Fort Behavioral Health
5833 OAKBEND TRL, Fort Worth, TX 76132 · Tarrant County
Program
- Type
- General residential operation
- Licensed capacity
- 128
- Ages
- 11-17
- Hours
- -
- Director / administrator
- Patricia Faye Martinez
- Phone
- (817) 678-7428
- Regulated since
- Mar 4, 2020
- HHSC IDs
- Operation 1334408 · number 1693628
- Official record
- HHSC Child Care Search
Violations by category
Year by year
| Year | Violations | Serious | Main categories |
|---|---|---|---|
| 2025 | 4 | 0 | Supervision & ratios (4) |
| 2023 | 224 | 62 | Cleanliness & sanitation (2), Illness & medication (36), Supervision & ratios (40), Discipline & child guidance (20), Safety & premises (14), Staff background & training (24), Records & paperwork (32), Other (56) |
| 2022 | 98 | 24 | Cleanliness & sanitation (2), Illness & medication (8), Supervision & ratios (14), Discipline & child guidance (10), Safety & premises (4), Staff background & training (20), Records & paperwork (10), Other (30) |
| 2021 | 6 | 2 | Other (6) |
Enforcement actions
- Seen Oct 1, 2026 — Adverse action in effect (HHSC operation record)
HHSC publishes these as current flags on the operation, not as dated actions. The date shown is when this site first saw the flag. The HHSC Child Care Search has the details.
Inspections, investigations & assessments
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Jul 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jul 29, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 21, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 21, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 20, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 20, 2026 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Nov 17, 2025 Assessment
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 17, 2025 Assessment
No violations cited on this visit.
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Oct 7, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 7, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 15, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
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Jul 15, 2025 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jan 23, 2025 Inspection · Deficiencies cited
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Supervision & ratios
Liability Insurance is expired. Operation did not provide updated documentation.
HHSC 748.158(1) — Operational Responsibilities- Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence
HHSC risk weight: Medium. Corrected 2025-02-24. Correction verified 2025-02-05.
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Supervision & ratios
Operation health inspection was not completed 12 months from the last inspection. The last health inspection was completed 10/23/2023.
HHSC 748.3001(a)(2) — Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection
HHSC risk weight: Medium High. Corrected 2025-06-30. Correction verified 2025-07-08.
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Supervision & ratios
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Jan 23, 2025 Inspection · Deficiencies cited
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Supervision & ratios
Liability Insurance is expired. Operation did not provide updated documentation.
HHSC 748.158(1) — Operational Responsibilities- Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence
HHSC risk weight: Medium. Corrected 2025-02-24. Correction verified 2025-02-05.
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Supervision & ratios
Operation health inspection was not completed 12 months from the last inspection. The last health inspection was completed 10/23/2023.
HHSC 748.3001(a)(2) — Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection
HHSC risk weight: Medium High. Corrected 2025-06-30. Correction verified 2025-07-08.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Oct 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 23, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Aug 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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May 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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May 14, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Feb 23, 2024 Inspection
No violations cited on this visit.
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Feb 23, 2024 Inspection
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Feb 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
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Feb 9, 2024 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jan 31, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jan 31, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Jan 17, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jan 17, 2024 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 20, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 20, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Dec 15, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 15, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Dec 8, 2023 Inspection · Deficiencies cited
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Safety & premises
2 of 2 child files reviewed did not indicate signatures from the children being admitted. During a follow up inspection on 12/8/2023, no documentation was received to support compliance for this standard due to administrators not being available. One admin was on leave and the other attending a family emergency.
HHSC 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
HHSC risk weight: Medium. Corrected 2023-12-11. Correction verified 2023-12-12.
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Safety & premises
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Dec 8, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Dec 8, 2023 Inspection · Deficiencies cited
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Safety & premises
2 of 2 child files reviewed did not indicate signatures from the children being admitted. During a follow up inspection on 12/8/2023, no documentation was received to support compliance for this standard due to administrators not being available. One admin was on leave and the other attending a family emergency.
HHSC 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
HHSC risk weight: Medium. Corrected 2023-12-11. Correction verified 2023-12-12.
HHSC inspection history · no longer published by HHSC; kept here
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Safety & premises
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Dec 8, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Nov 17, 2023 Inspection · Deficiencies cited
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Records & paperwork
2 of 2 child files reviewed did not indicate signatures from the children being admitted.
HHSC 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
HHSC risk weight: Medium. Corrected 2023-11-24. Correction verified 2023-12-12.
HHSC inspection history · no longer published by HHSC; kept here
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Records & paperwork
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Nov 17, 2023 Inspection · Deficiencies cited
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Records & paperwork
2 of 2 child files reviewed did not indicate signatures from the children being admitted.
HHSC 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
HHSC risk weight: Medium. Corrected 2023-11-24. Correction verified 2023-12-12.
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Records & paperwork
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Nov 1, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Nov 1, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Oct 27, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Oct 27, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Oct 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Oct 26, 2023 Inspection · Deficiencies cited
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Records & paperwork
2 of 4 employee files did not include date of employment.
HHSC 748.363(1) — Personnel records-Include date of employment
HHSC risk weight: Medium. Corrected 2023-11-02. Correction verified 2023-11-17.
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Records & paperwork
2 of 4 employee files does not include job description for current job title.
HHSC 748.363(4) — Personnel records-Personnel records-Include current job description.
HHSC risk weight: Medium. Corrected 2023-11-02. Correction verified 2023-11-17.
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Records & paperwork
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Oct 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 26, 2023 Inspection · Deficiencies cited
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Records & paperwork
2 of 4 employee files did not include date of employment.
HHSC 748.363(1) — Personnel records-Include date of employment
HHSC risk weight: Medium. Corrected 2023-11-02. Correction verified 2023-11-17.
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Records & paperwork
2 of 4 employee files does not include job description for current job title.
HHSC 748.363(4) — Personnel records-Personnel records-Include current job description.
HHSC risk weight: Medium. Corrected 2023-11-02. Correction verified 2023-11-17.
HHSC inspection history · no longer published by HHSC; kept here
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Records & paperwork
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Oct 20, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Oct 20, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Oct 11, 2023 Report · Deficiencies cited
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Other
A person who signed the admission assessment admitted to not conducting it.
HHSC 748.561(1) — Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement
HHSC risk weight: Medium Low. Corrected 2023-11-21. Correction verified 2023-12-06.
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Other
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Oct 11, 2023 Report · Deficiencies cited
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Other
A person who signed the admission assessment admitted to not conducting it.
HHSC 748.561(1) — Responsibilities of Professional level service provider-Completing an admission assessment or any other evaluation of a child for placement
HHSC risk weight: Medium Low. Corrected 2023-11-21. Correction verified 2023-12-06.
HHSC inspection history · no longer published by HHSC; kept here
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Other
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Oct 10, 2023 Report · Deficiencies cited
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Safety & premises
Discharge summary does not include child's reaction to discharge.
HHSC 748.1437(7) — Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction
HHSC risk weight: Medium Low. Corrected 2023-11-21. Correction verified 2023-12-13.
HHSC inspection history · no longer published by HHSC; kept here
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Safety & premises
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Oct 10, 2023 Report · Deficiencies cited
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Safety & premises
Discharge summary does not include child's reaction to discharge.
HHSC 748.1437(7) — Discharge/Transfer Documentation-For emergency discharge/transfer, document reason for discharge/transfer explained to child, and child's reaction
HHSC risk weight: Medium Low. Corrected 2023-11-21. Correction verified 2023-12-13.
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Safety & premises
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Oct 3, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Oct 3, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Oct 3, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Oct 3, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Sep 28, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Sep 28, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Sep 26, 2023 Report · Deficiencies cited
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Discipline & child guidance Serious
A 16-year-old child received a bruise when the caregiver pushed the child out of the door.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-11-02. Correction verified 2023-11-17.
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Discipline & child guidance Serious
A caregiver used inappropriate discipline by pushing a child when the child refused to leave a room.
HHSC 748.2303(a) — Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
HHSC risk weight: High. Corrected 2023-11-02. Correction verified 2023-11-17.
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Supervision & ratios
A caregiver did not follow the operation's policy and procedures for redirecting child behaviors.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-11-02. Correction verified 2023-11-17.
HHSC inspection history · no longer published by HHSC; kept here
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Discipline & child guidance Serious
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Sep 26, 2023 Report · Deficiencies cited
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Discipline & child guidance Serious
A 16-year-old child received a bruise when the caregiver pushed the child out of the door.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-11-02. Correction verified 2023-11-17.
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Discipline & child guidance Serious
A caregiver used inappropriate discipline by pushing a child when the child refused to leave a room.
HHSC 748.2303(a) — Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
HHSC risk weight: High. Corrected 2023-11-02. Correction verified 2023-11-17.
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Supervision & ratios
A caregiver did not follow the operation's policy and procedures for redirecting child behaviors.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-11-02. Correction verified 2023-11-17.
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Discipline & child guidance Serious
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Sep 26, 2023 Inspection · Deficiencies cited
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Other Serious
Condition #1 - Met Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Not Met Condition #12 - Met Condition #13 - Met Condition #14 - Met Condition #15 - Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-09-29. Correction verified 2023-10-03.
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Illness & medication
Medication log pill count shows a child was given more medication than instructed.
HHSC 748.2003(b)(3) — AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
HHSC risk weight: Medium High. Corrected 2023-09-27. Correction verified 2023-10-03.
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Other Serious
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Sep 26, 2023 Inspection · Deficiencies cited
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Other Serious
Condition #1 - Met Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Not Met Condition #12 - Met Condition #13 - Met Condition #14 - Met Condition #15 - Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-09-29. Correction verified 2023-10-03.
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Illness & medication
Medication log pill count shows a child was given more medication than instructed.
HHSC 748.2003(b)(3) — AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
HHSC risk weight: Medium High. Corrected 2023-09-27. Correction verified 2023-10-03.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
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Sep 16, 2023 Report · Deficiencies cited
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Supervision & ratios
The operation was out of ratio when two caregivers were left to care for 11 children. The operation continued to be out of ratio when one caregiver was left to care for ten children.
HHSC 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
HHSC risk weight: Medium High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Discipline & child guidance Serious
This standard was found deficient as part of a DFPS Investigation.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Illness & medication Serious
At 17:30, after being injured, a child was observed to bleed from the eye, enough to soak a shirt and cover the floor. The operation did not contact EMS until 17:50
HHSC 748.1553 — Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.
HHSC risk weight: High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Supervision & ratios
The operation was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required. One child was indicated to be on one-on-one supervision. The Administrator did not ensure the operation had sufficient staff to care for children in care. An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio.
HHSC 748.535(3)(A) — Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
HHSC risk weight: Medium High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Supervision & ratios Serious
Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children. Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety. As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Supervision & ratios
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Sep 16, 2023 Report · Deficiencies cited
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Supervision & ratios
The operation was out of ratio when two caregivers were left to care for 11 children. The operation continued to be out of ratio when one caregiver was left to care for ten children.
HHSC 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
HHSC risk weight: Medium High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Discipline & child guidance Serious
This standard was found deficient as part of a DFPS Investigation.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Illness & medication Serious
At 17:30, after being injured, a child was observed to bleed from the eye, enough to soak a shirt and cover the floor. The operation did not contact EMS until 17:50
HHSC 748.1553 — Child must be immediately treated by health prof, contact emergency svs or take child to ER for injury/illness requiring treatment by a health prof.
