HMIH CEDAR CREST, LLC

Staff did not intervene appropriately on children who were playing a potentially dangerous game of seeing how long they could hold their hands in fire ant beds. Multiple interviews indicate staff saw what the children were doing and redirected but did not continue to redirect or prevent children from gaining access to other ant beds. Two child had serious reactions to the ant bites and had to be taken to the emergency room.

A child in care attempted suicide on 4/24/24 and this was not reported to Residential Childcare Regulation until 4/28/24.

Two out of two staff interviewed regarding ratio report ratio was not being maintained during an incident as there were more than 10 children outside with two staff. One of two children interviewed regarding ratio report ratio was not being maintained during an incident as there were more than ten children outside with two staff.

Observation logs for several children note each child was inside the unit and calm during the same time the children were involved in an altercation outside the unit. Staff who report being inside the unit were completing observation logs on children who were reported to be outside the unit. A staff who says they were outside the unit, handling the physical altercation between children documented and initialed off on a child's observation log that the child was calm and inside and the same time the child was reportedly involved in an altercation outside the unit.

Multiple staff and children in care indicated that a staff used profane language at a child in care.

A staff member admitted to threatening pulling the hair of a child in care.

During the course of interviewing children four of five indicated that staff is using derogatory language that is belittling to children in care. The children also indicated that staff curse in general.

4 out of 4 interviews noted there were only 2 staff in ratio for 24 children the morning of 2.15.24.

3 children and 3 staff have received undercooked and/or molded items served in the cafeteria.

During the walk through of Unit I 24 children were observed with 3 staff. Two children were in the hall out of the sight of staff.

During interviews with caregivers and children it was evident the operation had not maintained the required 1:5 ratio.

After reviewing the information it was determined a child rose to the level of Suicide Attempt, but did not get assessed by a medical person that falls under the definition of a Mental Health Specialist.

Through interviews of staff and children it was determined that a caregiver did not use a permitted type of emergency behavior intervention when they had their legs wrapped around a child's waist.

During the course of the investigation it was found one of the victim's and another child were in an altercation and the other child was choked. This was not reported to Licensing and was found during the investigation process.

Two children were able to gain entry into a bathroom that is supposed to remain locked and only have one child at a time in there. While in the bathroom the two children had inappropriate contact with each other.

During review of operation documentation, a nurse's note was reviewed regarding an incident where a child was hit by a staff member on 1/17/24. This was not reported by the operation until 1/20/24. The staff that witnessed the incident did not report at all.

It was observed by staff that another staff struck a child in care after that child hit that staff.

In one of the employee files reviewed, references were not documented to verify or discuss the applicant's suitability to work with or around children.

It was found two staff got into a verbal altercation waking children up in the middle of the night due to yelling and cussing.

Statements from children in care and staff members stated that the operation only had one staff member for twelve residents.

Statements provided by both children in care and staff members stated that profane language is being used and directed at children in care.

A caregiver did not demonstrate prudent judgment or self-control when they cursed around a child, made intimating comments and stood in front of a child in an intimidating way.

Throughout the course of the investigation five children and four staff interviewed stated that a staff member purposely spilled iced coffee on a child in care.

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

Two children in care were put on a safety plan that included them to remain 10ft apart at all times. It was determined that this was not implemented at all times.

While reviewing documentation it was noted that a child's psych eval was signed and dated prior to the child presenting at the operation and not the date that the evaluation occurred.

During interviews it was evident the operation had not maintained the required 1:5 ratio. Ratios documented were 4:31 with a child on 1 to 1 supervision and 2:32 with a child on 1 to 1 supervision.

There was inappropriate graffiti on multiple bathroom walls in one of the units.

A child in care had a suicide attempt on 9/30/23. This was not reported until 10/3/23.

A child in care with a history of inappropriate boundaries was able to gain access to another child's room and acted out on that child. It was during a time when the hallway was not monitored by staff.

In reviewing the Serious Incident Reports from both incidents items were found to be missing such as treating doctor, names of police officer, names of child witnesses and how to identify them, complete information of staff involved.

In Reviewing the Service Plan and Admission Assessment several required items were determined to be missing. Some of the items included Safety Plan for High Risk Behaviors, Life Skills for children, Supervision, Family Information, Manging Conservator information, and Discipline.

Information gathered during the course of the investigation determined a child was restrained in order to get them to comply in two separate incidents.

The operation has not had a severe weather drill since March 18, 2022.

Two of two child files reviewed did not have results of past dental exams that had been done. There is no documentation showing a dental exam had been completed within required time frames.

Two of two child files reviewed did not have a placement agreement.

A child in care was injected with Toradol 3 times in a 3 day span without their parent being notified they were being administered the medication. The operation noted the medication was covered by the "Consent for Emergency Medical Treatment/ Advance Directive" form, however, the medication was administered 2 days after the child initially began feeling chest pains and shortness of pain.

