Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 1 High: 1 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2018 To 06/20/2018 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3684204 05/09/2018 01:00:00 05/09/2018 04:24:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2437039 05/09/2018 12:00:00 N Category Short Description Standard # Weight Discipline and Punishment Disciplinary Measures-must not be physically or emotionally damaging to the child 748.2301(b)(2) High Category Short Description Standard # Weight Children's Rights Children's rights-The right to be free from being subjected to or 748.1101(b)(4)(A)(ii) threatened with corporal punishment, including spanking or hitting TA Finding Admn Rvw Compliance Narrative: High TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3683273 05/03/2018 10:00:00 05/03/2018 02:07:10 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2442665 05/03/2018 12:00:00 N Category Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Standard # Weight High TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Monitoring Inspection 3677025 03/26/2018 09:35:00 Category Short Description Background Checks - TAC 745 Renewal background checks submitted - No later than two years from the date of your most recently requested initial or renewal background check Narrative: The background check renewal for 4 employees was not submitted in a timmely manner. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date End: Warning Letter/Due Notice given 03/26/2018 05:25:00 N Standard # Weight 745.625(b) High Page 1 of 3 TA Finding Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 1 High: 1 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2018 To 06/20/2018 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2419317 02/23/2018 12:00:00 N Category Short Description Standard # Weight Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain 748.1531(a)(2) High TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Investigation 2414651 02/08/2018 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain 748.1531(a)(2) High TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Investigation 2407314 01/11/2018 02:30:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(1)(B) neglect, and exploitation as defined in Texas Family Code 261.401 High Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment 748.2307(1) High Category Short Description Standard # Weight Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 748.507(1) Medium High TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 2 of 3 TA Finding Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 1 High: 1 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2018 To 06/20/2018 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3664324 01/10/2018 01:00:00 01/10/2018 03:54:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2405385 01/10/2018 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Children's Rights Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment. 748.1101(b)(4)(A) High Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 3 of 3 TA Finding Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3662878 12/28/2017 01:30:00 12/28/2017 03:53:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2398097 12/18/2017 12:00:00 N Category Short Description Standard # Weight Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain 748.1531(a)(2) High Short Description TA Finding Admn Rvw Compliance Narrative: Category Standard # Weight Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication Narrative: Medication was kept in a way that was accessible to residents. 748.2101(2) High Category Medication Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Child was able to get medication and go to the restroom with it. 748.685(a)(4) High Category Short Description Standard # Weight Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization 748.303(a)(2)(A) Medium High Short Description Standard # Weight 748.507(1) Medium High Personnel TA Finding Deficiency TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Waived Admn Rvw Compliance Narrative: Category Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: Staff left her personal belongings, including medication in reach of residents. TA Finding Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3655486 11/08/2017 12:15:00 11/08/2017 03:54:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 1 of 10 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Activity Type: Investigation Number Date Intake Rcvd: Investigation 2383731 11/08/2017 12:00:00 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Warning Letter/Due Notice given N Category Short Description Standard # Weight Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. High Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child 748.2307(8) Medium High TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3648662 09/28/2017 10:00:00 09/28/2017 02:01:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2360017 09/28/2017 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. High Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child 748.2307(8) Medium High TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3648338 09/27/2017 12:30:00 09/27/2017 02:15:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 2 of 10 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3646383 09/15/2017 11:10:00 09/15/2017 01:54:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2329652 08/08/2017 12:40:00 N Category Short Description Standard # Weight Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 748.507(1) Medium High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(1)(B) neglect, and exploitation as defined in Texas Family Code 261.401 TA Finding Admn Rvw Compliance Narrative: TA Finding High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3639916 08/07/2017 10:40:00 08/07/2017 02:03:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2355832 08/07/2017 12:00:00 N Category Short Description Standard # Weight Children's Rights Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family 748.1101(b)(4)(A)(v) Medium High Category Short Description Standard # Weight Emergency Behavior Intervention Emergency Behavior Intervention-Never used as punishment 748.2463(1) Medium High Category Short Description Standard # Weight Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding High Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 3 of 10 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2356331 08/07/2017 12:00:00 N Category Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Standard # Weight TA Finding High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3639400 08/02/2017 01:00:00 08/02/2017 02:36:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3638495 07/27/2017 01:00:00 07/27/2017 04:59:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3638401 07/27/2017 08:15:00 07/27/2017 01:22:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2354448 07/21/2017 12:10:00 N Category Short Description Standard # Weight Emergency Behavior Intervention-Never used as a means to get a child to comply Narrative: This standard was evaluated and deemed complaint. 748.2463(3) Medium High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: This standard was evaluated and deemed complaint. 748.2551(a) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention EBI Release-Child released from personal restraint as soon as child 748.2553(2)(C) is not a danger to self or others Narrative: This standard was evaluated and deemed complaint. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium High Page 4 of 10 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Category Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and deemed complaint. 748.2551(c)(1) High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and deemed complaint. 748.2551(c)(1) High Category Standard # Weight Emergency Behavior Intervention Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(1)(B) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and deemed complaint. High Category Short Description Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and deemed complaint. 748.2307(1) High Category Discipline and Punishment Short Description Standard # Weight Disciplinary Measures-must not be physically or emotionally damaging to the child Narrative: This standard was evaluated and deemed complaint. 748.2301(b)(2) High Category Standard # Weight Discipline and Punishment Short Description Emergency Behavior Intervention Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and deemed complaint. High Category Standard # Weight 748.2851(b) Medium Short Description Emergency Behavior Intervention EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and deemed complaint. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 5 of 10 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Category Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing Narrative: This standard was evaluated and deemed complaint. Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight 748.2461(b)(3) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3635904 07/13/2017 09:40:00 07/13/2017 11:56:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2349395 07/13/2017 12:00:00 N Category Short Description Standard # Weight Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain 748.1531(a)(2) High TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Investigation 2347712 06/22/2017 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: This standard was evaluated and found to be in compliance. 748.303(a)(2)(A) Medium High Category Standard # Weight 748.1531(a)(2) High Reports and Record Keeping Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3626260 05/18/2017 09:00:00 05/18/2017 01:02:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 6 of 10 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Investigation Medium High: 2 Run date: June 25, 2018 Compliance History Report Medium: 1 2339651 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 05/18/2017 12:00:00 N Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High Short Description Standard # Weight 748.683(2) Medium TA Finding Admn Rvw Compliance Narrative: Category Personnel Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately Narrative: A staff member was designated to be awake throughout the night was asleep. TA Finding Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2331580 05/08/2017 01:50:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(1)(B) neglect, and exploitation as defined in Texas Family Code 261.401 Standard # Weight High Category Short Description Weight Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. High Category Short Description Standard # Weight Children's Rights Child's rights-Make complaints/calls/reports w/o interference,coercion,punishment,retaliation,threats.Right to make them anonymously 748.1101(b)(7) High TA Finding Admn Rvw Compliance Narrative: Standard # TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3624026 05/08/2017 12:40:00 05/08/2017 05:47:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 7 of 10 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3618771 04/11/2017 10:00:00 04/11/2017 02:51:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 3618770 04/11/2017 10:00:00 04/11/2017 02:53:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2328539 04/11/2017 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Weight TA Finding High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3616686 03/30/2017 02:00:00 03/30/2017 02:57:04 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2325309 03/30/2017 12:00:00 Category Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 2323747 03/23/2017 12:00:00 Warning Letter/Due Notice given N Standard # Weight 748.507(1) Medium High TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Category Short Description Standard # Weight Children's Rights Children's rights-The right to be free from being subjected to or 748.1101(b)(4)(A)(ii) threatened with corporal punishment, including spanking or hitting High Short Description Weight TA Finding Admn Rvw Compliance Narrative: Category Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Page 8 of 10 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Children's Rights Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment. Weight: Id/Number: Admin Review Status: Low: 0 748.1101(b)(4)(A) Not Available: 0 High Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3611866 03/08/2017 10:00:00 03/08/2017 11:12:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2321338 03/08/2017 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment 748.2307(1) High Category Short Description Standard # Weight Children's Rights Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family 748.1101(b)(4)(A)(v) Medium High Category Short Description Standard # Weight Discipline and Punishment Discipline-person in care must not discipline or punish another person in care 748.2311 Medium High TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3609473 02/24/2017 09:00:00 02/24/2017 10:50:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3605587 02/03/2017 08:45:00 Category Short Description Physical Site Physical Site-Windows & doors must be in good repair & free of broken glass or hazards Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. 02/03/2017 11:52:00 N Standard # Weight 748.3301(c) Medium High TA Finding Page 9 of 10 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 5 High: 2 Medium High: 2 Run date: June 25, 2018 Compliance History Report Medium: 1 Report Criteria Period: 01/01/2017 To 12/31/2017 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3604369 01/27/2017 02:50:00 01/27/2017 04:07:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3601935 01/14/2017 02:00:00 Category Short Description Physical Site Physical Site-Windows & doors must be in good repair & free of broken glass or hazards Narrative: A closet door in bedroom 1 was observed with a hole and a linear crack. 01/14/2017 04:04:00 N Standard # Weight 748.3301(c) Medium High TA Finding Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2309713 01/14/2017 12:00:00 N Category Short Description Standard # Personnel Weight Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.1531(a)(2) High Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 10 of 10 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3599346 12/29/2016 09:30:00 12/29/2016 11:39:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3593361 11/22/2016 11:00:00 11/22/2016 01:48:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3592996 11/21/2016 10:30:00 11/21/2016 02:16:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3592997 11/21/2016 09:30:00 11/21/2016 02:18:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2295775 11/21/2016 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Child Care Weight Nutrition-Provide food of adequate variety, quality, and in sufficient 748.1693(a)(1) quantity to supply the nutrients needed for proper growth and development Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Nutrition-if meal or snack not appropriate to meet a child's individual needs, then must offer an appropriate nutritional substitute Narrative: This standard was evaluated and found to be in compliance. 748.1699(c) Medium Category Standard # Weight 748.2301(b)(5) Medium Child Care Short Description Discipline and Punishment Disciplinary Measures-must be appropriate to the incident and severity of the behavior demonstrated Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2295770 11/10/2016 11:15:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 1 of 11 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Discipline and Punishment Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Other Prohibited Punishments-subjecting a child to abusive or profane language Narrative: The standard evaluated was found to be in compliance. 748.2307(9) Medium High Category Standard # Weight Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: The standard evaluated was found to be in compliance. High Category Short Description Standard # Weight Short Personal Restraint-Caregiver may not use restraint that obstructs the caregiver's view of the child's face Narrative: The standard evaluated was found to be in compliance. 748.2461(b)(4) High Category Emergency Behavior Intervention Short Description Standard # Weight Short Personal Restraint-Caregiver may not use restraint that impairs child's breathing by putting pressure on torso Narrative: The standard evaluated was found to be in compliance. 748.2461(b)(2) High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Release-Child released from short personal restraint within 1 minute, or sooner if danger is over or disruptive behavior is de-escalated Narrative: The standard evaluated was found to be in compliance. 748.2553(1)(B) Medium High Category Emergency Behavior Intervention Short Description Standard # Weight Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: The standard evaluated was found to be in compliance. 748.2461(a)(2) High Category Standard # Weight Emergency Behavior Intervention Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Date End: Admn Rvw Compliance Warning Letter/Due Notice given Page 2 of 11 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3591312 11/10/2016 11:15:00 11/10/2016 01:25:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3590786 11/08/2016 09:30:00 11/08/2016 04:55:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3588278 10/26/2016 09:25:00 10/26/2016 04:15:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2288469 10/26/2016 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Children's rights-Adhere to the child's rights to be free from being threatened with corporal punishment Narrative: This standard was evaluated and found to be in compliance. 748.1101(b)(5)(C) Medium High Category Children's Rights Standard # Weight Personnel Caregiver responsibility - provide a safe environment Narrative: This standard was evaluated and found to be in compliance. Short Description 748.685(c)(2) High Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Personnel Short Description Standard # Weight Administration of Medication-Ensure a person trained in & authorized to administer prescription medication administers the medication Narrative: This standard was evaluated and found to be in compliance. 748.2003(b)(6) Medium High Category Standard # Weight 748.2307(8) Medium High Medication Short Description Discipline and Punishment Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 3 of 11 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3579078 09/10/2016 10:30:00 09/10/2016 11:57:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3577214 08/31/2016 10:10:00 08/31/2016 01:15:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 3576871 08/30/2016 10:00:00 08/30/2016 12:40:00 N Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated during a follow-up inspection and found to be in compliance. Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3576870 08/30/2016 10:00:00 08/30/2016 12:38:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2272657 08/30/2016 12:00:00 N Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3573941 08/15/2016 11:30:00 08/15/2016 03:47:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3573837 08/15/2016 09:45:00 08/15/2016 04:02:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2270621 08/15/2016 12:00:00 N Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 4 of 11 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Standard # Child/Caregiver Ratios Weight Child/caregiver ratio-Caregiver may care for 5 children if any 748.1003(a) require tx svcs, 8 children if not; children under 5 yrs old count as 2 children Narrative: This standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Personnel Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2307(8) Medium High Short Description Discipline and Punishment Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3571794 08/03/2016 09:30:00 08/03/2016 04:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2268291 07/29/2016 04:30:00 N Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Personnel Short Description Standard # Weight Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Narrative: This standard was evaluated and found to be in compliance. 748.2307(8) Medium High Category Standard # Weight Discipline and Punishment Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 5 of 11 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Children's Rights Not Available: 0 Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from being threatened with corporal punishment Narrative: This standard was evaluated and found to be in compliance. 748.1101(b)(5)(C) Medium High Category Standard # Weight 748.2003(b)(8) Medium High Children's Rights Short Description Medication Administration of Medication-Ensure a child is not physically forced to take prescription medication Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3570450 07/26/2016 02:30:00 07/26/2016 04:51:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3569185 07/20/2016 09:30:00 07/20/2016 01:46:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2264085 07/20/2016 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Discipline and Punishment Weight Other Prohibited Punishments-any harsh, cruel, unusual, 748.2307(1) unnecessary, demeaning, or humiliating discipline/punishment Narrative: This investigation was not completed due to it being upgraded to A/N; therefore findings were not established. High Category Weight Short Description Standard # Discipline and Punishment Other Prohibited Punishments-using sarcastic or cruel humor, and 748.2307(4) verbal abuse Narrative: This investigation was not completed due to it being upgraded to A/N; therefore findings were not established. TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3567922 07/13/2016 09:30:00 07/13/2016 01:02:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 6 of 11 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Activity Type: Investigation Number Date Intake Rcvd: Investigation 2262796 07/07/2016 01:50:00 Category Run date: June 25, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard evaluated was found to be in compliance. 