HHSC risk weight: High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Supervision & ratios
The operation was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required. One child was indicated to be on one-on-one supervision. The Administrator did not ensure the operation had sufficient staff to care for children in care. An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio.
HHSC 748.535(3)(A) — Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children
HHSC risk weight: Medium High. Corrected 2024-07-10. Correction verified 2024-08-22.
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Supervision & ratios Serious
Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children. Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety. As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2024-07-10. Correction verified 2024-08-22.
HHSC inspection history · no longer published by HHSC; kept here
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Supervision & ratios
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Sep 14, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Sep 14, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Sep 13, 2023 Inspection · Deficiencies cited
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Other Serious
Condition #1: Progress reviews for the improvement plan were not available for review. Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date.
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-09-15. Correction verified 2023-09-26.
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Other Serious
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Sep 13, 2023 Inspection · Deficiencies cited
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Other Serious
Condition #1: Progress reviews for the improvement plan were not available for review. Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date.
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-09-15. Correction verified 2023-09-26.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
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Sep 11, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Sep 11, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Sep 3, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Sep 3, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Aug 31, 2023 Report · Deficiencies cited
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Safety & premises
Child in care, with history of self-harming, continue to cut and scratched herself.
HHSC 748.685(b)(4) — Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
HHSC risk weight: Medium High. Corrected 2024-01-12. Correction verified 2024-01-17.
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Safety & premises
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Aug 31, 2023 Report · Deficiencies cited
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Safety & premises
Child in care, with history of self-harming, continue to cut and scratched herself.
HHSC 748.685(b)(4) — Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
HHSC risk weight: Medium High. Corrected 2024-01-12. Correction verified 2024-01-17.
HHSC inspection history · no longer published by HHSC; kept here
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Safety & premises
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Aug 30, 2023 Inspection · Deficiencies cited
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Other Serious
Condition #1 - Does not meet Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Met Condition #12 - Does Not Meet Condition #13 - Met Condition #14 - Met Condition #15 - Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-09-06. Correction verified 2023-09-13.
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Other
4 of 6 child files reviewed had preliminary service plans that were signed outside of 72 hours.
HHSC 748.1333 — Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services
HHSC risk weight: Medium. Corrected 2023-09-08. Correction verified 2023-09-13.
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Staff background & training
2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates.
HHSC 748.949(b)(5) — Annual Training Documentation-Includes the length of the training in hours
HHSC risk weight: Medium Low. Corrected 2023-09-08. Correction verified 2023-09-13.
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Other Serious
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Aug 30, 2023 Inspection · Deficiencies cited
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Other Serious
Condition #1 - Does not meet Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Met Condition #12 - Does Not Meet Condition #13 - Met Condition #14 - Met Condition #15 - Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-09-06. Correction verified 2023-09-13.
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Other
4 of 6 child files reviewed had preliminary service plans that were signed outside of 72 hours.
HHSC 748.1333 — Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services
HHSC risk weight: Medium. Corrected 2023-09-08. Correction verified 2023-09-13.
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Staff background & training
2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates.
HHSC 748.949(b)(5) — Annual Training Documentation-Includes the length of the training in hours
HHSC risk weight: Medium Low. Corrected 2023-09-08. Correction verified 2023-09-13.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
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Aug 29, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Aug 29, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 18, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Aug 18, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 17, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 17, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 17, 2023 Report · No deficiencies cited
No violations cited on this visit.
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Aug 17, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Aug 4, 2023 Report · Deficiencies cited
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Illness & medication
Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed.
HHSC 748.151(2) — Operational responsibilities - Operate according to your approved plans, policies, and procedures
HHSC risk weight: Medium. Corrected 2023-10-17. Correction verified 2023-10-26.
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Illness & medication
Non-prescription medication provided to a child in care was not documented on the medication log.
HHSC 748.2151(e) — Medication Record-must document non-prescription medication or supplement given to child and how often given
HHSC risk weight: Medium. Corrected 2023-10-17. Correction verified 2023-10-26.
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Safety & premises
Incident report does not indicate a restraint was used.
HHSC 748.2855(a)(4) — EBI Documentation-Must include the specific emergency behavior intervention administered
HHSC risk weight: Medium. Corrected 2023-10-17. Correction verified 2023-10-26.
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Illness & medication
-
Aug 4, 2023 Report · Deficiencies cited
-
Illness & medication
Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed.
HHSC 748.151(2) — Operational responsibilities - Operate according to your approved plans, policies, and procedures
HHSC risk weight: Medium. Corrected 2023-10-17. Correction verified 2023-10-26.
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Illness & medication
Non-prescription medication provided to a child in care was not documented on the medication log.
HHSC 748.2151(e) — Medication Record-must document non-prescription medication or supplement given to child and how often given
HHSC risk weight: Medium. Corrected 2023-10-17. Correction verified 2023-10-26.
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Safety & premises
Incident report does not indicate a restraint was used.
HHSC 748.2855(a)(4) — EBI Documentation-Must include the specific emergency behavior intervention administered
HHSC risk weight: Medium. Corrected 2023-10-17. Correction verified 2023-10-26.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Aug 4, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-11-13. Correction verified 2023-11-17.
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Supervision & ratios
Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan.
HHSC 748.1331(f) — Preliminary Service Plan-Implement and follow the preliminary service plan
HHSC risk weight: Medium. Corrected 2023-11-13. Correction verified 2023-11-17.
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Supervision & ratios Serious
A caregiver failed to provide appropriate supervision which allowed two children to engage in inappropriate contact while on duty at the operation.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-11-13. Correction verified 2023-11-17.
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Discipline & child guidance Serious
-
Aug 4, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-11-13. Correction verified 2023-11-17.
-
Supervision & ratios
Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan.
HHSC 748.1331(f) — Preliminary Service Plan-Implement and follow the preliminary service plan
HHSC risk weight: Medium. Corrected 2023-11-13. Correction verified 2023-11-17.
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Supervision & ratios Serious
A caregiver failed to provide appropriate supervision which allowed two children to engage in inappropriate contact while on duty at the operation.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-11-13. Correction verified 2023-11-17.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance Serious
-
Aug 2, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Aug 2, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 31, 2023 Inspection · Deficiencies cited
-
Cleanliness & sanitation
There was a toilet that was clogged and was not in working order.
HHSC 748.3391(a) — Bathrooms-Must be maintained in good repair & kept clean
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2023-07-31.
-
Cleanliness & sanitation
-
Jul 31, 2023 Inspection · Deficiencies cited
-
Cleanliness & sanitation
There was a toilet that was clogged and was not in working order.
HHSC 748.3391(a) — Bathrooms-Must be maintained in good repair & kept clean
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2023-07-31.
HHSC inspection history · no longer published by HHSC; kept here
-
Cleanliness & sanitation
-
Jul 27, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 27, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 27, 2023 Report · Deficiencies cited
-
Other
Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-11-07. Correction verified 2023-11-07.
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Safety & premises
Serious incident report does not indicate the specific emergency behavior technique.
HHSC 748.2855(a)(4) — EBI Documentation-Must include the specific emergency behavior intervention administered
HHSC risk weight: Medium. Corrected 2023-11-07. Correction verified 2023-11-07.
HHSC inspection history · no longer published by HHSC; kept here
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Other
-
Jul 27, 2023 Report · Deficiencies cited
-
Other
Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-11-07. Correction verified 2023-11-07.
-
Safety & premises
Serious incident report does not indicate the specific emergency behavior technique.
HHSC 748.2855(a)(4) — EBI Documentation-Must include the specific emergency behavior intervention administered
HHSC risk weight: Medium. Corrected 2023-11-07. Correction verified 2023-11-07.
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Other
-
Jul 25, 2023 Inspection · Deficiencies cited
-
Other Serious
Condition #1: Met Condition #2: Met Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement. Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation. Condition #14: Met Condition #15: Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-08-01. Correction verified 2023-08-17.
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Other
5 of 5 child files did not have dental visit scheduled.
HHSC 748.1225(b) — Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file
HHSC risk weight: Medium Low. Corrected 2023-08-08. Correction verified 2023-08-17.
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Illness & medication
5 of 5 child files did not have immunization records.
HHSC 748.1539(b) — Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
HHSC risk weight: Medium Low. Corrected 2023-08-08. Correction verified 2023-08-17.
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Other
5 of 5 child files reviewed did not have TB test results. 1 of 5 employee files did not have TB test results.
HHSC 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
HHSC risk weight: Medium. Corrected 2023-08-08. Correction verified 2023-08-17.
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Staff background & training
2 of 5 employee files did not have documentation of education.
HHSC 748.363(2) — Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position
HHSC risk weight: Medium. Corrected 2023-08-01. Correction verified 2023-08-17.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
-
Jul 25, 2023 Inspection · Deficiencies cited
-
Other Serious
Condition #1: Met Condition #2: Met Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement. Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation. Condition #14: Met Condition #15: Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-08-01. Correction verified 2023-08-17.
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Other
5 of 5 child files did not have dental visit scheduled.
HHSC 748.1225(b) — Admission-Dental exam for child 3 years old or older scheduled in 30 days and done in 90 days unless documentation of one within past year on file
HHSC risk weight: Medium Low. Corrected 2023-08-08. Correction verified 2023-08-17.
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Illness & medication
5 of 5 child files did not have immunization records.
HHSC 748.1539(b) — Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions
HHSC risk weight: Medium Low. Corrected 2023-08-08. Correction verified 2023-08-17.
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Other
5 of 5 child files reviewed did not have TB test results. 1 of 5 employee files did not have TB test results.
HHSC 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
HHSC risk weight: Medium. Corrected 2023-08-08. Correction verified 2023-08-17.
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Staff background & training
2 of 5 employee files did not have documentation of education.
HHSC 748.363(2) — Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position
HHSC risk weight: Medium. Corrected 2023-08-01. Correction verified 2023-08-17.
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Other Serious
-
Jul 21, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 21, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 17, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Jul 17, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 14, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 14, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 14, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 14, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 12, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 12, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 11, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 11, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 11, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
Abuse/Neglect investigation reported two staff members did not provide adequate medical care for a child in care.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-10-16. Correction verified 2023-10-26.
-
Supervision & ratios
Child?s preliminary service plan does not describe how the operation will meet the child?s medical needs or follow-up plan for possible side effects.
HHSC 748.1331(b)(3) — Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs
HHSC risk weight: Medium Low. Corrected 2023-10-19. Correction verified 2023-10-26.
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Illness & medication
Child?s preliminary service plan did not include self medication protocols for child and staff members to ensure the child?s health and safety.
HHSC 748.2051(2) — Medication Self-Administration-Self-medication program must be in the child's service plan & include requirements for caregiver supervision
HHSC risk weight: Medium. Corrected 2023-10-19. Correction verified 2023-10-26.
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Illness & medication
Record for daily insulin dosages were not documented in the medication log
HHSC 748.2053 — Medication Self-Administration-The child must record dosage or report medication to an employee who records the dosage daily
HHSC risk weight: Medium. Corrected 2023-10-19. Correction verified 2023-10-26.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance Serious
-
Jul 11, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
Abuse/Neglect investigation reported two staff members did not provide adequate medical care for a child in care.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-10-16. Correction verified 2023-10-26.
