New Vision Mission, LLC

A child s medication record for a prescription medication did not match the medication count. The medication record indicated there were 44 pills remaining while the bottle only contained 12 pills.

Resolution: Corrected: 2025-03-07

A child's prescription medications were not stored in the original medication bottle. The child was discharged on 2/24/2025 from the operation, then temporarily re-admitted to the operation. During the discharge, all medication bottles were returned to the CVS worker. When the child was re-admitted, the operation staff accepted medications provided in a pill reminder box and not the original packaging.

Resolution: Corrected: 2025-03-07

During the initial inspection, while reviewing the operation's recreation documents it was discovered two children in care recreation sheets had incorrect placement dates.

Resolution: Corrected: 2025-03-07

During the initial inspection, it was discovered while reviewing the recreation binder that 6 of the 6 children currently placed in the operation does not have a daily indoor/outdoor recreational activity scheduled. The recreation binder included the month of February recreation.

Resolution: Corrected: 2025-03-07

A child's medication record for a prescription medication indicated the dosage was increased to 2 pills every night beginning on 2/12/2025. The child was only administered 2 pills on that evening. The following days from 2/12/2025 to 2/24/2025, the child was administered 1 pill despite the documented medication changes.

Resolution: Corrected: 2025-03-07

During the initial inspection, while reviewing the operation's recreation documents it was discovered two children in care recreation sheets had incorrect placement dates.

Resolution: Corrected: 2025-03-07

A child s medication record for a prescription medication did not match the medication count. The medication record indicated there were 44 pills remaining while the bottle only contained 12 pills.

Resolution: Corrected: 2025-03-07

During the initial inspection, while reviewing the operation's recreation documents it was discovered two children in care recreation sheets had incorrect placement dates.

Resolution: Corrected: 2025-03-07

A child's prescription medications were not stored in the original medication bottle. The child was discharged on 2/24/2025 from the operation, then temporarily re-admitted to the operation. During the discharge, all medication bottles were returned to the CVS worker. When the child was re-admitted, the operation staff accepted medications provided in a pill reminder box and not the original packaging.

Resolution: Corrected: 2025-03-07

A child's medication record for a prescription medication indicated the dosage was increased to 2 pills every night beginning on 2/12/2025. The child was only administered 2 pills on that evening. The following days from 2/12/2025 to 2/24/2025, the child was administered 1 pill despite the documented medication changes.

Resolution: Corrected: 2025-03-07

During the initial inspection, it was discovered while reviewing the recreation binder that 6 of the 6 children currently placed in the operation does not have a daily indoor/outdoor recreational activity scheduled. The recreation binder included the month of February recreation.

Resolution: Corrected: 2025-03-07

A child s medication record for a prescription medication did not match the medication count. The medication record indicated there were 44 pills remaining while the bottle only contained 12 pills.

Resolution: Corrected: 2025-03-07

During the initial inspection, while reviewing the operation's recreation documents it was discovered two children in care recreation sheets had incorrect placement dates.

Resolution: Corrected: 2025-03-07

A child's prescription medications were not stored in the original medication bottle. The child was discharged on 2/24/2025 from the operation, then temporarily re-admitted to the operation. During the discharge, all medication bottles were returned to the CVS worker. When the child was re-admitted, the operation staff accepted medications provided in a pill reminder box and not the original packaging.

Resolution: Corrected: 2025-03-07

A child's prescription medications were not stored in the original medication bottle. The child was discharged on 2/24/2025 from the operation, then temporarily re-admitted to the operation. During the discharge, all medication bottles were returned to the CVS worker. When the child was re-admitted, the operation staff accepted medications provided in a pill reminder box and not the original packaging.

Resolution: Corrected: 2025-03-07

A child's medication record for a prescription medication indicated the dosage was increased to 2 pills every night beginning on 2/12/2025. The child was only administered 2 pills on that evening. The following days from 2/12/2025 to 2/24/2025, the child was administered 1 pill despite the documented medication changes.

Resolution: Corrected: 2025-03-07

During the initial inspection, it was discovered while reviewing the recreation binder that 6 of the 6 children currently placed in the operation does not have a daily indoor/outdoor recreational activity scheduled. The recreation binder included the month of February recreation.

Resolution: Corrected: 2025-03-07

A child s medication record for a prescription medication did not match the medication count. The medication record indicated there were 44 pills remaining while the bottle only contained 12 pills.

Resolution: Corrected: 2025-03-07

During the initial inspection, it was discovered while reviewing the recreation binder that 6 of the 6 children currently placed in the operation does not have a daily indoor/outdoor recreational activity scheduled. The recreation binder included the month of February recreation.

Resolution: Corrected: 2025-03-07

A child's medication record for a prescription medication indicated the dosage was increased to 2 pills every night beginning on 2/12/2025. The child was only administered 2 pills on that evening. The following days from 2/12/2025 to 2/24/2025, the child was administered 1 pill despite the documented medication changes.

Resolution: Corrected: 2025-03-07

During the inspection, I observed a child in care was arrested on 2/8/25, and the operation failed to report this incident to the hotline.

Resolution: Corrected: 2025-02-19

During the inspection, I observed all fire extinguishers mounted for emergency use were due for maintenance in January 2025, All extinguishers were 12 days overdue for maintenance.

Resolution: Corrected: 2025-02-19

During the inspection, I observed all fire extinguishers mounted for emergency use were due for maintenance in January 2025, All extinguishers were 12 days overdue for maintenance.

Resolution: Corrected: 2025-02-19

During the inspection, I observed a child in care was arrested on 2/8/25, and the operation failed to report this incident to the hotline.