748.507(1) Medium High Category Personnel Short Description Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: The standard evaluated was found to be in compliance. 748.683(1) Medium Category Standard # Weight 748.685(a)(4) High Personnel Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: The standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3566915 07/07/2016 01:50:00 07/07/2016 03:16:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3566502 07/06/2016 10:00:00 07/06/2016 05:18:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2262409 07/06/2016 12:00:00 N Category Short Description Personnel Standard # Caregiver responsibility - providing the level of supervision 748.685(a)(4) necessary to ensure each child's safety and well-being Narrative: Children in care were inadequately supervised due to staff members being distracted on their cellphones. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight TA Finding High Page 7 of 11 Deficiency Admn Rvw Upheld Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3563738 06/20/2016 10:00:00 06/20/2016 10:50:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3562085 06/10/2016 10:00:00 06/10/2016 01:19:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3560882 06/06/2016 09:30:00 06/06/2016 04:09:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2252886 06/06/2016 12:00:00 N Category Short Description Standard # Discipline and Punishment Weight Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's right to have adequate 748.1101(b)(12) personal clothing, suitable to his age and size and comparable with peers Narrative: This standard was evaluated and found to be in compliance. Medium Category Weight Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Physical Site Physical Site-Buildings must be structurally sound, clean, and in 748.3301(a) High good repair. Paints must be lead-free Narrative: After a physical walk-through of the 58D home, it was observed that there was mold on the ceiling of the kitchen pantry. It was corrected at inspection. Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2253527 05/31/2016 01:39:00 N Category Short Description Reports and Record Keeping Serious Incident-Report to Licensing as soon as aware of 748.303(a)(3)(A) allegations or indications of abuse, neglect, or exploitation of a child Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Medium High Page 8 of 11 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Narrative: Category Short Description Children's Rights Children's rights-Adhere to the child's right to report abuse, neglect, 748.1101(b)(29) exploitation, or violation of personal rights without fear of punishment Standard # Weight High Category Short Description Standard # Weight Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 748.507(1) Medium High Category Short Description Standard # Weight Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. High Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child 748.2307(8) Medium High Category Short Description Standard # Weight Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain 748.1531(a)(2) High TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3557763 05/18/2016 10:00:00 05/18/2016 02:46:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2248245 05/18/2016 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 9 of 11 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from being 748.1101(b)(5)(F) subjected to remarks that belittle or ridicule the child or the child's family Standard # Not Available: 0 Weight TA Finding Medium High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3553518 04/28/2016 10:59:00 04/28/2016 01:23:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2239961 04/08/2016 09:34:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found to be in compliance. 748.1101(b)(5) High Category Standard # Weight Children's Rights Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3549553 04/08/2016 09:34:00 04/08/2016 01:07:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3538776 02/13/2016 11:50:00 02/13/2016 12:40:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 10 of 11 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 2 High: 2 Monitoring Inspection Category Medium High: 0 Run date: June 25, 2018 Compliance History Report Medium: 0 3537409 Report Criteria Period: 01/01/2016 To 12/31/2016 Category: Standard: Type: ALL Finding: Medium Low: 0 02/08/2016 09:35:00 Short Description Physical Site Low: 0 Not Available: 0 02/08/2016 01:47:00 Standard # Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Narrative: Three out of six homes had torn cushions on the couches. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Weight: Id/Number: Admin Review Status: N Weight TA Finding Medium High Page 11 of 11 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3514100 11/20/2015 12:45:00 11/20/2015 05:15:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2186364 11/20/2015 12:00:00 N Category Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Personnel Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 2186491 11/20/2015 12:00:00 Category Short Description 748.685(a)(4) High Category Standard # Weight 748.1009(a) High Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: This standard was evaluated and found to be in compliance. Admn Rvw Compliance N Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Short Description TA Finding Warning Letter/Due Notice given Weight Child/Caregiver Ratios Admn Rvw Compliance High Standard # Personnel TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3505760 10/28/2015 12:30:00 10/28/2015 04:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2180418 10/28/2015 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 1 of 16 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Category Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and the agency was found to be in compliance. 748.685(a)(4) High Category Standard # Weight 748.507(1) Medium High Personnel Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2181041 10/28/2015 12:00:00 N Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and the facility was found to be in compliance. Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3505238 10/27/2015 09:45:00 10/27/2015 11:58:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3501246 10/13/2015 10:00:00 10/13/2015 03:05:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2175634 10/13/2015 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Weight Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Page 2 of 16 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Discipline and Punishment Disciplinary Measures-goal must be to teach a child acceptable behavior and self-control; caregiver must explain reason for discipline when imposed Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 0 748.2301(c) Not Available: 0 Medium Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3499120 10/02/2015 10:15:00 10/02/2015 03:50:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3498145 09/28/2015 09:45:00 09/28/2015 01:45:00 Standard # N Category Short Description Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 High Category Short Description Weight Medication Administration of Medication-Must obtain a general written 748.2001(a) consent to administer routine, preventive, & emergency medications TA Finding Admn Rvw Compliance Narrative: Standard # TA Finding High Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2169943 09/24/2015 12:00:00 N Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3496158 09/22/2015 09:30:00 09/22/2015 02:54:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2167748 09/22/2015 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 3 of 16 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Category Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3493822 09/11/2015 09:30:00 09/11/2015 10:39:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3493677 09/10/2015 11:00:00 09/10/2015 03:29:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2166021 09/10/2015 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Reports and Record Keeping Reporting serious incident-All serious incident reports to Licensing 748.309(a) must be made to the Child Abuse Hotline Narrative: This standard was evaluated and found to be in compliance. Medium Category Weight Short Description Standard # Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after an 748.303(a)(5)(A) incident of sexual abuse of a child against another child Narrative: This standard was evaluated and found to be in compliance. Medium High Category Standard # Weight 748.1007(b)(1) Medium High Short Description Child/Caregiver Ratios Child/caregiver ratio-Awake caregiver may care for 15 children if any child in group requires treatment services Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Date End: Admn Rvw Compliance Warning Letter/Due Notice given Page 4 of 16 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Monitoring Inspection Run date: June 25, 2018 Compliance History Report Medium: 0 3492564 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 09/04/2015 09:00:00 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 09/04/2015 03:24:00 Standard # N Category Short Description Weight Admission, Service Planning, Discharge Admission Documentation-Identification of child's high risk 748.1205(a)(13) behaviors and related safety plan staff and caregivers will implement High Category Short Description Standard # Weight Reports and Record Keeping Narrative: Active child record-Ensure record is kept accurate and current 748.393(b)(4) Medium TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3468994 08/05/2015 08:00:00 08/05/2015 12:17:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2138215 07/30/2015 08:54:00 N Category Short Description Standard # Emergency Behavior Intervention Weight Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and found to be in compliance High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance High Category Short Description Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance 748.2307(1) High Category Standard # Weight 748.2307(9) Medium High Discipline and Punishment Short Description Discipline and Punishment Other Prohibited Punishments-subjecting a child to abusive or profane language Narrative: This standard was evaluated and found to be in compliance Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 5 of 16 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Category Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and found to be in compliance 748.2851(b) Medium Category Emergency Behavior Intervention Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: This standard was evaluated and found to be in compliance 748.2551(a) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention Emergency Behavior Intervention Orders-Required for emergency 748.2501(3)(B) medication, written by a licensed physician Narrative: This standard was evaluated and found to be in compliance High Category Short Description Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and found to be in compliance 748.2551(c)(1) High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: This standard was evaluated and found to be in compliance High Category Short Description Weight Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3464803 07/30/2015 08:23:00 07/30/2015 01:50:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 6 of 16 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3464556 07/29/2015 09:00:00 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2136010 07/29/2015 12:00:00 N Category Short Description 07/29/2015 01:18:00 N Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: A staff member made inappropriate comments regarding child's alleged sexual orientation. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from being 748.1101(b)(5)(F) subjected to remarks that belittle or ridicule the child or the child's family Narrative: This standard was evaluated and found to be in compliance. TA Finding Deficiency TA Finding Medium High Admn Rvw Overturned Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3463714 07/28/2015 11:00:00 07/28/2015 04:03:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2136497 07/28/2015 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. Weight TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3462042 07/15/2015 01:12:00 07/15/2015 02:19:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2134149 07/15/2015 12:00:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 7 of 16 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Physical Site Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Bedding-Must provide each child with an individual bed or bunk bed, or crib as appropriate Narrative: This standard was evaluated and found to be in compliance. 748.3365(a) Medium Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evalulated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3455524 06/10/2015 09:00:00 06/10/2015 05:11:00 N Category Short Description Standard # Weight Administration of Medication-Ensure the child has taken the medication as prescribed Narrative: Two children records reviewed indicated medication was not given as prescribed. 748.2003(b)(5) Medium High Category Medication Short Description Standard # Weight Medication Record-Must include date (day, month, year) & time each medication was administered Narrative: One medication log observed did not have the time medication was administrated. 748.2151(b)(5) Medium High Category Standard # Weight 748.2151(c) Medium High Medication Short Description Medication Medication Record-Must include accurate daily count of each prescribed medication Narrative: Two records observed found that medication count does not match documentation. Activity Type: Investigation Number Date Intake Rcvd: Investigation 2122385 06/10/2015 12:00:00 Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding Deficiency TA Finding Deficiency Admn Rvw Waived Admn Rvw Waived Admn Rvw Waived Warning Letter/Due Notice given N Standard # Weight 748.685(a)(4) High TA Finding Page 8 of 16 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3452983 05/28/2015 02:00:00 05/28/2015 02:52:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 3443285 04/09/2015 11:30:00 04/09/2015 03:32:00 N Category Short Description Standard # Providing Children and Adult Care Weight Care for children and adults-assessment/approval by PLSP for adult 748.1937(2) resident to share bedroom with child must be documented in child's record Narrative: This standard was evaluated and found to be in compliance. Medium Low Category Short Description Standard # Weight Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old Narrative: This standard was evaluated and found to be in compliance. 748.2151(a) Medium High Category Standard # Weight Medication Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3443287 04/09/2015 11:30:00 04/09/2015 03:31:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3442996 04/09/2015 09:37:00 04/09/2015 12:05:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 3441152 03/30/2015 09:00:00 Category Short Description Discipline and Punishment Disciplinary Measures-must not be physically or emotionally damaging to the child Narrative: A follow up was completed and standard was found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. 03/30/2015 05:53:00 N Standard # Weight 748.2301(b)(2) High TA Finding Page 9 of 16 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3440827 03/30/2015 09:00:00 03/30/2015 05:53:00 N Category Short Description Standard # Weight TA Finding Admn Rvw Providing Children and Adult Care Care for children and adults-assessment/approval by PLSP for adult 748.1937(2) Medium Deficiency Waived resident to share bedroom with child must be documented in child's Low record Narrative: Two adults in care share rooms with children in care. The assessment and approval for children to share a bedroom with an adult in care needs to be documented in the file. Category Short Description Standard # Weight Medication Record-Maintain cumulative record of prescription medications dispensed to child, include nonprescription meds for child under five yrs old Narrative: One child's medication record reviewed had an inaccurate running count of medication. 748.2151(a) Medium High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Documentation-Must include the de-escalation attempted before and during the use of EBI and the child's reaction to those strategies 748.2855(a)(3) Medium Short Description Standard # Weight Medication TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Narrative: Category Physical Site Physical Site-The grounds of the operation must be well maintained 748.3301(f) and free of hazards Narrative: Lawns must be cut and maintained to prevent mosquitos. Children to be able to go outside for daily recreation. Medium High Category Weight Short Description Standard # Reports and Record Keeping Personnel records-For each person who transports a child, include 748.363(10) copy of valid driver's license or DPS driver's license check done in last 12 months Narrative: This standard was evaluated and found to be in compliance. Medium Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 10 of 16 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Reports and Record Keeping Not Available: 0 Personnel records- Include signed dated statement by the employee 748.363(8)(A) that he must immediately report suspected child abuse, neglect, or exploitation Narrative: This standard was evaluated and found to be in compliance. Medium Category Standard # Weight 748.4083(a) Medium High Short Description Transportation Vehicle and maintenance-Must maintain a vehicle in a safe operating condition at all times Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Assessment Id Date Assessment: Warning Letter/Due Notice given Assessment 175960 03/25/2015 08:55:00 N Category Short Description Safety and Emergency Practices Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection Narrative: The fire inspection for Magnolia House has expired. Standard # Weight 748.3101(2) Medium High TA Finding Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3439219 03/20/2015 08:15:00 03/20/2015 10:11:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2102331 03/16/2015 01:32:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Standard was evaluated and found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 11 of 16 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: Standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 0 748.2307(1) Not Available: 0 High Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3438412 03/16/2015 01:32:00 03/16/2015 02:55:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2099504 03/02/2015 02:00:00 N Category Short Description Standard # Discipline and Punishment Weight Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: The standard evaluated was found to be in compliance. High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard evaluated was found to be in compliance. 748.507(1) Medium High Category Standard # Weight 748.1531(a)(2) High Personnel Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: The standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3435843 03/02/2015 09:00:00 03/02/2015 04:52:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 12 of 16 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Activity Type: Investigation Number Date Intake Rcvd: Investigation 2096973 03/02/2015 12:00:00 Category Run date: June 25, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Warning Letter/Due Notice given N Standard # Weight Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: This standard was evaluated and found to be in compliance. 748.1009(a) High Category Child/Caregiver Ratios Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight 748.311 Medium Personnel Short Description Reports and Record Keeping Serious Incident Documentation-Documented in written report Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3433259 02/17/2015 09:37:00 02/17/2015 11:00:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2094912 02/10/2015 08:45:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 13 of 16 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 0 748.2307(1) Not Available: 0 High Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3432111 02/10/2015 08:45:00 02/10/2015 11:02:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3432118 02/09/2015 10:00:00 02/09/2015 02:34:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3430219 01/29/2015 10:30:00 01/29/2015 05:23:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2090244 01/29/2015 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Disciplinary Measures-goal must be to teach a child acceptable behavior and self-control; caregiver must explain reason for discipline when imposed Narrative: This standard was evaluated and found to be in compliance. 748.2301(c) Medium Category Standard # Weight Discipline and Punishment Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Children were inappropriately disciplined. TA Finding Admn Rvw Compliance TA Finding High Deficiency Admn Rvw Overturned Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2090379 01/29/2015 12:00:00 N Category Short Description Discipline and Punishment Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight 748.2307(6) High TA Finding Page 14 of 16 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2090408 01/29/2015 12:00:00 N Category Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight 748.683(1) Medium Personnel Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3429857 01/28/2015 01:00:00 01/28/2015 04:27:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2090710 01/28/2015 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Investigation 2092468 01/28/2015 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TA Finding Discipline and Punishment Disciplinary Measures-must not be physically or emotionally 748.2301(b)(2) High damaging to the child Narrative: Video tape footage was observed for the alleged incident which deomonstated a struggle took place between a staff member and a child in care. Activity Type: Investigation Number Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Intake Rcvd: Deficiency Admn Rvw Upheld Warning Letter/Due Notice given Page 15 of 16 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 6 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2015 To 12/31/2015 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation 2091056 01/21/2015 10:25:00 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3428258 01/21/2015 10:25:00 01/21/2015 01:45:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2089075 01/12/2015 01:10:00 N Category Short Description N Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2307(4) Medium High Short Description Discipline and Punishment Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3425887 01/06/2015 10:45:00 01/06/2015 01:32:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 16 of 16 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Activity Type: Investigation Number Date Intake Rcvd: Investigation 2086759 12/29/2014 04:05:00 Category Run date: June 25, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Warning Letter/Due Notice given Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was assessed and found to be compliant. High Category Short Description Standard # Weight Other occurrences-Report to parents within 7 days and document medically pertinent incidents, that do not rise to the level of a serious incident Narrative: This standard was assessed and found to be compliant. 