-
Supervision & ratios
Child?s preliminary service plan does not describe how the operation will meet the child?s medical needs or follow-up plan for possible side effects.
HHSC 748.1331(b)(3) — Preliminary Service Plan-For child receiving treatment services, include description of how operation will meet child's needs
HHSC risk weight: Medium Low. Corrected 2023-10-19. Correction verified 2023-10-26.
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Illness & medication
Child?s preliminary service plan did not include self medication protocols for child and staff members to ensure the child?s health and safety.
HHSC 748.2051(2) — Medication Self-Administration-Self-medication program must be in the child's service plan & include requirements for caregiver supervision
HHSC risk weight: Medium. Corrected 2023-10-19. Correction verified 2023-10-26.
-
Illness & medication
Record for daily insulin dosages were not documented in the medication log
HHSC 748.2053 — Medication Self-Administration-The child must record dosage or report medication to an employee who records the dosage daily
HHSC risk weight: Medium. Corrected 2023-10-19. Correction verified 2023-10-26.
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Discipline & child guidance Serious
-
Jul 10, 2023 Report · Deficiencies cited
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Other
Discharge documentation did not discuss when the child was informed of discharge or transfer.
HHSC 748.1437(2) — Discharge/Transfer Documentation-Must include date and time the child was informed of his discharge or transfer
HHSC risk weight: Low. Corrected 2023-08-24. Correction verified 2023-08-30.
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Other
-
Jul 10, 2023 Report · Deficiencies cited
-
Other
Discharge documentation did not discuss when the child was informed of discharge or transfer.
HHSC 748.1437(2) — Discharge/Transfer Documentation-Must include date and time the child was informed of his discharge or transfer
HHSC risk weight: Low. Corrected 2023-08-24. Correction verified 2023-08-30.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Jun 27, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 27, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Jun 27, 2023 Report · Deficiencies cited
-
Supervision & ratios
One caregiver was responsible for eight children when a physical altercation broke out between two children in care.
HHSC 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
HHSC risk weight: Medium High. Corrected 2023-08-03. Correction verified 2023-08-17.
-
Supervision & ratios
-
Jun 27, 2023 Report · Deficiencies cited
-
Supervision & ratios
One caregiver was responsible for eight children when a physical altercation broke out between two children in care.
HHSC 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
HHSC risk weight: Medium High. Corrected 2023-08-03. Correction verified 2023-08-17.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Jun 24, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 24, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 23, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 23, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jun 20, 2023 Inspection · Deficiencies cited
-
Staff background & training Serious
An employee is present at the operation with an inactive background check status.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected 2023-06-23. Correction verified 2023-07-21.
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Staff background & training Serious
Condition # 1: Pending - extention granted to 7/10/23. Condition #2: Met Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee Condition #4: Met Condition #5: Met Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition. Condition #14: Met Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-07-10. Correction verified 2023-07-21.
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Illness & medication
3 of 4 child files reviewed had missing medication dosages.
HHSC 748.2003(b)(3) — AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
HHSC risk weight: Medium High. Corrected 2023-06-23. Correction verified 2023-07-21.
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Staff background & training
Employee who has not completed medication administration training has given medication to a child in care.
HHSC 748.2003(b)(6) — Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication
HHSC risk weight: Medium High. Corrected 2023-06-27. Correction verified 2023-07-21.
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Illness & medication
4 of 4 mediaction files were missing prescribing health-care professional's name as well as reason for medication.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2023-06-27. Correction verified 2023-07-21.
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Illness & medication
4 of 4 medication logs were missing the medication pill count.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2023-06-27. Correction verified 2023-07-21.
-
Staff background & training Serious
-
Jun 20, 2023 Inspection · Deficiencies cited
-
Staff background & training Serious
An employee is present at the operation with an inactive background check status.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected 2023-06-23. Correction verified 2023-07-21.
-
Staff background & training Serious
Condition # 1: Pending - extention granted to 7/10/23. Condition #2: Met Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee Condition #4: Met Condition #5: Met Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition. Condition #14: Met Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-07-10. Correction verified 2023-07-21.
-
Illness & medication
3 of 4 child files reviewed had missing medication dosages.
HHSC 748.2003(b)(3) — AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders
HHSC risk weight: Medium High. Corrected 2023-06-23. Correction verified 2023-07-21.
-
Staff background & training
Employee who has not completed medication administration training has given medication to a child in care.
HHSC 748.2003(b)(6) — Administration of prescription medication-ensure a person trained in & authorized to administer prescription medication administers the medication
HHSC risk weight: Medium High. Corrected 2023-06-27. Correction verified 2023-07-21.
-
Illness & medication
4 of 4 mediaction files were missing prescribing health-care professional's name as well as reason for medication.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2023-06-27. Correction verified 2023-07-21.
-
Illness & medication
4 of 4 medication logs were missing the medication pill count.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2023-06-27. Correction verified 2023-07-21.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training Serious
-
Jun 17, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jun 17, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 16, 2023 Report · Deficiencies cited
-
Records & paperwork
On June 13th a child was provided a mental health assessment due to a suicide attempt. The child was then hospitalized for treatment. The incident was not reported to Licensing until 3 days later. The incident was not documented as a serious incident.
HHSC 748.311 — Serious Incident Documentation-Documented in written report
HHSC risk weight: Medium. Corrected 2023-08-03.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork
-
Jun 16, 2023 Report · Deficiencies cited
-
Records & paperwork
On June 13th a child was provided a mental health assessment due to a suicide attempt. The child was then hospitalized for treatment. The incident was not reported to Licensing until 3 days later. The incident was not documented as a serious incident.
HHSC 748.311 — Serious Incident Documentation-Documented in written report
HHSC risk weight: Medium. Corrected 2023-08-03.
-
Records & paperwork
-
Jun 16, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jun 16, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jun 11, 2023 Report · Deficiencies cited
-
Supervision & ratios
The operation documents a serious incident report as a incident report.
HHSC 748.311(8) — Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
HHSC risk weight: Medium. Corrected 2023-09-07. Correction verified 2023-09-26.
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Supervision & ratios Serious
A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt.
HHSC 748.685(a)(4) — Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
HHSC risk weight: High. Corrected 2023-09-07. Correction verified 2023-09-26.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Jun 11, 2023 Report · Deficiencies cited
-
Supervision & ratios
The operation documents a serious incident report as a incident report.
HHSC 748.311(8) — Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
HHSC risk weight: Medium. Corrected 2023-09-07. Correction verified 2023-09-26.
-
Supervision & ratios Serious
A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt.
HHSC 748.685(a)(4) — Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
HHSC risk weight: High. Corrected 2023-09-07. Correction verified 2023-09-26.
-
Supervision & ratios
-
Jun 1, 2023 Report · Deficiencies cited
-
Supervision & ratios
A child in care attempted suicide and the operation did not document the how the parent was notified.
HHSC 748.303(a)(12)(B) — Serious Incident-Report to parents immediately after ensuring the safety of the child any suicide attempt by their child.
HHSC risk weight: Medium. Corrected 2023-06-29. Correction verified 2023-06-27.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Jun 1, 2023 Report · Deficiencies cited
-
Supervision & ratios
A child in care attempted suicide and the operation did not document the how the parent was notified.
HHSC 748.303(a)(12)(B) — Serious Incident-Report to parents immediately after ensuring the safety of the child any suicide attempt by their child.
HHSC risk weight: Medium. Corrected 2023-06-29. Correction verified 2023-06-27.
-
Supervision & ratios
-
May 26, 2023 Report · Deficiencies cited
-
Other
Youth-in-care did not receive a new Suicide Full Assessment when admitted to care.
HHSC 748.125(d)(4)(A) — Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.
HHSC risk weight: Medium. Corrected 2023-07-25. Correction verified 2023-07-24.
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Other
In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented.
HHSC 748.125(e)(2)(E) — You must adhere to recommendations of the MH professional and update the child?s safety/service plan's if child is a potential risk for suicide.
HHSC risk weight: Medium High. Corrected 2023-07-25. Correction verified 2023-07-24.
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Other
-
May 26, 2023 Report · Deficiencies cited
-
Other
Youth-in-care did not receive a new Suicide Full Assessment when admitted to care.
HHSC 748.125(d)(4)(A) — Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.
HHSC risk weight: Medium. Corrected 2023-07-25. Correction verified 2023-07-24.
-
Other
In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented.
HHSC 748.125(e)(2)(E) — You must adhere to recommendations of the MH professional and update the child?s safety/service plan's if child is a potential risk for suicide.
HHSC risk weight: Medium High. Corrected 2023-07-25. Correction verified 2023-07-24.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
May 25, 2023 Inspection · Deficiencies cited
-
Illness & medication Serious
Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made. Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care. Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form. Condition #14: Met Condition #15: Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-06-08. Correction verified 2023-07-21.
-
Illness & medication Serious
3 medication files were observed to not have legal guardian signature for psychotrophic medication consent.
HHSC 748.2001(b) — Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication
HHSC risk weight: High. Corrected 2023-05-30. Correction verified 2023-06-16.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication Serious
-
May 25, 2023 Inspection · Deficiencies cited
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Illness & medication Serious
Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made. Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care. Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form. Condition #14: Met Condition #15: Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-06-08. Correction verified 2023-07-21.
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Illness & medication Serious
3 medication files were observed to not have legal guardian signature for psychotrophic medication consent.
HHSC 748.2001(b) — Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication
HHSC risk weight: High. Corrected 2023-05-30. Correction verified 2023-06-16.
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Illness & medication Serious
-
May 18, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
May 18, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
May 9, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 9, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
May 4, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
May 4, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
May 3, 2023 Report · Deficiencies cited
-
Supervision & ratios
Clinical Progress Logs documents that children were observed by staff members when they were not.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2023-06-26. Correction verified 2023-06-23.
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Other Serious
During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-06-26. Correction verified 2023-06-23.
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Other
Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed.
HHSC 748.685(c)(6) — Implement and follow the children's service plans.
HHSC risk weight: Medium. Corrected 2023-06-26. Correction verified 2023-06-23.
HHSC inspection history · no longer published by HHSC; kept here
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Supervision & ratios
-
May 3, 2023 Report · Deficiencies cited
-
Supervision & ratios
Clinical Progress Logs documents that children were observed by staff members when they were not.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2023-06-26. Correction verified 2023-06-23.
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Other Serious
During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-06-26. Correction verified 2023-06-23.
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Other
Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed.
HHSC 748.685(c)(6) — Implement and follow the children's service plans.
HHSC risk weight: Medium. Corrected 2023-06-26. Correction verified 2023-06-23.
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Supervision & ratios
-
Apr 28, 2023 Inspection · Deficiencies cited
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Other
2 service plans reviewed were not completed in 72 hours.
HHSC 748.1331(a) — Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
HHSC risk weight: Medium Low. Corrected 2023-05-05. Correction verified 2023-05-18.
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Other
-
Apr 28, 2023 Inspection · Deficiencies cited
-
Other
2 service plans reviewed were not completed in 72 hours.
HHSC 748.1331(a) — Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
HHSC risk weight: Medium Low. Corrected 2023-05-05. Correction verified 2023-05-18.
HHSC inspection history · no longer published by HHSC; kept here
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Other
-
Apr 23, 2023 Report · Deficiencies cited (self-report)
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Illness & medication
The operation failed to notify Licensing within 24 hours of a child in care being transported by EMS for emergent medical care.
