In re Derrick J. ( 2016 )


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  •                 IN THE COURT OF APPEALS OF TENNESSEE
    AT KNOXVILLE
    Assigned on Briefs June 2, 2016
    IN RE DERRICK J., ET AL.
    Appeal from the Juvenile Court for Washington County
    No. 44599, 44600, 44601 Sharon M. Green, Judge
    ___________________________________
    No. E2015-01507-COA-R3-PT-FILED-JULY 8, 2016
    ___________________________________
    This is a termination of parental rights case. Appellants appeal the trial court’s termination
    of their parental rights to three minor children on the grounds of: (1) abandonment by failure
    to provide suitable housing; (2) persistence of the conditions that led to the removal of the
    children from Appellants’ home; and (3) severe child abuse. As to Appellant/Mother, the
    trial court also found that Appellee, the Department of Children’s Services, had proven, by
    clear and convincing evidence, that mother failed to substantially comply with the
    requirements set out in the permanency plan; mother appeals the termination of her parental
    rights on this additional ground. Appellants also appeal the trial court’s determination that
    termination of their parental rights is in the best interests of the children. Discerning no
    error, we affirm and remand.
    Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Juvenile Court
    Affirmed and Remanded
    KENNY ARMSTRONG, J., delivered the opinion of the court, in which ANDY D. BENNETT, and
    THOMAS R. FRIERSON, II, JJ., joined.
    William Freemon, Johnson City, Tennessee, for the appellant, Elizabeth J., and Carl Roberts,
    Jr., Elizabethton, TN, for the appellant, Jeremiah J.
    Herbert H. Slatery, III, Attorney General and Reporter, and W. Derek Green, Assistant
    Attorney General, for the appellee, Tennessee Department of Children’s Services.
    OPINION
    I. Background
    This case involves three minor children, Derrick J. (born October 2006),1 Destiny J.
    (born February 2009), and Dustin J. (born October 2011) (collectively, the “Children”). The
    Children’s mother is Elizabeth J. (“Mother”), and their Father is Jeremiah J. (“Father,” and
    together with Mother, “Parents,” or “Appellants”).2         The Tennessee Department of
    Children’s Services (“DCS,” or “Appellee”) first became involved with this family on
    November 4, 2012, when it received a referral for drug exposed child. In November of 2012,
    Families Free, a faith-oriented, community-based organization that offers assistance to
    families with children at risk of going into the foster care system, visited the Appellants’
    home at DCS’s request. According to the testimony, the Families Free employee found
    Appellants’ home to be cluttered and dirty; it was also reported that Elizabeth J. was drunk
    and giving her four-year-old alcohol.
    On December 13, 2012, DCS received a second referral for environmental neglect.
    Upon investigation, DCS discovered that Destiny had lice and had been sent home from
    school eleven times since October of 2012. Although the school provided lice shampoo to
    Mother, the child continued to come to school with lice. DCS also conducted a home visit in
    December of 2012 and found that the home was in a deplorable condition and that no
    improvements had been made since Families Free had visited earlier that month. DCS met
    with the parents on December 18, 2012 to develop a non-custodial permanency plan to
    ensure the safety and well-being of the Children. DCS proposed that the family continue to
    work with in-home services, and Mother was charged with contacting a doctor to get
    prescription treatment for Destiny’s lice. In addition, the parents were to maintain a clean
    home free of all safety hazards, and Mother was to submit to drug and alcohol assessment
    and follow all recommendations. The parents agreed to the plan.
    On December 20, 2012, DCS filed a “Petition for Order Controlling Conduct and for
    Protective Supervision” in the Juvenile Court for Johnson City, Tennessee (the “trial court”).
    By order of February 12, 2013, the trial court continued the hearing on DCS’s petition
    pending appointment of counsel for the Parents. The trial court ordered that the Children
    would remain in Appellants’ custody pending an adjudicatory hearing. On March 26, 2013,
    the trial court held an adjudicatory hearing on DCS’s petition. At the hearing, both parents
    1
    There is dispute in the record as to the proper spelling of Derrick’s name. The child’s birth
    certificate lists the child’s name as “Derek;” for purposes of the appeal, we will use the spelling set
    out on the petition to terminate parental rights, i.e., Derrick. We also noted that there is discrepancy
    in the record as to the spelling of Father’s name. It is spelled both “Jerimiah” and “Jeremiah.” For
    purposes of the appeal, we will use the spelling indicated on the petition to terminate parental rights,
    i.e., Jeremiah.
    2
    In cases involving minor children, it is the policy of this Court to redact the parties’ names
    so as to protect their identities.
    -2-
    stipulated to a finding of dependency and neglect, by clear and convincing evidence, for the
    reasons set out in the petition, specifically:
    Upon investigation DCS discovered the home was in deplorable
    condition. There was dried food on the floor and the counters in the kitchen
    and dirty dishes in the sink. There were mattresses on the floor without sheets
    or linens which were very filthy. The children were improperly clothed for the
    weather and were not clean. There was [sic] liquor bottles found throughout
    the home all of which were empty. DCS determined the mother’s sister . . . her
    boyfriend . . . and their two children were also residing in the home.
    DCS drug screened the mother who tested positive for benzodiazepines
    without a valid prescription and no explanation. The father was unable to
    produce a sample for testing at the time of the home visit.
    On April 3, 2013, Family Support Services were placed in the home to address the
    issues that led to DCS’s involvement. DCS conducted home visits on April 12, 2013, April
    18, 2013, April 24, 2013, May 13, 2013, and June 14, 2013. DCS’s reports indicate that,
    during those visits, DCS employees observed numerous safety and environmental concerns in
    the Appellants’ home. The trial court held a hearing on June 18, 2013, at which time the
    court informed Appellants that, if their living situation did not improve, the court would
    remove the Children from the home. The court also ordered the Appellants to attend
    parenting classes and ordered Father to complete a drug and alcohol treatment program. On
    June 20, 2013, DCS conducted a home visit and found that the home was still in deplorable
    condition. At that time, DCS did a walkthrough of each room. DCS noted a cockroach
    infestation and observed roach feces and molded food in the kitchen cabinets. DCS also
    noted that alcohol was present in the home. DCS again advised Appellants that they needed
    to clean and maintain the home; to this end, DCS provided resources to assist the parents.
    DCS also noted that Derrick had a cough that needed to be addressed and instructed Mother
    to take the child to the doctor.
    On June 27, 2013, DCS conducted a follow-up visit. By this time, Rachel Ratliff had
    been appointed guardian ad litem, and Ms. Ratliff was present at this home visit. At that
    time, the following concerns were noted:
    1. The minor child, Dustin, had a diaper that was oversaturated in both urine and feces;
    2. Garbage and spoiled food were all about the house;
    3. The children were dirty, to such an extent that they appeared to not have been bathed
    in days;
    4. Dustin and Destiny had a foul odor of uncleanliness about their persons;
    5. Roaches and bugs were observed throughout the home;
    6. Dirty and unwashed dishes were left in the sink
    7. New bottles of alcohol were observed in the freezer
    -3-
    8. Father had not yet scheduled his drug and alcohol assessment
    9. Derrick had not been seen by a doctor for his cough
    10. Appellants had not scheduled parenting classes.
    After assessing the home environment, the DCS employee and the guardian ad litem agreed
    that the house was not safe for the Children and that the Children’s basic needs were not
    being met. Accordingly, DCS removed the Children from the home. Upon arrival at DCS,
    all three Children had to be bathed. During the bath, DCS employees observed a bruise on
    Destiny’s shoulder blade. When the child was asked how she suffered the injury, she
    informed DCS that Father had caused the injury by “poking” her. DCS also observed red
    marks that appeared to be insect bites on all of the Children’s bodies. On July 1, 2013, DCS
    filed a petition to adjudicate dependency and neglect and for temporary custody of the minor
    Children. On the same day, the trial court entered a protective custody order, placing
    temporary custody of the Children with DCS.
