Aspire 2 Dream

During the inspection, it was found that the operation did not have an updated fire inspection completed.

3 of 3 discharge summaries reviewed did not contain PLSP (Treatment Director) involvement in the discharge planning.

2 of 4 youth preliminary service plans were completed past the 72 hour requirement.

3 of 3 discharge summaries evaluated were observed to be missing information as required by 748.1439(b)(1)(A-F).

2 of 3 non-emergency discharge summaries were observed to have provided 2 days advance notice of planned discharge. There was no documented justification for not meeting the 4 days notice requirement.

Based on information gathered during an evaluation of two volunteer records, it was determined two out two volunteer records reviewed did not contain a statement signed and dated by the volunteer indicating the volunteer must immediately report any suspected incident of abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the operation?s administrator.

The 2nd. Quarter EBI Report has not been submitted to Child Care Regulation.

One out of the three child files reviewed showed an admission assessment that was missing information. There were a few pages that were blank with no entered information.

Three of the three child files did not have the PLSP signatures on the Admission Assessment/Preliminary Service Plan.

One child's medication logs documentation reviewed for the month of December of 2021 showed the child was not administered one of the required prescribed medications two times.

Two employees resigned approximately one month ago and the two staff still has active background checks.

One child's medication log documentation reviewed showed the child was not administered one of the required prescribed medications two times in the month of December 2021. The medication error was not documented.

The follow-up inspection conducted at the operation. the wardrobe in the front bedroom has been dismantled and removed from bedroom, and is located on the front porch away from the front door. One bedroom door is damaged and does not close, which does not allow for privacy. Another bedroom door is warped and separating. The two holes in the walls have been covered with plastic door protector. One set of blinds was observed to have broken slats.

A child complained of pain and was asked to be taken to the doctor by the staff after being punched approximately 10 times in the back of head by another child during an incident at the facility. The child was not taken to the doctor.

One child's service plan reviewed,supervision requirements addressed/ stated, at no time should the child be alone with younger children. It was founded that the child was sharing a bedroom with a younger child.

Based on interviews conducted and records reviewed, it was determined a caregiver who was in ratio, was pulled away from the group of children to the hallway by the treatment director to discuss a youth, allowing 2 youth the opportunity to runaway from the operation. At the time of the unauthorized absence of the 2 youth, there were 6 children in care (5 treatment services) with 2 caregivers assigned to ratio, as well as the office manager and administrator who were both engaged in administrative duties (not counted in ratio). The youth remained gone until the following day.

Based on interviews conducted and records reviewed, it was determined the unauthorized absence debriefing for the 2 youth was not conducted timely.

A review of the treatment plans of the 2 youth who ran away from the facility identified significant required information missing. One youth's service plan review was overdue and had not been completed. One youth's service plan review did not describe the trauma history or known triggers; identified the youth as a victim of or at risk of being victim of human trafficking, however, did not identify high risk behaviors or plans to address any; did not identify any progress/efforts made by the provider towards achieving the permanency goal; did not address transitioning to successful adulthood or life skills strengths/challenges; and describes that the youth receives 24/7 supervision.

During an inspection a wardrobe cabinet was observed to be severly damaged. Thier was blinds in one of the bedrooms that were observed to be damaged. Their were 2 holes observed in 2 different child's bedroom walls and one of the bedroom doors would not close where the hole was present.

Based on information obtained in interviews and records reviewed, it was founded that there were seven children in care at the operation, all of which were located in the t.v. room and two direct care staff present at the operation, both staff were putting away the children's medications located in the hallway of the facility. While both direct care staff were in the hallway, a fight started between two youth in the t.v. room where the children were located. Based on the layout of the facility the t.v. room can not be seen while a person is in the hallway and there is also a door located in the t.v. room.

Based on information obtained in interviews and records reviewed, there was only one staff on shift during the weekday mornings with 7 children in care, 6 of which were treatment services children.

A direct care staff with a hire date of 8/2/21, does not have an active background check.

A youth's activities were restricted for 30 days. There is no documentation in the youth's record showing approval by a PLSP nor the Treatment Director.

A child's service plan review did not document high risk behavior history of self harm and substance abuse, nor any plans to address. The service plan review did not address treatment services for emotional disorders nor any services to address substance abuse. The review plan did not include information from the recent psychological completed, did not include trauma history and triggers, did not include therapy information, nor any progress summary. The review plan did not identify/document efforts to transition to a lesser restrictive setting (plans for discharge).

After a review of the staff training records, it was found that one staff caregiver did not have the required EBI training.

Youth are being subjected to random drug testing conducted at the operation by the operation staff.

The 2nd quarter EBI report has not been submitted to Child Care Regulation.

Two of two initial plans reviewed did not include description of high risk behaviors and plans to address.

One initial service plan did not include the child's school information (grade, 504 accommodations, need for tutoring).

One initial service plan did not include the child's allergies to medication.

One intial service plan did not address conditions that require treatment services.

Two initial service plans did not include information from the child's psychological or CANS assessment.

One child record did not include chronic health condition in the electronic nor the paper file.

One initial service plan did not include plans for discharge.

One initial service plan did not incude conditions that require treatment services.

The background check validation for the operation was not submitted quarterly as required.

2 discharge files reviewed did not include a discharge summary. The child s case file did not include documentation that the child was informed of his discharge, who the child was discharged to, their contact information, and a list of the child s medications.

The operation s Professional Level Service Provider (PLSP) training record was evaluated and revealed that the PLSP did not complete pre-service training regarding emergency behavior intervention.

The operation s Treatment Director does not meet the qualifications to oversee treatment services for children with intellectual disabilities nor emotional disorders.

2 of 2 employee records were evaluated and revealed that employees have a TB skin test completed and showing a record of them being free of contagious TB.

The fire inspection for the operation was completed 14 days after the 12 month due date requirement from the last inspection. *A copy of the current fire inspection was obtained during the inspection.

The operation s Professional Level Service Provider (PLSP) training record was evaluated and revealed that the PLSP did not complete pre-service training regarding normalcy.

During the inspection, 2 initial plans were late, and 1 initial plan did not have a signature from the PLSP.

The operation s Professional Level Service Provider (PLSP) does not meet the qualifications to perform the PLSP required activities for having 7 children in care requiring more than 30% treatment services for emotional disorders.

4 employee files were evaluated and determined to not have drug test results on file prior to having access with children.