HHSC 748.303(a)(2)(A) — AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
HHSC risk weight: Medium High. Corrected 2023-06-23. Correction verified 2023-07-11.
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Records & paperwork
An incident report completed five days after the incident occurred did not include a description of the incident.
HHSC 748.311(7) — Serious Incident Documentation-Includes circumstances surrounding the incident
HHSC risk weight: Medium. Corrected 2023-06-23. Correction verified 2023-07-11.
HHSC inspection history · no longer published by HHSC; kept here
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Illness & medication
-
Apr 23, 2023 Report · Deficiencies cited (self-report)
-
Illness & medication
The operation failed to notify Licensing within 24 hours of a child in care being transported by EMS for emergent medical care.
HHSC 748.303(a)(2)(A) — AP Serious Incdt-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization
HHSC risk weight: Medium High. Corrected 2023-06-23. Correction verified 2023-07-11.
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Records & paperwork
An incident report completed five days after the incident occurred did not include a description of the incident.
HHSC 748.311(7) — Serious Incident Documentation-Includes circumstances surrounding the incident
HHSC risk weight: Medium. Corrected 2023-06-23. Correction verified 2023-07-11.
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Illness & medication
-
Apr 21, 2023 Report · Deficiencies cited
-
Records & paperwork
A restraint that lasted 3 to 5 minutes was not documented.
HHSC 748.2855(a) — EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
HHSC risk weight: Medium. Corrected 2023-07-20.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork
-
Apr 21, 2023 Report · Deficiencies cited
-
Records & paperwork
A restraint that lasted 3 to 5 minutes was not documented.
HHSC 748.2855(a) — EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
HHSC risk weight: Medium. Corrected 2023-07-20.
-
Records & paperwork
-
Apr 19, 2023 Inspection · Deficiencies cited
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Staff background & training Serious
5 out 15 probation conditions were not met. Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: the training was not due per conditions. Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023; Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023; Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023; Condition #11: Met Condition #12: Met Condition #13: Met Condition #14: Did not meet - one child file did not have parent notification; Condition #15: Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-05-03. Correction verified 2023-04-28.
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Other
2 service plans reviewed were not completed in 72 hours.
HHSC 748.1331(a) — Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-04-26.
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Illness & medication
5 Medication logs did not have prescribing doctor listed.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2023-04-26. Correction verified 2023-04-28.
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Illness & medication
3 medication logs show medication was taken without a stated reason.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-04-26. Correction verified 2023-04-28.
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Illness & medication
5 Medication logs did not have a pill count or inventory listed.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2023-04-26. Correction verified 2023-04-28.
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Staff background & training Serious
-
Apr 19, 2023 Inspection · Deficiencies cited
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Staff background & training Serious
5 out 15 probation conditions were not met. Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: the training was not due per conditions. Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023; Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023; Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023; Condition #11: Met Condition #12: Met Condition #13: Met Condition #14: Did not meet - one child file did not have parent notification; Condition #15: Met
HHSC 745.8641 — Requirements during probation
HHSC risk weight: High. Corrected 2023-05-03. Correction verified 2023-04-28.
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Other
2 service plans reviewed were not completed in 72 hours.
HHSC 748.1331(a) — Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-04-26.
-
Illness & medication
5 Medication logs did not have prescribing doctor listed.
HHSC 748.2151(c)(2) — Medication record - must include prescribing health-care professional's name
HHSC risk weight: Medium. Corrected 2023-04-26. Correction verified 2023-04-28.
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Illness & medication
3 medication logs show medication was taken without a stated reason.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-04-26. Correction verified 2023-04-28.
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Illness & medication
5 Medication logs did not have a pill count or inventory listed.
HHSC 748.2151(d) — Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model
HHSC risk weight: Medium High. Corrected 2023-04-26. Correction verified 2023-04-28.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training Serious
-
Apr 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 5, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 5, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 4, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 4, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Apr 3, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Apr 3, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Apr 2, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Apr 2, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 26, 2023 Assessment · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 26, 2023 Assessment · No deficiencies cited
No violations cited on this visit.
-
Mar 26, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 26, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Mar 7, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Mar 7, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 7, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Mar 7, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
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Feb 28, 2023 Report · Deficiencies cited
-
Supervision & ratios
A child placed a bag over the head with the intent to harm himself. The child was not properly assessed for safety after this incident by the operation as required by Minimum Standards.
HHSC 748.125(d)(4)(E) — Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
HHSC risk weight: Medium High. Corrected 2023-05-31. Correction verified 2023-06-16.
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Records & paperwork
A child's suicide attempt was not reported as required by minimum standards.
HHSC 748.303(a)(12)(A) — Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
HHSC risk weight: Medium High. Corrected 2023-05-31. Correction verified 2023-06-16.
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Supervision & ratios Serious
A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-05-31. Correction verified 2023-06-16.
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Supervision & ratios
-
Feb 28, 2023 Report · Deficiencies cited
-
Supervision & ratios
A child placed a bag over the head with the intent to harm himself. The child was not properly assessed for safety after this incident by the operation as required by Minimum Standards.
HHSC 748.125(d)(4)(E) — Suicide Screening- Must be administered immediately if the child exhibits warning signs that necessitate a suicide screening be conducted.
HHSC risk weight: Medium High. Corrected 2023-05-31. Correction verified 2023-06-16.
-
Records & paperwork
A child's suicide attempt was not reported as required by minimum standards.
HHSC 748.303(a)(12)(A) — Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child
HHSC risk weight: Medium High. Corrected 2023-05-31. Correction verified 2023-06-16.
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Supervision & ratios Serious
A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-05-31. Correction verified 2023-06-16.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Feb 15, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 15, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Feb 10, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Feb 8, 2023 Report · Deficiencies cited
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Safety & premises
Child in care was restrained after staff demonstrated behavior that escalated the child. Staff did not engage in appropriate de-escalation techniques.
HHSC 748.2455(a)(1) — Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective
HHSC risk weight: Medium High. Corrected 2023-04-21. Correction verified 2023-04-03.
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Other Serious
Staff conducted a restraint of a child where the child was lifted off their feet and taken to the floor. The child sustained an injury to the hand.
HHSC 748.2551(c)(2) — EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
HHSC risk weight: High. Corrected 2023-04-21. Correction verified 2023-04-03.
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Other
Children in care were allowed to remain in the same proximity when child restraints were performed.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-04-21. Correction verified 2023-04-03.
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Safety & premises
-
Feb 8, 2023 Report · Deficiencies cited
-
Safety & premises
Child in care was restrained after staff demonstrated behavior that escalated the child. Staff did not engage in appropriate de-escalation techniques.
HHSC 748.2455(a)(1) — Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective
HHSC risk weight: Medium High. Corrected 2023-04-21. Correction verified 2023-04-03.
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Other Serious
Staff conducted a restraint of a child where the child was lifted off their feet and taken to the floor. The child sustained an injury to the hand.
HHSC 748.2551(c)(2) — EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
HHSC risk weight: High. Corrected 2023-04-21. Correction verified 2023-04-03.
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Other
Children in care were allowed to remain in the same proximity when child restraints were performed.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-04-21. Correction verified 2023-04-03.
HHSC inspection history · no longer published by HHSC; kept here
-
Safety & premises
-
Feb 7, 2023 Report · Deficiencies cited
-
Safety & premises Serious
A caregiver implemented a personal restraint, prior to being trained in EBI.
HHSC 748.2453 — Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint
HHSC risk weight: High. Corrected 2023-04-04. Correction verified 2023-04-03.
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Other Serious
A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique.
HHSC 748.2605(b)(2) — Personal Restraints Prohibited-Prone and supine restraints except as a last resort when other less restrictive interventions have proven ineffective
HHSC risk weight: High. Corrected 2023-04-04. Correction verified 2023-04-03.
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Records & paperwork
A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video.
HHSC 748.393(b)(3) — Active child record - Ensure record is kept accurate and current
HHSC risk weight: Medium. Corrected 2023-04-04. Correction verified 2023-04-03.
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Other Serious
A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2023-04-04. Correction verified 2023-04-03.
-
Safety & premises Serious
-
Feb 7, 2023 Report · Deficiencies cited
-
Safety & premises Serious
A caregiver implemented a personal restraint, prior to being trained in EBI.
HHSC 748.2453 — Emergency Behavior Intervention-Only a qualified caregiver may administer emergency behavior intervention, except short personal restraint
HHSC risk weight: High. Corrected 2023-04-04. Correction verified 2023-04-03.
-
Other Serious
A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique.
HHSC 748.2605(b)(2) — Personal Restraints Prohibited-Prone and supine restraints except as a last resort when other less restrictive interventions have proven ineffective
HHSC risk weight: High. Corrected 2023-04-04. Correction verified 2023-04-03.
-
Records & paperwork
A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video.
HHSC 748.393(b)(3) — Active child record - Ensure record is kept accurate and current
HHSC risk weight: Medium. Corrected 2023-04-04. Correction verified 2023-04-03.
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Other Serious
A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2023-04-04. Correction verified 2023-04-03.
HHSC inspection history · no longer published by HHSC; kept here
-
Safety & premises Serious
-
Feb 6, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Feb 6, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 31, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 31, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 27, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 27, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 27, 2023 Report · Deficiencies cited
-
Illness & medication
1 of 1 medication log did not provide a reason medication was prescribed.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-03-03. Correction verified 2023-03-08.
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Discipline & child guidance
An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required.
HHSC 748.303(a)(5)(A) — Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child
HHSC risk weight: Medium High. Corrected 2023-03-03. Correction verified 2023-03-08.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Jan 27, 2023 Report · Deficiencies cited
-
Illness & medication
1 of 1 medication log did not provide a reason medication was prescribed.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-03-03. Correction verified 2023-03-08.
-
Discipline & child guidance
An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required.
HHSC 748.303(a)(5)(A) — Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child
HHSC risk weight: Medium High. Corrected 2023-03-03. Correction verified 2023-03-08.
-
Illness & medication
-
Jan 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 26, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 25, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 25, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 25, 2023 Assessment · Deficiencies cited
-
Supervision & ratios Serious
Operation did not allow children to be interviewed as part of an investigation.
HHSC HRC42.04412(a) - Interference with an investigation — HRC42.04412(a) - Interference with an investigation
HHSC risk weight: High. Corrected 2023-01-25. Correction verified 2023-01-25.
-
Supervision & ratios Serious
-
Jan 25, 2023 Assessment · Deficiencies cited
-
Supervision & ratios Serious
Operation did not allow children to be interviewed as part of an investigation.
HHSC HRC42.04412(a) - Interference with an investigation — HRC42.04412(a) - Interference with an investigation
HHSC risk weight: High. Corrected 2023-01-25. Correction verified 2023-01-25.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios Serious
-
Jan 24, 2023 Inspection · Deficiencies cited
-
Staff background & training Serious
An employee with an inactive background check was on property at the time of the inspection.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected at inspection. Corrected 2023-01-24.
-
Staff background & training
EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation.
HHSC 748.153(2)(A) — Notification - At least 15 days in advance - Changes to policies and procedures required by 748.103(b)
HHSC risk weight: Medium Low. Corrected 2023-02-09. Correction verified 2023-02-20.
-
Supervision & ratios
Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete.
