Capacity 16. 11-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Staff engaged in physical discipline by slamming child on a table due to child refusing to follow instructions. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Restraint was initiated in a non-emergency situation due to child refusing to release a lego. |
— |
| 2 | — |
748.3273(4) - First Aid Kits-Each one must contain cotton balls
Most of the first aid kits were observed missing several of the required supplies such as: cotton balls, adhesive tape, and thermometers. |
— |
| 4 | — |
748.1007(c)(1) - Child/caregiver ratio-Asleep caregiver may care for 10 children if any child in group requires treatment services
3 children stated that staff are sleeping while on shift. The operation currently has 11 children in care with one staff during overnight shift. |
— |
| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
There were three packages of chicken fajitas with a use by date of 02/17/2022. |
Yes |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of one childs file, different date of birth was noticed in the children list and another date of birth in the childs admission assessment Part 1. This was corrected at inspection. |
Yes |
| 4 | — |
748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
There was a black-two drawer file cabinet in the medication closet without a lock; preventing the "overflow" medication from being double locked. |
Yes |
| 4 | — |
748.1213(b) - Information For Caregivers-Op must inform caregivers of child's special needs. ie medical or dietary needs/conditions. Doc that info was shared.
The operation is not sharing any information regarding the child's needs such as coping skills and triggers there is also no documentation available that anything has been shared to the caregivers. The last documentation reviewed and available for caregivers was from 12/14/2020. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on October 11, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific "planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring." As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring necessitating extension. Furthermore, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a medium-low weighted citation in a pattern/trend category on September 26, 2023. Specifically, the operation was cited for 748.1335 Initial Service Plan-Complete the initial service plan within 45 days after admission. The operation met compliance on September 26, 2023. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
It was determined that staff was pinching a child's nose to get the child get off of him. |
— |
| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
Upon reviewing child's file, the TB test was missing from immunization list. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
One child service plan was reviewed today. It was observed during the review of the plan that the child was admitted on 08-10-23 but initial service plan was completed on 9-25-23 which is 46 days. Agency staff stated that the initial servce plan was completed on 09-22-23 and not 9-25-23 as indicated in the plan but was not able to provide me with any evidence that the meeting was held on 9-22-23. |
— |
| 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 facility several rotten pears were observed inside the fruit bowl in the kitchen counter. All rotten fruits were trashed by staff in my presence. |
Yes |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff member was overheard telling the resident that he was a liar and not credible. In the interview with staff member, staff member stated there was a pattern forming with the child having an attraction to his older roommates. Staff member even admits to bringing in the children and putting them against one another. However, he continued to put him with similar roommates, and failed to tell his therapist. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
Five out of five children interviewed stated staff members curse at them. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
The child's managing conservator stated he was not informed about the incident and found out about it when the child mentioned it to him. The PM, who is in charge of calling CPS stated he believed he had contacted the CPS worker but was not one hundred percent certain. The administrator stated the PM is the person who calls CPS as is required, but that unfortunately they don't have phone records of it occurring. Per the operation's policies and procedures, the facility will notify the caseworker as soon as possible but no later than 2 hours. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
Four of six children interviewed stated staff used profanity to or around them. Three of six children stated Supervisory Staff use abusive, profane and threatening language towards children in care. |
— |
| 3 | — |
748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner
There were several areas on the physical grounds that require attention such as the fence being broken in several areas, large trash that include furniture, trash, ant beds, and large rocks. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Staff member engaged in a power struggle with a child in care due child refusing to release a lego. Staff member slammed child on a table during the incident. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on October 14, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on April 10, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific "planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring." As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring necessitating extension. Furthermore, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a medium-low weighted citation in a pattern/trend category on February 15, 2023. Specifically, the operation was cited for 748.2857(b) A copy of EBI documentation provided to the parent must be maintained in the child?s record. The operation met compliance on February 16, 2023. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. -Operation was unable to meet compliance with Medium-High or High weighted licensing citations. |
— |
| 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
An altercation between two children that resulted in LE being called, was not reported to licensing. |
— |
| 5 | — |
748.2553(2)(B) - EBI Release-Child released from personal restraint within one minute of implementation of a prone or supine hold
Documentation shows a child was held in a prone position for 2 minutes. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
During walkthrough, it was observed that sofa chair in dayroom spring was broken, causing the chair to lean. |
— |
| 3 | — |
748.311(10) - Serious Incident Documentation-Includes resolution of the incident
