Capacity 20. 0-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.363(3) - Personnel records-Include current job description
During the inspection, I observed two of the four personnel records lacking current job descriptions. |
— |
| 2 | — |
748.345(2) - Electronic records policies - Computer security systems, including confidentiality, passwords, and employee procedures
In reviewing the policies and procedures, I observed the lack of a policy pertaining computer security systems addressing confidentiality, password protection parameters, and network access. |
— |
| 3 | — |
748.109(2) - Admission Policies - include characteristics of the population the program serves
In reviewing the policies and procedures, I observed that the admission policies state they will admit without regard to sex; however, the operation is only applying to provide services for girls. The policies and procedures include parameters for Primary Medical Needs children, but the operation is not applying to provide such services. The admission policies do not state that they do not take Primary Medical Needs or emotional disturbance. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
A child's medication record was missing pill counts for three days. Counts need to be entered within 2 hours after administration. |
— |
| 3 | — |
748.105(1) - Personnel Policies - Develop a written organizational chart showing administrative/professional/staffing structures and lines of authority
In reviewing the policies and procedures, I observed that the organizational chart does not label and specify the supervisory relationships between each tier of employee. |
— |
| 4 | — |
748.113(6) - EBI Policy - Post EBIs permitted at your operation viewable to children/clients and provide them with a personal copy of EBI policies
In reviewing the policies and procedures, I observed a lack of policies specifying the posting of EBI practices where they can be viewed by children and adults or policies related to providing the clients with copies of the operation's emergency behavior intervention policies. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
One child's medication record did not include the reason for prescribing the medication. |
Yes |
| 3 | — |
748.1103(a) - Informing child of rights-Review rights with child/parents within 7 days of child's admission; provide child/parents with written copy of rights
During the inspection, I observed that one of the records reviewed did not have record of the Child's rights form in the file. |
— |
| 1 | — |
748.101(3) - Plans to submit - sketch of operation's floor plan
In reviewing the policies and procedures, I observed that the floor plan provided identifies rooms marked as bedrooms, but does not specify where caregivers and children will be sleeping respectively. |
— |
| 2 | — |
748.343(2)(B) - Records protection policies - Clarify persons outside operation authorized by law to access records
In reviewing the policies and procedures, I observed that the policies do not specify the individuals outside of the operation with access to records. |
— |
| 2 | — |
748.1439(b)(2) - Discharge Documentation-Send copy of child's background info, including progress notes for past 60 days, to next placement/caregiver within 15 days
No background information or progress notes were given to the worker at discharged (or no documentation of it. |
— |
| 2 | — |
748.119(3) - Volunteer policy - Address orientation and training programs for the volunteers
In reviewing the policies and procedures, I observed that the volunteer policies do not specify the training requirements for volunteers. |
— |
| 3 | — |
748.109(1) - Admission Policies - Include program's goals and services provided, including whether emergency admissions accepted
In reviewing the policies and procedures, I observed that the admission policies do not specify whether the operation accepts emergency placements. The document states they will accept placement as needs arise for children. |
— |
| 3 | — |
748.3273(7) - First Aid Kits-Each one must contain sterile gauze pads
During the inspection, I observed that the first aid kits lacked scissors, adhesive tape, and thermometers. |
— |
| 3 | — |
748.363(1) - Personnel records-Include date of employment
During the inspection, I observed that three of the four employee files reviewed lacked documentation showing the date of employment for the individual. |
— |
| 1 | — |
748.345(5) - Electronic records policies - Limit access to persons within operation authorized to view specific information in file
In reviewing the policies and procedures, I observed the lack of a policy limiting access to the operation's files to persons within the operation authorized to access and see specific information in an electronic file. |
— |
| 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.