Resolution: Corrected: 2025-02-19

During the inspection, I observed all fire extinguishers mounted for emergency use were due for maintenance in January 2025, All extinguishers were 12 days overdue for maintenance.

Resolution: Corrected: 2025-02-19

During the inspection, I observed a child in care was arrested on 2/8/25, and the operation failed to report this incident to the hotline.

Resolution: Corrected: 2025-02-19

During the inspection, I observed all fire extinguishers mounted for emergency use were due for maintenance in January 2025, All extinguishers were 12 days overdue for maintenance.

Resolution: Corrected: 2025-02-19

During the inspection, I observed a child in care was arrested on 2/8/25, and the operation failed to report this incident to the hotline.

Resolution: Corrected: 2025-02-19

During the investigation, a staff member admitted to assisting the victim child in exiting the operation without verifying the child was under continued supervision, resulting in the child with known running behaviors leaving the grounds and running away.

Resolution: Corrected: 2025-03-26

During the investigation, a staff member admitted to assisting the victim child in exiting the operation without verifying the child was under continued supervision, resulting in the child with known running behaviors leaving the grounds and running away.

Resolution: Corrected: 2025-03-26

During the investigation, a staff member admitted to assisting the victim child in exiting the operation without verifying the child was under continued supervision, resulting in the child with known running behaviors leaving the grounds and running away.

Resolution: Corrected: 2025-03-26

During the investigation, a staff member admitted to assisting the victim child in exiting the operation without verifying the child was under continued supervision, resulting in the child with known running behaviors leaving the grounds and running away.

Resolution: Corrected: 2025-03-26

The operation failed to report the quarterly EBI data timely.

Resolution: Corrected: 2025-02-05

The operation failed to report the quarterly EBI data timely.

Resolution: Corrected: 2025-02-05

The operation failed to report the quarterly EBI data timely.

Resolution: Corrected: 2025-02-05

The operation failed to report the quarterly EBI data timely.

Resolution: Corrected: 2025-02-05

During the inspection child records were requested; however, a child service plan was requested at the beginning of the inspection, 9:30 am, however, it wasn't received until 11:45 am. Although, the child's folder was provided at the beginning of the inspection, the service plan was not included.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed did not include a TB test exam or results for a child in care.

Resolution: Corrected: 2024-12-26

During the inspection, a hole was located behind the door in the unisex shower bathroom. The operation did not have a work order for this damage.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed was missing a parent signature on the placement agreement.

Resolution: Corrected: 2024-12-26

Two of the four child records reviewed failed to indicate the reason for the placement on the Placement Agreement.

Resolution: Corrected: 2024-12-26

Four of the four records reviewed did not include documentation that invites to service plan meetings were sent to the child's parent.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed did not include a TB test exam or results for a child in care.

Resolution: Corrected: 2024-12-26

Four of the four records reviewed did not include documentation that invites to service plan meetings were sent to the child's parent.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed did not include a TB test exam or results for a child in care.

Resolution: Corrected: 2024-12-26

During the inspection, a hole was located behind the door in the unisex shower bathroom. The operation did not have a work order for this damage.

Resolution: Corrected: 2024-12-26

Two of the four child records reviewed failed to indicate the reason for the placement on the Placement Agreement.

Resolution: Corrected: 2024-12-26

Four of the four records reviewed did not include documentation that invites to service plan meetings were sent to the child's parent.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed was missing a parent signature on the placement agreement.

Resolution: Corrected: 2024-12-26

During the inspection child records were requested; however, a child service plan was requested at the beginning of the inspection, 9:30 am, however, it wasn't received until 11:45 am. Although, the child's folder was provided at the beginning of the inspection, the service plan was not included.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed was missing a parent signature on the placement agreement.

Resolution: Corrected: 2024-12-26

Two of the four child records reviewed failed to indicate the reason for the placement on the Placement Agreement.

Resolution: Corrected: 2024-12-26

During the inspection, a hole was located behind the door in the unisex shower bathroom. The operation did not have a work order for this damage.

Resolution: Corrected: 2024-12-26

During the inspection child records were requested; however, a child service plan was requested at the beginning of the inspection, 9:30 am, however, it wasn't received until 11:45 am. Although, the child's folder was provided at the beginning of the inspection, the service plan was not included.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed did not include a TB test exam or results for a child in care.

Resolution: Corrected: 2024-12-26

Four of the four records reviewed did not include documentation that invites to service plan meetings were sent to the child's parent.

Resolution: Corrected: 2024-12-26

During the inspection child records were requested; however, a child service plan was requested at the beginning of the inspection, 9:30 am, however, it wasn't received until 11:45 am. Although, the child's folder was provided at the beginning of the inspection, the service plan was not included.

Resolution: Corrected: 2024-12-26

One of the four child records reviewed was missing a parent signature on the placement agreement.

Resolution: Corrected: 2024-12-26

Two of the four child records reviewed failed to indicate the reason for the placement on the Placement Agreement.

Resolution: Corrected: 2024-12-26

During the inspection, a hole was located behind the door in the unisex shower bathroom. The operation did not have a work order for this damage.

Resolution: Corrected: 2024-12-26

In reviewing documentation, I observed a child's Initial Service Plan was completed on day 57 after admission to the operation.

Resolution: Corrected: 2025-02-07

In reviewing documentation, I observed a child's Initial Service Plan was completed on day 57 after admission to the operation.

Resolution: Corrected: 2025-02-07

In reviewing documentation, I observed a child's Initial Service Plan was completed on day 57 after admission to the operation.

Resolution: Corrected: 2025-02-07

In reviewing documentation, I observed a child's Initial Service Plan was completed on day 57 after admission to the operation.

