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Saint Francis Ministries - Residential Texas

Child care center · 125 CHICAGO AVE, Lubbock, TX 79416-1605 · License 1761811

0Compliance score
Poor

Capacity 21. 12-18

Violation history (384)

Severity	Date	Standard / narrative	Corrected
5	—	748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others The child's service plans reviewed did not include high risk behaviors.	—
4	—	748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication Agency staff did not intervene immediately when a suicidal child ran out of the facility and self-harmed with glass.	—
4	—	748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs Multiple medication errors were not approprpiately documented.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A caregiver failed to use reasonable judgement when a child in care obtained access to the caregiver's cell phone and viewed inappropriate pictures.	—
5	—	748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint A child in care intervened in a physical altercation between two other children in care by restraining the aggressing child and escorting the aggressing child away from the victim.	—
4	—	748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids A caregiver utilized tobacco products during shift when job responsibilities included providing supervision for children in care.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A caregiver had possession of a vape on the unit. The vape fell out of her pocket and became accessible to children in care.	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old The operation failed to ensure appropriate medication count for a prescription medication.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A caregiver at the operation failed to follow operation policies when overnight bed checks were not conducted as required every 10 minutes.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A caregiver failed to provide appropriate supervision and a child in care was able to use outside objects to climb on the roof of the operation.	—
3	—	748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older. A child in care was absent from the operation for more than 6 hours before it the incident was reported to law enforcement.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders A medication record showed that a child in care did not receive a prescribed medication for 4 consecutive days.	—
3	—	748.303(a)(10)(B) - Serious Incident-Report to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older. A child in care was absent from the operation for more than 6 hours before it the incident was reported to the parent.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures Overnight caregivers did not conduct bed checks during sleeping hours according to operation policies.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The operation provided two incident reports documenting separate incidents occurring on separate dates but included identical information regarding the circumstances.	—
3	—	748.1337(b)(1)(A)(vi)(I) - Initial Service Plan - Normalcy - Include plans for social, extracurricular, recreation, and leisure activities Three out of three service plans reviewed did not contain specific information related to normalcy activities at the operation.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety Two staff conducting routing visual supervision of a child in care failed to intervene when the child had attempted self-harm by tying a plastic bag around their neck.	—
2	—	748.1117 - Documentation of searches-Caregiver documents searches in the child's record A child in care returned from runaway status and the search conducted by staff was not documented in the child record.	—
3	—	748.303(a)(9)(B) - Serious Incident- Report to parents within 2 hours of determining absence of a child developmentally/chronologically 6 to 12yrs. A child in care was absent from the operation for more than 2 hours before it the incident was reported to the parent.	—
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 Two caregivers were present and aware that a staff was utilizing an unapproved form of EBI and did not report or intervene for the safety and well-being of a child in care.	—
5	—	748.2551(b)(1) - EBI Implementation-The caregiver must consider the characteristics of the immediate physical environment A caregiver implemented a personal restraint in a public venue, in view of onlookers to intervene in an unauthorized absence after the child had left the facility and law enforcement had been notified. There was no immediate danger to the child.	—
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 One out of ten child right's was not signed at the time of admission. An additional child refused to sign the rights of children and additional attempts to have the document signed have not been completed.	—
2	—	748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs One out of three service plans reviewed did not contain updated information related to psychotropic medication appointments.	—
3	—	748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction The operation was unable to access the employee training records for licensing immediate review.	—
3	—	748.125(d)(6) - Suicide Screening- Must be documented. A suicide risk screening conducted verbally on May 7, 2023 was not documented until June 2, 2023.	—
5	—	748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain The operation failed to obtain timely medical care for a child after they ingested over the counter medication during an unauthorized departure.	—
3	—	748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained Two of two admission assessments reviewed lacked the legal status, current medical status, dental status, mental health status, substance abuse history, developmental function, education needs, services that will be provided, goals of placement, parent?s expectations of placement, and/or the child's understanding of placement as required under subsection b of this standard.	—
5	—	745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions A caregiver at the operation with restricted duties was providing sole supervision for a child in care.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A caregiver failed to demonstrate employee responsibilities when he participated in aggressive horseplay with a child in care, pushing the child down two times.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child A caregiver yelled profanities at a child in care. A caregiver also ridiculed a child in care's appearance.	—
4	—	748.303(a)(9)(A) - Serious Incident-Report to CCL within 2 hours of notifying LE the absence of a child developmentally/chronologically 6 to 12 years old. The operation did not report the absence of a child in care to the hotline within two hours of notifying law enforcement.	—
2	—	748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation The operation did not have appropriate documentation related to fire and severe weather drills.	—
2	—	748.1437(7) - Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction One record reviewed did not contain detailed information regarding the emergency discharge of a child in care.	—
