summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content: During the initial inspection, four of four personnel records reviewed, were lacking 1 hour of annual suicide prevention training.


state: TX

facility_name: Open Hearts Children and Family Services - The Village

summary: 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

raw_content: During the initial inspection, one of the four personnel records reviewed, did not have a TB exam.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No


summary: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

raw_content: During the initial inspection, a caregiver was heard yelling at a child about taking clothes that didn't belong to the child.

Standard Risk Level: Medium High


summary: 748.911(b)(3)(A) - One caregiver in ratio must have certificate of training with an expiration or renewal date in Pedi/Adult CPR if serving children 0 to 17.

raw_content: During the initial inspection, three of four personnel records reviewed did not have the correct CPR training to serve pediatrics/adult as required by Minimum Standards.

Category: Training and Professional Development


summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed staff did not report a child's suicide attempt, timely. Corrections were due on 5/30/2024. During the follow up inspection on 6/26/2024, corrections had not been received and the operation was re-cited for the deficiency.

Correction Narrative: On 6/27/2024, the operation's Director provided a corrective action plan which included all management and direct care staff will complete additional Serious Incident and Reporting training. All training will be completed by July 15, 2024. All training certificates will be placed in the staff personnel file upon completion.


summary: 748.1339(a) - Initial Service Plan-Service planning team must develop the service plan

raw_content: During the follow up inspection, a child's service plan was reviewed for corrections from a previous deficiency, and at that time it was observed that the service plan was completed but it was developed without the service planning team's involvement.

Standard Risk Level: Low


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed staff did not maintain current, true, accurate and complete records. Corrections were due on 6/6/2024. During the follow up inspection on 6/26/2024, corrections had not been received and the operation was re-cited for the deficiency.

Correction Narrative: On 6/27/2024, the operation's Director provided a corrective action plan which included all management and direct care staff will complete additional medication management training. The Village of Open Hearts will institute a double check process to manage the accuracy of medication records. The medication records will be checked twice daily by a supervisor/case manager, once in the morning and once in the evening. Effective 6/27/2024


summary: 748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed

raw_content: During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed staff did not complete a child's discharge documentation correctly. Corrections were due on 6/6/2024. During the follow up inspection on 6/26/2024, corrections had not been received and the operation was re-cited for the deficiency.

Correction Narrative: On 6/27/2024, the operation's Director provided a corrective action plan which included all management staff will complete additional Intake and Discharge training. The administrator or Program Director will sign off on discharge summaries. Effective 6/27/2024


summary: 748.3445(b) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: During the inspection, I observed a freezer unit in the pantry area that did not seal well, creating a rim of ice that prevents the freezer from being closed fully.  Food items were stored in this freezer.


summary: 748.2003(b)(7) - Administration of prescription medication-maintain documentation provided by health-care professional on the administration of current medication

raw_content: During the follow-up inspection, I observed the child's nasal spray still stored without the prescription label and with the child's name handwritten on the side of the bottle.  No corrections have been submitted for this standard.

Correction Narrative: During the follow-up inspection, I observed improperly stored medication has been removed from the facility as the child has been discharged. This brings this standard into compliance.


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed several bedrooms/bathrooms were not in good repair. Corrections were due on 6/10/2024. During the follow up inspection on 6/26/2024, there were three bedrooms with chipped paint. The operation was re-cited for the deficiency.


summary: 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name

raw_content: During the follow-up inspection, I observed one of six children's records still failed to record the prescribing physician for two prescription medications.  This standard will be recited.

Correction Narrative: During the follow-up inspection, I observed the med sheet lacking the prescribing doctor was no longer in the records due to the child being discharged.  This brings this standard into compliance.


summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content: During the follow-up inspection, I observed damage to the drywall in a recreation room, a cracking drywall patch in a bedroom, and an unsecured nail in the wall of a resident with recent self-injurious behaviors.  These errors were not corrected from the preceding inspection.


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

raw_content: During the inspection, I observed a mini-fridge in the kitchen still lacked a thermometer.


summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed a child's record did not contain an admission assessment. Corrections were due on 6/6/2024. During the follow up inspection on 6/26/2024, corrections had not been received and the operation was re-cited for the deficiency.


summary: 748.303(e)(3)(A) - Serious Incident- Report to licensing no later than 24 hours after temporarily moving to or providing care at any location not noted on your permit.

raw_content: The operation had to temporarily relocate the children in care due to a physical site concern and did not report the incident to licensing.

Correction Narrative: The operation was notified of HHSC's intent to deny a permit on 8/5/2024, and as of this date, the operation has not requested an administrative review. The operation has no children in care and is no longer allowed to operate. A follow up inspection was conducted at the operation on 8/14/2024. The operation appears to be closed, and there does not appear to be any staff or children present at the operation. The permit holder was contacted via phone call during the inspection. The permit holder confirmed that all children have been discharged, and there are no staff working at the operation. The permit holder was not able to meet licensing at the operation at the time of the inspection. The permit holder contacted two former operation staff to see if they could meet licensing at the operation. Neither staff was available. The permit holder was provided with instructions on how to mail the operation's permit to licensing.


raw_content: Multiple training certificates include the signature of the administrator, but the administrator denied being present for the training, facilitating the training, or signing the certificates.

Standard Number / Description: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records


summary: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During an inspection it was found that there were several issues with the exterior of the building. There was paint peeling off the building and siding was missing with insulation exposed. In the interior of the building the floors in the hallway and staff areas needed repair. There was paint peeling in 4 of the occupied rooms and 2 of the unoccupied rooms. In 2 of the occupied and unoccupied rooms screens needed to be installed properly. Several of the screens had holes in them and needed repair. In two of the occupied rooms the drywall had cracks. In one of bathrooms the bathtub was slow to drain.

Correction Narrative: CEO sent email that the landlord had been notified of the physical site issues and repairs are scheduled to begin on 7/16/2024. A follow up inspection was conducted today, and repairs were being done while the inspectors were at the operation.


summary: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

raw_content: During a review of the medication records 2 children's records showed missed doses of medication with no explanation given. One child's medication was missed, and the explanation was the child was on an outing.

Correction Narrative:
CEO sent email that all management and direct care staff will complete additional medication management training.
-The Village of Open Hearts will institute a double check process to manage the accuracy of medication records.  The medication records will be checked twice daily by a supervisor/case manager, once in the morning and once in the evening. A follow up inspection was conducted on 7/31/2024 where medication was checked and found to be in compliance.


summary: 748.2101(1) - Medication Storage-Store medication in a locked container

raw_content: The operation was required to relocate the children due to safety concerns and during the transport of the medication it was not secured in a locked container. The unlocked medication was transported with the children.

Standard Risk Level: High

Correction Narrative: CEO sent email that they would ensure all medication is stored under a locked container and retrain staff. Follow up inspection was conducted on 7/31/2024, Medication storage was checked and found to be in compliance.


summary: 748.685(c)(2) - Caregiver responsibility - provide a safe environment

raw_content: During the investigation it was learned that the operation had mold in part of the building. The operation was supposed to have this mold tested but never sent licensing the results.

Correction Narrative: Ceo sent email that a mold team would be at the facility on 7/18/2024 to clean up the mold.


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content: During the investigation, it was learned that the administrator has not been to the operation for on-site administrative oversite. It appears that none of the children and many of the staff are no familiar with the administrator and have not either met her or seen her in months.

Correction Narrative: CEO sent email that case manager is in the process of becoming the administrator. During the transition time the current administrator would be working 30 hours a week with sign in sheets at the facilty.


raw_content: During the inspection, I observed damage to the drywall in a recreation room, a cracking drywall patch in a bedroom, and unsecured nails in the wall of a resident with recent self-injurious behaviors.

Standard Number / Description: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair


summary: 748.2103(a) - Medication Storage & Destruction-Discontinued or expired meds & meds left at the operation must be inventoried & stored separately from current meds

raw_content: In reviewing the medications, I observed two discontinued medications stored in the active medication bins.

Correction Narrative: During the follow-up inspection, I observed the expired medications were removed from the operation.  This brings this standard into compliance.


raw_content: In reviewing medication records, I observed a child was administered a medication several days after the label indicated the medication should be discontinued.

Standard Number / Description: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

Correction Narrative: During the follow-up inspection, I observed the noted medication was  removed from the operation, preventing possible recurrance.  This brings this standard into compliance.


raw_content: In reviewing the medicaitons, I observed the prescription nasal spray for one child was stored without the prescription label denoting the administration instructions and identity of receiving child.

Standard Number / Description: 748.2003(b)(7) - Administration of prescription medication-maintain documentation provided by health-care professional on the administration of current medication


raw_content: During the inspection, I observed a mini-fridge in the kitchen area that lacked a thermometer.