Resolution: Corrected: 2025-02-07

Two of the four children interviewed reported that a staff member used profane language towards a child in care. Both children reported the same staff and child in their report of the incident.

Resolution: Corrected: 2025-01-28

Two of the four children interviewed reported that a staff member used profane language towards a child in care. Both children reported the same staff and child in their report of the incident.

Resolution: Corrected: 2025-01-28

Two of the four children interviewed reported that a staff member used profane language towards a child in care. Both children reported the same staff and child in their report of the incident.

Resolution: Corrected: 2025-01-28

Two of the four children interviewed reported that a staff member used profane language towards a child in care. Both children reported the same staff and child in their report of the incident.

Resolution: Corrected: 2025-01-28

During the walk-through, three of the four child medications and medication records were reviewed and indicated the pill counts were not accurate. One child s record stated 19 pills, however, the count indicated there were 18. Another child s medication record said there were 19 pills, but there were 20 pills. A third child s medication record indicated there were 44 pills and there were 46 pills.

Resolution: Corrected: 2024-11-18

During the walk-through, a closet containing several chemicals was observed unlocked and accessible to children in the laundry room.

Resolution: Corrected at inspection

While reviewing employee records, one of the four records reviewed indicated three attempts were made to contact a previous employer during the same time frame each day. Documentation in the file indicated an email would be sent to the previous employer to request a reference; however, there was no documentation that an email had been sent.

Resolution: Corrected: 2024-11-18

During the walk-through, a child was observed lying on his mattress that was located on the floor in his room.

Resolution: Corrected: 2024-11-18

During the walk-through, the freezer thermometer indicated the freezer was ten degrees Fahrenheit. The thermometer log on the outside of the freezer indicated the temperatures on several days was not in range.

Resolution: Corrected: 2024-11-18

During the walk-through, a child was observed lying on his mattress that was located on the floor in his room.

Resolution: Corrected: 2024-11-18

During the walk-through, a child was observed lying on his mattress that was located on the floor in his room.

Resolution: Corrected: 2024-11-18

During the walk-through, three of the four child medications and medication records were reviewed and indicated the pill counts were not accurate. One child s record stated 19 pills, however, the count indicated there were 18. Another child s medication record said there were 19 pills, but there were 20 pills. A third child s medication record indicated there were 44 pills and there were 46 pills.

Resolution: Corrected: 2024-11-18

During the walk-through, the freezer thermometer indicated the freezer was ten degrees Fahrenheit. The thermometer log on the outside of the freezer indicated the temperatures on several days was not in range.

Resolution: Corrected: 2024-11-18

During the walk-through, a closet containing several chemicals was observed unlocked and accessible to children in the laundry room.

Resolution: Corrected at inspection

While reviewing employee records, one of the four records reviewed indicated three attempts were made to contact a previous employer during the same time frame each day. Documentation in the file indicated an email would be sent to the previous employer to request a reference; however, there was no documentation that an email had been sent.

Resolution: Corrected: 2024-11-18

During the walk-through, three of the four child medications and medication records were reviewed and indicated the pill counts were not accurate. One child s record stated 19 pills, however, the count indicated there were 18. Another child s medication record said there were 19 pills, but there were 20 pills. A third child s medication record indicated there were 44 pills and there were 46 pills.

Resolution: Corrected: 2024-11-18

During the walk-through, a child was observed lying on his mattress that was located on the floor in his room.

Resolution: Corrected: 2024-11-18

During the walk-through, the freezer thermometer indicated the freezer was ten degrees Fahrenheit. The thermometer log on the outside of the freezer indicated the temperatures on several days was not in range.

Resolution: Corrected: 2024-11-18

During the walk-through, a closet containing several chemicals was observed unlocked and accessible to children in the laundry room.

Resolution: Corrected at inspection

While reviewing employee records, one of the four records reviewed indicated three attempts were made to contact a previous employer during the same time frame each day. Documentation in the file indicated an email would be sent to the previous employer to request a reference; however, there was no documentation that an email had been sent.

Resolution: Corrected: 2024-11-18

While reviewing employee records, one of the four records reviewed indicated three attempts were made to contact a previous employer during the same time frame each day. Documentation in the file indicated an email would be sent to the previous employer to request a reference; however, there was no documentation that an email had been sent.

Resolution: Corrected: 2024-11-18

During the walk-through, the freezer thermometer indicated the freezer was ten degrees Fahrenheit. The thermometer log on the outside of the freezer indicated the temperatures on several days was not in range.

Resolution: Corrected: 2024-11-18

During the walk-through, three of the four child medications and medication records were reviewed and indicated the pill counts were not accurate. One child s record stated 19 pills, however, the count indicated there were 18. Another child s medication record said there were 19 pills, but there were 20 pills. A third child s medication record indicated there were 44 pills and there were 46 pills.

Resolution: Corrected: 2024-11-18

During the walk-through, a closet containing several chemicals was observed unlocked and accessible to children in the laundry room.

Resolution: Corrected at inspection

Upon reviewing the children's records, it was noted that four out of five did not indicate whether the child exhibited any high-risk behaviors.

Resolution: Corrected: 2024-09-06

During the initial inspection, five child records were reviewed. One child's record had an inaccurate medication count. The record reflected the child had 13 pills, however the medication bottle had only 11 pills.

Resolution: Corrected: 2024-08-30

Out of the five child records reviewed, three did not have the necessary suicide screenings documented.

Resolution: Corrected: 2024-09-06

Upon reviewing children's records, one out of five records did not have a current medical appointment.

