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Her Heart Can

Child care center · 3608 MARIANNE CIR, Denton, TX 76209-7941 · License 1797707

0Compliance score
Poor

Capacity 9. 0-17

Violation history (408)

Severity	Date	Standard / narrative	Corrected
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety During the incident, staff did not intervene appropriately which led to children being injured at the facility.	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. During today inspection, several items were in need of maintenance.	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.	—
5	—	748.1757(b) - AP Prohibited for infants-Crib must be bare except for tight fitting sheet & crib mattress cover per 748.1757(c) for infant less than 12 months During the walk through of the operation, an infants crib did not have a tight fitting sheet. A bottle was also observed in the crib.	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation The operation was not able to provide verifiable proof that the administrator is working full time at the operation.	—
1	—	748.4111(b)(1) - Transportation records-Must maintain the insurance verification in the vehicle At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.	—
3	—	748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills The staff that was lacking documentation in the file showing the caregiver had the necessary skills is still lacking .	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The administrators' timecards reviewed did not include accurate information reflected.	—
2	—	748.3313(2) - Water-May use private water system if operation keeps records indicating water supply meets Texas Commission on Environmental Quality requirements The water quality test was not done for the private water supply.	—
5	—	745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation The operation has allowed two individuals access to children in care without received the eligibility notification.	Yes
3	—	748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references. One of the staff file reviewed during the inspection did not include the required two references.	—
3	—	748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation The operation has admitted a child in care that does not meet the operation's admission policy.	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form One of two caregiver files reviewed did not have an affidavit on file.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. The operation failed to notify RCCR of the unauthorized absence of two youth in care.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. In the two staff file reviewed both had only one of the previous employers contacted to verify employment.	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.	—
3	—	748.103(b)(4) - Policies and procedure to submit - Admission Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this. The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.	—
4	—	748.3107(a)(2)(A) - Smoke Detector-If no fire inspector available to give location recommendations, smoke detectors located in hallways/open areas outside bedrooms There was a smoke detector outside of one of the bedroom.	—
3	—	748.563(a) - Professional level service provider-meet specific qualifications if operation provides certain amount of treatment services for emotional disorders The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.	—
4	—	748.103(b)(13) - Policies and procedures to submit - Tobacco and e-cigarette The tobacco policy did not address smoking in the vehicle.	—
3	—	748.453(a)(2) - Unauthorized Absence - Annual summary log must include time and date absence was discovered The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.	—
3	—	748.103(b)(3) - Policies and procedures to submit - Conflict of interest Conflict of interest policies did not meet the requirements of 748.107(1) and (2).	—
3	—	748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond. A child in care was arrested from school. This was not reported.	—
4	—	748.4003(1)(C) - General requirements-When transporting a child the operation must ensure each driver has a current driver's license for the type of vehicle used A drive was allowed to transport at least one youth in care with an expired drivers license.	Yes
4	—	748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).	—
3	—	748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment. One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.	—
3	—	748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills One of two caregiver files reviewed did not have documentation showing the caregiver had the necessary skills.	—
3	—	748.605(c) - Treatment director-must meet specific professional qualifications if most prevalent population is children with emotional disorders The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.	—
3	—	748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident A serious incident report was not completed for a medical event that occured at the operation.	Yes
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 In the last seven weeks, the documentation reflects the treatment director not being full time.	—
1	—	748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate. There was no policy that included this information.	—
4	—	748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children During the time of the incident, there were 1 staff and six children. The operation also had a baby in the home at the time as well. The operation has a treatment director and has children in care that requires treatment services.	Yes
4	—	748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.	—
5	—	745.4151(c)(8)(B) - Documentation-Drug test results must be kept for one year after employee's last work day or until any investigation involving person is resolved One of two caregiver's file did not the results of the drug testing.	—
1	—	748.101(3) - Plans to submit - sketch of operation's floor plan The diagram did not include the designated location in the case of fire. The diagrams were fixed during the inspection.	Yes
4	—	748.125(d)(4)(b)(i) - Suicide Screening- Must be conducted at admission for children under 10 yrs if info. given at admission shows a history of suicide attempts/thoughts. The policy did not address any of the standards regarding children under the age of 10.	—