748.307(1)(B) Medium Category Standard # Weight Reports and Record Keeping Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was assessed and found to be compliant. High Category Standard # Weight 748.2307(15) High Short Description Discipline and Punishment Other Prohibited Punishments-using or threatening to use emergency behavior intervention as discipline or punishment Narrative: This standard was evaluated and technical assistance was deemed most appropriate. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3425018 12/26/2014 01:30:00 12/26/2014 02:39:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3423267 12/17/2014 09:00:00 12/17/2014 12:25:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2084644 12/17/2014 12:00:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight TA Finding Page 1 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Children's Rights Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Weight: Id/Number: Admin Review Status: Low: 0 748.1101(b)(5) Not Available: 0 High Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3417824 11/19/2014 11:00:00 11/19/2014 05:54:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2078407 11/19/2014 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Weight Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and found to be in compliance. 748.2851(b) Medium Category Standard # Weight 748.393(b)(4) Medium Emergency Behavior Intervention Short Description Reports and Record Keeping Active child record-Ensure record is kept accurate and current Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2078398 11/14/2014 12:00:00 N Category Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Standard # Weight 748.1531(a)(2) High TA Finding Date End: Admn Rvw Compliance Warning Letter/Due Notice given Page 2 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3416943 11/12/2014 10:45:00 11/12/2014 03:23:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 3416944 11/12/2014 10:40:00 11/12/2014 03:21:00 N Category Short Description Medication Medication Record-Must include accurate daily count of each prescribed medication Narrative: This standard was found to be in compliance. Standard # Weight 748.2151(c) Medium High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3416400 11/07/2014 09:30:00 11/07/2014 03:45:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2075467 11/07/2014 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight 748.1009(a) High Personnel Short Description Child/Caregiver Ratios Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Follow-up Inspection 3415251 11/04/2014 02:00:00 Category Short Description Admn Rvw Compliance 11/04/2014 03:56:00 N Medication Record-Must include date (day, month, year) & time each medication was administered Narrative: This standard was found to be in complinace. 748.2151(b)(5) Medium High Category Standard # Weight Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Warning Letter/Due Notice given Weight Short Description Admn Rvw Compliance Date End: Standard # Medication TA Finding TA Finding Admn Rvw Compliance TA Finding Page 3 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Medication Medication Record-Must include accurate daily count of each prescribed medication Narrative: During the inspection, the medication log for one medication had a culmative count which was wrong. A second medication log did not have the culmative count completed for one medication. Weight: Id/Number: Admin Review Status: Low: 0 748.2151(c) Not Available: 0 Medium High Deficiency Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3409940 10/08/2014 01:30:00 10/08/2014 05:57:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2067513 10/08/2014 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Personal Restraint Monitor-Qualified caregiver monitors child for signs of physical distress & ensures ample respiration, circulation, well-being Narrative: This standard was evaluated and found to be in compliance. 748.2601(a) High Category Emergency Behavior Intervention Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Emergency Behavior Intervention Admn Rvw EBI Implementation-Caregiver must minimize risk of physical 748.2551(c)(1) High Deficiency discomfort, harm, or pain to the child Narrative: A child dropped to the ground during a restraint and the child was helped up off the ground by the wrist. The child could have received an injury by this action. Waived Category Admn Rvw Short Description Standard # Emergency Behavior Intervention Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Weight TA Finding High Date End: Compliance Warning Letter/Due Notice given Page 4 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Monitoring Inspection Medium High: 3 Medium: 0 3404450 Category Run date: June 25, 2018 Compliance History Report Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 09/12/2014 09:00:00 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 09/12/2014 01:28:00 Standard # N Weight TA Finding Admn Rvw Medication Medication Record-Must include date (day, month, year) & time 748.2151(b)(5) Medium Deficiency Waived each medication was administered High Narrative: Several medication logs in one home had missing medication documentation from the previous weekend. Medication logs had different pill counts from the number of pills in the container. Category Short Description Standard # Weight Medication Medication Record-Medication records of prescription & nonprescription medication dispensed to the child must be incorporated into child's record 748.2151(e) Medium Low TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3404078 09/11/2014 09:00:00 09/11/2014 03:51:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3403556 09/09/2014 11:15:00 09/09/2014 12:13:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3398821 08/18/2014 08:04:00 08/18/2014 11:28:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Initial Inspection 3396268 08/05/2014 08:38:00 08/05/2014 12:12:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3394202 07/29/2014 10:00:00 07/29/2014 12:39:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2051017 07/29/2014 12:00:00 N Category Short Description Reports and Record Keeping Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: The above standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight 748.303(a)(2)(A) Medium High TA Finding Page 5 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Activity Type: Investigation Number Date Intake Rcvd: Investigation 2051950 07/25/2014 09:03:00 Category Run date: June 25, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Weight Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention EBI Release-Child released from personal restraint as soon as child 748.2553(2)(C) is not a danger to self or others Narrative: This standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Training and Professional Development Annual Training-Every 6 months a caregiver must complete at least 748.931(a)(1)(B) 4 hours of training in EBI Narrative: This standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Emergency Behavior Intervention EBI Documentation-Caregiver must document EBI in child's record 748.2855(a) as soon as possible, but no later than 24 hours after initiation of the intervention Narrative: This standard was evaluated and found to be in compliance. Medium Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: This standard was evaluated and found to be in compliance. 748.2551(a) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 6 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Emergency Behavior Intervention Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and found to be in compliance. 748.2551(c)(1) High Category Standard # Weight Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight Background Checks - TAC 745 Required background checks-each person employed Narrative: This standard was evaluated and found to be in compliance. Short Description 745.615(a)(2) High Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Personnel Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Personnel Short Description Standard # Weight EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and found to be in compliance. 748.2851(b) Medium Category Emergency Behavior Intervention Short Description Standard # Weight Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: This standard was evaluated and found to be in compliance. 748.2461(a)(2) High Category Standard # Weight Emergency Behavior Intervention Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 7 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Emergency Behavior Intervention Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 0 748.2455(a)(2) Not Available: 0 Medium High Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3393879 07/23/2014 12:00:00 07/23/2014 06:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3393700 07/23/2014 09:30:00 07/23/2014 11:34:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2050524 07/22/2014 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child Narrative: This standard has been evaluated and was found to be in compliance with minimum standards. 748.2307(8) Medium High Category Discipline and Punishment Short Description Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard has been evaluated and was found to be in compliance with minimum standards. 748.683(1) Medium Category Standard # Weight 748.1101(b)(5)(C) Medium High Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from being threatened with corporal punishment Narrative: This standard has been evaluated and was found to be in compliance with minimum standards. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2049109 07/11/2014 10:45:00 N Category Short Description Emergency Behavior Intervention EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight 748.2551(a) Medium High TA Finding Page 8 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Category Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight 748.2455(a)(2) Medium High Personnel Short Description Emergency Behavior Intervention Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3391717 07/11/2014 10:45:00 07/11/2014 11:57:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3387812 06/20/2014 09:30:00 06/20/2014 11:32:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2044161 06/20/2014 12:00:00 Category Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was reviewed and found to be in compliance. Warning Letter/Due Notice given N Standard # Weight 748.1531(a)(2) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3383886 06/02/2014 12:35:00 06/02/2014 05:11:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3383451 05/29/2014 12:37:00 05/29/2014 01:49:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3380102 05/13/2014 09:00:00 05/13/2014 12:14:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2035769 05/13/2014 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 9 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free from being subjected to corporal punishment 748.1101(b)(5)(B) High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's right to discipline that is appropriate to the child's age and developmental level; 748.1101(b)(6) Medium High TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2034805 05/08/2014 10:13:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. 748.2307(1) High Category Standard # Weight Discipline and Punishment Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3378919 05/08/2014 10:13:00 05/08/2014 02:04:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2030796 04/23/2014 12:00:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 10 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Background Checks - TAC 745 Narrative: Required background checks-each person employed 745.615(a)(2) High Category Short Description Standard # Weight Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) discomfort, harm, or pain to child High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child 748.2551(c)(1) High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed 748.2551(a) Medium High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Documentation-Caregiver must document EBI in child's record 748.2855(a) as soon as possible, but no later than 24 hours after initiation of the intervention Medium Category Short Description Standard # Weight Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 748.507(1) Medium High Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-subjecting a child to abusive or profane language 748.2307(9) Medium High Compliance TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Date End: Warning Letter/Due Notice given Page 11 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3370154 03/26/2014 09:30:00 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2025232 03/26/2014 12:00:00 N Category Short Description 03/26/2014 03:44:00 N Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Child Care Medical care-A child in care must receive medical care as needed 748.1531(a)(2) for injury, illness, and pain Narrative: A resident was found to have fractured his hand on 03/18/14 and no medical care was provided to resident until 03/20/14. High Category Short Description Standard # Weight Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: The incident was reported to licensing 3 days after a resident was found to have fractured his hand. 748.303(a)(2)(A) Medium High Category Standard # Weight Reports and Record Keeping Short Description TA Finding Admn Rvw Compliance TA Finding Deficiency TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Waived Admn Rvw Background Checks - TAC 745 Required FBI check-Persons who have lived outside of TX in the 745.615(b)(2)(A) High Deficiency Waived previous 5 years prior to an initial background check Narrative: One staff member lived in Colorado 2 months prior to employment with agency. No FBI finger print check was completed at the time of hiring in 2010. FBI check was eventually requested in 04/12. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3369483 03/19/2014 11:00:00 03/19/2014 04:45:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 2022419 03/19/2014 12:00:00 Category Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight 748.685(a)(4) High TA Finding Page 12 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Category Run date: June 25, 2018 Compliance History Report Medium: 0 Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Short Description Child/Caregiver Ratios Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Monitoring Inspection 3362231 02/08/2014 09:30:00 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight 748.1009(a) High TA Finding Date End: Warning Letter/Due Notice given 02/08/2014 12:18:00 Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's right to have adequate 748.1101(b)(12) personal clothing, suitable to his age and size and comparable with peers Admn Rvw Compliance N Weight TA Finding Medium Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3358474 01/17/2014 09:30:00 01/17/2014 03:40:00 N Category Short Description Reports and Record Keeping Serious Incident Documentation-Includes names or other means of 748.311(5) identifying witnesses to the incident, if any Standard # Weight TA Finding Medium Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2011097 01/17/2014 12:00:00 N Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 13 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 6 High: 3 Medium High: 3 Run date: June 25, 2018 Compliance History Report Medium: 0 Personnel Report Criteria Period: 01/01/2014 To 12/31/2014 Category: Standard: Type: ALL Finding: Medium Low: 0 Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. 748.685(a)(4) Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 High Page 14 of 14 Compliance Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3353811 12/17/2013 08:13:00 12/17/2013 09:17:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3352698 12/11/2013 08:43:00 12/11/2013 12:24:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2004968 12/03/2013 08:51:00 N Category Short Description Standard # Weight EBI Release-Child released from short personal restraint immediately in emergency health situation and treatment obtained immediately Narrative: This standard was evaluated and found to be in compliance. 748.2553(1)(A) High Category Standard # Weight Emergency Behavior Intervention Short Description Training and Professional Development Annual Training-Every 6 months a caregiver must complete at least 748.931(a)(1)(B) 4 hours of training in EBI Narrative: This standard was evaluated and found to be in compliance. Medium High Category Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: This standard was evaluated and found to be in compliance. 748.2551(a) Medium High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and found to be in compliance. 748.2551(c)(1) High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force 748.2551(c)(2) High Emergency Behavior Intervention TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 1 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Narrative: This standard was evaluated and found to be in compliance. Category Standard # Weight Background Checks - TAC 745 Required background checks - each person employed Narrative: This standard was evaluated and found to be in compliance. Short Description 745.615(a)(2) High Category Standard # Weight Short Description Emergency Behavior Intervention Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2851(b) Medium Short Description Emergency Behavior Intervention EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3349022 11/21/2013 08:30:00 11/21/2013 03:52:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3348673 11/18/2013 11:00:00 11/18/2013 04:48:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3348793 11/18/2013 09:40:00 11/18/2013 03:58:00 N Category Short Description Standard # Weight Child/Caregiver Ratios Child/caregiver ratio-If operation provides treatment services, staffing plan includes enough caregivers for 24-hr & one-on-one supervision 748.1009(b)(1) Medium Category Short Description Standard # Weight Organization and Administration Permit holder responsibilities-Ensure all required documentation is 748.103(a)(4) current, accurate, and complete Medium TA Finding Admn Rvw Compliance Narrative: Technical assistance given. TA Finding Narrative: Technical assistance given. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 2 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Child Orientation-Include policies on emergency behavior intervention, including policies & practices on the use of personal restraint Narrative: The child's preferred de-escalation technique was not documented in 1 of 4 child records reviewed. 748.1209(b)(6) Medium High Category Short Description Standard # Weight Admission, Service Planning, Discharge Admission-Re-admission requires new admission documentation unless child was discharged in past 12 months 748.1227 Medium Low Category Short Description Standard # Weight Admission, Service Planning, Discharge Emergency Admission Documentation-Include brief description of 748.1271(1) circumstances necessitating emergency admission Medium Low Short Description Weight Admission, Service Planning, Discharge TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Narrative: Technical assistance given. TA Finding Admn Rvw Compliance Narrative: Technical assistance given. Category Standard # TA Finding Admission, Service Planning, Discharge Admn Rvw Preliminary Service Plan-Complete plan that addresses child's 748.1331(a) Medium Deficiency immediate needs within 72 hours of admission Low Narrative: The preliminary service plans for children who re-admitted to the operation were not completed for the most recent admission in 2 of 4 child records reviewed. Waived Category Admn Rvw Short Description Standard # Child Care Weight TB exam-Documentation of baseline test or chest xray results in 748.1583(b) person's record w/in 40 days of beginning to live, work, volunteer at facility Narrative: There was no documentation of TB test results observed ini 1 of 4 child records reviewed. Medium Low Category Short Description Standard # Weight Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 748.507(1) Medium High Short Description Standard # Weight TA Finding Deficiency TA Finding Waived Admn Rvw Compliance Narrative: Technical assistance given. Category Training and Professional Development Annual Training-Every 6 months a caregiver must complete at least 748.931(a)(1)(B) 4 hours of training in EBI Narrative: At least 4 hours of emergency behavior intervention training was not obtained every 6 months in 1 of 6 employee records reviewed. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Medium High Page 3 of 20 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight First-aid-CPR training-Each caregiver must have current 748.981(a)(1) certification in first-aid Narrative: There was no documentation of current CPR/First aid certification observed in 2 of 6 employee records reviewed. Medium High Training and Professional Development TA Finding Deficiency Admn Rvw Waived Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 2002395 11/18/2013 12:00:00 N Category Short Description Standard # Weight TA Finding Emergency Behavior Intervention Short Personal Restraint-Caregiver must minimize risk of physical 748.2461(a)(1) High discomfort, harm, or pain to child Narrative: Multiple residents observed two staff members restraining a child by putting pressure on his legs and face causing pain and minor injuries. Category Short Description Standard # Weight Deficiency TA Finding Admn Rvw Upheld Admn Rvw Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use a prone or supine 748.2461(b)(1) High Deficiency Upheld restraint Narrative: Multiple residents observed a child being restraint in a prone position for at least 10 minutes on a van. Staff members also stated child was placed on his back on the seat of the van during the restraint. Category Short Description Standard # Weight TA Finding Admn Rvw Emergency Behavior Intervention Emergency Behavior Intervention-Never used as a means to get a 748.2463(3) Medium Deficiency Upheld child to comply High Narrative: A resident refused to comply with staff's instruction. Resident was restrained after pushing staff out of his way from blocking him and preventing him from going to the living room. Category Short Description Standard # Weight Behavior intervention policies-Include obtaining child's input during orientation on preferred de-escalation Narrative: This standard was evaluated and found to be in compliance. 748.237(5)(C) Medium High Category Standard # Weight 748.1101(b)(20) Medium Organization and Administration Short Description Children's Rights Children's rights-Adhere to the child's right to be able to communicate in a language or any other means that is understandable to the child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 4 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Standard # Children's Rights Not Available: 0 Weight Children's rights-Adhere to the child's rights to appropriate care and 748.1101(b)(1) treatment in least restrictive setting available that meets the child's needs Narrative: This standard was evaluated and found to be in compliance. Medium High Category Standard # Weight 748.2851(b) Medium Short Description Emergency Behavior Intervention EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3348346 11/15/2013 09:00:00 11/15/2013 11:19:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3345905 11/04/2013 11:32:00 11/04/2013 12:43:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3346211 11/04/2013 09:30:00 11/04/2013 03:13:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1997744 10/25/2013 12:49:00 N Category Short Description Standard # Personnel Weight Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Narrative: Based on the information obtained during this investigation, there was not a violation of this standard. High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Based on the information obtained during this investigation, there was not a violation of this standard. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3344709 10/25/2013 12:30:00 10/25/2013 02:24:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 5 of 20 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Activity Type: Investigation Number Date Intake Rcvd: Investigation 1995813 10/23/2013 12:00:00 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Warning Letter/Due Notice given N Category Short Description Standard # Weight Child Care Nutrition-Provide food appropriate for the child's age and activity level 748.1693(a)(2) High Short Description TA Finding Admn Rvw Compliance Narrative: Technical assistance given. Category Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight 748.2307(15) High Personnel Short Description Discipline and Punishment Other Prohibited Punishments-using or threatening to use emergency behavior intervention as discipline or punishment Narrative: This standard was evaluated and found to be in compliance. Activity Type: Assessment Id Date Assessment: Assessment 154437 10/18/2013 01:44:00 Category Short Description TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Organization and Administration Fiscal requirements-Complete professional audit annually and make 748.163 it available for Licensing's review Narrative: A professional audit has not been completed for 2011 and 2012. Weight TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3341840 10/11/2013 11:55:00 10/11/2013 02:50:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1994717 10/11/2013 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 6 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Narrative: Category Short Description Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Standard # Weight High Category Short Description Weight Personnel Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety High Category Short Description Standard # Weight Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks 748.507(1) Medium High Category Short Description Standard # Weight Background Checks - TAC 745 Narrative: Required background checks - each person employed 745.615(a)(2) High Category Short Description Standard # Weight Reports and Record Keeping Narrative: Serious Incident Documentation-Documented in written report 748.311 Medium TA Finding Admn Rvw Compliance Narrative: Standard # TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3338095 09/23/2013 09:30:00 09/23/2013 11:41:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3336861 09/17/2013 01:35:00 09/17/2013 01:39:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1988458 09/17/2013 10:30:00 N Category Short Description Standard # Weight Personnel Caregiver responsibility - provide a safe environment 748.685(c)(2) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 7 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Narrative: Based on the information obtained during this investigaiton, there was not a violation of this standard. Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Based on the information obtained during this investigaiton, there was not a violation of this standard. High Category Standard # Weight 748.683(1) Medium Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: Based on the information obtained during this investigaiton, there was not a violation of this standard. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3337039 09/17/2013 10:15:00 09/17/2013 11:54:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3337230 09/17/2013 09:15:00 09/17/2013 12:49:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3336840 09/16/2013 09:30:00 09/16/2013 05:17:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1988020 09/16/2013 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Emergency Behavior Intervention-Basis for EBI is an emergency situation or to administer medication Narrative: This standard was evaluated and found to be in compliance. 748.2455(a)(2) Medium High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Follow-Up-Caregivers involved in EBI must make reasonable efforts to debrief with children in care who witness the incident 748.2851(c)(2) Medium Low Emergency Behavior Intervention TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Technical assistance given. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Date End: Warning Letter/Due Notice given Page 8 of 20 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3336604 09/13/2013 01:00:00 09/13/2013 04:28:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3335058 09/10/2013 12:00:00 09/10/2013 04:05:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1985314 09/10/2013 12:00:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's right to discipline that is appropriate to the child's age and developmental level; Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1982712 08/23/2013 01:00:00 Category Short Description Standard # Weight 748.1101(b)(6) Medium High N Weight EBI Release-Child released from short personal restraint immediately in emergency health situation and treatment obtained immediately Narrative: This standard was reviewed and found to be in compliance. 748.2553(1)(A) High Category Short Description Standard # Weight EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was reviewed and found to be in compliance. 748.2851(b) Medium Category Standard # Weight Emergency Behavior Intervention Short Description Training and Professional Development Annual Training-Every 6 months a caregiver must complete at least 748.931(a)(1)(B) 4 hours of training in EBI Narrative: This standard was reviewed and found to be in compliance. Medium High Category Weight Short Description Children's Rights Standard # Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was reviewed and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance Warning Letter/Due Notice given Standard # Emergency Behavior Intervention TA Finding TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Page 9 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Background Checks - TAC 745 Required background checks - each person employed Narrative: This standard was reviewed and found to be in compliance. 745.615(a)(2) High Category Short Description Standard # Weight EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers Narrative: This standard was reviewed and found to be in compliance. 748.2551(d)(1) Medium Category Emergency Behavior Intervention Short Description Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was reviewed and found to be in compliance. 748.2551(c)(1) High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was reviewed and found to be in compliance. High Category Standard # Weight 748.2551(a) Medium High Short Description Emergency Behavior Intervention EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: This standard was reviewed and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3332709 08/23/2013 12:30:00 08/23/2013 04:40:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3332338 08/21/2013 09:15:00 08/21/2013 04:09:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3331427 08/16/2013 01:12:00 08/16/2013 03:44:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1979282 08/15/2013 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 10 of 20 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Emergency Behavior Intervention Emergency Behavior Intervention-Never used as a convenience for 748.2463(4) caregivers or other persons Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1979116 08/05/2013 01:30:00 N Category Short Description Standard # Weight Human Resources Code, Chapter 42 Reporting incidents and Violations-arrest, abuse, neglect, exploitation, running away, attempted suicide, or death of a child HRC42.063(a)(1) High Category Short Description Standard # Weight Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 TA Finding Admn Rvw Compliance Narrative: TA Finding High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3329184 08/05/2013 01:30:00 08/05/2013 03:35:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3327328 07/24/2013 10:00:00 07/24/2013 12:47:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3326597 07/19/2013 09:20:00 07/19/2013 03:33:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1974513 07/19/2013 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 11 of 20 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Standard # Not Available: 0 Weight TA Finding Admn Rvw Personnel Employee general responsibilities-Demonstrate competency, 748.507(1) Medium Deficiency Upheld prudent judgment, self-control in presence of children and when High performing assigned tasks Narrative: Prudent judgment was not demonstrated when a staff member pulled on the chair a child was sitting in efforts to move the child to another location after the child did not comply with verbal directive causing the child to fall out of the chair. Category Short Description Standard # Weight Discipline and Punishment Disciplinary Measures-goal must be to teach a child acceptable behavior and self-control; caregiver must explain reason for discipline when imposed 748.2301(c) Medium Short Description Standard # Weight 748.2307(1) High TA Finding Admn Rvw Compliance Narrative: Technical assitance given. Category Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Monitoring Inspection 3323900 07/02/2013 09:45:00 Category Short Description TA Finding Date End: Warning Letter/Due Notice given 07/02/2013 04:40:00 Standard # N Weight TA Finding Medication Medication Record-Must include accurate daily count of each 748.2151(c) Medium Deficiency prescribed medication High Narrative: The daily medication count for a child's prescription medication was not accurate. The actual medication count did not match the documented medication count. Activity Type: Inspection Id Date Begin: Monitoring Inspection 3323393 06/28/2013 09:00:00 Category Short Description Date End: Waived N Weight TA Finding Background Checks - TAC 745 Required background check- Requesting background checks on 745.615(d) High professionals who have background checks through another governmental entity. Narrative: A DPS criminal history background check and central registry background check was not completed for a person who contracts with the operation. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Warning Letter/Due Notice given 06/28/2013 04:50:00 Standard # Admn Rvw Compliance Page 12 of 20 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Standard # Not Available: 0 Weight TA Finding Admn Rvw Children's Rights Informing child of rights-Review rights with child/parents within 7 748.1103(a) Medium Deficiency Waived days of child's admission; provide child/parents with written copy of rights Narrative: The documentation use to share the child rights with the child and the child's parent does not cover all required child rights from the minimum standards in 2 of 2 child record reviewed. Category Short Description Standard # Weight TA Finding Admn Rvw Personnel Caregiver qualifications- HS diploma or GED from program 748.681(2) Medium Deficiency Waived recognized by TEA, TPSAC, other state or documentaion of equivalency from home schooling Narrative: A employee record for a caregiver did not have documentation from a program recognized by the Texas Education Agency (TEA) or a public educational entity outside of Texas in one of 2 employee records reviewed. Activity Type: Inspection Id Date Begin: Investigation Inspection 3321604 06/26/2013 10:00:00 Category Short Description Date End: Warning Letter/Due Notice given 06/26/2013 03:42:00 Standard # Admission, Service Planning, Discharge N Weight Admission Assessment-Prior to initial service plan, add rationale 748.1217(c)(15) for appropriateness of admission Narrative: Child was admitted on 04/24/13 as a non-emergency placement and Admission Assessment was completed on 05/09/13. Medium Low Category Short Description Weight Personnel Caregiver responsibility-for a child receiving treatment services for 748.685(e) an emotional disorder must maintain daily, signed and dated progress notes Standard # TA Finding Deficiency TA Finding Medium Admn Rvw Waived Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Investigation 1970540 06/26/2013 12:00:00 Category Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight 748.683(1) Medium TA Finding Page 13 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Medication Administration of Medication-Only the child for whom the prescription medication was prescribed may use the medication Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight 748.2003(b)(11) Medium High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3317660 05/29/2013 10:00:00 05/29/2013 12:39:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3315534 05/20/2013 11:30:00 05/20/2013 04:30:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3316007 05/20/2013 10:15:00 05/20/2013 11:34:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1962791 05/20/2013 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Medication Weight Medication Record-Must include accurate daily count of each 748.2151(c) prescribed medication Narrative: Child's May medication log reviewed found documentation of 05/07/13 and 05/11/13 did not reflect the accurate daily count. Medium High Category Standard # Weight 748.2551(c)(1) High Short Description Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and found to be in compliance. TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3313907 05/08/2013 01:40:00 05/08/2013 03:46:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1961701 05/08/2013 11:40:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 14 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Standard # Personnel Weight Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1960986 05/08/2013 12:00:00 TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Warning Letter/Due Notice given N Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment 748.2307(1) High Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High Category Short Description Standard # Weight Background Checks - TAC 745 Narrative: Required background checks - each person employed 745.615(a)(2) High Category Short Description Standard # Weight Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Date End: Warning Letter/Due Notice given Page 15 of 20 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Investigation Inspection 3313319 05/06/2013 12:37:00 05/06/2013 02:09:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3313130 05/06/2013 08:16:00 05/06/2013 11:46:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3312736 05/02/2013 10:30:00 05/02/2013 01:46:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1959397 05/02/2013 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.683(1) Medium Category Standard # Weight 748.685(a)(4) High Personnel Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1958782 04/23/2013 09:32:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard has been evaluated and found to be in compliance. High Category Short Description Standard # Weight Initial Service Plan-Include instructions to caregivers about discipline techniques Narrative: This standard has been evaluated and found to be in compliance. 748.1337(b)(1)(D)(ii) Medium High Category Standard # Weight 748.311 Medium Admission, Service Planning, Discharge Short Description Reports and Record Keeping Serious Incident Documentation-Documented in written report Narrative: This standard has been evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 16 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Background Checks - TAC 745 Required background checks - each person employed Narrative: This standard has been evaluated and found to be in compliance. 745.615(a)(2) High Category Standard # Weight Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard has been evaluated and found to be in compliance. High Category Standard # Weight 748.1531(a)(2) High Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard has been evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3310482 04/23/2013 09:32:00 04/23/2013 11:59:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1957298 04/18/2013 08:57:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: This standard was evaluated and found to be in compliance. 748.2551(a) Medium High Category Standard # Weight 748.2551(c)(1) High Emergency Behavior Intervention Short Description Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 17 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Category Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Standard # Emergency Behavior Intervention Not Available: 0 Weight Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention EBI Release-Child released from personal restraint as soon as child 748.2553(2)(C) is not a danger to self or others Narrative: This standard was evaluated and found to be in compliance. Medium High Category Short Description Standard # Weight EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and found to be in compliance. 748.2851(b) Medium Category Emergency Behavior Intervention Short Description Standard # Weight Pre-service training for emergency behavior intervention-Includes drawings, photographs, videos of each personal or mechanical restraint Narrative: This standard was evaluated and found to be in compliance. 748.903(c)(9) Medium High Category Standard # Weight Training and Professional Development Short Description Emergency Behavior Intervention EBI Documentation-Must include child's condition following EBI, 748.2855(a)(10) including any injury child sustained or any adverse effects caused by use of EBI Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3309453 04/18/2013 08:57:00 04/18/2013 11:39:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3308023 04/10/2013 01:30:00 04/10/2013 04:56:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3301394 03/07/2013 10:30:00 03/07/2013 05:04:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 18 of 20 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 3298775 02/22/2013 09:30:00 02/22/2013 04:05:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1946655 02/22/2013 12:00:00 N Category Short Description Standard # Weight Other Prohibited Punishments-using sarcastic or cruel humor, and verbal abuse Narrative: This standard was evaluated and found to be in compliance. 748.2307(4) Medium High Category Discipline and Punishment Short Description Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. 748.2307(1) High Category Short Description Standard # Weight Children's Rights Personal Care-Child has reasonable opportunities to select his clothing as outlined in the operation's policies 748.1105(1) Medium Low Short Description Standard # Weight Discipline and Punishment TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Category Children's Rights Children's rights-Adhere to the child's right to have adequate 748.1101(b)(12) personal clothing, suitable to his age and size and comparable with peers Narrative: This standard was evaluated and found to be in compliance TA Finding Medium Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1945213 02/13/2013 12:00:00 N Category Short Description Standard # Weight EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force Narrative: This standard was evaluated and found to be in compliance. 