Resolution: Corrected: 2024-09-06

Upon reviewing the records of children, it was found that none of the five records had a preliminary service plan completed within 72 hours of placement.

Resolution: Corrected: 2024-09-06

During the initial inspection, the door to the medication closet was unlocked, making all medications (including schedule II) located inside the locked cabinet only single locked.

Resolution: Corrected: 2024-08-28

During the initial inspection, four of five child medication records were reviewed and observed to be missing name and signature of person who administered the medication.

Resolution: Corrected: 2024-08-30

During the initial inspection, child records were reviewed, and it was observed three of five children had missed doses of prescription medication. One child did not receive daily allergy medication for 4 days, another child did not receive vitamin D3 and prescription iron supplements for 4 days, and a third child was allowed to take half the dose of his prescription medication.

Resolution: Corrected: 2024-08-28

During the initial inspection, one of five child records reviewed was missing the reason medication was prescribed.

Resolution: Corrected: 2024-08-30

Upon reviewing the records of five children, it was found that none included an admission assessment.

Resolution: Corrected: 2024-09-06

The review of the fire drill revealed that there was no designated meeting place established for the drill.

Resolution: Corrected: 2024-09-06

Upon inspection of the two first aid kits, it was found that one kit lacked a guide for the emergency contents.

Resolution: Corrected at inspection

During the monitoring inspection, it was noted that three of five records reviewed were missing immunization records.

Resolution: Corrected: 2024-09-06

Upon reviewing the children's records, it was found that four out of five children did not have a tuberculosis (TB) test on file.

Resolution: Corrected: 2024-09-06

Upon reviewing children's records, one out of five records did not have a current medical appointment.

Resolution: Corrected: 2024-09-06

Upon reviewing the records of children, it was found that none of the five records had a preliminary service plan completed within 72 hours of placement.

Resolution: Corrected: 2024-09-06

During the initial inspection, five child records were reviewed. One child's record had an inaccurate medication count. The record reflected the child had 13 pills, however the medication bottle had only 11 pills.

Resolution: Corrected: 2024-08-30

During the monitoring inspection, it was noted that three of five records reviewed were missing immunization records.

Resolution: Corrected: 2024-09-06

Out of the five child records reviewed, three did not have the necessary suicide screenings documented.

Resolution: Corrected: 2024-09-06

Upon reviewing the children's records, it was noted that four out of five did not indicate whether the child exhibited any high-risk behaviors.

Resolution: Corrected: 2024-09-06

Upon reviewing the records of five children, it was found that none included an admission assessment.

Resolution: Corrected: 2024-09-06

The review of the fire drill revealed that there was no designated meeting place established for the drill.

Resolution: Corrected: 2024-09-06

During the initial inspection, four of five child medication records were reviewed and observed to be missing name and signature of person who administered the medication.

Resolution: Corrected: 2024-08-30

During the initial inspection, one of five child records reviewed was missing the reason medication was prescribed.

Resolution: Corrected: 2024-08-30

During the initial inspection, five child records were reviewed. One child's record had an inaccurate medication count. The record reflected the child had 13 pills, however the medication bottle had only 11 pills.

Resolution: Corrected: 2024-08-30

During the monitoring inspection, it was noted that three of five records reviewed were missing immunization records.

Resolution: Corrected: 2024-09-06

Out of the five child records reviewed, three did not have the necessary suicide screenings documented.

Resolution: Corrected: 2024-09-06

Upon reviewing the children's records, it was noted that four out of five did not indicate whether the child exhibited any high-risk behaviors.

Resolution: Corrected: 2024-09-06

Upon reviewing the records of five children, it was found that none included an admission assessment.

Resolution: Corrected: 2024-09-06

The review of the fire drill revealed that there was no designated meeting place established for the drill.

Resolution: Corrected: 2024-09-06

During the initial inspection, four of five child medication records were reviewed and observed to be missing name and signature of person who administered the medication.

Resolution: Corrected: 2024-08-30

Upon reviewing children's records, one out of five records did not have a current medical appointment.

Resolution: Corrected: 2024-09-06

During the initial inspection, one of five child records reviewed was missing the reason medication was prescribed.

Resolution: Corrected: 2024-08-30

Upon reviewing the records of children, it was found that none of the five records had a preliminary service plan completed within 72 hours of placement.

Resolution: Corrected: 2024-09-06

Upon reviewing the children's records, it was found that four out of five children did not have a tuberculosis (TB) test on file.

Resolution: Corrected: 2024-09-06

During the initial inspection, child records were reviewed, and it was observed three of five children had missed doses of prescription medication. One child did not receive daily allergy medication for 4 days, another child did not receive vitamin D3 and prescription iron supplements for 4 days, and a third child was allowed to take half the dose of his prescription medication.

Resolution: Corrected: 2024-08-28

Upon inspection of the two first aid kits, it was found that one kit lacked a guide for the emergency contents.

Resolution: Corrected at inspection

During the initial inspection, the door to the medication closet was unlocked, making all medications (including schedule II) located inside the locked cabinet only single locked.

Resolution: Corrected: 2024-08-28

Upon inspection of the two first aid kits, it was found that one kit lacked a guide for the emergency contents.

Resolution: Corrected at inspection

The review of the fire drill revealed that there was no designated meeting place established for the drill.

Resolution: Corrected: 2024-09-06

Upon reviewing children's records, one out of five records did not have a current medical appointment.

Resolution: Corrected: 2024-09-06

During the initial inspection, one of five child records reviewed was missing the reason medication was prescribed.

Resolution: Corrected: 2024-08-30

During the initial inspection, the door to the medication closet was unlocked, making all medications (including schedule II) located inside the locked cabinet only single locked.

