New Horizons – Audrey Grace House

Risk level: Medium High : 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

One staff admitted to pushing a child onto their bed as well as three children reported that same staff gets into the children's faces and uses intimidation as a scare tactic.

Risk level: High : 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment.

A child in care was grabbed by the arm to comply.

Risk level: Medium High : 748.1101(b)(4)(A)(vii) - Children's rights- Free from demeaning behavior to embarrass/control/harm/intimidate/isolate the child

A staff member made demeaning, crude, inappropriate comments and threats to children in care.

Risk level: Medium High : 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

The Clinical Director admitted to cussing when children in care were present. Six other individuals confirmed hearing Clinical Director cuss on several occasions while children in care were present, during therapy sessions or in professional settings.

Risk level: Medium : 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

A personal restraint occurred on 2/13/24, but was not documented until 3 days later, 2/16/24.

Risk level: Low : 748.1339(a)(1) - Initial Service Plan-Service planning team must include at least one of the child's current caregivers

One child's service plan did not have a caregiver participant/signature when reviewed.

Risk level: Medium Low : 748.3273(6) - First Aid Kits-Each one must contain scissors

Four first aid kits reviewed did not have all the required supplies needed.

Risk level: Medium High : 748.2203(c) - Medication Error-Operation must meet documentation requirements within 24 hrs

A child in care had a medication error not reported.

Risk level: Medium : 748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return

Three run away incident reports were reviewed. Two of the reports did not include law enforcement notification date and time- One of those two also did not include the name of person notified. The other run-away incident report did not include name of person spoken to.

Risk level: High : 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

A child was left unsupervised with an unlocked medication cabinet, resulting in the child ingesting a significant amount of medication in a suicide attempt.

Risk level: High : 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication

A child in care had unsupervised access to the medication cabinet that a staff member left unlocked. As a result of this, the child in care ingested a significant amount of medication in a suicide attempt.

Risk level: Medium : 748.313(3)(B) - Serious Incident child absent without permission-document notice to parents and law enforcement about child's absence and subsequent location/return

In a review of the incident report, there are concerns with the times of the runaway notification not being documented to the guardian and to law enforcement. Additionally, the date is not listed for the notification to law enforcement, only the name of the person who was spoken to and the case number are documented. The name of the guardian who was notified is also missing.

Risk level: High : 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.

A staff slapped a child in care.

Risk level: High : 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

During the DFPS ANE investigation, this standard was found to be deficient. A child in care was slapped by a staff member.

Risk level: High : 748.2801(2)(A) - EBI Time Limits-Maximum length of time for personal restraint for a child of any age is 30 minutes.

A child was restrained for more than 30 minutes. Three children and three staff involved said it was about 35-40 minutes, and the incident report states 38 minutes.

Risk level: Medium : 748.2857(a) - No later than 72 hours after the initiation of the intervention, you must provide written notice to the parent.

The child's case worker was not notified of the restraint within 72 hours.

Risk level: High : 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity

Three children in care put cleaning supplies into another child's shampoo and on their deodorant. Staff were present during the time of children cleaning; however, the children were still able to obtain and create these mixtures without staff noticing.

Risk level: Medium High : 748.4703(b) - Child/caregiver ratio-Caregiver must remain awake during night-time sleeping hours

5 out of 7 children interviewed stated a night staff was asleep while working.

Risk level: Medium High : 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

Multiple staff and children in care stated an employee cussed at children in care.

Risk level: Medium High : 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

All children interviewed reported staff yelling at children, and/or being loud and in their faces. Two staff reported they have seen staff yell or raise their voice when they could have handled the situation better.

Risk level: Medium High : 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

One staff admitted calling a child a liar and in a separate incident a different staff admitted making a comment to a child in care stating they should cut down on eating cookies and mashed potatoes, making an implication to weight.

Risk level: Medium High : 748.2003(b)(10) - Administration of prescription medication-must not borrow or administer prescription medication to a child that is prescribed to another person

A medication log stated that a pill was borrowed from another child in care. The campus nurse confirmed that this did occur based on her medical knowledge and approval.

Risk level: Medium High : 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

A staff member admitted to playing games on their cell phone when directly supervising children in care.

Risk level: Medium High : 748.3421(3) - Poisons-Ensure poisonous/flammable material is stored in an area that is inaccessible to children unless child is capable to use responsibly.

Cleaning supplies were found in an unlocked cabinet under the sink in a bathroom that is assessible to children in care.

Risk level: Medium : 748.705(b)(3) - Reasonable & prudent parent standard-must consider the child's behavioral history and ability to safely participate in proposed activity

A staff member provided razors to children in care with a history of self-harm. Although using razors for shaving is a part of normalcy for teenage children, it seems the staff did not ensure the razors were taken back from the children.