Capacity 31. 2-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During the walk through of all four resident homes there were broken blinds, a hole in a closet door, mold in two bathrooms, a broken soap holder in one shower, and numerous used cigarettes butts on ground outside one home. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
A child in care took another child's medication. |
Yes |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
A child's medication record containing 5 prescribed medications do not reflect a medication count for any of the medications. |
— |
| 4 | — |
748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration
There was one prescription medication that was in the refrigerator not locked up. While at the facility, the medication was placed in a locked box and placed back in the fridge. |
Yes |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
On 06/19/2021 a Direct Care Worker grilled food outside of the home. This act left a 15 year old child in care unattended. The child in care had a history of aggressive behaviors. While unsupervised the child in care engaged in inappropriate sexual contact with an adult in care. |
— |
| 3 | — |
748.3365(a) - Bedding-must provide each child with an individual bed or bunk bed in child's room that elevates mattress off floor, or crib as appropriate
In one of the homes it was observed that a child was sleeping on a mattress on the floor. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During an inspection it was found that the operation is only maintaining a current pill count on the controlled substance medications and not not all medication. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
Children in care's supervision plan required constant supervision. This plan was not followed by direct care staff. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
Numerous medication logs did not document the prescribing physician's name, the reason for the medication or the administration of the medication. |
— |
| 3 | — |
748.363(12) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months.
During a heightened monitoring visit, a staff member who transports children did not have a copy of their driver's license or driver's license check in their personnel file. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
Two employee files were reviewed, and their SAMA training certificates for the previous annual year could not be provided. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
During a heightened monitoring visit on 2/9/26, House 29 there were Clorox wipes on the kitchen counter and one of the cabinets where chemicals are stored above the washer and dryer was left unlocked which contained laundry soap. |
— |
| 3 | — |
748.455(a)(2) - Unauthorized Absence?Debrief include trauma informed strategies child can use to avoid future unauth absences & how op. can support strategies
An SIR report does not document a debriefing with the child. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
There is no documented trauma informed care training for a caregiver during 2023 and 2024. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
During the inspection at the operation, cleaning supplies and other chemicals were observed in the laundry room, kitchen, and closet in the boy's bedroom that were all unlocked and accessible to the youth in care. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
A medication report was missing a time of when an emergency medication was given. |
— |
| 3 | — |
748.1101(b)(6)(A) - Child rights-medical,dental,vision,MH,develp services that meet child need. Right to request services separate from adults who receive services
The CANS Assessment for 5 children in care recommended that the child participate in Case Management and Skills Training and see a Developmental Disability Specialist these services were not being provided to the child. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
Caregivers were not aware of child's on-going activity, which led to inappropriate contact with residents. |
— |
| 3 | — |
748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record
Of the three child files reviewed, one child's file did not have the Child Right's form signed by the child and one child's file did not have the form. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
There were no initials on who administered two separate medications in two separate days. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
A staff member has used inappropriate language around children in care multiple times and has made inappropriate remarks to children in care. |
— |
| 4 | — |
748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
The operation's staffing schedule allowed children in care unsupervised time outside the home. |
— |
| 3 | — |
748.2951(a)(1) - Evaluation-Overall annual evaluation includes use and effectiveness of emergency behavior interventions at operation
During an inspection, the operation indicated that it has not been completing an annual review. |
— |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
On 06/20/2021 A Direct Care Worker, who recently failed to supervise a child appropriately, left a child in care unattended again. The Direct Care Worker took a shower. The child's service plan required constant supervision to prevent aggressive behaviors and elopement. While unattended the child walked 3 miles away from the facility. |
— |
| 2 | — |
748.3393(d) - Toilets-Toilets must be equipped with toilet paper at all times
One of the two bathrooms did not have toilet paper in the bathroom. This was corrected at Inspection, when staff put toilet paper in the bathroom |
Yes |
| 4 | — |
748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required
A child's service plan is not tailored to their individual and specific supervision needs. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Physical discipline was used on a child in care. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
A 14 year old child in care sustained injuries to the face from being slapped by a staff member. |
— |
| 3 | — |
748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.