    On July 2, 2013, the trial court held a preliminary hearing on the petition for
    dependency and neglect. Appellants were present at the hearing and waived the probable
    cause hearing. The trial court entered subsequent orders that the Children would remain in
    DCS custody pending an adjudicatory hearing. DCS and the Parents entered into
    permanency plans for the Children, discussed infra. The last of these plans was affirmed and
    ratified by the trial court on December 6, 2013.
    On October 15, 2013, the trial court held an adjudicatory hearing on DCS’s July 1,
    2013 dependency and neglect petition. The trial court entered an order on November 11,
    2013. In relevant part, the order provides that “[t]he Parents, through counsel, stipulated to
    dependency and neglect by clear and convincing evidence based only on environmental
    neglect.” Based on the Parents’ stipulation, the trial court found that the children were
    dependent and neglected. The dispositional phase of the hearing was continued to December
    6, 2013.
    On December 6, 2013, the trial court approved a ninety-day trial home placement,
    which was to begin on December 20, 2013. The trial home placement was subject to certain
    conditions, namely: (1) the parents would keep the home as clean as it appeared in
    photographs presented to the court at the adjudicatory hearing; (2) the parents would clean
    the kitchen and bathroom daily; (3) the parents would not leave any food out in an unsanitary
    manner; (4) the parents would find another home for their dog and cat due to animal feces
    and urine inside the home; (5) parents would spray the perimeter of the home with bug spray;
    and (6) parents would ensure that there was no alcohol in the home. On December 17, 2013,
    the guardian ad litem filed a motion to revoke the trial home placement, which had not yet
    begun, due to the deteriorated conditions in Appellants’ home. The trial court granted the
    guardian ad litem’s motion and suspended the December 2013 trial home placement. The
    Children remained in DCS’s custody.
    -4-
    Despite the previous suspension of the trial home placement, on April 15, 2014, the
    court allowed a trial home placement to proceed; however, the Children remained in the legal
    custody of DCS during the trial home placement. On June 10, 2014, the trial court held a
    status hearing. Although, at that time, DCS did not request suspension of the home
    placement, both DCS and the guardian ad litem noted that the conditions in the home had
    once again deteriorated. Based on the testimony, the trial court found that: (1) the Children
    had expressed that they were hungry while living in Appellants’ home; (2) there were no
    sheets on the Children’s beds when DCS went to the home; (3) food was scattered
    throughout the home; (4) bugs were observed in the home; (5) food was left in the oven; (6)
    the Parents had either missed or failed to schedule follow-up appointments with the
    Children’s doctors; and (7) the Children were dirty.
    Six days later, on June 16, 2014, DCS went to the Appellants’ home at approximately
    8:00 p.m. DCS observed a mattress in the middle of the floor, and noted that it was difficult
    to walk around the mattress because of trash and clutter. According to Child Protective
    Services (“CPS”) investigators, Karen Thompson and Emily Hodge, all of the Children were
    dirty. Dustin was observed to have on nothing but a diaper, a pair of socks, and a t-shirt. He
    was in need of a diaper change and had dried feces on his buttocks. Ms. Thompson and Ms.
    Hodge also observed that Dustin had a burn on his arm. The Parents had created a makeshift
    bandage out of toilet paper and scotch tape; however, part of the burn could be seen beneath
    the bandage. The toilet paper bandage was dirty, and pieces of the child’s skin were falling
    off at the burn site. The Parents presented a tube of Neosporin and indicated that they had
    been applying the salve to the burn; however, DCS observed that the Neosporin had expired
    in 2009. When asked, Mother told Ms. Hodge that the child had been burned by a bowl of
    Ramen noodles. Specifically, Mother told Ms. Hodge that she had turned around to help
    Destiny, and, while her back was turned, Dustin (while standing on a stool) had pulled the
    bowl of soup out of the microwave onto himself. Mother was unable to produce the stool
    when asked to do so. At that time, Dustin was too young to tell what had happened to cause
    the burn; however, it is undisputed that Mother was the sole caregiver at the time of the
    injury. Mother was the only adult present when Dustin was burned; when Father returned
    home and observed the injury, however, he did not seek medical treatment. The burn was
    ultimately diagnosed as a second-degree burn. Based on the foregoing testimony, on June 16,
    2014, the trial court revoked the trial home placement by ex parte order. The Children were
    then returned to the physical custody of DCS.
    By August 25, 2014, DCS had assigned the case to Family Service Worker, Amy
    Serota-Cook. Ms. Serota-Cook testified that she went to the home on August 25, 2014 and
    found that no one was home. When Ms. Serota-Cook made contact with Appellants, they
    informed her that Mother had left the home because the Appellants were fighting, but Mother
    had subsequently returned to the home. There is no evidence that Appellants informed DCS
    that their living situation had changed.
    -5-
    On September 9, 2014, DCS filed a petition to terminate Appellants’ parental rights.
    As grounds for termination of parental rights, DCS averred: (1) abandonment by failure to
    provide a suitable home, Tennessee Code Annotated Sections 36-1-113(g)(1) and 36-1-
    102(1)(A)(ii); (2) substantial noncompliance with the Tennessee Code Annotated Section37-
    2-403 permanency plan, Tennessee Code Annotated Sections 36-1-113(g)(2); (3) persistence
    of conditions, Tennessee Code Annotated Section 36-1-113(g)(3); and (4) severe child abuse,
    Tennessee Code Annotated Sections 36-1-113(g)(4) and 37-1-102(b)(21). DCS also averred
    that termination of Appellants’ parental rights was in the Children’s best interests. On
    November 24, 2014, Elizabeth J. filed an answer in opposition to the petition to terminate her
    parental rights. Likewise, on December 2, 2014, Jeremiah J. filed an answer in opposition to
    the petition to terminate his parental rights.
    On November 3, 2014, DCS held a child and family team meeting to discuss the fact
    that the Appellants were on the verge of being evicted. The Parents were, in fact, evicted in
    December of 2014; however, there is no evidence that they advised DCS of this fact. When
    DCS attempted to conduct a home visit on January 7, 2015, the Parents were not at home,
    and the house appeared to be vacant. On January 14, 2015, Ms. Serota-Cook spoke with
    Mother, who stated that she and Father were staying with Mother’s sister in public housing.
    The record indicates that, by March 4, 2015, the Appellants were living in a motel. Although
    the hearing on the petition to terminate their parental rights had commenced on January 26,
    2015, on April 1, 2015, DCS discovered that the Parents had signed a lease for a new
    residence. A copy of the lease was admitted into evidence at the hearing on the petition to
    terminate parental rights. In relevant part, the lease agreement provides that the apartment
    had only two bedrooms, and the agreement states that adults and no children will be living
    there. On April 20, 2015, DCS attempted to conduct a home visit at the Parents’ new
    residence. Ms. Serota-Cook noted a foul odor around the new home, although she could not
    testify as to the cause of the odor. During the hearing on the petition to terminate parental
    rights, Appellants presented photographs of the new home that were allegedly taken within
    three weeks of the time Appellants had moved into the apartment. As noted in the trial
    court’s order terminating parental rights, the photographs “depict a home that is basically
    empty of children’s beds.” The photographs “show an air mattress on the floor in close
    proximity to a wall heater with bedding stacked on it.” “The photographs also show a large
    flat screen entertainment center with wiring for multiple attachments, an extensive DVD
    collection;” however, the only furnishing in the room is a chair with no legs.
    On June 10, 2015, DCS conducted another home visit at the Appellants’ apartment.