HHSC 748.361(a) — Personnel records - All active records maintained at the operation
HHSC risk weight: Medium Low. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Records & paperwork
The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided.
HHSC 748.399(a) — Records Available for Licensing-all active records immediately available for review and reproduction
HHSC risk weight: Medium. Corrected 2023-02-09. Correction verified 2023-02-16.
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Records & paperwork
A child was reported absent 3 times to statewide intake. The child's name was not recorded on the unauthorized absence report.
HHSC 748.453(a)(1) — Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
HHSC risk weight: Medium. Corrected 2023-02-09. Correction verified 2023-02-16.
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Records & paperwork
A child in care was reported missing on 12/15/22, 12/16/22, and 12/21/22. The child returned after 12/21/22. A trigger review was not completed.
HHSC 748.457(a) — Unauthorized Absence?Triggered Review of child?s unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-05-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training Serious
-
Jan 24, 2023 Inspection · Deficiencies cited
-
Staff background & training Serious
An employee with an inactive background check was on property at the time of the inspection.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected at inspection. Corrected 2023-01-24.
-
Staff background & training
EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation.
HHSC 748.153(2)(A) — Notification - At least 15 days in advance - Changes to policies and procedures required by 748.103(b)
HHSC risk weight: Medium Low. Corrected 2023-02-09. Correction verified 2023-02-20.
-
Supervision & ratios
Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete.
HHSC 748.361(a) — Personnel records - All active records maintained at the operation
HHSC risk weight: Medium Low. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Records & paperwork
The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided.
HHSC 748.399(a) — Records Available for Licensing-all active records immediately available for review and reproduction
HHSC risk weight: Medium. Corrected 2023-02-09. Correction verified 2023-02-16.
-
Records & paperwork
A child was reported absent 3 times to statewide intake. The child's name was not recorded on the unauthorized absence report.
HHSC 748.453(a)(1) — Unauthorized Absence ? Annual summary log must include name, age, gender, date of admission
HHSC risk weight: Medium. Corrected 2023-02-09. Correction verified 2023-02-16.
-
Records & paperwork
A child in care was reported missing on 12/15/22, 12/16/22, and 12/21/22. The child returned after 12/21/22. A trigger review was not completed.
HHSC 748.457(a) — Unauthorized Absence?Triggered Review of child?s unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Staff background & training Serious
-
Jan 24, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 24, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 23, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 23, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 23, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 23, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 19, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 19, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 18, 2023 Inspection · Deficiencies cited
-
Other
A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23.
HHSC 748.1335 — Initial Service Plan-Complete the initial service plan within 45 days after admission
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-01-18.
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Other
A care coordinator/caregiver was not involved in the development of 1 child's service plan. The child was not identified to receive treatment services.
HHSC 748.1339(a) — Initial Service Plan-Service planning team must develop the service plan
HHSC risk weight: Low. Corrected 2023-03-24. Correction verified 2023-05-18.
-
Records & paperwork
A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders.
HHSC 748.1339(b) — Initial Service Plan-For treatment services, service planning team must include two professionals
HHSC risk weight: Low. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Illness & medication
A child's record filed a medication log that did not record the reason for the medication, the prescriber's name, or the person who administered the medication.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-03-24. Correction verified 2023-05-18.
-
Staff background & training
2 of the 15 files reviewed did not contain a record of training taken by the employee.
HHSC 748.363(11) — Personnel records-Include record of training and training hours
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Supervision & ratios
Staff members were made inactive as of 12/05/22 and 01/13/23. The reason for their separations was not found in the employee record.
HHSC 748.363(13) — Personnel records-Include date and reason for the person's separation from the operation, if applicable
HHSC risk weight: Medium Low. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Staff background & training
13 employee records did not contain education and/or CPR and First Aid verification as required by the job description.
HHSC 748.363(2) — Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Records & paperwork
7 out of 15 employee records were missing job descriptions.
HHSC 748.363(3) — Personnel records-Include current job description
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Supervision & ratios
2 nursing staff files did not contain a license.
HHSC 748.363(4) — Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Records & paperwork
8 of 15 employee files were missing TB exams.
HHSC 748.363(5) — Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Records & paperwork
11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record.
HHSC 748.363(6) — Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Discipline & child guidance
2 of 15 employee records did not have sign statements to abide by this rule.
HHSC 748.363(8) — Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Staff background & training Serious
3 of 15 files did not contain background check request information.
HHSC 748.363(9) — Personnel records-Include proof of request for background checks
HHSC risk weight: High. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Staff background & training
6 caregivers did not have information to support receiving training prior to performing assigned work duties.
HHSC 748.863(a)(3) — Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Other
-
Jan 18, 2023 Inspection · Deficiencies cited
-
Other
A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23.
HHSC 748.1335 — Initial Service Plan-Complete the initial service plan within 45 days after admission
HHSC risk weight: Medium Low. Corrected at inspection. Corrected 2023-01-18.
-
Other
A care coordinator/caregiver was not involved in the development of 1 child's service plan. The child was not identified to receive treatment services.
HHSC 748.1339(a) — Initial Service Plan-Service planning team must develop the service plan
HHSC risk weight: Low. Corrected 2023-03-24. Correction verified 2023-05-18.
-
Records & paperwork
A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders.
HHSC 748.1339(b) — Initial Service Plan-For treatment services, service planning team must include two professionals
HHSC risk weight: Low. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Illness & medication
A child's record filed a medication log that did not record the reason for the medication, the prescriber's name, or the person who administered the medication.
HHSC 748.2151(c)(3) — Medication record - must include reason medication was prescribed, for prescription medication
HHSC risk weight: Medium. Corrected 2023-03-24. Correction verified 2023-05-18.
-
Staff background & training
2 of the 15 files reviewed did not contain a record of training taken by the employee.
HHSC 748.363(11) — Personnel records-Include record of training and training hours
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Supervision & ratios
Staff members were made inactive as of 12/05/22 and 01/13/23. The reason for their separations was not found in the employee record.
HHSC 748.363(13) — Personnel records-Include date and reason for the person's separation from the operation, if applicable
HHSC risk weight: Medium Low. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Staff background & training
13 employee records did not contain education and/or CPR and First Aid verification as required by the job description.
HHSC 748.363(2) — Personnel records-Include documentation showing that the person meets minimum age and qualifications for the position
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Records & paperwork
7 out of 15 employee records were missing job descriptions.
HHSC 748.363(3) — Personnel records-Include current job description
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Supervision & ratios
2 nursing staff files did not contain a license.
HHSC 748.363(4) — Personnel records-Include evidence of valid professional licensures, certifications, or registrations required for the position
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Records & paperwork
8 of 15 employee files were missing TB exams.
HHSC 748.363(5) — Personnel records-Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Records & paperwork
11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record.
HHSC 748.363(6) — Personnel records-Include notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, 42.059
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Discipline & child guidance
2 of 15 employee records did not have sign statements to abide by this rule.
HHSC 748.363(8) — Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Staff background & training Serious
3 of 15 files did not contain background check request information.
HHSC 748.363(9) — Personnel records-Include proof of request for background checks
HHSC risk weight: High. Corrected 2023-04-01. Correction verified 2023-03-07.
-
Staff background & training
6 caregivers did not have information to support receiving training prior to performing assigned work duties.
HHSC 748.863(a)(3) — Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-05-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Jan 18, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 18, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 17, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 17, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 17, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 17, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Jan 15, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 15, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 13, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
A caregiver solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-10-17. Correction verified 2023-10-26.
-
Other
A caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-10-17. Correction verified 2023-10-26.
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Other Serious
A child in care used facetime to contact an unknown male often. When the behavior was identified, follow up actions were not implemented to ensure child safety.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-10-17. Correction verified 2023-10-26.
-
Supervision & ratios Serious
The operation did not provide the videos requested by the Investigator pertaining to a particular employee.
HHSC HRC42.04412(a) - Interference with an investigation — HRC42.04412(a) - Interference with an investigation
HHSC risk weight: High. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Discipline & child guidance Serious
-
Jan 13, 2023 Report · Deficiencies cited
-
Discipline & child guidance Serious
A caregiver solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2023-10-17. Correction verified 2023-10-26.
-
Other
A caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-10-17. Correction verified 2023-10-26.
-
Other Serious
A child in care used facetime to contact an unknown male often. When the behavior was identified, follow up actions were not implemented to ensure child safety.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2023-10-17. Correction verified 2023-10-26.
-
Supervision & ratios Serious
The operation did not provide the videos requested by the Investigator pertaining to a particular employee.
HHSC HRC42.04412(a) - Interference with an investigation — HRC42.04412(a) - Interference with an investigation
HHSC risk weight: High. Corrected 2023-04-01. Correction verified 2023-05-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance Serious
-
Jan 13, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Jan 13, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 11, 2023 Report · Deficiencies cited
-
Discipline & child guidance
Concerns of abuse of a child in care by was not reported within timeframes.
HHSC 748.303(a)(3)(A) — Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
HHSC risk weight: Medium High. Corrected 2023-03-10. Correction verified 2023-04-03.
-
Records & paperwork
Child was observed to have redness to the armpit area and seen by the facility nurse. The medical encounter was not documented as required on an incident report.
HHSC 748.311(8) — Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
HHSC risk weight: Medium. Corrected 2023-03-10. Correction verified 2023-04-03.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance
-
Jan 11, 2023 Report · Deficiencies cited
-
Discipline & child guidance
Concerns of abuse of a child in care by was not reported within timeframes.
HHSC 748.303(a)(3)(A) — Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
HHSC risk weight: Medium High. Corrected 2023-03-10. Correction verified 2023-04-03.
-
Records & paperwork
Child was observed to have redness to the armpit area and seen by the facility nurse. The medical encounter was not documented as required on an incident report.
HHSC 748.311(8) — Serious Incident Documentation-Includes interventions made during and after the incident, i.e. medical interventions, contacts made, other actions
HHSC risk weight: Medium. Corrected 2023-03-10. Correction verified 2023-04-03.
-
Discipline & child guidance
-
Jan 9, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 9, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 6, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 6, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 6, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 6, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 6, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 6, 2023 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Jan 5, 2023 Report · Deficiencies cited
-
Discipline & child guidance
Multiple staff members were informed of an allegation of a staff member touching children in care and did not report the allegation as required.
HHSC 748.303(a)(3)(A) — Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-05-18.
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Other
A staff member engaged in tickling, touching, and hugging of children in care without consent. The staff member's actions were indicated to make children uncomfortable.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-01-19.
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Other Serious
Caregivers were notified of allegations regarding staff behaviors that posed a risk to children in care. The staff did not take any action to reduce risk to the children and provide a safe environment.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2023-04-01. Correction verified 2023-05-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance
-
Jan 5, 2023 Report · Deficiencies cited
-
Discipline & child guidance
Multiple staff members were informed of an allegation of a staff member touching children in care and did not report the allegation as required.
HHSC 748.303(a)(3)(A) — Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Other
A staff member engaged in tickling, touching, and hugging of children in care without consent. The staff member's actions were indicated to make children uncomfortable.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-04-01. Correction verified 2023-01-19.
-
Other Serious
Caregivers were notified of allegations regarding staff behaviors that posed a risk to children in care. The staff did not take any action to reduce risk to the children and provide a safe environment.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Discipline & child guidance
-
Jan 5, 2023 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 5, 2023 Report · No deficiencies cited
No violations cited on this visit.