During a walkthrough of the operation it was noted that the front gate to home 25 cannot be closed due to a bent lock. It was also noted home 29 had parts of the fence broken. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
One of the child's medications did not have the name of prescribing physician in the medication record. |
— |
| 4 | — |
748.2003(b)(2) - Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
A child's prescription medication was stored in a blister pack created by the operation; however, it did not contain the same label. |
— |
| 5 | — |
748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication
Children in care were left unattended with distributed medication. |
Yes |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
There were 2 staff members that did not complete Trauma Informed Care training in 2021. |
— |
| 3 | — |
748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication
A child's medication record shows that there are 5 prescribed medications, and none have the reason the medications were prescribed. |
— |
| 1 | — |
748.1349(b)(2) - Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign
Three of the five child files reviewed contained service plans that did not indicate if the child participated in the service plan. |
— |
| 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 03/12/2026 it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plan for this operation included a specific ?planned end date? at the 12-month mark by which the 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 the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
During the inspection at the operation: House 12 had cleaning supplies that were accessible to youth in care in the kitchen, laundry room, under the boy's bathroom sink, and in the closet in the boy's bathroom. House 29 had cleaning supplies unlocked and accessible to youth in care in the kitchen. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A child in care touches a caregiver's back. The caregiver turns and gestures as if to hit the child due to this interaction. |
— |
| 2 | — |
748.949(b)(5) - Annual Training Documentation-Includes the length of the training in hours
Three EBI training certificates did not document the number of training hours completed. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
Noted in a visit was soiled bed linen and strong smell of urine in a home along with clothes scattered in a closet. Observed was a broken barbeque grill in the courtyard. Photographs were taken. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care ran out of the room after being slapped. Two staff members observed this incident and did not respond. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
A caregiver was hired in 10/2021 and there was no trauma informed care training until 09/3/2024. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
An adult in care attacked two children in care, a staff, and another adult in care. There is a DFPS investigation pertaining to similar incidents involving the same adult in care. |
— |
| 3 | — |
748.935(a)(2) - Annual Training Timeline-Each person must complete the required annual training during each subsequent 12-month period
When reviewing annual training hours, it was found that two employees had not completed Normalcy training, and one employee's Trauma Informed Care training had expired on June 9, 2023. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The facility has not been documenting unauthorized absences. |
— |
| 3 | — |
748.363(10) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months
One employee who has been transporting children has an expired drivers license. The agency came into compliance during the inspection by having the employee sign a statement that he would not transport children in care until he provides the facility with a copy of his updated and current driver's license. |
Yes |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
Serious incident reports were not being documented. |
— |
| 4 | — |
748.2903(a) - Triggered Reviews-Must occur as soon as possible, but no later than 30 days after the review is triggered
During an inspection it was noted the operation is not completing a triggered review for children in 3 Emergency Medication incidents have occurred within 30 days. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
A child in care was left unsupervised outside the operation home. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
There were three instances that medication was not properly stored that included an unsecured single dose medication blister on the van floor, 10 medication bubble pack cards sitting on a table and medication cups out in an open area. Photographs were taken. |
— |
| 4 | — |
748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards
One of the homes where children currently reside has missing or damaged fence pickets. There are also visible nails that are not properly driven in. Also, in this same home the skylight in the porch was damaged. Photographs were obtained. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
A child in care hit a staff member multiple times. The staff member did not implement a restraint. |
— |
| 4 | — |
748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.
There was no documented psychotropic medication training for a caregiver during 2023 or 2024. |
— |
| 4 | — |
748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.
A caregiver was hired in October 2021 and there was no psychotropic medication training until 2025. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During an inspection it was found that the operation is only maintaining a current pill count on the controlled substance medications and not not all medication. |
— |
| 1 | — |
748.395(1) - Active child record - All documentation in the record no later than 30 days after occurrence or event
During an HM visit, the operation could not produce a psychological exam completed on 09/2024 and several months have lapsed. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
During a walkthrough of House 12, a cabinet in the laundry area containing chemicals was not locked. This laundry room is located in an area that is accessible to children in care. |
— |
| 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
The operation does not currently have a treatment director. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
14- and 16-year-old children in care were left unsupervised by a caregiver. This resulted in a physical altercation, damaged property, and self-harm. At an inspection completed on 1/3/2024, this standard was evaluated for compliance and found to be compliant, the operation terminated the staff member involved in the incident. |
— |
| 4 | — |
748.153(3)(B) - Notification - New controlling person
Operation's full controlling person information has been requested multiple times and has not been submitted. |
— |
| 1 | — |
748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals
Five of the five child files reviewed contained service plans that did not have two professionals participate. |
— |
| 2 | — |
748.1381(2) - Service Plan Review-If child receiving treatment services for ED, ASD, or PMN, review at least 90 days from date of last service plan
Four of the five child files reviewed contained service plans that were not completed every 90 days. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
Multiple medication logs reviewed did not have the prescribing professional's name or the reason the medication was prescribed documented on the log. |
— |
| 4 | — |
748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair
In House 12, a child's headboard was not attached to the frame of the bed and staff confirmed that a child currently slept in that bed. Photographs were taken. In a separate bedroom, a detached exposed cable was observed in a room that a child with has a history of aggressive behavior. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