Standard Number / Description: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below


raw_content: In reviewing the medication records, I observed two of three children's records reviewed failed to document the name of physician prescribing the medication.

Standard Number / Description: 748.2151(c)(2) - Medication record - must include prescribing health-care professional's name


summary: 748.3441(n) - Food Preparation-Food must be protected from contamination

raw_content: During the inspection, I observed two plates of food stored in refrigerators with no covering or protection from contamination.

Correction Narrative: During the inspection, I observed all food to be properly stored and protected from contamination.  This brings this standard into compliance.


summary: 748.1531(d) - Medical care-Obtain follow-up medical treatment as recommended by the health-care professional

raw_content: During the investigation, I discovered the operation failed to complete the follow-up medical appointment for a child taken to the hospital for suicidal evaluation in a timely manner.

Correction Narrative: The operation reported this to be an oversight on the part of the case manager.  Expectations were reviewed with the case manager regarding after care instructions.  The operation provided proof of a training held on 7/31/24 with a second training to be held on 8/6/24.  All staff will be retrained with training certificates in the file by 8/2/24 for those trained on 7/31/24 and within 48 hours for those trained on 8/6/24.  This mitigates the risk of recurrence.


summary: 748.1217(b)(10) - Admission Assessment-At admission, must include any applicable requirements of 748.1219

raw_content: During the investigation, I discovered the admission assessment for a resident receiving treatment services was not completed until 20 days after admission.

Correction Narrative: The operation indicated this was an oversight on the case manager's part. The operation submitted proof of training held on 7/31/24 for the case manager responsible for completing the admission assessments.  This mitigates the risk of recurrence.


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

raw_content: During the investigation, I discovered the operation failed to properly supervise a resident according to his safety plan following a recent suicide attempt.

Correction Narrative: On 8/1/24 and 8/5/24, I contacted the operation regarding the need for a correction plan entry for this standard.  The operation failed to reply.  The operation was denied their initial permit and ceased operating on 8/5/24.  Due to the closure, the operation will not be providing supervision to any more children in care, and as such, this standard is brought into compliance.


summary: 748.125(e)(1)(D) - You must alert each person responsible for a childs care/supervision of the high risk for suicide and any new or updated safety plan.

raw_content: During the investigation, I discovered the caregivers and supervising staff were not made aware of the line-of-sight supervision expectation noted in the child's safety plan and do not receive copies of the plans nor notification of their contents.

Correction Narrative: The operation noted this to be a training oversight and indicated direct care staff would be made aware of all children's supervision levels.  The operation provided proof of a training held on 7/31/24 with a second training to be held on 8/6/24.  All staff will be retrained with training certificates in the file by 8/2/24 for those trained on 7/31/24 and within 48 hours for those trained on 8/6/24.  This mitigates the risk of recurrence.


summary: 748.125(g)(2)(B) - You must not leave the child alone until a mental health professional assesses the child, in the event of a suicide attempt.

raw_content: During the investigation, I discovered a child exited the building to the parking lot alone after a suicide attempt while caregivers remained in the building.

Correction Narrative: The operation provided proof of a training held on 7/31/24 with a second training to be held on 8/6/24.  All staff will be retrained with training certificates in the file by 8/2/24 for those trained on 7/31/24 and within 48 hours for those trained on 8/6/24.  This mitigates the risk of recurrence.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: During the first initial inspection, while reviewing a child's medication, it was discovered that the operation combined two separate strengths of the same medication, on a single document which created an inaccuracy in the medication log.


summary: 748.125(g)(2)(E)(ii) - You must offer MH resources for children/staff who have a difficult time coping including referrals to grief counseling and support groups.

raw_content: During the investigation, I discovered the operation failed to debrief with the residents and staff following the suicide attempt to offer mental health referrals as required.

Correction Narrative: Administration reviewed the suicide policy with the case manager to ensure she is aware of to address proper follow-ups.  The operation provided proof of a training held on 7/31/24 with a second training to be held on 8/6/24.  All staff will be retrained with training certificates in the file by 8/2/24 for those trained on 7/31/24 and within 48 hours for those trained on 8/6/24.  This mitigates the risk of recurrence.


summary: 748.125(g)(2)(F) - You must conduct a review of lessons learned from the childs suicide attempt.

raw_content: During the investigation, I discovered the operation failed to complete the postvention review of lessons learned following this suicide attempt.

Correction Narrative: The operation provided proof of communication to the behavioral health services provider clarifying the need for the postvention plan.  This mitigates the risk of recurrence.


summary: 748.125(d)(4)(A) - Suicide Screening- A screening tool must be administered at admission for each child 10 years of age or older.

raw_content: During the investigation, I discovered the first administration of the suicide screening tool on a resident was completed four months after admission to the operation.

Correction Narrative: The operation met with their behavioral health services provider to ensure they understood the minimum standards requirements and the screening tool was added to their intake checklist.  The operation provided proof of a training held on 7/31/24 with a second training to be held on 8/6/24.  All staff will be retrained with training certificates in the file by 8/2/24 for those trained on 7/31/24 and within 48 hours for those trained on 8/6/24.  This mitigates the risk of recurrence.


summary: 748.125(d)(4)(D) - Suicide Screening- Must be administered every 90 days after admission for children 10 years of age or older in a GRO that is not a RTC.

raw_content: During the investigation, I discovered a resident over the age of ten years did not receive his 90-day administration of the suicide screening tool.


summary: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures

raw_content: During the investigation, I discovered the operation failed to operate according to its accepted suicide prevention, intervention, and postvention policies.


summary: 748.2003(b)(3) - AP Administration of prescription medication-Administer medications according to instructions or a prescribing health-care professional's orders

raw_content: During the first initial inspection, there were two medication records that did not follow the prescribing health care professional's orders. One child was missing multiple days of medication while another child was missing one single dose of medication.

Category: Medication


summary: 748.1437(5) - Discharge/Transfer Documentation-Must include list of medications child is taking, dosage, frequency, and reason prescribed

raw_content: During the first initial inspection, one of four records reviewed did not contain the discharge documentation for a child.

Category: Admission, Service Planning, Discharge


summary: 748.1217(a) - Admission Assessment-Must provide initial evaluation of appropriate placement & ensure that necessary information for service planning is obtained

raw_content: During the first initial inspection, there was one child's record that did not include an admissions assessment.


summary: 748.1583(b) - TB exam-Documentation of baseline test or chest xray results in person's record w/in 40 days of beginning to live, work, volunteer at facility

raw_content: During the first initial inspection, two of four records reviewed were missing TB test results for the children.

Category: Child Care

Standard Risk Level: Medium Low

Correction Narrative: During the follow up inspection, the deficiency was observed to be in compliance.


summary: 748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication

raw_content: During the first initial inspection, there were two medication records that were missing the name and signature of person who administered the medication.


summary: 748.3303(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During the first initial inspection, there were five bedrooms observed with chipped paint in the bathroom or bedrooms, there were two bedrooms with dirty toilets, one bedroom had exposed wires, the recreation room had exposed wires, and one bedroom without lights due what appeared to be to electrical issues.

Category: Physical Site


summary: 748.1335 - Initial Service Plan-Complete the initial service plan within 45 days after admission

raw_content: During the first initial inspection, one child's case file was missing a completed initial service plan within 45 days of admission.


summary: 748.303(a)(12)(A) - Serious Incident-Report to Licensing as soon as aware of a suicide attempt by a child

raw_content: During the first initial inspection, it was discovered that a serious incident report was documented for a child's suicide attempt, however, licensing was not contacted timely and notified of the incident.


summary: 748.1205(a)(14) - Admission Documentation- Includes the results of the suicide screening at admission, if required.

raw_content: During the first initial inspection, there were four child records reviewed and all four were missing suicide screenings at admission.


summary: 748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below

raw_content: During the first initial inspection, there was a standalone freezer that was observed to have been accidentally unplugged causing the ice to melt and the food to spoil.

Corrected at Inspection: Yes


summary: 748.1539(b) - Immunizations-The operation must maintain current immunizations records for each child in care, including any exemptions or exceptions

raw_content: During the first initial inspection, there were four child files reviewed and it was observed that three did not contain immunizations records.


summary: 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

raw_content: During the DFPS investigation, it was discovered staff was aware of allegations of abuse, neglect, or exploitation and did not notify RCCR.

Correction Narrative: TVOH hosted a virtual meeting to re-train all staff on serious incidents and reporting abuse and neglect.  See document library for correction response.


summary: 745.8411(b)(3) - Responsibilities - Provides access to all records

raw_content: During the course of the DFPS investigation, video footage was requested on seven different occasions by the investigator. Video footage was never made available.

