Capacity 22. 10-18
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.2855(a) - EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
During the inspection, I observed that the mock file did not include a mock EBI report for review. |
Yes |
| 5 | — |
748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583
During the follow up inspection, two of three personnel files did not contain the required TB test results. |
— |
| 5 | — |
748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.
The operation's suicide prevention, intervention, and postvention policy found on page 177, indicates the operation will utilize the training curriculum by the Suicide Coalition of Texas, ASK Gatekeeper. |
— |
| 5 | — |
748.3(a) - The permit holder must ensure compliance with applicable minimum standards rules
During the initial inspection, it was discovered the permit holder has failed to maintain compliance with Minimum Standards at all times. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
The operation failed to submit proof of a thermometer reading 40 degrees Fahrenheit or below in the mini fridge in the kitchen by the compliance date. |
— |
| 5 | — |
748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.
During the initial inspection, four of four personnel records reviewed, were lacking 1 hour of annual suicide prevention training. During the follow up inspection completed on 7/8/2024, the four personnel records still did not have the annual suicide prevention training. |
— |
| 4 | — |
748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean
During the walkthrough, it was noted that room #311 was missing a shower head. It was also noted that room #8 the bathtub was stopped up and there was sitting brown water that was unable to drain. I observed room #9 to have a toilet that did not work. The laundry room had a non-working toilet as well, and the toilet bowel was full of brown stains, and there was missing sheet rock with exposed pipes. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
During the inspection, the operation was unable to provide access to all active records for immediate review. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During an inspection it was found that there were several issues with the exterior of the building. There was paint peeling off the building and siding was missing with insulation exposed. In the interior of the building the floors in the hallway and staff areas needed repair. There was paint peeling in 4 of the occupied rooms and 2 of the unoccupied rooms. In 2 of the occupied and unoccupied rooms screens needed to be installed properly. Several of the screens had holes in them and needed repair. In two of the occupied rooms the drywall had cracks. In one of bathrooms the bathtub was slow to drain. |
— |
| 3 | — |
748.539 - Child-care administrator must designate a licensed child-care administrator responsible for the operation while the administrator is absent
During the initial inspection, it was observed the child care administrator has been frequently absent and did not have a licensed child care administrator designated to be responsible for the operation in their absence. |
— |
| 5 | — |
748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583
During the follow up inspection, two of three personnel files did not contain the required TB test results. |
— |
| 5 | — |
748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.
During the initial inspection, four of four personnel records reviewed, were lacking 1 hour of annual suicide prevention training. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
During the investigation it was learned that the operation had mold in part of the building. The operation was supposed to have this mold tested but never sent licensing the results. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the inspection it was noted that several bedrooms had blinds that broken, a bedroom had a tear in the wallpaper, bedroom light wasn't working, exposed wires in offices and living room, 5 gallon bucket of paint in the bathroom, and the room with the Saints decor was missing trim. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During the first initial inspection, there were two medication records that did not follow the prescribing health care professional's orders. One child was missing multiple days of medication while another child was missing one single dose of medication. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed staff did not complete a child's discharge documentation correctly. Corrections were due on 6/6/2024. During the follow up inspection on 6/26/2024, corrections had not been received and the operation was re-cited for the deficiency. |
— |
| 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 four fire extinguishers at the operation were due for inspection in November of 2023. |
— |
| 4 | — |
748.3443(a)(3) - Food Preparation-Food items must be protected from contamination
During the inspection, I observed an uncovered drink cup containing fluid in the mini-fridge and a container of animal crackers with no lid, leaving both items intended for consumption unprotected from contamination. |
— |
| 3 | — |
748.123 - Vaccine preventable policy - develop and implement written policy for vaccine-preventable diseases
The operation did not provide a policy (748.123), to include how they plan on protecting the children in care from vaccine-preventable diseases of employees. |
— |
| 3 | — |
748.303(e)(1)(A) - Serious Incident-Report to Licensing no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary
During the initial inspection, it was discovered the operation did not notify RCCR when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
The operation was required to relocate the children due to safety concerns and during the transport of the medication it was not secured in a locked container. The unlocked medication was transported with the children. |
— |
| 4 | — |
748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.
