Capacity 24. 13-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Operation has not provided corrected operational policy. |
— |
| 1 | — |
748.1339(a) - Initial Service Plan-Service planning team must develop the service plan
2 of the 3 plans reviewed did not specify who was included or present in developing the service plans |
— |
| 2 | — |
748.753(c)(2) - Pre-Employment Screening-You must document your diligent efforts to contact the reference, which must include more than one attempt to contact.
An employee file did not have documented the number of attempts made to contact the employees' former employers or the employers refusal to provide information. In the result area of contact it stated "NA" |
— |
| 3 | — |
748.4009(c) - General requirements-There must be emergency transportation available at all times
Operation utilized a drive sharing service to transport a child who was accompanied by staff from the hospital back to the operation. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Operation staff showed inappropriate boundaries towards a resident on multiple occasions. Additional staff were aware and made comments stating it would make the child's life easier if they changed their story. In addition, staff were demeaning a child by using inappropriate labels related to child's mental health. |
— |
| 1 | — |
748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents
2 of the 3 plans reviewed did not have confirmation that required parties were notified of the date the service plans would be completed and did not give those parties an opportunity to respond |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
Residential Child Care Regulation observed the operation's emergency evacuation posters to be without documentation of a designated outside meeting point. |
— |
| 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 an inspection, record review for 1 of 5 staff files reflected only one reference was contacted instead of two. |
— |
| 4 | — |
748.2753(b) - Simultaneous Interventions-May use emergency medication with personal restraint or seclusion only if written orders justify the combination
There are no clinical orders nor documentation in the EBI report justifying the use of containment simultaneously with emergency medication or who ordered this intervention. |
— |
| 5 | — |
748.1709(a) - Nasogastric tube-must be inserted by a physician or registered nurse according to a physician's written orders
Registered Nurse or physician did not insert nasogastric tube for child in care. |
— |
| 2 | — |
748.1205(a)(8) - Admission Documentation-Includes allergies (food, medication, sting, and skin allergies)
Two child files were reviewed. The children's files did not include all necessary information within the file at the time of admission. |
— |
| 1 | — |
748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents
2 of the 3 service plans reviewed were unclear as to who received a copy of the plan |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
A caregiver initiated a personal restraint on a child when it was not required, as de-escalation techniques appeared to be managing the situation effectively and the child was not displaying aggressive behavior at the time of the restraint. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
The initial service plan time frame was outside the window of date of placement. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
A child in care cheeked medication and took more than the prescribed amount. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Operation did not provide requested documents to licensing that were requested for investigation. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
During the inspection, record review of serious incident report reflected it did not contain all the required sections of a serious incident report to include: physical address, telephone number, names of adults involved and/or their role to child, witness information, interventions made during and after incident. |
— |
| 3 | — |
748.753(b) - Pre-Employment Screening- At least one reference must be an employer who has supervised or familiar with the history of the applicant.
