Texas › Spring › Hearts with Hope Foundation-GRO

Hearts with Hope Foundation-GRO

Child care center · 3407 SPRING CREEK DR, Spring, TX 77373-6118 · License 1105326

0Compliance score
Poor

Capacity 29. 7-17

Violation history (296)

Severity	Date	Standard / narrative	Corrected
3	—	748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures A resident in care used a staff members cell phone to communicate with an individual.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication 6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.	—
1	—	748.1217(c)(1) - Admission Assessment-Prior to initial service plan, add child's social history One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.	—
3	—	748.685(c)(6) - Implement and follow the children's service plans. Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.	—
3	—	748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.	—
2	—	748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement The Case Manager is currently still performing the job responsibilities of a PLSP such as admissions assessments.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A child in care was physically harmed while attempting to deescalate her peers from engaging in an altercation.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.	—
3	—	748.453(a)(2) - Unauthorized Absence ? Annual summary log must include time and date absence was discovered The annual summary log does not include the time the absence was discovered.	—
3	—	748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan The victim's service plan states, "Due to the victim's intense level of care and unpredictable behaviors, she may receive 1:1 supervision when her behaviors warrant." When the staff arrived to assist with the situation, instead of staying to assist the caregiver that was already there to provide 1:1 supervision, the staff left, leaving the other staff to handle the situation alone with 2 other children in care that were receiving dental treatments.	—
3	—	748.303(e)(4)(A) - Serious Incident-Report to Licensing within 24 hours of awareness of allegation a person under auspices of operation abused drugs in past 7 days The operation failed to report a child made allegations of a staff member allegedly using drugs.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.	—
5	—	748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting Three out of five kids interviewed disclosed physical discipline was used in the facility by a staff.	—
4	—	748.863(b) - Caregivers who have not completed all pre-service training may not be counted in ratio unless there is a qualified caregiver counted at same time. Two direct care staff have not completed all of their pre-service training.	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.	—
3	—	748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older. During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.	—
4	—	748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.	—
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 Reviewing unauthorized absence log on date 10/25/2021 & 12/11/2021 it was noted that debriefing was not conducted as well as time/ date was not entered into the form on 12/11/2021	—
5	—	748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity During the investigation it was found that a child in care was left unsupervised.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records One of the medication logs did not accurately reflect the pills counted.	—
4	—	748.869(d)(3)(A) - Training on EBI must at the end, require each participant to demonstrate knowledge and competency of the training in writing. All staff files reviewed did not contain written knowledge and competency of the training material.	—
4	—	748.881(5) - General pre-service training curriculum-Includes location and use of fire extinguishers and first aid equipment The Disaster and Emergency curriculum does not have the required components such as the location and use of the fire extinguishers and first aid equipment.	—
4	—	748.2255(1) - Operation does not employ professional who prescribes psychotropic meds-Operation gives required info to medical consenter before requesting consent It was determined that an unauthorized person consented to medication during a child in cares hospital stay.	—
2	—	748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. The operation did not notify licensing of a child's AWOL within the 6 hour time frame.	—
3	—	748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request. The annual summary log was not available upon request for review. It was requested at 4:30pm and was not recived until the exit of this inspection.	Yes
4	—	748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave There was a bag of chicken left to thaw in the kitchen sink.	Yes
4	—	748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.	—
3	—	748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers The staffing plan provided does not include a plan for back up care providers for emergencies.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.	—
3	—	748.1101(b)(3)(F) - Children's rights-to personal care, hygiene, and grooming equipment and supplies and training in how to use them Children in care were observed to not have a toothbrush and not sufficient and adequate clothing, the child had long sleeve shirts and sweatpants.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.	—
4	—	748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected Three out of the four child files reviewed did not have a hearing screening.	—
3	—	748.363(3) - Personnel records-Include current job description A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The training logs that were observed were not accurate and did not match the training certificates observed in the files. A file was observed to not have a valid drivers license on file.	—
3	—	748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved Age, gender and date of admission of the child/children involved not found in document.	—
3	—	748.453(c) - Unauthorized Absence - Annual summary logs should be available to Licensing for review and reproduction, upon request. The annual summary log was not available upon request for review. It was requested at 4:30pm and was not recived until the exit of this inspection.	Yes
2	—	748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement The Case Manager is currently still performing the job responsibilities of a PLSP such as admissions assessments.	—
4	—	748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.	—
4	—	748.2255(1) - Operation does not employ professional who prescribes psychotropic meds-Operation gives required info to medical consenter before requesting consent It was determined that an unauthorized person consented to medication during a child in cares hospital stay.	—
4	—	748.863(b) - Caregivers who have not completed all pre-service training may not be counted in ratio unless there is a qualified caregiver counted at same time. Two direct care staff have not completed all of their pre-service training.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. The operation did not notify licensing of a child's AWOL within the 6 hour time frame.	—
3	—	748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.	—
3	—	748.685(c)(6) - Implement and follow the children's service plans. Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.	—
2	—	748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.	—
3	—	748.311(3) - Serious Incident Documentation-Includes name, age, gender, and date of admission of the child or children involved Age, gender and date of admission of the child/children involved not found in document.	—
3	—	748.705(b)(9) - Reasonable & prudent parent standard-must consider the supervision instructions in the child's service plan The victim's service plan states, "Due to the victim's intense level of care and unpredictable behaviors, she may receive 1:1 supervision when her behaviors warrant." When the staff arrived to assist with the situation, instead of staying to assist the caregiver that was already there to provide 1:1 supervision, the staff left, leaving the other staff to handle the situation alone with 2 other children in care that were receiving dental treatments.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.	—
