summary: Visit conducted on ___1-29-27_____. Visit covered 11 main areas/topics. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ___Waterford Country School - ITTC___________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:___1-29-27_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
NH - Supv
B G-F - Program Dir
KS - Asst. PD

List of Areas / Topics covered during visit:
•	Census - 3. Waitlist of 3. Eventually the LBC will be increased to 6.
•	The program continues to be on a provisional license.
•	There are currently (approximately) 5 open staff positions.
•	Additional staff are being recruited and trained for the program.
•	Recreational activities have been introduced. Art therapy has been offered. Equine therapy is available but the current residents are not interested. Cookie decorating was also offered.
•	The expansion of the ITTC program (male unit) may not open for approx. 2-3 months.
•	Discharge planning now includes consideration of a "Plan B" as residents are surpassing the 30 day stay.
•	It was reported that securing admission paperwork has not yet been an issue and that the clinician is insisting that all paperwork be provided before an admission can occur.
•	The common spaces, bedrooms and bathrooms were clean and free from clutter.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.

____Terri Bohara__________________________            _2-2-26________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


state: CT

facility_name: Waterford Country School, Inc. STAR / TS#145/Qhill

summary: Visit conducted on __1-29-26______. Visit covered 12 main areas/topics. Found 9 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____Waterford Country School - STTAR _______________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:__1-29-26______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
TR
BF
DM

List of Areas / Topics covered during visit:
•	Census - 5. Several residents have exceeded the length of stay.
•	A 1:1 was ordered by DCF for one of the residents who has been targeted by a couple of the residents.
•	A tour of the house. The downstairs living area was clean and organized. There are no TV's as the two TV's were broken by the residents. The front storm door is missing and there is a small hole in the existing door. There is a missing cabinet door and drawer in the kitchen.
•	The upstairs area has extensive damage.  There were holes in the sheetrock in every bedroom and extensive damage to the wall at the top of the stairs. Spindles were missing from the staircase handrail.
•	In the master bedroom closet there were at least 25 holes in the walls. The front part of the baseboard heater (in one section) was missing. There was a stain on the floor. Staff reported that attempts have been made to remove the substance but they have been unsuccessful.
•	In several rooms (bedrooms and bathrooms) switch plates and light switches were broken. In one room the outlet was protruding from the wall.
•	In JH's room there were holes in the wall, missing switch plates, stains on the floor and piles of dirty laundry.
•	A panel was missing from a door in one room.
•	Laundry is kept in baskets while dressers go underutilized.  There is nothing to distinguish clean from dirty laundry. It was suggested that drawers be labeled.
•	A smoke detector in the basement was damaged.
•	The agency has hired a separate contractor however residents now routinely damage walls to the extent that it difficult to keep up with repairs. While it was previously confined to a couple residents, there now damage inflicted by all of the residents.

Corrective Actions implemented as a result of previous visit:
•	A bathroom window in the master bathroom has been repaired.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63 Chief administrative officer.
•	Some of the spindles from the stair case hand rail are missing.
•	A smoke detector in the finished basement was broken.

Section 17a-145-73 Sleeping accommodations.
•	Every bedroom has multiple holes in the sheetrock.  The wall in the upstairs hallway had significant damage.
•	Switch plates and light switches were broken in multiple rooms.
•	Baseboard covers were missing in two rooms.
•	Floors were stained in two rooms.
•	A panel was missing from a bedroom door in one room.

Section 17a-145-76 Kitchens, equipment, food-handling.
•	A cabinet door and a kitchen drawer were missing.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
     Terri Bohara                                                 2-3-26
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

type: general

description: 63 Chief administrative officer.

description: Floors were stained in two rooms.

personnel: TR BF DM


summary: Visit conducted on __11-12-25______. Visit covered 12 main areas/topics. Found 9 compliance issues. Implemented 2 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ___WCS - STTAR___________________________________

 TIME OF VISIT (FROM - TO):       ___Afternoon__________________     DATE:__11-12-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:

Supervisor
Program Director

List of Areas / Topics covered during visit:
•	Census - 5
•	There is a lot of staff transitioning occurring due to the opening of the new programs. There may be 1 staff opening once all the staff movements have occurred. The previous program clinician has been promoted and will be the program director of the new ITTC program.
•	A review of one personnel file was conducted on 11-12-25. The employee did not yet have certifications in TCI and CPR.
•	A new dishwasher has been purchased for the house.
•	Residents were home at the time of the visit.
•	One of the living room spaces has been relocated.  There are now living room spaces on either side of the staircase.
•	A tour of the upstairs bedrooms found that there were holes in several walls. Two of the residents took responsibility for creating the holes when angry. In the double bedroom there was a hole in the main room and the closet. There was an odor in the closet from the dirty laundry.  The vanity in the bathroom had a missing panel and a cracked door. The window in the bathroom remains boarded up. The supervisor indicated that needed repairs have been reported to the maintenance department.
•	In one of the single bedrooms the switchplate for the lightswitch and the electrical outlet are missing. There was a fairly strong odor in the room from the dirty laundry observed in the basket. The youth has hygiene issues which significantly contribute to the odor. The supervisor indicated that staff attempt to assist him in addressing the issues. It was suggested to involve the nurse and  the clinician to develop protocols to involve the youth in his own self care.
•	There was a large hole in the wall of the second single bedroom which the resident admitted creating.  He indicated he was angry. He said that frequent AWOL's were to visit with his girlfriend who lives in New London and attends NL high school. He said he met her through a former resident. He said he was happy now that he obtained his PlayStation 4. He was playing on it during the visit and indicated that he was able to communicate with other game players. The supervisor indicated that the resident is inconsistent in taking his prescribed medication.
•	While the other resident was observed he would not allow staff to enter his room and held the door closed with his body. It was decided not to escalate the situation. He had appeared escalated.
•	Spokes in the handrail leading upstairs have been broken/removed. The short handrail at the landing at the top of the stairs has been damaged and is not securely attached to the wall. Only a couple of spokes remain in that section of the handrail.

Corrective Actions implemented as a result of previous visit:
•	The agency has contracted with an outside contractor to do repairs to the house.
•	The agency has requested the removal of the youth who is responsible for most of the damage. DCF denied the request due to a lack of placement options.

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-63 Chief administrative officer.
•	The handrail leading to the upstairs is missing the majority of the spokes. The upstairs section is loosely secured to the wall and missing most of the spokes.

Section 17a-145-64. Personnel policies and procedures.
•	One personnel file was reviewed on 11-12-25.
•	The file did not contain documentation of TCI (restraint) certification.
•	The file did not contain documentation of CPR certification.

Section 17a-145-73 Sleeping accommodations.
•	Three of the bedrooms had holes in the walls.
•	There was noticeable odors in two of the bedrooms from dirty laundry.

Section 17a-145-74. Lavatory
•	A panel on the sink vanity is missing and a vanity door is cracked.
•	A broken window remains boarded up.