A serious incident report was missing the resolution of the incident. |
— |
| 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 walkthrough, it was observed that a staff that is not counted in ratio was watching a group of children. |
Yes |
| 4 | — |
748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply
Restraint was initiated due to child refusing to follow directives from staff. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
It was determined that a child grabbed a pair of scissors that were unattended from the kitchen counter and threatened to stab staff. |
— |
| 5 | — |
748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back
Both the victim child and the Caregiver who performed a restraint, stated the child's arms was placed behind his back. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on April 12, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citation issued on September 26, 2023, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a high weighted citation in a pattern/trend category on December 4, 2023. Specifically, the operation was cited for 748.2307(6) Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child. The operation met compliance on December 11, 2023. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
It was determined that child was left outside unsupervised for about 10 to 15 minutes while staff was inside the facility. |
— |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
The emergency evacuation & relocation diagrams observed do no include a designated shelter inside location nor an identified meeting place on the outside of the operation. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
Two bottles of medication was observed in the staff room; not in the medication container where medication is kept. |
Yes |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
One of the bathrooms was observed to be clogged and had fecal matter in it. A window was observed not to be in good repair and was pushed out on one side. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on October 7, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific "planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring." As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring necessitating extension. Furthermore, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a medium-weighted citation in a pattern/trend category on September 6, 2022. Specifically, the operation was cited for 748.3301(a)(2) Physical Site- Buildings must be clean and in good repair. The operation met compliance on September 22, 2022. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
The victim child and the Caregiver supervising the group stated the Caregiver had stepped away to help another resident when a physical altercation happened. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.
During the walkthrough of the facility, one Hot Shot ant, roach and spider killer and one insect repellant net weight 8.125 oz were observed on top of the fridge in the kitchen while children are at the facility due to spring break. |
Yes |
| 2 | — |
748.2857(b) - A copy of the documentation provided to the parent must be maintained in the child?s record.
Four out of four EBI documentation reviewed did not document that the youth's parent was notified. |
— |
| 4 | — |
748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
The administrator confirmed that the incident went on for several hours. Licensing was not made aware of the incident until the following day. |
— |
| 5 | — |
748.3301(a)(1) - Physical Site- Buildings must be structurally sound and not pose a risk to the health and safety of children.
It was observed during the walkthrough of the facility that the Air Conditioner in the Day room is leaking water from the unit to the ground. It appears the leak has been going on for some days which has resulted to some part of the wall appeared to be soaked from the leaking water from the A/C Unit. |
— |
| 5 | — |
748.3421(1) - Poisons-The operation must ensure that poisonous or flammable materials are stored in their original, labeled containers
During the walkthrough of the facility, one Green gallon of all purpose pinalen Fresh pine cleaner was observed on top of counter next to the washing machine. |
Yes |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
Children that were interviewed stated that a staff member talks to them rudely and at time uses profane language. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
Two medication record logs were missing pills that are not accounted for. One Log has 20 pills listed but only 18 pills were found and the second log had 23 pills listed and only 22 pills accounted for. |
— |
| 5 | — |
748.3421(2) - Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces
A can of Lysol was on the kitchen counter next to several bags of chips and next to the stove where food was being cooked. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
It was observed during the review of a childs file that the admission assessment form Part 1 has wrong date of admission for the child. Child correct date of admission was 6-16-23 but the date of admission in the admission assessment form Part 1 has 3-8-21. The Administrator corrected the information to reflect the correct date of admission which was 6-16-23. |
Yes |
| 4 | — |
748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child
Several children in care stated that they have been threatened by staff at the facility. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
It is determined that a child was found outside the home, close to the street with no supervision. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of a childs initial service plan, it was observed that the DOB for the child in the initial Service plan is different from the correct DOB which is in the childs DFPS placement authorization. |
Yes |
| 4 | — |
748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family
6 children reported that profane language and belittling remarks were made by the staff. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Children's shoes are being stored in a locked mudroom. |
— |
| 2 | — |
748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
One out of four child records reviewed did not include an immunization record or documented attempts to obtain the record. |
Yes |
| 4 | — |
748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
Three out of five children interviewed stated a staff member calls them names. |
— |
| 4 | — |
748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container
There was a black-two drawer file cabinet in the medication closet without a lock; preventing the "overflow" medication from being double locked. |