Correction Narrative: Previous video surveillance company referred OH to another company that will be in a better position to service the operation better. They received a quote and will move forward.  They will ensure that all management personnel are trained to download video footage and provide a copy upon request and/or investigation.


summary: 748.1209(a) - Child Orientation-Provided to child who is 5 years old or older within 7 days of admission and geared to child's intellectual level

raw_content: During the inspection, two of two child's records were reviewed and both were missing orientation information completed with the children within 7 days of placement.

Correction Narrative: On 3/8/2024, the Director provided a copy of the completed orientation forms for both child records.


raw_content: During the inspection of medications, I reviewed 2 children's medication records consisting of 6 medication logs. All records reviewed had the initials of the person who administered the medication but did not match the person who signed the medication log.

Standard Number / Description: 748.2151(c)(6) - Medication record - must include name & signature of person who administered each medication

Correction Narrative: On 3/1/2024, the program director provided an email attachment with printed and signed names of all persons who have administered medications to the children in care. The operation has created an updated medication log to require printed names and signatures of all caregivers who administer medication.


summary: 748.535(1) - Child-care administrator responsibilities-Daily supervision and on-site administrative responsibility for the overall operation

raw_content: The Child Care Administrator was not present for the monitoring inspection and has not been present for any monitoring inspections since issuance of the initial permit.

Correction Narrative: On 3/26/2024, the Director provided corrections for the administrative duties to include written duties and a working schedule.


summary: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

raw_content: During the walkthrough, I observed four rooms with baseboards that were separating from the wall or that needed caulking, two rooms with cracked paint in need of repair, damaged tile on the floor of the laundry room and in the hallway, exposed wires in the recreation room capped with wiring nuts but accessible to children, and an exposed drain in the hallway that needs capping.

Correction Narrative:
On 3/25/2024, the Director emailed photographs of physical site corrections including wall repairs, flooring in the laundry room, flooring in the staff area, and hallway flooring. The Director noted temporary flooring was installed while they wait on permanent flooring to be delivered and base is currently being replaced, today.

On 3/26/2024, the Director provided photographs of physical site corrections including covering wires in the recreation room, fixed baseboards, painted walls, and covered drain pipe.


summary: 748.1215(b) - Admission Assessment-Professional level service provider must sign & date assessment, which must be in child's record

raw_content: During the sampling inspection, one of two child's record reviewed, was missing a non-emergency admission assessment prior to admission.

Correction Narrative: On 3/8/2024, the Director provided a copy of the child's missing admission assessment.


raw_content: During the monitoring inspection, the freezer thermometer indicated the freezer was at 12 degrees fahrenheit, and not at the required 0 degrees or below.

Standard Number / Description: 748.3443(b)(2) - Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below

Correction Narrative: On 3/26/2024, the Director provided a photograph to verify correction of freezer thermometer.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: During the walk-through it was noted the window in room twenty did not have a screen. It was also noted room eighteen had insects in the room.

Correction Narrative: On 1/26/2024, the Director provided a photograph to verify the screen has been replaced on the window.


summary: 748.3117(a) - Fire Extinguisher-Company licensed by State Fire Marshal must inspect each fire extinguisher at least annually & conduct any service or testing

raw_content: The four fire extinguishers at the operation were due for inspection in November of 2023.

Correction Narrative: On 1/18/2024, the Director provided photographs to reflect the operation had the fire extinguishers serviced.


raw_content: During the walkthrough of the operation, it was observed in several designated bedroom's bathrooms have dirty water running out of the faucets. In one of the designated bedroom's bathroom, it was observed a shelf was sitting in the sink instead of being mounted on the wall.

Standard Number / Description: 748.3301(a)(2) - Physical Site- Buildings must be clean and in good repair.

Correction Narrative: On 1/29/2024, the Director advised she has contacted the city who reported they are installing new pipes throughout the city. She advised she has requested a letter of confirmation. On 2/13/2024, the Director advised a letter has not been provided by the city and the operation will not place children in the effected rooms until the water issue has been resolved.


summary: 748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583

raw_content: During the follow up inspection, two of three personnel files did not contain the required TB test results.

Correction Narrative: On 10/5/2023, the executive director provided TB test results for the administrator and treatment director.


summary: 748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director

raw_content: During the follow up inspection, it was noted the operation is providing treatment services, but does not have a treatment director that has completed the hiring process.

Correction Narrative: On 10/4/2023, the Executive Director provided documentation to reflect the treatment director had completed her background checks and was eligible with provisions. On 10/5/2023, the Executive Director provided training certificates to reflect the treatment director has completed the hiring process and is actively employed.


summary: 748.361(a) - Personnel records - All active records maintained at the operation

raw_content: During the follow up inspection, employee records maintained at the operation were not complete. The employee records were missing training certificates for CPR/First Aid, EBI, orientation, pre-service training, and drug test results.

Correction Narrative: On 9/28/2023, the executive director provided corrections via email stating The Village of Open Hearts will ensure that all personnel records are maintained at the operation. At the time of the visit, personnel documents were being sent to the corporate office for processing. The Village of Open Hearts has ensured that all current active files are processed, recorded, and maintained at the operation and that future documents are sent directly to the operation for processing and stored in personnel files.


summary: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.

raw_content: During the follow up inspection, one of three personnel files reviewed did not contain the documentation to reflect the operation contacted the required references to verify that the applicant is suitable to work with or around children.

Correction Narrative: On 9/28/2023, the executive director provided corrections via email; two candidate reference checks were provided for the treatment director.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: During the inspection, I observed that the mock file does not include a field on the exterior of the file or easily identifiable upon the interior of the file folder wherein staff would note any known allergies or medical conditions for emergency reference.

Correction Narrative: The operation's executive director provided a template that will be used in the children's case file to provide the DOB, date of admit, allergies, and chronic health conditions.


summary: 748.1935(c) - Care for children and adults-adult residents may not be counted as caregivers in the child/caregiver ratio.

raw_content: The care for children and adults policy beginning on page 215, states "adults in care act as caregivers and The Village of Open Hearts will maintain its caregiver ratios."

Correction Narrative: On 9/19/2023, the executive director provided an updated copy of the policy which reflected the required changes.


Standard Number / Description: 748.505(b)(2) - Minimum qualifications for employees-Record of a TB screening showing the employee is free of contagious TB as provided in 749.1583

Deficiency Narrative: During the follow up inspection, two of three personnel files did not contain the required TB test results.


Standard Number / Description: 748.361(a) - Personnel records - All active records maintained at the operation

Deficiency Narrative: During the follow up inspection, employee records maintained at the operation were not complete. The employee records were missing training certificates for CPR/First Aid, EBI, orientation, pre-service training, and drug test results.


summary: 748.1333 - Preliminary Service Plan-Treatment director or PLSP must develop, sign, and date the plan for children receiving treatment services

raw_content: During the inspection, I observed that the mock preliminary service plan did not include a field to be approved by the Treatment Director or PLSP.  The form indicates it is to be signed by a CPMS.

Correction Narrative: The operation's executive director provided a template that will be used in the children's case file to document the preliminary service plan which included a field for approval from the case manager and treatment director/PLSP


Standard Number / Description: 748.601 - Treatment Director-Facility providing treatment services to 25 or more children or to more than 30% of children in care must have treatment director

Deficiency Narrative: During the follow up inspection, it was noted the operation is providing treatment services, but does not have a treatment director that has completed the hiring process.


summary: 748.363(4) - Personnel records-Personnel records-Include current job description.

raw_content: During the follow up inspection, two of three personnel files did not contain the current job description document required by minimum standards.

Correction Narrative: The operation's executive director provided a copy of the job description for the missing employee files (facility manager and treatment director.


summary: 748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules

raw_content: Per the operation's transportation and travel policy on page 174, the operation allows transportation of children by caregivers over the age of 18. The transportation policy beginning on page 248, reflects the caregiver must be over the age of 21.


summary: 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

raw_content: During the inspection, I observed that the mock file did not include a mock EBI report for review.


raw_content: During the inspection it was observed that bedrooms 7, 18, and 19 did not have working hot water in the shower.

Correction Narrative: The operation's executive director provided a copy of the invoice to verify the operation contacted a local plumber and they fixed the hot water in the bathrooms.


summary: 748.1437(1) - Discharge/Transfer Documentation-Must include date and circumstances of discharge or transfer

raw_content: During the inspection, I observed that the mock file lacked documentation for resident discharge.

Correction Narrative: The operation's executive director provided a template that will be used in the children's case file to document discharge/transfers.


raw_content: During the follow up inspection, two of three personnel files reviewed did not contain the documentation to reflect the operation contacted the required references to verify that the applicant is suitable to work with or around children.

