Redicare

it was observed during todays inspection at the facility that the health inspectiton expired on 5-10-25. The administrator confirmed it has expired and that they have scheduled for the inspection to be completed tomorrow 6-14-25.

Child CONCERTA Medication was discontinued by the doctor upon child discharge from the hospital on 5-12-25. However, the medication log for CONCERTA for 5-12 and 5-13 did not state the medication was discontinued by the doctor at the hospital.

A service plan reviewed did not list the child's Autistic disorder diagnosis.

The operation is providing services to 2 children with a diagnosis of ASD, a service not listed on their permit.

Several windows at the operation did not have screens. Note: This was corrected at inspection due to window screens recently being installed on windows.

The victim child was seen on 3/6/2025 and was prescribed Clonidine 0.1mg to take 2 tablets in the morning and 1 table in the evening. A psychiatric evaluation was completed at In Touch Psychiatry on 3/11/2025 and reports that Clonidine is to be taken twice daily, once in the morning and once in the evening. However, after the change the medication log shows that clonidine 0.1mg was still given twice in the morning and once in the evening.

The serious incident report provided did not include the required components.

The admissions assessment for the child's file reviewed did not include a signature from the professional level service provider.

The daily count on a child's medication log was observed to be inaccurate.

The employee file viewed for a direct care staff member did not have a copy of the staff's high school diploma or GED.

A bedroom window where a child in care currently resides in has been boarded up (interior) for approximately three months. There is no mechanical ventilation system.

An employee has worked with the facility since September and never received an eligible status stating that he was cleared to work at the facility.

A staff member at the facility has worked with the operation for about two months and never had a completed drug test.

Multiple children in care are not being allowed to use the phone to call caseworkers and attorneys. Multiple caseworkers are having issues getting ahold of the facility.

A staff member told a child in care they would not make it in the military due to their sexuality.

Multiple children in care reported staff sleeping on air mattress.

The child's service plan is not being followed.

I was observing the child's safety plan and noticed another child's name documented in it.

During a review of personnel records, four employees were missing proof of request for background checks.

The facility did not have a required no trespassing sign posted.

During a review of one of the child's files, a child in care was missing her signature on her child's right form.

During a review of personnel files, four employees were missing documentation of reference checks.

One out of three child files reviewed contained conflicting names with signatures on a medical consenter form. The same child file also did not include the child's signature on the service plan. A few files reviewed contained other documents in them pertaining to other individuals.

Two out of three employee files reviewed did not contain documentation of the reference and employment checks being completed.

The operation's administrator has had an expired LCCA license for almost 2 months.

Two out of three child files reviewed did not contain a copy of the child's immunization record or any documentation indicating attempts to obtain it.

One out of three employee files reviewed did not contain the required 50 hours for annual training.

One out of three employee files reviewed did not contain a copy of TB test results or a signed & notarized affidavit for employment.

One out of three employee files reviewed did not contain all required components for the pre-service training curriculum.

The fire extinguishers upstairs and downstairs were both last inspected about 14 months ago evidenced by their tags which is over the required inspection timeframe.

The operation has not entered EBI data in their provider portal for Quarter 4 of 2023.

Three out of four youth in care files reviewed did not contain an admission assessment that included the majority of the required information.

One out of four youth files reviewed referenced another youth throughout their service plan and contained wrong admission dates on different documents in the file.

One out of four youth files reviewed did not contain a discharge summary.

A caregiver didn't demonstrate prudent judgement when leaving medications unattended which resulted in a youth in care ingesting unprescribed medications.

Documentation was not completed for a medication count error.

One medication record reviewed did not include the daily count.

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

One out of four youth files reviewed did not contain a discharge summary.

One out of four youth files reviewed referenced another youth throughout their service plan and contained wrong admission dates on different documents in the file.

Two out of four youth files reviewed did not contain a suicide screening from admission.

One out of four youth files reviewed contained a preliminary service plan that was not signed by a treatment director or a PLSP.

During the inspection, there was observed a youth's nasal spray in an unlocked drawer in the kitchen.

Three out of four youth in care files reviewed did not contain an admission assessment that included the majority of the required information.

Three out of three employee files reviewed did not contain verification of suicide training being completed.

Three out of three youth medication files reviewed contained count errors versus the actual remaining count of medications administered. One out of the three files reviewed had a medication dosage documented incorrectly.

Three out of three employee files reviewed did not contain documentation of the results of the reference and employment history checks.

Two out of four youth files reviewed contained a preliminary service plan that was completed more than the required 72 hours after their admission date.

One out of four youth files reviewed did not contain documentation to show that the youth had a TB skin test.

It was determined that a signature on the medical consent form was not signed by person listed.

The medication logs reviewed are prefilled for 7am and 7pm, which is not the time that multiple residence are receiving medication. The date that a resident was given medication at 2pm is still listed as being given at 7pm.