Please submit a regulatory compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulatory compliance plan must be submitted to the attention of the undersigned at the address listed above.
     Terri Bohara                                              11-18-25
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 63 Chief administrative officer.

description: One personnel file was reviewed on 11

description: A broken window remains boarded up.

personnel:
Supervisor
Program Director


summary: Visit conducted on _8-6-25_______. Visit covered 9 main areas/topics. Found 8 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____WCS - STTAR program_________________________________

 TIME OF VISIT (FROM - TO):       __Afternoon_______________           DATE:_8-6-25_______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DM - PD
DV - Supervisor
EB - Supervisor

List of Areas / Topics covered during visit:
•	Census - 5, 1 AWOL
•	There are currently no staff openings. Three staff, plus the PD, were present at the house.
•	The newest admission was approx. 3 weeks ago.
•	Summer recreation activities have included fishing, "Dave & Buster's", 6 Flags, and movies. There is a volleyball net set up in the yard. Staff have also planted a vegetable garden which is providing produce for the house.
•	Security boxes that will allow residents to store personal items are to be installed. Staff will have access.
•	There were holes in the sheetrock in the living room and several bedrooms. One of the residents is largely responsible for the damage in the house. There is evidence that some holes were repaired. There were approx. 11 holes that were not repaired between the bedrooms and the living room.  A bedroom door panel was also cracked. One resident did not have sheets on his bed. He reportedly refuses to sleep on sheets. His mattress cover was in need of washing. Two of the windows in one of the bedrooms did not have screens however the window was not opened at the time of the visit.
•	The area around the base of the toilet in the upstairs bathroom and the tub were in need of cleaning. The window in the master bathroom remains boarded up.
•	The dishwasher is broken. The PD indicated that a new one has been purchased, and they are just waiting on it to be installed. Staff indicated that the water in the kitchen was extremely hot. The water heater was set at the "low" scald setting but the water was very hot to the touch and it was requested that they turn the setting down even more.

Corrective Actions implemented as a result of previous visit:
•	The issue of piles of laundry and odors in the room have been partially addressed. There was no obvious odors and two of the rooms show an improvement in the washing/storage of laundry.

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-68. Heating, ventilation, lighting.
•	Screens were missing from windows in an upstairs bedroom.

Section 17a-145-71 Living Room.
•	There were 4 significant holes in the wall in the living room.

Section 17a-145-73 Sleeping accommodations.
•	Three of the bedrooms had holes in the walls that were not patched.
•	The mattress had no sheets and the covering was in need of washing.
•	The panel of the bedroom door in one bedroom was cracked.

Section 17a-145-74. Lavatory facilities. Toilet articles and linens.
•	The base of the toilet in one bathroom was dirty.
•	The tubs in both bathrooms were dirty.

Please submit a regulatory compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulatory compliance plan must be submitted to the attention of the undersigned at the address listed above.
    Terri Bohara                                                8-11-25
______________________________            _________________
Regulatory Consultant                                   Date|

description: 68. Heating, ventilation, lighting.

description: The tubs in both bathrooms were dirty.

personnel:
DM - PD
DV - Supervisor
EB - Supervisor


summary: Visit conducted on _June 12, 2025____. Visit covered 15 main areas/topics. Found 4 compliance issues. Includes 1 recommendations.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: __WCS STTAR__ ________________________
 TIME OF VISIT (FROM - TO): Announced early afternoon_____DATE: _June 12, 2025____

AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
KW	CCW
NH (provided coverage while DV played in a charity basketball game)

Areas / Topics covered during visit:
•	Census - 5. There was a new admission that occurred 3 days before the visit.
•	There are no current staff openings. A new staff person was just recently hired.
•	Walk through of the house. Downstairs common areas (Kitchen and living room) were clean and free from clutter. Food in the refrigerator was dated.
•	Bedrooms were in varying degrees of cleanliness but showed improvement. The issue of accumulating dirty clothes continues but there was less clothing on the floor. A check of dressers and closets found several empty drawers and that there was ample space for the storage of the clothing. One room still had a slight odor.
•	Holes in the wall observed on a previous visit had been patched however new (unpatched) ones were observed during this visit.
•	There was a missing baseboard cover in the master bedroom.
•	One of the residents damaged his bedroom door.
•	The (non-working) tub in the master bedroom was dirty. Staff reported that residents smoke in their room and use it as an ash tray.
•	Staff have started a vegetable garden in the yard.
•	Talked with 2 residents who had no complaints about the program.  A recently arrived resident said he liked the country setting and the food. Another resident was outside washing a van.
•	It was suggested that window screens be placed in the bedroom windows so that rooms could be aired out. It was noted that there has been a long standing issue of residents destroying window screens so this may not be feasible.
•	There was a chore list posted downstairs that noted daily cleaning expectations and a weekly super clean. It was suggested that the posting contain very specific instructions as to what is expected of each resident each morning and throughout their stay.
•	An activities list was also posted.

Corrections implemented as a result of previous visit/Follow up to Previous citations:
•	Holes in the bedroom walls that were observed during a previous visit have been patched.
•	There were fewer clothing items on the floor in the bedrooms.

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73 Sleeping accommodations.
•	There were unpatched holes in the walls of some of the bedrooms.
•	An entry door is cracked.
•	The accumulation of dirty clothes and storage of clean clothes continues to be an issue.

Please submit a regulatory compliance plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulatory compliance plan must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                  6-17-25
______________________________            _________________
Terri Bohara, Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 73 Sleeping accommodations.

description: An entry door is cracked.

visit_time: Announced


summary: Visit conducted on __5-20-25______. Visit covered 10 main areas/topics. Found 9 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____WCS STTAR__________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:__5-20-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
EB - Supervisor
GD - CCW (on-call)

List of Areas / Topics covered during visit:
•	Unannounced visit.
•	Three boys home. One left during the visit for a scheduled appt.  Two at school. One of the boys at home indicated he did not go to school because his "head hurt".
•	There is one part time position open. Shifts are covered by  staff switching shifts  or calling in "on call " staff.
•	School will be ending in a couple weeks. Staff will be developing a summer schedule that involves local activities.
•	Physical plant tour.
•	There were baskets of dirty laundry in each of the bedrooms. Staff reported that there is a scheduled day to do laundry for each resident however sometimes residents are resistant to doing their laundry. There was a slight odor from the laundry and it was suggested that 2 days be assigned to address the piles and the odor. Floors in two bedrooms had a black paint like substance on them. Floors were in need of vacuuming.
•	Bathrooms in the upstairs hallway and the master bathroom had dirty sinks and tubs.  One sink had a vomit like substance in it. In the master bathroom the toilet paper holder was removed from the wall. There was a broken window which was boarded up with plywood.
•	A window in one of the bedrooms was open with no screen. A window in another bedroom had no curtain.
•	One bedroom had 5 holes in the wall. There were holes (covered) in the upstairs hallway and at the landing at the foot of the stairs. Staff reported that one resident was responsible and that the damage occurred in one occurrence.
•	Food in the refrigerator was improperly stored.  Food was not properly covered or dated.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73 Sleeping accommodations.
•	Bedrooms had baskets of dirty laundry in each of the bedrooms. Several had laundry that was piled high and had an odor.
•	Floors in the bedrooms were in need of vacuuming and cleaning. Paint stains was observed on the floors in some of the rooms.
•	A window was open with no screen. (Staff did close the window.)
•	One bedroom had 5 holes in the sheetrock.
•	One bedroom window had no curtain.

Section 17a-145-74. Lavatory facilities. Toilet articles and linens.
•	Sinks and bathtubs in both upstairs bathrooms were dirty and in need of cleaning.
•	A window in the master bathroom was broken (covered with plywood).