Standard Number / Description: 748.753(a)(2) - Pre-Employment Screening-You must contact each of the two references to verify that the applicant is suitable to work with or around children.


summary: 748.111(4) - Child-care policy - Child's right to receive and give gifts

raw_content: The admission policy, beginning on page 39, does not specify the child's rights to receive and give gifts to family, friends, employees, or other children in care, including any restrictions on gifts.

Category: Organization and Administration

Correction Narrative: The operation's policy contained child's rights to recei e and give gifts.


raw_content: During the inspection it was noted that several bedrooms had blinds that broken, a bedroom had a tear in the wallpaper, bedroom light wasn't working, exposed wires in offices and living room, 5 gallon bucket of paint in the bathroom, and the room with the Saints decor was missing trim.


summary: 748.3273(1) - First Aid Kits-Each one must contain a current guide to first aid and emergency care

raw_content: During the walkthrough it was noted the first-aid kit was missing the following, adhesive tape, scissors, and tweezers.

Category: Safety and Emergency Practices

Correction Narrative: Each first aid kit, contained all required supplies.


summary: 748.125(c)(2) - Suicide Training-You must promote suicide prevention training for non-employees, as appropriate.

raw_content: The operation's suicide prevention, intervention, and postvention policy found on page 177, does not indicate the operation will promote suicide prevention training for non-employees.

Correction Narrative: The operation's suicide policy contained promotion for non-employees to complete suicide prevention training.


summary: 748.311(1) - Serious Incident Documentation-Includes name of the operation, physical address, and telephone number

raw_content: The operation's incident report does not include the operation's telephone number.

Category: Reports and Record Keeping

Correction Narrative: During the inspection, I observed that the Serious Incident Report has been updated to show pending  as the phone number instead of the incorrect number previously noted as the operation awaits a permanent operation line.


raw_content: During the standard-by-standard inspection, it was noted the operation is providing treatment services, but does not have a treatment director.

Category: Personnel


summary: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

raw_content: During the walkthrough, it was noted that room #311 was missing a shower head. It was also noted that room #8 the bathtub was stopped up and there was sitting brown water that was unable to drain. I observed room #9 to have a toilet that did not work. The laundry room had a non-working toilet as well, and the toilet bowel was full of brown stains, and there was missing sheet rock with exposed pipes.

Correction Narrative: During the follow up inspection, the bathrooms were clean, maintained and in good repair.


raw_content: Per the operation's transportation policy, the operation allows transportation of children by caregivers over the age of 18.

Standard Number / Description: 748.103(a) - Policies & procedures to submit-must comply or exceed Chapter 42 of HRC, Chapters 745,748,& all other applicable laws and rules


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: The purpose and mission statement, located on page 2, states "Open Hearts Children and Family Services (also referred to as Open Hearts or OHCFS in this document) is a license Foster Care Child Placement and Adoption Agency."

Correction Narrative: The operation provided an updated copy of the policy removing the erroneous notation of the operation as a CPA and correctly identifying it as a GRO.


summary: 745.621(a)(7) - AP Initial background checks submitted - At the time you become aware of anyone requiring a background check under 745.605

raw_content: During the inspection, it was observed that four of the six employees still had pending background checks. CBCU advised fingerprints had not been completed and the background checks were set to be closed as non-compliant.

Correction Narrative: All employees with direct contact with children have completed back ground check information.


raw_content: The care for children and adults policy beginning on page 215, states "adults in care act as caregivers and The Village of Open Hearts will maintain its caregiver ratios."

Standard Number / Description: 748.1935(c) - Care for children and adults-adult residents may not be counted as caregivers in the child/caregiver ratio.

Category: Providing Children and Adult Care


summary: 748.125(d)(5) - Suicide Screening- Must be performed in a manner that protects the childs privacy.

raw_content: The operation's suicide prevention, intervention, postvention policy on page 105, indicates that if a parent insists, they can be present for the screening.

Correction Narrative: During the follow up inspection, the suicide prevention, intervention, and postvention policy was reviewed and reflected how the operation may perform screenings that meet the child's privacy.


summary: 748.399(a) - Records Available for Licensing-all active records immediately available for review and reproduction

raw_content: During the inspection, the operation was unable to provide access to all active records for immediate review.

Correction Narrative: During the inspection, the operation was able to produce a mock resident file and requested employee files.


summary: 748.115(5) - Discipline policy - Include a statement that discipline of any type is not allowable for infants

raw_content: The discipline and punishment policy, beginning on page 221, does not include a statement that discipline of any type is not allowable for infants.

Correction Narrative: The operation's policy contained a statement that discipline of any type is not allowable for infants.


summary: 748.3235 - Evacuation-Must post the emergency evacuation & relocation diagram in a prominent/visible location in all buildings

raw_content: During the walk-through it was noted the operation failed to post the emergency evacuation & relocation diagram.

Correction Narrative: The operation has posted emergency evacuation and relocation diagrams in the main hallway.


summary: 748.3443(b)(1) - Food Preparation-Must have a thermometer in refrigerators & store refrigerated food at 40 degrees Fahrenheit or below

raw_content: The operation's refrigerator and freezer did not contain a thermometer to measure the temperature.

Correction Narrative: During the follow up inspection, it was observed that the operation had working thermometers in the refrigerator and freezer.


summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content: The operation's suicide prevention, intervention, and postvention policy found on page 177, indicates the operation will utilize the training curriculum by the Suicide Coalition of Texas, ASK Gatekeeper.

Correction Narrative: During the follow up inspection, the suicide prevention, intervention, and postvention policy was reviewed and reflected at least one hour of annual suicide prevention training is required for each employee.


summary: 748.123 - Vaccine preventable policy - develop and implement written policy for vaccine-preventable diseases

raw_content: The operation did not provide a policy (748.123), to include how they plan on protecting the children in care from vaccine-preventable diseases of employees.

Correction Narrative: The operation's policy contained a policy to develop and implement vaccine preventable diseases.


summary: 748.3101(1) - Fire Inspection-Must have fire inspection before initial permit issued

raw_content: During the standard-by-standard inspection, the operation failed to have their fire inspection completed.

Correction Narrative: During the inspection, the operation provided proof of a completed and cleared fire inspection.


summary: 748.125(d)(3) - Suicide Screening- Document that any person conducting a suicide screening meets the conditions and training requirements.

raw_content: The operation's suicide prevention, intervention, and postvention policy does not indicate that the person conducting the suicide screening must meet the conditions and training requirements.

Correction Narrative: During the follow up inspection, the suicide prevention, intervention, and postvention policy was reviewed and reflected how the person conducting a suicide screening must meet the conditions and training requirements.


summary: 748.127(a) - Operation plans, policies and procedures must indicate date adopted and effective date

raw_content: The operation's plans, policies, and procedures does not indicate the date adopted and effective date.

Correction Narrative: The operation plans and policies included dates adopted and effective.


summary: 748.109 - Admission policies must include description of each program you offer

raw_content: The admission policy, located on page 36, states "The Village of Open Hearts to provide Emergency Care Services to you in need of substitute foster care or other out of home care." It is also observed that the policy uses emergency care services and emergency admissions, interchangeably.

Correction Narrative: During the follow up inspection, the operation's policy was reviewed and included a description of each program offered.


summary: 748.393(a) - Active child record-kept at operation where child is receiving services

raw_content: During the inspection, the operation did not provide a complete child's record for review.

Correction Narrative: The operation provided a mock case file for review.


summary: 748.2101(3) - Medication Storage-Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container

raw_content: During the walk-through it was noted that the operation's medication room had a keypad/key lock on the door, however, inside the room they did not have a lock box or a lock on a cabinet to ensure Schedule II medications were double locked. The staff reported they would purchase a lock to go on the cabinet.

Correction Narrative: During the inspection, I observed the medication storage to be appropriately locked and secured.


summary: 748.3001(a)(1) - Sanitation Inspection-Sanitation official must conduct a sanitation inspection before initial permit issued

raw_content: During the standard-by-standard inspection, the operation reported having the health inspection completed, but failed to provide the documentation.

Correction Narrative: During the inspection, the operation provided proof of a completed and clear health inspection.


facility_name: Embracing Destiny Foundation RTC

summary: 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

raw_content: It was determined that the operation failed to report to Licensing that a child in care sustained an injury requiring medical treatment, including a fractured hand.

Correction Narrative:
Provided by Email from LCCA on 03/30/2026: Effective immediately, Embracing Destiny Foundation Facility Manager in collaboration with all staff members will ensure a report is submitted regardless if license contacts the facility to inform the facility of the suspected abuse.

In lieu of duplicating a report and abusing resources, they will assume that acknowledgement of the incident was already accomplished. From this day forward they will immediately notify licenses for all matters noted as a Serious Incident.


summary: 748.2855(a)(8) - EBI Documentation-Must include the name of the person(s) who observed the child

raw_content: EBI Incident Report does not indicate which staff member/s restrained the child (6/5/25).

