sufficient pressure to meet the demands of children When conducting a walk through in the girl's unit, it was observed that one of the hand washing sinks did not have sufficient hot water pressure.	—
4	—	748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair During the walkthrough it was observed in room #4 a dresser drawer and a window blind were damaged. In Room#2 the window blind was damaged. Work orders were submitted on 3/16/2023 during the inspection.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair During the walkthrough I observed toilets in 58C to not be cleaned properly, and the refrigerator door to be dirty. In house 58B I observed a cloth mattress to be without a mattress cover and exposed wire trimming.	—
4	—	748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly During the walkthrough two bottle of cleaning supply where left in unlocked cabinets.	Yes
3	—	748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling One staff record reviewed missing proof of education.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A staff member did not use prudent judgement and self-control while trying to de-escalate a child having maladaptive behaviors which led to the child being injured.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. During a monitoring inspection, it was found that one out of four staff files reviewed there was no documentation of any contact with the applicant's previous employers.	—
4	—	748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication The review of two restraint reports showed the basis for EBI was not an emergency situation.	—
4	—	748.931(a)(1)(B)(i) - Annual Training-Must include 2 hours on trauma informed care Staff member only has 1 hour of the T.I.C training when the requirement is 2 hourss.	—
3	—	748.2951(d) - Evaluation-Results of each overall annual evaluation made available to Licensing for review. The operation did not have an overall annual EBI evaluation for review.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A 13-year-old child with documented high-risk behaviors was not adequately supervised, and proper de-escalation techniques were not utilized by direct care staff.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone There are 4 staff members currently working in the homes that do not have background checks.	—
2	—	748.1101(b)(3)(I) - Children's rights-The right to have personal items in the child's room and get additional items within reasonable limits A staff member removed items from a child's bedroom as punishment.	—
4	—	748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child A staff member witnessed a serious incident and did not immediately report it.	—
5	—	748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway An operational staff member placed a child in a prone and supine position during a restraint on a couch. The staff member failed to discontinue the restraint when the child verbally indicated that he was having difficulty with breathing.	—
5	—	748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute. An operational staff member exceeded the required time limit when utilizing prone and supine restraints as required in Minimum Standards.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation Operation employees failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in TFC ?261.001 and further defined in TAC Rule ?707.801, which resulted in an immediate danger to a child's physical health and safety.	—
4	—	748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others An operational staff member failed to release a youth from a physical hold, when the youth was no longer displaying behavior that exhibited that the child was a danger to himself or others.	—
3	—	748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position During a monitoring inspection a staff record reviewed did not contain a copy of a high school diploma to indicate that they qualify for their position at the operation.	—
3	—	748.363(4) - Personnel records-Personnel records-Include current job description. During a monitoring inspection staff files reviewed did not include the personnel's job description.	—
4	—	748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective Staff did not attempt de-escalation or a lesser intervention prior to utilizing a restraint.	—
4	—	748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly. While conducting a walkthrough of the girls unit, it was observed that the cleaning supplies were accessible and not locked back.	Yes
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 Operation failed to assure staff Background checks are being verified every 3 months.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.A child was injured by a staff member after an accident.	—
5	—	748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work. A caregiver aggressively shoved a 13-year-old child in care on three occasions during a struggle over the caregiver's personal items.	—
3	—	748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation All eleven interviewed children reported that they were not familiar with the administrator's name since their placement. Five of seven direct care staff identified someone else as the administrator. Additionally, all staff reported that staff meetings have been conducted by shift supervisors or trainers. The administrator acknowledged that her school responsibilities may have limited her involvement in her role at the RTC.	—
4	—	748.2455(a)(1) - Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective Staff did not attempt de-escalation or a lesser intervention prior to utilizing a restraint.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation During a DFPS investigation, it was found a 13-year-old child in care was neglectfully supervised when a caregiver repeatedly failed to de-escalate her.	—
2	—	748.3273(9) - First Aid Kits-Each one must contain tweezers One of the two first aid kits did not contain tweezers.	—
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.A child was injured by a staff member after an accident.	—
4	—	748.1205(a)(7) - Admission Documentation-Includes child's immunization record Immunization record was missing from one of the children's records reviewed.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The details documented in the operational Emergency Personal Restraint Report are inconsistent with the events observed in the operational video recording.	—
4	—	748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child A staff member witnessed a serious incident and did not immediately report it.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A staff member did not use prudent judgement and self-control while trying to de-escalate a child having maladaptive behaviors which led to the child being injured.	—
5	—	748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment An operational staff member responded to a child in a physically aggressive manner by pushing the child as a means of discipline prior to conducting an inappropriate restraint.	—