4	—	748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks Caregivers aware of a child's frequent elopements left the child unsupervised for at least 8-10 minutes allowing the child ample time to leave without permission.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A caregiver failed to use prudent judgement when she allowed a child in care to put lotion on her ankles and feet and failed to use appropriate language after being provoked by a child in care.	—
3	—	748.393(b)(3) - Active child record - Ensure record is kept accurate and current The child's service plan was not updated with correct information regarding runaway prevention.	—
4	—	748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks Caregivers failed to ensure the safety and supervision of a child in care when she left the operation without permission 4 separate times during a 12 hour period of time.	—
4	—	748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks Two children with histories of elopement and suspected of planning an elopement were allowed to participate in outdoor activities from which they eloped on two separate dates. Caregivers failed to consider the risk of allowing the children to participate in the activities.	—
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model Medication logs did not contain accurate medication count for prescription medication.	—
5	—	748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force A caregiver used an inappropriate form of EBI when a child in care was drug by her feet in a supine position.	—
3	—	748.125(d)(6) - Suicide Screening- Must be documented. An operation staff reported that the initial suicide prevention screening was completed but not documented.	—
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.	—
1	—	748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record Three records reviewed did not have an admission assessment was not completed prior to admission. The professional level service provider must sign and date the admission assessment prior to admission.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures Operation staff failed to follow policy regarding cell phone and social media usage while on duty and in the presence of children in care.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. The operation did not report the absence of a child in care for more than six hours to the hotline.	—
2	—	748.1337(b)(1)(A)(ii) - Initial Service Plan-Include dental needs, including scheduled dental exams and plans for recommended follow-up treatment Three out of three child records reviewed did not contain information related to previous dental status or upcoming dental appointments that have been scheduled.	—
4	—	748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply A caregiver used an unapproved form of EBI as a means for a child to comply with an instruction.	—
4	—	748.303(a)(9)(C) - Serious Incident-Report to law enforcement w/in 2 hrs of determining absence of a child developmentally/chronologically 6 to 12yrs. A child in care was absent from the operation for more than 2 hours before it the incident was reported to law enforcement.	—
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.	—
2	—	748.1385(1) - Service Plan Review-Must include evaluation of child's progress and effectiveness of strategies and techniques used to meet identified needs One out of three service plans reviewed did not contain updated information related to psychotropic medication appointments.	—
1	—	748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record Three records reviewed did not have an admission assessment was not completed prior to admission. The professional level service provider must sign and date the admission assessment prior to admission.	—
2	—	748.3239(d) - Evacuation-Must document fire and severe weather drills, including date, time, type of drill, and length of time for evacuation/relocation The operation did not have appropriate documentation related to fire and severe weather drills.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures Overnight caregivers did not conduct bed checks during sleeping hours according to operation policies.	—
3	—	748.303(a)(10)(B) - Serious Incident-Report to parents no later than 6 hours after determining unauthorized absence of a child 13 years old or older. A child in care was absent from the operation for more than 6 hours before it the incident was reported to the parent.	—
5	—	748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others The child's service plans reviewed did not include high risk behaviors.	—
3	—	748.393(b)(3) - Active child record - Ensure record is kept accurate and current The child's service plan was not updated with correct information regarding runaway prevention.	—
5	—	745.635(3) - AP Background ck determination - If provisionally eligible w/conditions or eligible w/conditions you must restrict duties per conditions/restrictions A caregiver at the operation with restricted duties was providing sole supervision for a child in care.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A caregiver failed to demonstrate employee responsibilities when he participated in aggressive horseplay with a child in care, pushing the child down two times.	—
3	—	748.303(a)(9)(B) - Serious Incident- Report to parents within 2 hours of determining absence of a child developmentally/chronologically 6 to 12yrs. A child in care was absent from the operation for more than 2 hours before it the incident was reported to the parent.	—
4	—	748.1661(b) - Tobacco Products-Adult may not smoke tobacco products, e-cigarettes, or vaporizers in children's living areas/inside any building on premises w/ kids A caregiver utilized tobacco products during shift when job responsibilities included providing supervision for children in care.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The operation provided two incident reports documenting separate incidents occurring on separate dates but included identical information regarding the circumstances.	—
5	—	748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain The operation failed to obtain timely medical care for a child after they ingested over the counter medication during an unauthorized departure.	—
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 One out of ten child right's was not signed at the time of admission. An additional child refused to sign the rights of children and additional attempts to have the document signed have not been completed.	—
4	—	748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks Caregivers failed to ensure the safety and supervision of a child in care when she left the operation without permission 4 separate times during a 12 hour period of time.	—
4	—	748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old The operation failed to ensure appropriate medication count for a prescription medication.	—
5	—	748.2453 - Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint A child in care intervened in a physical altercation between two other children in care by restraining the aggressing child and escorting the aggressing child away from the victim.	—
3	—	748.125(d)(6) - Suicide Screening- Must be documented. An operation staff reported that the initial suicide prevention screening was completed but not documented.	—