A staff member did not demonstrate prudent judgment when they allowed a child in care to use their personal phone to access social media platforms. Additionally the staff used social media while working. The staff brought fast food to a child in care without prior approval to do so and ignored the appearance of favoritism to one specific child in care.

Through interviews it was determined that a staff member did engage in inappropriate contact with a child in care in such a way that meets Texas Family Code and Texas Administrative Code definitions of abuse.

A child in care was not free from abuse when a staff member pulled the child to the ground by their hair.

Through interviews it was determined that appropriate ratio was not being maintained when one staff was left alone on one side of the unit with 12 children.

Through interviews it was determined five children in care were able to assault another child in care due to a lack of supervision by caregivers. The child that was assaulted sustained serious injuries.

Caregivers were unaware that a child in care, who had history of suicidal gestures, went into the restroom until the door was opened for another child. The child was found unresponsive with clothing around their neck. Additionally two children were placed on 1:1 precaution and one caregiver was observed to be watching both children, which would not meet the 1:1 criteria.

There were multiple reports that ratio was not being maintained on a day when a child was found unresponsive with clothing around their neck. It was reported there was at least one child on 1:1 supervision, leaving 4 staff to supervise the remaining 28 children.

Two children were able to engage in consensual inappropriate sexual contact with each other. One of the children was on a side of the unit they were not assigned to and was in another child's bedroom, which is not allowed. Both children had history of inappropriate boundaries and due to a lack of being appropriately supervised, they were able to engage in inappropriate behavior.

Through interviews with staff and children it was determined unit 1 was out of ratio on the day an incident between two children occurred. Multiple reports were that one staff was supervising 12 children.

It was discovered that there were only two caregivers with 14 children. This left the group out of ratio. During a second walkthrough it was found that 1 of 3 units were out of ratio. There were 24 children with 3 caregivers. Two nurses were on the unit found to be working in the nurse station at the time.

Documentation was requested in person, through phone call, and through email over multiple times throughout this investigation and two other investigations.

It was determined that two children in care were missing from the operation for about 15 minutes before staff realized they were gone. It was also determined that staff did not realize a door that was supposed to be secured was left opened and children were able to leave the building.

The log was requested 10 days after the runaway, the 5/27/2023 runs were not documented on the log.

Two children's service plans did not have any information regarding supervision requirements.

In reviewing the Serious Incident Reports, items were found to be missing; names of all staff involved and names of all witnesses (outside of children directly involved).

A child in care was restrained to keep them from going out of a fence.

Three children in care who were on restriction got out of the locked home and locked fence and ran away. None of the staff interviewed could say who was responsible for the children involved in the incident.

One of the units had 28 children on the unit. One child required 1:1 supervision. For a period of time there were 3 other staff to supervise the remaining 27 children.

There's sufficient evidence to show that staff members were on their phones while counted in ratio and supervising children.

It was observed that a caregiver restrained a child in care without an emergency situation occuring and did not attempt to de-escaltate.

It was discovered that there were only two caregivers with 14 children. This left the group out of ratio.

The operation did not maintain true and accurate records as staff training records showed staff did 6 days of orientation in 2 days or less, that staff did 40 hours of observation in one day, staff signed that they did 40 hours of observation but no form was filled out, and training documentation noted staff did CPI training on 2/27/23 but the CPI card notes the training being done on 2/28/23.

The administrator of record is not a full time employee of the operation.

It was noted there were several pillows being used by children that did not have pillow cases. The pillows had vinyl coverings that were ripped. Several beds did not have sheets.

An incident report reviewed showed an incident was documented on 5/7/23 that two children were involved in non consensual sexual activity and this was not reported to Licensing.

The operation has had a new CEO since April 2023 that would need to be added as a new controlling person. As of 5/18/23 this person still was not added as a controlling person.

Through interviews of staff and children it was determined the residential treatment center units (1, 2, and 5) are frequentlly out of ratio, with times where one staff is supervising 20 children.

By several caregiver's own admission, it was stated that administrative personnel have breached this standard by sending staff from cottage to cottage while under-staffed to create the illusion they are in ratio when Licensing personnel are on the Operation's premises.

A current staff member providing direct care services did not have an active background check. The background check was inactivated on 4.20.23.

At least 2 caregivers did not have annual trauma informed care training. Refer to TIC annual training as well, 748.930(b)(3).

Based on interviews and the staffing schedule, there were at least 3 times a unit was out of ratio due to not having enough workers in the unit.

Based on the staffing schedule and interviews, there were at least 6 times that unqualified caregivers were placed in ratio with the children.

Based on interviews and the staffing schedule, there were at least 4 occasions where staff were documented to have worked who did not actually work that unit.

At least 3 caregivers did not have their pre-service training completed for trauma informed care. Refer to pre-service normalcy training as well, 748.748.881(7).

A caregiver did not consider permitted types of emergency behavior intervention when they pushed a child to stop them from trying to fight another child. The child was pushed into another child, who fell and hit their head.

