Capacity 20. 5-17
| Severity | Date | Standard / narrative | Corrected |
|---|
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
A review of a child's medication log did not have required name and signature of staff who administered medication. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
When a child had escalated behaviors, staff member pulled a child hair in order to gain compliance. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Two staff members at the operation failed to prevent a child in care from assaulting other children in care with an object. |
— |
| 2 | — |
748.1117 - Documentation of searches-Caregiver documents searches in the child's record
The staff conducted a search of the youths' room, took cell phones, and did not document the search. |
— |
| 3 | — |
748.453(a)(3) - Unauthorized Absence ? Annual summary log must include how long the child was gone or if the child did not return
The unauthorized absence log is missing how long the child was gone or did not return, the name of the caregiver responsible for the child at the time the child?s absence was discovered, the intake report number and the number of the police report. |
— |
| 2 | — |
748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
During the course inspection it was found that the operation vaccinated a child in care that had a signed affidavit stating for the child not to be vaccinations. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Children in care were able to gain access to staff keys and be unsupervised in the gym for several hours. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
One of the service plans reviewed did not document the supervision in the preliminary service plan for the child. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Two children were seen going in and out of the closet. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
Out of four staff EBI training reviewed, one was not current and three did not have documented EBI training every 6 months. |
— |
| 3 | — |
748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan
A child was escalated and the staff member failed to use coping mechanisms listed on the service plan. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A new preliminary service plan was not completed when a child discharged but then was readmitted to the operation several days later. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location
A child's chronic condition of being epileptic or having seizures was not on the exterior of the file and was not clearly visidble in the file. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
One child's bedroom has been without window blinds for a month. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Two staff members failed to follow policies and procedures by not implementing an effective manual restraint during an emergency situation involving imminent risk of harm to another child in care. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A caregiver slapped a child in care in the face. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
One child's bedroom does not have blinds, curtains or anything covering the window to provide privacy. |
— |
| 4 | — |
748.459(a) - Unauthorized Absence-Triggered review of child?s unauthorized absences must include, child, designated staff, and child?s case manager
two of the three triggered reviews did not indicate that the child's case manager was present for the triggered review. The child's case manager must participate in the triggered review. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A child was allowed to intervene with another child who was destroying property at the operation. Staff did not intervene but stayed outside of the room as both children were in the room and one child was hitting the walls and door with a metal pole. |
— |
| 5 | — |
748.3301(b) - Physical Site-Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes
During the walk through a broken exit sign with exposed wire and broken furniture with exposed nails were found the gym that the children had access to. Also in the bedroom two pollows did not have pollow cases. In one room a dresser drawer was missing. Pictures were taken |
— |
| 3 | — |
748.2851(b)(1) - EBI Follow-Up-Caregiver involved in EBI must conduct post discussion with child to discuss child's behavior and circumstances that required EBI
One child was restrained and there was no EBI post discussion with the child and the staff involved. |
— |
| 2 | — |
748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer
2 of 2 child files reviewed did not have complete discharge summaries completed to include required information including circumstances of discharge, assessment of child needs, support resources and aftercare plans. |
— |
| 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
Two chidren did not have a debriefing within 24 hours of returning to the operation following an unauthorized absence. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
One caregivers trauma informed care training expired on 5/3/2022. Note: This was corrected at inspection due to the staff completing the training during the inspection. |
Yes |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
While under the supervision of caregivers an 11 year old stabbed a 13 year old in the chest and back with a stick causing an injury. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
One medication had two separate medication logs for the same medication prescribed. One medication log had documented medication given prior to iit being administered. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A child in care was left outside of the operation. |
— |
| 3 | — |
748.455(a)(4) - Unauthorized Absence?Debriefing includes where child went, who was w/ child, child?s activities & any other relevant info to child?s health &safety
Two debriefings do not include required documentation such as what occurred while the child was away, where the child went, and the child's activities. One debriefing does not include the child's condition upon returning. |
— |
| 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
A child in care ran was absent from the facility 04/19, 04/20, 04/24, and an attempt on 04/25. The child stated that the running away was an attempt to obtain cigarettes. The incident report does not document how the operation planned to reduce the probability of additional absences. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Children engaged in inappropriate contact due to the adequate supervision of the caregiver. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Staff did not use any measure to encourage the children to not run away. |
— |
| 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
A debriefing was not conducted with 24 hours following an unauthorized absences. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
After reviewing the video, it shows staff sitting at a table on their cell phone. Staff never look up to see the child leaving from the common area. |
— |
| 3 | — |
748.1337(b)(1)(D)(iii) - Initial Service Plan-Include child's trauma triggers
One initial service plan is missing several pieces of required information such as the child's personal trauma history, trauma triggers, plans for educating on STD's and human reproduction, and plans for preparation for independent living. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
Youths missed four days of Trazadone medication because refills were not obtained in a timely manner. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
On May 7th Christopher P. was administer Trazodone by staff member ASA,. ASA did not document the time the medication was provided. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
During the review staff reported that he told victim he was lucky he wasn?t 18 because he would have beat his ass. |
— |
| 4 | — |
748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.