    DCS discovered that the Parents had permitted another family of five to move into the
    apartment with them. The family of five had moved their belongings into one of the two
    bedrooms. Father testified that this family was “staying” in the apartment. Ms. Serota-Cook
    testified that Father told her the other family was “living” in the apartment. Regardless,
    while at the residence, DCS observed live maggots on the kitchen floor and a broken toddler
    bed with a sharp, rusted brace hanging from it.
    -6-
    The trial court heard the petition to terminate Appellants’ parental rights on January
    26, 2015, April 21, 2015, April 22, 2015, June 10, 2015, and June 24, 2015. By order of July
    27, 2015, the trial court terminated Appellants’ parental rights on the grounds of: (1)
    abandonment by failure to provide a suitable home; (2) persistence of conditions; and (3)
    severe child abuse. Although DCS also asserted the ground of substantial noncompliance
    with the requirements of the permanency plan against both Parents, the trial court specifically
    found that DCS had not met its burden of proof as to this ground vis-à-vis Father. However,
    the trial court found that DCS had proven the substantial noncompliance ground as to
    Mother. The trial court specifically held that DCS had made reasonable efforts to assist
    Appellants. Appellants appeal.
    II. Issues
    We note that Mother and Father are represented by different lawyers in this appeal,
    and both have filed separate appellate briefs. However, the issues raised in their respective
    briefs are essentially the same. We restate the dispositive issues as follows:
    1. Whether there is clear and convincing evidence to support at least one of the
    grounds for termination of Appellants’ respective parental rights.
    2. Whether there is clear and convincing evidence to support the trial court’s
    finding that termination of the Appellants’ respective parental rights is in the
    children’s best interests.
    III. Standard of Review
    Under both the United States and Tennessee Constitutions, a parent has a fundamental
    right to the care, custody, and control of his or her child. Stanley v. Illinois, 
    405 U.S. 645
    ,
    651 (1972); Nash-Putnam v. McCloud, 
    921 S.W.2d 170
    , 174 (Tenn. 1996). Thus, the state
    may interfere with parental rights only when a compelling interest exists. 
    Nash–Putnam, 921 S.W.2d at 174-75
    (citing Santosky v. Kramer, 
    455 U.S. 745
    (1982)). Our termination statutes
    identify “those situations in which the state’s interest in the welfare of a child justifies
    interference with a parent’s constitutional rights by setting forth grounds on which
    termination proceedings can be brought.” In re W.B., Nos. M2004-00999-COA-R3-PT,
    M2004-01572-COA-R3-PT, 
    2005 WL 1021618
    , at *7 (Tenn. Ct. App. Apr. 29, 2005) (citing
    Tenn. Code Ann. § 36-1-113(g)). A person seeking to terminate parental rights must prove
    both the existence of one of the statutory grounds for termination and that termination is in
    the children’s best interest. Tenn. Code Ann. § 36-1-113(c); In re D.L.B., 
    118 S.W.3d 360
    ,
    367 (Tenn. 2003); In re Valentine, 
    79 S.W.3d 539
    , 546 (Tenn. 2002).
    Because of the fundamental nature of the parent’s rights and the grave consequences
    of the termination of those rights, courts must require a higher standard of proof in deciding
    termination cases. 
    Santosky, 455 U.S. at 769
    . Accordingly, both the grounds for termination
    -7-
    and that termination of parental rights is in the children’s best interests must be established
    by clear and convincing evidence. Tenn. Code Ann. § 36-3-113(c)(1); In re 
    Valentine, 79 S.W.3d at 546
    . Clear and convincing evidence “establishes that the truth of the facts asserted
    is highly probable . . . and eliminates any serious or substantial doubt about the correctness of
    the conclusions drawn from the evidence.” In re M.J.B., 
    140 S.W.3d 643
    , 653 (Tenn. Ct.
    App. 2004). Such evidence “produces in a fact-finder’s mind a firm belief or conviction
    regarding the truth of the facts sought to be established.” 
    Id. at 653.
    In light of the heightened standard of proof in termination of parental rights cases, a
    reviewing court must modify the customary standard of review in Tennessee Rule of
    Appellate Procedure 13(d). As to the trial court’s findings of fact, our review is de novo with
    a presumption of correctness unless the evidence preponderates otherwise. Tenn. R. App. P.
    13(d). We must then determine whether the facts, as found by the trial court or as supported
    by the preponderance of the evidence, clearly and convincingly establish the elements
    necessary to terminate parental rights. Jones v. Garrett, 
    92 S.W.3d 835
    , 838 (Tenn. 2002).
    IV. Grounds for Termination of Parental Rights
    As noted earlier, the trial court relied on the following statutory grounds in
    terminating Appellants’ parental rights: (1) abandonment by failure to provide a suitable
    home, Tennessee Code Annotated Sections 36-1-113(g)(1) and 36-1-102(1)(A)(ii); (2)
    substantial noncompliance with the Tennessee Code Annotated Section 37-2-403
    permanency plan, Tennessee Code Annotated Sections 36-1-113(g)(2); (3) persistence of
    conditions, Tennessee Code Annotated Section 36-1-113(g)(3); and (4) severe child abuse,
    Tennessee Code Annotated Sections 36-1-113(g)(4) and 37-1-102(b)(21). Although only one
    ground must be proven by clear and convincing evidence in order to terminate a parent’s
    rights, the Tennessee Supreme Court has instructed this Court to review every ground relied
    upon by the trial court to terminate parental rights in order to prevent “unnecessary remands
    of cases.” In re Angela E., 
    303 S.W.3d 240
    , 251 n.14 (Tenn. 2010). Accordingly, we will
    review all of the foregoing grounds.
    A. Reasonable Efforts
    Before addressing the specific grounds for termination of Appellants’ parental rights,
    we note that, historically, the decision to pursue a termination of parental rights on the
    grounds of abandonment and/or substantial noncompliance with a permanency plan has
    invoked DCS’s statutory duty to make reasonable efforts to facilitate the safe return of
    children to the parent's home. In re R.L.F., 
    278 S.W.3d 305
    , 315 (Tenn. Ct. App. 2008)
    (citing Tenn. Code Ann. §§ 37-1-166(b), –166(a)(2), –166(g)(2)); see also In re Tiffany B.,
    
    228 S.W.3d 148
    , 151, 160 (Tenn. Ct. App. 2007) (vacating a finding of abandonment,
    substantial noncompliance, and persistence of conditions for failure to make reasonable
    efforts). However, in In re Kaliyah S., 
    455 S.W.3d 533
    (Tenn. 2015), the Tennessee
    -8-
    Supreme Court specifically overruled “the holding of In re Tiffany B. and other cases
    following the holding in In re C.M.M. to the extent that the court required DCS to prove by
    clear and convincing evidence that it made reasonable efforts to reunify as a precondition to
    termination of parental rights (citations omitted).” 
    Id. at 555
    n.34. Proof of reasonable
    efforts is specifically required by statute to prove the ground of abandonment by failure to
    provide a suitable home. However, even under that ground for termination, DCS’s efforts to
    assist the parent “may be found to be reasonable if such efforts exceed the efforts of the
    parent or guardian toward the same goal.” 
    Id. (citing Tenn.
    Code. Ann. § 36-1-102(1)(A)(ii)).
    In Kaliyah, the Court specifically stated that
    proof of reasonable efforts is not a precondition to termination of parental
    rights of a respondent parent. As with other factual findings made in
    connection with the best interest analysis, reasonable efforts must be proven by
    a preponderance of the evidence, not by clear and convincing evidence. In re
    Audrey 
    S., 182 S.W.3d at 861
    . After making the underlying factual findings,
    the trial court should then consider the combined weight of those facts to
    determine whether they amount to clear and convincing evidence that the
    termination is in the child’s best interest (citations omitted).