Resolution: Corrected: 2024-08-28

Upon reviewing the children's records, it was found that four out of five children did not have a tuberculosis (TB) test on file.

Resolution: Corrected: 2024-09-06

During the initial inspection, child records were reviewed, and it was observed three of five children had missed doses of prescription medication. One child did not receive daily allergy medication for 4 days, another child did not receive vitamin D3 and prescription iron supplements for 4 days, and a third child was allowed to take half the dose of his prescription medication.

Resolution: Corrected: 2024-08-28

Upon reviewing the children's records, it was noted that four out of five did not indicate whether the child exhibited any high-risk behaviors.

Resolution: Corrected: 2024-09-06

During the monitoring inspection, it was noted that three of five records reviewed were missing immunization records.

Resolution: Corrected: 2024-09-06

During the initial inspection, four of five child medication records were reviewed and observed to be missing name and signature of person who administered the medication.

Resolution: Corrected: 2024-08-30

Upon reviewing the records of five children, it was found that none included an admission assessment.

Resolution: Corrected: 2024-09-06

During the initial inspection, five child records were reviewed. One child's record had an inaccurate medication count. The record reflected the child had 13 pills, however the medication bottle had only 11 pills.

Resolution: Corrected: 2024-08-30

Upon reviewing the records of children, it was found that none of the five records had a preliminary service plan completed within 72 hours of placement.

Resolution: Corrected: 2024-09-06

Out of the five child records reviewed, three did not have the necessary suicide screenings documented.

Resolution: Corrected: 2024-09-06

During the initial inspection, the door to the medication closet was unlocked, making all medications (including schedule II) located inside the locked cabinet only single locked.

Resolution: Corrected: 2024-08-28

Upon inspection of the two first aid kits, it was found that one kit lacked a guide for the emergency contents.

Resolution: Corrected at inspection

During the initial inspection, child records were reviewed, and it was observed three of five children had missed doses of prescription medication. One child did not receive daily allergy medication for 4 days, another child did not receive vitamin D3 and prescription iron supplements for 4 days, and a third child was allowed to take half the dose of his prescription medication.

Resolution: Corrected: 2024-08-28

Upon reviewing the children's records, it was found that four out of five children did not have a tuberculosis (TB) test on file.

Resolution: Corrected: 2024-09-06

One of the three records reviewed failed to document diligent efforts to contact an employment reference. The document indicates that three attempts were made dated for the same date not indicating times to verify attempts made.

Resolution: Corrected: 2024-06-13

Two of the three records reviewed failed to have reference checks completed by unrelated individuals. Both records included two reference checks completed by relatives.

Resolution: Corrected: 2024-06-13

One of the three records reviewed failed to document diligent efforts to contact an employment reference. The document indicates that three attempts were made dated for the same date not indicating times to verify attempts made.

Resolution: Corrected: 2024-06-13

Two of the three records reviewed failed to have reference checks completed by unrelated individuals. Both records included two reference checks completed by relatives.

Resolution: Corrected: 2024-06-13

One of the three records reviewed failed to document diligent efforts to contact an employment reference. The document indicates that three attempts were made dated for the same date not indicating times to verify attempts made.

Resolution: Corrected: 2024-06-13

One of the three records reviewed failed to document diligent efforts to contact an employment reference. The document indicates that three attempts were made dated for the same date not indicating times to verify attempts made.

Resolution: Corrected: 2024-06-13

Two of the three records reviewed failed to have reference checks completed by unrelated individuals. Both records included two reference checks completed by relatives.

Resolution: Corrected: 2024-06-13

Two of the three records reviewed failed to have reference checks completed by unrelated individuals. Both records included two reference checks completed by relatives.

Resolution: Corrected: 2024-06-13

The policy failed to include how the operation will explain and document to a child the way to provide voluntary comments during or after an EBI.

Resolution: Corrected: 2024-03-22

The child care policy does not indicate whether the operation admits or cares for a pregnant child.

Resolution: Corrected: 2024-03-22

The policy failed to state that the majority of members of the governing body must consist of persons who do not have a conflict of interest.

Resolution: Corrected: 2024-03-22

The EBI policy did not include that Post EBIs permitted at the operation would be viewable to children/clients and will provide them with a personal copy of EBI policies.

Resolution: Corrected: 2024-03-22

All staff folders reviewed included the name of references with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

The EBI policy did not include the qualifications for caregivers who assume the responsibility for EBI implementation.

Resolution: Corrected: 2024-03-22

Two staff folders did not have a signed and dated form indicating that an employee must immediately report any suspected incident of child abuse, neglect and exploitation to the Texas Abuse and Neglect Hotline and to the operation?s administrator or designee.

Resolution: Corrected: 2024-04-02

The child care policy does not indicate whether the operation offers any religious programs or activities, or whether children must participate.

Resolution: Corrected: 2024-03-22

The policy did not include the process for a child to make written comments after an EBI.

Resolution: Corrected: 2024-03-22

The operation does not have a formal policy regarding drug testing. The operation provided a drug and alcohol testing consent form.

Resolution: Corrected: 2024-03-22

The operation did not indicate which suicide screening tool the operation will utilize in the policy.

Resolution: Corrected: 2024-03-22

One of the four staff folders reviewed had a notarized Affidavit for Applicants for Employment, but the form did not indicate the individual?s name that the form was being notarized for. Another of the four staff folders reviewed did not have an Affidavit on file.

Resolution: Corrected: 2024-03-22

The operation requires the forms; however, they do not indicate how they will maintain the records.

Resolution: Corrected: 2024-03-22

The EBI policy states that the operation uses CPI, however, they do not include a descriptor of the curriculum for the system.