-
Jan 3, 2023 Report · Deficiencies cited
-
Other
A youth's job was threatened by a staff member as discipline.
HHSC 748.1101(b)(3)(L) — Children's rights-Based on child's age/maturity seek employment, keep own money/bank acct, paid for work done at op except for chores as discipline
HHSC risk weight: Medium Low. Corrected 2023-02-20. Correction verified 2023-03-07.
-
Supervision & ratios
The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth.
HHSC 748.1337(b)(1)(D)(ii) — Initial Service Plan-Include instructions to caregivers about level of supervision required
HHSC risk weight: Medium High. Corrected 2023-02-20. Correction verified 2023-03-01.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Jan 3, 2023 Report · Deficiencies cited
-
Other
A youth's job was threatened by a staff member as discipline.
HHSC 748.1101(b)(3)(L) — Children's rights-Based on child's age/maturity seek employment, keep own money/bank acct, paid for work done at op except for chores as discipline
HHSC risk weight: Medium Low. Corrected 2023-02-20. Correction verified 2023-03-07.
-
Supervision & ratios
The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth.
HHSC 748.1337(b)(1)(D)(ii) — Initial Service Plan-Include instructions to caregivers about level of supervision required
HHSC risk weight: Medium High. Corrected 2023-02-20. Correction verified 2023-03-01.
-
Other
-
Jan 2, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 2, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 2, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jan 2, 2023 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jan 2, 2023 Report · Deficiencies cited
-
Other
The service plan was not signed by any of the team members.
HHSC 748.1351 — Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting
HHSC risk weight: Medium Low. Corrected 2023-03-14. Correction verified 2023-03-14.
-
Other
-
Jan 2, 2023 Report · Deficiencies cited
-
Other
The service plan was not signed by any of the team members.
HHSC 748.1351 — Initial Service Plan-Implement & follow plan as soon as all team members have reviewed/signed it, but no later than 15 days after date of meeting
HHSC risk weight: Medium Low. Corrected 2023-03-14. Correction verified 2023-03-14.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Dec 31, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 31, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 30, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 30, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 29, 2022 Report · No deficiencies cited (self-report)
No violations cited on this visit.
-
Dec 29, 2022 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 27, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 27, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 22, 2022 Report · Deficiencies cited (self-report)
-
Discipline & child guidance
A contracted mental health professional documented in a child's file that a child was "jumped" by other children in care. The professional described the physical injuries observed. The operation did not report this incident to Regulations.
HHSC 748.303(a)(4)(A) — Serious Incident-Report to Licensing as soon as aware of an incident of physical abuse of a child against another child
HHSC risk weight: Medium High. Corrected 2023-03-02. Correction verified 2023-05-18.
-
Other
The annual log was provided and two children in care who ran away for the facility was not listed.
HHSC 748.453(a)(2) — Unauthorized Absence ? Annual summary log must include time and date absence was discovered
HHSC risk weight: Medium. Corrected 2023-02-27. Correction verified 2023-03-01.
-
Staff background & training
An employee was named as the Treatment Director for children with Autism Spectrum Disorder. The employee did not meet the requirement of this rule.
HHSC 748.605(a) — Treatment director-must meet specific professional qualifications if prevalent population has intellectual disabilities or autism spectrum disorder
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Staff background & training
A Treatment Director was named as providing services to children with Emotional Disorders. The person identified did not meet the qualifications of this rule.
HHSC 748.605(c) — Treatment director-must meet specific professional qualifications if most prevalent population is children with emotional disorders
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Staff background & training
37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement.
HHSC 748.607 — Treatment Director-If more than 1 treatment service provided, can have 1 treatment director if qualifications met for the most prevalent services
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance
-
Dec 22, 2022 Report · Deficiencies cited (self-report)
-
Discipline & child guidance
A contracted mental health professional documented in a child's file that a child was "jumped" by other children in care. The professional described the physical injuries observed. The operation did not report this incident to Regulations.
HHSC 748.303(a)(4)(A) — Serious Incident-Report to Licensing as soon as aware of an incident of physical abuse of a child against another child
HHSC risk weight: Medium High. Corrected 2023-03-02. Correction verified 2023-05-18.
-
Other
The annual log was provided and two children in care who ran away for the facility was not listed.
HHSC 748.453(a)(2) — Unauthorized Absence ? Annual summary log must include time and date absence was discovered
HHSC risk weight: Medium. Corrected 2023-02-27. Correction verified 2023-03-01.
-
Staff background & training
An employee was named as the Treatment Director for children with Autism Spectrum Disorder. The employee did not meet the requirement of this rule.
HHSC 748.605(a) — Treatment director-must meet specific professional qualifications if prevalent population has intellectual disabilities or autism spectrum disorder
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Staff background & training
A Treatment Director was named as providing services to children with Emotional Disorders. The person identified did not meet the qualifications of this rule.
HHSC 748.605(c) — Treatment director-must meet specific professional qualifications if most prevalent population is children with emotional disorders
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Staff background & training
37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement.
HHSC 748.607 — Treatment Director-If more than 1 treatment service provided, can have 1 treatment director if qualifications met for the most prevalent services
HHSC risk weight: Medium. Corrected 2023-04-01. Correction verified 2023-05-18.
-
Discipline & child guidance
-
Dec 22, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 22, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 21, 2022 Report · Deficiencies cited
-
Discipline & child guidance Serious
A staff member pushed a child against a wall as a form of discipline.
HHSC 748.2303(a) — Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
HHSC risk weight: High. Corrected 2023-01-24. Correction verified 2023-02-10.
-
Other Serious
Two caregivers held a child's arms behind her back as a form of restraint.
HHSC 748.2461(b)(6) — Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back
HHSC risk weight: High. Corrected 2023-01-27. Correction verified 2023-02-10.
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Other
A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation.
HHSC 748.2551(a) — EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
HHSC risk weight: Medium High. Corrected 2023-01-27. Correction verified 2023-02-10.
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Other
A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-01-27. Correction verified 2023-02-10.
HHSC inspection history · no longer published by HHSC; kept here
-
Discipline & child guidance Serious
-
Dec 21, 2022 Report · Deficiencies cited
-
Discipline & child guidance Serious
A staff member pushed a child against a wall as a form of discipline.
HHSC 748.2303(a) — Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
HHSC risk weight: High. Corrected 2023-01-24. Correction verified 2023-02-10.
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Other Serious
Two caregivers held a child's arms behind her back as a form of restraint.
HHSC 748.2461(b)(6) — Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back
HHSC risk weight: High. Corrected 2023-01-27. Correction verified 2023-02-10.
-
Other
A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation.
HHSC 748.2551(a) — EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed
HHSC risk weight: Medium High. Corrected 2023-01-27. Correction verified 2023-02-10.
-
Other
A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-01-27. Correction verified 2023-02-10.
-
Discipline & child guidance Serious
-
Dec 19, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 19, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 18, 2022 Report · Deficiencies cited (self-report)
-
Other
Children in care were allowed to have personal cell phone devices. This process was not according to policy.
HHSC 748.126(b) — All employees and caregivers must be aware of and follow your policies and procedures
HHSC risk weight: Medium. Corrected 2023-02-15. Correction verified 2023-02-01.
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Other
-
Dec 18, 2022 Report · Deficiencies cited (self-report)
-
Other
Children in care were allowed to have personal cell phone devices. This process was not according to policy.
HHSC 748.126(b) — All employees and caregivers must be aware of and follow your policies and procedures
HHSC risk weight: Medium. Corrected 2023-02-15. Correction verified 2023-02-01.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Dec 14, 2022 Report · Deficiencies cited
-
Other
The admission assessment did not include the child's legal status.
HHSC 748.1217(b)(1) — Admission Assessment-At admission, must include child's legal status
HHSC risk weight: Low. Corrected 2023-02-08. Correction verified 2023-05-18.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Dec 14, 2022 Report · Deficiencies cited
-
Other
The admission assessment did not include the child's legal status.
HHSC 748.1217(b)(1) — Admission Assessment-At admission, must include child's legal status
HHSC risk weight: Low. Corrected 2023-02-08. Correction verified 2023-05-18.
-
Other
-
Dec 14, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 14, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 14, 2022 Report · Deficiencies cited
-
Other
A staff member yelled at a child in care.
HHSC 748.2307(8) — Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
HHSC risk weight: Medium High. Corrected 2023-01-27. Correction verified 2023-02-10.
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Other
A group of children were allowed to remain in the same area during a physical incident involving a staff member and another child and a subsequent restraint.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-03-03. Correction verified 2023-03-06.
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Other
A staff member physically fought with a child and had to be held back by another staff to stop the conflict.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-01-27. Correction verified 2023-02-10.
HHSC inspection history · no longer published by HHSC; kept here
-
Other
-
Dec 14, 2022 Report · Deficiencies cited
-
Other
A staff member yelled at a child in care.
HHSC 748.2307(8) — Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child
HHSC risk weight: Medium High. Corrected 2023-01-27. Correction verified 2023-02-10.
-
Other
A group of children were allowed to remain in the same area during a physical incident involving a staff member and another child and a subsequent restraint.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2023-03-03. Correction verified 2023-03-06.
-
Other
A staff member physically fought with a child and had to be held back by another staff to stop the conflict.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2023-01-27. Correction verified 2023-02-10.
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Other
-
Dec 12, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 12, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Dec 10, 2022 Report · Deficiencies cited
-
Supervision & ratios Serious
There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene.
HHSC 748.685(a)(4) — Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
HHSC risk weight: High. Corrected 2023-02-24. Correction verified 2023-04-19.
-
Supervision & ratios Serious
-
Dec 10, 2022 Report · Deficiencies cited
-
Supervision & ratios Serious
There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene.
HHSC 748.685(a)(4) — Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being
HHSC risk weight: High. Corrected 2023-02-24. Correction verified 2023-04-19.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios Serious
-
Dec 9, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Dec 9, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 1, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Dec 1, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Nov 28, 2022 Inspection · Deficiencies cited
-
Cleanliness & sanitation
There was one bathroom that had a hole in the wall.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2022-12-08. Correction verified 2022-12-09.
-
Cleanliness & sanitation
-
Nov 28, 2022 Inspection · Deficiencies cited
-
Cleanliness & sanitation
There was one bathroom that had a hole in the wall.
HHSC 748.3301(a)(2) — Physical Site- Buildings must be clean and in good repair.
HHSC risk weight: Medium. Corrected 2022-12-08. Correction verified 2022-12-09.
HHSC inspection history · no longer published by HHSC; kept here
-
Cleanliness & sanitation
-
Nov 23, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Nov 23, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 22, 2022 Inspection · Deficiencies cited
-
Staff background & training Serious
The operation has two staff who were shadowing a staff person who did not have current background checks. There were also four employees who were working and had inactive backgeound checks.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected 2022-11-24. Correction verified 2022-11-24.
-
Staff background & training Serious
-
Nov 22, 2022 Inspection · Deficiencies cited
-
Staff background & training Serious
The operation has two staff who were shadowing a staff person who did not have current background checks. There were also four employees who were working and had inactive backgeound checks.
