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Youth Health Associates Glenn Heights Academy

Child care center · 1201 E BEAR CREEK RD, Glenn Heights, TX 75154-8609 · License 1807875

0Compliance score
Poor

Capacity 28. 12-17

Violation history (448)

Severity	Date	Standard / narrative	Corrected
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language Children in care were subjected to profane language.	—
5	—	748.3301(a)(3) - Physical Site- Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes. The operation had a loose tile, and a child was able to use that tile to cause harm to self. A loose tile is against the city's ordinance.	—
3	—	748.2151(c)(2) - Medication record - must include prescribing health-care professional's name The medications logs reviewed did not include the prescribing health-care professional name.	—
4	—	748.936(1) - Annual Training- Caregivers must have EBI w/in 6 months from the date they last received the training if operation provides treatment services Six of six staff EBI training reviewed was not completed every six months. The training had been completed ever 10-12 months.	—
5	—	748.685(c)(2) - Caregiver responsibility - provide a safe environment Staff member failed to use self-control meanwhile trying to de-escalate a situation by resorting to making inappropriate comments to child in care about their family.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed Review of the medication administration log revealed discrepancies in the medication count; as no medication errors or refusals were documented.	—
2	—	748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs The possible side effects of medications were not listed in the preliminary service plan.	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication During medical review, it is indicated that a child medicaiton was not documented.	—
3	—	748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care When reviewing a child's admission assessment, it was observed multiple required information needed at the time of admission wasn't documented on the admission assessment.	—
5	—	745.621(a)(1) - Initial background checks submitted - At the time you submit your application The applicant and the designee do not have a background check submitted.	—
3	—	748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest It was discovered that staff members were monitoring children's phone calls without providing restrictions in the children's 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 One of the children had a foot fracture on 2/17/26 and it was reported to the statewide hotline on 2/20/26 which was past the 24-hour mark.	—
2	—	748.111(5) - Child-care policy - How a child obtains clothing The procedures for obtaining clothing indicate that children will have adequate clothing at placement. The budget does not have a line item for how clothing will be purchased or provided.	—
3	—	748.685(c)(6) - Implement and follow the children's service plans. The operation did not follow 3/3 children in care service plans due to supervision.	—
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. 2 of 2 case files did not contain support that references were contacted.	—
2	—	748.363(15) - Personnel records-Include date and reason for the person's separation, if applicable. 1 employee is no longer working with the operation. The case file does not represent the termination-	—
3	—	748.1101(b)(3)(G) - Children's rights-comfortable clothing suitable to age/size/similar to peers in community. Teenagers have reasonable chance to select clothing A youth in care was observed to not have enough clothing at the operation.	—
2	—	748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours Three of six staff EBI training certificates reviewed did not have the length of time documented.	—
5	—	748.103(b)(12) - Policies and procedures to submit - Weapons, firearms, explosive materials and projectiles In the weapons policy PDF on pg. 242, it states that weapons will be prohibited. However, on page 229 of the YHA policies and procedures it states that children may engage in high-risk activities that include weapons, etc.	—
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 2 of 2 files did not contain this document .	—
4	—	748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist. 2 out of 2 trainings files reviewed for staff did not have training on pyschotrophic medication by a Health Care professional.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders In review of the medication logs, seven prescription medications had lacking documentation showing doses were or were not given, given the wrong number of doses in a day, or given at the wrong time of day.	—
3	—	748.115(2) - Discipline policy - Integrate trauma informed care into the care, treatment, and management of each child The policies and procedure do not address this rule.	—
3	—	748.153(2)(C) - Notification - At least 15 days in advance - Adding a swimming pool or other permanent body of water This rule is not addressed in the policies and procedures.	—
3	—	748.105(8) - Personnel Policies - Ensure employees report serious incidents and suspected abuse/neglect and exploitation directly to DFPS YHA's policy reporting serious incidents do not align with all the requirements found at 748.105 (8) and 748.303(a)	—
3	—	748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position The minimum qualification for the PLSP, in YHA's plan, is that the person would have a degree in social work or a bachelor's degree. This is not according to minimum standard rule 748.563(a).	—
3	—	748.107(2) - Conflict of interest policies-statement that majority of members of the governing body must consist of persons who do not have a conflict of interest Conflict of Interest section did not have a statement which informs that governing body does not have a conflict of interest.	—