    
    Id. at 555
    .
    In the instant case, the trial court found that DCS made reasonable efforts to assist the
    Parents in satisfying the requirements contained in the permanency plans, see discussion
    infra. Specifically, the trial court found that,
    [t]hroughout the entirety of these proceedings, DCS has provided extensive
    services to assist the parents. DCS has made tremendous efforts to help them.
    Further, DCS has continually made many, many referrals and many, many
    efforts to assist the family throughout the underlying dependency and neglect
    proceedings that gave rise to this cause.
    As set out in full context below, Tennessee Code Annotated Section 36-1-102(1)(A)(ii)’s
    definition of abandonment requires DCS to make reasonable efforts to assist the parents to
    establish a suitable home. The statute focuses on the four month period following removal of
    the children from the parents’ custody. Here, the four-month period is June 27, 2013 through
    October 27, 2013. In its order terminating Appellants’ parental rights, the trial court found
    that “[d]uring that four (4) month time, DCS made many reasonable efforts to assist the
    parents in providing a suitable home for the children. . . .” Although Appellants do not raise
    an issue concerning the trial court’s findings on DCS’s reasonable efforts, because DCS’s
    obligation to provide reasonable efforts is triggered by the trial court’s reliance on the
    grounds of abandonment by failure to provide suitable housing and substantial
    noncompliance with the requirements of the permanency plan, we have reviewed the record
    -9-
    to determine whether the evidence preponderates in favor of the trial court’s findings
    concerning DCS’s reasonable efforts. The record indicates that, during the relevant four-
    month period, DCS provided the following services:
    a. DCS funded an in-home service provider, Families Free, to assist the family. Families
    Free provided Appellants’ assistance with homemaking skills, parenting skills, and
    budgeting.
    b. DCS made a referral for a clinical parenting assessment to be completed by in-home
    service provider, Foundations for Life Principles.
    c. DCS conducted numerous home visits, 
    see supra
    . During these visits DCS made
    suggestions on how the Appellants’ could institute sanitary conditions in the home.
    d. DCS kept the Appellants apprised of the Children’s medical appointments.
    e. DCS worked as liaison between AGAPE and Appellants to assist Appellants in
    procuring the required parenting classes.
    f. DCS assisted father in completing a drug and alcohol assessment.
    g. DCS provided therapeutic visitation services through Families Free.
    h. DCS conducted a child and family team meeting on July 17, 2013 to develop a
    permanency plan to address the reasons for the Children’s removal from the
    Appellants’ home.
    i. DCS maintained contact with the service providers to monitor Appellants’
    compliance.
    j. DCS attended foster care review board meetings for the Children.
    k. DCS kept the Parents apprised of court hearings and meetings regarding the Children.
    l. After the Children were removed from Appellants’ custody, DCS made numerous
    foster home visits to ensure that the Children’s needs were being met. Specifically,
    DCS conducted six foster home visits during the first six weeks that the Children were
    in DCS custody.
    Based on the foregoing services and the totality of the circumstances, we conclude that the
    record preponderates in favor of the trial court’s finding that DCS satisfied its requirement to
    make reasonable efforts to assist the Appellants. Having determined that the reasonable
    efforts criterion is met for both the ground of abandonment by failure to provide suitable
    housing and the ground of substantial noncompliance with the requirements of the
    permanency plans, we now turn to address the specific grounds for termination of
    Appellants’ parental rights.
    B. Abandonment by Failure to Provide Suitable Housing
    Tennessee Code Annotated Section 36-1-113(g)(1) provides that termination of parental
    rights may be based on the ground of “[a]bandonment by the parent or guardian, as defined in
    § 36-1-102. . . .” Tennessee Code Annotated Section 36-1-102(1)(A)(ii) defines
    “abandonment” for purposes of termination of parental rights, in relevant part, as follows:
    - 10 -
    (ii) The child has been removed from the home of the parent or parents or a
    guardian or guardians as the result of a petition filed in the juvenile court in
    which the child was found to be a dependent and neglected child, as defined in
    § 37-1-102, and the child was placed in the custody of the department or a
    licensed child-placing agency, that the juvenile court found, or the court where
    the termination of parental rights petition is filed finds, that the department or a
    licensed child-placing agency made reasonable efforts to prevent removal of
    the child or that the circumstances of the child’s situation prevented reasonable
    efforts from being made prior to the child’s removal; and for a period of four
    (4) months following the removal, the department or agency has made
    reasonable efforts to assist the parent(s) or guardian(s) to establish a suitable
    home for the child, but that the parent(s) or guardian(s) have made no
    reasonable efforts to provide a suitable home and have demonstrated a lack of
    concern for the child to such a degree that it appears unlikely that they will be
    able to provide a suitable home for the child at an early date.
    
    Id. This Court
    has previously held that “in determining whether grounds for termination of
    the parental rights of a biological parent are established, both the trial court and this Court
    must look to the evidence of the parent’s past actions, rather than the parent’s future
    aspirations.” In re Adoption of Logan A.S., No. W2009-02661-COA-R3-PT, 
    2010 WL 3984712
    , at *8 (Tenn. Ct. App. Oct. 12, 2010). As discussed above, the Children were taken
    from Appellants’ custody and were adjudicated dependent and neglected, in part, because of
    Appellants’ failure to provide a clean and stable home. The trial court’s November 11, 2013
    order on DCS’s petition for dependency and neglect indicates that the Parents stipulated to
    dependency and neglect based on environmental neglect, and the court so found. The
    adjudication of dependency and neglect is not contested on appeal. The record indicates that
    DCS’s petition was precipitated by a home visit on June 27, 2013, at which time DCS
    observed the following environmental problems in the home: (1) the minor child, Dustin, had
    a diaper that was oversaturated in both urine and feces; (2) garbage and spoiled food were all
    about the house; (3) the Children were dirty, to such an extent that they appeared to not have
    been bathed in days; (4) Dustin and Destiny had a foul odor of uncleanliness about their
    persons; (5) roaches and bugs were observed throughout the home; (6) dirty and unwashed
    dishes were left in the sink.
    Almost immediately after DCS became involved with this family in 2012, Family Support
    Services were employed to assist the Appellants. At the hearing on the petition to terminate
    parental rights, Julie Lowry, the DCS Family Support Services case manager assigned to
    work with the family, testified. Ms. Lowry was assigned to the case in April 2013. In its
    order terminating Appellants’ parental rights, the trial court made a specific finding that Ms.
    Lowry was a credible witness. Where the trial court’s factual findings are based on its
    - 11 -
    determinations of the credibility of the witnesses, then this Court will afford great weight to
    those credibility determinations and will not reverse such determinations absent clear
    evidence to the contrary. See McCaleb v. Saturn Corp., 
    910 S.W.2d 412
    , 415 (Tenn. 1995).
    Ms. Lowry testified concerning the conditions she observed in the Appellants’ home
    during her tenure on the case. At her initial visit to the home, Ms. Lowry observed large,
    black, garbage bags in the living room, dirty dishes in the sink, old food on the stove, alcohol
    in the freezer, and “extensive clutter” throughout the home. Ms. Lowry noted that Father
    smelled of alcohol; when she asked him whether he was drinking, he told her the odor was
    “from the night before.” At this time, Ms. Lowry indicated that, on a scale of one to ten, with
    one being the lowest, the condition of the home was a three.
    Within a few days of her initial visit, Ms. Lowry returned to the home on April 16, 2013.
    In her opinion, the condition of the home had deteriorated since her first visit earlier that
    month. Ms. Lowry now indicated that the condition, on a scale of one to ten, had fallen to a
    two. Specifically, she observed the youngest child, Dustin, to be very dirty. He was wearing
    only a dirty sock. She noted that there was a dirty mattress on the floor of the living room.