HHSC 745.641 — AP Background check results - Must receive notification prior to allowing subject to be present at your operation
HHSC risk weight: High. Corrected 2022-11-24. Correction verified 2022-11-24.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training Serious
-
Nov 18, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 18, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Nov 16, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 16, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Nov 9, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Nov 9, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 5, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Nov 5, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 5, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Nov 5, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Nov 1, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Nov 1, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 25, 2022 Report · Deficiencies cited
-
Records & paperwork Serious
Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls
HHSC 748.1101(b)(7) — Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously
HHSC risk weight: High. Corrected 2022-12-29. Correction verified 2023-01-12.
HHSC inspection history · no longer published by HHSC; kept here
-
Records & paperwork Serious
-
Oct 25, 2022 Report · Deficiencies cited
-
Records & paperwork Serious
Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls
HHSC 748.1101(b)(7) — Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously
HHSC risk weight: High. Corrected 2022-12-29. Correction verified 2023-01-12.
-
Records & paperwork Serious
-
Oct 19, 2022 Inspection · Deficiencies cited
-
Illness & medication
A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning.
HHSC 748.2003(b)(2) — Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-10-19.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication
-
Oct 19, 2022 Inspection · Deficiencies cited
-
Illness & medication
A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning.
HHSC 748.2003(b)(2) — Administration of Medication-Store medication in the original container unless there is an additional container with the same label & instructions
HHSC risk weight: Medium High. Corrected at inspection. Corrected 2022-10-19.
-
Illness & medication
-
Oct 5, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Oct 5, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Oct 5, 2022 Report · Deficiencies cited
-
Illness & medication Serious
A child was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead.
HHSC 748.1531(a)(2) — Medical care-A child in care must receive medical care as needed for injury, illness, and pain
HHSC risk weight: High. Corrected 2022-11-11. Correction verified 2022-11-22.
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Records & paperwork
Records that were requested during the course of this investigation were not given to RCCR timely. Some documents were requested but not made available to RCCR until another request 13 days later. Additionally records that were requested during an inspection were not provided during the inspection or 2 days later even after an additional request.
HHSC 748.399(a) — Records Available for Licensing-all active records immediately available for review and reproduction
HHSC risk weight: Medium. Corrected 2022-11-11. Correction verified 2022-11-22.
HHSC inspection history · no longer published by HHSC; kept here
-
Illness & medication Serious
-
Oct 5, 2022 Report · Deficiencies cited
-
Illness & medication Serious
A child was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead.
HHSC 748.1531(a)(2) — Medical care-A child in care must receive medical care as needed for injury, illness, and pain
HHSC risk weight: High. Corrected 2022-11-11. Correction verified 2022-11-22.
-
Records & paperwork
Records that were requested during the course of this investigation were not given to RCCR timely. Some documents were requested but not made available to RCCR until another request 13 days later. Additionally records that were requested during an inspection were not provided during the inspection or 2 days later even after an additional request.
HHSC 748.399(a) — Records Available for Licensing-all active records immediately available for review and reproduction
HHSC risk weight: Medium. Corrected 2022-11-11. Correction verified 2022-11-22.
-
Illness & medication Serious
-
Sep 24, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Sep 24, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 22, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 22, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Sep 15, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Sep 15, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Sep 9, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Sep 9, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 23, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 23, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 15, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 15, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 8, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Aug 8, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 5, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 5, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Aug 3, 2022 Inspection · Deficiencies cited
-
Staff background & training
A staff member's training records indicated that they received 37 hours of training in one day.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Records & paperwork
On 11 of 11 EBI reports reviewed there was no post restraint discussion documented
HHSC 748.2853(4) — EBI Documentation-Content of the post discussion, if applicable
HHSC risk weight: Medium Low. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Supervision & ratios
The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint.
HHSC 748.2855(a) — EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
HHSC risk weight: Medium. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Staff background & training
The supervised experience log documents that the caregiver received 8 hours of "supervised training" on the same date as the training certificates show the caregiver is receiving training. There is no documentation that the caregiver received 40 hours of supervised experience with children in care.
HHSC 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
HHSC risk weight: Medium High. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Staff background & training
The preservice is part of orientation.
HHSC 748.865 — Pre-Service Training-Orientation training must be separate from pre-service training
HHSC risk weight: Medium Low. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Staff background & training
The EBI training certificates read that 50% of the training was focused on physical skills training and not 75% focused on techniques for less restrictive interventions
HHSC 748.889(a) — If you allow EBI, 75% of EBI training must focus on the identification of problem behaviors & strategies/techniques for less restrictive interventions
HHSC risk weight: Medium High. Corrected 2022-08-17. Correction verified 2022-08-23.
HHSC inspection history · no longer published by HHSC; kept here
-
Staff background & training
-
Aug 3, 2022 Inspection · Deficiencies cited
-
Staff background & training
A staff member's training records indicated that they received 37 hours of training in one day.
HHSC 748.151(3) — Operational responsibilities - Maintain current, true, accurate, and complete records
HHSC risk weight: Medium. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Records & paperwork
On 11 of 11 EBI reports reviewed there was no post restraint discussion documented
HHSC 748.2853(4) — EBI Documentation-Content of the post discussion, if applicable
HHSC risk weight: Medium Low. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Supervision & ratios
The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint.
HHSC 748.2855(a) — EBI Documentation-Caregiver must document EBI in child's record as soon as possible, but no later than 24 hours after initiation of the intervention
HHSC risk weight: Medium. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Staff background & training
The supervised experience log documents that the caregiver received 8 hours of "supervised training" on the same date as the training certificates show the caregiver is receiving training. There is no documentation that the caregiver received 40 hours of supervised experience with children in care.
HHSC 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
HHSC risk weight: Medium High. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Staff background & training
The preservice is part of orientation.
HHSC 748.865 — Pre-Service Training-Orientation training must be separate from pre-service training
HHSC risk weight: Medium Low. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Staff background & training
The EBI training certificates read that 50% of the training was focused on physical skills training and not 75% focused on techniques for less restrictive interventions
HHSC 748.889(a) — If you allow EBI, 75% of EBI training must focus on the identification of problem behaviors & strategies/techniques for less restrictive interventions
HHSC risk weight: Medium High. Corrected 2022-08-17. Correction verified 2022-08-23.
-
Staff background & training
-
Aug 2, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Aug 2, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 28, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 28, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 26, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 26, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 21, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 21, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 20, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 20, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 18, 2022 Report · Deficiencies cited (self-report)
-
Supervision & ratios
Three service plans did not have signatures of the child.
HHSC 748.1349(b)(2) — Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign
HHSC risk weight: Low. Corrected 2022-12-09. Correction verified 2024-02-01.
-
Other
A staff member used physical discipline with a child in care instead of de-escalating, or other more appropriate methods to deal with a conflict.
HHSC 748.2301(b)(5) — Disciplinary Measures-must be appropriate to the incident and severity of the behavior demonstrated
HHSC risk weight: Medium. Corrected 2022-12-09. Correction verified 2022-12-09.
-
Discipline & child guidance Serious
A staff member hit a child in the chest after the child had a verbal altercation with the staff member.
HHSC 748.2303(a) — Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
HHSC risk weight: High. Corrected 2022-12-09. Correction verified 2022-12-09.
-
Supervision & ratios
-
Jul 18, 2022 Report · Deficiencies cited (self-report)
-
Supervision & ratios
Three service plans did not have signatures of the child.
HHSC 748.1349(b)(2) — Initial Service Plan- When given to child then child must sign or operation document child's refusal to sign
HHSC risk weight: Low. Corrected 2022-12-09. Correction verified 2024-02-01.
-
Other
A staff member used physical discipline with a child in care instead of de-escalating, or other more appropriate methods to deal with a conflict.
HHSC 748.2301(b)(5) — Disciplinary Measures-must be appropriate to the incident and severity of the behavior demonstrated
HHSC risk weight: Medium. Corrected 2022-12-09. Correction verified 2022-12-09.
-
Discipline & child guidance Serious
A staff member hit a child in the chest after the child had a verbal altercation with the staff member.
HHSC 748.2303(a) — Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.
HHSC risk weight: High. Corrected 2022-12-09. Correction verified 2022-12-09.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Jul 14, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 14, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 13, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 13, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 10, 2022 Report · Deficiencies cited (self-report)
-
Supervision & ratios
The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred
HHSC 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
HHSC risk weight: Medium High. Corrected 2022-09-21. Correction verified 2022-09-23.
-
Supervision & ratios
-
Jul 10, 2022 Report · Deficiencies cited (self-report)
-
Supervision & ratios
The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred
HHSC 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
HHSC risk weight: Medium High. Corrected 2022-09-21. Correction verified 2022-09-23.
HHSC inspection history · no longer published by HHSC; kept here
-
Supervision & ratios
-
Jul 8, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
-
Jul 8, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 7, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
-
Jul 7, 2022 Report · No deficiencies cited
No violations cited on this visit.
-
Jul 5, 2022 Report · Deficiencies cited
-
Safety & premises
Staff admitted to leaving children unsupervised on a couple of occasions when emergencies occurred.
HHSC 748.685(b)(4) — Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
HHSC risk weight: Medium High. Corrected 2022-08-16. Correction verified 2022-08-23.
HHSC inspection history · no longer published by HHSC; kept here
-
Safety & premises
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Jul 5, 2022 Report · Deficiencies cited
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Safety & premises
Staff admitted to leaving children unsupervised on a couple of occasions when emergencies occurred.
HHSC 748.685(b)(4) — Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
HHSC risk weight: Medium High. Corrected 2022-08-16. Correction verified 2022-08-23.
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Safety & premises
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Jun 28, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 28, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 24, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 24, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 24, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 24, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 22, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 22, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 16, 2022 Report · Deficiencies cited (self-report)
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Illness & medication
Two staff performed a restraint on a child for a situation that was not considered an emergency.
HHSC 748.2455(a)(2) — Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
HHSC risk weight: Medium High. Corrected 2022-08-24. Correction verified 2022-08-23.
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Staff background & training Serious
Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.
HHSC 748.2551(c)(2) — EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
HHSC risk weight: High. Corrected 2022-08-24. Correction verified 2022-08-23.
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Other
No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2022-08-24. Correction verified 2022-08-23.
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Records & paperwork
The incident report which documented the restraint did not include he length of time the child was restrained.
HHSC 748.2855(a)(6) — EBI Documentation-Must include the length of time the child was restrained or secluded
HHSC risk weight: Medium. Corrected 2022-08-24. Correction verified 2022-08-23.
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Illness & medication
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Jun 16, 2022 Report · Deficiencies cited (self-report)
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Illness & medication
Two staff performed a restraint on a child for a situation that was not considered an emergency.
HHSC 748.2455(a)(2) — Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication
HHSC risk weight: Medium High. Corrected 2022-08-24. Correction verified 2022-08-23.
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Staff background & training Serious
Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.
HHSC 748.2551(c)(2) — EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force
HHSC risk weight: High. Corrected 2022-08-24. Correction verified 2022-08-23.
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Other
No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children.
HHSC 748.2551(d)(1) — EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers
HHSC risk weight: Medium. Corrected 2022-08-24. Correction verified 2022-08-23.
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Records & paperwork
The incident report which documented the restraint did not include he length of time the child was restrained.
HHSC 748.2855(a)(6) — EBI Documentation-Must include the length of time the child was restrained or secluded
HHSC risk weight: Medium. Corrected 2022-08-24. Correction verified 2022-08-23.