Correction Narrative: The operation provided documentation that explained all necessary information included for the restraint. The report has been uploaded into the document library.


summary: 748.3115(3) - Fire Extinguisher-Must ensure fire extinguishers are serviced as required by manufacturer's instructions, or as required by fire inspector

raw_content: While conducting a team inspection it was discovered that fire extinguishers throughout the facility has expired along with the extinguisher in the vehicle that did not contain a tag.

Correction Narrative: This standard was evaluated and found to be compliant due to the fire extinguisher being replaced. Pictures taken and uploaded into the document library.


summary: 748.3701(a) - Recreation responsibility-Must provide daily indoor/outdoor recreational & other activities appropriate to needs, interests, and abilities of children

raw_content: During a team monitoring inspection, it was discovered that daily recreation activity calendar only listed one outdoor activity or an indoor activity and not both.

Category: Recreation Activities

Correction Narrative: This standard was evaluated and found to be compliant. A copy of the indoor/outdoor recreation calendar was provided upon request.


summary: 748.4041 - Driver & passengers must follow all laws when driving, including laws on use of child passenger safety seat systems, seat belts & liability insurance

raw_content: While conducting a team inspection it was discovered that the seat belt in the middle seat of the facility van is broken and inoperable.

Correction Narrative: This standard was evaluated and found to be compliant. A in person inspection was conducted and the safety seat system (seatbelts) were repaired in the van.


summary: 748.3301(f) - Physical Site-The grounds of the operation must be well maintained and free of hazards

raw_content: Licensing observed a pile of fence post wood with exposed nails outside.

Correction Narrative: The Operation sent an email and photographs of the grounds showing that the same is now clear of hazards and that the pile of wood (with nails) were removed by maintenance crew. A copy of the email (with photograph) is uploaded in document library.


summary: 748.3301(i) - Physical Site-Equipment and furniture must be safe for children and must be kept clean and in good repair

raw_content: Three laundry baskets were observed to be broken with jagged edges. Two broken laundry baskets were observed upstairs near the fire extinguisher, and one broken laundry basket was downstairs in the common area/living room.

Correction Narrative: Operation submitted a compliance plan for all deficiencies on March 25, 2024.  Regarding this citation, the response is as follows: The baskets were replaced.


summary: 748.311 - Serious Incident Documentation-Documented in written report

raw_content: Several required components are missing in the serious incident report.

Correction Narrative:
Operation submitted a compliance plan for all deficiencies on March 25, 2024.  Regarding this citation, the response is as follows: After reviewing our serious incident report the following changes have been updated; the
physical address has replaced the mailing address and the phone number has been added.


summary: 748.3391(a) - Bathrooms-Must be maintained in good repair & kept clean

raw_content: Bathroom observed with mold/mildew around the bathtub, tiles, and ceiling.  Shower rod and plastic shower curtain, in the same bathroom, were observed on floor/not hanging.

Correction Narrative: Operation submitted a compliance plan for all deficiencies on March 25, 2024.  Regarding this citation, the response is as follows: The calking used was brown, but it has since been changed to prevent any confusion. The shower rod fell at the time of the inspection, but it has been addressed as of the day of the inspection. It was a normal occurrence and required us to respond as normal. The onsite inspector witnessed the staff explaining the situation as we walked upstairs.


summary: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment

raw_content: A child in care was administered cruel and unnecessary physical discipline as a result of not being able to follow instructions from a caregiver.

Correction Narrative:
Due to our training of each caregiver upon hiring and throughout employment with
Embracing Destiny Foundation being consistent with the minimum standards, the actions
being described are not aligned with the Embracing Destiny Foundation practices. The
caregiver noted as the perpetrator has been terminated due to the outcome of this
investigation.


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

raw_content: In the case at bar, it is unrebutted that a child in care engages in self-harming activities which causes injury to his person and with staff apparently around and aware of these instances.


summary: 748.1101(b)(4)(B) - Children's rights-The right to discipline that is appropriate to the child's age, maturity, and developmental level

raw_content: A child in care was disciplined in such a way that the child's rights to discipline that is in consonance with his age, maturity, and developmental level were disregarded.


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

raw_content: A caregiver failed to adhere to a child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 when the caregiver physically abused a child in care. This standard was found deficient as part of a DFPS investigation.


summary: 748.930(b)(4) - Annual Training- Caregivers must have 2 hours transportation safety training if caring for children younger than 9 yrs old.

raw_content: A review of the transportation training revealed that the staff need to finish 2 hours of transportation training as required by Minimum Standards.

Correction Narrative:
Training on transportation were updated for all staff in both RTC and GRO.
Certificates as well as the training attendance are uploaded in Sharepoint.


summary: 748.453(a)(1) - Unauthorized Absence  Annual summary log must include name, age, gender, date of admission

raw_content: The operation had no knowledge a summary log  was required to document unauthorized absences for the operation.

Correction Narrative:
The facility submitted a Corrective Action Plan addressing the deficiency cited in compliance thereto. In this respect, the corrective action plan is hereby reproduced, thus:

It is always the goal of Embracing Destiny Foundation to address any discrepancy
brought to our attention and implement corrective actions that will ensure that our
residents are treated fairly and kept safe at all times.
During your visit you addressed the following area of needed improvement:
1. 748.753(a)(1), on failure to maintain an unauthorized absence log for your facility
Corrective Action Implemented:
Embracing Destiny Foundation has created an annual summary log to document children
that leave the campus and are considered AWOL. The document will be posted in the
administrative office and will be updated as an incident occurs.
Anticipated date of completion:
06/15/2022
Again, we thank you for your insight regarding this matter and we will be available to
provide any further information requested.


summary: 748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate

raw_content: During the inspection; an observation of tools were observed in the garage area which were accessible to the children in care.

Correction Narrative: An observation of the tools were removed from the garage area and placed out of reach of the children in care.


summary: 748.3301(h) - Physical Site-The building must be free of rodents and insects

raw_content: During the inspection; an observation of ants were observed crawling on the kitchen counter.

Correction Narrative:
The operation has a pest control contract for quarterly service. The last visited was March 2022, but have been scheduled to revisit on
05/24/2022.This was the earliest date the company could schedule the inspection. The operation reported very limited sightings of ants since the last inspection.


summary: 748.3421(2) - Poisons-The operation must ensure that poisonous or flammable materials are kept separate from medication, food, food prep and dining surfaces

raw_content: During the inspection; a pack of matches and dishwashing liquid were observed in the kitchen area.

Correction Narrative:
The matches and dishwashing liquids were removed and placed out of reach of the children in care. The operation agreed to ensure that poisonous or flammable materials are kept separate from
medication, food, food prep and dining surfaces.


summary: 748.3441(a) - Food Preparation-Food & drinks must be of safe quality, stored, prepared, distributed, & served under sanitary & safe conditions

raw_content: During the inspection; an observation of expired food was located inside of refrigerator, freezer, and pantry, at the facility.

Correction Narrative:
The operation will be more vigilant of the items  purchase. In shopping monthly, it is the
expectation that items will last through the time of use. Due to the very short shelf life of
the items being sold, we will have to ensure there is enough time within the date to be
used.


raw_content: The child was not adequately supervised which is a violation of the child's right to be free from abuse, neglect, and exploitation. The incident pinpoints to a scenario where the child was momentarily left unattended and as a consequence, he committed an unauthorized absence which exposed him to possible abuse, neglect, and/or exploitation.

Standard Number / Description: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

Correction Narrative: During the follow up inspection, it was observed that the staff were adequately supervising the children in care.


raw_content: The child left the operation without him being noticed, the caregiver failed to recognize that the child has limited verbal activity, high risk behaviors, and was found inside a neighbor's pool.

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

Correction Narrative: During the inspection, it was observed that the children in care were adequately supervised by the operation's staff.


summary: 748.1009 - Child/caregiver ratio-Must employ an adequate number of caregivers to meet the needs of children

raw_content: One staff was responsible for monitoring the child which required one-on-one supervision, and another room with additional children in care occupied.  This translated into a serious ratio problem especially since one child required one-on-one supervision at all times.

Correction Narrative: During the follow up inspection, ratio was evaluated and the operation was in compliance as there were 4 staff supervising 7 residents.


summary: 748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required

raw_content: The operation's caregiver failed to comply with the child in care's service plan requirements for one on one, auditory, and eyesight supervision.

Correction Narrative: During the follow up inspection, it was observed that the caregivers were following the supervision requirements for the children in care.


summary: 748.1101(b)(4)(A)(iv) - Children's rights-Free from being denied food, sleep, a bathroom, mail, or family visits as punishment

raw_content: Four of the six children and two caregivers interviewed reported the children are required to discard of their food as a result of talking during meal time.