5	—	748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force Three children in care reported that force was used during a restraint.	—
2	—	748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs Supervision is not addressed in the preliminary service plan.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A staff member admitted to falling asleep while on duty.	—
3	—	748.105(9) - Personnel Policies - Must require those with access to information about a child be informed of their responsibility to maintain confidentiality. The policies and procedures do not specify confidentiality requirements for contractors and volunteers.	—
4	—	748.2203(c)(2) - Medication Error-Document the medication error It was noted that a medication error occurred, but it was not documented.	—
3	—	748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission The Unauthorized Absence Log was missing the following information: gender, the time the unauthorized absence was discovered, the name of the caregiver responsible for the child at the time the child's absence was discovered, the intake report number (if a report was made to Licensing or the Department of Family and Protective Services), and whether law enforcement was contacted (including the name of any law enforcement agency that was contacted and the number of the police report, if applicable).	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders 4 children in care were not provided medications appropriately. As well as 5 prescriptions were not found in the child's medication box.	—
4	—	748.2151(c)(8) - Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years In review of the medication logs, an as needed psychotropic medication was given on three dates in early December without the specific reason.	—
4	—	748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others Three children report that a youth in care expressed discomfort and was not released.	—
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 2 of 2 files did not contain this document .	—
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. 2 of 2 case files did not contain support that references were contacted.	—
3	—	748.125(d)(1) - Your policy must describe the suicide risk screening tool that you will use and the process for implementing the screenings. On page 253, the specific screening tool and its application is not defined.	—
3	—	748.455(a)(1) - Unauthorized Absence - The debriefing should include the circumstances that led to the unauthorized absence The debriefing form did not have documentation including the child's response for leaving the facility.	—
3	—	748.363(10) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation. Three out of three files reviewed indicated that there was no signed statement from the employee that he or she will report suspected child abuse, neglect or exploitation	—
3	—	748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan The child's preliminary service plan states that they will have their own living space, but they were placed in a room with another child in care.	—
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 policies and procedures submitted in certain areas speak to the rights of the guardian only.	—
5	—	748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute. Staff completed a prone personal restrain that lasted more than one minute.	—
3	—	748.109(2) - Admission Policies - include characteristics of the population the program serves The application states that children with emotional disorders will be admitted. However, the admission policies found on pages 118, 124, and 130 conflict.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication For medication logs reviewed, two of nine prescription medication did not have documentation of the reason the medication was prescribed.	—
4	—	748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return The operation did not provide a debrief form for one child in care.	—
2	—	748.153(2)(B) - Notification - At least 15 days in advance - Changes to floor plan This rule was not addressed in the policies and procedures.	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. The staff house is not in an appropriate condition for children in care. The house would need to be cleaned, cleared, and beds added prior to operating. The larger house has several bathroom handles and sink knob that required replacement. Some flooring was soiled. The garage was filled with items to be discarded. The pool house is blocked and in need of repairs/maintenance. The house where the heater is stored is dilapidated and contains discarded items.	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication The medication logs reviewed did not include the name and signature of the person administering the medication.	—
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 Inspeciton, serious incident report was reviewed. The file reviewed indicated that a child in care had a restraint completed on him. The details of the documentaiton was not in detail. 748.2855(a)- 748.2855(a)(9)	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. There was a hole in the wall and pieces of dry wall was on the floor. The toilets were dirty. The doorknob to the Eagle's room is loose.	—
3	—	748.455(a)(1) - Unauthorized Absence - The debriefing should include the circumstances that led to the unauthorized absence The Unauthorized Absence debriefing was missing the following information: the circumstances that led to the child?s unauthorized absence, the trauma informed strategies the child can use to avoid future unauthorized absences and how the operation can support those strategies, the child?s condition, what occurred while the child was away from the operation (including where the child went, who was with the child, the child?s activities, and any other information that may be relevant to the child?s health and safety), and including any routine activity that would be inappropriate for the child to return to and the explanation for why the activity is inappropriate.	—