748.2551(c)(2) High Category Standard # Weight Emergency Behavior Intervention Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 19 of 20 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 16 High: 3 Medium High: 7 Run date: June 25, 2018 Compliance History Report Medium: 3 Report Criteria Period: 1/01/2013 To 12/31/2013 Category: Standard: Type: ALL Finding: Medium Low: 3 Organization and Administration Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Behavior intervention policies-Explain to the child what action the 748.237(5)(B)(vi) child must exhibit to be released from the intervention and document explanation Narrative: This standard was evaluated and found to be in compliance. Medium High Category Short Description Standard # Weight Personal Restraints Prohibited-Restraints that twist or place the child's limb(s) behind the child's back Narrative: This standard was evaluated and found to be in compliance. 748.2605(a)(5) High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention EBI Implementation-As soon as possible, caregiver must explain to 748.2551(e)(1) child the behaviors required for release or to have EBI reduced, as applicable Narrative: This standard was evaluated and found to be in compliance. Medium High Category Short Description Standard # Weight EBI Follow-Up-Caregivers involved in EBI must make reasonable efforts to debrief with children in care who witness the incident Narrative: This standard was evaluated and found to be in compliance. 748.2851(c)(2) Medium Low Category Standard # Weight Emergency Behavior Intervention Short Description Child Care Nutrition-Provide food of adequate variety, quality, and in sufficient 748.1693(a)(1) quantity to supply the nutrients needed for proper growth and development Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Discipline and Punishment Standard # Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Page 20 of 20 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3287898 12/20/2012 10:30:00 12/20/2012 12:29:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 3288168 12/20/2012 10:15:00 12/20/2012 03:51:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3284091 11/30/2012 12:46:00 11/30/2012 01:27:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3281366 11/15/2012 09:50:00 11/15/2012 12:54:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1930617 11/02/2012 10:36:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Personnel Short Description Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: Standard was evaluated and found to be in compliance. 748.683(1) Medium Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3278348 11/01/2012 09:09:00 11/01/2012 12:34:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3278302 11/01/2012 09:00:00 11/01/2012 03:22:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 1 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Investigation Category Run date: June 28, 2018 Compliance History Report Medium: 3 1929310 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 10/26/2012 10:10:00 Short Description N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight Background Checks - TAC 745 Required background checks - each person employed Narrative: This standard was evaluated and found to be in compliance. Short Description 745.615(a)(2) High Category Standard # Weight Short Description Emergency Behavior Intervention EBI Implementation-As soon as possible, caregiver must explain to 748.2551(e)(1) child the behaviors required for release or to have EBI reduced, as applicable Narrative: This standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # TA Finding TA Finding TA Finding Short Description Standard # Weight EBI Follow-Up-Caregivers must provide child with an appropriate 748.2851(a)(1) transition and offer child an opportunity to return to regular activities Narrative: This standard was evaluated and found to be in compliance. Medium Category Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the 748.2551(a) behavior demonstrated, and de-escalation must have failed Narrative: A resident restrained was not offered any of their preferred de-escalation techniques prior to being placed in a restraint. Medium High Category Short Description Weight Emergency Behavior Intervention EBI Release-Child released from personal restraint as soon as child 748.2553(2)(C) is not a danger to self or others Emergency Behavior Intervention Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Admn Rvw Compliance TA Finding EBI Follow-Up-Caregivers involved in EBI must conduct a post 748.2851(b) Medium discussion with child Narrative: Per review of external documentation and interviews, the post discussion was conducted by the supervisor on shift and not by any of the staff members who participated in the emergency behavior intervention. Emergency Behavior Intervention Admn Rvw Compliance Emergency Behavior Intervention Category Admn Rvw Compliance Deficiency TA Finding Admn Rvw Overturned Admn Rvw Compliance TA Finding Deficiency TA Finding Medium High Page 2 of 14 Compliance Admn Rvw Upheld Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Narrative: This standard was evaluated and found to be in compliance. Category Short Description Standard # Emergency Behavior Intervention Weight Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical 748.2551(c)(1) High Deficiency Upheld discomfort, harm, or pain to the child Narrative: A resident reported being inappropriately restrained. Also, per review of video recording, the staff member used excessive amounts of force, resulting in pain and discomfort to the resident being restrained. Category Short Description Standard # Discipline and Punishment Weight Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: During review of video recording, a staff member shoved a resident prior to initiating emergency behavior intervention. High Category Weight Short Description Standard # Personnel Employee general responsibilities-Demonstrate competency, 748.507(1) prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: After review of video recording, a staff member did not exhibit self-control both verbally and physically in initiating a restraint.. Medium High Category Weight Short Description Standard # TA Finding Deficiency TA Finding Deficiency TA Finding Emergency Behavior Intervention EBI Implementation-Caregiver must make every effort to protect 748.2551(d)(1) Medium the child's privacy, including shielding the child from onlookers Narrative: Based on review of camera recording and information gathered during interviews, two residents remained present while a third resident was restrained. Category Short Description Standard # Weight Emergency Behavior Intervention EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child 748.2851(b) Medium Short Description Standard # Weight Deficiency TA Finding Admn Rvw Overturned Admn Rvw Upheld Admn Rvw Waived Admn Rvw Compliance Narrative: Category Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 3 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Emergency Behavior Intervention Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 EBI Implementation-The caregiver must consider the characteristics 748.2551(b)(1) of the immediate physical environment Not Available: 0 High Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3277147 10/26/2012 10:10:00 10/26/2012 02:02:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 3276200 10/23/2012 07:00:00 10/23/2012 01:11:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3275581 10/18/2012 01:30:00 10/18/2012 03:57:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3274356 10/12/2012 01:00:00 10/12/2012 06:11:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1926614 10/12/2012 08:30:00 N Category Short Description Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: The standard evaluated was found to be in compliance. 748.2307(1) High Category Discipline and Punishment Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard evaluated was found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 4 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Emergency Behavior Intervention Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 EBI Orders-PRN for personal restraint that allows more than 3 restraints in 7 days must include a plan for reducing emergency behavior interventions Narrative: The standard evaluated was found to be in compliance. 748.2507(2)(B) Medium High Category Short Description Standard # Weight Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective Narrative: The standard evaluated was found to be in compliance. 748.2455(a)(1) Medium High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: The standard evaluated was found to be in compliance. 748.2551(a) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention Emergency Behavior Intervention Orders-Required order in child's 748.2503 record before EBI used, except verbal seclusion order if child endangers self/others Narrative: The standard evaluated was found to be in compliance. Medium High Category Weight Short Description Standard # Emergency Behavior Intervention EBI Orders-Written order must include a complete description of 748.2505(a)(4) the behaviors and circumstances under which the intervention may be used Narrative: The standard evaluated was found to be in compliance. Medium High Category Short Description Standard # Weight EBI Orders-For emergency medication, order must include instructions on how to administer the medication Narrative: The standard evaluated was found to be in compliance. 748.2505(b) Medium High Category Standard # Weight 748.2551(c)(2) High Emergency Behavior Intervention Short Description Emergency Behavior Intervention EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force Narrative: The standard evaluated was found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 5 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3274251 10/12/2012 08:30:00 10/12/2012 12:12:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1926231 10/12/2012 12:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Physical Site Toilets-Toilets must be equipped with toilet paper at all times 748.3393(d) Medium Low Standard # Weight TA Finding Admn Rvw Compliance Narrative: This standard was evaluated and found to be in compliance. Category Short Description Medication Administration of Medication-Administer medications according to 748.2003(b)(3) label instructions or a prescribing health-care professional's subsequent orders Narrative: This standard was evaluated and found to be in compliance. Medium High Category Short Description Standard # Weight Other Prohibited Punishments-subjecting a child to abusive or profane language Narrative: This standard was evaluated and found to be in compliance. 748.2307(9) Medium High Category Standard # Weight Discipline and Punishment Short Description Emergency Behavior Intervention EBI Implementation-The caregiver must consider the potential risk 748.2551(b)(3) of harm in using EBI versus the risk of not using EBI Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Emergency Behavior Intervention EBI Implementation-Must be an appropriate response to the 748.2551(a) Medium Deficiency Upheld behavior demonstrated, and de-escalation must have failed High Narrative: A staff member attempted to have a child comply with a request by touching a child's shoulder. This action led to aggressive act of a child and a restraint. De-escalation techniques were not offered prior to the start of the restraint. Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 6 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Emergency Behavior Intervention EBI Implementation-Caregiver must make every effort to protect the child's privacy, including shielding the child from onlookers Narrative: Staff members did not protect the privacy of a child being restrained. Weight: Id/Number: Admin Review Status: Low: 0 748.2551(d)(1) Not Available: 0 Medium Deficiency Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3273896 10/11/2012 10:51:00 10/11/2012 12:44:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1926471 10/11/2012 09:46:00 Category Short Description Warning Letter/Due Notice given N Standard # Emergency Behavior Intervention Weight Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: Standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: Standard was evaluated and found to be in compliance. 748.2551(a) Medium High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: Standard was evaluated and found to be in compliance. 748.2551(c)(1) High Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention EBI Release-Child released from personal restraint as soon as child 748.2553(2)(C) is not a danger to self or others Narrative: Standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Children's Rights Standard # Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Page 7 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Category Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: Standard was evaluated and found to be in compliance. 748.2307(1) High Category Standard # Weight 748.2851(b) Medium Discipline and Punishment Short Description Emergency Behavior Intervention EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3268802 09/18/2012 10:00:00 09/18/2012 01:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3268451 09/17/2012 10:30:00 09/17/2012 03:54:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1921913 09/17/2012 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Reports and Record Keeping Serious Incident-Report to Licensing as soon as aware of a suicide 748.303(a)(11)(A) attempt by a child Narrative: This standard was reviewed and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3262461 08/15/2012 09:15:00 08/15/2012 09:53:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 3260014 08/01/2012 10:35:00 08/01/2012 12:38:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 8 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring and Investigation Inspection 3259426 07/30/2012 09:30:00 07/30/2012 03:00:00 N Category Short Description Admission, Service Planning, Discharge Initial Service Plan-Include instructions to caregivers about level of 748.1337(b)(1)(D)(i) supervision required Standard # Weight Medium High Category Short Description Weight Admission, Service Planning, Discharge Service Plan Review-If child receiving treatment services for ED, 748.1381(2) PDD, or PMN, review at least 90 days from date of last service plan Medium Low Category Short Description Weight Admission, Service Planning, Discharge Service Plan Review-Must identify any new needs and strategies or 748.1385(2) techniques to meet these needs, including instructions to employees Medium Low Short Description Weight TA Finding Admn Rvw Compliance Narrative: Standard # TA Finding Admn Rvw Compliance Narrative: Standard # TA Finding Admn Rvw Compliance Narrative: Category Standard # Admission, Service Planning, Discharge Service Plan Review-Must comply with notification, participation, 748.1387 implementation, and documentation requirements for an initial service plan Narrative: One caregiver must be involved in the initial and service plan reviews. TA Finding Medium Low Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3221348 07/06/2012 01:05:00 07/06/2012 02:49:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1881819 07/06/2012 12:00:00 N Category Short Description Standard # Personnel Weight Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Page 9 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Personnel Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Short Description Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Child/Caregiver Ratios Child/caregiver ratio-Caregiver may care for 5 children if any 748.1003(a) require tx svcs, 8 children if not; children under 5 yrs old count as 2 children Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3209384 06/28/2012 09:00:00 06/28/2012 10:40:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3175164 06/08/2012 12:30:00 06/08/2012 01:27:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1851420 06/07/2012 02:00:00 N Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance 748.507(1) Medium High Category Personnel Short Description Standard # Weight Children's rights-Adhere to the child's right to discipline that is appropriate to the child's age and developmental level; Narrative: This standard was evaluated and found to be in compliance. 748.1101(b)(6) Medium High Category Standard # Weight Children's Rights Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 10 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Children's Rights Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Children's rights-Adhere to the child's rights to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating punishment Narrative: This standard was evaluated and found to be in compliance 748.1101(b)(5) High Category Standard # Weight Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance High Category Standard # Weight 748.1101(b)(5)(B) High Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from being subjected to corporal punishment Narrative: This standard was evaluated and found to be in compliance Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3176310 06/07/2012 02:00:00 06/07/2012 04:26:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3157364 05/24/2012 01:00:00 05/25/2012 01:44:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3053434 03/13/2012 01:30:00 03/13/2012 03:45:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 3018806 02/14/2012 11:00:00 02/14/2012 04:30:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Standard # Weight High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed 748.2551(a) Medium High TA Finding Admn Rvw Compliance Narrative: TA Finding Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 11 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Category Short Description Standard # Weight Emergency Behavior Intervention EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child 748.2551(c)(1) High Category Short Description Standard # Weight Emergency Behavior Intervention EBI Release-Child released from personal restraint as soon as child 748.2553(2)(C) is not a danger to self or others TA Finding Admn Rvw Compliance Narrative: TA Finding Medium High Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3022824 02/14/2012 11:00:00 02/14/2012 04:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1725661 02/14/2012 12:00:00 N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free from being denied food, sleep, toileting facilities, mail, or family visits as punishment Narrative: This standard was evaluated and found to be in compliance. Standard # Weight 748.1101(b)(5)(E) High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3015203 02/09/2012 12:30:00 02/09/2012 02:16:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3012204 02/06/2012 11:55:00 02/06/2012 02:49:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1721595 02/06/2012 12:00:00 Category Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given N Standard # Weight 748.683(1) Medium TA Finding Page 12 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Category Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight 748.685(a)(4) High TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1722361 01/30/2012 09:45:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. High Category Short Description Standard # Weight Emergency Behavior Intervention-Never used as a means to get a child to comply Narrative: Standard evaluated and found to be in compliance. 748.2463(3) Medium High Category Standard # Weight Emergency Behavior Intervention Short Description Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Standard evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3010006 01/30/2012 09:45:00 01/30/2012 10:32:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 3007309 01/23/2012 01:00:00 01/23/2012 03:34:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 3003053 01/12/2012 11:00:00 01/12/2012 03:49:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1716035 01/12/2012 12:00:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 13 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 9 High: 2 Medium High: 3 Category Run date: June 28, 2018 Compliance History Report Medium: 3 Report Criteria Period: 01/01/2012 To 12/31/2012 Category: Standard: Type: ALL Finding: Medium Low: 1 Short Description Weight: Id/Number: Admin Review Status: Low: 0 Not Available: 0 Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be compliant. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Child/Caregiver Ratios Child/caregiver ratio-Caregiver may care for 5 children if any 748.1003(a) require tx svcs, 8 children if not; children under 5 yrs old count as 2 children Narrative: This standard was evaluated and found to be compliant. TA Finding Admn Rvw Compliance TA Finding Medium High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 3001406 01/11/2012 09:30:00 01/11/2012 02:58:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 14 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2989347 12/28/2011 12:00:00 12/28/2011 12:35:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2981404 12/09/2011 09:00:00 12/09/2011 02:32:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2978572 12/06/2011 09:56:00 12/06/2011 01:03:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2974580 11/29/2011 01:30:00 11/29/2011 02:36:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1692336 11/21/2011 02:13:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight TA Finding Admn Rvw Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) High Deficiency Upheld neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The caregiver breached his duty as a caregiver when he restrained a resident at the operation without sufficient cause. The caregiver did not use the minimal amount of force necessary in the incident, and caused the child to sustain an injury to a vital body area. Category Short Description Standard # Weight TA Finding Emergency Behavior Intervention Admn Rvw EBI Implementation-Caregiver must minimize risk of physical 748.2551(c)(1) High Deficiency discomfort, harm, or pain to the child Narrative: The caregiver caused injury to the child when he restrained the child and threw him to the floor. The child stated he had difficulty breathing during the restraint. Overturned Category Admn Rvw Short Description Standard # Reports and Record Keeping Weight Serious Incident-Report to Licensing as soon as aware of 748.303(a)(3)(A) allegations or indications of abuse, neglect, or exploitation of a child Narrative: This standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Standard # Emergency Behavior Intervention Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Compliance TA Finding Admn Rvw Compliance TA Finding Page 1 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Emergency Behavior Intervention EBI Implementation-Must be an appropriate response to the 748.2551(a) Medium Deficiency Waived behavior demonstrated, and de-escalation must have failed High Narrative: The implementation of the restraint was not an appropriate response to the child's behavior. The child was not in danger of harming himself or others at the time the restraint was initiated. Category Short Description Standard # Emergency Behavior Intervention Weight EBI Release-Child released from personal restraint as soon as child 748.2553(2)(C) is not a danger to self or others Narrative: The child did not appear to be a danger to himself of others and should have been released from the restraint sooner. Medium High Category Short Description Standard # Weight EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: This standard was evaluated and found to be in compliance. 748.2851(b) Medium Category Standard # Weight Emergency Behavior Intervention Short Description Emergency Behavior Intervention Personal Restraint Monitor-Qualified caregiver monitors child for 748.2601(a) signs of physical distress & ensures ample respiration, circulation, well-being Narrative: The staff member who was present during the implementation of the restraint did not properly monitor the child for signs of distress. High Category Weight Short Description Standard # Personnel Implement and follow the children's service plans. 748.685(c)(6) Narrative: The staff member did not follow the child in care's treatment plan by failing to utilize his preferred method of de-escalation. Medium Category Weight Short Description Standard # TA Finding Deficiency TA Finding Admn Rvw Overturned Admn Rvw Compliance TA Finding Deficiency TA Finding Deficiency TA Finding Admn Rvw Upheld Admn Rvw Waived Admn Rvw Emergency Behavior Intervention EBI Implementation-Caregiver must use the minimal amount of 748.2551(c)(2) High Deficiency Waived reasonable and necessary physical force Narrative: The caregiver failed to use the minimal amount of physical force necessary during the implementation of the restraint by lifting the child off the ground and then dropping the child to the ground. The staff member put his body on top of the child while on the ground and put pressure on the child's torso. Category Short Description Standard # Weight TA Finding Emergency Behavior Intervention Admn Rvw Personal Restraints Prohibited-Restraints that impair child's 748.2605(a)(1) High Deficiency breathing by putting pressure on child's torso Narrative: The staff member implemented a prohibited restraint technique when he put the weight of his body on top of the child's torso while lying on the ground. Upheld Category Admn Rvw Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 2 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Personnel Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) High Deficiency ensure child's safety Narrative: A staff member who was not involved in the restraint of the child in care was present during the restraint and did not intervene to ensure the child's safety. Overturned Category Admn Rvw Short Description Standard # Weight TA Finding Personnel Caregiver responsibility - provide a safe environment 748.685(c)(2) High Narrative: The staff members failed to provide a safe environment for the child in care due to using prohibited restraint techniques and causing harm to the child. Category Short Description Standard # Organization and Administration Weight General operational policies-Employees must be aware of and 748.231(d) follow policies and procedures and have a copy at the operation for their review Narrative: The staff member did not follow operation policy regarding appropriate and approved restraint techniques. Medium Category Weight Short Description Standard # Emergency Behavior Intervention Emergency Behavior Intervention-Basis for EBI is an emergency 748.2455(a)(2) situation or to administer medication Narrative: The situation was not an emergency as defined by minimum standards, and therefore did not warrant a restraint to be implemented. Deficiency TA Finding Deficiency TA Finding Medium High Deficiency Upheld Admn Rvw Waived Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2972728 11/21/2011 02:13:00 11/21/2011 03:55:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2970772 11/18/2011 09:30:00 11/18/2011 11:29:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1689115 11/18/2011 12:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2967358 11/14/2011 09:45:00 11/14/2011 02:03:00 N Category Short Description Emergency Behavior Intervention EBI Implementation-As soon as possible, caregiver must permit the 748.2551(e)(2) child to suggest actions caregivers can take to help the child de-escalate Standard # Weight TA Finding Medium High Narrative: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 3 of 23 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1687175 11/11/2011 12:00:00 N Category Short Description Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in commpliance. 748.683(1) Medium Category Standard # Weight Personnel Short Description Background Checks - TAC 745 Required background checks - Persons 14 years or older, other than 745.615(a)(7) clients, who will regularly or frequently be present while children are in care Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Reports and Record Keeping Reporting serious incident-All serious incident reports to Licensing 748.309(a) must be made to the Child Abuse Hotline Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Medium Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1676616 10/28/2011 08:45:00 N Category Short Description Standard # Weight EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child Narrative: The standard evaluated was found to be in compliance. 748.2551(c)(1) High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Release-Child released from short personal restraint immediately in emergency health situation and treatment obtained immediately Narrative: The standard evaluated was found to be in compliance. 748.2553(1)(A) High Category Standard # Weight Emergency Behavior Intervention Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 4 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Children's Rights Not Available: 0 Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention Emergency Behavior Intervention-Only a qualified caregiver may 748.2453 administer emergency behavior intervention, except short personal restraint Narrative: The standard evaluated was found to be in compliance. High Category Short Description Standard # Weight EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed Narrative: The standard evaluated was found to be in compliance. 748.2551(a) Medium High Category Emergency Behavior Intervention Short Description Standard # Weight Short Personal Restraint-Caregiver may not use restraint that obstructs the caregiver's view of the child's face Narrative: The standard evaluated was found to be in compliance. 748.2461(b)(4) High Category Emergency Behavior Intervention Short Description Standard # Weight EBI Follow-Up-Caregivers involved in EBI must conduct a post discussion with child Narrative: The standard evaluated was found to be in compliance. 748.2851(b) Medium Category Emergency Behavior Intervention Short Description Standard # Weight Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force Narrative: The standard evaluated was found to be in compliance. 748.2461(a)(2) High Category Standard # Weight 748.1531(a)(2) High Emergency Behavior Intervention Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: The standard was evaluated and found to be in compliance. Activity Type: Inspection Id Note: Prior to January 1, 2007, all Standards were not associated with a weight. Date Begin: Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Date End: Admn Rvw Compliance Warning Letter/Due Notice given Page 5 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Investigation Inspection 2956666 10/28/2011 08:00:00 10/28/2011 11:35:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2952369 10/24/2011 06:30:00 10/24/2011 08:30:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1674405 10/24/2011 08:30:00 N Category Standard # Weight Personnel Caregiver responsibility - provide a safe environment Narrative: Based on the information obtained during this inspection, there was not a violation of this standard. Short Description 748.685(c)(2) High Category Standard # Weight Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Based on the information obtained during this inspection, there was not a violation of this standard High Category Weight Short Description Standard # Personnel Employee general responsibilities-Know and comply with rules of 748.507(3) Chapter 748 and any other rules and laws relevant to person's duties Narrative: Based on the information obtained during this inspection, there was not a violation of this standard Medium High Category Standard # Weight 748.683(1) Medium Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: Based on the information obtained during this inspection, there was not a violation of this standard TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2951819 10/24/2011 08:30:00 10/24/2011 01:25:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2948943 10/19/2011 08:30:00 10/19/2011 04:13:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2949144 10/19/2011 08:30:00 10/19/2011 04:14:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 6 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Investigation Inspection 2941695 10/12/2011 09:00:00 Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1663706 10/12/2011 12:00:00 N Category Short Description 10/12/2011 03:29:00 Standard # Admission, Service Planning, Discharge N Weight Admission Documentation-Identification of child's high risk 748.1205(a)(13) behaviors and related safety plan staff and caregivers will implement Narrative: No safety plan was addressed during admission for a resident wih a history of high risk behaviors. High Category Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Admission, Service Planning, Discharge Initial Service Plan-Complete the initial service plan within 40 days 748.1335 after admission Narrative: One out of two children records reviewed found the Initial Service Plan was completed prior to admission date. Medium Low Category Short Description Standard # Weight Caregiver responsibility - be aware of children's habits, interests, and any special needs Narrative: This standard was evaluated and found to be in compliance. 748.685(c)(1) Medium High Category Standard # Weight Personnel Short Description TA Finding Deficiency TA Finding Admn Rvw Overturned Admn Rvw Compliance TA Finding Deficiency TA Finding Admn Rvw Upheld Admn Rvw Compliance TA Finding Admn Rvw Admission, Service Planning, Discharge Initial Service Plan-Implement & follow plan as soon as all team 748.1351 Medium Deficiency Upheld members have reviewed/signed it, but no later than 10 days after Low date of meeting Narrative: One out of two children records reviewed found the Service Plan Meeting was held on 08/04/11 and the plan was not shared with child until 08/29/11 and with a treatment team member until 08/20/11. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2941109 10/10/2011 08:00:00 10/10/2011 12:03:00 N Activity Type: Investigation Number Date Intake Rcvd: Note: Prior to January 1, 2007, all Standards were not associated with a weight. Warning Letter/Due Notice given Page 7 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Investigation Category Run date: June 28, 2018 Compliance History Report Medium: 4 1660495 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 10/04/2011 09:15:00 Short Description N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This minimum standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Texas Family Code, Chapter 261 Admn Rvw Interference with Investigation/court order-person may not interfere TFC261.303 High Deficiency with investigation of report of child abuse or neglect conducted by licensing Narrative: Two staff members reported to speaking with other operation staff about information that was sensitive to this investigation prior to being interviewed by Licensing. Waived Category Admn Rvw Short Description Standard # Weight Governing body responsibilities-Approving and having authority over the facility's operational policies and activities Narrative: This minimum standard was evaluated and found to be in compliance. 748.131(a)(3) Medium Category Standard # Weight Organization and Administration Short Description Reports and Record Keeping Serious Incident-Report to Licensing as soon as aware of 748.303(a)(3)(A) allegations or indications of abuse, neglect, or exploitation of a child Narrative: Two staff members did not report allegations of abuse to Licensing in a timely manner. Medium High Category Weight Short Description Standard # Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Narrative: This minimum standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This minimum standard was evaluated and found to be in compliance. 748.507(1) Medium High Category Short Description Standard # Weight Personnel Child-care administrator responsibilities-Overseeing staffing patterns to ensure supervision and child-care services meet the needs of children 748.535(2)(A) Medium High Personnel Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Compliance TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 8 of 23 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Narrative: This minimum standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2935884 10/04/2011 09:15:00 10/04/2011 04:23:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2929467 09/23/2011 11:00:00 09/23/2011 03:07:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1651296 09/23/2011 12:00:00 N Category Short Description Standard # Personnel Weight Caregiver responsibility - providing the level of supervision 748.685(a)(4) necessary to ensure each child's safety and well-being Narrative: Children with known histories of inappropriate behavior were not supervised appropriately and were able to act out inappropriately. High Category Weight Short Description Standard # Personnel Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Narrative: Standard evaluated and found in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1649475 09/19/2011 10:20:00 Category Short Description Deficiency TA Finding High Weight High Category Weight Standard # TA Finding Standard # Weight Admn Rvw Compliance TA Finding Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) High such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Based on the information obtained during this investigation , there is not enough information to determine if corporal punishment was used. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Admn Rvw Compliance Discipline and Punishment Short Description Overturned N Standard # Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Based on the information obtained in this investigation, there is not enough evidence to determine if abuse occurred. Category Admn Rvw Warning Letter/Due Notice given Children's Rights Short Description TA Finding Admn Rvw Compliance TA Finding Page 9 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Personnel Employee general responsibilities-Demonstrate competency, 748.507(1) prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: A staff member did not demonstrate self control or competency when he struck residents in the course of his job. Not Available: 0 Medium High Deficiency Overturned Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2923524 09/19/2011 10:15:00 09/19/2011 11:34:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2916846 09/09/2011 10:00:00 09/09/2011 11:55:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2914507 09/07/2011 09:45:00 09/07/2011 12:47:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2900743 08/22/2011 09:30:00 08/22/2011 01:59:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1627300 08/22/2011 12:00:00 N Category Short Description Standard # Weight TA Finding Admn Rvw Medication Administration of Medication-Ensure the child has taken the 748.2003(b)(5) Medium Deficiency Overturned medication as prescribed High Narrative: Three residents were able to cheek medications. Some of the residents snorted the medications and one child sold medications. The facility was notified of the cheeking of the medication and improper medication procedures in March 2011. The facility now has the residents eat a snack after taking medications and sit in a common area for at least 10 minutes to be supervised. Category Short Description Child/Caregiver Ratios Child/caregiver ratio-Must employ an adequate number of caregivers to meet children's needs and consider amount of supervision needed Narrative: This standard was evaluated and found to be in compliance. Standard # Weight 748.1009(a) High TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1628257 08/15/2011 11:30:00 N Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding Page 10 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Emergency Behavior Intervention Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing Narrative: This standard was evaluated and found to be in compliance. 748.2461(b)(3) High Category Standard # Weight Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Emergency Behavior Intervention Short Personal Restraint-Caregiver must use minimal amount of 748.2461(a)(2) High Deficiency Waived reasonable and necessary physical force Narrative: Staff used excessive force when trying to turn the child toward the wall to prevent the child from kicking. The staff also admitted that when the child tried to grab his private parts is when he reacted by using additional force. Staff did not use the minimal amount of reasonable force to control the child during the restraint. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2897024 08/15/2011 10:45:00 08/15/2011 01:45:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2894282 08/09/2011 10:00:00 08/09/2011 03:04:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1622020 08/09/2011 12:00:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's right to have a humane 748.1101(b)(8) environment, including any treatment environment, which provides protection from harm Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2307(1) High Short Description Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 11 of 23 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Activity Type: Inspection Id Date Begin: Follow-up Inspection 2885572 07/27/2011 10:40:00 Category Run date: June 28, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Date End: Warning Letter/Due Notice given 07/27/2011 03:44:00 Standard # N Weight TA Finding Admn Rvw Training and Professional Development Annual Training-Caregivers in an operation that provides a certain 748.931(a)(2)(A) Medium Compliance amount of treatment services must complete 50 hrs Narrative: One staff member record that was reviewed at the last inspection did not complete all 2010 hours had made up the additional hours by applying the first year quarter hours of 2011. The staff member will need to still complete 50 hours for the 2011 training year. Activity Type: Inspection Id Date Begin: Monitoring Inspection 2875263 07/08/2011 10:00:00 Category Short Description Date End: Warning Letter/Due Notice given 07/08/2011 03:42:00 Standard # Training and Professional Development Annual Training-Caregivers in an operation that provides a certain 748.931(a)(2)(A) amount of treatment services must complete 50 hrs Narrative: One of three staff members records reviewed was missing training hours. The staff member needs 4 additional training hours. N Weight TA Finding Medium Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 2856668 06/14/2011 09:00:00 06/15/2011 03:02:00 N Category Short Description Medication Administration of Medication-Ensure the child has taken the medication as prescribed Narrative: This standard was evaluated and found to be in compliance. Activity Type: Inspection Id Date Begin: Monitoring Inspection 2856667 06/14/2011 09:00:00 Category Short Description Standard # Weight 748.2003(b)(5) Medium High TA Finding Date End: Warning Letter/Due Notice given 06/15/2011 02:58:00 Standard # Admn Rvw Compliance N Weight TA Finding Admission, Service Planning, Discharge Admn Rvw Initial Service Plan-Service planning team must include at least one 748.1339(a)(1) Low Deficiency Waived of the child's current caregivers Narrative: One of four children's records reviewed did not have the signatures of who participated in the service planning. A caseworker did sign off on the admission assessment. The initial service plan was later signed during the inspection. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 12 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Activity Type: Inspection Id Date Begin: Follow-up Inspection 2826605 05/23/2011 09:00:00 Category Run date: June 28, 2018 Compliance History Report Short Description Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Date End: Warning Letter/Due Notice given 05/23/2011 04:38:00 N Standard # Weight Mandatory Drug Testing-All Employees are Subject to Random, Unannounced Drug Testing Narrative: This standard was evaluated and found to be in compliance. 