Correction Narrative: Follow up was done during HM visit on 8/1/22. Children were interviewed and no concerns were brought up about food being used a form of discipline.


summary: 748.1387 - Service Plan Review-Must comply with notification, participation, implementation, and documentation requirements for an initial service plan

raw_content: Child had a review servce plan completed on 7/8/2021 and there were no notifications sent out.

Correction Narrative:
The operation has a process with notification,
participation, implementation, and documentation requirements for an initial service
plan.


raw_content:
During the monitoring inspection; ten serious incidents reports were reviewed and majority did not include names of all adults involved and their role in relation to the child,  resolutions of the incident, nature of the incident, names or other means of identifying witnesses to the incident,circumstances surrounding the incident, interventions made during and after the incident, such as medical interventions, contacts
made, and other follow-up actions.

Standard Number / Description: 748.311 - Serious Incident Documentation-Documented in written report

Correction Narrative: The operation agreed to improve their methods of documenting serious incident reports.


summary: 748.4083(a) - Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times

raw_content: The tire pressure light is on and the air did not work throughout the entire van.

Category: Transportation

Correction Narrative: The operation provided an maintenance receipt for the vehicle on July 7, 2021.


summary: 748.1331(b)(4) - Preliminary Service Plan-For child receiving treatment services, identify any issues or concerns child may have that could escalate child's behavior

raw_content: One of two records reviewed did not identify the concerns that could escalate a child's behavior.

Correction Narrative: The operation submitted a copy of the preliminary service plan for child in care and notified the clinical treatment director immediately.


summary: 748.4003(1)(B) - General requirements-When transporting a child the operation must ensure each driver is covered by automobile insurance

raw_content: During the monitoring inspection; the vehicle insurance which transport the children expired June 6, 2021.

Correction Narrative: During an inspection at the GRO location, the owner was able to provide an updated insurance policy. It renewed June 22, 2021 and expires on June 22, 2022.


facility_name: Hands of Healing

summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: A child's Admissions Assessment and current Service Plan contains conflicting information regarding his allergies, health condition, and medications.

Correction Narrative:
8/30/23: Per the Administrator, Hands of Healing will maintain current, true, accurate, and complete records. The child's Hands of Healing Case manager will make sure this information is correct and accurate upon the client's admission with the assigned DFPS worker to the program and will ask questions where needed.
8/29/23: Operation provided a copy of the corrected information. Written corrections only restated the standard, returned for more details.


summary: 748.393(b)(2) - Active child record-Includes known allergies and chronic conditions or

raw_content: It is documented on a child's face sheet that he does not have any allergies or other conditions, when has a known health condition and allergies.

Correction Narrative:
8/30/23: Per the Administrator, Hands of Healing will document all allergies and conditions on a child's face sheet, upon entering the program.  The child's Hands of Healing Case manager will make sure this information is correct and accurate upon the client's admission with the assigned DFPS worker to the program and will ask questions where needed.
8/29/23: Operation provided a copy of the corrected information. Written corrections only restated the standard, returned for more details.


summary: 748.1203(a) - Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation

raw_content: An 8yo child was placed at the operation on 3/3/2023. However, the operation is licensed for ages 9-17 at the time of placement through present date.

Correction Narrative: Per Administrator Maria Laflam during HM PPM visit on 8/15/23, resident was discharged 8/8/23. Via email she stated "Hands of Healing will not admit children into the operation whose do not meet admission requirements or whose needs Hands or Healing can not assist/meet."


summary: 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

raw_content: The operation failed to report about a youth in care self-harming and being admitted to the hospital timely.

Correction Narrative: Per the Administrator, Hands of Healing has added a spot-on serious incident report, with the phone number to hotline along with phone number to contracts. The staff writing the serious incident will be responsible to call in with in 24 hours. Program Director and Assistant Program Director will check for compliance with in the 24 hour period.


raw_content: The operation failed to report an injury to a child who received medical attention at an urgent care center for a sprained thumb. Medical documentation confirms the child was diagnosed with a sprained finger and was also taken for a follow-up evaluation with an orthopedic specialist.

Standard Number / Description: 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

Correction Narrative: Hands of Healing will report all serious incidents no less than 24 hours after injury/illness.


raw_content: A staff directly involved in an incident was not documented on the serious incident report.

Standard Number / Description: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

Correction Narrative: Per the Administrator, all staff involved in incidents will be documented in an incident report. Another staff signature spot was added to the incident report for extra staff involved to sign. And staff were retrained on documentation.


summary: 748.2551(b)(3) - EBI Implementation-The caregiver must consider the potential risk of harm in using EBI versus the risk of not using EBI

raw_content: Two staff did not consider the risk of harm to a child when deciding not to restrain the child.

Correction Narrative:
EBI/Crisis Prevention Intervention training has been done with Hands of Healing staff.
Hands of Healing Staff were retrained on Emergency Behavior Interventions especially as it relates to self-harm. Hands of Healing staff were refreshed on the protocol of assisting with a child who is bleeding and intervening immediately. Hands of Healing staff will continue to be refreshed on this information, they were informed of the importance of a restraint in this situation. It can reduce self-harm behavior.


summary: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety

raw_content: Two Direct Care Staff did not intervene while a child was self-harming, due to the child bleeding.

Correction Narrative:
The two staff that did not intervene while the child was self-harming have been terminated.
Hands of Healing staff were educated on their daily responsibilities. They were informed that their job is to ensure the safety of all children living at Hands of Healing.
Hands of Healing Staff were retrained on EBI especially as it relates to self-harm. Hands of Healing staff were refreshed on the protocol of assisting with a child who is bleeding and intervening immediately. Hands of Healing staff will continue to be refreshed on this information, they were informed of the importance of a restraint in this situation. It can reduce the self-harm behavior.

Hands of Healing has done training to remedy this situation in order to keep it an isolated incident. Hands of Healing will continue to provide training with staff in areas where Hands of Healing notices staff may need further training.
5/31/23: Training and all staff meetings sign-in sheets were provided by the operation at PPM visit on 5/31/23. Per BGC for staff involved in the incident were inactive as of 4/28/23.


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

raw_content: A Direct Care Staff did not demonstrate prudent judgement when recording a child displaying self-injurious behaviors for proof that the child injured himself and the staff did not.

Correction Narrative:
Hands of Healing staff will maintain responsibility for the health, safety, and well-being of children at all times. Hands of Healing has been trained to maintain the rights of all children admitted into the Hands of Healing program. Hands of Healing staff will protect the rights of all children in care, staff will safeguard the health of all children, assure the children of appropriate and necessary equipment, supplies, and facilities to meet their personal, recreational, and educational needs.
5/31/23: Training and all staff meetings sign-in sheets were provided by the operation at PPM visit on 5/31/23. Per BGC for staff directly involved in the incident were inactive as of 4/28/23.


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

raw_content: A child was neglectfully supervised by two Direct Care Staff resulting in the child being able to self-harm.

Correction Narrative: Hands of Healing had a refresher training course with staff, regarding child rights. Staff are being monitored by Shift Lead, Program Director, and Administrator for their compliance to child rights. Hands of Healing also participated in a Trauma Informed Training with Dr. Holly to talk about Trauma which develops from abuse, neglect, exploitation, and how it relates to the boys along with their behavior.


summary: HRC42.04412(a) - Interference with an investigation

raw_content: Two children in care expressed that a staff told them what an investigation was in reference to, prior to being interviewed.

Correction Narrative: Per the Administrator, Hands of Healing Staff will not interfere with an investigation. Hands of Healing staff will not discuss investigations or inform the children of investigations.


summary: 745.651(2)(A) - Background Check Validation  Every 3 months each operation, other than a licensed, registered, or listed home, must validate current list

raw_content: upon review of background checks it was seen the operation has not validated their background checks since 6-27-22.

Correction Narrative: Hands of Healing will validate current background list every three month. Hands of Healing will place this with training items, so it will show red, when it is due. And it will be strategically kept up with.


summary: 748.3021 - Tools-Dangerous tools & equipment stored so they are inaccessible to children; children use these with caregiver supervision as appropriate

raw_content: During the walkthrough of the facility there were several doors  to office and hallway closets unlocked where scisors and cleaning chemicals are found. There was also an outside generator unlocked for a child to be able to access the inside componets and can cause harm.

Correction Narrative: Hands of Healing will lock all chemicals and doors as required. Generator will be always locked. All will be checked during facility walk through, daily.


summary: 748.461(2) - Unauthorized Absence-Triggered Review must include a review of service plan elements in 749.1309(b)(1)(D)&(H) & as applicable 749.1309(b)(2)&(3)

raw_content: The triggered reviews documented do not have the required components outlined in 748.461(1)-(4).