    She found a child’s crib that was cluttered with items, including pennies. The blankets were
    dirty, and, in fact, the child, Destiny, had been diagnosed with scabies.
    Ms. Lowry came back to the home on April 18, 2013, and the condition had not
    improved. Although Ms. Lowry testified that she tried to encourage the Parents to take steps
    to clean up the house and, in fact, demonstrated how to clean the areas of concern, she again
    observed that the Children were dirty. There were piles of dirty clothes in the home. Dustin
    had mucus crusted on his nose. Ms. Lowry also observed dirty dishes, including the
    Children’s sippy cups.
    On June 20, 2013, Ms. Lowry visited the home and observed live cockroaches in the
    house. Ms. Lowry demonstrated to the Parents how to scrub the floors, wash the walls, and
    clean the bathroom. However, in a follow-up visit on June 27, 2013 (i.e., the visit that led to
    the removal of the Children from the Parents’ home), Ms. Lowry observed that Dustin was
    wearing only a soiled diaper, and he had dried food on his face. Dustin’s hair was “very,
    very matted and greasy.” Destiny’s hair was also matted. Mother told Ms. Lowry that the
    Children had been bathed “a couple of days ago.” However, the Children had a foul odor
    about them. Ms. Lowry also observed bugs on the floor and window sills, a moldy pot of
    beans on the stove, and a bag of bread on the floor.
    Ms. Lowry testified that she visited Appellants’ home approximately nine times during
    the time she was assigned to the case. She testified that, at least 95% of the time, she
    observed food on the floor. Ms. Lowry further testified that she observed the Children eating
    food off the floor, or eating food that had been lying out for some time.
    - 12 -
    After the Children were taken into DCS custody, in July of 2013, the case was assigned to
    DCS employee, Brant Lee Orren. Like Ms. Lowry, Mr. Orren conducted several home visits.
    His first visit was on or about September 12, 2013. He testified that, when he arrived for the
    visit, Father was at home alone. Mr. Orren observed Father “playing Nintendo and drinking
    beer.” Mr. Orren testified that the house was cluttered and dirty, with dirty dishes in the sink
    and on the stove. In Destiny’s bedroom, Mr. Orren observed a hole in the ceiling and bugs in
    the window sill. When Mr. Orren confronted Father about the bugs, Father stated that “it
    would only take five minutes for him to clean them out . . . .” Following this visit, DCS
    noted some small improvement in the condition of the home, and, as noted above, the trial
    court approve a trial home placement on April 15, 2014. However, at a hearing on December
    10, 2014, DCS and the guardian ad litem informed the trial court that the conditions in the
    home had again deteriorated. DCS informed the trial court that the case worker had observed
    bugs in the home, old food in the oven, food scattered throughout the house, no sheets on the
    Children’s bed, and that the Children were dirty.
    Despite reasonable efforts on the part of DCS, 
    see supra
    , the record indicates that,
    following removal of the Children from Appellants’ home, conditions did not improve. All
    evidence indicates that the Parents have failed to make necessary changes to ensure that their
    home is sanitary. Photographs that were admitted into evidence show that, throughout these
    proceedings, the conditions in the home remained relatively unchanged. There are pictures
    of what appears to be animal feces and urine on the floors and on the beds. One photograph
    shows animal feces lying on a child’s toy; another shows feces on a bed next to a child’s
    sippy cup. There are pictures of food left sitting on the stove and dirty dishes strewn
    throughout the house. There are also numerous pictures of bugs, both dead and alive,
    throughout the house. Bug excrement appears in several photographs. In addition, there are
    photos of alcohol in the home; beer cans are in the refrigerator and scattered around the
    house. One photograph depicts a floor HVAC vent. The vent is rusting and dirty, and there
    appear to be cigarette butts filling the vent itself as if the vent has been used as an ashtray.
    The photographs of the bathroom show a very dirty tub, with caulk hanging in strips where it
    has come out of the joint. There is also photographic evidence of the continuing clutter in the
    home. Clothes are piled around the house, and food is scattered on the floor. Mr. Orren
    testified that, from June 27, 2013 through October 27, 2013, he could not recommend that the
    Children be returned to the Appellants’ home. We agree. After reviewing the entire record,
    we conclude that the evidence preponderates in favor of the trial court’s factual findings, and
    that those findings establish by clear and convincing evidence that Appellants’ parental rights
    may be terminated on the ground of abandonment by failure to provide a suitable home.
    C. Persistence of the Conditions that Led to the Children’s Removal
    Tennessee Code Annotated Section 36-1-113(g)(3) provides that termination of parental
    rights may be based upon persistence of conditions. Persistence of conditions is defined as:
    - 13 -
    (3) The child has been removed from the home of the parent or guardian by
    order of a court for a period of six (6) months:
    (A)       The conditions that led to the child’s removal or other conditions that in
    all reasonable probability would cause the child to be subjected to further
    abuse or neglect and that, therefore, prevent the child's safe return to the
    care of the parent(s) or guardian(s), still persist;
    (B)      There is little likelihood that these conditions will be remedied at an
    early date so that the child can be safely returned to the parent(s) or
    guardian(s) in the near future; and
    (C) The continuation of the parent or guardian and child relationship greatly
    diminishes the child's chances of early integration into a safe, stable and
    permanent home.
    The purpose behind the “persistence of conditions” ground for terminating parental rights is
    “to prevent the child’s lingering in the uncertain status of foster child if a parent cannot
    within a reasonable time demonstrate an ability to provide a safe and caring environment for
    the child.” In re Arteria H., 
    326 S.W.3d 167
    , 178 (Tenn.Ct.App.2010), overruled on other
    grounds by In re Kaliyah S., 
    455 S.W.3d 533
    (Tenn.2015).
    In In re Audrey S., 
    182 S.W.3d 838
    , 872 (Tenn.Ct.App.2005), this Court held that, based
    on the statutory text and its historical development, the ground of persistence of conditions
    found in Tennessee Code Annotated Section 36-1-113(g)(3) provides a ground for
    termination of parental rights only where the prior court order removing the child from the
    parent’s home was based on a judicial finding of dependency, neglect, or abuse. In the
    instant case, and as discussed above, the Parents stipulated to a finding, by clear and
    convincing evidence, of dependency and neglect based on environmental neglect. As
    discussed in great detail above, the conditions that led to the Children’s removal from
    Appellants’ home, i.e., unsanitary conditions, bugs, and filth, have not been remedied. It
    appears that despite DCS’s best efforts, the Parents have made no reasonable efforts to
    provide a clean home for these Children. The fact that there has been no marked
    improvement in the Appellants’ living conditions during the entire pendency of this matter
    demonstrates a lack of concern for the Children to such a degree that it appears unlikely that
    Appellants’ will be able to provide a suitable home for the Children at any near date.
    Accordingly, we affirm this ground for termination of their parental rights.
    D. Substantial Noncompliance with the Permanency Plan
    As noted above, the trial court found that DCS had not met its burden to prove the ground
    of substantial noncompliance with the permanency plan on the part of Father. However, the
    - 14 -
    court did find sufficient proof to establish the ground vis-à-vis Mother. DCS does not raise
    an issue as to the trial court’s findings on this ground as to Father. Accordingly, we will only
    discuss the permanency plan requirements pertinent to Mother.