HHSC inspection history · no longer published by HHSC; kept here
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Illness & medication
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Jun 13, 2022 Report · Deficiencies cited
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Records & paperwork
The incident reports which documented the restraint did not include the length of time the child was restrained.
HHSC 748.2855(a)(6) — EBI Documentation-Must include the length of time the child was restrained or secluded
HHSC risk weight: Medium. Corrected 2022-08-17. Correction verified 2022-08-23.
HHSC inspection history · no longer published by HHSC; kept here
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Records & paperwork
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Jun 13, 2022 Report · Deficiencies cited
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Records & paperwork
The incident reports which documented the restraint did not include the length of time the child was restrained.
HHSC 748.2855(a)(6) — EBI Documentation-Must include the length of time the child was restrained or secluded
HHSC risk weight: Medium. Corrected 2022-08-17. Correction verified 2022-08-23.
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Records & paperwork
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Jun 11, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Jun 11, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 9, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 9, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 9, 2022 Report · Deficiencies cited
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Other Serious
A caregiver did not assist a staff member when two youths were involved in an altercation.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2022-07-21. Correction verified 2022-07-21.
HHSC inspection history · no longer published by HHSC; kept here
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Other Serious
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Jun 9, 2022 Report · Deficiencies cited
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Other Serious
A caregiver did not assist a staff member when two youths were involved in an altercation.
HHSC 748.685(c)(2) — Caregiver responsibility - provide a safe environment
HHSC risk weight: High. Corrected 2022-07-21. Correction verified 2022-07-21.
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Other Serious
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Jun 9, 2022 Report · Deficiencies cited
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Discipline & child guidance Serious
A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Illness & medication Serious
A staff member failed to seek medical attention for two children in care when they were observed with blood on their clothing and one child was complaining of pain and discomfort.
HHSC 748.1531(a)(2) — Medical care-A child in care must receive medical care as needed for injury, illness, and pain
HHSC risk weight: High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Supervision & ratios
After receiving two children into care, a staff member took two children to an unauthorized location. She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Discipline & child guidance
A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake.
HHSC 748.507(2) — Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
HHSC risk weight: Medium High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Safety & premises
Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away.
HHSC 748.685(b)(4) — Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
HHSC risk weight: Medium High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Discipline & child guidance Serious
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Jun 9, 2022 Report · Deficiencies cited
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Discipline & child guidance Serious
A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.
HHSC 748.1101(b)(1)(B) — Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation
HHSC risk weight: High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Illness & medication Serious
A staff member failed to seek medical attention for two children in care when they were observed with blood on their clothing and one child was complaining of pain and discomfort.
HHSC 748.1531(a)(2) — Medical care-A child in care must receive medical care as needed for injury, illness, and pain
HHSC risk weight: High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Supervision & ratios
After receiving two children into care, a staff member took two children to an unauthorized location. She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Discipline & child guidance
A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake.
HHSC 748.507(2) — Employee general responsibilities-Report suspected abuse, neglect, and exploitation to Child Abuse Hotline and the designated employee/administrator
HHSC risk weight: Medium High. Corrected 2022-12-24. Correction verified 2022-12-27.
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Safety & premises
Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away.
HHSC 748.685(b)(4) — Caregiver responsibility - when deciding how close to supervise take into account the surrounding circumstances, hazards, and risks
HHSC risk weight: Medium High. Corrected 2022-12-24. Correction verified 2022-12-27.
HHSC inspection history · no longer published by HHSC; kept here
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Discipline & child guidance Serious
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Jun 6, 2022 Assessment · No deficiencies cited
No violations cited on this visit.
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Jun 6, 2022 Assessment · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 3, 2022 Report · Deficiencies cited
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Supervision & ratios
The operation did not have a staff that was able to communicate by using ASL with a child in care that was hearing impaired. Communication devices were taken from a child in care as a form of discipline.
HHSC 748.1101(b)(3)(A) — Children's rights-communicate in language or other means understandable to child; have at least one person at all times who can communicate with child
HHSC risk weight: Medium. Corrected 2022-08-15. Correction verified 2022-08-23.
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Other
A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior.
HHSC 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
HHSC risk weight: Medium. Corrected 2022-08-26. Correction verified 2022-08-23.
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Other
A preliminary service was not completed for a child in care.
HHSC 748.1331(a) — Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
HHSC risk weight: Medium Low. Corrected 2022-08-15. Correction verified 2022-08-23.
HHSC inspection history · no longer published by HHSC; kept here
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Supervision & ratios
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Jun 3, 2022 Report · Deficiencies cited
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Supervision & ratios
The operation did not have a staff that was able to communicate by using ASL with a child in care that was hearing impaired. Communication devices were taken from a child in care as a form of discipline.
HHSC 748.1101(b)(3)(A) — Children's rights-communicate in language or other means understandable to child; have at least one person at all times who can communicate with child
HHSC risk weight: Medium. Corrected 2022-08-15. Correction verified 2022-08-23.
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Other
A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior.
HHSC 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
HHSC risk weight: Medium. Corrected 2022-08-26. Correction verified 2022-08-23.
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Other
A preliminary service was not completed for a child in care.
HHSC 748.1331(a) — Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission
HHSC risk weight: Medium Low. Corrected 2022-08-15. Correction verified 2022-08-23.
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Supervision & ratios
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Jun 2, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Jun 2, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Jun 2, 2022 Report · Deficiencies cited
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Supervision & ratios Serious
A caregiver did not provide adequate supervision for children in care and was unaware of the ongoing activities that the youth were conducting.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2022-07-21. Correction verified 2022-07-21.
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Supervision & ratios Serious
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Jun 2, 2022 Report · Deficiencies cited
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Supervision & ratios Serious
A caregiver did not provide adequate supervision for children in care and was unaware of the ongoing activities that the youth were conducting.
HHSC 748.685(a)(3) — Caregiver responsibility - being aware of and accountable for each child's on-going activity
HHSC risk weight: High. Corrected 2022-07-21. Correction verified 2022-07-21.
HHSC inspection history · no longer published by HHSC; kept here
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Supervision & ratios Serious
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May 14, 2022 Report · Deficiencies cited
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Other
A child in care was restrained longer than one minute.
HHSC 748.2801(1) — EBI Time Limits-Maximum length of time for short personal restraint is one minute
HHSC risk weight: Medium High. Corrected 2022-07-20. Correction verified 2022-08-03.
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Other
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May 14, 2022 Report · Deficiencies cited
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Other
A child in care was restrained longer than one minute.
HHSC 748.2801(1) — EBI Time Limits-Maximum length of time for short personal restraint is one minute
HHSC risk weight: Medium High. Corrected 2022-07-20. Correction verified 2022-08-03.
HHSC inspection history · no longer published by HHSC; kept here
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Other
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May 13, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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May 13, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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May 6, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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May 6, 2022 Report · No deficiencies cited
No violations cited on this visit.
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May 1, 2022 Report · No deficiencies cited (self-report)
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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May 1, 2022 Report · No deficiencies cited (self-report)
No violations cited on this visit.
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Apr 29, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Apr 29, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 26, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 26, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 25, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Apr 25, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 25, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 25, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Apr 21, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 21, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 21, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Apr 21, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 18, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 18, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 15, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Apr 15, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 13, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 13, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Apr 7, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 7, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 7, 2022 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Apr 7, 2022 Report · No deficiencies cited
No violations cited on this visit.
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Apr 6, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
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Apr 6, 2022 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Feb 8, 2022 Inspection · Deficiencies cited
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Staff background & training
Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours.
HHSC 748.989(b)(4) — Documentation of first-aid and CPR certification-Includes the trainer's name and qualifications
HHSC risk weight: Medium Low. Corrected 2022-02-22. Correction verified 2022-02-16.
HHSC inspection history · no longer published by HHSC; kept here
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Staff background & training
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Feb 8, 2022 Inspection · Deficiencies cited
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Staff background & training
Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours.
HHSC 748.989(b)(4) — Documentation of first-aid and CPR certification-Includes the trainer's name and qualifications
HHSC risk weight: Medium Low. Corrected 2022-02-22. Correction verified 2022-02-16.
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Staff background & training
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Dec 20, 2021 Report · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Dec 20, 2021 Report · No deficiencies cited
No violations cited on this visit.
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Oct 19, 2021 Inspection · No deficiencies cited
No violations cited on this visit.
HHSC inspection history · no longer published by HHSC; kept here
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Oct 19, 2021 Inspection · No deficiencies cited
No violations cited on this visit.
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Aug 11, 2021 Report · Deficiencies cited (self-report)
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Other
A child did not receive good care and treatment at a facility, when a caregiver was able to use the child's treatment needs to coerce him to engage in inappropriate relations.
HHSC 748.1101(b)(1)(A) — Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible
HHSC risk weight: Medium High. Corrected 2022-01-29. Correction verified 2022-02-08.
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Other Serious
A caregiver was providing a child with tobacco products.
HHSC 748.1661(a) — Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers
HHSC risk weight: High. Corrected 2022-01-29. Correction verified 2022-02-08.
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Other
A caregiver did not demonstrate self-control by having inappropriate sexual conversations, exchanging nude photos, and propositioning to engage in sexual activities with a child in care.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2022-01-29. Correction verified 2022-02-08.
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Other
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Aug 11, 2021 Report · Deficiencies cited (self-report)
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Other
A child did not receive good care and treatment at a facility, when a caregiver was able to use the child's treatment needs to coerce him to engage in inappropriate relations.
HHSC 748.1101(b)(1)(A) — Children's rights-rights to good care and treatment that meets the child's needs in the most family-like setting possible
HHSC risk weight: Medium High. Corrected 2022-01-29. Correction verified 2022-02-08.
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Other Serious
A caregiver was providing a child with tobacco products.
HHSC 748.1661(a) — Tobacco Products and E-Cigarettes -Children may not use or possess tobacco products, e-cigarettes or any type of vaporizers
HHSC risk weight: High. Corrected 2022-01-29. Correction verified 2022-02-08.
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Other
A caregiver did not demonstrate self-control by having inappropriate sexual conversations, exchanging nude photos, and propositioning to engage in sexual activities with a child in care.
HHSC 748.507(1) — Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks
HHSC risk weight: Medium High. Corrected 2022-01-29. Correction verified 2022-02-08.
HHSC inspection history · no longer published by HHSC; kept here
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Other
Get the full file
HHSC publishes inspections, investigations and assessments from October 2017 onward, with each cited deficiency and its risk weight. Investigation narratives, complaint files and older history require a public information request. The Texas Public Information Act (Texas Government Code Chapter 552) gives anyone the right to ask. You don't have to say why.
Email the request Printable letter (fax or mail)
- Send to
- HHSC Open Records Coordinator, MC-1070 · OpenRecordsRequest@hhs.texas.gov · fax 512-424-6586 · 4601 W. Guadalupe Street, Austin, Texas 78751-3146 · agency instructions
Show the letter text
If something is happening now, report a concern to HHSC Child Care Regulation. For suspected abuse, contact your county child protective services or law enforcement.
Source: Texas Health and Human Services Commission, Child Care Regulation datasets on data.texas.gov. Last read Oct 1, 2026. Violation text is HHSC's own wording. The categories are ours, added to help you scan. About this data.