3	—	748.363(2) - Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position One of two staff records reviewed, did not detail how the staff was qualified for their role at the operation.	—
3	—	748.103(b)(1) - Policies and procedures to submit - Related to record keeping, including where records will be located. Several policies violated the requirements of 748.303 and 748.313. Further there were no policies for record storage in regards to SIRs.	—
1	—	748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).	Yes
3	—	745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.	—
2	—	748.831(b) - Orientation-Document the completion of the orientation in the appropriate personnel record In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the review of files at the inspection, the files were not complete. This was demonstrated the management staffing finding documents, printing, and placing the documents in the files.	—
4	—	748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation There has not been a full time administrator at the operation for the last two of four weeks.	—
3	—	748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment. The staff file reviewed during the last inspection still does not have the documentation of the pre-employment affidavit on file. An additional staff file reviewed during today's inspection also did not have documentation of the pre-employment affidavit.	Yes
3	—	748.125(g)(1)(A) - You must create a Postvention Team, Written Action Plan and Protocols. The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.	—
4	—	748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment. One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.	—
1	—	748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. During today inspection, the well house was in need of maintenance.	—
3	—	748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean One bathroom sink had a crack in the bowl that was leaking in the under cabinet.	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation There has not been a full time administrator at the operation for the last two of four weeks.	—
1	—	748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate. There was no policy that included this information.	—
2	—	748.3313(2) - Water-May use private water system if operation keeps records indicating water supply meets Texas Commission on Environmental Quality requirements The water quality test was not done for the private water supply.	—
1	—	748.101(3) - Plans to submit - sketch of operation's floor plan The diagram did not include the designated location in the case of fire. The diagrams were fixed during the inspection.	Yes
4	—	748.103(b)(6) - Policies and procedures to submit - Emergency behavior intervention The written EBI policies did not meet standard 748.2801(2)(A), 748.2901(a)(2) or (B), 748.113(a)(v), (viii), (ix) or (6).	—
3	—	748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills The staff that was lacking documentation in the file showing the caregiver had the necessary skills is still lacking .	—
3	—	748.303(a)(6)(A) - Serious Incident-Report to Licensing no later than 24 hours after becoming aware that child is indicted, charged, or arrested or when police respond. A child in care was arrested from school. This was not reported.	—
3	—	748.505(b)(3) - Minimum qualifications for employees-Physically, mentally, emotionally capable of performing assigned tasks; has the necessary skills One of two caregiver files reviewed did not have documentation showing the caregiver had the necessary skills.	—
3	—	748.753(a)(1) - Pre-Employment Screening-You must complete reference checks by obtaining the name and contact info of two individuals who can serve as references. One of the staff file reviewed during the inspection did not include the required two references.	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation The operation was not able to provide verifiable proof that the administrator is working full time at the operation.	—
3	—	748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment. The staff file reviewed during the last inspection still does not have the documentation of the pre-employment affidavit on file. An additional staff file reviewed during today's inspection also did not have documentation of the pre-employment affidavit.	Yes
3	—	748.505(b)(5) - Minimum qualifications for employees- Must complete a Pre-Employment Affidavit for Applicants for Employment. One of two caregiver files reviewed did not have documentation of the pre-employment affidavit on file.	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation There has not been a full-time administrator at the operation two of four weeks based on timecards reviewed.	—
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 In the last seven weeks, the documentation reflects the treatment director not being full time.	—
4	—	748.125(d)(4)(b)(i) - Suicide Screening- Must be conducted at admission for children under 10 yrs if info. given at admission shows a history of suicide attempts/thoughts. The policy did not address any of the standards regarding children under the age of 10.	—
4	—	748.3107(a)(2)(A) - Smoke Detector-If no fire inspector available to give location recommendations, smoke detectors located in hallways/open areas outside bedrooms There was a smoke detector outside of one of the bedroom.	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form One of two caregiver files reviewed did not have an affidavit on file.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. There are 3 runaway reports on the unauthorized absence log that indicate children were away from the operation more than 6 hours. The reports were not received timely and or documentation of the unauthorize absence log is incomplete.	—
1	—	748.3391(c) - Bathrooms-Child must not have to cross a common use room to access a bathroom from the child's bedroom Bedroom #4 did not have direct access to a bathroom without having to cross activity spaces.	—
4	—	748.505(b)(6) - Minimum qualifications for employees- Must have cleared pre-employment screening assessment. One of two caregiver's file reviewed did not have documentation showing the pre-emoloymeent screening assessment.	—