Correction Narrative: The agency created a triggered review meeting report that discusses AWOL occurrences, Safety Plans, AWOL debriefings, and incorporates trauma informed strategies.


summary: 745.8641 - Requirements during evaluation or probation

raw_content:
Condition 1-Met

Condition 2-Met

Condition 3-Met

Condition 4-Not met-- 5 children quarterly meetings were not conducted for quarter 3. The adminstrator was asked by rccr staff for the completed child quarterly notes, and the adminstrator stated that she was unable to find the child quarterly meeting notes for the five children.

Condition 5-Met

Correction Narrative: An email was sent to rccr staff on 07/18/2022 stating the following: : Hands of Healing Administrator will check monthly on the 4 tasks of probation. To ensure documentation is being done and filed. Hands of Healing Administrator will check monthly until the end of the quarter, for completing of Licensing Probation Task 4.


summary: 748.455(c) - Unauthorized Absence-debriefing must be documented in childs record, including routine activity that would be inappt for child to return to and why

raw_content: The required unauthorized absence debreifing was not documented in a child's record.

Correction Narrative: An email was sent to rccr staff on 06/22/2022 with the newly formatted debriefing form for unauthorized absences that will be utilized moving forward to conduct debriefings with each child after an unauthorized absence.


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

raw_content: A staff member's choice of words used while redirecting a child in care were found to be inappropriate.

Correction Narrative:
Email received from the operations.
Correction for the citation. It is the responsibility of Hands of Healing to ensure the safety of each youth in care. Each staff is expected to demonstrate self-control in the presences of youth in care.  Each staff has been trained in Non-Violent Crisis Interventions and Verbal Crisis Interventions. The staff that was subject of this investigation received Verbal Crisis Intervention and Verbal De-Escalating Techniques Training during Pre-Service on 5/19/2021, and again on 5/9/2022. If any staff is found to be not exercising prudent judgment when dealing with youth in care will be reprimanded. This will be monitored by the staff supervisor and the Program Administrator.


summary: 748.453(a)(4) - Unauthorized AbsenceAnnual summary log must include name of caregiver responsible for child at time absence discovered

raw_content: The unauthorized absence log reviewed for the year of 2022 did not show the required caregivers names documented that was responsible for the child at the time of the runaway.

Correction Narrative: An email was sent stating a training with the staff was conducted regarding unauthorized absences documentation was conducted. A sign in sheet was sent to rccr staff with the staff attendance for the training was obtained.


summary: 748.3351(1) - Interior Space-Provide living space, appropriate furnishings, & bathroom facilities that are safe, clean and maintained in good repair

raw_content: During an inspection one shower faucet was observed not to be working.


summary: 745.651(1) - Background Check Validation - You must inactivate a subject who is no longer associated with your operation within 7 days of leaving

raw_content: One employee was no longer working at the operation as of 04/07/2022 and the employee still had an active background check in the system.

Correction Narrative: The employee was made inactive in the system, verified by rccr staff in the class system. An email was sent to rccr staff on 04/29/2022 stating the employee was made inactive.


summary: 748.3301(c) - Physical Site-Windows & doors must be in good repair & free of broken glass or hazards

raw_content: One bedroom window was observed to be cracked. One bedroom window was jammed and would not open due to the knobs that lock and unlock the window being broken.

Correction Narrative: An email was sent to rccr staff on 11/23/2021 stating all windows has been fixed and are in good repair. The corrective action states moving forward the operation will check the windows daily during the facility checklist in order to maintain compliance. An inspection was completed on 12/15/2021 and the windows were inspected and determined to be in compliance.


summary: 748.3017(a)(1) - Animals-allowed if operation has documentation showing dogs and cats are vaccinated for rabies as required by TX Health and Safety Code, Ch 826

raw_content: Two pet vaccinations that were reviewed were expired.

Correction Narrative: An email was sent to RCCR staff: A copy of both pets vaccination documentation was obtained dated 10/07/2021. An email from the operation staff stated: Going forward Administrative Assistant will manage this and make sure the Dogs receive all vaccinations on time.


summary: 748.3475(a)(2) - Safety Requirements-The administrator or designee must inspect the equipment and surfacing material for broken or missing parts

raw_content: An inspection was conducted on the playground area. Hazards that were identified are as follows: The  perimeter boards around the playground  equipment area are in need of repair, their were nails exposed around the boards.  One sign that identified the type of equipment was shattered. The playground area did not have the required uncompressed loose fill number of inches and the loose fill had debris in it.


summary: 748.4083(b) - Vehicle and maintenance-Each vehicle used must be registered and have a current inspection sticker for the state in which it is registered

raw_content: 2 of 2 vans used to transport children in care registration was expired. One of the vans registraion was expired since May 2021 and the other van was expired as of June 2021. The insurance documentation placed in each of the van's was expired as of February 2021.

Correction Narrative: Photos of the operations transport van inspection stickers were sent to rccr staff via email on 10/04/2021. A corrective action plan was sent to rccr staff on 10/04/2021 from the operation's administrative staff. The email correspondence are as follows: As of 10/4/2021 both vans have been inspected and received their current inspection sticker. The new insurance documentation is placed in both vans. Going forward the safety coordinator will make sure the vans are inspected weekly and registration is on time. Safety coordinator will update the vans insurance documentation as needed.


summary: 748.3441(i) - Food Preparation-Food packages must be in good condition & protect the integrity of the contents

raw_content: Their were foods exposed in the freezer due to the packaging of the food tearing.                           *Corrected during the inspection by throwing away the foods that were exposed.


summary: 748.3441(c) - Food Preparation-Must keep furniture, equipment, surfaces & other areas where food is prepared, eaten or stored clean & in good repair

raw_content: The stove located in the kitchen area used for cooking was not clean. Their was a grease build up on and around the surfaces of the stove.

Correction Narrative: An email was sent to rccr staff from administrative staff with photos of a new stove installed in the operation's kitchen area. The corrective action sent via email from the administrative staff are as follows: ): A new stove has been purchased and installed 10/4/2021. All areas of the kitchen were deep cleaned. Going forward the kitchen manager will be cleaning the kitchen daily and deep cleaning every two weeks. Kitchen manager will  always be responsible for the cleanliness of the kitchen.


summary: 748.4001(b) - General requirements-must ensure the safety of all children during any transportation that the operation provides

raw_content: Five of 5 children stated multiple seatbelts were broken on each van. This was verified during inspection and photos taken.

Correction Narrative: Inspection conducted at the operation; Transportation SC evaluated; both vans were inspected. The seatbelts were fixed and in working order.


summary: 748.1101(b)(3)(E) - Children's rights-privacy to send/receive unopened mail,have phone conversations,keep journal,have visitors unless the child's best interest

raw_content: A staff admitted to listening to a client's private phone call while the client was communicating with their bio parent.

Correction Narrative: An email was sent to rccr staff stating Staff will respect clients rights to privacy. Staff will not listen to client's private phone calls, while supervising children. (Unless a restriction is requested).


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

raw_content: The operation was aware of a child's aggressive behaviors, from recent altercations with other residents, and did not have that  child on increased supervision prior to an incident that resulting in a resident being injured.

Correction Narrative: An email was sent to rccr staff stating Hands of Healing has restaffed program. Provide more supervision, with the new position of staff supervisor added. If a client is being aggressive, will place 1:1 or with staff supervisor/administrative staff, away from peers, in prevention of physical altercations. An administrative review was requested.


summary: HRC42.04412(a) - Interference with an investigation

raw_content: A staff was asked to provide video footage of an incident to an investigator and the staff failed to provide the requested video footage to the investigator.

Correction Narrative:
An email was sent to rccr on 07/28/2021 stating the operation's camera system was not working properly at the time of the request.
The operation has requested an admin review.


summary: 748.2553(2)(C) - EBI Release-Child released from personal restraint as soon as child is not a danger to self or others

raw_content: A caregiver failed to release a child from a restraint when the child was no longer a threat.

Correction Narrative: An email was sent to rccr staff on 07/30/2021 stating:Hands of Healing direct care staff will be retrained on ebi. Training dates will be 8/3/2021 and 8/5/2021 to ensure all direct care staff are able to attend. Training objectives and staff who participated will be sent to rccr staff.The staff directly involved in this incident was terminated.


summary: 748.151(3) - Operational responsibilities - Maintain current, true, accurate, and complete records

raw_content: An incident report that was documented wasn't consistent with what happened during an incident that resulting in a child being injured.

Correction Narrative: An email was sent to rccr staff stating Hands of Healing direct care staff will be retrained on incident reporting. Training dates will be 8/3/2021 and 8/5/2021 to ensure all direct care staff are able to attend. Training objectives and staff who participated will be sent to rccr staff.


summary: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force

raw_content: A caregiver used excessive force during a restraint, causing substantial physical injury to a child.