Staff admitted to intentionally giving a child in care medication earlier than the child was supposed to receive the medication.

During review of records, it was found that 3 out of 4 records reviewed lacked documentation showing the amount of time caregivers attended transportation training.

During inspection, 3 of 4 records reviewed showed personnel with less than 50 hours of annual training.

During inspection, it was verified that the treatment directdor doesn't work 32 hours per week. The treatment doctor works an average of 20 hours a week.

Refrigerated medication was observed to be kept unlocked in the refrigerator.

Two fire extinguishers were observed to have an outdated annual inspection.

During inspection, 1 of 4 records indicated personnel's last EBI training had been completed over 6 mths ago.

There was no documentation of the smoke detectors being tested monthly.

During the inspection, it was observed that the date on the menu showed 6/06/2021 ? 6/12/2021.

The treatment director was said to only work about 20 hours per week instead of full-time hours.

During inspection, 3 of 4 records reviewed showed personnel with less than 50 hours of annual training.

During the inspection, it was discovered a staff who transports children doesn't have a valid driver's license on file.

During inspection, it was noticed that 1 of 4 personnel records has only 8 hrs of EBI training completed within a month of hire but lacks the other 8 hrs of EBI training within 90 days.

There was only one fire drill documented as completed in an annual timeframe. There was no severe weather drill documented as completed. The fire drill was indicated to be completed over the required three minutes.

During review of records, it was found that 3 out of 4 records reviewed lacked documentation showing the amount of time caregivers attended transportation training.

It was discovered during the investigation caregivers were not aware what the service plan stated for the supervision needs of the children.

It was discovered in this investigation caregivers forgot a youth alone at an event for about an hour before discovering the youth was missing.

Two staff members used inappropriate language while performing their assigned tasks.

The child/caregiver ratio is currently 1:6 for children receiving treatment services.

One out of three employee records reviewed did not include a TB skin test, a signed affidavit for employment, nor a signed acknowledgment for operational policies as well as reporting abuse/neglect.

The operation has not reported any data regarding EBI's to Licensing.

The operation's current employee list in the portal has not been validated in over three months.

Three out of three employee records reviewed did not indicate a date of employment.

The operation failed to inactivate several employees no longer associated with the operation in the portal within the required timeframe.

A youth in care was on an unauthorized absence from the operation for more than 6 hours, and it had failed to be reported to Licensing.

A youth in care was on an unauthorized absence from the operation for more than 6 hours, and it had failed to be reported to Licensing.

The child/caregiver ratio was 1:7 for children receiving treatment services which resulted in runaways from the operation.

The pantry which has food for the residence, also has cleaning supply, which should be kept seperate from food.

Medication counts were off on two different prescribed medications.

Staff file reviewed is missing the majority of the required trainings certificates or a collective sheet to indicate which trainings were taken.

A youth in care did not receive a prescribed medication for three months.

Child's file did not contain indication that an orientation was provided as no signed documentation was located in the file verifying this.

Staff file reviewed is missing education required documentation .

Staff file reviewed is missing the majority of the required trainings certificates or a collective sheet to indicate which trainings were taken.

Child records did not provide easy access to known allergies and chronic health conditions.

Daily medication log was not documented to include the remaining count.

Medication log daily log was not documented.

Child's file was missing immunizations records.

Child's file did not have signed orientation.

Staff file reviewed is missing the required trainings.

Child records did not provide easy access to known allergies and chronic health conditions.

Staff file reviewed is missing education required documentation .

Staff threaten to use corporal punishment to child in care.

Staff member used profane language to a child in care.

One out of two child files reviewed had an acknowledgement of the child's rights signed by operational staff but not the child.

Four out of five first aid kits did not contain a thermometer.

One out of three employee records reviewed did not contain a signed Affidavit for Employment.

One out of two child files reviewed did not contain an immunization record or documented attempts to obtain.

One out of three employee records reviewed did not contain verification that a drug test was completed.

Three out of five first aid kits did not contain cotton balls.

One out of three employee records reviewed did not contain verification of a TB skin test completed.

Three out of five first aid kits did not contain scissors.

The operational Admissions Assessment document does not state if the child is on medication and what medication the child is taking, if any.

Two of the staff files reviewed did not contain information to verify educational requirements for the job positions.

No policy on exempt employees for vaccine preventable diseases.

No statement indicating discipline of infants in the discipline policy.

Discharge form is missing a place to document the information of who the child is being discharged to.

Discharge form is missing a place to document that service plans were given.

Discharge form is missing the date and time child was informed.

In one record reviewed it was missing the proof of education.

Discharge form is missing a place to document for an emergency discharge/transfer.

Discharge form is missing a place to document any medical follow needed.

The current discipline policy includes EBI as a discipline measure which is prohibited discipline.