During the walkthrough, I observed cleaning chemicals and lice treatments stored in an unlocked cabinet in the kitchen, accessible to children. The operation relocated these chemicals to a secured location. |
Yes |
| 4 | — |
748.113(2) - EBI policy - the specific techniques that caregivers can use
In reviewing the policies and procedures, I observed that the EBI policies do not list specific techniques approved for use by caregivers and the general descriptions do not match what was identified on the application. |
— |
| 3 | — |
748.363(5) - Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care
During the inspection, I observed that three of the four employee files reviewed lacked proof of TB test. |
— |
| 4 | — |
748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use
In reviewing the policies and procedures, I observed that the EBI policies list a number of EBI procedures that do not match the EBI procedures listed on the application. The EBI description is not specific to the EBI system used. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the inspection, it was observed that a refrigerator in the kitchen lacked a thermometer. |
— |
| 3 | — |
748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees
In reviewing the policies and procedures, I observed that the personnel policies do not contain policies specifying the training requirements for employees and caregivers. |
— |
| 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
During the inspection, I observed that one of the four employee records reviewed lacked a copy of the employees' proof of educational level or equivalency. |
— |
| 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 inspection, I observed that three of the fire extinguishers in the operation have not been inspected or serviced by a fire marshall or qualified entity within the past twelve months. |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The administrator's license expired on 12/14/23, and his renewal packet was submitted on 12/16/23, bringing the standard back into compliance on that date. |
— |
| 4 | — |
748.153(3)(C) - Notification - Remove controlling person
During the inspection, the operation identified three individuals that ceased to be controlling persons on 10/17/23 that were not reported to licensing within the timeframe. |
— |
| 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
The fire extinguishers need to be serviced annually. |
— |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
Upon review of 2 employees files it was found that both employees completed the required TB test after their start date with the operation. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
During the inspection, I observed one of four children?s medication records reflected the operation failed to administer the second dose of a medication prescribed for administration twice daily. |
— |
| 4 | — |
748.113(9)(A) - A person for filing a complaint, presenting grievance, or providing information relating to the misuse of EBI at the operation
In reviewing the policies and procedures, I observed that the EBI policies lack a prohibition against retaliation toward an individual for filing a complaint, presenting a grievance, or otherwise providing information about the misuse of emergency behavior interventions at the operation. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
A child was injured at school and taken to er the following day with a fracture. This should have been called into SWI |
— |
| 3 | — |
748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position
During the inspection, we observed 4 of 4 job descriptions that lacked documentation of position-required qualifications. |
— |
| 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
Fire and weather drill forms include the date, type, and length of evacuation, but no actual time that the drills took place. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During the walkthrough, I witnessed a child in care holding an applicator of over-the-counter medication she spilled on her blanket with no caregiver within auditory or visual range of the child. |
— |
| 2 | — |
748.345(4) - Electronic records policies - Anti-virus protection systems
In reviewing the documentation, I observed the lack of a policy addressing anti-virus protection systems. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the inspection, I observed that the administrator was not present and does maintain daily supervision and oversight of the operation. |
— |
| 5 | — |
748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements
In reviewing the policies and procedures, I observed that the background check policies do not specify the types of background checks applicable to the various positions employed by the facility. |
— |
| 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
During the inspection, it was observed that four of the four personnel records reviewed lacked documentation of proof of education level for the employee. |
— |
| 1 | — |
748.345(1) - Electronic records policies - What records must be in external paper file and those that can be stored in electronic file
In reviewing the policies and procedures, I observed the lack of a policy specifying which records must be in external paper files and those that can be stored electronically. |
— |
| 3 | — |
748.115(2) - Discipline policy - Integrate trauma informed care into the care, treatment, and management of each child