An employee file had reference checks; however, it was not documented if the references were professional or personal. |
— |
| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
Two child files were reviewed, there were multiple items that were missing within each child's admission assessment. |
— |
| 4 | — |
748.2753(a)(1) - Simultaneous Interventions-May use emergency medication with personal restraint or seclusion only if allowed by operation's policies
A child in care was administered emergency medication while in a two-person containment; however, the operation's EBI policy doesn't mention the use of simultaneous interventions. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During an inspection at the operation, it was found an employee did not have a completed initial background check. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
It was confirmed that a staff member told a child in care to shut up. |
— |
| 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
Two child files were reviewed. The orientation information provided to the children within seven days of admission did not include all information regarding operation policies. |
— |
| 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
11 of the 16 fire drills reviewed did not have required information. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
During an inspection, 1 of 5 staff files reflected the notarized affidavit was provided and signed but was not completed in the exception area. |
— |
| 4 | — |
748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs
Residential Child Care Regulation observed a care giver's training record to be without 40 hours of on-the-job training. The explanation note read that the care giver had this at a previous operation. |
— |
| 3 | — |
748.311(2) - Serious Incident Documentation-Includes time and date of incident
Incident reports were missing some information regarding time and date and names of adults involved. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During the walkthrough of the kitchen multiple dry and wet food items were expired and multiple food items were not stored properly. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
Two of two child admission assessments did not have a professional level service provider signature or date. |
— |
| 3 | — |
748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being
Staff member was allowed continued contact with child in care after operation was alerted of inappropriate behaviors. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Children in care were able to access razors from secured operation locations. |
— |
| 3 | — |
748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly
During walk through of operation it was observed that fire extinguishers had not been inspected for the month of October 2023. Operation staff admitted no monthly check was completed on during the month of October 2023. |
— |
| 5 | — |
748.1337(b)(1)(H)(ii) - Initial Service Plan-child w/ high risk behaviors, include specific safety contract developed btwn child & staff to ensure safety
The initial service plan provided by the operation does not discuss the child's high-risk behaviors or a specific contract developed. The operation is aware of the child's high-risk behaviors as this is the second time at this operation. |
— |
| 3 | — |
748.1207(b) - Placement agreement - Must be signed by parent
Two of two child placement agreements were reviewed, and neither were signed by the child's parent/managing conservator. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
A child in care was administered an emergency medication during a containment; however, the staff members did not follow and/or didn't provide documentation that the child received continuous 1:1 observation as required after the resident is given emergency medication for 60 minutes nor is there documentation of vital signs, skin assessment, Range of Motion, psychological assessment, and a neurological assessment completed every 15 minutes after the administration of emergency medication, nor documentation reflecting Q15 Minute assessment per the operation's EBI policies and procedures. |
— |
| 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
Intake came in on 2/15/26 stating the incident occurred on 2/13/26 and received medical treatment for their injury on the same day. This was not reported to CCR within the allocated time frame. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
Staff member engaged in a verbal confrontation with a child in care. |
— |
| 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
Child in care on 1:1 supervision swallowed a foreign object which required medical treatment such as x-rays as this could result in an unhealthy condition of the body and mind. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
Two serious incident reports did not have the operation's phone number. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Children in care were able to access razors from secured operation locations. |
— |
| 3 | — |
748.753(b) - Pre-Employment Screening- At least one reference must be an employer who has supervised or familiar with the history of the applicant.
An employee file had reference checks; however, it was not documented if the references were professional or personal. |
— |
| 4 | — |
748.2753(b) - Simultaneous Interventions-May use emergency medication with personal restraint or seclusion only if written orders justify the combination
There are no clinical orders nor documentation in the EBI report justifying the use of containment simultaneously with emergency medication or who ordered this intervention. |
— |
| 1 | — |
748.1339(a) - Initial Service Plan-Service planning team must develop the service plan
2 of the 3 plans reviewed did not specify who was included or present in developing the service plans |
— |
| 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
Child in care on 1:1 supervision swallowed a foreign object which required medical treatment such as x-rays as this could result in an unhealthy condition of the body and mind. |
— |
| 3 | — |
748.4009(c) - General requirements-There must be emergency transportation available at all times
Operation utilized a drive sharing service to transport a child who was accompanied by staff from the hospital back to the operation. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
It was confirmed that a staff member told a child in care to shut up. |
— |
| 3 | — |
748.1207(b) - Placement agreement - Must be signed by parent
Two of two child placement agreements were reviewed, and neither were signed by the child's parent/managing conservator. |
— |
| 4 | — |
748.2753(a)(1) - Simultaneous Interventions-May use emergency medication with personal restraint or seclusion only if allowed by operation's policies
A child in care was administered emergency medication while in a two-person containment; however, the operation's EBI policy doesn't mention the use of simultaneous interventions. |
— |
| 2 | — |
748.753(c)(2) - Pre-Employment Screening-You must document your diligent efforts to contact the reference, which must include more than one attempt to contact.