    Tennessee Code Annotated Section 36-1-113(g)(2) provides that parental rights may be
    terminated when “[t]here has been substantial noncompliance by the parent . . . with the
    statement of responsibilities in a permanency plan.” However, as discussed by this Court in
    In re M.J.B., 
    140 S.W.3d 643
    (Tenn.Ct.App.2004):
    Terminating parental rights based on Tenn. Code Ann. § 36-1-113(g)(2)
    requires more proof than that a parent has not complied with every jot and tittle
    of the permanency plan. To succeed under Tenn. Code Ann. § 36-1-113(g)(2),
    the Department must demonstrate first that the requirements of the permanency
    plan are reasonable and related to remedying the conditions that caused the
    child to be removed from the parent's custody in the first place, In re
    
    Valentine, 79 S.W.3d at 547
    ; In re L.J.C., 
    124 S.W.3d 609
    , 621 (Tenn. Ct.
    App. 2003), and second that the parent's noncompliance is substantial in light
    of the degree of noncompliance and the importance of the particular
    requirement that has not been met. In re 
    Valentine, 79 S.W.3d at 548-49
    ; In re
    Z.J.S., 
    2003 WL 21266854
    , at *12. Trivial, minor, or technical deviations
    from a permanency plan's requirements will not be deemed to amount to
    substantial noncompliance. In re 
    Valentine, 79 S.W.3d at 548
    .
    
    Id. at 656-57.
    “Nonetheless, the permanency plans are not simply a series of hoops for the
    biological parent to jump through in order to have custody of the children returned.” In re
    C.S., Jr., et al., No. M2005-02499-COA-R3-PT , 
    2006 WL 2644371
    , at *10 (Tenn. Ct. App.
    Sept. 14, 2006). Rather,
    the requirements of the permanency plan are intended to address the problems
    that led to removal; they are meant to place the parent in a position to provide
    the children with a safe, stable home and consistent appropriate care. This
    requires the parent to put in real effort to complete the requirements of the plan
    in a meaningful way in order to place herself in a position to take responsibility
    for the children.
    
    Id. As noted
    above, the trial court ratified the initial permanency plans on December 6, 2013,
    finding that the Appellants’ requirements were reasonably related to remedying the reason for
    foster care and were in the Children’s best interests. The permanency plans were revised on
    June 24, 2014. The revised plans reiterated the requirements set out in the initial plan, but
    added that Mother would complete a metal health assessment and follow any
    - 15 -
    recommendations thereof. The revised plan also required the Parents to attend marriage
    counseling. The Parents signed the revised plan on June 24, 2014, and the trial court ratified
    the revised plans on August 12, 2014. Again, the trial court found that the requirements
    contained in the revised plans were reasonably related to remedying the reasons for foster
    care and were in the best interests of the Children. Mother’s responsibilities under these
    plans were to: (1) submit to random drug screens; (2) procure stable employment; (3)
    maintain stable clean housing appropriate for the Children; (4) demonstrate candor during
    assessments and with providers; (5) cooperate with service providers; (6) sign releases; (7)
    attend parenting classes; (8) submit to alcohol and drug assessment; (9) learn appropriate
    cleaning skills; (10) learn appropriate parenting skills; (11) submit to individual
    therapy/mental health intake; (12) pay child support; (13) participate in visitation; and (14)
    attend marriage counseling.
    Concerning the foregoing requirements, in its order terminating her parental rights, the
    trial court made specific findings that Mother: (1) had submitted to random drug screens; (2)
    had not procured employment; (3) had not maintained a clean and stable house; (4)
    demonstrated candor with the providers; (5) signed releases; (7) attended parenting classes;
    (8) did not complete alcohol and drug assessment; (9) did not learn appropriate cleaning
    skills; (10) has failed to demonstrate that she has learned effective parenting skills; (11) did
    not complete individual therapy; (12) did not pay child support; (13) did participate in
    marriage counseling, but has not addressed issues raised in those sessions.
    Turning to the record, it appears that Mother was well informed of her responsibilities
    under the permanency plans. Furthermore, it appears that Mother understood her
    responsibilities. As discussed above, DCS made reasonable efforts to help Mother to satisfy
    the permanency plan requirements. Despite DCS’s efforts, the record indicates that Mother
    failed to make reasonable efforts.
    The record shows that, at the time of the hearing, Mother was unemployed. She testified
    that she occasionally babysits, but there is no evidence that this is stable employment. The
    evidence indicates that the family is not financially stable. At the time of the hearing, Father
    was employed at Burger King, but was only making $8.25 per hour. Mother had no income
    except for the occasional babysitting job.
    Concerning the condition of the home, we have previously discussed the evidence
    demonstrating that the conditions in the home have not substantially improved throughout
    these proceedings. Even after the Parents moved from the original residence, the apartment
    they rented was only two bedrooms, with a clause in the lease that no children would be
    living there. Despite the lease condition, the evidence indicates that Appellants allowed a
    family of five to move into one room in the apartment. In addition, DCS, upon inspection,
    discovered live maggots and other dangerous and unsanitary conditions throughout the
    residence.
    - 16 -
    Lisa Tipton, the Executive Director of Families Free, testified that, from her review of the
    records, the Parents have a “world view” that is indicative of a value system that it is okay to
    live in unclean housing conditions. Ms. Tipton testified that Families Free employees had
    addressed environmental concerns and trash in the home many, many times, but had not seen
    any substantial improvement. Accordingly, Ms. Tipton testified that there “was very little
    progress being consistent with the service plan [and Parents] do not [seem] to notice the
    unsanitary conditions around them.” In sum, the record shows that whatever efforts Mother
    made fell far short of reaching the overall goal of the permanency plans, which was for
    Mother to demonstrate that she had changed her conditions so that she could take full
    responsibility for raising her three Children in a healthy, safe, stable home. Therefore, we
    conclude that the evidence preponderates in favor of the trial court’s factual findings, and
    that those findings establish by clear and convincing evidence that Mother did not comply
    substantially with the requirements of the permanency plan, and that her parental rights may
    be terminated on this ground.
    E. Severe Child Abuse
    Tennessee Code Annotated Section 36-1-113(g)(4) provides a ground for termination of
    parental rights where:
    The parent or guardian has been found to have committed severe child abuse
    as defined in § 37-1-102, under any prior order of a court or is found by the
    court hearing the petition to terminate parental rights or the petition for
    adoption to have committed severe child abuse against the child who is the
    subject of the petition or against any sibling or half-sibling of such child, or
    any other child residing temporarily or permanently in the home of such parent
    or guardian[.]
    Tennessee Code Annotated Section 37-1-102(b)(21)defines “severe child abuse,” in relevant
    part, as:
    (A)(i) The knowing exposure of a child to or the knowing failure to protect a
    child from abuse or neglect that is likely to cause serious bodily injury or death
    and the knowing use of force on a child that is likely to cause serious bodily
    injury or death;
    (ii) “Serious bodily injury” shall have the same meaning given in § 39-15-
    402(d).
    Tennessee Code Annotated Section 39-15-402(d) provides, in relevant part, that “serious
    bodily injury . . . to the child includes, but is not limited to, second- or third-degree burns . . .
    injuries to the skin that involve severe bruising . . . .” This Court has discussed the
    “knowing” criterion set out in Tennessee Code Annotated Section 37-1-102(b)(21)(A)(i) as
    - 17 -
    follows:
    The words “knowing” and “knowingly” do not have fixed or uniform
    meanings. Their meanings in particular cases vary depending on the context in
    which they are used or the character of the conduct at issue. Still v. Comm'r of
    the Dep't of Employment & Training, 
    657 N.E.2d 1288
    , 1293 n. 7 (Mass.
    App .Ct. 1995), aff'd, 
    672 N.E.2d 105
    (Mass.1996); State v. Contreras, 
    253 A.2d 612
    , 620 (R.I.1969). Because the parties have not supplied us with
    definitions of these terms, statutory or otherwise, we will employ the basic
    rules of statutory construction to ascertain their meaning. Accordingly, we will
    give these words their natural and ordinary meaning, Frazier v. East Tenn.