In reviewing the policies and procedures, I observed that the discipline policies do not detail how Trauma Informed Care is integrated into the care of the children. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
During the walkthrough, I observed that the med log for the only child taking prescription medications did not record the name of the prescribing doctor nor the reason for the prescription. |
— |
| 3 | — |
748.111(13) - Child-care policy - Types and frequency of reports to parents
In reviewing the policies and procedures, I observed the frequency of reports to parents is not specified. The policy mentions regular reports but does not specify frequency. |
— |
| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
During the inspection, I observed two of four employee files showed TB test completed outside the 30 day window from date of employment or starting to volunteer at the operation. |
— |
| 2 | — |
748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge
No services, accomplishments, or assessments were included in discharge paperwork |
— |
| 4 | — |
748.113(8) - EBI policy - Training for emergency behavior intervention
In reviewing the policies and procedures, I observed a lack of policies specifying the Emergency Behavior Intervention training requirements, the curriculum that will be utilized, the amount and type of training required, training content, and how the training will be delivered. |
— |
| 4 | — |
748.113(3) - EBI policy - the qualifications for caregivers who assume the responsibility for EBI implementation
In reviewing the policies and procedures, I observed that the EBI policies state that only qualified caregivers can administer EBI, but the policy does not specify the training requirements or criteria by which a caregiver is deemed qualified. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
During the inspection, I observed that two of the four personnel files reviewed lacked drug testing results in accordance with the operation's policies. |
— |
| 4 | — |
748.113(9)(B) - EBI policy - A child/adult client/resident because someone on behalf of the client files a complaint, provides information relating to misuse of EBI
In reviewing the policies and procedures, I observed that the EBI policies do not include a prohibition against retaliating against an individual for filing a complaint, grievance, or providing good-faith information regarding the misuse of emergency behavior intervention on behalf of another individual. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
During the inspection, I observed three bedrooms that lacked curtains over the windows allowing shade for rest. |
— |
| 2 | — |
748.343(1) - Records protection policies - how paper and electronic records will be protected from destruction and loss
In reviewing the policies and procedures, I observed the lack of a policy specifying plans for protection of paper or electronic records from destruction or loss. |
— |
| 4 | — |
748.113(5)(A) - EBI policy - For orientation, explain and document to a child in a manner that the child can understand
In reviewing the policies and procedures, I observed that the policies do not include an orientation discussion with the child regarding the Emergency Behavior Intervention policies required in 748.113(5)(A)(i-ix). |
— |
| 4 | — |
748.3563(c) - Protective Surfacing-If loose-fill surfacing materials are used, the operation must install 9 inches or more of uncompressed loose-fill material
During the inspection, I observed the protective surface fill to be at least two inches below the nine inch measuring mark on the equipment. |
— |
| 2 | — |
748.343(2)(A) - Records protection policies - Clarify persons within operation authorized to access records
In reviewing the policies and procedures, I observed that the policies do not specify the individuals within the operation with access to records. |
— |
| 3 | — |
748.363(9) - Personnel records - Include a statement signed and dated by the employee that he has read a copy of the operational policies.
During the inspection, I observed 4 of 4 employee records reviewed lacked a statement signed by the employee acknowledging having read the operation Policies and Procedures. |
— |
| 2 | — |
748.533(a)(5) - Child-care administrator-Can be administrator for two operations if the Operations are contiguous
In review of the operation records, I observed that the administrator for the operation is also the administrator for another non-contiguous General Residential Operation in another region. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During the walkthrough, I observed the window in the kitchen that would be used to ventilate in case of smoke not having a screen. |
— |
| 2 | — |
748.1439(b)(4) - Discharge Documentation-Send copy of assessments and/or evaluations you performed to next placement/caregiver within 15 days
No assessments or evaluations were given to the worker when the child was discharged. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
During the walkthrough, I observed three over the counter medication logs lacked the time the medicine was administered. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location
During the inspection, I observed that three of the four records reviewed did not have allergy information clearly identified in the file or on the outside of the record. |
— |
| 2 | — |
748.345(3) - Electronic records policies - Requirements for routine back-up of data