During the follow up inspection, two of three personnel files reviewed did not contain the documentation to reflect the operation contacted the required references to verify that the applicant is suitable to work with or around children. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed staff did not maintain current, true, accurate and complete records. Corrections were due on 6/6/2024. During the follow up inspection on 6/26/2024, corrections had not been received and the operation was re-cited for the deficiency. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
The purpose and mission statement, located on page 2, states "Open Hearts Children and Family Services (also referred to as Open Hearts or OHCFS in this document) is a license Foster Care Child Placement and Adoption Agency." |
— |
| 2 | — |
748.111(4) - Child-care policy - Child's right to receive and give gifts
The admission policy, beginning on page 39, does not specify the child's rights to receive and give gifts to family, friends, employees, or other children in care, including any restrictions on gifts. |
— |
| 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
During the DFPS investigation, it was discovered staff was aware of allegations of abuse, neglect, or exploitation and did not notify RCCR. |
— |
| 4 | — |
748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds
In reviewing the medications, I observed two discontinued medications stored in the active medication bins. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walkthrough of the operation, it was observed in several designated bedroom's bathrooms have dirty water running out of the faucets. In one of the designated bedroom's bathroom, it was observed a shelf was sitting in the sink instead of being mounted on the wall. |
— |
| 2 | — |
748.393(a) - Active child record-kept at operation where child is receiving services
During the inspection, the operation did not provide a complete child's record for review. |
— |
| 4 | — |
748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
During the walk-through it was noted that the operation's medication room had a keypad/key lock on the door, however, inside the room they did not have a lock box or a lock on a cabinet to ensure Schedule II medications were double locked. The staff reported they would purchase a lock to go on the cabinet. |
— |
| 3 | — |
748.125(g)(2)(E)(ii) - You must offer MH resources for children/staff who have a difficult time coping including referrals to grief counseling and support groups.
During the investigation, I discovered the operation failed to debrief with the residents and staff following the suicide attempt to offer mental health referrals as required. |
— |
| 3 | — |
748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records
Multiple training certificates include the signature of the administrator, but the administrator denied being present for the training, facilitating the training, or signing the certificates. |
— |
| 4 | — |
748.1935(c) - Care for children and adults-adult residents may not be counted as caregivers in the child/caregiver ratio.
The care for children and adults policy beginning on page 215, states "adults in care act as caregivers and The Village of Open Hearts will maintain its caregiver ratios." |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
During the investigation, I discovered the operation failed to operate according to its accepted suicide prevention, intervention, and postvention policies. |
— |
| 4 | — |
748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
During the standard-by-standard inspection, it was noted the operation is providing treatment services, but does not have a treatment director. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
The operation's serious incident report policy states that employees shall report serious incidents to the abuse hotline, without delegating the reporting to another party. Based on the information provided, staff are required to only document serious incidents so management staff can review the incidents and report to the hotline when deemed necessary. Therefore, operation staff failed to follow their written serious incident reporting policy. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
During the first initial inspection, one child's case file was missing a completed initial service plan within 45 days of admission. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
During the initial inspection, a caregiver was heard yelling at a child about taking clothes that didn't belong to the child. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency. |
— |
| 2 | — |
748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
During the first initial inspection, there were four child files reviewed and it was observed that three did not contain immunizations records. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
During the first initial inspection, there were two medication records that were missing the name and signature of person who administered the medication. |
— |
| 4 | — |
748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair
During the second follow-up inspection, I observed the freezer unit in the pantry area does not close properly, resulting in frost ringing the unit and the freezer not sealing properly. The freezer has food items stored within. |
— |
| 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
The operation failed to submit a correction plan or proof of corrections addressing the caregiver's TB test results by the compliance date. |
— |
| 4 | — |
748.303(e)(3)(A) - Serious Incident- Report to licensing no later than 24 hours after temporarily moving to or providing care at any location not noted on your permit.
The operation had to temporarily relocate the children in care due to a physical site concern and did not report the incident to licensing. |
— |
| 2 | — |
748.1349(a)(3) - Initial Service Plan-Give copy or summary of plan to child's caregivers
When a child's service plan has been completed, the operation's management staff does not discuss service plan requirements with direct care staff. |
— |
| 3 | — |
748.539 - Child-care administrator must designate a licensed child-care administrator responsible for the operation while the administrator is absent
After conducting an investigation inspection, Licensing was unable to exit with the administrator. Two attempts were made to contact the administrator by telephone. It was reported by the case manager the administrator was out due to an eye procedure, and she was not aware of who was left in charge. |
— |
| 4 | — |
748.911(b)(3)(A) - One caregiver in ratio must have certificate of training with an expiration or renewal date in Pedi/Adult CPR if serving children 0 to 17.