745.4151(c)(4)(B) High Category Drug Testing - TAC 745 Short Description Standard # Weight Permit holder responsibilities-Maintain true, current, accurate, and 748.103(a)(3) complete records at operation for Licensing's review Narrative: This standard was evaluated and found to be in compliance. Medium Category Weight Organization and Administration Short Description Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Admission, Service Planning, Discharge Admission Documentation-Identification of child's high risk 748.1205(a)(13) High Compliance behaviors and related safety plan staff and caregivers will implement Narrative: Licensing provided training to the facility on 05/23/11 regarding Admission Assessment and Service Plan. The agency is given until 06/15/11 to come into compliance. Records will be reviewed for compliance after that date. Category Short Description Standard # Weight TA Finding Admn Rvw Admission, Service Planning, Discharge Admission Assessment-At admission, must include child's legal 748.1217(b)(1) Low Compliance status Narrative: Licensing provided training to the facility on 05/23/11 regarding Admission Assessment and Service Plan. The agency is given until 06/15/11 to come into compliance. Records will be reviewed for compliance after that date. Category Short Description Standard # Weight TA Finding Admn Rvw Admission, Service Planning, Discharge Admission Assessment-Prior to initial service plan, add child's birth 748.1217(c)(3) Low Compliance and neonatal history Narrative: Licensing provided training to the facility on 05/23/11 regarding Admission Assessment and Service Plan. The agency is given until 06/15/11 to come into compliance. Records will be reviewed for compliance after that date. Category Short Description Standard # Weight TA Finding Admission, Service Planning, Discharge Admn Rvw Preliminary Service Plan-For child receiving treatment services, 748.1331(b)(5) Medium Compliance designate who will be responsible for meeting each of the child's Low needs Narrative: Licensing provided training to the facility on 05/23/11 regarding Admission Assessment and Service Plan. The agency is given until 06/15/11 to come into compliance. Records will be reviewed for compliance after that date. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 13 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Category Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Short Description Standard # Admission, Service Planning, Discharge Initial Service Plan-Complete the initial service plan within 40 days 748.1335 after admission Narrative: Initial Service Plan should not be completed on the day of placement. Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Weight TA Finding Medium Low Admn Rvw Compliance Licensing provided training to the facility on 05/23/11 regarding Admission Assessment and Service Plan. The agency is given until 06/15/11 to come into compliance. Records will be reviewed for compliance after that date. Category Short Description Standard # Weight TA Finding Admn Rvw Admission, Service Planning, Discharge Initial Service Plan-Include child's needs identified in admission 748.1337(b)(1)(A) Medium Compliance assessment Low Narrative: Licensing provided training to the facility on 05/23/11 regarding Admission Assessment and Service Plan. The agency is given until 06/15/11 to come into compliance. Records will be reviewed for compliance after that date. Category Short Description Standard # Weight TA Finding Admn Rvw Admission, Service Planning, Discharge Initial Service Plan-For child who exhibits high risk behaviors, 748.1337(b)(1)(H) Medium Compliance include plans to minimize risk of harm to self or others High Narrative: Licensing provided training to the facility on 05/23/11 regarding Admission Assessment and Service Plan. The agency is given until 06/15/11 to come into compliance. Records will be reviewed for compliance after that date. Category Short Description Standard # Weight TA Finding Admn Rvw Admission, Service Planning, Discharge Initial Service Plan-Must give the child's parent(s) at least two 748.1341(a) Low Compliance weeks advance notice of the meeting Narrative: Shiloh will print the weekly staff schedule for each month two weeks prior to the beginning of the month and email it to the parent/managing conservator. A copy of this email will be placed in the file. Category Short Description Standard # Weight TA Finding Admn Rvw Admission, Service Planning, Discharge Initial Service Plan-PLSP must sign and date the plan; If PLSP 748.1347(b) Low Compliance disagrees with any portion of the plan, he must document issue(s) before signing it Narrative: The agency submitted their corrective action plan stating that Shiloh will include a line for the date next to each signature line to indicate the date the treatment plan was reviewed and accepted by the PLSP. Category Short Description Standard # Weight Medication Administration of Medication-Ensure the child has taken the medication as prescribed 748.2003(b)(5) Medium High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 14 of 23 Deficiency Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Narrative: One out of four medication records reviewed found a resident did not receive his medication for 05/19/11 as required. Category Short Description Standard # Weight Medication Record-Must include date (day, month, year) & time each medication was administered Narrative: This standard was evaluated and found to be in compliance. 748.2151(b)(5) Medium High Category Medication Standard # Weight Reports and Record Keeping Personnel records-Include date of employment Narrative: This standard was evaluated and found to be in compliance. Short Description 748.363(1) Medium Category Standard # Weight Short Description Reports and Record Keeping Personnel records-Include notarized Licensing Affidavit for 748.363(6) Applicants for Employment form as specified in Human Resources Code, 42.059 Narrative: This standard was evaluated and found to be in compliance. Medium Category Standard # Weight 748.949(b)(4) Medium Low Short Description Training and Professional Development Annual Training Documentation-Includes the trainer's name and qualifications, or the source of the training for self-instructional training Narrative: This standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2826607 05/23/2011 09:00:00 05/23/2011 04:39:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1550491 05/06/2011 12:00:00 N Category Short Description Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in complaince. 748.683(1) Medium Category Standard # Weight Personnel Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 15 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Emergency Behavior Intervention Personal Restraints Prohibited-Restraints that twist or place the 748.2605(a)(5) High Deficiency Overturned child's limb(s) behind the child's back Narrative: A two man upper torso restraint was performed on a child and during the restraint the child struggled to get away from staff. Due to the child struggling, the child's arms became in position behind the child's back. Facility was made aware of this during an inspection on 5/23/11 after video was reviewed. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2801875 05/05/2011 01:00:00 05/06/2011 04:35:00 N Category Short Description Standard # Weight TA Finding Admission, Service Planning, Discharge Admission Documentation-Identification of child's high risk 748.1205(a)(13) High behaviors and related safety plan staff and caregivers will implement Narrative: Two out of 4 children records reviewed found child exhibits high risk behaviors and no safety plan was created to ensure child and other's safety. Category Short Description Standard # Weight Admission, Service Planning, Discharge Placement agreement-Must include the reason for placement & anticipated length of time in care 748.1207(3) Low Short Description Standard # Weight Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance Narrative: Category TA Finding Admission, Service Planning, Discharge Admission Assessment-At admission, must include child's legal 748.1217(b)(1) Low status Narrative: Two out of four children records reviewed found Admission Assessment was not completed prior to placement for non-emergency admission. Category Short Description Standard # Weight Deficiency TA Finding Admn Rvw Waived Admn Rvw Admission, Service Planning, Discharge Admission Assessment-Prior to initial service plan, add child's birth 748.1217(c)(3) Low Deficiency Waived and neonatal history Narrative: Must obtain the following information prior to completion of Service Plan: -Child's birth and neonatal history -Child's grades earned and special achievements at previous schools. -Child's skills and special interests. Category Short Description Admission, Service Planning, Discharge Emergency Admission Documentation-Include brief description of 748.1271(1) circumstances necessitating emergency admission Standard # Weight Medium Low Short Description Weight TA Finding Admn Rvw Compliance Narrative: Category Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Page 16 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Admission, Service Planning, Discharge Preliminary Service Plan-For child receiving treatment services, 748.1331(b)(5) Medium Deficiency Waived designate who will be responsible for meeting each of the child's Low needs Narrative: Four children records reviewed found Preliminary Service Plan was not signed and dated. Service Plan did not address immediate needs (educational, medical, dental needs) including possible Side effects of medications or treatment prescribed. No documentation of how needs will be met, and designate responsible person for meeting each need. Category Short Description Standard # Admission, Service Planning, Discharge Weight Initial Service Plan-Complete the initial service plan within 40 days 748.1335 after admission Narrative: Initial Service Plan should not be completed on the day of placement. Medium Low Category Weight Short Description Standard # TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Admission, Service Planning, Discharge Initial Service Plan-Include child's needs identified in admission 748.1337(b)(1)(A) Medium Deficiency Waived assessment Low Narrative: The following information is missing from your Service Plan: -Medical/Dental needs (scheduled exams, plans for recommended follow-ups) -Plan for social, recreation, leisure activities. -Plan for integrating child into community as appropriate -Cultural identity needs -Recent data from current caregiver's evaluation of child behavior's level of functioning -Plan for trips or visits away from operation. -If child 13 or older, plan for educating child on: *Healthy interpersonal relationships *Healthy boundaries *Pro-social communication skills *Human reproduction -If child 14 or older, provide training in experiential life skills -If child 16 or older, preparation for independent living -Discharge plan Category Short Description Standard # Weight TA Finding Admn Rvw Admission, Service Planning, Discharge Initial Service Plan-For child who exhibits high risk behaviors, 748.1337(b)(1)(H) Medium Deficiency Waived include plans to minimize risk of harm to self or others High Narrative: Two out of four children records reviewed child exhibits high risk behaviors and Service Plan did not include a safety contract between child and operation to minimize risk of harm to self/others. Category Short Description Standard # Admission, Service Planning, Discharge Weight Initial Service Plan-Must give the child's parent(s) at least two 748.1341(a) weeks advance notice of the meeting Narrative: Four children records reviewed found advance two weeks notice of service plan meeting was not given to managing conservator. Low Category Short Description Standard # Weight Initial Service Plan-PLSP must sign and date the plan; If PLSP disagrees with any portion of the plan, he must document issue(s) before signing it Narrative: PLSP must sign and date the Service Plan. Document sharing plan or summary with parents 748.1347(b) Low Category Standard # Weight Admission, Service Planning, Discharge Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Deficiency TA Finding Deficiency TA Finding Page 17 of 23 Admn Rvw Waived Admn Rvw Waived Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Child Care Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Immunizations-Immunization record must include the child's name 748.1543(a)(1) and birth date Medium Low Category Short Description Standard # Weight Recreation Activities Recreation responsibility-Child receiving treatment services-caregiver must ensure the child has opportunities to participate in community activity 748.3701(e)(2)(A) Medium Low Compliance Narrative: TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2800507 05/04/2011 09:15:00 05/04/2011 10:10:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1530135 04/20/2011 11:40:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Based on the information obtained during this investigation, there was not a violation of this standard High Category Weight Short Description Standard # Discipline and Punishment Corporal Punishment-May not use/threaten corporal punishment, 748.2303(a) such as hitting/spanking, forced exercise, holding physical position, unproductive work. Narrative: Based on the information obtained during this investigation, there was not a violation of this standard. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2781444 04/20/2011 11:40:00 04/20/2011 02:58:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Follow-up Inspection 2770454 04/13/2011 08:30:00 04/13/2011 04:00:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2753524 03/29/2011 10:00:00 03/30/2011 11:57:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 18 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2750484 03/25/2011 12:01:00 03/25/2011 03:34:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2750280 03/25/2011 12:00:00 03/25/2011 03:33:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1505270 03/25/2011 12:00:00 N Category Short Description Standard # Admission, Service Planning, Discharge Weight Admission Documentation-Identification of child's high risk 748.1205(a)(13) behaviors and related safety plan staff and caregivers will implement Narrative: This standard was evaluated and found to be in compliance. High Category Short Description Standard # Weight Capacity-Must not exceed capacity on permit, includes adults in care, children receiving respite care, and caregiver's own children sharing space Narrative: This standard was evaluated and found to be in complaince. 748.109 Medium High Category Organization and Administration Short Description Standard # Weight Fire Inspection-State or local fire inspector must conduct fire inspection Narrative: This standard was evaluated and found to be in compliance. 748.3103(a) Medium Category Safety and Emergency Practices Short Description Standard # Weight Admission Assessment-Prior to initial service plan, add determination of whether operation can meet child's needs Narrative: This standard was evaluated and found to be in compliance. 748.1217(c)(14) Medium Low Category Standard # Weight Admission, Service Planning, Discharge Short Description Children's Rights Children's rights-Adhere to the child's rights to appropriate care and 748.1101(b)(1) treatment in least restrictive setting available that meets the child's needs Narrative: This standard was evaluated and found to be in compliance. Medium High Category Weight Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 19 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Admission, Service Planning, Discharge Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Admission-Operation may only admit children and young adults who meet admission policy and whose needs can be met at the operation Narrative: This standard was evaluated and found to be in compliance. 748.1203(a) Medium Category Standard # Weight 748.3101(2) Medium High Short Description Safety and Emergency Practices Fire Inspection-Must have fire inspection at least once every 12 months from date of last fire inspection Narrative: This standard was evaluated and found to be in compliance. Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2746985 03/22/2011 01:00:00 03/22/2011 02:42:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2746749 03/22/2011 10:40:00 03/22/2011 11:36:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1499008 03/17/2011 10:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.2307(1) High Short Description Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standards was evaluted and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2743469 03/17/2011 10:00:00 03/17/2011 12:38:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2743160 03/16/2011 09:30:00 03/17/2011 05:13:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 20 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Investigation Inspection 2736890 03/09/2011 09:00:00 03/09/2011 12:12:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2733364 03/04/2011 10:00:00 03/04/2011 04:50:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1487715 03/04/2011 12:00:00 N Category Short Description Standard # Weight Physical Site Narrative: Bathing-Bath & shower areas must provide for individual privacy 748.3397(a) Medium Category Short Description Standard # Weight TA Finding Admn Rvw Compliance TA Finding Admn Rvw Emergency Behavior Intervention Seclusion-Only for child with ED or PDD when 25+ children with 748.2451(a)(4)(A) Medium Deficiency Waived ED or PDD or >30% of children with ED or PDD; not allowed for High child in therapeutic camp Narrative: The facilities policies do not allow for seclusion. A staff member used seclusion when the staff member prevented a child from leaving the child's room by standing in the child's bedroom door and using their body to block the child from leaving the bedroom. Category Short Description Standard # Weight TA Finding Admn Rvw Emergency Behavior Intervention Emergency Behavior Intervention-Basis for EBI is an emergency 748.2455(a)(2) Medium Deficiency Overturned situation or to administer medication High Narrative: A child was restrained when it was not an emergency situation. A child attempted to leave their room and was punished by having their MP3 player removed. The child then attempted to bite the staff member and wrestle with the staff member. The staff member then restrained the child. The child did not bite the staff member. The restraint report written stated no injuries. Category Short Description Standard # Emergency Behavior Intervention Weight EBI Documentation-Must include child's condition following EBI, 748.2855(a)(10) including any injury child sustained or any adverse effects caused by use of EBI Narrative: This standard was evaluated and found to be in compliance. Medium Category Standard # Weight 748.2307(1) High Short Description Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Date Intake Rcvd: Admn Rvw Compliance Warning Letter/Due Notice given Page 21 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Investigation Medium: 4 1475819 Category Run date: June 28, 2018 Compliance History Report Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 03/01/2011 12:00:00 Short Description N Standard # Medication Weight Medication Record-Must include name & signature of person who 748.2151(b)(6) administered each medication Narrative: Staff signature was missing from one resident's medication record. Videotape verified the medication was administered on 2/20/2011 but the staff did not sign the medication record. Medium Category Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Personnel Short Description Standard # Weight Emergency Behavior Intervention-Before using EBI, the caregiver must attempt less restrictive interventions that prove to be ineffective Narrative: This standard was evaluated and found to be in compliance. 748.2455(a)(1) Medium High Category Standard # Weight 748.311 Medium Emergency Behavior Intervention Short Description Reports and Record Keeping Serious Incident Documentation-Documented in written report Narrative: This standard was evaluated and found to be in compliance. TA Finding Deficiency TA Finding Admn Rvw Waived Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2702684 02/11/2011 10:30:00 02/11/2011 11:47:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1462037 02/11/2011 12:00:00 N Category Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 22 of 23 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 38 High: 13 Medium High: 10 Run date: June 28, 2018 Compliance History Report Medium: 4 Report Criteria Period: 01/01/2011 To 12/31/2011 Category: Standard: Type: ALL Finding: Medium Low: 6 Children's Rights Weight: Id/Number: Admin Review Status: Low: 5 Not Available: 0 Child Rights contact others-Document in the child's record any reason for restricting the child's mail or telephone calls Narrative: This standard was evaluated and found to be in compliance. 