2	—	748.1117 - Documentation of searches-Caregiver documents searches in the child's record A child in care returned from runaway status and the search conducted by staff was not documented in the child record.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A caregiver failed to use reasonable judgement when a child in care obtained access to the caregiver's cell phone and viewed inappropriate pictures.	—
4	—	748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication Agency staff did not intervene immediately when a suicidal child ran out of the facility and self-harmed with glass.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. The operation did not report the absence of a child in care for more than six hours to the hotline.	—
4	—	748.303(a)(9)(C) - Serious Incident-Report to law enforcement w/in 2 hrs of determining absence of a child developmentally/chronologically 6 to 12yrs. A child in care was absent from the operation for more than 2 hours before it the incident was reported to law enforcement.	—
2	—	748.1437(7) - Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction One record reviewed did not contain detailed information regarding the emergency discharge of a child in care.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A caregiver failed to provide appropriate supervision and a child in care was able to use outside objects to climb on the roof of the operation.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures Operation staff failed to follow policy regarding cell phone and social media usage while on duty and in the presence of children in care.	—
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 Two caregivers were present and aware that a staff was utilizing an unapproved form of EBI and did not report or intervene for the safety and well-being of a child in care.	—
4	—	748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply A caregiver used an unapproved form of EBI as a means for a child to comply with an instruction.	—
3	—	748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older. A child in care was absent from the operation for more than 6 hours before it the incident was reported to law enforcement.	—
3	—	748.1337(b)(1)(A)(vi)(I) - Initial Service Plan - Normalcy - Include plans for social, extracurricular, recreation, and leisure activities Three out of three service plans reviewed did not contain specific information related to normalcy activities at the operation.	—
3	—	748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction The operation was unable to access the employee training records for licensing immediate review.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety Two staff conducting routing visual supervision of a child in care failed to intervene when the child had attempted self-harm by tying a plastic bag around their neck.	—
3	—	748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained Two of two admission assessments reviewed lacked the legal status, current medical status, dental status, mental health status, substance abuse history, developmental function, education needs, services that will be provided, goals of placement, parent?s expectations of placement, and/or the child's understanding of placement as required under subsection b of this standard.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A caregiver at the operation failed to follow operation policies when overnight bed checks were not conducted as required every 10 minutes.	—
4	—	748.303(a)(9)(A) - Serious Incident-Report to CCL within 2 hours of notifying LE the absence of a child developmentally/chronologically 6 to 12 years old. The operation did not report the absence of a child in care to the hotline within two hours of notifying law enforcement.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders A medication record showed that a child in care did not receive a prescribed medication for 4 consecutive days.	—
4	—	748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model Medication logs did not contain accurate medication count for prescription medication.	—
4	—	748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs Multiple medication errors were not approprpiately documented.	—
2	—	748.1337(b)(1)(A)(ii) - Initial Service Plan-Include dental needs, including scheduled dental exams and plans for recommended follow-up treatment Three out of three child records reviewed did not contain information related to previous dental status or upcoming dental appointments that have been scheduled.	—
5	—	748.2551(b)(1) - EBI Implementation-The caregiver must consider the characteristics of the immediate physical environment A caregiver implemented a personal restraint in a public venue, in view of onlookers to intervene in an unauthorized absence after the child had left the facility and law enforcement had been notified. There was no immediate danger to the child.	—
5	—	748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force A caregiver used an inappropriate form of EBI when a child in care was drug by her feet in a supine position.	—
3	—	748.125(d)(6) - Suicide Screening- Must be documented. A suicide risk screening conducted verbally on May 7, 2023 was not documented until June 2, 2023.	—
4	—	748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks Two children with histories of elopement and suspected of planning an elopement were allowed to participate in outdoor activities from which they eloped on two separate dates. Caregivers failed to consider the risk of allowing the children to participate in the activities.	—
4	—	748.685(b)(4) - Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks Caregivers aware of a child's frequent elopements left the child unsupervised for at least 8-10 minutes allowing the child ample time to leave without permission.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks A caregiver failed to use prudent judgement when she allowed a child in care to put lotion on her ankles and feet and failed to use appropriate language after being provoked by a child in care.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child A caregiver yelled profanities at a child in care. A caregiver also ridiculed a child in care's appearance.	—
3	—	748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures A caregiver had possession of a vape on the unit. The vape fell out of her pocket and became accessible to children in care.	—
1	—	748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record Three records reviewed did not have an admission assessment was not completed prior to admission. The professional level service provider must sign and date the admission assessment prior to admission.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child A caregiver yelled profanities at a child in care. A caregiver also ridiculed a child in care's appearance.	—
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 Two caregivers were present and aware that a staff was utilizing an unapproved form of EBI and did not report or intervene for the safety and well-being of a child in care.	—
5	—	748.1337(b)(1)(H)(i) - Initial Service Plan-For child who exhibits high risk behaviors, include plans to minimize risk of harm to self or others The child's service plans reviewed did not include high risk behaviors.	—

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

Inspections (240)

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

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