3	—	748.605(c) - Treatment director-must meet specific professional qualifications if most prevalent population is children with emotional disorders The named treatment director does not have documentation on file showing they meet the specific educational/professional qualifications.	—
4	—	748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate A trailer was observed in the back yard with nails sticking up that could become hazardous to youth in care.	—
3	—	748.125(g)(1)(A) - You must create a Postvention Team, Written Action Plan and Protocols. The suicide postvention written plan did not include the required items in 748.125(g)(B)(i) (I-VI).	—
2	—	748.831(b) - Orientation-Document the completion of the orientation in the appropriate personnel record In one of two staff records reviewed, dates are missing from training documentation, unable to verify if pretraining was completed within 90 days of beginning job duties.	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. During today inspection, the well house was in need of maintenance.	—
3	—	748.303(b) - Serious Incident-Not required to report medically pertinent incident if not level of serious incident. Document same as a serious incident A serious incident report was not completed for a medical event that occured at the operation.	Yes
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. The operation failed to notify RCCR of the unauthorized absence of two youth in care.	—
4	—	748.103(b)(13) - Policies and procedures to submit - Tobacco and e-cigarette The tobacco policy did not address smoking in the vehicle.	—
5	—	748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety During the incident, staff did not intervene appropriately which led to children being injured at the facility.	—
5	—	745.4151(c)(8)(B) - Documentation-Drug test results must be kept for one year after employee's last work day or until any investigation involving person is resolved One of two caregiver's file did not the results of the drug testing.	—
1	—	748.4111(b)(1) - Transportation records-Must maintain the insurance verification in the vehicle At the time of the inspection, the operation did not have insurance for the vehicle being used to transport the children in care.	—
3	—	748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation The operation has admitted a child in care that does not meet the operation's admission policy.	—
1	—	748.1703(a) - Menus-must maintain daily menus showing all meals and snacks that the operation prepares and serves During Walkthrough of the operation, it was discovered that the menu was not completely filled out and substitutions were not offered (Standard 1703 b).	Yes
5	—	745.641 - AP Background check results - Must receive notification prior to allowing subject to be present at your operation The operation has allowed two individuals access to children in care without received the eligibility notification.	Yes
3	—	748.103(b)(3) - Policies and procedures to submit - Conflict of interest Conflict of interest policies did not meet the requirements of 748.107(1) and (2).	—
3	—	748.531(a)(3) - Child-care administrator-Is full-time employee of the operation Based on the weekly schedule and timecards, the LCCA is not a full-time employee of the operation.	—
3	—	748.453(a)(2) - Unauthorized Absence - Annual summary log must include time and date absence was discovered The unauthorized absence log did not include the time the absence was discovered by the staff on two of two occasions, the hotline report number for one of two occasions nor information on the length of time the youth was missing or if the youth returned on two of two occasions.	—
4	—	748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards During the outside walk through, sharp items and sharp glass was observed on the ground, near the barn.	—
4	—	748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children During the time of the incident, there were 1 staff and six children. The operation also had a baby in the home at the time as well. The operation has a treatment director and has children in care that requires treatment services.	Yes
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. During today inspection, several items were in need of maintenance.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. In the two staff file reviewed both had only one of the previous employers contacted to verify employment.	—
3	—	748.103(b)(4) - Policies and procedure to submit - Admission Operation is getting licensed for girls only, and biological girls that are currently pregnant, policies did not state this. The application indicates children ages 14-17 are admitted, however the policy states ages 7-17.	—
3	—	748.563(a) - Professional level service provider-meet specific qualifications if operation provides certain amount of treatment services for emotional disorders The PLSP file reviewed did not have documentation showing they meet the qualifications requirements.	—
5	—	748.1757(b) - AP Prohibited for infants-Crib must be bare except for tight fitting sheet & crib mattress cover per 748.1757(c) for infant less than 12 months During the walk through of the operation, an infants crib did not have a tight fitting sheet. A bottle was also observed in the crib.	—
3	—	745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving A caregiver is showing active in the operation people list, the caregiver has not been employed with the operation for twenty days.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The administrators' timecards reviewed did not include accurate information reflected.	—
3	—	748.3395(a) - Hand-washing-Hand-washing sinks must be maintained in good repair and kept clean One bathroom sink had a crack in the bowl that was leaking in the under cabinet.	—
4	—	748.4003(1)(C) - General requirements-When transporting a child the operation must ensure each driver has a current driver's license for the type of vehicle used A drive was allowed to transport at least one youth in care with an expired drivers license.	Yes
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records During the review of files at the inspection, the files were not complete. This was demonstrated the management staffing finding documents, printing, and placing the documents in the files.	—

Severity 5 = most serious. Source: official state record.

Inspections (96)

96 inspection record(s) on file from TX-HHSC.

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