Census: 14. Buildings and grounds conducted with no concerns noted. MARs reviewed for 5 clients with no concerns noted. No recent issues with elopements, broken windows or doors.
PRLU or OLTC
Visit Compliance Report
Police Report
Non Police Incident
Officers secured the scene for MEMS for an aggressive juvenile that the facility wanted taken to ACH for evaluation.
PRLU or OLTC
Notice of Incident
- ER Visit (Self-inflicted Injury) – Client became dysregulated and punched a wall with his hand. Client was transported to ER and received x-ray that determined client had a slight fracture of the fifth metacarpal of the right hand. Client’s hand was not placed in a cast. Follow-up appointment scheduled with an orthopedist on 2/27/22.
Police Report
Non Police Incident
Secured scene for MEMS.
Police Report
Non Police Incident
Juvenile was transported by MEMS to Methodist Behavioral Health in Maumelle for suicidal behavior.
PRLU or OLTC
Visit Compliance Report
Census: 15. Buildings and grounds conducted for Destiny House and MARs checked for 5 clients. Records reviewed for 10 clients with no licensing concerns.
PRLU or OLTC
Visit Compliance Report
Census: 23. Buildings and grounds conducted; No regs out of compliance. MARs checked for 5 residents.
Police Report
Assault Third Degree
Staff stated 2 juveniles were in physical altercation and the rest of the residents are refusing to return to their rooms. Both juveniles were “talking in circles” and were vague while speaking with officers. No visible injuries observed.
PRLU or OLTC
Visit Compliance Report
Buildings and grounds conducted for Destiny’s House; Census 17. Leak observed under washing machine which maintenance (who were present) was aware of and indicated they would fix. MARs checked for multiple residents. Two residents had missing entries; Staff indicated the clients were on therapeutic leave thus no med administration entries were made.
Medicaid Inspection of Care
On-Site Inspection
- Included: IOC
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
PRLU or OLTC
Visit Compliance Report
- Dorms, bathrooms, eating area, rec room, and classrooms checked with no concerns noted. MARs checked for 5 clients’; All medication initialed and up to date.
- TA –
- 706.2.f – “N/A”
Police Report
False Alarm
Officers responded to facility and searched the outside of the business for signs of suspicious activity with negative results. All doors and windows seemed secure.
PRLU or OLTC
Visit Compliance Report
Reviewed 10 client’s records; No concerns noted.
PRLU or OLTC
Visit Compliance Report
Buildings and grounds visit conducted; A MAR review was conducted for 3 residents. No concerns noted; Census 52.
PRLU or OLTC
Visit Compliance Report
Buildings and grounds visit conducted; MARs not reviewed due to computers being down. No concerns noted.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
- Complaint #AR00027401 was substantiated. Regs out of compliance –
- N 188 – Facility failed to ensure all staff involved in an ESI participated in a debriefing for 1 client who required the use of a personal restraint.
- N 189 – Facility failed to ensure all staff involved in an ESI participated in a debriefing for 1 client who required the use of a personal restraint.
- Plan of Correction –
- Retraining on ESI documentation and 12th Street Crisis Management Protocol; ESI forms will be reviewed daily.
- During the Revisit Survey conducted on 12/15/21, the facility was found to be in compliance with program requirements.
Police Report
Assault Third Degree
Staff stated Juvenile got upset when staff pointed out the misuse of phone privileges and yelled and pushed staff. When staff tried to restrain Juvenile, he punched staff in the face. Staff advised the cameras were not working, and the facility has started in investigation. Staff wanted a report made.
PRLU or OLTC
Notice of Incident
- Overdose
- Client was transported to ER after stating she took 10 pills that she had regurgitated and put in a book. ER staff stated there were no signs of client taking extra medications due to tests/vital signs. Staff at facility stated client has been on med watch and she has been sitting for 30 minutes after taking medication and mouth is checked before she is able to return to activities.
- Client was sent to acute; Client has been on and will stay on med watch and tongue dispenser is inserted in mouth when medication is taken.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R911.15.d – Shorts with string that could be taken out and used for self-harm was removed during walkthrough. Client was new to the program and Director stated they were just missed.
- Checked MARs for 3 residents with no concerns noted. EMCC was not visited due to outbreak of lice. EMAC was not visited due to incident.
PRLU or OLTC
Revisit Survey, Validation Survey
- A 5-year validation survey was conducted from 10/25/21 through 10/28/21.
- Regs out of compliance –
- E 004 – Facility failed to ensure a comprehensive emergency preparedness (EP) plan was reviewed and updated at least annually and operationalized to prepare for resident and staff safety in the event of a potential emergency or disaster situations.
- During the Revisit Survey conducted on 12/15/21, the facility was found to be in compliance with program requirements.
Police Report
Disturbance
Staff stated J1, J2, and J3 were in a verbal altercation and were rough with staff when they began to intervene. The juveniles made statements of self-harm; MEMS were advised to respond. Decision was made to keep juveniles on the property.
PRLU or OLTC
Notice of Incident
- Sexual Activity
- Client stated to staff that he had sex with another client while the 2 were at another facility together. This was reported to Child Abuse Hotline and accepted (referral # unknown).
- Clients are being assigned to separate dorms, classrooms, and group sessions. Staff have been informed to keep clients separated during outside time, meal services, and other activities.
Police Report
Battery Third Degree
Staff advised Juvenile 1 attacked Juvenile 2 in class. Juvenile 2 stated he was talking to himself after Juvenile 1 told him to stop talking to him, and Juvenile 1 got up and put his hands on him. Officers observed small knot on Juvenile 2s forehead.
PRLU or OLTC
Visit Compliance Report
No regs out of compliance. Reviewed MARs for 4 residents with no issues found.
PRLU or OLTC
Visit Compliance Report
No regs noted out of compliance. Reviewed MARs for 3 residents with no issues found.