Capacity 15. 8-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 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
While reviewing the child's file in one file out of two there was an email sent on 05/11/2024 requesting Tuberculosis exam, however the results have not been received and there is no record of other attempts to obtain. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
The incident report states that the restraint lasted one minute. However, interviews with both staff members and residents indicate that the restraint lasted over 30 minutes. Additionally, the second staff member arrived approximately 20 minutes after the child had already been restrained in the living room. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
While conducting a walk-through of the operation there were two doors that where busted and no work order was provided. Another room door is hard to open with child in care is residing. |
— |
| 3 | — |
748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed
The medication list, dosage, frequency and reason required information is missing from the documentation of one child's file. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
A child's service plan review was not completed timely. |
— |
| 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 Contracts visits to the operation on 9/24/2025, it was observed that a child in care was not administered a prescribed medication for at least 5 days due to the medication not being refilled timely. |
— |
| 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
The operation's policies and procedures all the requirements for a Residential Treatment Care facility and the operations policies and procedures had multiple errors mentioning other care type services such as child placing agency. |
— |
| 2 | — |
748.1437(3) - Discharge/Transfer Documentation-Must include name, address, telephone number, and relationship of person to whom child is discharged
The address, and relationship of person is missing on the discharge summary of one of the child's file. |
— |
| 4 | — |
748.505(b)(5) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment.
A pre-screening was not completed prior to hiring in one of two employees' files. |
— |
40 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.