    Baptist Hosp., Inc., 
    55 S.W.3d 925
    , 928 (Tenn. 2001), and we will construe
    them in the context of the entire statute and the statute’s general purpose. State
    v. Flemming, 
    19 S.W.3d 195
    , 197 (Tenn.2000). We will also construe the
    words in a manner consistent with the rules of grammar and common usage.
    The word “knowing,” when used as an adjective, connotes a state of
    awareness. In re D.P., 
    96 S.W.3d 333
    , 336 (Tex. Ct. App. 2001). Thus, it
    requires some inquiry into the actor’s state of mind. A person’s conduct is
    “knowing,” and a person acts or fails to act “knowingly,” when he or she has
    actual knowledge of the relevant facts and circumstances or when he or she is
    either in deliberate ignorance of or in reckless disregard of the information that
    has been presented to him or her. Persons act “knowingly” when they have
    specific reason to know the relevant facts and circumstances but deliberately
    ignore them.
    For the purpose of determining whether a parent’s conduct runs afoul of Tenn.
    Code Ann. § 37-1-102(b)(21), parents who are present when a child is abused
    but who fail to intervene to protect the child have knowingly exposed the child
    to or have failed to protect the child from abuse. However, the “knowing”
    requirement in Tenn. Code Ann. § 37-1-102(b)(21) is not limited to parents
    who are present when severe abuse actually occurs. A parent’s failure to
    protect a child will also be considered “knowing” if the parent had been
    presented with sufficient facts from which he or she could have and should
    have recognized that severe child abuse had occurred or that it was highly
    probable that severe child abuse would occur. West Va. Dep't of Health &
    Human Res. ex rel. Wright v. Doris 
    S., 475 S.E.2d at 878-879
    .
    In re R.C.P., No. M2003-01143-COA-R3-PT, 
    2004 WL 1567122
    , at *7 (Tenn. Ct. App. July
    13, 2004). With the foregoing authority in mind, we turn to the record.
    - 18 -
    Here, the finding of severe child abuse stems from the burn that Dustin sustained
    while in his Mother’s care and, as it applies to Father, from the failure to procure medical
    attention for Dustin’s wound. As discussed briefly above, on June 16, 2014, during a home
    visit, DCS employees noted that Dustin had a burn on his wrist and lower arm. Mother told
    Ms. Hodge that the child had been burned several days earlier when he spilled a bowl of
    Ramen noodles on himself. She explained that Dustin had used a stool to reach the
    microwave where the bowl of soup was. However, Mother could not produce the stool when
    asked to do so. At the time of the injury, Dustin was too young to explain how he sustained
    the burn. The only witness to the event was Mother. The record indicates that, when Father
    returned home, he chose not to seek medical attention for the child. Rather, he explained that
    he called a local pharmacy to ask about treatment. Father stated that he went to the pharmacy
    and purchased “extra strength pain reliever Neosporin.” When DCS examined the tube of
    ointment, however, they noted that it had expired in 2009.
    Father testified that he did not cause the burn and that he was not present when it
    occurred. When asked why they had not taken the child to the hospital, both parents replied
    that they had not had time. Father specifically stated that he had not sought medical
    treatment for the child because he thought he was capable of dealing with the injury at home.
    He stated that he had dealt with second degree burns at work “all his life,” and that he had
    sustained far worse injuries himself without seeking medical attention. Father testified that,
    when he arrived home on the day Dustin suffered the injury, the child’s arm had already been
    bandaged. Father stated that he wiped the burn down with alcohol and a cotton ball. He also
    stated that he used Neosporin on the wound. Father further testified that he would sometimes
    apply honey along with the Neosporin. He stated that he had been “popping” the burn
    blisters that would arise on the wound. DCS noted that the child’s wound was wrapped in
    toilet paper secured with scotch tape.
    After removing the Children from the home, DCS took Dustin to the emergency room.
    Although Dustin did not initially appear to be in great distress with his wound, when the
    doctors cleaned and dressed the wound, he did cry at that point. Photographs of Dustin’s arm
    were admitted into evidence. They show a rather large burn, with darker, burned skin
    coming off it. The wound is red and appears irritated.
    Dr. Susan W. Jeansonne’s testimony was admitted, by deposition, at the hearing on the
    petition to terminate parental rights. All parties stipulated that Dr. Jeansonne would be
    certified as an expert in the field of pediatric clinical care. Dr. Jeansonne was Dustin’s
    treating physician. She testified that Dustin’s burn was a “partial thickness burn with
    portions of skin still intact.” She stated that this was a well-demarcated burn on the child’s
    wrist, which almost completely encircled it. Some areas of the burn were first degree burns,
    which were red and similar to sunburned areas; other portions of the burn were second
    degree burns, which involved blistering. Dr. Jeansonne diagnosed the burn as a “thermal
    direct contact burn.” She further diagnosed Dustin as neglected due to his poor hygiene and
    - 19 -
    the delay in seeking treatment. Additionally, she diagnosed child abuse.
    Importantly, Dr. Jeansonne testified that, in her medical opinion, the child’s burn did
    not occur from a splash-type incident with liquid being poured down and flowing onto the
    arm, as Mother had stated. Dr. Jeansonne did state that a hot liquid poured on an article of
    clothing that the child was wearing “could” cause a burn such as the one she observed on
    Dustin’s arm, but such injury would only occur if the child was wearing clothing with a tight
    cuff. She also testified that the demarcation “could” have occurred if the liquid had spilled
    farther up his arm on his sleeve and soaked into the bottom around his wrist. The trial court
    noted that there was no testimony that Dustin was wearing any type of shirt or sweatshirt
    when he sustained the injury.
    Dr. Jeansonne testified that a burn such as Dustin’s would have caused him substantial
    and consistent pain, which could have been lessened by pain medication and proper
    treatment. She further testified that, left untreated, the burn posed a serious risk for infection
    and scarring. Dr. Jeansonne stated that the Parents should have sought immediate medical
    attention. Had they done so, the wound could have been properly cleaned, debrided, and
    bandaged. Dr. Jeansonne opined that the blisters on Dustin’s burn should not have been
    burst as this action would increase the risk of scarring and infection. Dr. Jeansonne testified
    that, in her medical opinion, the injury to Dustin’s arm was consistent with non-accidental
    trauma.3
    In finding that DCS had met its burden of proof on the ground of severe child abuse as
    to Mother, the trial court, in its order terminating Appellants’ parental rights, made the
    following, relevant findings:
    138. The Court finds that the mother was the only witness to the second (2nd)
    degree burn sustained by the minor child, Dustin. Further, the Court finds that
    Dustin was very young when he sustained the wound, and is not capable of
    describing how the injury took place.
    ***
    140. According to the medical testimony presented in this cause, the burn was
    not a splash burn similar to what the mother told DCS. Expert testimony
    established that the injury to the child was non-accidental in nature.
    141. DCS has proven, by clear and convincing evidence, the ground of severe
    3
    Based on the injuries to Dustin’s arm, at the time of the hearing, both parents were charged
    with two counts of felony child abuse. At the time of the hearing, the charges had been bound over
    to the Grand Jury.
    - 20 -
    child abuse against Respondent Elizabeth J[.].
    Based on the testimony and evidence outlined above, we conclude that the evidence
    preponderates in favor of the trial court’s factual findings, and that those findings establish
    by clear and convincing evidence that Mother’s parental rights may be terminated on the
    ground of severe child abuse as set out at Tennessee Code Annotated Section 36-1-113(g)(4).