In reviewing the policies and procedures, I observed that the lack of a policy addressing the requirements for routine back-up of data. |
— |
| 3 | — |
748.111(1) - Child-care policy - Describes visitation
In reviewing the policies and procedures, I observed that the visitation rights policies do not include policies for visitation between the children and friends. Dating is covered, but visitation with friends is absent. |
— |
| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
During the inspection, I observed that one of four employee files lacked proof of Tuberculosis screening completed within 30 days of initiating employment. |
— |
| 4 | — |
748.3271(3) - First Aid Kits-Each one must be in good condition and not have expired medications or supplies
During the inspection, I observed that the first aide kits reviewed contained several expired medications or supplies. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
During the inspection, I observed that two of the four personnel files reviewed lacked drug testing results in accordance with the operation's policies. |
— |
| 4 | — |
748.3271(3) - First Aid Kits-Each one must be in good condition and not have expired medications or supplies
During the inspection, I observed that the first aide kits reviewed contained several expired medications or supplies. |
— |
| 3 | — |
748.115(2) - Discipline policy - Integrate trauma informed care into the care, treatment, and management of each child
In reviewing the policies and procedures, I observed that the discipline policies do not detail how Trauma Informed Care is integrated into the care of the children. |
— |
| 3 | — |
748.509 - TB screening-Caregivers, employees, volunteers, contract service providers screened for TB before having contact with children in care
Upon review of 2 employees files it was found that both employees completed the required TB test after their start date with the operation. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
During the inspection, I observed one of four children?s medication records reflected the operation failed to administer the second dose of a medication prescribed for administration twice daily. |
— |
| 2 | — |
748.1439(b)(1) - Discharge Documentation-Discharge summary provided to next placement or caregiver within 15 days of discharge
No services, accomplishments, or assessments were included in discharge paperwork |
— |
| 3 | — |
748.363(9) - Personnel records - Include a statement signed and dated by the employee that he has read a copy of the operational policies.
During the inspection, I observed 4 of 4 employee records reviewed lacked a statement signed by the employee acknowledging having read the operation Policies and Procedures. |
— |
| 5 | — |
748.105(6) - Personnel Policies - Ensure that personnel policies comply with background check requirements
In reviewing the policies and procedures, I observed that the background check policies do not specify the types of background checks applicable to the various positions employed by the facility. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
During the walkthrough, I witnessed a child in care holding an applicator of over-the-counter medication she spilled on her blanket with no caregiver within auditory or visual range of the child. |
— |
| 4 | — |
748.113(2) - EBI policy - the specific techniques that caregivers can use
In reviewing the policies and procedures, I observed that the EBI policies do not list specific techniques approved for use by caregivers and the general descriptions do not match what was identified on the application. |
— |
| 2 | — |
748.119(3) - Volunteer policy - Address orientation and training programs for the volunteers
In reviewing the policies and procedures, I observed that the volunteer policies do not specify the training requirements for volunteers. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
A child's medication record was missing pill counts for three days. Counts need to be entered within 2 hours after administration. |
— |
| 4 | — |
748.113(1) - EBI policy - a complete description of EBIs that you permit caregivers to use
In reviewing the policies and procedures, I observed that the EBI policies list a number of EBI procedures that do not match the EBI procedures listed on the application. The EBI description is not specific to the EBI system used. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location
During the inspection, I observed that three of the four records reviewed did not have allergy information clearly identified in the file or on the outside of the record. |
— |
| 3 | — |
748.105(4) - Personnel Policies - Develop written policies on the training requirements for employees
In reviewing the policies and procedures, I observed that the personnel policies do not contain policies specifying the training requirements for employees and caregivers. |
— |
| 4 | — |
748.303(a)(2)(A) - AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
A child was injured at school and taken to er the following day with a fracture. This should have been called into SWI |
— |
| 2 | — |
748.343(2)(A) - Records protection policies - Clarify persons within operation authorized to access records
In reviewing the policies and procedures, I observed that the policies do not specify the individuals within the operation with access to records. |
— |
| 2 | — |
