Overview of This Report
Earlier this year, DRA learned that LCBH was planning to expand its operations with the construction of two new buildings, a 24-bed and 16-bed building, on the property of LCBH, with construction expected to be completed by the end of 2024. LCBH plans to expand its exclusively out-of-state PRTF license by 24 beds. Having previously identified what appeared to be gaps in the oversight scheme related to this uniquely situated facility, talks of expansion prompted DRA to more fully investigate who was providing what oversight and their effectiveness.
DRA was already very familiar with the extent of Arkansas oversight of LCBH. We reached out to many of the at least 27 states that have placed children at LCBH in an attempt to determine whether placing states are reviewing the facility to ensure compliance with the CMS Conditions of Participation. The responses received indicated that the placing states completing reviews are doing so through the lens of state standards.
We decided to conduct a survey of LCBH roughly following the guidelines laid out in the State Operations Manual, in order to determine the extent of the effect of oversight gaps. As part of this review, we looked at facility policies, restraint and seclusion logs, and resident charts. We also interviewed the Director of Risk Management, the Director of Nursing (DON), and the Clinical Director. In keeping with our state survey agency’s method of review, we did not interview residents. Our survey sample included ten residents. The residents included in this review had stayed within the review period of 1.5 – 13 months.
The following report outlines identified deficiencies related to the use of restraint and seclusion, treatment plan creation, implementation, and review, and the use of and medical oversight related to prescription medications. This report is not intended to be a comprehensive assessment of this facility, nor is it to be considered a complete representation of all areas of non-compliance. The goal of our survey was to determine whether the oversight scheme created for this unique facility has been effective. It has not been. The goal of this report is to alert state officials of the serious implications of their oversight failures and the urgency of re-evaluating their processes.