An employee file did not have documented the number of attempts made to contact the employees' former employers or the employers refusal to provide information. In the result area of contact it stated "NA" |
— |
| 2 | — |
748.1205(a)(8) - Admission Documentation-Includes allergies (food, medication, sting, and skin allergies)
Two child files were reviewed. The children's files did not include all necessary information within the file at the time of admission. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During an inspection at the operation, it was found an employee did not have a completed initial background check. |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
Residential Child Care Regulation observed the operation's emergency evacuation posters to be without documentation of a designated outside meeting point. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Operation staff showed inappropriate boundaries towards a resident on multiple occasions. Additional staff were aware and made comments stating it would make the child's life easier if they changed their story. In addition, staff were demeaning a child by using inappropriate labels related to child's mental health. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
A child in care was administered an emergency medication during a containment; however, the staff members did not follow and/or didn't provide documentation that the child received continuous 1:1 observation as required after the resident is given emergency medication for 60 minutes nor is there documentation of vital signs, skin assessment, Range of Motion, psychological assessment, and a neurological assessment completed every 15 minutes after the administration of emergency medication, nor documentation reflecting Q15 Minute assessment per the operation's EBI policies and procedures. |
— |
| 1 | — |
748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record
Two of two child admission assessments did not have a professional level service provider signature or date. |
— |
| 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
11 of the 16 fire drills reviewed did not have required information. |
— |
| 3 | — |
748.311(2) - Serious Incident Documentation-Includes time and date of incident
Incident reports were missing some information regarding time and date and names of adults involved. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
During the inspection, record review of serious incident report reflected it did not contain all the required sections of a serious incident report to include: physical address, telephone number, names of adults involved and/or their role to child, witness information, interventions made during and after incident. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
Staff member engaged in a verbal confrontation with a child in care. |
— |
| 3 | — |
748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form
During an inspection, 1 of 5 staff files reflected the notarized affidavit was provided and signed but was not completed in the exception area. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
A caregiver initiated a personal restraint on a child when it was not required, as de-escalation techniques appeared to be managing the situation effectively and the child was not displaying aggressive behavior at the time of the restraint. |
— |
| 5 | — |
748.1337(b)(1)(H)(ii) - Initial Service Plan-child w/ high risk behaviors, include specific safety contract developed btwn child & staff to ensure safety
The initial service plan provided by the operation does not discuss the child's high-risk behaviors or a specific contract developed. The operation is aware of the child's high-risk behaviors as this is the second time at this operation. |
— |
| 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
Two child files were reviewed. The orientation information provided to the children within seven days of admission did not include all information regarding operation policies. |
— |
| 3 | — |
748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction
Operation did not provide requested documents to licensing that were requested for investigation. |
— |
| 1 | — |
748.1341(b) - Initial Service Plan-Child's record must include documentation of advance notice to parents of planning meeting and any responses from the parents
2 of the 3 plans reviewed did not have confirmation that required parties were notified of the date the service plans would be completed and did not give those parties an opportunity to respond |
— |
| 4 | — |
748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs
Residential Child Care Regulation observed a care giver's training record to be without 40 hours of on-the-job training. The explanation note read that the care giver had this at a previous 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
Intake came in on 2/15/26 stating the incident occurred on 2/13/26 and received medical treatment for their injury on the same day. This was not reported to CCR within the allocated time frame. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During the walkthrough of the kitchen multiple dry and wet food items were expired and multiple food items were not stored properly. |
— |
| 3 | — |
748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly
During walk through of operation it was observed that fire extinguishers had not been inspected for the month of October 2023. Operation staff admitted no monthly check was completed on during the month of October 2023. |
— |
| 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 an inspection, record review for 1 of 5 staff files reflected only one reference was contacted instead of two. |
— |
| 1 | — |
748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents
2 of the 3 service plans reviewed were unclear as to who received a copy of the plan |
— |
| 3 | — |
748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being
Staff member was allowed continued contact with child in care after operation was alerted of inappropriate behaviors. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
A child in care cheeked medication and took more than the prescribed amount. |
— |
| 5 | — |
