Disability Rights Arkansas

Centers for Youth and Families Little Rock

*Photos taken by DRA staff during onsite monitoring visits. Photos reflect the most recent conditions observed by DRA staff but may not reflect the current conditions at the facility. If you are associated with a facility and have updated information or photos you would like to share, please contact DRA at [email protected]

Location: Little Rock, AR

Population Served: Youth ages 5-18

# of residents per unit: Up to 8 Residents per room: 1-3 Capacity: 82 beds (PRTF and residential)

Contact with family (Calls and visit schedule): Facility declined to provide specifics regarding call frequency or schedule

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? No

Treatment Components

Clinical Director - LCSW

Therapists: Facility declined to identify, report number employed, or share credential status of any therapists.

Treatment modalities offered: Facility declined to identify any specific modalities available.

# of individual therapy sessions/week: Facility declined to provide a number or range.

# of group therapy sessions led by a licensed mental health professional/week: Facility declined to provide a number or range.

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PRLU or OLTC

Visit Compliance Report

  • Building and grounds inspection; Checked fire drill logs, disaster logs, and med logs with no regs out of compliance.
  • TA –
    • R911.6 – The shower in the private dorm is still inoperable and the staff advised that they are still waiting on parts to fix it. The hall is currently vacant.

Medicaid Inspection of Care

Notice of Sanction

  • 07.19.21 Actions: After careful review of the IOC reports and the CAP submitted by CYF, DMS has concluded that the following actions are necessary and appropriate:
    • Monitor the corrective action plan submitted by CYF to determine the level of compliance with the terms stated therein.
    • Suspend provider referrals and disallow future admissions pending progress made on the CAP submitted by CYF.
    • Additionally, DMS reserves the right to recoup payments made for services determined to not be medically necessary or that fail to meet professionally recognized standards for healthcare.
  • 11.23.21 Actions: Given the progress made by your facility and maintaining awareness of the seriousness of the previously cited deficiencies, DMS hereby amends the sanctions against your facility.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance –
    • R911.15.f – A drawstring was found in a girl’s room in the dorm. Staff removed the item as directed.
  • TA –
    • R911.6 – All faucets in the private dorm and one showerhead were not functioning properly. Staff advised they are waiting on parts to finish repairs.

PRLU or OLTC

Notice of Incident

  • Injury – Accidental
    • Client reportedly fell in the shower. Client complained of head, arm, and shoulder pain as a result of her fall.

PRLU or OLTC

Notice of Incident

  • Injury – Self-inflicted
    • During a client’s admission process, the client was observed to have swollen right hand. The client said she had hit a wall during an argument with her mother. The client had received no medical treatment for her injured hand. Client said that her hand hurt.

PRLU or OLTC

Notice of Incident

  • Injury – Accidental
    • Client got a splinter in his hand while running his hand up the railing. Nursing staff attempted to remove but were advised to clean and monitor it; Follow up appointment.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance –
    • R911.15.f – Drawstrings were found in clothing in room 1 Dorm North and room 2 Dorm South; Corrected during visit. Clothing removed from room by staff and strings removed from clothing.
  • Regs not correctable –
    • R908.8 – When checking electronic med logs, client had several missing days of meds being logged and no explanation as to why.
  • TA –
    • R911.6 – The faucet in girl’s bathroom on Dorm South wasn’t working (sensor was malfunctioning).

PRLU or OLTC

Notice of Incident

  • Other – Client’s in Attic
    • 2 Clients pulled ladder down and went into the attic of facility; Fire department and police were called to the location. Client 1 exited the attic after approximately 30 minutes and Client 2 after approximately 1.5 hours.
    • Staff member was immediately suspended pending termination. All attic access was secured by screwing shut attic doors. Family therapy session with client’s mother was conducted and addressed with therapist. Child Abuse Hotline was called, not accepted.

Police Report

Information Report

Upon arrival, staff stated that Juvenile climbed into the attic and refused to come down. Staff stated there were staff members up there with Juvenile. Juvenile came down once fire dept. and staff member spoke with him. No injuries noted.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance –
    • R905.9 – Ensure minimal force is used when performing restraints (ESI used 6/9/21).
    • R907.2 – Ensure child caring staff be responsible for providing the level of supervision, care, and treatment necessary to ensure the safety and well-being of each child at the facility (Restraint used 6/9/21).
  • TA –
    • R908.8 – Ensure medicine is logged only when given (Meds were accidentally logged while client was in acute).

PRLU or OLTC

Complaint Survey, Workload Report

  • Complaint #AR00026744 unsubstantiated.
  • Survey Team Composition and Workload Report –
    • One surveyor onsite 4 hours 8am – 6pm, 1.75 hours 6pm – 12am; 3.5 travel hours, 1.75 off-site report prep hours (06/21/21 – 06/22/21).

