Capacity 13. 5-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child that was required 1:1 supervision was left unsupervised with another child resulting in inappropriate contact between the children. The children were also allowed to be on the couch together under blankets. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Multiple medication logs reviewed did not have the reason medication was prescribed. |
— |
| 4 | — |
748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
One employee's file reviewed did not have a completed pre-employment screening. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
The child in care did not receive his insulin according to the management plan. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
Two Medication logs reviewed were missing the time each medication was provided. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
A child in care was not given his prescription eye drops as instructed by the doctor. |
— |
| 3 | — |
748.363(11) - Personnel records-Include record of training and training hours
Employee records missing ceritifcations or memorandum of training completed per minimum standard requirement. |
— |
| 4 | — |
748.2005(b) - Medication Orders-A verbal order must be documented in the record, including the health care professional's name, date and time of call
On January 12, 2024 medical documentation indicates that a child should take Ondansetron and fluocinolone to manage their medical condition. These prescriptions were not filled by the operation. |
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
Two children files did not have TB Test results |
Yes |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
1 out 3 staffs files didnt have thier First Aid completed. |
Yes |
| 4 | — |
748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
A staff member who was using EBI on a child in care was assisted by a staff member who was not trained in EBI. |
— |
| 3 | — |
748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period
A staff member did not complete annual trainings in a timely manner nor by the required time frame. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child in care requires 1:1 supervision. The child is being provided line of sight supervision. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
A child in care medication log was not signed by staff. The medication log was seen in the child's binder. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
The written incident report still does not include the phone number for the operation. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition 1 - Met; Condition 2 - Met; Condition 3 - Not Met - Two children had errors on their medication audits that were not reviewed by the LCCA or contained a compliance plan; Condition 4 - Met; Condition 5 - Not Met - Observation reports were not signed by all three governing body members. |
— |
| 2 | — |
748.1545(b) - Vision and hearing screening - Results on file for child, or parental statement that school has records or screening should not be done
The three children files reviewed did not have vision or hearing exams. |
Yes |
| 4 | — |
748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations
A child did not receive their medication for 03/13/25 and there was not a documentation addressing the error completed. |
— |
| 3 | — |
748.2953(a) - Evaluation-Quarterly, operation must collect, document, & review aggregate numbers of emergency behavior interventions by type of intervention
EBI Quarterly reports were not submitted for the 1st, 2nd and 3rd quarters. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
The medication log did not have a specific time as to when the medication was given. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Two staff members were not properly supervising a child who was attempting to cause harm to own wrist and was able to gain access to an item and place around the neck. |
— |
| 1 | — |
748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom
There were two bedrooms that are designated for male children that is not near a restroom. The children have to walk through the case manager's office, living room, two hallways and the master bedroom to reach the restroom that is designated for them. |
— |
| 4 | — |
748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication
A staff member provided medications to a child in care without being trained. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
One employee's file reviewed had an affidavit that was not notarized. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The incident report reviewed had incorrect documentation on whether the child loss consciousness or not. Also, the EBI reports did not document the restraints as separate documents. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition 1: Met Condition 2: No met. A training for a staff member expired in December and there was no documentation showing the staff was notified of her expired training or when they were due. Condition 3: Met Condition 4: Not due yet. Condition 5: Not met. There were two noted concerns by a youth with no plan to follow up on the concerns. |
— |
| 4 | — |
748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.
Personnel file support that trainings were completed online through DFPS. The instructor lead portion is not being completed by a medical professional. |
Yes |
| 3 | — |
748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded
One report reviewed indicated two restraints were used on a child and both restraints did not have a time documented for how long the restraints lasted. |
— |
| 5 | — |
748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.