Yes |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on April 10, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific "planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring." As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring necessitating extension. Furthermore, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a medium-low weighted citation in a pattern/trend category on February 15, 2023. Specifically, the operation was cited for 748.2857(b) A copy of EBI documentation provided to the parent must be maintained in the child?s record. The operation met compliance on February 16, 2023. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. -Operation was unable to meet compliance with Medium-High or High weighted licensing citations. |
— |
| 3 | — |
748.311(10) - Serious Incident Documentation-Includes resolution of the incident
A serious incident report was missing the resolution of the incident. |
— |
| 4 | — |
748.1007(c)(1) - Child/caregiver ratio-Asleep caregiver may care for 10 children if any child in group requires treatment services
3 children stated that staff are sleeping while on shift. The operation currently has 11 children in care with one staff during overnight shift. |
— |
| 2 | — |
748.3273(4) - First Aid Kits-Each one must contain cotton balls
Most of the first aid kits were observed missing several of the required supplies such as: cotton balls, adhesive tape, and thermometers. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
It was determined that staff was pinching a child's nose to get the child get off of him. |
— |
| 4 | — |
748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child
Several children in care stated that they have been threatened by staff at the facility. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
Two bottles of medication was observed in the staff room; not in the medication container where medication is kept. |
Yes |
| 2 | — |
748.2857(b) - A copy of the documentation provided to the parent must be maintained in the child?s record.
Four out of four EBI documentation reviewed did not document that the youth's parent was notified. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
Four of six children interviewed stated staff used profanity to or around them. Three of six children stated Supervisory Staff use abusive, profane and threatening language towards children in care. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.
During the walkthrough of the facility, one Hot Shot ant, roach and spider killer and one insect repellant net weight 8.125 oz were observed on top of the fridge in the kitchen while children are at the facility due to spring break. |
Yes |
| 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
An altercation between two children that resulted in LE being called, was not reported to licensing. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
One of the bathrooms was observed to be clogged and had fecal matter in it. A window was observed not to be in good repair and was pushed out on one side. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
It was determined that a child grabbed a pair of scissors that were unattended from the kitchen counter and threatened to stab staff. |
— |
| 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 walkthrough, it was observed that a staff that is not counted in ratio was watching a group of children. |
Yes |
| 4 | — |
748.3233(b)(3) - Evacuation-Emergency evacuation & relocation diagram must include designated location inside operation to take shelter from threatening weather
The emergency evacuation & relocation diagrams observed do no include a designated shelter inside location nor an identified meeting place on the outside of the operation. |
— |
| 3 | — |
748.3301(g) - Physical Site-The grounds must be free of garbage & debris & maintained in a sanitary manner
There were several areas on the physical grounds that require attention such as the fence being broken in several areas, large trash that include furniture, trash, ant beds, and large rocks. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
It was determined that child was left outside unsupervised for about 10 to 15 minutes while staff was inside the facility. |
— |
| 4 | — |
748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply
Restraint was initiated due to child refusing to follow directives from staff. |
— |
| 4 | — |
748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair
During walkthrough, it was observed that sofa chair in dayroom spring was broken, causing the chair to lean. |
— |
| 3 | — |
748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures
The child's managing conservator stated he was not informed about the incident and found out about it when the child mentioned it to him. The PM, who is in charge of calling CPS stated he believed he had contacted the CPS worker but was not one hundred percent certain. The administrator stated the PM is the person who calls CPS as is required, but that unfortunately they don't have phone records of it occurring. Per the operation's policies and procedures, the facility will notify the caseworker as soon as possible but no later than 2 hours. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
Five out of five children interviewed stated staff members curse at them. |
— |
| 2 | — |
748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission
One child service plan was reviewed today. It was observed during the review of the plan that the child was admitted on 08-10-23 but initial service plan was completed on 9-25-23 which is 46 days. Agency staff stated that the initial servce plan was completed on 09-22-23 and not 9-25-23 as indicated in the plan but was not able to provide me with any evidence that the meeting was held on 9-22-23. |
— |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on October 11, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific "planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring." As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring necessitating extension. Furthermore, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a medium-low weighted citation in a pattern/trend category on September 26, 2023. Specifically, the operation was cited for 748.1335 Initial Service Plan-Complete the initial service plan within 45 days after admission. The operation met compliance on September 26, 2023. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Staff member was overheard telling the resident that he was a liar and not credible. In the interview with staff member, staff member stated there was a pattern forming with the child having an attraction to his older roommates. Staff member even admits to bringing in the children and putting them against one another. However, he continued to put him with similar roommates, and failed to tell his therapist. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
