Open Hearts Children and Family Services - The Village

The operation failed to submit a correction plan or proof of corrections addressing the physical site by the compliance date.

The operation failed to submit a correction plan or proof of corrections addressing the direct care staff yelling at a child in care by the compliance date.

The operation failed to submit a correction plan or proof of corrections addressing the service planning team involvement in the development of a child's service plan by the compliance date.

During interviews it was determined the three victims discovered a wine bottle in the refrigerator, however the four staff interviewed denied being aware of the wine bottle at the location. It was noted the bottle of wine was in the refrigerator within reach of children for three days.

An opened bottle of wine was observed in a refrigerator accessible to children in care during a walkthrough of the operation's temporary location.

The operation failed to provide corrections for physical site issues that were found during an inspection.

The operation failed to provide corrections for this citation that was issued on 7/9/2024. This citation was given due to the mold being present at the operation.

The operation failed to provide corrections for this citation given on 7/9/2024. The operation's administrator has not been present and provided on-site duties.

The operation failed to provide corrections for this citation given on 7/9/2024. This is a result of medication not being stored in a locked container during the time the children were being transported to a relocation center.

The operation failed to submit proof of the repair or removal of the deep freeze unit by the compliance date.

The operation failed to submit proof of a thermometer reading 40 degrees Fahrenheit or below in the mini fridge in the kitchen by the compliance date.

The operation failed to submit evidence of thermometers being installed in all freezers and exhibiting temperatures below 0 degrees Fahrenheit by the compliance date.

The operation failed to submit corrections exhibiting completion of the repairs to the drywall in the bedroom and rec room or the securing of the bare nail in the resident wall by the compliance date.

The operation failed to submit a correction plan or proof of corrections addressing the uncovered food stored in the refrigerator and pantry by the compliance date.

Two direct care staff failed to provide adequate supervision due to them sleeping while on shift supervising children in care.

During a follow up inspection, it was found that there were still several issues with the exterior of the building. There was paint peeling off the building and siding was missing with insulation exposed. In the interior of the building the floors in the hallway and staff areas needed repair. There was paint peeling in 4 of the occupied rooms and 2 of the unoccupied rooms. Several of the screens had holes in them and needed repair. In two of the occupied rooms the drywall had cracks.

During the inspection, I observed the deep freezer in the pantry area that does not close and containes food items lacks a thermometer and internal temperature cannot be verified.

During the inspection, I observed an uncovered drink cup containing fluid in the mini-fridge and a container of animal crackers with no lid, leaving both items intended for consumption unprotected from contamination.

During the second follow-up inspection, I observed the freezer unit in the pantry area does not close properly, resulting in frost ringing the unit and the freezer not sealing properly. The freezer has food items stored within.

During the second follow-up inspection, I observed a mini-fridge in the kitchen still lacked a thermometer.

During the second follow-up inspection, I observed the damage to the drywall in the recreation room remains unrepaired, a cracking drywall patch in a bedroom remains unrepaired, and an unsecured nail in a bedroom remained. The previous resident of the room had recent self-injurious behaviors, and the room is currently occupied by a new resident without the nail being removed. These errors were not corrected from the preceding follow-up inspection.

During the first initial inspection on 5/30/2024, the operation was issued a deficiency as it was observed several bedrooms/bathrooms were not in good repair. Corrections were due on 6/10/2024. During the follow up inspection on 6/26/2024 and 7/8/2024, there were three bedrooms with chipped paint. The operation was re-cited for the deficiency.

During the initial inspection, it was discovered the child care administrator was not present. Six children were interviewed and all denied knowing who she was or having seen her. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

During the initial inspection, a caregiver was heard yelling at a child about taking clothes that didn't belong to the child. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

During the initial inspection, it was discovered that 3 of the 6 children currently enrolled, were missing a 90 day follow up suicide screening as required in Minimum Standards. During the follow up inspection completed on 7/8/2024, the three child's records still did not have a 90 day follow up suicide screening.

During the initial inspection, it was discovered the operation did not notify parents when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

During the follow up inspection, a child's service plan was reviewed for corrections from a previous deficiency, and at that time it was observed that the service plan was completed but it was developed without the service planning team's involvement. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

During the initial inspection, three of four personnel records reviewed did not have the correct CPR training to serve pediatrics/adult as required by Minimum Standards. During the follow up inspection completed on 7/8/2024, the three personnel records still did not have pediatrics/adult CPR certificates.

During the initial inspection, it was discovered the operation did not notify RCCR when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

During the initial inspection, one of the four personnel records reviewed, did not have a TB exam. During the follow up inspection completed on 7/8/2024, the personnel record still did not have a TB exam.

During the initial inspection, it was discovered the permit holder has failed to maintain compliance with Minimum Standards at all times. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

During the initial inspection, four of four personnel records reviewed, were lacking 1 hour of annual suicide prevention training. During the follow up inspection completed on 7/8/2024, the four personnel records still did not have the annual suicide prevention training.

During the initial inspection, it was observed the child care administrator has been frequently absent and did not have a licensed child care administrator designated to be responsible for the operation in their absence. Corrections were due on 7/3/2024 and at the time of the follow-up inspection on 7/8/2024, the corrections were not made. The operation was re-cited for this deficiency.

The operation's administrator and permit holder have failed to provide adequate oversight of all operation staff and supervise their job duties appropriately as they are not present at the operation full-time or available immediately to assist in an emergency situation or intervene when an incident occurs at the operation.

Between 7/3/2024 and 7/14/2024, five requests were made to obtain operation documents. The documents were not provided until 7/18/2024.

When a child's service plan has been completed, the operation's management staff does not discuss service plan requirements with direct care staff.

Operation staff failed to provide appropriate supervision for a 13-year-old child in care that was required to have line-of-sight supervision. The staff member allowed the child to play outside of the operation alone, unsupervised and also allowed the child to leave the operation without a staff member or an approved adult to supervise.

During the investigation it was learned that a non-staff member verbal threatened to physically discipline a child in care.

During the investigation, it was learned that a non-staff member was at the operation on several occasions and did not have a complete background check. This non-staff member had access to children in care.

During the course of the investigation, it was determined that a non-staff member engaged in a verbal altercation and threatened a child in care.

During the course of the investigation, it was determined that the operation failed to provide a safe environment. Staff members failed to intervene when a non-staff member engaged in a verbal altercation with a child in care.

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

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

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

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

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

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

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

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

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

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

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

During the initial inspection, it was discovered the permit holder has failed to maintain compliance with Minimum Standards at all times.

During the initial inspection, it was discovered the child care administrator was not present. Six children were interviewed and all denied knowing who she was or having seen her.

During the initial inspection, it was discovered the operation did not notify parents when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location.

During the initial inspection, it was discovered the operation did not notify RCCR when the operation was rendered unsafe or unsanitary requiring the children and staff to relocate to another location.

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

During the initial inspection, it was observed the child care administrator has been frequently absent and did not have a licensed child care administrator designated to be responsible for the operation in their absence.

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

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

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

During the initial inspection, it was discovered that 3 of the 6 children currently enrolled, were missing a 90 day follow up suicide screening as required in Minimum Standards.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

During the investigation, I discovered a resident's suicide screening record was incomplete, lacking prompted responses in three places; a serious incident report lacks documentation of the date and time the parent was notified despite interviews confirming this notification occurred; and a list of individuals approved to administer the suicide screening tool was provided including the name of a case manager unqualified to administer the tool.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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