3	—	748.303(c) - Serious Incident- Doc unauthorized absence that does not meet the reporting time reqs defined in subsection (a)(8)-(10) of this section in 24 hrs Two unauthorized absences were not documented timely.	Yes
2	—	748.119(2) - Volunteer policy - Address qualifications, screening, and selection procedures for the volunteers A description for volunteer responsibilities, the criteria for the selection process, and required training is not explained.	—
3	—	748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren) During a review of records for Emergency Behavior Intervention. Serious Incident report was reviewed and found to not have the information on who conducted a restraint on a child	—
2	—	748.1331(b)(2) - Preliminary Service Plan-For child receiving treatment services, include a description of child's immediate educational, medical, and dental needs The possible side effects of medications were not listed in the preliminary service plan.	—
3	—	748.453(a)(1) - Unauthorized Absence - Annual summary log must include name, age, gender, date of admission The Unauthorized Absence Log was missing the following information: gender, the time the unauthorized absence was discovered, the name of the caregiver responsible for the child at the time the child's absence was discovered, the intake report number (if a report was made to Licensing or the Department of Family and Protective Services), and whether law enforcement was contacted (including the name of any law enforcement agency that was contacted and the number of the police report, if applicable).	—
3	—	748.363(10) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation. Three out of three files reviewed indicated that there was no signed statement from the employee that he or she will report suspected child abuse, neglect or exploitation	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders In review of the medication logs, seven prescription medications had lacking documentation showing doses were or were not given, given the wrong number of doses in a day, or given at the wrong time of day.	—
3	—	748.311(4) - Serious Incident Documentation-Includes names of all adults involved and their role in relation to the child(ren) During a review of records for Emergency Behavior Intervention. Serious Incident report was reviewed and found to not have the information on who conducted a restraint on a child	—
3	—	748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication The medication logs reviewed did not include the name and signature of the person administering the medication.	—
4	—	748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others Three children report that a youth in care expressed discomfort and was not released.	—
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. 2 of 2 case files did not contain support that references were contacted.	—
3	—	748.2151(c)(2) - Medication record - must include prescribing health-care professional's name The medications logs reviewed did not include the prescribing health-care professional name.	—
3	—	748.109(2) - Admission Policies - include characteristics of the population the program serves The application states that children with emotional disorders will be admitted. However, the admission policies found on pages 118, 124, and 130 conflict.	—
2	—	748.111(5) - Child-care policy - How a child obtains clothing The procedures for obtaining clothing indicate that children will have adequate clothing at placement. The budget does not have a line item for how clothing will be purchased or provided.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication For medication logs reviewed, two of nine prescription medication did not have documentation of the reason the medication was prescribed.	—
4	—	748.455(a) - Unauthorized Absence-After a child returns from unauthorized absence, foster parent must conduct debriefing w/child no later than 24 hrs after return The operation did not provide a debrief form for one child in care.	—
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 policies and procedures submitted in certain areas speak to the rights of the guardian only.	—
4	—	748.2151(c)(8) - Medication record-must include reasons for administering psychotropic medication or non-prescription medication/supplement for a child under 5 years In review of the medication logs, an as needed psychotropic medication was given on three dates in early December without the specific reason.	—
4	—	748.869(c) - Training on administering psych. medication must be instructor-led. The instructor must be a health-care professional or pharmacist. 2 out of 2 trainings files reviewed for staff did not have training on pyschotrophic medication by a Health Care professional.	—
4	—	748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders 4 children in care were not provided medications appropriately. As well as 5 prescriptions were not found in the child's medication box.	—
3	—	748.1217(b)(2) - Admission Assessment-At admission, must include description of circumstances that led to child's referral for substitute care When reviewing a child's admission assessment, it was observed multiple required information needed at the time of admission wasn't documented on the admission assessment.	—
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 One of the children had a foot fracture on 2/17/26 and it was reported to the statewide hotline on 2/20/26 which was past the 24-hour mark.	—
3	—	748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair. The staff house is not in an appropriate condition for children in care. The house would need to be cleaned, cleared, and beds added prior to operating. The larger house has several bathroom handles and sink knob that required replacement. Some flooring was soiled. The garage was filled with items to be discarded. The pool house is blocked and in need of repairs/maintenance. The house where the heater is stored is dilapidated and contains discarded items.	—