748.1709(a) - Nasogastric tube-must be inserted by a physician or registered nurse according to a physician's written orders
Registered Nurse or physician did not insert nasogastric tube for child in care. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
Two serious incident reports did not have the operation's phone number. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Operation has not provided corrected operational policy. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
The initial service plan time frame was outside the window of date of placement. |
— |
| 3 | — |
748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained
Two child files were reviewed, there were multiple items that were missing within each child's admission assessment. |
— |
| 3 | — |
748.311(2) - Serious Incident Documentation-Includes time and date of incident
Incident reports were missing some information regarding time and date and names of adults involved. |
— |
| 1 | — |
748.1349(a)(2) - Initial Service Plan-Give copy or summary of plan to child's parents
2 of the 3 service plans reviewed were unclear as to who received a copy of the plan |
— |
| 3 | — |
748.1207(b) - Placement agreement - Must be signed by parent
Two of two child placement agreements were reviewed, and neither were signed by the child's parent/managing conservator. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
The initial service plan time frame was outside the window of date of placement. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
It was confirmed that a staff member told a child in care to shut up. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
A child in care was administered an emergency medication during a containment; however, the staff members did not follow and/or didn't provide documentation that the child received continuous 1:1 observation as required after the resident is given emergency medication for 60 minutes nor is there documentation of vital signs, skin assessment, Range of Motion, psychological assessment, and a neurological assessment completed every 15 minutes after the administration of emergency medication, nor documentation reflecting Q15 Minute assessment per the operation's EBI policies and procedures. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
A caregiver initiated a personal restraint on a child when it was not required, as de-escalation techniques appeared to be managing the situation effectively and the child was not displaying aggressive behavior at the time of the restraint. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
During the walkthrough of the kitchen multiple dry and wet food items were expired and multiple food items were not stored properly. |
— |
| 3 | — |
748.4009(c) - General requirements-There must be emergency transportation available at all times
Operation utilized a drive sharing service to transport a child who was accompanied by staff from the hospital back to the operation. |
— |
| 5 | — |
745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation
During an inspection at the operation, it was found an employee did not have a completed initial background check. |
— |
| 1 | — |
748.1339(a) - Initial Service Plan-Service planning team must develop the service plan
2 of the 3 plans reviewed did not specify who was included or present in developing the service plans |
— |
| 3 | — |
748.753(b) - Pre-Employment Screening- At least one reference must be an employer who has supervised or familiar with the history of the applicant.
An employee file had reference checks; however, it was not documented if the references were professional or personal. |
— |
| 3 | — |
748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number
Two serious incident reports did not have the operation's phone number. |
— |
| 3 | — |
748.3115 - Fire Extinguisher-Must inspect fire extinguisher(s) monthly
During walk through of operation it was observed that fire extinguishers had not been inspected for the month of October 2023. Operation staff admitted no monthly check was completed on during the month of October 2023. |
— |
| 2 | — |
748.753(c)(2) - Pre-Employment Screening-You must document your diligent efforts to contact the reference, which must include more than one attempt to contact.
An employee file did not have documented the number of attempts made to contact the employees' former employers or the employers refusal to provide information. In the result area of contact it stated "NA" |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Operation has not provided corrected operational policy. |
— |
| 4 | — |
748.2753(a)(1) - Simultaneous Interventions-May use emergency medication with personal restraint or seclusion only if allowed by operation's policies
A child in care was administered emergency medication while in a two-person containment; however, the operation's EBI policy doesn't mention the use of simultaneous interventions. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
During the inspection, record review of serious incident report reflected it did not contain all the required sections of a serious incident report to include: physical address, telephone number, names of adults involved and/or their role to child, witness information, interventions made during and after incident. |
— |
| 5 | — |
748.1709(a) - Nasogastric tube-must be inserted by a physician or registered nurse according to a physician's written orders
Registered Nurse or physician did not insert nasogastric tube for child in care. |
— |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
Staff member engaged in a verbal confrontation with a child in care. |
— |
| 3 | — |
748.683(1) - Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being
Staff member was allowed continued contact with child in care after operation was alerted of inappropriate behaviors. |
— |
| 4 | — |
748.3233(b)(2) - Evacuation-Emergency evacuation & relocation diagram must include designated location outside operation where all caregivers & children meet
Residential Child Care Regulation observed the operation's emergency evacuation posters to be without documentation of a designated outside meeting point. |
— |
152 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.