During the initial inspection, three of four personnel records reviewed did not have the correct CPR training to serve pediatrics/adult as required by Minimum Standards. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the initial inspection, it was discovered the child care administrator was not present. Six children were interviewed and all denied knowing who she was or having seen her. |
— |
| 3 | — |
748.303(e)(1)(A) - Serious Incident-Report to Licensing no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary
During the initial inspection, it was discovered the operation did not notify RCCR when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
During the sampling inspection, one of two child's record reviewed, was missing a non-emergency admission assessment prior to admission. |
— |
| 4 | — |
748.303(a)(2)(B) - AP Serious Incdt- Report to parents any injury/illness that warrants treatment from a medical prof. directly after ensuring the safety of the child.
During two separate incidents, two children in care sustained injuries that required medical treatment. These incidents were not reported to the children's caseworkers. |
— |
| 3 | — |
748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules
Per the operation's transportation and travel policy on page 174, the operation allows transportation of children by caregivers over the age of 18. The transportation policy beginning on page 248, reflects the caregiver must be over the age of 21. |
— |
| 4 | — |
748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director
During the follow up inspection, it was noted the operation is providing treatment services, but does not have a treatment director that has completed the hiring process. |
— |
| 4 | — |
748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional
During the investigation, I discovered the operation failed to complete the follow-up medical appointment for a child taken to the hospital for suicidal evaluation in a timely manner. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
The operation failed to submit a correction plan or proof of corrections addressing the direct care staff yelling at a child in care by the compliance date. |
— |
| 5 | — |
745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605
During the inspection, it was observed that four of the six employees still had pending background checks. CBCU advised fingerprints had not been completed and the background checks were set to be closed as non-compliant. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
During the first initial inspection, one of four records reviewed did not contain the discharge documentation for a child. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the inspection, I observed the deep freezer in the pantry area that does not close and containes food items lacks a thermometer and internal temperature cannot be verified. |
— |
| 4 | — |
748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair
During the inspection, I observed a freezer unit in the pantry area that did not seal well, creating a rim of ice that prevents the freezer from being closed fully. Food items were stored in this freezer. |
— |
| 2 | — |
748.361(a) - Personnel records - All active records maintained at the operation
During the follow up inspection, employee records maintained at the operation were not complete. The employee records were missing training certificates for CPR/First Aid, EBI, orientation, pre-service training, and drug test results. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Between 7/3/2024 and 7/14/2024, five requests were made to obtain operation documents. The documents were not provided until 7/18/2024. |
— |
| 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 initial inspection, one of the four personnel records reviewed, did not have a TB exam. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Operation staff failed to provide appropriate supervision for a 13-year-old child in care that was required to have line-of-sight supervision. The staff member allowed the child to play outside of the operation alone, unsupervised and also allowed the child to leave the operation without a staff member or an approved adult to supervise. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
During the second follow-up inspection, I observed a mini-fridge in the kitchen still lacked a thermometer. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During the second follow-up inspection, I observed the damage to the drywall in the recreation room remains unrepaired, a cracking drywall patch in a bedroom remains unrepaired, and an unsecured nail in a bedroom remained. The previous resident of the room had recent self-injurious behaviors, and the room is currently occupied by a new resident without the nail being removed. These errors were not corrected from the preceding follow-up inspection. |
— |
| 3 | — |
748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care
During the walkthrough it was noted the first-aid kit was missing the following, adhesive tape, scissors, and tweezers. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
During the first initial inspection, there was a standalone freezer that was observed to have been accidentally unplugged causing the ice to melt and the food to spoil. |
Yes |
| 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, I observed a mini-fridge in the kitchen area that lacked a thermometer. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
During interviews it was determined the three victims discovered a wine bottle in the refrigerator, however the four staff interviewed denied being aware of the wine bottle at the location. It was noted the bottle of wine was in the refrigerator within reach of children for three days. |
— |
| 4 | — |
748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards
During the walk-through it was noted the window in room twenty did not have a screen. It was also noted room eighteen had insects in the room. |
— |
| 3 | — |
748.683(2) - Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately
The operation's administrator and permit holder have failed to provide adequate oversight of all operation staff and supervise their job duties appropriately as they are not present at the operation full-time or available immediately to assist in an emergency situation or intervene when an incident occurs at the operation. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
In reviewing the medication records, I observed two of three children's records reviewed failed to document the name of physician prescribing the medication. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
During a review of the medication records 2 children's records showed missed doses of medication with no explanation given. One child's medication was missed, and the explanation was the child was on an outing. |
— |
| 2 | — |
748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level
During the inspection, two of two child's records were reviewed and both were missing orientation information completed with the children within 7 days of placement. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
In reviewing medication records, I observed a child was administered a medication several days after the label indicated the medication should be discontinued. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
During the course of the investigation, it was determined that the operation failed to provide a safe environment. Staff members failed to intervene when a non-staff member engaged in a verbal altercation with a child in care. |
— |
| 3 | — |
748.303(e)(1)(B) - Serious Incident-Report to parents no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary
During the initial inspection, it was discovered the operation did not notify parents when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. |
— |
| 4 | — |
748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings
During the walk-through it was noted the operation failed to post the emergency evacuation & relocation diagram. |
— |
| 3 | — |
748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below
The operation's refrigerator and freezer did not contain a thermometer to measure the temperature. |
— |
| 2 | — |
748.127(a) - Operation plans, policies and procedures must indicate date adopted and effective date
The operation's plans, policies, and procedures does not indicate the date adopted and effective date. |
— |
| 3 | — |
748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.