Section 17a-145-76. Kitchens, equipment, food-handling.
•	Food in the refrigerator was improperly stored and not dated.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
   Terri Bohara                                                 5-23-25
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 73 Sleeping accommodations.

personnel:
EB - Supervisor
GD - CCW (on-call)


raw_content:
March 6, 2025

Waterford Country School, Inc.
78 Hunts Brook Rd.; PO Box 408
Quaker Hill, CT  06375
Attn: Mr. Christopher Lacey, CEO

Re: Licensing Inspection for WCS STTAR program - Montville
Inspectors: Terri Bohara, Pat Hughes and Jim Funaro

Dear Mr. Lacey,

During February 2025 a biennial re-licensing inspection was conducted at the Waterford Country School STTAR program.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a regulatory compliance plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed below.   Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a service development plan.

Section 17a-145-64. Personnel Policies and procedures.
•	Two personnel files were reviewed.
•	 One file had no evidence of restraint training and certification.
•	One file did not have evidence of CPR certification.

Section 17a-145-86. Instructions in safety procedures. Supervision.
•	Documentation of one drill (3rd quarter/2rd shift - 2024) was not provided.

Once licensing has reviewed and accepted the regulatory compliance plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at 959-255-0614/ (860) 550-6395.

Sincerely,

Terri Bohara
_______________________________________
Terri Bohara, Regulatory Consultant

Copy: file|

report_type: unstructured


summary: Visit conducted on ____10-23-24____. Visit covered 7 main areas/topics. Found 4 compliance issues. Implemented 1 corrective actions.

raw_content:
NAME OF FACILITY / PROGRAM: ____WCS - STTAR__________________________________

 TIME OF VISIT (FROM - TO):       ___Afternoon_______________________         DATE:____10-23-24____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Supervisor (E)

List of Areas / Topics covered during visit:
•	Census - 5
•	Staff - 1 Lead CCW position is open.
•	A couple of the dining chairs have been broken. A bench is being ordered. Extra chairs are available.
•	The bed in one of the rooms was unmade, sheets were pulled off and the mattress cover was ripped. The resident was reportedly on overnight visit. Indicated that the room should be presentable (prior to youth leaving the program).  The walls in the Master bedroom had multiple scuff marks. A hole was covered with a piece of wood and there was a small indentation in the wall. This was reportedly as a result of an altercation between residents.
•	The rods for the toilet paper holders were missing in two of the bathrooms.
•	Fire Drills for 2024 were reviewed.  There were no second shift drills noted for the second and third quarter.
•	The program received approval on the day of the visit to use an upstairs room as an additional bedroom.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
Section17a-145-73. Sleeping accommodation.
•	The walls in the master bedroom were scuffed and there was a dent in the sheetrock.
•	The mattress cover on one of the beds was ripped. The resident had left the program leaving the sheets pulled off and the linens piled up.

Section 17a-145-86. Instructions in safety procedures. Supervision.
•	Second shift fire drills were not documented for the second and third quarter of 2024.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
        Terri Bohara                                                10-24-24
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 73. Sleeping accommodation.


summary: Visit conducted on ____7-31-24______. Visit covered 5 main areas/topics. Found 6 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ___Waterford Country School - STAR ________________________

 TIME OF VISIT (FROM - TO):       ___________________DATE: ____7-31-24______

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
EB	Supv
DV

List of Areas / Topics covered during visit:
•	Census - 4 (1 hospitalized) Two positions open. A per diem position was just filled.
•	Program slated to move to the former Fire St. TGH. In approx. a month.
•	Tour of physical plant. Items (Bar of soap, wash clothes, etc.) found on the shower/bathroom floor. One bedroom window was open with no screen.  One room did not have a curtain. The resident indicated that he did not like curtains and he had taken it down. He indicated he would take any covering down.  Requirements for privacy were explained and resident agreed to a covering on the bottom half of the window. In one room the bed frame (bent leg) was damaged by the resident. A drawer on the desk was damaged leaving nails exposed. Although the resident was currently not residing in the room the immediate removal of the bed and desk were requested. There was another bed and desk available in the room. In one bedroom a resident had clothing piled in the laundry basket. He noted it was clean but that he did not like to fold his laundry. Floors were in varying states of cleanliness. There was a boarded up window in the dining room.
•	Staff reported that a cook out was planned for the following weekend.  Staff reported that no cook outs have been held this year as residents had thrown the two grills around and it was unclear if the grills had sustained damage.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-45-68. Heating, ventilation, lighting.
•	A window was open with no screen.

Section 17a-145-73 Sleeping accommodations.
•	One room had a damaged bed frame and desk in the room. Damage was such that continued use presented risks to the resident.
•	Floors throughout the unit were in varying state of cleanliness.

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	Items were left on the shower and bathroom floor.

Section 17a-145-77. Dining areas and supervision.
•	A window in the dining room is broken and is boarded up.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                 8-2-24
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 68. Heating, ventilation, lighting.

personnel:
EB	Supv
DV


summary: Visit conducted on ___5-22-24_____. Visit covered 7 main areas/topics. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ___Watercord CS - STAR___________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:___5-22-24_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
KW - Lead staff
BG - clinician

List of Areas / Topics covered during visit:
•	Census - 5
•	There are two full time staff openings.  A review of a personnel file of one employee who has since left. He was employed there 4 months.  The staff had not yet completed the CPR or TCI training prior to leaving.
•	Physical plant tour. Windows in two bedrooms were boarded up (due to windows being broken). Staff reported that work orders have been submitted however maintenance is having difficulty finding replacements due to sizing issues and damage to the window frame.
•	The fire alarm was triggered the morning of the visit by a resident vaping. Staff reported that they asked for the vape pen but the resident refused to turn it over. Staff indicated that they are not allowed to forcefully take the pens away from residents. It was suggested that "No Vape pens" be added to the admission paperwork.
•	One of the residents was in his bed with no sheets. In another room a resident had no pillow case. Staff reported they are made available, but residents do not like to put them on.
•	A file review was done on one record.  There were no protocols noted for staff in how to deal with the child's enuresis. Staff reported they do address it as incidents occur.  It was suggested that a plan be developed with the nurse to help get resident on a predictable schedule prior to bedtime. The treatment plan was not signed by the social worker. It was suggested that the plan be faxed to the social worker with a request to return a signed page.
•	Common areas were clean. Bedrooms had varying degrees of organization of belongings.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
 Terri Bohara                                                        6-12-24
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

personnel:
KW - Lead staff
BG - clinician


summary: Visit conducted on ___2-14-24_____. Visit covered 7 main areas/topics. Found 4 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____WCS - STAR__________________________________

 TIME OF VISIT (FROM - TO):       ____Afternoon_____________         DATE:___2-14-24_____

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DV

List of Areas / Topics covered during visit:
•	Census - 6  One resident was AWOL. Three boys were on site.
•	One resident has been at the STAR program in excess of a year (total). His room had clothing piled about the room. He indicated that a large pile was dirty laundry. He indicated that he had access to machines to do his laundry but did not appear motivated to address it. There were no sheets on his bed or pillow case on his pillow. He said he did not like the feel of pillow cases on his face. The youth was engaged with his two phones.
•	Several of the bedrooms had piles of clothing throughout the rooms. It could not be determined if the laundry was clean or dirty.
•	Two bedrooms had broken windows. Staff reported windows have been ordered.
•	The sinks in the bathroom have been reinforced with piping along the front after residents broke several sinks by leaning on them (sinks pulled from the wall). Mold was present along the bottom of one of the shower stalls.
•	Several concerns were noted with regard to certain residents. (AWOL; contraband; extended length of stay; hygiene)

Corrective Actions implemented as a result of previous visit:
•	A toilet tank cover has been replaced.