Resolution: Corrected: 2024-03-22

The policy included a flow chart that shows a straight-line declination of positions, however, it does not specify the lines of responsibility and to whom each report. The written staffing pattern doesn't indicate this information either.

Resolution: Corrected: 2024-03-22

The abuse and neglect policy does not include methods for increasing employee awareness of prevention techniques for child abuse and neglect.

Resolution: Corrected: 2024-03-22

There is a form included in the policies for the specified individuals to sign stating they will not disclose any information regarding children in care, however, the document does not include an explanation any form of explanation that the children's confidentiality is protected by law, and it is their obligation to maintain and protect that privacy.

Resolution: Corrected: 2024-03-22

The suicide policy did not indicated which screening tool the operation would be utilizing.

Resolution: Corrected: 2024-03-22

During the inspection one of the bedrooms windows had a window that was painted and did not provide natural lighting.

Resolution: Corrected: 2024-03-22

The operation created a Postvention Team, written action plan and protocols, however, they did not indicate the specific job titles of each individual included on the postvention team.

Resolution: Corrected: 2024-03-22

During the standard by standard it was observed there was no mock preliminarily service plan.

Resolution: Corrected: 2024-03-22

The mock discharge summary was missing the following information required for 1439(b)(1)(A)-(F). (1) A written discharge summary, which must include]: (A) Services provided to the child while in your care; (B) Accomplishments of the child while in your care; (C) An assessment of the child?s remaining needs (D) Recommendations about the services to meet the child?s remaining needs; (E) Support resources for the child, including telephone numbers and addresses; and (F) Aftercare plans and recommendations for the child, including medical, psychiatric, psychological, dental, educational, and social appointments

Resolution: Corrected: 2024-03-22

The tobacco products and E-Cigarettes policy prohibits the use of drugs, alcohol, and tobacco; however, it does not prohibit the possession of these products.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed did not have a statement dated and signed indicating the individual has read a copy of the operational policies.

Resolution: Corrected: 2024-04-02

During the standard by standard it was observed the mock children's file did not have an initial service plan.

Resolution: Corrected at inspection

The abuse and neglect policy did not include strategies for coordinating between the operation and appropriate community organizations.

Resolution: Corrected: 2024-03-22

There is a policy related to code of conduct, however, it does not include the parameters for entering into financial relationships or transactions.

Resolution: Corrected: 2024-03-22

During the walkthrough at the standard by standards inspection, I observed the two roaches in the administration room at the facility. One of the two roaches were alive.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed had the Pre-Employment Screening Template that indicated names of former employers with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

The policy did not include a statement indicating that restraints should be used as preventive measures and de-escalating interventions to avoid EBI.

Resolution: Corrected: 2024-03-22

The policy failed to include how the operation will explain and document to a child the way to provide voluntary comments during or after an EBI.

Resolution: Corrected: 2024-03-22

All staff folders reviewed included the name of references with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

The EBI policy did not include that Post EBIs permitted at the operation would be viewable to children/clients and will provide them with a personal copy of EBI policies.

Resolution: Corrected: 2024-03-22

Two staff folders did not have a signed and dated form indicating that an employee must immediately report any suspected incident of child abuse, neglect and exploitation to the Texas Abuse and Neglect Hotline and to the operation?s administrator or designee.

Resolution: Corrected: 2024-04-02

The child care policy does not indicate whether the operation offers any religious programs or activities, or whether children must participate.

Resolution: Corrected: 2024-03-22

The child care policy does not indicate whether the operation admits or cares for a pregnant child.

Resolution: Corrected: 2024-03-22

During the inspection one of the bedrooms windows had a window that was painted and did not provide natural lighting.

Resolution: Corrected: 2024-03-22

During the standard by standard it was observed the mock children's file did not have an initial service plan.

Resolution: Corrected at inspection

There is a policy related to code of conduct, however, it does not include the parameters for entering into financial relationships or transactions.

Resolution: Corrected: 2024-03-22

The operation created a Postvention Team, written action plan and protocols, however, they did not indicate the specific job titles of each individual included on the postvention team.

Resolution: Corrected: 2024-03-22

The operation requires the forms; however, they do not indicate how they will maintain the records.

Resolution: Corrected: 2024-03-22

The policy included a flow chart that shows a straight-line declination of positions, however, it does not specify the lines of responsibility and to whom each report. The written staffing pattern doesn't indicate this information either.

Resolution: Corrected: 2024-03-22

There is a form included in the policies for the specified individuals to sign stating they will not disclose any information regarding children in care, however, the document does not include an explanation any form of explanation that the children's confidentiality is protected by law, and it is their obligation to maintain and protect that privacy.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed had the Pre-Employment Screening Template that indicated names of former employers with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

One of the four staff folders reviewed had a notarized Affidavit for Applicants for Employment, but the form did not indicate the individual?s name that the form was being notarized for. Another of the four staff folders reviewed did not have an Affidavit on file.

Resolution: Corrected: 2024-03-22

The tobacco products and E-Cigarettes policy prohibits the use of drugs, alcohol, and tobacco; however, it does not prohibit the possession of these products.

Resolution: Corrected: 2024-03-22

The suicide policy did not indicated which screening tool the operation would be utilizing.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed did not have a statement dated and signed indicating the individual has read a copy of the operational policies.

Resolution: Corrected: 2024-04-02

The operation does not have a formal policy regarding drug testing. The operation provided a drug and alcohol testing consent form.

Resolution: Corrected: 2024-03-22

The EBI policy states that the operation uses CPI, however, they do not include a descriptor of the curriculum for the system.