748.1111(b)(1) Medium Low Category Standard # Weight Short Description Admission, Service Planning, Discharge Service Plan Review-If child receiving treatment services for ED, 748.1381(2) PDD, or PMN, review at least 90 days from date of last service plan Narrative: The service plans completed monthly and weekly did not meet all the requirements that a 90 day service plan should include. Compliance TA Finding Medium Low Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2697506 02/08/2011 09:30:00 02/08/2011 03:01:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2675308 01/25/2011 08:15:00 01/25/2011 03:58:00 N Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 23 of 23 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Activity Type: Inspection Id Date Begin: Investigation Inspection 2623404 12/07/2010 02:20:00 Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Date End: Warning Letter/Due Notice given 12/07/2010 03:00:00 Category Short Description Standard # Children's Rights Children's rights-Adhere to the child's right to have adequate 748.1101(b)(12) personal clothing, suitable to his age and size and comparable with peers N Weight TA Finding Medium Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Investigation Inspection 2622287 12/07/2010 10:30:00 Date End: Warning Letter/Due Notice given 12/07/2010 12:30:00 N Category Short Description Standard # Weight Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being 748.685(a)(4) High TA Finding Admn Rvw Compliance Narrative: Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1398958 12/07/2010 12:00:00 N Category Short Description Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.683(1) Medium Category Standard # Weight 748.1531(a)(2) High Personnel Short Description Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1397476 12/03/2010 03:34:00 Category Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Warning Letter/Due Notice given N Standard # Weight TA Finding Page 1 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Personnel Not Available: 0 Caregiver responsibility - being aware of and accountable for each 748.685(a)(3) child's on-going activity Narrative: Standard evaluated and found to be in compliance. High Category Weight Short Description Standard # Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: Standard evaluated and found to be in compliance. High Category Short Description Standard # Weight Child Care Tobacco Products-An adult may only smoke tobacco products on the premises at a safe distance from the children's living quarters 748.1661(c) Medium High Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Narrative: Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2618830 12/03/2010 03:34:00 12/03/2010 04:23:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1394515 12/01/2010 05:01:00 N Category Short Description Standard # Weight Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. 748.685(a)(4) High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.683(2) Medium Short Description Personnel Caregiver Supervision-Provide oversight of caregivers to ensure that assigned duties are performed adequately Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 2 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2615403 12/01/2010 05:01:00 12/01/2010 06:16:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2608244 11/23/2010 11:00:00 11/23/2010 02:16:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1379775 11/23/2010 12:00:00 N Category Short Description Standard # Children's Rights Weight Children's rights-Adhere to the child's right to have personal 748.1101(b)(19) earnings, allowances, possessions, and gifts as his personal property Narrative: Allegations are being investigated as an abuse investigation. Medium Low Category Short Description Standard # Weight Personal Care-Child has reasonable opportunities to select his clothing as outlined in the operation's policies Narrative: Allegations are being investigated as an abuse investigation. 748.1105(1) Medium Low Category Standard # Weight 748.507(1) Medium High Children's Rights Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: Allegations are being investigated as an abuse investigation. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2598164 11/16/2010 09:00:00 11/16/2010 12:57:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2571068 10/22/2010 10:47:00 10/22/2010 11:38:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1353475 10/22/2010 10:01:00 Warning Letter/Due Notice given N Category Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Note: Prior to January 1, 2007, all Standards were not associated with a weight. Standard # Weight TA Finding High Page 3 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Narrative: Standard found to be in compliance. Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child 748.2307(6) High Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment 748.2307(1) High TA Finding Admn Rvw Compliance Narrative: Standard found to be in compliance. TA Finding Admn Rvw Compliance Narrative: Standard found to be in compliance. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2561586 10/15/2010 11:50:00 10/15/2010 01:16:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2539548 10/01/2010 09:00:00 10/01/2010 01:38:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1322075 10/01/2010 12:00:00 N Category Short Description Standard # Emergency Behavior Intervention Weight Personal Restraints Prohibited-Prone and supine restraints except as 748.2605(b)(1) a transitional hold that lasts no longer than 1 minute Narrative: This standard was evaluated and found to be in compliance. High Category Weight Short Description Standard # Emergency Behavior Intervention Personal Restraints Prohibited-Restraints that obstruct child's airway748.2605(a)(2) Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.1101(b)(20) Medium Short Description Children's Rights Children's rights-Adhere to the child's right to be able to communicate in a language or any other means that is understandable to the child Narrative: Staff present at the time of a serious incident could not speak the child's language fluently. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 4 of 14 Deficiency Admn Rvw Overturned Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2522563 09/13/2010 04:53:00 09/13/2010 06:45:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2499843 08/25/2010 04:36:00 08/25/2010 06:55:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1295055 08/25/2010 12:00:00 N Category Short Description Standard # Reports and Record Keeping Weight Serious Incident-Report to Licensing no later than 24 hours after an 748.303(a)(5)(A) incident of sexual abuse of a child against another child Narrative: The standard was evaluated and was found to be compliant. Medium Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: The standard was evaluated and was found to be compliant. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2464985 08/05/2010 02:15:00 08/05/2010 03:15:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1252975 07/29/2010 09:45:00 N Category Short Description Standard # Weight Other Prohibited Punishments-using or threatening to use emergency behavior intervention as discipline or punishment Narrative: This minimum standard was evaluated and found to be in compliance. 748.2307(15) Medium High Category Discipline and Punishment Short Description Standard # Weight Emergency Behavior Intervention-Basis for EBI is emergency situation, to administer medication, or property damage (short personal restraint only) Narrative: This minimum standard was evaluated and found to be in compliance. 748.2455(2) Medium Category Standard # Weight Emergency Behavior Intervention Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 5 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This minimum standard was evaluated and found to be in compliance. Not Available: 0 High Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2453064 07/29/2010 09:45:00 07/29/2010 12:54:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2397684 06/25/2010 09:00:00 06/25/2010 09:59:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2385923 06/18/2010 01:30:00 Category Short Description 06/18/2010 07:05:00 Standard # Emergency Behavior Intervention EBI Time Limits-Maximum length of time for seclusion for a child 748.2801(4)(B) nine years old or older is two hours Narrative: A resident has been in seclusion for more than the two hour limit on more than one occasion. N Weight TA Finding Medium Deficiency Admn Rvw Overturned Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2386483 06/18/2010 11:15:00 06/18/2010 12:06:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2385103 06/17/2010 04:30:00 06/17/2010 07:22:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1196496 06/16/2010 11:15:00 Category Short Description Warning Letter/Due Notice given N Standard # Children's Rights Weight Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and found to be in compliance. High Category Standard # Weight 748.685(a)(4) High Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 6 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Category Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Short Description Personnel Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: This standard was evaluated and found to be in compliance. Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Standard # Weight 748.507(1) Medium High TA Finding Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2381203 06/16/2010 11:15:00 06/16/2010 03:08:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2379903 06/15/2010 02:15:00 Category Short Description 06/15/2010 05:09:00 N Standard # Weight Background checks submitted - Every 24 months after each person's background check was first submitted Narrative: This standard was evaluated and found to be in compliance. 745.625(7) High Category Standard # Weight 748.3301(a) High Background Checks - TAC 745 Short Description Physical Site Physical Site-Buildings must be structurally sound, clean, and in good repair. Paints must be lead-free Narrative: This standard was evaluated and found to be in compliance. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1188457 06/11/2010 09:00:00 Category Short Description Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: This standard was evaluated and the facility was found to be in compliance. 748.685(a)(4) High Category Standard # Weight Short Description Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: This standard was evaluated and the facility was found to be in compliance. Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance N Weight Children's Rights Admn Rvw Compliance Warning Letter/Due Notice given Standard # Personnel TA Finding TA Finding Admn Rvw Compliance TA Finding High Page 7 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2373023 06/11/2010 09:00:00 06/11/2010 02:14:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2366243 06/08/2010 11:50:00 06/08/2010 01:33:00 N Activity Type: Investigation Number Date Intake Rcvd: Investigation 1180835 06/08/2010 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Caregiver Supervision-Provide oversight of caregivers to protect children's health, safety and well-being Narrative: Standard was evaluated and found to be in compliance. 748.683(1) Medium Category Standard # Weight 748.685(a)(4) High Personnel Short Description Personnel Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being Narrative: Standard was evaluated and found to be in compliance. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1128601 05/11/2010 12:00:00 N Category Short Description Standard # Weight Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: The standard was evaluated and was found to be compliant. 748.303(a)(2)(A) Medium Category Standard # Weight Reports and Record Keeping Short Description Personnel Caregiver responsibility - being able to intervene when necessary to 748.685(a)(5) ensure child's safety Narrative: The standard was evaluated and was found to be compliant. High Category Short Description Standard # Weight Child Care Medical care-A child in care must receive medical care as needed for injury, illness, and pain 748.1531(a)(2) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Page 8 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Narrative: The standard was evaluated and was found to be compliant. Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2302664 05/10/2010 04:00:00 05/10/2010 05:10:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2298163 04/29/2010 09:00:00 04/29/2010 09:44:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2223283 03/22/2010 09:00:00 03/22/2010 11:46:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Other Inspection 2209115 03/10/2010 01:49:00 03/10/2010 03:34:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2202783 03/08/2010 11:56:00 Category Short Description 03/08/2010 04:21:00 Standard # Medication Medication Storage-Store medication in a locked container 748.2101(1) Narrative: Psychotropic medication was found in an unlocked closet located inside a bedroom that is used by children. N Weight TA Finding High Admn Rvw Compliance Follow-up: Compliance Met Category Short Description Standard # Physical Site Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Narrative: The fabric on a sofa in the Magnolia House was torn and the interior cotton padding was exposed. Weight TA Finding Medium Admn Rvw Compliance A shower curtain in House 58D was covered with mold and mildew. Follow-up: Compliance Met Category Short Description Standard # Weight TA Finding Physical Site Admn Rvw Bedroom Space-Rooms commonly used for other purposes cannot 748.3359(1) Low Compliance be used as bedrooms Narrative: I observed space being used as a bedroom in the Woods house that is prohibited. Two beds were observed in space located in the foyer that is adjacent to the hallway that leads to bedrooms. The space was separated by a curtain. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 9 of 14 Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Category Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Short Description Physical Site Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below Narrative: The freezer thermometer in Houses 58B, 58C and 58D was 10 degrees below the required temperature. Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Standard # Weight 748.3443(b)(2) Medium Standard # Weight TA Finding Admn Rvw Compliance Follow-up: Compliance Met Category Short Description TA Finding Admn Rvw Transportation Vehicle and maintenance-Must maintain a vehicle in a safe 748.4083(a) Medium Compliance operating condition at all times High Narrative: The 2nd row seat on one of the vehicles inspected was not securely bolted down to the floor. The seat could be moved by pushing or pulling it in a 45 degree angle. Note: 2 vehicles had seat belts that did not operate properly. All vehicles need first aid kits, fire extinguishers and require cleaning. Follow-up: Compliance Met Category Short Description Human Resources Code, Chapter 42 Employment Affidavit Narrative: 4 out 6 personnel records evaluated did not have a notarized employment affidavit. Standard # Weight HRC42.059 High TA Finding Admn Rvw Compliance Follow-up: Compliance Met Activity Type: Investigation Number Date Intake Rcvd: Investigation 1028235 03/08/2010 12:00:00 Category Short Description Warning Letter/Due Notice given N Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard was evaluated and it was found to be compliant. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 10 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Reports and Record Keeping Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Serious Incident-Report to Licensing no later than 24 hours after injury/illness that warrants treatment by a medical professional or hospitalization Narrative: The standard was evaluated and it was found to be compliant. 748.303(a)(2)(A) Medium Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: The standard was evaluated and it was found to be compliant. 748.1531(a)(2) High Category Standard # Weight Child Care Short Description Emergency Behavior Intervention Short Personal Restraint-Caregiver may not use restraint that twists 748.2461(b)(6) or places the child's limb(s) behind the child's back Narrative: The standard was evaluated and it was found to be compliant. High Category Standard # Weight 748.1101(b)(20) Medium Short Description Children's Rights Children's rights-Adhere to the child's right to be able to communicate in a language or any other means that is understandable to the child Narrative: Staff present at the time of a serious incident could not speak the child's language fluently. Compliance TA Finding Admn Rvw Compliance TA Finding Admn Rvw Compliance TA Finding Deficiency Admn Rvw Waived Note: The use of verbal de-escalation techniques may have been more effective if a Spanish speaking staff was present to translate. Category Short Description Standard # Weight TA Finding Admn Rvw Emergency Behavior Intervention Personal Restraint Monitor-Qualified caregiver monitors child for 748.2601(a) Medium Deficiency Waived signs of physical distress & ensures ample respiration, circulation, High well-being Narrative: The restraint technique used requires that the caregiver stand behind the client, which would prevent the caregiver from having a clear view of the child's face. There was no second caregiver present at the time of the restraint to monitor the child for signs of physical distress and to ensure that he was breathing properly. Activity Type: Investigation Number Date Intake Rcvd: Investigation 1037978 03/04/2010 09:00:00 Warning Letter/Due Notice given N Category Short Description Standard # Weight Discipline and Punishment Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment 748.2307(1) High Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Page 11 of 14 Compliance Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Narrative: The standard evaluated was found to be in compliance. Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard evaluated was found to be in compliance. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Children's Rights Children's rights-Adhere to the child's rights to be free of abuse, 748.1101(b)(4) neglect, and exploitation as defined in Texas Family Code 261.401 Narrative: The standard evaluated was found to be in compliance. TA Finding Admn Rvw Compliance TA Finding High Admn Rvw Compliance Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2199887 03/04/2010 09:00:00 03/04/2010 10:27:00 N Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Monitoring Inspection 2181664 02/22/2010 09:24:00 02/22/2010 03:12:00 N Category Short Description Child Care TB exam-documentation of TB screening, chest radiograph, and/or 748.1583(c) treatment must be maintained in file where the person lives, works, or volunteers Standard # Weight Medium Low Short Description Weight TA Finding Admn Rvw Compliance Narrative: Category Standard # Medication Medication Storage-Store medication in a locked container 748.2101(1) Narrative: Psychotropic medication was found in an unlocked closet located inside a bedroom that is used by children. High Category Weight Short Description Physical Site Standard # Physical Site-Equipment and furniture must be safe for children and 748.3301(i) must be kept clean and in good repair Narrative: The fabric on a sofa in the Magnolia House was torn and the interior cotton padding was exposed. TA Finding Deficiency TA Finding Medium A shower curtain in House 58D was covered with mold and mildew. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Page 12 of 14 Deficiency Admn Rvw Waived Admn Rvw Waived Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Category Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Short Description Weight: Id/Number: Admin Review Status: Low: 1 Standard # Not Available: 0 Weight TA Finding Admn Rvw Physical Site Bedroom Space-Rooms commonly used for other purposes cannot 748.3359(1) Low Deficiency Upheld be used as bedrooms Narrative: I observed space being used as a bedroom in the Woods house that is prohibited. Two beds were observed in space located in the foyer that is adjacent to the hallway that leads to bedrooms. The space was separated by a curtain. Category Short Description Standard # Weight Food Preparation-Must have a thermometer in freezers & store frozen food at 0 degrees Fahrenheit or below Narrative: The freezer thermometer in Houses 58B, 58C and 58D was 10 degrees below the required temperature. 748.3443(b)(2) Medium Category Standard # Weight Physical Site Short Description TA Finding Deficiency TA Finding Transportation Vehicle and maintenance-Must maintain a vehicle in a safe 748.4083(a) Medium Deficiency operating condition at all times High Narrative: The 2nd row seat on one of the vehicles inspected was not securely bolted down to the floor. The seat could be moved by pushing or pulling it in a 45 degree angle. Admn Rvw Waived Admn Rvw Waived Note: 2 vehicles had seat belts that did not operate properly. All vehicles need first aid kits, fire extinguishers and require cleaning. Category Short Description Human Resources Code, Chapter 42 Employment Affidavit Narrative: 4 out 6 personnel records evaluated did not have a notarized employment affidavit. Standard # Weight HRC42.059 High TA Finding Deficiency Admn Rvw Waived Activity Type: Inspection Id Date Begin: Date End: Warning Letter/Due Notice given Investigation Inspection 2165243 02/10/2010 04:13:00 02/10/2010 05:10:00 N Activity Type: Investigation Number Date Intake Rcvd: Warning Letter/Due Notice given Investigation 1003356 02/10/2010 12:00:00 N Category Short Description Standard # Weight Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks Narrative: The standard was evaluated and was found to be compliant. 748.507(1) Medium High Category Standard # Weight Personnel Short Description Note: Prior to January 1, 2007, all Standards were not associated with a weight. TA Finding Admn Rvw Compliance TA Finding Page 13 of 14 Admn Rvw Texas Health and Human Services Commission Requested By: JOSE GARCIA Operation Type: General Residential Operation - Residential Treatment Center Operation Number/Name: 517689 Shiloh Treatment Center License Type: Full Permit Dt Issued: 10/12/1996 Total Deficiencies cited: 10 High: 2 Medium High: 2 Run date: June 28, 2018 Compliance History Report Medium: 5 Report Criteria Period: 01/01/2010 To 12/31/2010 Category: Standard: Type: ALL Finding: Medium Low: 0 Children's Rights Weight: Id/Number: Admin Review Status: Low: 1 Not Available: 0 Children's rights-Adhere to the child's right to receive appropriate treatment for physical problems that affect his treatment or safety Narrative: The standard was evaluated and was found to be compliant. 748.1101(b)(28) Medium High Category Short Description Standard # Weight Medical care-A child in care must receive medical care as needed for injury, illness, and pain Narrative: The standard was evaluated and was found to be compliant. 748.1531(a)(2) High Category Standard # Weight Child Care Short Description Emergency Behavior Intervention EBI Release-Child released from personal restraint immediately in 748.2553(2)(A) emergency health situation and treatment obtained immediately Narrative: The standard was evaluated and was found to be compliant. Note: Prior to January 1, 2007, all Standards were not associated with a weight. Compliance TA Finding Admn Rvw Compliance TA Finding High Page 14 of 14 Compliance Admn Rvw