748.345(2) - Electronic records policies - Computer security systems, including confidentiality, passwords, and employee procedures
In reviewing the policies and procedures, I observed the lack of a policy pertaining computer security systems addressing confidentiality, password protection parameters, and network access. |
— |
| 2 | — |
748.533(a)(5) - Child-care administrator-Can be administrator for two operations if the Operations are contiguous
In review of the operation records, I observed that the administrator for the operation is also the administrator for another non-contiguous General Residential Operation in another region. |
— |
| 3 | — |
748.363(1) - Personnel records-Include date of employment
During the inspection, I observed that three of the four employee files reviewed lacked documentation showing the date of employment for the individual. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
During the walkthrough, I observed three over the counter medication logs lacked the time the medicine was administered. |
— |
| 3 | — |
748.105(1) - Personnel Policies - Develop a written organizational chart showing administrative/professional/staffing structures and lines of authority
In reviewing the policies and procedures, I observed that the organizational chart does not label and specify the supervisory relationships between each tier of employee. |
— |
| 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
The fire extinguishers need to be serviced annually. |
— |
| 4 | — |
748.113(9)(B) - EBI policy - A child/adult client/resident because someone on behalf of the client files a complaint, provides information relating to misuse of EBI
In reviewing the policies and procedures, I observed that the EBI policies do not include a prohibition against retaliating against an individual for filing a complaint, grievance, or providing good-faith information regarding the misuse of emergency behavior intervention on behalf of another individual. |
— |
| 4 | — |
748.113(9)(A) - A person for filing a complaint, presenting grievance, or providing information relating to the misuse of EBI at the operation
In reviewing the policies and procedures, I observed that the EBI policies lack a prohibition against retaliation toward an individual for filing a complaint, presenting a grievance, or otherwise providing information about the misuse of emergency behavior interventions at the operation. |
— |
| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
During the inspection, I observed that one of four employee files lacked proof of Tuberculosis screening completed within 30 days of initiating employment. |
— |
| 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.
During the walkthrough, I observed cleaning chemicals and lice treatments stored in an unlocked cabinet in the kitchen, accessible to children. The operation relocated these chemicals to a secured location. |
Yes |
| 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 inspection, I observed that three of the fire extinguishers in the operation have not been inspected or serviced by a fire marshall or qualified entity within the past twelve months. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the inspection, I observed that the administrator was not present and does maintain daily supervision and oversight of the operation. |
— |
| 2 | — |
748.343(2)(B) - Records protection policies - Clarify persons outside operation authorized by law to access records
In reviewing the policies and procedures, I observed that the policies do not specify the individuals outside of the operation with access to records. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
During the walkthrough, I observed that the med log for the only child taking prescription medications did not record the name of the prescribing doctor nor the reason for the prescription. |
— |
| 3 | — |
748.111(13) - Child-care policy - Types and frequency of reports to parents
In reviewing the policies and procedures, I observed the frequency of reports to parents is not specified. The policy mentions regular reports but does not specify frequency. |
— |
| 1 | — |
748.345(1) - Electronic records policies - What records must be in external paper file and those that can be stored in electronic file
In reviewing the policies and procedures, I observed the lack of a policy specifying which records must be in external paper files and those that can be stored electronically. |
— |
| 4 | — |
748.113(5)(A) - EBI policy - For orientation, explain and document to a child in a manner that the child can understand
In reviewing the policies and procedures, I observed that the policies do not include an orientation discussion with the child regarding the Emergency Behavior Intervention policies required in 748.113(5)(A)(i-ix). |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
During the inspection, I observed three bedrooms that lacked curtains over the windows allowing shade for rest. |
— |
| 1 | — |
748.101(3) - Plans to submit - sketch of operation's floor plan
In reviewing the policies and procedures, I observed that the floor plan provided identifies rooms marked as bedrooms, but does not specify where caregivers and children will be sleeping respectively. |
— |
| 3 | — |
748.363(3) - Personnel records-Include current job description
During the inspection, I observed two of the four personnel records lacking current job descriptions. |
— |
88 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.