Resolution: Corrected: 2024-03-22

During the standard by standard it was observed there was no mock preliminarily service plan.

Resolution: Corrected: 2024-03-22

The policy did not include the process for a child to make written comments after an EBI.

Resolution: Corrected: 2024-03-22

The abuse and neglect policy did not include strategies for coordinating between the operation and appropriate community organizations.

Resolution: Corrected: 2024-03-22

The operation did not indicate which suicide screening tool the operation will utilize in the policy.

Resolution: Corrected: 2024-03-22

The policy failed to state that the majority of members of the governing body must consist of persons who do not have a conflict of interest.

Resolution: Corrected: 2024-03-22

The mock discharge summary was missing the following information required for 1439(b)(1)(A)-(F). (1) A written discharge summary, which must include]: (A) Services provided to the child while in your care; (B) Accomplishments of the child while in your care; (C) An assessment of the child?s remaining needs (D) Recommendations about the services to meet the child?s remaining needs; (E) Support resources for the child, including telephone numbers and addresses; and (F) Aftercare plans and recommendations for the child, including medical, psychiatric, psychological, dental, educational, and social appointments

Resolution: Corrected: 2024-03-22

The abuse and neglect policy does not include methods for increasing employee awareness of prevention techniques for child abuse and neglect.

Resolution: Corrected: 2024-03-22

During the walkthrough at the standard by standards inspection, I observed the two roaches in the administration room at the facility. One of the two roaches were alive.

Resolution: Corrected: 2024-03-22

The EBI policy did not include the qualifications for caregivers who assume the responsibility for EBI implementation.

Resolution: Corrected: 2024-03-22

The policy did not include a statement indicating that restraints should be used as preventive measures and de-escalating interventions to avoid EBI.

Resolution: Corrected: 2024-03-22

There is a policy related to code of conduct, however, it does not include the parameters for entering into financial relationships or transactions.

Resolution: Corrected: 2024-03-22

The EBI policy states that the operation uses CPI, however, they do not include a descriptor of the curriculum for the system.

Resolution: Corrected: 2024-03-22

During the standard by standard it was observed the mock children's file did not have an initial service plan.

Resolution: Corrected at inspection

The suicide policy did not indicated which screening tool the operation would be utilizing.

Resolution: Corrected: 2024-03-22

The operation does not have a formal policy regarding drug testing. The operation provided a drug and alcohol testing consent form.

Resolution: Corrected: 2024-03-22

The policy failed to state that the majority of members of the governing body must consist of persons who do not have a conflict of interest.

Resolution: Corrected: 2024-03-22

The abuse and neglect policy did not include strategies for coordinating between the operation and appropriate community organizations.

Resolution: Corrected: 2024-03-22

One of the four staff folders reviewed had a notarized Affidavit for Applicants for Employment, but the form did not indicate the individual?s name that the form was being notarized for. Another of the four staff folders reviewed did not have an Affidavit on file.

Resolution: Corrected: 2024-03-22

The child care policy does not indicate whether the operation offers any religious programs or activities, or whether children must participate.

Resolution: Corrected: 2024-03-22

The EBI policy did not include the qualifications for caregivers who assume the responsibility for EBI implementation.

Resolution: Corrected: 2024-03-22

During the standard by standard it was observed there was no mock preliminarily service plan.

Resolution: Corrected: 2024-03-22

The policy failed to include how the operation will explain and document to a child the way to provide voluntary comments during or after an EBI.

Resolution: Corrected: 2024-03-22

There is a form included in the policies for the specified individuals to sign stating they will not disclose any information regarding children in care, however, the document does not include an explanation any form of explanation that the children's confidentiality is protected by law, and it is their obligation to maintain and protect that privacy.

Resolution: Corrected: 2024-03-22

The EBI policy did not include that Post EBIs permitted at the operation would be viewable to children/clients and will provide them with a personal copy of EBI policies.

Resolution: Corrected: 2024-03-22

During the walkthrough at the standard by standards inspection, I observed the two roaches in the administration room at the facility. One of the two roaches were alive.

Resolution: Corrected: 2024-03-22

All staff folders reviewed included the name of references with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

The policy did not include the process for a child to make written comments after an EBI.

Resolution: Corrected: 2024-03-22

The operation did not indicate which suicide screening tool the operation will utilize in the policy.

Resolution: Corrected: 2024-03-22

The abuse and neglect policy does not include methods for increasing employee awareness of prevention techniques for child abuse and neglect.

Resolution: Corrected: 2024-03-22

The tobacco products and E-Cigarettes policy prohibits the use of drugs, alcohol, and tobacco; however, it does not prohibit the possession of these products.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed did not have a statement dated and signed indicating the individual has read a copy of the operational policies.

Resolution: Corrected: 2024-04-02

The policy did not include a statement indicating that restraints should be used as preventive measures and de-escalating interventions to avoid EBI.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed had the Pre-Employment Screening Template that indicated names of former employers with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

The child care policy does not indicate whether the operation admits or cares for a pregnant child.

Resolution: Corrected: 2024-03-22

During the inspection one of the bedrooms windows had a window that was painted and did not provide natural lighting.

Resolution: Corrected: 2024-03-22

The operation created a Postvention Team, written action plan and protocols, however, they did not indicate the specific job titles of each individual included on the postvention team.

Resolution: Corrected: 2024-03-22

Two staff folders did not have a signed and dated form indicating that an employee must immediately report any suspected incident of child abuse, neglect and exploitation to the Texas Abuse and Neglect Hotline and to the operation?s administrator or designee.

Resolution: Corrected: 2024-04-02

The operation requires the forms; however, they do not indicate how they will maintain the records.