One restraint report reviewed documented that a child was held in a personal restraint for an hour and 45 minutes. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
The grass in the backyard needed to be mowed and there was a tree in the middle of the property that had fallen. |
— |
| 3 | — |
748.363(1) - Personnel records-Include date of employment
The Treatment Director's case file does not support a hire date. The case file also is missing numbers 3, 4, 6-9, and 11-14 of this rule. |
Yes |
| 4 | — |
748.2651(a) - Seclusion-Caregivers must continuously observe the child; use of window or one-way mirror allowed; use of video camera not permitted
The entry/exit doors to a room have child locking devices on the doorknobs. This room was used to isolate a child while escalated. The child was left alone in the room without a method to supervise. The operation is not permitted to provide seclusion services as a behavior intervention. |
— |
| 5 | — |
748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back
A caregiver restrained a child by placing both arms behind the back. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
The caregiver did not use prudent judgement when distributing medication to two non-verbal children in care, resulting in the children receiving the wrong medication. |
— |
| 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 staff member with a provisional status is not following all the conditions of the restrictions by administering medication to children. |
— |
| 4 | — |
748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person
Prescription medication for two siblings was administered incorrectly which resulted in one sibling being given the other siblings medication. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Child in care was hit by a staff member. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition 1- Compliant Condition 2- The operation's timeframe to implement this condition has not expired. Pending Review. Condition 3- Compliant Condition 4-The operation's timeframe to implement this condition has not expired. Pending Review. Condition 5- Deficient-. The observation forms did not include the signature of the Governing Body within 48 hours of the observation. The observation log did ensure that all observations were conducted by the Administrator, Designee on record, or Designated person in Management (not to include Direct Staff or Direct Care Supervisors). The observation did not evaluate the interactions of the Direct Care Supervisors, Caregivers, and Children in Care |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
A child in care medication log was not signed by staff. The medication log was seen in the child's binder. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition 1 - Met; Condition 2 - Met; Condition 3 - Not Met - Two children had errors on their medication audits that were not reviewed by the LCCA or contained a compliance plan; Condition 4 - Met; Condition 5 - Not Met - Observation reports were not signed by all three governing body members. |
— |
| 4 | — |
748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
A staff member who was using EBI on a child in care was assisted by a staff member who was not trained in EBI. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Multiple medication logs reviewed did not have the reason medication was prescribed. |
— |
| 5 | — |
748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back
A caregiver restrained a child by placing both arms behind the back. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
A child in care was not given his prescription eye drops as instructed by the doctor. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
The medication log did not have a specific time as to when the medication was given. |
— |
| 3 | — |
748.363(1) - Personnel records-Include date of employment
The Treatment Director's case file does not support a hire date. The case file also is missing numbers 3, 4, 6-9, and 11-14 of this rule. |
Yes |
| 4 | — |
748.2203(a) - Medication Error-If prescription medication, contact a health-care professional immediately & follow health-care professional's recommendations
A child did not receive their medication for 03/13/25 and there was not a documentation addressing the error completed. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
The child in care did not receive his insulin according to the management plan. |
— |
| 2 | — |
748.1545(b) - Vision and hearing screening - Results on file for child, or parental statement that school has records or screening should not be done
The three children files reviewed did not have vision or hearing exams. |
Yes |
| 3 | — |
748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded
One report reviewed indicated two restraints were used on a child and both restraints did not have a time documented for how long the restraints lasted. |
— |
| 4 | — |
748.2651(a) - Seclusion-Caregivers must continuously observe the child; use of window or one-way mirror allowed; use of video camera not permitted
The entry/exit doors to a room have child locking devices on the doorknobs. This room was used to isolate a child while escalated. The child was left alone in the room without a method to supervise. The operation is not permitted to provide seclusion services as a behavior intervention. |
— |
| 3 | — |
748.2953(a) - Evaluation-Quarterly, operation must collect, document, & review aggregate numbers of emergency behavior interventions by type of intervention
EBI Quarterly reports were not submitted for the 1st, 2nd and 3rd quarters. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child that was required 1:1 supervision was left unsupervised with another child resulting in inappropriate contact between the children. The children were also allowed to be on the couch together under blankets. |
— |
| 5 | — |
748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.
One restraint report reviewed documented that a child was held in a personal restraint for an hour and 45 minutes. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition 1- Compliant Condition 2- The operation's timeframe to implement this condition has not expired. Pending Review. Condition 3- Compliant Condition 4-The operation's timeframe to implement this condition has not expired. Pending Review. Condition 5- Deficient-. The observation forms did not include the signature of the Governing Body within 48 hours of the observation. The observation log did ensure that all observations were conducted by the Administrator, Designee on record, or Designated person in Management (not to include Direct Staff or Direct Care Supervisors). The observation did not evaluate the interactions of the Direct Care Supervisors, Caregivers, and Children in Care |
— |
| 3 | — |
748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period
A staff member did not complete annual trainings in a timely manner nor by the required time frame. |
— |
| 4 | — |
748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.
Personnel file support that trainings were completed online through DFPS. The instructor lead portion is not being completed by a medical professional. |
Yes |
| 4 | — |
748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
One employee's file reviewed did not have a completed pre-employment screening. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The incident report reviewed had incorrect documentation on whether the child loss consciousness or not. Also, the EBI reports did not document the restraints as separate documents. |
— |
| 3 | — |
748.363(11) - Personnel records-Include record of training and training hours
Employee records missing ceritifcations or memorandum of training completed per minimum standard requirement. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
One employee's file reviewed had an affidavit that was not notarized. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Child in care was hit by a staff member. |
— |
| 4 | — |
748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person
Prescription medication for two siblings was administered incorrectly which resulted in one sibling being given the other siblings medication. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child in care requires 1:1 supervision. The child is being provided line of sight supervision. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
The grass in the backyard needed to be mowed and there was a tree in the middle of the property that had fallen. |
— |
| 4 | — |
748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication
A staff member provided medications to a child in care without being trained. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition 1: Met Condition 2: No met. A training for a staff member expired in December and there was no documentation showing the staff was notified of her expired training or when they were due. Condition 3: Met Condition 4: Not due yet. Condition 5: Not met. There were two noted concerns by a youth with no plan to follow up on the concerns. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Two staff members were not properly supervising a child who was attempting to cause harm to own wrist and was able to gain access to an item and place around the neck. |
— |
| 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
Two children files did not have TB Test results |
Yes |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
1 out 3 staffs files didnt have thier First Aid completed. |
Yes |
| 1 | — |
748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom
There were two bedrooms that are designated for male children that is not near a restroom. The children have to walk through the case manager's office, living room, two hallways and the master bedroom to reach the restroom that is designated for them. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
The written incident report still does not include the phone number for the operation. |
— |
| 4 | — |
748.2005(b) - Medication Orders-A verbal order must be documented in the record, including the health care professional's name, date and time of call
On January 12, 2024 medical documentation indicates that a child should take Ondansetron and fluocinolone to manage their medical condition. These prescriptions were not filled by the operation. |
Yes |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
The caregiver did not use prudent judgement when distributing medication to two non-verbal children in care, resulting in the children receiving the wrong medication. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
Two Medication logs reviewed were missing the time each medication was provided. |
— |
| 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 staff member with a provisional status is not following all the conditions of the restrictions by administering medication to children. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
The medication log did not have a specific time as to when the medication was given. |
— |
| 4 | — |
748.911(c)(1) - Each caregiver must be certified in first aid within 90 days of employment.