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73 Sleeping accommodations.
•	There were broken windows in two of the bedrooms.
•	Several rooms had piles of clothing on the floor/surfaces. It could not be distinguished if it was clean or dirty.

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	There was a line of mold in one of the shower stalls.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.

_Terri Bohara             _____________________________            ___2-20-24______________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 73 Sleeping accommodations.


summary: Visit conducted on _11-16-23. Visit covered 8 main areas/topics. Found 2 compliance issues.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: _____WCS - STAR_________________________________

 TIME OF VISIT (FROM - TO):       _____Morning/Afternoon_____________ DATE: _11-16-23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
KW - CCW

List of Areas / Topics covered during visit:
•	Census - 6
•	One full time staff opening. Review of 4 personnel files however all employees have been employed for over a year or had transferred into the program. TCI training is occurring in November and December. CARE trainers just got re-certified in the new model.
•	Three residents were at the program. One had done damage at his school the day before and opted not to return on the day of visit. It was not clear if he had been suspended.  One of the residents had recently been admitted and school transportation had not been arranged.
•	Ongoing issues with one of the residents who has been a disruptive influence in the program. He has spent over a year in a STAR level of care with no viable discharge plan. There is a tentative plan for placement in a program in MA. A reloadable debit card was observed in his room. Staff reported that his mother puts money on the account which he then uses for vapes and Ubers.
•	In one room clothing was piled on the floor. There were also 2 full baskets of clothing.
•	There was a ripped screen in the window of one bedroom. This should be replaced prior to warmer weather.
•	The toilet tank cover does not fit properly. This has been noted previously.

Corrective Actions implemented as a result of previous visit: n/a

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	The tank cover being utilized does not fit correctly.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                      11-22-23
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on _____8-16-23 ________. Visit covered 9 main areas/topics. Found 4 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ___WCS - STAR ________________________________________

 TIME OF VISIT (FROM - TO):       __Morning___________________DATE: _____8-16-23 ________

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
DM
DV

List of Areas / Topics covered during visit:
•	Census - 6.  1 full time staff position open. The program recently experienced the sudden passing of a long term staff member. Staff supported each other and residents during this time.
•	A resident gave a tour of the building.
•	The resident pointed out that one of the shower stalls is not utilized. It was later confirmed that it is functional. There were dead bugs on the shower floor.  A tank cover was placed on top of the tank but did not fit correctly.
•	A bed in one room had no sheets or pillow cases. The resident stated that staff give the resident linens but he refuses to put them on his bed. Given the resident's resistance to linens it was suggested that a disinfecting protocol for the mattress be implemented.
•	One bedroom had a slight odor. Clothing was on the floor.
•	One bedroom had clothing piled on the bed. It could not be determined if the clothing was clean or dirty.
•	Discussed hierarchy within the unit and the challenges presented with new admissions.
•	Discussed challenges presented by a lack of discharge planning/options. One youth has been at the program approx. 8 months. The resident conducting the tour was unaware of his discharge plan.

Corrective Actions implemented as a result of previous visit:
•	The back deck was replaced. Additional construction on the steps and landing was continuing at the time of the visit.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73 Sleeping accommodations.
•	There were two rooms with clothing strewn about on various surfaces. One room had a slight odor.

Section 17a-145-74 Lavatory facilities. Toilet articles and linens.
•	The tank cover being utilized does not fit correctly.
•	The floor of one shower stall was dirty (dead bugs, etc.).

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

___Terri Bohara___________________________            __8-23-23_______________
Regulatory Consultant                                                          Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 73 Sleeping accommodations.

personnel: DM DV


summary: Visit conducted on ______5-31-23____________. Visit covered 6 main areas/topics. Found 5 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ________WCS - STAR Program _____________________________

 TIME OF VISIT (FROM - TO):       ____Morning/Afternoon_________DATE: ______5-31-23____________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
Dir. Of Residential Services

List of Areas / Topics covered during visit:
•	Current census is 5. One resident has been in the shelter for over a year.
•	There are currently no staff openings.
•	There are now some double rooms in the STAR program due to moving some staff to the building.
•	One bedroom had burn holes in the curtains. There were no sheets on the bed, food in the room, no screens in the windows and the desk had nail polish over the top surface. Another bedroom had open windows (no screens). Maintaining screens has been an ongoing issue as residents destroy them when leaving through the windows.
•	The toilet tank cover was missing in one bathroom stall.
•	Wood on the back deck is extremely weathered. Pieces of wood have broken away, is rotted in places and nails have "popped" out in several areas. The deck is currently utilized by the program for cookouts.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-63. Chief administrative officer.
•	The deck off of the back of the STAR program is extremely worn in spots. There are areas of cracked and broken wood as well as nails "popping out" throughout the structure.

Section 17a-245-68. Heating, ventilation, lighting.
•	Two rooms were noted to have open windows with no screens.

Section 17a-245-73. Sleeping accommodations.
•	One bedroom had no sheets on the bed and food in the room.

Section 17a-145-74. Lavatory facilities. Toilet articles and linens.
•	The toilet tank cover was missing from one toilet.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

_Terri Bohara                                 6-14-23_____________________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 63. Chief administrative officer.


raw_content:
March 15, 2023

Waterford Country School, Inc.
78 Hunts Brook Rd.; PO Box 408
Quaker Hill, CT  06375
Attn: Mr. Christopher Lacey, CEO

Re: Licensing Inspection for WCS STAR program - Waterford (Quaker Hill)
Inspectors: Terri Bohara and Keith Bryan

Dear Mr. Lacey,

During March 2023 a biennial re-licensing inspection was conducted at the Waterford Country School STAR program.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a service development plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed below.   Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a service development plan.

Section 17a-145-64. Personnel Policies and procedures.
•	Four personnel files were reviewed (2 CCW).
•	 One file had no evidence of restraint training and certification.

Section 17a-145-86. Instructions in safety procedures. Supervision.
•	Two drills did not note the presence of residents.

Section 17a- 145-94. Written treatment plan.
•	Treatment plans were not signed by residents in several records indicating involvement in the process.

Once licensing has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at 959-255-0614/ (860) 550-6395.