Resolution: Corrected: 2024-03-22

The policy included a flow chart that shows a straight-line declination of positions, however, it does not specify the lines of responsibility and to whom each report. The written staffing pattern doesn't indicate this information either.

Resolution: Corrected: 2024-03-22

The mock discharge summary was missing the following information required for 1439(b)(1)(A)-(F). (1) A written discharge summary, which must include]: (A) Services provided to the child while in your care; (B) Accomplishments of the child while in your care; (C) An assessment of the child?s remaining needs (D) Recommendations about the services to meet the child?s remaining needs; (E) Support resources for the child, including telephone numbers and addresses; and (F) Aftercare plans and recommendations for the child, including medical, psychiatric, psychological, dental, educational, and social appointments

Resolution: Corrected: 2024-03-22

There is a policy related to code of conduct, however, it does not include the parameters for entering into financial relationships or transactions.

Resolution: Corrected: 2024-03-22

The EBI policy states that the operation uses CPI, however, they do not include a descriptor of the curriculum for the system.

Resolution: Corrected: 2024-03-22

During the standard by standard it was observed the mock children's file did not have an initial service plan.

Resolution: Corrected at inspection

The suicide policy did not indicated which screening tool the operation would be utilizing.

Resolution: Corrected: 2024-03-22

The operation does not have a formal policy regarding drug testing. The operation provided a drug and alcohol testing consent form.

Resolution: Corrected: 2024-03-22

The policy failed to state that the majority of members of the governing body must consist of persons who do not have a conflict of interest.

Resolution: Corrected: 2024-03-22

The abuse and neglect policy did not include strategies for coordinating between the operation and appropriate community organizations.

Resolution: Corrected: 2024-03-22

One of the four staff folders reviewed had a notarized Affidavit for Applicants for Employment, but the form did not indicate the individual?s name that the form was being notarized for. Another of the four staff folders reviewed did not have an Affidavit on file.

Resolution: Corrected: 2024-03-22

The child care policy does not indicate whether the operation offers any religious programs or activities, or whether children must participate.

Resolution: Corrected: 2024-03-22

The EBI policy did not include the qualifications for caregivers who assume the responsibility for EBI implementation.

Resolution: Corrected: 2024-03-22

During the standard by standard it was observed there was no mock preliminarily service plan.

Resolution: Corrected: 2024-03-22

The policy failed to include how the operation will explain and document to a child the way to provide voluntary comments during or after an EBI.

Resolution: Corrected: 2024-03-22

The tobacco products and E-Cigarettes policy prohibits the use of drugs, alcohol, and tobacco; however, it does not prohibit the possession of these products.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed did not have a statement dated and signed indicating the individual has read a copy of the operational policies.

Resolution: Corrected: 2024-04-02

The policy did not include a statement indicating that restraints should be used as preventive measures and de-escalating interventions to avoid EBI.

Resolution: Corrected: 2024-03-22

Two of the four staff folders reviewed had the Pre-Employment Screening Template that indicated names of former employers with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

The child care policy does not indicate whether the operation admits or cares for a pregnant child.

Resolution: Corrected: 2024-03-22

During the inspection one of the bedrooms windows had a window that was painted and did not provide natural lighting.

Resolution: Corrected: 2024-03-22

The operation created a Postvention Team, written action plan and protocols, however, they did not indicate the specific job titles of each individual included on the postvention team.

Resolution: Corrected: 2024-03-22

Two staff folders did not have a signed and dated form indicating that an employee must immediately report any suspected incident of child abuse, neglect and exploitation to the Texas Abuse and Neglect Hotline and to the operation?s administrator or designee.

Resolution: Corrected: 2024-04-02

The operation requires the forms; however, they do not indicate how they will maintain the records.

Resolution: Corrected: 2024-03-22

The policy included a flow chart that shows a straight-line declination of positions, however, it does not specify the lines of responsibility and to whom each report. The written staffing pattern doesn't indicate this information either.

Resolution: Corrected: 2024-03-22

The mock discharge summary was missing the following information required for 1439(b)(1)(A)-(F). (1) A written discharge summary, which must include]: (A) Services provided to the child while in your care; (B) Accomplishments of the child while in your care; (C) An assessment of the child?s remaining needs (D) Recommendations about the services to meet the child?s remaining needs; (E) Support resources for the child, including telephone numbers and addresses; and (F) Aftercare plans and recommendations for the child, including medical, psychiatric, psychological, dental, educational, and social appointments

Resolution: Corrected: 2024-03-22

There is a form included in the policies for the specified individuals to sign stating they will not disclose any information regarding children in care, however, the document does not include an explanation any form of explanation that the children's confidentiality is protected by law, and it is their obligation to maintain and protect that privacy.

Resolution: Corrected: 2024-03-22

The EBI policy did not include that Post EBIs permitted at the operation would be viewable to children/clients and will provide them with a personal copy of EBI policies.

Resolution: Corrected: 2024-03-22

During the walkthrough at the standard by standards inspection, I observed the two roaches in the administration room at the facility. One of the two roaches were alive.

Resolution: Corrected: 2024-03-22

All staff folders reviewed included the name of references with their prospective telephone numbers and titles. There was no indication that these individuals have been contacted and due to no results of the contacts.

Resolution: Corrected: 2024-03-22

The policy did not include the process for a child to make written comments after an EBI.

Resolution: Corrected: 2024-03-22

The operation did not indicate which suicide screening tool the operation will utilize in the policy.

Resolution: Corrected: 2024-03-22

The abuse and neglect policy does not include methods for increasing employee awareness of prevention techniques for child abuse and neglect.

Resolution: Corrected: 2024-03-22