1 out 3 staffs files didnt have thier First Aid completed. |
Yes |
| 4 | — |
748.2003(b)(6) - Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication
A staff member provided medications to a child in care without being trained. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
A child in care medication log was not signed by staff. The medication log was seen in the child's binder. |
— |
| 5 | — |
748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.
One restraint report reviewed documented that a child was held in a personal restraint for an hour and 45 minutes. |
— |
| 4 | — |
748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person
Prescription medication for two siblings was administered incorrectly which resulted in one sibling being given the other siblings medication. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
One employee's file reviewed had an affidavit that was not notarized. |
— |
| 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 staff member with a provisional status is not following all the conditions of the restrictions by administering medication to children. |
— |
| 3 | — |
748.363(1) - Personnel records-Include date of employment
The Treatment Director's case file does not support a hire date. The case file also is missing numbers 3, 4, 6-9, and 11-14 of this rule. |
Yes |
| 5 | — |
745.8641 - Requirements during probation
Condition 1- Compliant Condition 2- The operation's timeframe to implement this condition has not expired. Pending Review. Condition 3- Compliant Condition 4-The operation's timeframe to implement this condition has not expired. Pending Review. Condition 5- Deficient-. The observation forms did not include the signature of the Governing Body within 48 hours of the observation. The observation log did ensure that all observations were conducted by the Administrator, Designee on record, or Designated person in Management (not to include Direct Staff or Direct Care Supervisors). The observation did not evaluate the interactions of the Direct Care Supervisors, Caregivers, and Children in Care |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
A child in care requires 1:1 supervision. The child is being provided line of sight supervision. |
— |
| 3 | — |
748.363(11) - Personnel records-Include record of training and training hours
Employee records missing ceritifcations or memorandum of training completed per minimum standard requirement. |
— |
| 4 | — |
748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist.
Personnel file support that trainings were completed online through DFPS. The instructor lead portion is not being completed by a medical professional. |
Yes |
| 4 | — |
748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
A staff member who was using EBI on a child in care was assisted by a staff member who was not trained in EBI. |
— |
| 3 | — |
748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period
A staff member did not complete annual trainings in a timely manner nor by the required time frame. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
Multiple medication logs reviewed did not have the reason medication was prescribed. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Two staff members were not properly supervising a child who was attempting to cause harm to own wrist and was able to gain access to an item and place around the neck. |
— |
| 4 | — |
748.2005(b) - Medication Orders-A verbal order must be documented in the record, including the health care professional's name, date and time of call
On January 12, 2024 medical documentation indicates that a child should take Ondansetron and fluocinolone to manage their medical condition. These prescriptions were not filled by the operation. |
Yes |
| 3 | — |
748.2855(a)(6) - EBI Documentation-Must include the length of time the child was restrained or secluded
One report reviewed indicated two restraints were used on a child and both restraints did not have a time documented for how long the restraints lasted. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
The grass in the backyard needed to be mowed and there was a tree in the middle of the property that had fallen. |
— |
| 2 | — |
748.1545(b) - Vision and hearing screening - Results on file for child, or parental statement that school has records or screening should not be done
The three children files reviewed did not have vision or hearing exams. |
Yes |
| 5 | — |
745.8641 - Requirements during probation
Condition 1 - Met; Condition 2 - Met; Condition 3 - Not Met - Two children had errors on their medication audits that were not reviewed by the LCCA or contained a compliance plan; Condition 4 - Met; Condition 5 - Not Met - Observation reports were not signed by all three governing body members. |
— |
| 5 | — |
745.8641 - Requirements during probation
Condition 1: Met Condition 2: No met. A training for a staff member expired in December and there was no documentation showing the staff was notified of her expired training or when they were due. Condition 3: Met Condition 4: Not due yet. Condition 5: Not met. There were two noted concerns by a youth with no plan to follow up on the concerns. |
— |
| 3 | — |
748.2953(a) - Evaluation-Quarterly, operation must collect, document, & review aggregate numbers of emergency behavior interventions by type of intervention
EBI Quarterly reports were not submitted for the 1st, 2nd and 3rd quarters. |
— |
152 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.