Of the five child files reviewed, two had a service plan team meeting invite that was not sent out to the CPS worker. |
— |
| 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
The operation had not validated their person list in the last 12 months. |
— |
| 4 | — |
748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
The child's prescription required that Pediasure, Risperidone and Clonidine should be given 3 times daily. Methylphenidate was prescribed daily. This recommendation was not being followed. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
A child had a safety plan in place stating he would remain in line of sight supervision but this was not followed by the caregiver which resulted in the child injuring another child in care. |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation had 60 days from 09/15/25 to acquire a licensed childcare administrator and one was obtained. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
A heightened monitoring visit occurred on 1/29/26 and a child's medication log was reviewed. This medication log did not contain initials that three medications were administered on 1/28/26 PM. |
— |
| 4 | — |
748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate
During the walk through of house 12, there were three knives, a screwdriver, and sharp freezer thermometer was unlocked and accessible to children in care. |
— |
| 1 | — |
748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan
Five of five child's records reviewed contained service plans that were missing required signatures. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
The EBI training reviewed for three staff members were not completed within the 6 months' timeframe. |
— |
| 1 | — |
748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting
Of the five child files reviewed, two had a service plan team meeting invite that was not sent out to the CPS worker. |
— |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
During a walkthrough of House 12, a cabinet in the laundry area containing chemicals was not locked. This laundry room is located in an area that is accessible to children in care. |
— |
| 4 | — |
748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate
During the walk through of house 12, there were three knives, a screwdriver, and sharp freezer thermometer was unlocked and accessible to children in care. |
— |
| 3 | — |
748.2151(c)(2) - Medication record - must include prescribing health-care professional's name
Multiple medication logs reviewed did not have the prescribing professional's name or the reason the medication was prescribed documented on the log. |
— |
| 5 | — |
748.2101(1) - Medication Storage-Store medication in a locked container
There were three instances that medication was not properly stored that included an unsecured single dose medication blister on the van floor, 10 medication bubble pack cards sitting on a table and medication cups out in an open area. Photographs were taken. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
A heightened monitoring visit occurred on 1/29/26 and a child's medication log was reviewed. This medication log did not contain initials that three medications were administered on 1/28/26 PM. |
— |
| 3 | — |
748.363(10) - Personnel records-For each person who transports a child, include copy of valid driver's license or DPS driver's license check done in last 12 months
One employee who has been transporting children has an expired drivers license. The agency came into compliance during the inspection by having the employee sign a statement that he would not transport children in care until he provides the facility with a copy of his updated and current driver's license. |
Yes |
| 1 | — |
748.1339(b) - Initial Service Plan-For treatment services, service planning team must include two professionals
Five of the five child files reviewed contained service plans that did not have two professionals participate. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
During an inspection it was found that the operation is only maintaining a current pill count on the controlled substance medications and not not all medication. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
Physical discipline was used on a child in care. |
— |
| 3 | — |
748.453(a)(1) - Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
The facility has not been documenting unauthorized absences. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
On 06/19/2021 a Direct Care Worker grilled food outside of the home. This act left a 15 year old child in care unattended. The child in care had a history of aggressive behaviors. While unsupervised the child in care engaged in inappropriate sexual contact with an adult in care. |
— |
| 4 | — |
748.153(3)(B) - Notification - New controlling person
Operation's full controlling person information has been requested multiple times and has not been submitted. |
— |
| 4 | — |
748.2101(4) - Medication Storage-make provisions for storing medication that requires refrigeration
There was one prescription medication that was in the refrigerator not locked up. While at the facility, the medication was placed in a locked box and placed back in the fridge. |
Yes |
| 3 | — |
748.685(c)(6) - Implement and follow the children's service plans.
On 06/20/2021 A Direct Care Worker, who recently failed to supervise a child appropriately, left a child in care unattended again. The Direct Care Worker took a shower. The child's service plan required constant supervision to prevent aggressive behaviors and elopement. While unattended the child walked 3 miles away from the facility. |
— |
| 4 | — |
748.535(3)(A) - Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
The operation's staffing schedule allowed children in care unsupervised time outside the home. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
Two employee files were reviewed, and their SAMA training certificates for the previous annual year could not be provided. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
A child in care took another child's medication. |
Yes |
| 4 | — |
748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.
During the inspection at the operation, cleaning supplies and other chemicals were observed in the laundry room, kitchen, and closet in the boy's bedroom that were all unlocked and accessible to the youth in care. |
— |
| 4 | — |
748.2151(a) - Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old
Numerous medication logs did not document the prescribing physician's name, the reason for the medication or the administration of the medication. |
— |
| 4 | — |
748.930(b)(5) - Annual Training- Caregivers must have psychotropic medication training if the caregiver administers psychotropic medication.
A caregiver was hired in October 2021 and there was no psychotropic medication training until 2025. |
— |
| 3 | — |
748.311 - Serious Incident Documentation-Documented in written report
Serious incident reports were not being documented. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
The EBI training reviewed for three staff members were not completed within the 6 months' timeframe. |
— |
| 4 | — |
748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
A child in care hit a staff member multiple times. The staff member did not implement a restraint. |
— |
| 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
The operation had not validated their person list in the last 12 months. |
— |
| 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
The operation does not currently have a treatment director. |
— |
| 5 | — |
748.151(1) - Operational responsibilities - Designate a qualified full-time child-care administrator
The operation had 60 days from 09/15/25 to acquire a licensed childcare administrator and one was obtained. |
— |
313 inspection record(s) on file from TX-HHSC.
Licensed facilities near this one, highest compliance score first.