Sincerely,

Terri Bohara
_______________________________________
Terri Bohara, Regulatory Consultant

Copy: file|


summary: Visit conducted on __10-11-22__________. Visit covered 10 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ___WCS - STAR ______________________________________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: __10-11-22__________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
ET - COO

List of Areas / Topics covered during visit:
•	The current census is 4.
•	There is one full time child care worker and one clinician opening in the program.
•	The common areas and kitchen were clean. The unit was renovated after the fire sprinklers were engaged and did substantial water damage to the unit.
•	Bathrooms were renovated as part of the overall renovations.  Shower stalls and a separate toilet area have been upgraded.
•	Rooms were clean and well organized.
•	Staff have installed  low light night lights in the bedrooms. Residents have responded positively to the lights as some are uncomfortable at night (in new surroundings).
•	There was a discussion regarding the difficulty of getting residents to clean their rooms. The need to determine a resident's understanding of what clean means to them was discussed.
•	The kitchen in the unit was renovated including new appliances and counters. Staff are able to prepare meals on weekends and when necessary.
•	Review of treatment plan and assessment of resident KC (DOA 9-8-22). The treatment plan has not yet been signed by the resident and guardian.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
•	There were no citations   noted during this visit.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

____Terri Bohara                                  10-17-22___________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on ____8-2-22______________. Visit covered 5 main areas/topics. Found 4 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: __Waterford Country School - STAR ______________

 TIME OF VISIT (FROM - TO):       ______Morning____________________       DATE: ____8-2-22______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
DV - Supervisor

List of Areas / Topics covered during visit:
•	The STAR has returned to its former location in Cottage #1. Census is 4.
•	The building has new flooring throughout the hallways and rooms. Bathrooms and the kitchen have been renovated. New furniture was purchased for the living room area. Two residents were laying on bean bags purchased for the living room area.
•	The microwave in the kitchen was in need of cleaning. It was suggested that a cleaning schedule for the kitchen be established.
•	Overall bedrooms looked clean. One bed had no sheets but they were in a basket ready to be washed. One room had a slight odor. There are windows without screens however they have reportedly been ordered. Windows should be closed as long as there are no screens present.
•	All of the buildings have now been sided.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-64 Personnel policies and procedures.
•	Four staff do not have current CPR certification.
•	Two staff do not have current TCI (restraint) certification.

Section 17a-145 -76 Kitchens, equipment, food-handling.
•	The microwave in the kitchen needed cleaning.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                      8-15-22
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 64 Personnel policies and procedures.


summary: Visit conducted on ____5-24-22______________. Visit covered 11 main areas/topics. Found 8 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: _______ Waterford Country school - STAR _________________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: ____5-24-22______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
RG - CCW
JE     - Supervisor
MM - Clinician
JB - Dir. Of Residential Services

List of Areas / Topics covered during visit:
•	Move back to main campus is anticipated in the next couple of weeks. Renovation of the Cottage 1 building has been mostly completed. Kitchen and Bathrooms have been fully remodeled.
•	Current census is 5 with a pending admission. There are currently 2 CCW openings.
•	Physical plant tour of the Bent STAR location.
•	Two bedrooms had open windows with no screens. Clothing was left on the floor in Room 7.
•	The oven was in need of cleaning (grease on door and bottom).
•	The refrigerator/freezer had uncovered/undated food.
•	One shower stall had bars of soap and a used face cloth on the floor. A used band-aide was on the floor. Tooth-brushes were left on the counter. Shower stall was in need of cleaning.
•	Review of the Standing Orders and the MAR of one resident found no issues.
•	A switch plate cover was missing from an outlet in the living room.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-68. Heating, ventilation, lighting.
•	Windows in two of the bedrooms were open without screens.

Section 17a -145-71 Living room, lounge.
•	A switch plate cover is missing from an electrical outlet.

Section 17a-145-73 Sleeping accommodations.
•	One bedroom had clothing on the floor.

Section 17a-145-74. Lavatory facilities. Toilet articles.
•	One shower had used bars of soap and a facecloth in the shower stall.
•	A used band aide was on the floor outside the shower stall.
•	There were tooth brushes left uncovered on the counter.
•	A shower stall was in need of cleaning.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.
Terri Bohara                                                     6-6-22
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: 68. Heating, ventilation, lighting.


state: TX

facility_name: Medina Childrens Home

summary: 748.1337(b)(1)(F) - Initial Service Plan-If child is 14 years old or older, include plans for experiential life skills training

raw_content: This section is omitted in the child's initial service plan.

Category: Individual Standards Evaluated

Standard Risk Level: Medium

Corrected at Inspection: No

Correction Narrative: On 1/19/24 an email was sent by administrator stating that "moving forward will be corrected to attached modifications regarding 748.1337(b)(1)(F)." "When a child is 14 years old and older, include plans for experiential life skills raining." "We erroneously had ours marked at 16 years and older."


summary: 748.1337(b)(1)(D)(i) - Initial Service Plan-Include child's personal trauma history

raw_content: Initial service plans are missing the child's personal trauma history, child's trauma triggers, and methods to respond that will improve a child's ability to trust.

Correction Narrative: The operation has corrected this and has included it into the initial plan of service. This information was previously included the intake paperwork but will now be included in the initial plan of service. All Plans of Service moving forward with reflect this correction.


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

raw_content: Due to a lack of supervision by caregivers a child was injured while bike riding.

Standard Risk Level: High

Correction Narrative: Due to normalcy, and considering the standard that we were sited on, 748.685 (a)(4) we previously operated where our residents were able to, when appropriate, have unsupervised time riding bikes.  But due to this citation, we will no longer allow any child to be outside riding bicycles unsupervised.  All caregivers have been informed of this change.


facility_name: Pleasant Hills Children's Home

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

raw_content: During the walk through several doors were found to have holes, one was falling off the hinges, another had a door knob falling off, the ceiling in the kitchen appears to have leaks.

Correction Narrative: All repairs were made to the cottage. A walk through was completed.


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

raw_content: It was determined during the investigation that a staff member will yell at children when frustrated with the behaviors.

Standard Risk Level: Medium High


facility_name: Methodist Children's Home BCC

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: A serious incident report of alleged abuse and neglect was not reported within an appropriate time frame to licensing.

Correction Narrative:
Methodist Childrens Home has taken action to address licensing reporting standards compliance. A reminder was sent out via Microsoft Teams to all case managers and residential supervisors on 08/28/2025 addressing the following:

 MCH is required to report any injury to licensing hotline as soon as we are aware of allegations o indications of abuse, neglect, or exploitation of a child.
 All case managers and residential supervisors at the Waco Campus acknowledged receiving the reminder.

In addition, an individual meeting was held with the supervisor directly involved in this incident. During this meeting, the specific requirements of §748.303(a)(3)(A) were reviewed and discussed the importance of immediate reporting upon awareness of any allegations or indications of abuse, neglect, or exploitation.


raw_content: The purpose of this rule is to prevent harm to children due to the use of behavior management techniques that inflict physical or emotional pain or discomfort.  These prohibited methods of punishment are considered physically, psychologically and/or emotionally abusive.  Using positive methods of discipline and guidance encourage self-esteem, self-control, and self-direction.

Standard Number / Description: 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

Correction Narrative: MCH has terminated employment of Ms. Flaggs as of today (5/1/2025).  In addition, MCH had a meeting with staff and youth on the Ashcraft Unit to address the concerns to ensure they feel supported and want them to come forward with any issues/concerns immediately regarding mistreatment, abuse/neglect.  MCH management also had a meeting with staff to convey that staff are to step away from youth if there are reasons to believe behaviors are escalating and tempers are not controlled.  To further ensure the safety and well-being of the youth, the Residential Director will increase unannounced walkthroughs of the home. These walkthroughs will help monitor staff behavior and interactions, ensuring adherence to the guidelines discussed.


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: A child in care was taken to the hospital and received medical care. This was not reported within 24 hours.

Correction Narrative:
RCCR Inspector Fielteau Conducted an unannounced Inspection at the Methodist Children Home on 12/9/2024 at 1:00 pm.  Three staff members and the Program Administrator were interviewed.