    Concerning the ground of severe child abuse as it applies to Father, in its order
    terminating parental rights, the trial court made the following, relevant, findings:
    142. The Court finds that Respondent Jeremiah J[.] knowingly failed to
    protect the minor child from abuse or neglect that is likely to cause serious
    bodily injury or death. The Court finds that the father’s failure to protect the
    child was “knowing” because, by his own testimony, he was aware that the
    child sustained a second degree burn. Father testified that he was aware
    enough to know that the child needed some type of treatment for the injury, but
    that, instead of seeking medical care for the child, he instead elected to go ask
    a pharmacist . . . how to treat the wound.
    143. The Court finds that the minor child had TennCare insurance at the time
    that he was burned in the home. The Court finds that all the father had to do to
    seek treatment was to contact the child’s family service worker at DCS.
    Further, the Court finds that, if the family was out of money such that they
    could not afford bandaging for the injury, the father could have taken the child
    to the emergency room or other medical provider at no cost to himself or the
    family.
    ***
    146. The Court finds that the father was presented with sufficient facts from
    which he could have and should have recognized that severe child abuse had
    occurred, and that he had actual knowledge of the relevant facts and
    circumstances and either was in deliberate ignorance of or in reckless disregard
    of the information that was presented to him. He knowingly failed to act to
    protect his son from severe child abuse.
    147. DCS has proven, by clear and convincing evidence, the ground of severe
    child abuse against Respondent Jeremiah J[.].
    Based on the testimony and evidence outlined above, we conclude that the evidence
    preponderates in favor of the trial court’s factual findings, and that those findings establish
    by clear and convincing evidence that Father’s parental rights may be terminated on the
    - 21 -
    ground of severe child abuse as set out at Tennessee Code Annotated Section 36-1-113(g)(4).
    V. Best Interests
    When at least one ground for termination of parental rights has been established, the
    petitioner must then prove by clear and convincing evidence that termination of the parent's
    rights is in the child's best interest. White v. Moody, 
    171 S.W.3d 187
    , 192 (Tenn. Ct.
    App.1994). When a parent has been found to be unfit (upon establishment of ground(s) for
    termination of parental rights), the interests of parent and child diverge. In re Audrey S 
    ., 182 S.W.3d at 877
    . The focus shifts to the child’s best interest. 
    Id. at 877.
    Because not all
    parental conduct is irredeemable, Tennessee’s termination of parental rights statutes
    recognize the possibility that terminating an unfit parent’s parental rights is not always in the
    child’s best interest. 
    Id. However, when
    the interests of the parent and the child conflict,
    courts are to resolve the conflict in favor of the rights and best interest of the child. Tenn.
    Code Ann. § 36-1-101(d). Further, “[t]he child's best interest must be viewed from the
    child’s, rather than the parent’s, perspective.” 
    Moody, 171 S.W.3d at 194
    .
    The Tennessee Legislature has codified certain factors that courts should consider in
    ascertaining the best interest of the child in a termination of parental rights case. These
    factors include, but are not limited to, the following:
    (1)Whether the parent or guardian has made such an adjustment of
    circumstance, conduct, or conditions as to make it safe and in the child’s best
    interest to be in the home of the parent or guardian;
    (2) Whether the parent or guardian has failed to effect a lasting adjustment
    after reasonable efforts by available social services agencies for such
    duration of time that lasting adjustment does not reasonably appear
    possible;
    ***
    (5) The effect a change of caretakers and physical environment is likely to
    have on the child’s emotional, psychological and medical condition;
    ***
    (7) Whether the physical environment of the parent’s or guardian's home is
    healthy and safe. . . .
    (8) Whether the parent’s or guardian's mental and/or emotional status would
    be detrimental to the child or prevent the parent or guardian from
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    effectively providing safe and stable care and supervision for the child . . . .
    Tenn. Code Ann. § 36-1-113(i). This Court has noted that “this list [of factors] is not
    exhaustive, and the statute does not require a trial court to find the existence of each
    enumerated factor before it may conclude that terminating a parent’s rights is in the best
    interest of a child.” In re M.A.R., 
    183 S.W.3d 652
    , 667 (Tenn. Ct. App. 2005). Depending on
    the circumstances of an individual case, the consideration of a single factor or other facts
    outside the enumerated, statutory factors may dictate the outcome of the best interest
    analysis. In re Audrey S
    ., 182 S.W.3d at 877
    . As explained by this Court:
    Ascertaining a child’s best interests does not call for a rote
    examination of each of Tenn. Code Ann. § 36-1-113(i)’s nine
    factors and then a determination of whether the sum of the
    factors tips in favor of or against the parent. The relevancy and
    weight to be given each factor depends on the unique facts of
    each case. Thus, depending upon the circumstances of a
    particular child and a particular parent, the consideration of one
    factor may very well dictate the outcome of the analysis.
    White v. Moody, 
    171 S.W.3d 187
    , 194 (Tenn. Ct. App. 2004).
    As discussed in detail above, the record indicates that the Parents’ living conditions
    continue to be unsanitary and, thus, unsafe for these Children. Even after extensive services
    have been offered to the Appellants, it does not appear that they have made, or will be able to
    make, a lasting adjustment so as to be able to properly care for these Children. As indicated
    by Ms. Tipton, even after having their Children removed from their custody, Appellants still
    do not seem to comprehend the severity of their living situation and the effect that it has had
    on the Children. Their continual denial in this regard does not bode well for long term
    parenting success.
    Meanwhile, the evidence suggests that these Children have flourished in their foster
    home. The foster mother testified that all three Children have been in her home since June
    27, 2013; i.e., approximately two years from the time of removal from Appellants’ custody
    to the date of hearing on the petition to terminate parental rights. The Children’s foster
    parents are both employed as pharmacists; while the foster parents are at work, the Children
    are cared for by the foster grandparents or a family friend. The evidence indicates that the
    Children are well adjusted in the foster home. The foster mother testified that the Children
    enjoy playing games, and they have helped to raise and care for two chickens. Derrick has
    participated in football, basketball, and soccer; he also enjoys dance classes. Destiny is
    involved in cheerleading and dance. Dustin has participated in soccer and enjoys watching
    his older sibling participating in their various activities. The Children have gone on
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    vacations together with their foster parents.
    The evidence further indicates that the Children are doing well academically. The
    foster mother testified that she and her husband work on homework with the Children.
    Although the Children were described as “disruptive” when they first came into foster care,
    the foster mother testified that their behavior has improved, and the Children now listen to
    instructions from the foster parents.
    After the trial home placement was revoked in June of 2014, the Children came back
    into the foster home. The foster mother testified that, at first, the Children reverted to
    behavior similar to that demonstrated when they first came into DCS custody. However,
    after approximately one week back in the foster home, the Children’s behaviors readjusted.
    The foster mother testified that she and her husband would “absolutely like to adopt the
    children.”
    From the totality of the evidence, it appears that these Children have found, in their
    current foster home, perhaps the only stability they have ever known. To remove the
    Children from this stable environment would likely be detrimental to their emotional,
    psychological, and physical wellbeing. This is especially so in light of the overwhelming
    evidence that the Parents have failed to make an adjustment in their living conditions such
    that they could provide a proper home for these Children at any near date. Therefore, we
    conclude that there is clear and convincing evidence in the record to support the trial court’s
    finding that termination of Appellants’ parental rights is in the best interests of these
    Children.
    VI. Conclusion
    We affirm the order of the trial court, terminating the parental rights of both of the
    Appellants. The case is remanded for such further proceedings as may be necessary and are
    consistent with this opinion. Costs of the appeal are assessed one-half to Appellant/Father,
    Jeremiah J., and one-half to Appellant/Mother, Elizabeth J. Because both Appellants are
    proceeding in forma pauperis in this appeal, execution for costs may issue if necessary.
    _________________________________
    KENNY ARMSTRONG, JUDGE
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