Correction Narrative: An email was sent to rccr staff on 07/30/2021 stating:Hands of Healing direct care staff will be retrained on EBI Training dates will be 8/3/2021 and 8/5/2021 to ensure all direct care staff are able to attend. Training objectives and staff who participated will be sent to rccr staff. Training curriculum and a training sign in date was submitted as of 08/05/2021.The operation requested an administrative review.


summary: 748.2455(a)(2) - Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication

raw_content: A caregiver initiated a restraint on a child that was not warranted.

Correction Narrative: An email was sent to rccr staff on 07/30/2021 stating:Hands of Healing direct care staff will be retrained on ebi. Training dates will be 8/3/2021 and 8/5/2021 to ensure all direct care staff are able to attend. Training objectives and staff who participated will be sent to rccr staff.Training curriculum and a training sign in date was submitted as of 08/05/2021.


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

raw_content: A child sustained a fracture to his ankle as a result of a caregiver's actions.

Correction Narrative: The staff that was directly involved in the incident is no longer with the operation.


raw_content: A staff dragged a child across the floor by gripping his ankles one with each hand and pulled the child.

Correction Narrative: A phone call was made to the operation regarding the employee involved in the incident, the administrator the staff is no longer employed at the facility. An email was sent to RCCR staff stating the employee involved in this incident is no longer employed with the operation.


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

raw_content: It was reporting that while a staff was dragging a child, the staff stated inappropriate words to the child in order to get to child to comply.


summary: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child

raw_content: It was reported that a staff conducted an improper restraint.


facility_name: Kaufman County Children's Emergency Shelter

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

raw_content: 4 out of 5 children in care reported a staff driving recklessly during an outing and 5 out of 5 children in care reporter this same staff member being verbally aggressive with another staff member.

Correction Narrative: RCCR received documents that showed the operation had a meeting with all staff members involved in the investigation and were re-trained for driving safe.


summary: 748.911(a) - Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking

raw_content: The CPR/First Aid training expired on 3/21/25 for two caregivers.

Correction Narrative: An email was received from the Administrator on 04/17/25. The new checklist to indicate when training will be expired was received. The training is scheduled for April 29th for renewal of the CPR and first aid. The second training for the staff that was unable to make the 29th is on May 9, 2025. The staff will not be counting in the ratio until the training is current.


summary: 748.1331(a) - Preliminary Service Plan-Complete plan that addresses child's immediate needs within 72 hours of admission

raw_content: After reviewing the preliminary service plans there were no documentation of the child's supervision requirements.

Correction Narrative: An email was received from the Administrator on 04/17/25 indicating that the Preliminary Service Plan template has been updated to ensure the supervision is documented clearly.  A copy of the template was provided.


summary: 748.3893(10) - Trampolines as Gym Equipment-must be checked for tears, rust, & detachments at least monthly & repaired prior to its next use

raw_content: The trampoline had part of the padding that was tore and the safety netting was detached from the top of the poles.

Correction Narrative: The Administrator sent pictures of the trampoline that was repaired.  He also indicated that an audit check list has been created to ensure that the trampoline and any equipment outside will be checked regularly.  This will be conducted weekly, and staff will have to date and sign the form after the inspection has been completed.  The form will be available for review. The Administrator moved the trampoline out from underneath a tree for safety. The pictures were uploaded in CLASS Library.


summary: 748.125(c)(1) - Suicide Training-All caregivers and employees must complete at least one hour of annual suicide prevention training.

raw_content: 2 staff files that were reviewed did not have current suicide training.

Correction Narrative: The Administrator sent a copy of the sign in sheets for the suicide training. The certificates were also attached and upload into CLASS Library. The operation has checklist on each staff file that will also be audited monthly.


summary: 748.1337(b)(1)(D)(ii) - Initial Service Plan-Include instructions to caregivers about level of supervision required

raw_content: 2 initial and 1 preliminary service plan did not provide a method or protocol for how supervision must be carried out.

Correction Narrative: The Administrator indicated that he has retrained the Case Manager on ensuring all areas of the service plans are details and have protocol for the supervision plan of each child. They did implement a secondary verification check on all service plans before they are filed in the children's file or sent out to the case workers.


summary: 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

raw_content: There was one staff with 10 children in care.

Correction Narrative: Interviews with the staff and children indicated that there are always 2 staff always present inside and outside of the building.  The staff had a staff meeting on 06/10/24.  At the inspection there were 2 children with 2 staff.


summary: 748.151(2) - Operational responsibilities - Operate according to your approved plans, policies, and procedures

raw_content: Agency policy requires staff not sleep during their shifts; one staff member was found sleeping on their shift.

Correction Narrative: The staff and children were interviewed regarding staff sleeping during the shifts.  The staff involved understood that this was incorrect.  There were staff meetings that was held on 06/03/24 and 06/10/24 to discuss the minimum standards and the deficiencies that were cited.


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

raw_content: Children in care and an SIR support that children were engaged in an altercation on the playground. This happened without a direct care staff being present.

Correction Narrative: RCCR inspected the operation on 06/20/2024 due to supervision concerns. The operation was proactive regarding the supervision concern and put in a plan. The staff and children were interviewed regarding supervision while the children are outside.  The children, staff and observation confirmed that there are always staff outside interacting with the children, while they are playing. There was a staff meeting that was held on 06/10/24 to reinforce the requirement.


summary: 748.4207(a)(2) - Placement Extension-if there is appropriate reason for continuing care, a child five or older may continue placement for a total of 90 days

raw_content: 3 children in care placement extension expired on 06/17/2024.

Correction Narrative: An email was received indicating that the Administrator will closely review the variance approval letters to ensure the expiration does not expire. In addition, he stated that he will print out all extensions to make sure they are not missed. The sibling group had two different variances.


summary: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

raw_content: Staff were humiliating children in care by using derogatory statements about the children and calling children names.

Correction Narrative: The staff and children were interviewed regarding using derogatory words or statements. There were staff meetings that was held on 06/03/24 and 06/10/24 to discuss the minimum standards and the deficiencies that were cited.


summary: 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply

raw_content: Children in care confirmed that a caregiver pulled a child by the arm and escorted to the child's bedroom.

Correction Narrative: The staff and children were interviewed regarding using appropriate measures to make a child comply.  The staff involved understood that this was incorrect.  There were staff meetings that was held on 06/03/24 and 06/10/24 to discuss the minimum standards and the deficiencies that were cited.


summary: 748.685(a)(5) - Caregiver responsibility - being able to intervene when necessary to ensure child's safety

raw_content: The children were not being supervised while outside on the playground and got into a fight.

Correction Narrative: The staff and children were interviewed regarding supervision while the children are outside.  The children, staff and observation confirmed that there are always staff outside interacting with the children, while they are playing.   There was a staff meeting that was held on 06/10/24 to discuss the minimum standards and the deficiencies that were cited.


summary: 748.363(6) - Personnel records- Include copy of a cleared tuberculosis screening conducted prior to the person having contact with children in care.

raw_content:
Two files that were reviewed did not have verfication of TB testing.

One file did not have a affividat notorized. 748.363(7).

One file did not have the current driver license in the file. 748.363(11)(A).

Correction Narrative: The Administrator sent over the employee's current driver's license and training on Trauma that was conducted on 02/15/24. The Administrator indicated that from now on, they will have during pre-employment they will require at the same time the drug test and TB.


summary: 748.930(b)(1)(A) - Annual Training-Caregivers in operations other than cottage homes must have 4 hrs of EBI every 6 months.

raw_content:
Two files that were reviewed one caregiver had expired EBI and the other caregiver did not have enough EBI hours.

One file had expired trauma training 748.930 (b)(2).

One file did not have transportation training documented for a driver.748.930(a)(3).

Correction Narrative: An email was received from the Administrator regarding EBI training. It was indicated that he has all staff on the same training date, however this was overlooked. There will be a training for all staff on 02/22/24 and 02/23/24 for EBI.  A copy of the sign in sheet will be sent after the training.  The trauma training certificates were sent for the staff that were expired.  The Administrator sent an email stating that all current and new employees are required to complete transportation training.


summary: 748.681(2) - Caregiver qualifications- HS diploma or GED from program recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling

raw_content: Two files that were reviewed did not have verification that the caregiver completed high school or received a GED.

Correction Narrative:
An email was received from the Administrator, indicating that ongoing they will ensure a copy of HS diploma or college transcripts are obtained.  The current working is trying to get ahold of the school for verification. He will have info regarding this by 02/23/24.

An email was received from the Administrator with a copy of the high school diploma.