Children that were interviewed stated that a staff member talks to them rudely and at time uses profane language. |
— |
| 5 | — |
748.2553(2)(B) - EBI Release-Child released from personal restraint within one minute of implementation of a prone or supine hold
Documentation shows a child was held in a prone position for 2 minutes. |
— |
| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of one childs file, different date of birth was noticed in the children list and another date of birth in the childs admission assessment Part 1. This was corrected at inspection. |
Yes |
| 4 | — |
748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family
6 children reported that profane language and belittling remarks were made by the staff. |
— |
| 5 | — |
748.3421(2) - Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces
A can of Lysol was on the kitchen counter next to several bags of chips and next to the stove where food was being cooked. |
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| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
During the review of a childs initial service plan, it was observed that the DOB for the child in the initial Service plan is different from the correct DOB which is in the childs DFPS placement authorization. |
Yes |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on October 14, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
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| 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 facility several rotten pears were observed inside the fruit bowl in the kitchen counter. All rotten fruits were trashed by staff in my presence. |
Yes |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
Children's shoes are being stored in a locked mudroom. |
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| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Staff engaged in physical discipline by slamming child on a table due to child refusing to follow instructions. |
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| 4 | — |
748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions
There were three packages of chicken fajitas with a use by date of 02/17/2022. |
Yes |
| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on April 12, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citation issued on September 26, 2023, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a high weighted citation in a pattern/trend category on December 4, 2023. Specifically, the operation was cited for 748.2307(6) Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child. The operation met compliance on December 11, 2023. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with Medium-High or High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans. |
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| 3 | — |
748.393(b)(3) - Active child record - Ensure record is kept accurate and current
It was observed during the review of a childs file that the admission assessment form Part 1 has wrong date of admission for the child. Child correct date of admission was 6-16-23 but the date of admission in the admission assessment form Part 1 has 3-8-21. The Administrator corrected the information to reflect the correct date of admission which was 6-16-23. |
Yes |
| 5 | — |
748.3421(1) - Poisons-The operation must ensure that poisonous or flammable materials are stored in their original, labeled containers
During the walkthrough of the facility, one Green gallon of all purpose pinalen Fresh pine cleaner was observed on top of counter next to the washing machine. |
Yes |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
It is determined that a child was found outside the home, close to the street with no supervision. |
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| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
Restraint was initiated in a non-emergency situation due to child refusing to release a lego. |
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| 4 | — |
748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
The administrator confirmed that the incident went on for several hours. Licensing was not made aware of the incident until the following day. |
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| 4 | — |
748.1213(b) - Information For Caregivers-Op must inform caregivers of child's special needs. ie medical or dietary needs/conditions. Doc that info was shared.
The operation is not sharing any information regarding the child's needs such as coping skills and triggers there is also no documentation available that anything has been shared to the caregivers. The last documentation reviewed and available for caregivers was from 12/14/2020. |
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| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
Staff member engaged in a power struggle with a child in care due child refusing to release a lego. Staff member slammed child on a table during the incident. |
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| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
The victim child and the Caregiver supervising the group stated the Caregiver had stepped away to help another resident when a physical altercation happened. |
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| 4 | — |
748.535(2) - AP Child-care administrator responsibilities- Ensure the operation complies with current heightened monitoring plans, if applicable.
During a review conducted on October 7, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific "planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring." As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring necessitating extension. Furthermore, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: Your operation received a medium-weighted citation in a pattern/trend category on September 6, 2022. Specifically, the operation was cited for 748.3301(a)(2) Physical Site- Buildings must be clean and in good repair. The operation met compliance on September 22, 2022. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. |
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| 5 | — |
748.2605(a)(5) - Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back
Both the victim child and the Caregiver who performed a restraint, stated the child's arms was placed behind his back. |
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| 3 | — |
748.1583(a) - TB exam-Persons over 1 yr old who live, work, volunteer at facility have exam w/in 30 days, unless person had previous exam that meets requirements
Upon reviewing child's file, the TB test was missing from immunization list. |
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288 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.