During the investigation, I discovered a resident over the age of ten years did not receive his 90-day administration of the suicide screening tool. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
The operation's incident report does not include the operation's telephone number. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Two direct care staff failed to provide adequate supervision due to them sleeping while on shift supervising children in care. |
— |
| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
During the first initial inspection, there was one child's record that did not include an admissions assessment. |
— |
| 5 | — |
748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain
On two separate occasions, a child in care sustained head injuries when they hit their head on concrete and the tile floor. The head injuries were described by staff as bleeding and "a good size bump." Staff failed to take the child to be evaluated by medical professionals. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During a follow up inspection, it was found that there were still several issues with the exterior of the building. There was paint peeling off the building and siding was missing with insulation exposed. In the interior of the building the floors in the hallway and staff areas needed repair. There was paint peeling in 4 of the occupied rooms and 2 of the unoccupied rooms. Several of the screens had holes in them and needed repair. In two of the occupied rooms the drywall had cracks. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walkthrough, I observed four rooms with baseboards that were separating from the wall or that needed caulking, two rooms with cracked paint in need of repair, damaged tile on the floor of the laundry room and in the hallway, exposed wires in the recreation room capped with wiring nuts but accessible to children, and an exposed drain in the hallway that needs capping. |
— |
| 3 | — |
748.363(4) - Personnel records-Personnel records-Include current job description.
During the follow up inspection, two of three personnel files did not contain the current job description document required by minimum standards. |
— |
| 3 | — |
748.115(5) - Discipline policy - Include a statement that discipline of any type is not allowable for infants
The discipline and punishment policy, beginning on page 221, does not include a statement that discipline of any type is not allowable for infants. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the initial inspection, it was discovered the child care administrator was not present. Six children were interviewed and all denied knowing who she was or having seen her. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
During the initial inspection, a caregiver was heard yelling at a child about taking clothes that didn't belong to the child. |
— |
| 3 | — |
748.3443(a)(6) - Food Preparation-Food items must be covered when stored in the refrigerator
During the walk-through, there was a roll of sausage in the refrigerator that was not properly packaged and stored. This was corrected at inspection. |
Yes |
| 3 | — |
748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed several bedrooms/bathrooms were not in good repair. Corrections were due on 6/10/2024. During the follow up inspection on 6/26/2024, there were three bedrooms with chipped paint. The operation was re-cited for the deficiency. |
— |
| 3 | — |
748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below
The operation failed to submit evidence of thermometers being installed in all freezers and exhibiting temperatures below 0 degrees Fahrenheit by the compliance date. |
— |
| 3 | — |
748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.
The operation failed to submit a correction plan or proof of corrections addressing the physical site by the compliance date. |
— |
| 3 | — |
748.303(e)(1)(B) - Serious Incident-Report to parents no later than 24 hours after the incident if all or part of operation rendered unsafe or unsanitary
During the initial inspection, it was discovered the operation did not notify parents when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency. |
— |
| 3 | — |
748.109 - Admission policies must include description of each program you offer
The admission policy, located on page 36, states "The Village of Open Hearts to provide Emergency Care Services to you in need of substitute foster care or other out of home care." It is also observed that the policy uses emergency care services and emergency admissions, interchangeably. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
The operation failed to submit corrections exhibiting completion of the repairs to the drywall in the bedroom and rec room or the securing of the bare nail in the resident wall by the compliance date. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
During the inspection, I observed damage to the drywall in a recreation room, a cracking drywall patch in a bedroom, and unsecured nails in the wall of a resident with recent self-injurious behaviors. |
— |
| 3 | — |
748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation
During the investigation, it was learned that the administrator has not been to the operation for on-site administrative oversite. It appears that none of the children and many of the staff are no familiar with the administrator and have not either met her or seen her in months. |
— |
| 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, I observed a mini-fridge in the kitchen still lacked a thermometer. |
— |
224 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.