It was determined through interviews that a staff member did push a child, making the child fall and hit their head. It was determined by DFPS this meets to definition for abuse.

Through interviews of children and staff it was determined when an incident occurred on 4/4/23 the unit was not in ratio. There were 30 children on the unit and only 4 direct care staff could be confirmed to be working when the incident occurred.

Staff were not aware and accountable of a child's activities when the child was able to obtain a razor and cut themselves seriously enough to where the child required medical attention and had stitches for the injury.

A child's service plan did not have specific information about the level of supervision the child would have at the operation.

Rubbing alcohol was not stored in a way that was inaccessible to children in care. A child in care was able to obtain access to the bottle. Several children then ingested the rubbing alcohol. One of the children became sick and required medical attention.

A staff member used profane, threatening language to a child in care after a child used inappropriate language.

Staff did not demonstrate prudent judgment or self control when they threw a binder on to the ground and cornered a child for a negative comment the child made.

Through interviews of staff and children it was determined that during a physical altercation between children at least one, possibly two staff responding to the incident did not assist in intervening on the children fighting. One of the children involved sustained multiple injuries including bruising and swelling to their face.

On the morning of 3/11/23, children in care reported allegations of sexual abuse of by a caregiver. This was not reported to Licensing until 3/13/23. A report made by one of the administrative staff did not include sufficient details of the abuse to be referred to the appropriate investigative program.

During the course of the investigation it was determined a staff member encouraged children in care to show staff their private parts and requested that the children engage in inappropriate sexual activity. Additionally, the staff was observed touching themselves inappropriately.

Through interviews it was determined a staff member did not demonstrate prudent judgment when they violated professional boundaries between children in care and caregivers. Staff made promises to children in care of drugs, money, phones, jewelry, and marriage. Additionally, the staff promised to take the children out of the operation.

4 of the 4 child files reviewed did not have documentation that a vision or hearing screening was conducted.

Through interviews of children and staff it was determined a child's sweatshirt was pulled over a child's face/mouth during the course of a restraint.

Staff did not exercise prudent judgment when having children in care clean up another child's excrement as incentive for those children to be able to go on an outing.

It was determined a child in care was neglectfully supervised at the operation when they were able to obtain and ingest several different medications, that required the child to be hospitalized.

Medication was not kept inaccessible other than employees responsible for storing the medication, as a child was able to obtain 6 bottles of medication and ingested an unknown amount of medication, requiring that child to be hospitalized.

During the course of the investigation through interviews with children and staff it was determined staff members are making belittling remarks to children such as telling them to shut up, calling them bullies, saying their hair is "nappy", saying children are annoying, that children stink, and commenting that children have not "washed between their legs."

During the course of this investigation through interviews of children and staff it was determined that some staff did not demonstrate prudent judgment or self control when they got mad, yelled, and punched a wall or meal cart. Additionally, another staff member has made threatening comments to children in care which does not demonstrate prudent judgment.

In reviewing the Serious Incident Report several items were found to be missing. Names of all staff and children involved, names of all witnesses, description of the differences between the children in size, weight, mental level.

It was determined through the course of the investigation two children were in a physical altercation. During the time of separation in an attempt to de-escalate, one of the children came in where the other child was still upset and staff admitted to not intervening to ensure there would be no further altercations which allowed another altercation to occur and left one of the children with an injury.

After reviewing documentation, it was determined that this was reported after 24 hours of being injured and receiving medical care.

On multiple occasions at the operation, a staff member sexually abused a child resident who was left in this staff member's care.

4 of the 4 child files read did not contain documentation/reports of dental exams in the child's records.

4 of the 4 child files read did not contain placement agreement documentation.

During the course of the investigation, staff admitted to reaching hand down victim child's pants to retrieve bouncy ball.

During the course of the investigation, it was determined that the caregiver restrained the child for an inappropriate reason.

During the course of the investigation, it was discovered that the child was given cleaning solution by a staff member without ensuring that the child needed it or that the child was being supervised while using it. The staff member who gave the child the cleaning solution did not notify the child's supervising staff that the child was in possession of the cleaning solution.

During the course of the investigation, it was determined a Serious Incident occurred in which a child injured themselves, but was not report to the Hotline for five days.

During the review of the person's involved, it was discovered a person is currently working, but their background check has been inactive since November 2020.

During the course of the investigation, it was documented that several individuals interviewed stated that staff were on their phones constantly and not supervising correctly which might have contributed to one of the children in care being able to touch peers inappropriately.

During the course of the investigation, the children in care interviewed all stated that the staff has yelled and cursed at them or other children at the operation.

In Reviewing the Service Plans it was found that several of the requirements were not included. The child also did not sign and it is not documented if they received a copy.

In reviewing background checks for persons interviewed, it was found that a staff quit in Mid-March, but is still active as of this date.

During the course of the investigation, it was discovered that the child was on an increased supervision plan that required they have 5 minute checks. That does not appear to have occurred.