5	—	748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force Three children in care reported that force was used during a restraint.	—
3	—	748.455(a)(1) - Unauthorized Absence - The debriefing should include the circumstances that led to the unauthorized absence The debriefing form did not have documentation including the child's response for leaving the facility.	—
3	—	748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code ?42.0563 2 of 2 files did not contain this document .	—
4	—	748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language Children in care were subjected to profane language.	—
3	—	748.105(2) - Personnel Policies - Develop written job descriptions including minimum qualifications and job responsibilities for each position The minimum qualification for the PLSP, in YHA's plan, is that the person would have a degree in social work or a bachelor's degree. This is not according to minimum standard rule 748.563(a).	—
4	—	748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication During medical review, it is indicated that a child medicaiton was not documented.	—
5	—	748.3301(a)(3) - Physical Site- Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes. The operation had a loose tile, and a child was able to use that tile to cause harm to self. A loose tile is against the city's ordinance.	—
3	—	748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest It was discovered that staff members were monitoring children's phone calls without providing restrictions in the children's service plans.	—
2	—	748.1331(b)(3) - Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs Supervision is not addressed in the preliminary service plan.	—
4	—	748.2203(c)(2) - Medication Error-Document the medication error It was noted that a medication error occurred, but it was not documented.	—
3	—	748.105(8) - Personnel Policies - Ensure employees report serious incidents and suspected abuse/neglect and exploitation directly to DFPS YHA's policy reporting serious incidents do not align with all the requirements found at 748.105 (8) and 748.303(a)	—
3	—	748.153(2)(C) - Notification - At least 15 days in advance - Adding a swimming pool or other permanent body of water This rule is not addressed in the policies and procedures.	—
5	—	748.103(b)(12) - Policies and procedures to submit - Weapons, firearms, explosive materials and projectiles In the weapons policy PDF on pg. 242, it states that weapons will be prohibited. However, on page 229 of the YHA policies and procedures it states that children may engage in high-risk activities that include weapons, etc.	—
3	—	748.1101(b)(3)(G) - Children's rights-comfortable clothing suitable to age/size/similar to peers in community. Teenagers have reasonable chance to select clothing A youth in care was observed to not have enough clothing at the operation.	—
2	—	748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours Three of six staff EBI training certificates reviewed did not have the length of time documented.	—
3	—	748.455(a)(1) - Unauthorized Absence - The debriefing should include the circumstances that led to the unauthorized absence The Unauthorized Absence debriefing was missing the following information: the circumstances that led to the child?s unauthorized absence, the trauma informed strategies the child can use to avoid future unauthorized absences and how the operation can support those strategies, the child?s condition, what occurred while the child was away from the operation (including where the child went, who was with the child, the child?s activities, and any other information that may be relevant to the child?s health and safety), and including any routine activity that would be inappropriate for the child to return to and the explanation for why the activity is inappropriate.	—
3	—	748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan The child's preliminary service plan states that they will have their own living space, but they were placed in a room with another child in care.	—
5	—	748.2801(2)(B) - EBI Time Limits-Prone or supine personal restraint hold may not exceed one minute. Staff completed a prone personal restrain that lasted more than one minute.	—
5	—	748.685(c)(2) - Caregiver responsibility - provide a safe environment Staff member failed to use self-control meanwhile trying to de-escalate a situation by resorting to making inappropriate comments to child in care about their family.	—
3	—	748.303(c) - Serious Incident- Doc unauthorized absence that does not meet the reporting time reqs defined in subsection (a)(8)-(10) of this section in 24 hrs Two unauthorized absences were not documented timely.	Yes
3	—	748.685(c)(6) - Implement and follow the children's service plans. The operation did not follow 3/3 children in care service plans due to supervision.	—
3	—	748.107(2) - Conflict of interest policies-statement that majority of members of the governing body must consist of persons who do not have a conflict of interest Conflict of Interest section did not have a statement which informs that governing body does not have a conflict of interest.	—
3	—	748.105(9) - Personnel Policies - Must require those with access to information about a child be informed of their responsibility to maintain confidentiality. The policies and procedures do not specify confidentiality requirements for contractors and volunteers.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed Review of the medication administration log revealed discrepancies in the medication count; as no medication errors or refusals were documented.	—

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

Inspections (144)

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

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