One caregivers normalcy training expired on 5/3/2022. Note: This was corrected at inspection due to the staff completing the training during the inspection. |
Yes |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
On May 7th Christopher P. was administer Trazodone by staff member ASA,. ASA did not document the time the medication was provided. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
One caregivers trauma informed care training expired on 5/3/2022. Note: This was corrected at inspection due to the staff completing the training during the inspection. |
Yes |
| 4 | — |
748.930(b)(3) - Annual Training- Caregivers must have 1 hour normalcy training.
One caregivers normalcy training expired on 5/3/2022. Note: This was corrected at inspection due to the staff completing the training during the inspection. |
Yes |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
One of the service plans reviewed did not document the supervision in the preliminary service plan for the child. |
— |
| 4 | — |
748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
One medication had two separate medication logs for the same medication prescribed. One medication log had documented medication given prior to iit being administered. |
— |
| 4 | — |
748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
A child in care was left outside of the operation. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A caregiver slapped a child in care in the face. |
— |
| 3 | — |
748.2851(b)(1) - EBI Follow-Up-Caregiver involved in EBI must conduct post discussion with child to discuss child's behavior and circumstances that required EBI
One child was restrained and there was no EBI post discussion with the child and the staff involved. |
— |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Two staff members failed to follow policies and procedures by not implementing an effective manual restraint during an emergency situation involving imminent risk of harm to another child in care. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
During the review staff reported that he told victim he was lucky he wasn?t 18 because he would have beat his ass. |
— |
| 5 | — |
748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety
Two staff members at the operation failed to prevent a child in care from assaulting other children in care with an object. |
— |
| 3 | — |
748.455(a)(4) - Unauthorized Absence?Debriefing includes where child went, who was w/ child, child?s activities & any other relevant info to child?s health &safety
Two debriefings do not include required documentation such as what occurred while the child was away, where the child went, and the child's activities. One debriefing does not include the child's condition upon returning. |
— |
| 3 | — |
748.453(a)(3) - Unauthorized Absence ? Annual summary log must include how long the child was gone or if the child did not return
The unauthorized absence log is missing how long the child was gone or did not return, the name of the caregiver responsible for the child at the time the child?s absence was discovered, the intake report number and the number of the police report. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Children engaged in inappropriate contact due to the adequate supervision of the caregiver. |
— |
| 2 | — |
748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer
2 of 2 child files reviewed did not have complete discharge summaries completed to include required information including circumstances of discharge, assessment of child needs, support resources and aftercare plans. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A child was allowed to intervene with another child who was destroying property at the operation. Staff did not intervene but stayed outside of the room as both children were in the room and one child was hitting the walls and door with a metal pole. |
— |
| 4 | — |
748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed
Youths missed four days of Trazadone medication because refills were not obtained in a timely manner. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Two children were seen going in and out of the closet. |
— |
| 2 | — |
748.1117 - Documentation of searches-Caregiver documents searches in the child's record
The staff conducted a search of the youths' room, took cell phones, and did not document the search. |
— |
| 3 | — |
748.1337(b)(1)(D)(iii) - Initial Service Plan-Include child's trauma triggers
One initial service plan is missing several pieces of required information such as the child's personal trauma history, trauma triggers, plans for educating on STD's and human reproduction, and plans for preparation for independent living. |
— |
| 2 | — |
748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
A new preliminary service plan was not completed when a child discharged but then was readmitted to the operation several days later. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
Out of four staff EBI training reviewed, one was not current and three did not have documented EBI training every 6 months. |
— |
| 5 | — |
748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child
When a child had escalated behaviors, staff member pulled a child hair in order to gain compliance. |
— |
| 3 | — |
748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication
A review of a child's medication log did not have required name and signature of staff who administered medication. |
— |
| 2 | — |
748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
During the course inspection it was found that the operation vaccinated a child in care that had a signed affidavit stating for the child not to be vaccinations. |
— |
| 3 | — |
748.1331(f) - Preliminary Service Plan-Implement and follow the preliminary service plan
A child was escalated and the staff member failed to use coping mechanisms listed on the service plan. |
— |
| 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
A debriefing was not conducted with 24 hours following an unauthorized absences. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
One child's bedroom has been without window blinds for a month. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location
A child's chronic condition of being epileptic or having seizures was not on the exterior of the file and was not clearly visidble in the file. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Children in care were able to gain access to staff keys and be unsupervised in the gym for several hours. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
One child's bedroom does not have blinds, curtains or anything covering the window to provide privacy. |
— |
| 5 | — |
748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
While under the supervision of caregivers an 11 year old stabbed a 13 year old in the chest and back with a stick causing an injury. |
— |
| 5 | — |
748.685(c)(2) - Caregiver responsibility - provide a safe environment
Staff did not use any measure to encourage the children to not run away. |
— |
| 4 | — |
748.459(a) - Unauthorized Absence-Triggered review of child?s unauthorized absences must include, child, designated staff, and child?s case manager