3	—	748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation All eleven interviewed children reported that they were not familiar with the administrator's name since their placement. Five of seven direct care staff identified someone else as the administrator. Additionally, all staff reported that staff meetings have been conducted by shift supervisors or trainers. The administrator acknowledged that her school responsibilities may have limited her involvement in her role at the RTC.	—
2	—	748.3395(b)(3) - Hand-washing-Provide hand-washing sinks with hot & cold running water under sufficient pressure to meet the demands of children When conducting a walk through in the girl's unit, it was observed that one of the hand washing sinks did not have sufficient hot water pressure.	—
5	—	748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute. An operational staff member exceeded the required time limit when utilizing prone and supine restraints as required in Minimum Standards.	—
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. While reviewing employee files, it was observed that 1 out of the 6 files reviewed did not conduct reference checks.	—
5	—	748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work. A caregiver aggressively shoved a 13-year-old child in care on three occasions during a struggle over the caregiver's personal items.	—
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 Operation failed to assure staff Background checks are being verified every 3 months.	—
5	—	745.621(a)(2) - AP Initial background checks submitted - At the time you hire someone There are 4 staff members currently working in the homes that do not have background checks.	—
4	—	748.931(a)(1)(B)(i) - Annual Training-Must include 2 hours on trauma informed care Staff member only has 1 hour of the T.I.C training when the requirement is 2 hourss.	—
4	—	748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others An operational staff member failed to release a youth from a physical hold, when the youth was no longer displaying behavior that exhibited that the child was a danger to himself or others.	—
4	—	748.983(b) - First-aid-CPR renewal-The caregiver counted in the ratio who must have current CPR certification must maintain a current certification Four staff records reviewed were missing documentation of current CPR/First Aid certificate.	—
3	—	748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position While reviewing staff files, 4 out of 6 staff files did not contain job descriptions.	—
2	—	748.1211(b)(2)(B) - Parent Orientation-Must review & provide written materials on type & frequency of notifications made to parents The parent orientation does not have any information on the frequency of notifications that will be made to parents.	—
3	—	748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission The unauthorized absence log does not have the required components such as the child's age, gender or date of admission.	—
5	—	748.2601(a) - Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being Two caregivers were involved in a physical restraint of a child, and staff members failed to ensure that signs of distress were monitored appropriately during the restraint.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures Two operational staff members completed an EBI transport for a child by dragging the child across the living room area of the home.	—
5	—	748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain There was a delay in the child receiving medical care.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. Two staff records reviewed were missing documentation of the results of any contact with an applicant's previous employers. Two other records did not include results of contact from all previous employers prior to application date.	—
3	—	748.1501(a)(1) - Dental care-Children in care must receive dental care initially according to the requirements in 748.1225 Two children did not received their dental exam within 90 days of admission.	—
4	—	748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair During the walkthrough I observed toilets in 58C to not be cleaned properly, and the refrigerator door to be dirty. In house 58B I observed a cloth mattress to be without a mattress cover and exposed wire trimming.	—
4	—	748.3421(3) - Poisons-Ensure poisonous or flammable materials are inaccessible to children unless child has been evaluated as capable & likely to use responsibly During the walkthrough two bottle of cleaning supply where left in unlocked cabinets.	Yes
2	—	748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility Three children records reviewed were missing TB screening results.	—
4	—	748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly. While conducting a walkthrough of the girls unit, it was observed that the cleaning supplies were accessible and not locked back.	Yes
5	—	748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation Operation employees failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in TFC ?261.001 and further defined in TAC Rule ?707.801, which resulted in an immediate danger to a child's physical health and safety.	—
5	—	745.4151(a) - Operation must adopt the DFPS drug testing policy or have its own that meets or exceeds criteria for model policy The operations policy advises that the facility administers drug test quarterly but multiple staff have not had drug test in a number of years.	—
5	—	748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway An operational staff member placed a child in a prone and supine position during a restraint on a couch. The staff member failed to discontinue the restraint when the child verbally indicated that he was having difficulty with breathing.	—
4	—	748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child Operation did not report a child's allegation of abuse by a staff member until four days after the allegations were made.	—
3	—	748.125(c)(1)(A) - Caregivers and employees must complete 1hr annual suicide training with curriculum that includes risk & protective factors, and warning signs. Documentation of suicidal training that covers the risk factors, protective factors, and warning signs of suicide was missing in three staff records reviewed.	—
2	—	748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan One of the children records reviewed found the last service plan review was completed on February 20, 2025.	—
3	—	748.311 - Serious Incident Documentation-Documented in written report The operation failed to complete an incident report related to a non-routine incident concerning aggression and an EBI incident that occurred between a youth and two operational staff members.	—
4	—	748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication The review of two restraint reports showed the basis for EBI was not an emergency situation.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records A staff member failed to accurately depict the incident when completing the incident report. The staff member did not detail the role they played in the incident or the harm they caused to the child. The staff member falsified records by omitting dragging the child and portraying the child as the aggressor.	—

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

Inspections (136)

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

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