The staff were aware they are required to report serious incidents to licensing within24 hours.  The Program Director stated all staff were re-educated on the procedure of reporting serious incidents to licensing. The Program Director stated staff were informed that all unscheduled visits to the hospital must be reported to licensing.

There were not any further incidents.  No Incident Reports were reviewed.

An email was received on 12/4/24 from Methodist Children's Home administration that states

"Methodist Children's Home has taken action to address licensing reporting standards compliance. A reminder was sent out via Microsoft Teams to all case managers and residential supervisors on 12/03/2024 addressing the following:
 MCH is required to report any injury to licensing hotline within 24 hours.
 All case managers and residential supervisors at the Waco Campus acknowledged receiving the reminder."


summary: 748.685(c)(1) - Caregiver responsibility - be aware of children's habits, interests, and any special needs including supervision

raw_content: A review of the Plan of Service for Dynasty stated the criteria for her supervision required the caregiver to be attentive and knowledgeable of appropriate supervision, which will not allow Dynasty to engage in inappropriate or unsafe activities. Three victims stated they engaged in inappropriate touching.

Correction Narrative:
The operation provided copy of the calendar of the scheduled all supervisors meeting and attendance that was held on 10/31/2024. The meeting discussed policy on supervision and provided the supervisors with instructions they and their staff can use to provide appropriate level of supervision for the children in care, promote safety and the ability to intervene as needed.

Three children and three staff were interviewed. The children stated they are more closely watched and supervised.  Staff stated before going on Shift, they verified the level of supervision that must be given to each child in their care.  There has not been any further incident.


raw_content: It was discovered that the incident was reported more than 24 hours after the child was provided with medical attention.

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:
The Administrator, Dorothy Philipps stated all nonscheduled medical visits including ER and Urgent care visits will be reported to the hotline in order to ensure we are meeting the 24-hour deadline required by licensing.

This information was shared in our on-call chat on 9/9 with Residential Supervisors, Case Managers, Residential Directors etc., and shared again verbally in our monthly incident review meeting on 9/16 with Residential Directors, and Program Administrator.


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

raw_content: This standard was found deficient as part of a DFPS investigation.


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

Deficiency Narrative: This standard was found deficient as part of a DFPS investigation.


summary: 748.3001(a)(2) - Sanitation Inspection-Sanitation official must conduct sanitation inspection at least once every 12 months from date of last inspection

raw_content: It was noted that the operations health inspection expired in March and has still not been completed as of this day.

Category: Safety and Emergency Practices

Corrected at Inspection: Yes


summary: 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

raw_content: It was determined a staff member has been argumentative, yelling, and instigating situations with children in care.


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

raw_content: While reviewing the document it was observed that the incident was made known to the operation on 11/26/2023 but was reported to DFPS Hotline on 11/27/2023.

Correction Narrative: All applicable standards were reviewed with on-call staff on January 3rd, 2024, and will be reviewed periodically and monitored for compliance.


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

raw_content: It was noted during the course of a DFPS medication, a child in care was given another child in care's medication in error.

Correction Narrative: The staff involved in this was placed on corrective action.  The staff was retrained in medication administration and medication errors.


summary: 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

raw_content: It was discovered during the course of the investigation that a caregiver used inappropriate and profane language in the presence of children.

Correction Narrative: The operation's Administrator indicated that they are revising the orientation with new employees to ensure it is clear what appropriate communication with children and others should be.  This will also be implemented into ongoing trainings. As an immediate response to this citation, they informed that both principal staff are no longer employed at the operation.


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

raw_content:
There was at least one time where two staff got into a verbal altercation with one another in front of the children.
A staff continuously asked children to keep secrets from other staff at the operation. The staff admitted to asking the children to keep secrets from one staff.

Correction Narrative: An email was received on 9.11.23 from the operation. All staff involved were met with regarding expectations of professionalism, prudent judgement, and self control in the presence of children. Supervisor presence in the Bowen home has increased. Children have been educated and will continued to be about secrets and the effect of them.


summary: 748.3421(3) - Poisons-Ensure poisonous/flammable material isstored in an area that is inaccessible to children unless child is capable to use responsibly.

raw_content: During the investigation it was found that drinking water had been contaminated with bleach.

Correction Narrative: All staff will continue to ensure that all poisonous/flammable materials are stored in an area that is locked and inaccessible to children as stated in minimum standard 748.3421(3). Staff will disperse according to dilution ratios and provide supervision during the use of any poisonous/flammable materials utilized for cleaning purposes. All residential supervisors have reviewed minimum standard 748.3421(3) with all staff to ensure continued best practices and safety of children in regards to use of poisonous/flammable materials.


raw_content: Two children in care had inappropriate contact while one of the children was on one on one supervision.  A staff indicated they had been looking at their cell phone some during that time.

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: In response to the deficiency and technical assistance given, the Methodist Children's Home will ensure that all staff provide effective supervision of the students at all times. The Methodist Children's Home will also ensure that all staff in each home are made aware of when an individual student is placed on a safety plan and that all staff adhere to the guidelines of the safety plan to ensure the safety and well-being of the individual student. All Residential Supervisors that directly oversee all direct care staff participated in a training on 12/8/21 that focused on the responsibilities that a caregiver has when supervising a child or children. Each Residential Supervisors will review this information with their teams within one week and will have all trainings completed by Friday, December 18, 2021. Each training will include a training sign in sheet to verify participation in the training.


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

raw_content: It was found that a child with a history of self-injury was able to obtain a razor and self-harm.

Correction Narrative: A process for checking in and out razors including the use of sign in and out sheet has been implemented by the facility. A training will be given on 10/4/2021 over this new system. A training will also be provided on 10/7/2021 for all supervisors to be made aware of how to locate children in cares significant histories in there service plans and admissions assessments. All staff will receive this training from their supervisors by 10/15/2021.


summary: 748.303(e)(6)(A) - Report to Lic. within 24hrs of awareness of arrest/indictment/criminal complaint of person under auspices of op or LE responds to alleged incident

raw_content: While reviewing documents it was determined that an incident occurred and law enforcement responded on campus to an alleged incident. The facility did not report this incident.

Correction Narrative: The agency will be providing a staff training on 9/22/2021 concerning reporting practices.


facility_name: K Star Emergency Shelter

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: The operation failed to inactivate the background check for three staff member who are no longer employed by the operation.

Correction Narrative:
RCCR Inspector received email from operation
KSTAR Quality Assurance will ensure that the Executive Director removes any terminated or resigned staff member from all systems within seven days of leaving. QA will also conduct a weekly review with the Executive Director to verify that all individuals no longer associated with the shelter have been removed.


summary: 748.3443(a)(5) - Food Preparation-Food items must be refrigerated immediately after use & after meals, if the food requires refrigeration

raw_content: A bowl of cooked bacon was observed improperly stored on the kitchen counter.


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:
A child in care was evaluated in the emergency department and subsequently
prescribed antibiotics. The attending medical provider issued a prescription sufficient to treat
both, the child who was examined and a sibling residing in the same placement, who
exhibited similar but milder symptoms and was not formally assessed during the visit. While
the provider conveyed verbal instructions regarding the administration of the medication,
written orders were neither requested nor obtained. Despite the absence of written
documentation, both children received the prescribed antibiotics.