two of the three triggered reviews did not indicate that the child's case manager was present for the triggered review. The child's case manager must participate in the triggered review. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
After reviewing the video, it shows staff sitting at a table on their cell phone. Staff never look up to see the child leaving from the common area. |
— |
| 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
Two chidren did not have a debriefing within 24 hours of returning to the operation following an unauthorized absence. |
— |
| 5 | — |
748.3301(b) - Physical Site-Buildings must comply with applicable building, plumbing, electrical, fire, and similar codes
During the walk through a broken exit sign with exposed wire and broken furniture with exposed nails were found the gym that the children had access to. Also in the bedroom two pollows did not have pollow cases. In one room a dresser drawer was missing. Pictures were taken |
— |
| 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
A child in care ran was absent from the facility 04/19, 04/20, 04/24, and an attempt on 04/25. The child stated that the running away was an attempt to obtain cigarettes. The incident report does not document how the operation planned to reduce the probability of additional absences. |
— |
| 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
A child in care ran was absent from the facility 04/19, 04/20, 04/24, and an attempt on 04/25. The child stated that the running away was an attempt to obtain cigarettes. The incident report does not document how the operation planned to reduce the probability of additional absences. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
After reviewing the video, it shows staff sitting at a table on their cell phone. Staff never look up to see the child leaving from the common area. |
— |
| 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
Two chidren did not have a debriefing within 24 hours of returning to the operation following an unauthorized absence. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
One child's bedroom has been without window blinds for a month. |
— |
| 3 | — |
748.2851(b)(1) - EBI Follow-Up-Caregiver involved in EBI must conduct post discussion with child to discuss child's behavior and circumstances that required EBI
One child was restrained and there was no EBI post discussion with the child and the staff involved. |
— |
| 2 | — |
748.1117 - Documentation of searches-Caregiver documents searches in the child's record
The staff conducted a search of the youths' room, took cell phones, and did not document the search. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Children engaged in inappropriate contact due to the adequate supervision of the caregiver. |
— |
| 3 | — |
748.1337(b)(1)(D)(iii) - Initial Service Plan-Include child's trauma triggers
One initial service plan is missing several pieces of required information such as the child's personal trauma history, trauma triggers, plans for educating on STD's and human reproduction, and plans for preparation for independent living. |
— |
| 2 | — |
748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer
2 of 2 child files reviewed did not have complete discharge summaries completed to include required information including circumstances of discharge, assessment of child needs, support resources and aftercare plans. |
— |
| 3 | — |
748.453(a)(3) - Unauthorized Absence ? Annual summary log must include how long the child was gone or if the child did not return
The unauthorized absence log is missing how long the child was gone or did not return, the name of the caregiver responsible for the child at the time the child?s absence was discovered, the intake report number and the number of the police report. |
— |
| 2 | — |
748.3351(5) - Interior Space-provide bedroom windows with curtains, blinds, shades, or other provisions for rest and privacy
One child's bedroom does not have blinds, curtains or anything covering the window to provide privacy. |
— |
| 4 | — |
748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.
Out of four staff EBI training reviewed, one was not current and three did not have documented EBI training every 6 months. |
— |
| 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
A debriefing was not conducted with 24 hours following an unauthorized absences. |
— |
| 4 | — |
748.2151(c)(5) - Medication record - must include date (day/month/year) & time each medication was administered
On May 7th Christopher P. was administer Trazodone by staff member ASA,. ASA did not document the time the medication was provided. |
— |
| 4 | — |
748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language
During the review staff reported that he told victim he was lucky he wasn?t 18 because he would have beat his ass. |
— |
| 3 | — |
748.455(a)(4) - Unauthorized Absence?Debriefing includes where child went, who was w/ child, child?s activities & any other relevant info to child?s health &safety
Two debriefings do not include required documentation such as what occurred while the child was away, where the child went, and the child's activities. One debriefing does not include the child's condition upon returning. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Children in care were able to gain access to staff keys and be unsupervised in the gym for several hours. |
— |
| 5 | — |
748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity
A child was allowed to intervene with another child who was destroying property at the operation. Staff did not intervene but stayed outside of the room as both children were in the room and one child was hitting the walls and door with a metal pole. |
— |
| 5 | — |
748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
A caregiver slapped a child in care in the face. |
— |
| 4 | — |
748.930(b)(2) - Annual Training- Caregivers must have 2 hrs trauma informed care.
One caregivers trauma informed care training expired on 5/3/2022. Note: This was corrected at inspection due to the staff completing the training during the inspection. |
Yes |
| 3 | — |
748.126(b) - All employees and caregivers must be aware of and follow your policies and procedures
Two staff members failed to follow policies and procedures by not implementing an effective manual restraint during an emergency situation involving imminent risk of harm to another 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
While under the supervision of caregivers an 11 year old stabbed a 13 year old in the chest and back with a stick causing an injury. |
— |
| 5 | — |
748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
Two children were seen going in and out of the closet. |
— |
| 4 | — |
748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or "no known allergies" on exterior of record or in a clearly visible location
A child's chronic condition of being epileptic or having seizures was not on the exterior of the file and was not clearly visidble in the file. |
— |
164 inspection record(s) on file from TX-HHSC.