PRLU or OLTC

Revisit Survey with POC, Workload Report

  • Regs out of compliance –
    • N 143 – Facility failed to ensure a physician order was obtained at the times of a restraint for 1 client by not obtaining an order for a restraint during the restraint or immediately after the restraint.
    • N 144 – Facility failed to ensure a physician’s order was documented for 2 clients who required an ESI.
    • N 155 – Facility failed to ensure an ESI Report Form was completed for each restraint used for 2 clients who required a use of a restraint. Facility failed to ensure there was a cumulative log of all restraints utilized.
    • N 167 – Facility failed to ensure an assessment was completed immediately after the use of a restraint for 1 client who required the use of a restraint.
  • Plan of Correction: Training documentation developed and daily review of ESI forms initiated.
  • 07.19.21 Revisit for 06.17.21 deficiencies; Facility in compliance with program requirements.
  • Survey Team Composition and Workload Report –
    • Surveyor 1 onsite 12.5 hours, 8am – 6pm; 5 travel hours, 5.5 off-site report prep hours (06/16/21 – 06/17/21).
    • Surveyor 2 onsite 12.5 hours 8am – 6pm; 1.5 travel hours, 3 off-site report prep hours (06/16/21 – 06/17/21.
    • One surveyor onsite 4.5 hours 8am – 6pm; 3 travel hours, 1 off-site report prep hours (07/19/21).

PRLU or OLTC

Visit Compliance Report

  • During visit, video footage was reviewed of incident involving an alleged improper restraint. After reviewing the video, it was determined no actions would be taken at that time. Investigation is still pending. (Staff was viewed grabbing client’s arm and client snatched arm away possibly causing injury; Noted that staff is viewed swatting at client as client is snatching arm away)
  • A building and grounds monitoring visit was also conducted with no deficiencies noted.

PRLU or OLTC

Complaint Survey, Workload Report

  • Complaint #AR00026706 unsubstantiated.
  • Survey Team Composition and Workload Report –
    • Surveyor 1 onsite 6.25 hours 8am – 6pm; 2.5 travel hours (06/15/21).
    • Surveyor 2 onsite 6.25 hours 8am – 6pm; 1.5 travel hours, 2.5 off-site report prep hours (06/15/21).

PRLU or OLTC

Visit Compliance Report

  • TA – Ensure all required legal documents (Birth certificates, social security cards, court orders, etc.) are obtained and placed in children’s file. Specialist reviewed 14 children’s records; Certain legal documents were missing, however, a request form requesting information was in the file.

Medicaid Inspection of Care

On-Site Inspection

  • Included: IOC, CAP, Sanction Letters, Reconsideration Determination Letter
  • Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.

PRLU or OLTC

Visit Compliance Report

  • Specialist made visit to view video footage of incident that took place at facility. Upon viewing the video, it was determined that the staff member failed to de-escalate the situation allowing for incident to get out of control.
  • Cited for regulation 907.2 – Child caring staff shall be responsible for providing the level of supervision, care, and treatment necessary to ensure the safety and well-being of each child at the facility taking into account the child’s age, individual differences and abilities, surrounding circumstances, hazards and risks.

PRLU or OLTC

Notice of Incident

Injury – Peer Altercation

  • Client 1 became upset when staff asked him to take a shower and began throwing objects at staff and hitting staff. Client 2 became triggered due to Client 1 hitting staff, and both clients ultimately engaged in a physical altercation after Client 1 began throwing objects at Client 2. Client 1 sustained several minor injuries and sent to ACH ER, where he received a tetanus booster and given a prescription for Augmentin, a bite protocol for ACH.
  • Video footage of incident requested.

PRLU or OLTC

Visit Compliance Report

Regs out of compliance

  • R911.15 – Shoestrings found in a pair of shoes in a room on Dorm East. Corrected 6.2.21.

TA

  • R911.6 – A used urine bag was found in child’s closet on Dorm North.

Not correctable

  • R908.8 – Client meds were not documented as given/administered, dates May 27 & 28.

CWARB Actions

Corrective Action Agreement, Letter of Reprimand

  • Centers has recently failed to maintain substantial compliance with the Minimum Licensing Standards in the areas of Behavior Management, Ratio & Supervision and Inspections, Investigation & Corrective Action.
  • The attached CAA reflects the excessive citations and lack of sustained compliance at Centers for Youth and Families – Elizabeth Mitchell Centers. Because of this, youth are not receiving the required care as intended by the Minimum Licensing Requirements.