Correction Narrative:
8/25-Email received from operation's Quality Assurance staff: K'STAR will ensure all prescription medications are given only with written orders from a licensed provider. The involved staff will be retrained by their supervisor on proper medication protocols.

8/29 In person inspection Staff responsible for maintaining medication logs and medical records verified completion of
review/retraining of medication procedures. In addition, the staff responsible for the medication administration error was
provided retraining for medication administration. Provided documentation verified retraining. In addition, medication logs
were reviewed to verify proper administration and documentation of medication administration.


summary: 748.2151(c)(4) - Medication record - must include medication name, strength and dosage

raw_content:
A review of two non-prescription medication logs indicated that several entries
were incomplete, as they did not consistently document the strength and/or dosage of the medication administered to the child(ren) in care.

Correction Narrative:
8/25-Email received from operation's Quality Assurance staff on 8/25/25: K'STAR will ensure that all OTC medication logs include the full medication name, strength (as listed on the package), and dosage given. Staff will be retrained on documentation requirements, with emphasis on recording the strength exactly as labeled (e.g., 200 mg tablet or 160 mg/5 mL). Supervisors will review logs daily to confirm completeness.

8/29 In person Follow Up Inspection Medication log pages were reviewed to ensure all required information was noted and entered. In addition, staff responsible for maintaining logs and reviewing orders was retrained to ensure compliance.


summary: 748.2203(c)(5) - Medication Error-Document the health-care professional's medical recommendations

raw_content:
Review of the medication error incident report revealed that it did not include guidance provided by Poison Control. Specifically, Poison Control advised against
administering the prescribed antibiotics following the accidental administration of Nyquil to children in care. This advisory was omitted from the documented incident report.

Correction Narrative:
8/25/25-Email received from operation's Quality Assurance staff: K'STAR will ensure that all medical recommendations provided during a medication error (including from Poison Control, a prescribing provider, or other licensed health-care professionals) are fully documented in the incident report. Staff will be retrained on proper medication error reporting procedures, and supervisors will review all incident reports for completeness before submission.

8/29 In person Inspection Medication logs were reviewed for orders as well as verifying all required information was included.
Staff was interviewed to verify a review/retraining of medication policies and procedures was completed. Going forward, all
recommendation and/or orders will be documented in the incident reports and child records.


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

raw_content: Food was observed to be expired.

Deficiency Narrative: Food was observed to be expired.


raw_content: The operation failed to inactivate a background check for a staff member who has not been employed by the operation for over a month.

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

Correction Narrative:
Immediate Corrective Actions Taken: The background check for the former staff member was inactivated immediately upon discovery. 07/18/2025
A full audit of current and past staff background check statuses has been conducted to ensure all records are up-to-date and compliant. 07/18/2025
Accountability: The Executive Director or Quality Assurance will be responsible for confirming all background check removals within the required 7-day window and documenting compliance.


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

raw_content: A staff member physically prevented a child from exiting an enclosed toy box as a form of punishment.

Correction Narrative: A training in TBRI, safe environment and appropriate punishments was conducted with all staff members.  In addition, staff were reminded they should not be complacent and should intervene if they see and/or hear staff utilizing inappropriate discipline with the children in care. The staff involved was also retrained in person and put on a safety plan. During walkthrough the toybox involved in the incident was observed to have the lid removed.


summary: 748.2307(10) - Other Prohibited Punishments-placing a child in a dark room, bathroom, or closet

raw_content: A child was locked in a bathroom by a staff member while another staff member witnessed the incident and failed to intervene.

Correction Narrative: The operation terminated the two employees related to this incident. In addition, a training in TBRI, safe environment and appropriate punishments was conducted with all staff members.  In addition, staff were reminded they should not be complacent and should intervene if they see and/or hear staff utilizing inappropriate discipline with the children in care.


summary: 748.363(8) - Personnel records - Include a Pre-Employment Affidavit for Applicants for Employment as specified in Texas Human Resources Code §42.0563

raw_content: A review of one of the records revealed that the pre-employment affidavit form was not included.

Category: Reports and Record Keeping

Correction Narrative: Email received from Administrator noted operation will ensure all employees will complete the Form 2912 Pre Employment Affidavit.


summary: 748.2151(b)(1) - Medication record - update cumulative record within 2 hours of administering medication

raw_content: While reviewing a child's medication log it was found the child was administered medication on two dates and this was not documented on the medication log.

Category: Medication

Correction Narrative: During the inspection of the medication log binder, it was confirmed that the operation created a new medication log that includes all the required information and is being utilized and updated within the specified timeframe. Two staff members were interviewed, and they verified that they were aware of the new forms and the procedures for documenting information on the forms.


summary: 748.2151(c)(3) - Medication record - must include reason medication was prescribed, for prescription medication

raw_content: Children medication logs did not provide the reason for medication being prescribed.

Correction Narrative: Operation sent updated medication form/log to include all required information. In addition, Staff will be retrained on medication policies and procedures on March 17, 2025.


summary: 748.2151(d) - Medication Record-must include accurate daily count of each prescribed medication, unless operate on a cottage home model

raw_content: Medication logs reviewed did not have an accurate cumulative daily count following medication being dispensed to child.

Correction Narrative: The operation is providing training to staff members regarding medication and the proper completion of daily medication documentation. The medication binder was reviewed, and the medication log reflected an accurate daily count of medications. Two staff members were interviewed, and they verified that they were aware of the new forms and the procedures for documenting information on the forms.


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: A serious incident involving an injury to a child in care requiring treatment from an outside healthcare provider was not reported to the hotline. Verification call was made could not be provided.

Correction Narrative: The operation is providing staff members with training on reporting and documenting serious incidents. A review of serious incident reports was conducted, and it was verified that the operation is reporting incidents to licensing as required. Two staff members were interviewed. Both were aware of the incidents that require reporting to licensing. They confirmed that the administrator staff had completed a briefing regarding the proper documentation.


summary: 748.3239(b) - Evacuation-Must practice severe weather drill at least once every 6 months from date of last severe weather drill

raw_content: The operation has not completed a severe weather drill in over a year.

Correction Narrative: Operation provided form to track and verify Severe Weather drills are being completed at least every 6 months. KSTAR will use the HHSC Emergency Practices Form 7263 to document all severe weather practices that need to be done every 6 months.


summary: 748.303(e)(5)(A) - Serious Incident-Report to Licensing within 24 hours of awareness of allegation a person under auspices of operation abused drugs in past 7 days.

raw_content: A staff member possessed and offered to use drugs with another staff member on the operation's property, this was not reported to licensing.

Correction Narrative: Operation sent compliance plan via email. Operation staff will ensure that when they are made aware of an allegation of possible drug use within the past 7 days, they will report to the hotline within 24 hours of said allegation. In addition, all staff will be informed of the Standard and the requirement to report incidents to the hotline.


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 staff member was placing children in their lap.

Correction Narrative: Staff have stated that this has been addressed in staff meetings and they are kept aware of maintaining boundaries.


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

raw_content: Staff was asleep during visit from licensing.

Correction Narrative: Staff has stated that they are encouraged to take their breaks and admin may step in when it is needed to relive staff for a break to prevent incident from occurring. Staff writte-up was provided.


summary: 748.1111(b)(1) - Child Rights contact others-Document in the child's record any reason for restricting the child's mail or telephone calls

raw_content: More than one child and staff  interviewed stated that the they are not allowed to make calls if they are short staffed.