3	—	748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers The staffing plan provided does not include a plan for back up care providers for emergencies.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records One of the medication logs did not accurately reflect the pills counted.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.	—
5	—	748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting Three out of five kids interviewed disclosed physical discipline was used in the facility by a staff.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.	—
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 Reviewing unauthorized absence log on date 10/25/2021 & 12/11/2021 it was noted that debriefing was not conducted as well as time/ date was not entered into the form on 12/11/2021	—
4	—	748.881(5) - General pre-service training curriculum-Includes location and use of fire extinguishers and first aid equipment The Disaster and Emergency curriculum does not have the required components such as the location and use of the fire extinguishers and first aid equipment.	—
4	—	748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected Three out of the four child files reviewed did not have a hearing screening.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication 6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A child in care was physically harmed while attempting to deescalate her peers from engaging in an altercation.	—
3	—	748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older. During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.	—
1	—	748.1217(c)(1) - Admission Assessment-Prior to initial service plan, add child's social history One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.	—
3	—	748.303(e)(4)(A) - Serious Incident-Report to Licensing within 24 hours of awareness of allegation a person under auspices of operation abused drugs in past 7 days The operation failed to report a child made allegations of a staff member allegedly using drugs.	—
4	—	748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.	—
5	—	748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity During the investigation it was found that a child in care was left unsupervised.	—
3	—	748.363(3) - Personnel records-Include current job description A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.	—
4	—	748.869(d)(3)(A) - Training on EBI must at the end, require each participant to demonstrate knowledge and competency of the training in writing. All staff files reviewed did not contain written knowledge and competency of the training material.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records The training logs that were observed were not accurate and did not match the training certificates observed in the files. A file was observed to not have a valid drivers license on file.	—
3	—	748.453(a)(2) - Unauthorized Absence ? Annual summary log must include time and date absence was discovered The annual summary log does not include the time the absence was discovered.	—
4	—	748.3441(m) - Food Preparation-Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave There was a bag of chicken left to thaw in the kitchen sink.	Yes
3	—	748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures A resident in care used a staff members cell phone to communicate with an individual.	—
3	—	748.1101(b)(3)(F) - Children's rights-to personal care, hygiene, and grooming equipment and supplies and training in how to use them Children in care were observed to not have a toothbrush and not sufficient and adequate clothing, the child had long sleeve shirts and sweatpants.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.	—
2	—	748.561(1) - Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.	—
4	—	748.2003(b)(5) - Administration of prescription medication-Ensure the child has taken the medication as prescribed While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.	—
3	—	748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records One of the medication logs did not accurately reflect the pills counted.	—
1	—	748.1217(c)(1) - Admission Assessment-Prior to initial service plan, add child's social history One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.	—
3	—	748.303(a)(10)(C) - Serious Incident-Report to law enforcement no later than 6 hours after determining unauthorized absence of a child 13 years old or older. During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.	—
5	—	748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity During the investigation it was found that a child in care was left unsupervised.	—
4	—	748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.	—
3	—	748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.	—
3	—	748.303(e)(4)(A) - Serious Incident-Report to Licensing within 24 hours of awareness of allegation a person under auspices of operation abused drugs in past 7 days The operation failed to report a child made allegations of a staff member allegedly using drugs.	—
4	—	748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected Three out of the four child files reviewed did not have a hearing screening.	—
3	—	748.105(3)(C) - Personnel policies-develop professional staffing plan that documents staffing patterns/ratios/hours of coverage/plans for backup caregivers The staffing plan provided does not include a plan for back up care providers for emergencies.	—
5	—	748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being A child in care was physically harmed while attempting to deescalate her peers from engaging in an altercation.	—
4	—	748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.	—
2	—	748.751(b)(2) - Pre-Employment Screening-You must document the results of any contact with an applicant's previous employers in the personnel file. Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.	—
3	—	748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication 6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.	—
4	—	748.861(b) - Pre-Service Training-If facility provides certain amount of tx svcs, caregiver must have 40 hours experience in operation that provides same tx svcs A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.	—
3	—	748.685(c)(6) - Implement and follow the children's service plans. Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.	—
4	—	748.2255(1) - Operation does not employ professional who prescribes psychotropic meds-Operation gives required info to medical consenter before requesting consent It was determined that an unauthorized person consented to medication during a child in cares hospital stay.	—
4	—	748.863(b) - Caregivers who have not completed all pre-service training may not be counted in ratio unless there is a qualified caregiver counted at same time. Two direct care staff have not completed all of their pre-service training.	—
4	—	748.869(d)(3)(A) - Training on EBI must at the end, require each participant to demonstrate knowledge and competency of the training in writing. All staff files reviewed did not contain written knowledge and competency of the training material.	—
4	—	748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.	—
3	—	748.303(a)(10)(A) - Serious Incident-Report to Licensing no later than 6 hours after determining unauthorized absence of a child 13 yrs old or older. The operation did not notify licensing of a child's AWOL within the 6 hour time frame.	—
3	—	748.363(3) - Personnel records-Include current job description A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.	—
3	—	748.453(a)(2) - Unauthorized Absence ? Annual summary log must include time and date absence was discovered The annual summary log does not include the time the absence was discovered.	—
3	—	748.505(b)(4) - Minimum qualifications for employees-Complete notarized Licensing Affidavit for Applicants for Employment form One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.	—

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

Inspections (168)

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

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