Girls Haven

During a review conducted on March 14, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32.

A staff EBI SAMA training certificate was expired.

During an investigation, several children in care indicated that staff were loud with them or had yelled at them.

During an investigation, several children in care indicated they had been hit on the hand by a staff for trying to change the radio or turn the volume up. Other children in care witnesses this occurring.

During a review conducted on September 9, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan. An administrative penalty will be assessed as a result of this citation, in accordance with the Texas Human Resources Code Sec. 42.078, but the administrative penalty will be probated pending the results of any open investigations. If a penalty is assessed, the penalty amount will be $150 based on the total capacity of 32.

During the investigation, it was discovered that a caregiver fell asleep on an evening shift.

During a review conducted on March 7, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the failure of your operation?s administrator to ensure compliance include the following: -Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

A staff member at the operation was not providing adequate supervision to children in care due to the staff sleeping.

Med logs were reviewed during a heightened monitoring contracts inspection on 11/1/2023 for youth D.M. During the review of the medication log and medication, RCM observed the medication count for AM Risperidone did not correspond with medication log. According to the medication log there were 2 tablets for Risperidone remaining on the AM log; however, there was only one pill remaining.

Four of four reviewed child files were missing information regarding: (3) A description of the child?s behavior, including appropriate and maladaptive behavior, and any high-risk behavior (4) Any history of physical, sexual, or emotional abuse or neglect (5) Any history of trauma (6) Current medical and dental status, including the available results of any medical and dental examinations (7) Current substance abuse status, including available results of any psychiatric evaluation, psychological evaluation, or psychosocial assessment (9) The child?s current educational level and any school problems (15) The child?s understanding of the placement (16) A determination of whether and how you can meet the needs of the child

Four of four child records do not include whether or not a child has a chronic illness. Including a child that has asthma.

A child's record contains inconsistent information regarding the child's admission date on the ISP and 72Hr. Another child's record has conflicting information regarding the recreational and normalcy activities.

Four of four reviewed 72 hour plans do not address the following information: b) In addition, for a child receiving treatment services the preliminary service plan must include: (2) A description of the child?s immediate educational, medical, and dental needs, including possible side effects of medications or treatment prescribed to the child (3) A description of how you will meet the child?s needs, including any necessary increased supervision or follow-up actions of possible side effects of medication or treatment provided to the child (4) The identification of any issues or concerns the child may have that could escalate a child?s behavior. Identification of a child?s issues or concerns must serve to avoid the use of unnecessary emergency behavior interventions with the child. Child concerns may include issues with food, eye contact, physical touch, personal property, or certain topics

Four of four records do not document an assessment of the child's information to evaluate the appropriateness of placement.

Four of four reviewed records did not document the operation's efforts to obtain information missing in order to complete the child's record.

Four of four child's records do not address the child's specific needs for supervision.

A child's record did not document when their dental appointment was scheduled or if the child has had a dental examination within the past year.

Four of four child records did not address the known contraindications to the use of restraints.

The following information was not added to four of four reviewed records, prior to the ISP being conducted: (3) The child?s birth and neonatal history (4) The child?s developmental history (5) The child?s mental health and substance abuse history (6) The child?s school history, including the names of previous schools attended and the dates the schools were attended, grades earned, and special achievements (7) The child?s history of any other placements outside the child?s home, including the admission and discharge dates and reasons for placement (8) The child?s criminal history (9) The child?s skills and special interests

During a review conducted on September 5, 2023, it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plan for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring.

No written plan for indoor and outdoor recreation was available for review during inspection.

2016 Ford Transit 350 used to transport children in care indicated needing an oil change. Oil change was conducted/completed during inspection at the operation.

First Aid Kit was observed without adhesive tape and thermometer. Items were placed in the First Aid Kit prior to exiting the inspection.

Based on information gathered during an evaluation of the operation's records, it was found a child's record contained inaccurate documentation as related to a document in the child's record.

4 of 4 volunteers records was observed to be missing the TB screening/results.

1 of 9 employee files did not contain the pre-employment drug testing results.

During a review conducted on 2/28/2023 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plans for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High weighted citations.

During a walk thru multiple foods were expired in the pantry area.

A child in care had head lice, and the operation staff failed to provide continuous care in order to ensure the head lice was no longer present.

One child annual well-child check up record instructions included a follow up visit to be conducted in two weeks for a diagnoses of an infection. The child?s follow-up visit wasn?t conducted.

6 of 9 employee records reviewed contained employment affidavits that were not notarized. 1 of 9 employees records reviewed did not contain an employment affidavit.

One staff training records reviewed was inaccurate. A new staff member?s training records showed multiple online and in person trainings completed that exceeded the maximum amount of hours the employee worked. One of the training records reviewed date of training was incorrect.

1 of 9 staff records was observed to be missing a job description.

A review of the PLSP's record reveals the PLSP does not meet the professional requirements for the position, only meets the education requirements. The PLSP does not meet the requirement of having 1 year full time experience in residential child care operation.

The food menu did not have the month or the dates on the menu.

The food menu did not have any food substitutions listed on the menu.

The medication was prescribed on 09-06-22 and not administered/received by the operation until 09-16-22.

During a review conducted on 8/26/2022 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plans for this operation included a specific ?planned end date? at the 12-month mark by which the operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

Room 5 had mildew on the closet ceiling.

The operation's fire inspection has expired as of 03/02/2022.

During the inspection, a medication error was discovered. In the child's file reviewed, a medication error occurred in which the remaining medication count was 52. However, the medication log reflected 53.

The operation continues to be without a qualified full time Licensed Child Care Administrator. The operation's board continues efforts in the search for an Administrator.

A child fell on the return from school on 11/19/21, injuring her arm and leg, requiring medical treatment (received same day), and follow ups. The operation did not report the serious incident until 11/21/21.

During the course of interviews with children in the operation, it was found that that one staff member made comments that were demeaning and negative towards their body and weight.

The operation does not have a qualified full time Licensed Child Care Administrator.

A child in care was placed in a restraint due to staff retaliation.

A child in care was restrained because she threw a ball that hit an employee on the leg.

During the inspection, it was found that the Development Public Relation Coordinator did not have a background check submitted or cleared prior to being allowed to be present at the operation. In order to assure timely completion of background checks, it is recommended that the operation submit background checks prior to allowing employees to be present at the facility.

One child did not have a 6 month dental exam.

One child did not have a TB screening until 3 months after placement.

One child's initial service plan does not document history of high risk behaviors nor plans to address the high risk behavior.

One service plan review does not document plans to address risk of runaway for a child who has a history of running away.

Two bathrooms at the facility (R-4 and A-19) have visible water damage on the ceiling tiles.

During the inspection, 1 child did not receive prescribed medication as prescribed. The child was out of medication on 04-25-21 and was provided the nonprescription brand, until the prescription was filled on 04-30-21.