Standard Risk Level: Medium Low

Correction Narrative:
Reviewed Response 12/3: We facilitate phone calls during the hours 4:30pm-7:15pm. M-F during the school year. If a staff member is doing their other duties, we ask the child to wait until the duties are completed with that child so that the call can be made if it is supervised. If phone privileges are taken away by the managing conservator, then we will not facilitate the call.

Inspection Follow up 12/6:Staff stated that children are receiving calls and they are allowed to make 3 calls and receive 3 calls. When calls are missed weekends are utilized.


summary: 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

raw_content: Staff did not complete EBI training within the appropriate time frame.

Category: Training and Professional Development

Correction Narrative: Reviewed response was provide on 9/25: The EBI training that was not completed withing the 90 days was due to our contracted trainer not being available during the holidays. This obviously created issues that was addressed by completely changing our training to HWC and our in house trainer so that this would not happen again.


summary: 748.563(c) - Professional level service provider-must meet specific educational and professional qualifications

raw_content: Staff responsible for professional service level activities does not have the required education.

Category: Personnel

Correction Narrative: Email Response 9/6:  We want to request a variance that will allow out shelter manager to continue to run our successful shelter while finishing her courses. We request a variance through March of 2025; this should enable the shelter manager to complete her remaining classes.


summary: 748.191(1) - Required Postings-Post the permit in a prominent and publicly accessible place where others may easily view it at all times

raw_content: Permit was not present in a public and accessible area of the operation.

Category: Organization and Administration

Correction Narrative: Email Response 9/6: Photograph of the was provided with the permit being place in a viewable location by the stairs.


summary: 748.863(a)(1) - Pre-Service Training-All caregivers must receive 8 hrs of general pre-service training & 4hrs before being counted in child/caregiver ratio.

raw_content: General Pre-service trainings are absent from the operation.

Correction Narrative: Email response 9/6: A Pre-Service training outline was provided to licensing.


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

raw_content: Operation did not have a preliminary service plan for the child.

Correction Narrative: Compliance plan received via email. KSTAR will complete the Preliminary Plan of Service within 72 hours of placement. KSTAR will create a checklist to ensure all proper documents are completed and filled out within the allotted timeframe. A copy of the folder audit form was included with the email.


raw_content: Staff admitted to inappropriate interaction between them and a child in care during the child's residency.

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

Correction Narrative: Staff confirmed to trainings and discussions regarding boundaries and fostering to be completed.


summary: 745.4151(c)(4)(C) - Mandatory drug testing-employee that is subject of child abuse or neglect investigation must be drug tested within 24 hours of notification by DFPS

raw_content: The operation did not conduct drug testing for the requested staff member within 24 hours of notification.

Correction Narrative: Staff confirmed that drug tests occur and random drug tests are implemented.


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: This standard was found deficient as part of a DFPS Investigation.

Correction Narrative: It was confirmed staff has been terminated from the agency.


summary: 748.1545(a) - Vision and hearing screening-must ensure that each child is screened; must have professional exam if problems are detected

raw_content: A child record did not have a hearing exam.

Category: Child Care

Correction Narrative: Records showed recent admissions to have the hearing and vision screening. Appointed staff confirmed they are collecting all needed information from the medical office and then a secondary check is made for anything that may have been missed.


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: A damaged picnic table was present with protruding nails. A damaged bench was present. Over grown grass was present in the playground.

Correction Narrative: All previous hards and concerns regarding the picnic table and grass were removed and cut. No other immediate hazards were present.


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: Staff file showed a TB tested conducted outside of the given time frame from the date of hire.

Correction Narrative: Staff confirmed that TB is done prior to staff starting responsibilities and staff confirmed that they are made aware of any issues or any additional steps that may be taken. Three files for TB were provided and were done within two days of hire.


summary: 748.1103(d) - Informing child of rights-Person being informed must sign statement indicating he read and understands the rights-signed copy filed in child's record

raw_content: Child Rights Signature for child in care was not present in the child record.

Category: Children's Rights

Correction Narrative: Child rights for two recent admission were reviewed and were present in the record. Staff stated that they are making packets for all new admission with required paper work and demonstrated the packet to the inspector with a checklist attached.


summary: 748.363(8) - Personnel records - Include signed dated statement by the employee that he must immediately report suspected child abuse, neglect, or exploitation.

raw_content: 1 out of 2 employee records had signed and dated statement present.

Correction Narrative:
6/29/23 Email received from operation.

6/29/23- Operation has plan in place- Mandatory agreement form is part of the new hire paperwork, and all employees will be required to read and sign the form. All current employees now have a signed copy in the employee file.


summary: 748.1331(c) - Preliminary Service Plan-Must be compatible with the information in the  admission assessment

raw_content: 4 out of 4 records showed that the preliminary service plan did not contain all the information previously gathered from the admission assessment with the new information.

Category: Admission, Service Planning, Discharge

Correction Narrative:
5/1/23 Email received from operation

5/1/23 Operation has the following plan in place "If the placing agency provides Admission Assessment information upon arrival, the information will be included in the child's preliminary service plan. If the Admission Assessment is not completed at the time of placement, K'STAR Shelter Manager will attempt to get the worker to comply. The Shelter Manager will document all efforts to get  caseworkers to complete the Admission Assessment.


summary: 748.1205(a)(7) - Admission Documentation-Includes child's immunization record

raw_content: 4 out of 4 records did not have immunization records present.

Correction Narrative:
5/1/23 Email received from operation.

5/1/23 Operation has the following plan in place "If the placing agency provides a copy of the child's immunization record, it will be placed in the child's file. This documentation is rarely if ever provided at the time of placement. K'STAR will find the child's medical immunization history on the superior website and print a copy for the file. All doctor's appointments, including immunizations, will be logged in the office visit paperwork and placed in the child's file."


summary: 748.1337(b)(1)(N) - Initial Service Plan-Include signatures of service planning team members that were involved in development of service plan

raw_content: 4 out of 4 records did not include all signatures of the required service planning team members.

Standard Risk Level: Low

Correction Narrative:
5/1/23 Email received

5/1/23 Operation as plan in place "K'STAR Administrative staff will ensure all required signatures are obtained for the child's Plan of Service. If we cannot get DFPS personnel to sign the document in a timely manner. K'STAR will document out attempts to contact DFPS personnel. We will let out Licensing Representative and contract manager know of the difficulties."


summary: 748.2953(b) - Evaluation-Operation's quarterly data on EBI's must be reported to Licensing no later than 15 days after the end of each quarter.

raw_content: Quarterly EBI was not reported after multiple notifications made to facility.

Correction Narrative: On 01/03/2023 an email received stating a generated virtual reminder will be added to the shelter manager's calendar.


raw_content: Two bunk bed rails were loose in the red and blue room. The screws were loose on multiple bunkbeds. The blue room also contained a damaged bunk bed. Two of the showers had the shower handle loose.

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

Category: Physical Site

Correction Narrative:
Screws were tightened while at the operation. Pictures were sent where bunkbed was fixed. Work orders were sent as well to comply that they will be fixed.

All bunkbeds have been thoroughly checked and all of the screws have been tightened.  The repair needed on the damaged bunk has been fixed.
The shelter manager will do random spot checks to assure all of the beds are in good repair and there are no loose screws or damage.