No deficiencies were cited during the Inspection of Care (IOC) conducted on 09/23/24.
PRLU or OLTC
IOC Report
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Building & Grounds conducted from 9 am-10 am.
Census: 20. A discussion was had about a few small areas on the walls with chipped paint that could become a future issue. No issues were noted otherwise.
MARs reviewed for multiple residents. All are electronically entered and up to date.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Children’s Record Review conducted. All items were viewed electronically except for the immunization record for one resident.
Technical Assistance will be given for 902.3. Immunizations will be provided to licensing by 8/7/24.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Buildings & Grounds conducted from 9:00AM-10:00AM. Census: 18
Cafeteria staff/client ratio: 2:7. Outside play area staff/client ratio: 2:5. Hallway staff/client ratio: 1:5.
Outside area clean and free of safety hazards. Cafeteria clean and sanitary. Girls Hall clean, safe and in good repair. Bathrooms clean and sanitary with functioning sinks, showers and toilets. Boys Hall clean and in good repair. Bathrooms clean and sanitary with functioning sinks, showers and toilets.
Waistband drawstrings found in boy’s rooms 3, 9, 10 and 13. All drawstrings were removed on-site during visit. Drawstrings will be removed, and clothing items returned. Facility cited 911.15f. Staff will conduct inventory on all clothing items to check for strings and remove them.
MARs checked electronically. All initialed and up to date.
PRLU or OLTC
Accidental Injury, Notice of Incident
Clients were having outside time. Two clients were racing when one fell in an awkward position on his shoulder. The client was taken to the local clinic for evaluation.
Diagnosis: Fractured Clavicle
Client will receive no surgery or cast but is restricted from lifting anything over his head or raising his arm. Next follow-up will be 7/15/2024.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
After hours visit conducted. Census: 23; Staff/client ratio: 5/18
Five staff awake, alert, and engaged in morning activities. All areas observed to be clean and in good repair. Grounds clean and free of safety hazards. MARs checked. All initialed and up-to-date.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Client reported that a staff member placed his hands around the client’s neck, attempting to choke him. Client was in his bedroom with one-on-one staff sitting in a chair outside the room.
Licensing Specialist: Clayton DeBoer
Licensing Specialist visited the facility and reviewed available video of the hallway, which shows staff entering client’s room for approximately 40 seconds. There is no video of the bedroom. At no time does staff appear visually aggressive, upset, or out of control. Client had no marks or bruises on his neck during Licensing’s visit, approximately 24 hours after alleged incident occurred.
Licensing complaint has been determined to be UNFOUNDED.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Personnel Records training portion reviewed for all staff through Credible online monitoring system.
All training accounted for.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Personnel Record Review attempted. Centers is transitioning from paper to “Credible” online training completion verification. Some verification on paper, some in “Credible”. Neither listed the number of credit hours for completion.
Technical Assistance provided (105.13): All licensing requirements listed in today’s visit were not readily present in each employee file and did not include the date, number of hours, name of the source, and the topic or title. All of these items for every employee of Centers Monticello need to be ready for review by 5/1/24. If an extension is needed to continue the transition from paper to online training verification, licensing must be notified.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Resident reported that an employee of Centers allegedly got rough with her and pushed her to the wall, causing bruises on the face, leg, and arms. FSW Smith immediately took pictures of the bruises. Resident reported broken bones in her face and was taken for an x-ray. While at the doctor’s office, client reported dizziness and blurred vision and was taken to the ER for a CT scan, which came back normal. Employee was placed on suspension pending investigation.
Licensing Specialist: Clayton DeBoer.
Facility visited 2/22/24. Emergency Safety Intervention nursing notes and camera footage of restraint holds were reviewed for 2/18/24, 2/19/24, and 2/20/24. Camera footage did not yield what appeared to be aggressive or inappropriate holds by staff.
CACD investigation unsubstantiated. Licensing complaint was unfounded.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Annual Review/Policies PRTF completed. All items on checklist accounted for.
Buildings & Grounds conducted from 9:00AM – 10:30AM. Census 20. Classroom 1 staff/client ratio: 2:12, Classroom 2 staff/client ratio: 2:5.
Grounds clean and free of safety hazards. Cafeteria clean and sanitary. Sleeping areas reasonably well-kept, furnished, safe, and in good repair. Bathrooms clean and sanitary with functioning sinks, showers, and toilets. Client rights, emergency escape diagrams and fire extinguisher observed. MARs checked.
Facility cited 908.8: PM meds for 1/10/24 marked “missed” on electronic MAR due to an entry error.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings and Grounds conducted from 10:30 AM – 11:30 AM. Census:23
Areas observed: Classroom 1 staff/client ratio: 2:9, Classroom 2 staff/client ratio: 2:7
Grounds clean and free of safety hazards. Living and sleeping areas clean, safe and in good repair. Showers clean and sanitary with functioning sinks, showers, and toilets. Emergency escape diagrams and client rights posted. MARS checked.
Annual Review/Policies PRTF document checklist completed today. All items on checklist accounted for except there was no current log or file of all calls to the child abuse hotline. A file was made by Karen Walker of Centers Monticello during today’s visit.
Facility cited 110.11: The agency shall maintain a log or file of all calls to the child abuse hotline.
Medicaid Inspection of Care
Corrective Action Plan, Inspection of Care Report
Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted on 10/02/23. All deficiencies overturned.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings & Grounds conducted from 10am – 11am. Census: 21. Areas observed: Classroom, outside area, sleeping areas, and bathrooms. Wall brackets for fold-up tables were inspected and noted to be securely fastened to the wall. MARs checked for 5 residents.
No licensing concerns were noted during visit.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Building & Grounds conducted from 10:00AM-12:00PM.
Census: 20. 2 classrooms observed, staff/client ratios: 2:9, 2:9. Bathrooms have hot water and functioning sinks and toilets. Sleeping areas furnished, clean and free of safety hazards. Facility grounds clean and free of safety hazards. MAR checked for 5 residents; All initialed and up to date.
Facility cited 911.6: Hall 1 bathrooms had two torn shower curtains. Hall 2 right bathroom toilet had gaps at the base between toilet and floor and needs to be reset.
PRLU or OLTC
Accidental Injury, Notice of Incident, Visit Compliance Report
On 08.12.2023, due to the extreme heat, a male group was in the cafeteria area playing basketball. This area has 4 cafeteria tables that fold up to the wall to provide room for the inside basketball goal to be utilized. [REDACTED] went to the side of the metal box holding the table and pulled. The table fell from the wall landing on top of [REDACTED]. The nurse and staff immediately came to his aid. Staff lifted the table over [REDACTED] allowing to move. [REDACTED] complained of his wrist hurting and was immediately taken to Drew Memorial Emergency room to be evaluated. Drew Memorial stated a possible break. [REDACTED] was transferred to Children’s Hospital. Children’s determined [REDACTED] had a break located on the thumb side of the hand, lying laterally in the lower arm. A cast and sling were secured.
Licensing Specialist: Clayton DeBoer.
Facility visited 8/17/23 and video reviewed of incident. Facility cited 911.6: Video review determined fold-away table box was not securely fastened to the wall resulting in the injury of a client.
There would be no indication that these boxes are not securely fastened to the wall unless pulled. Additional hex bolts will be added to the fold-away table boxes as soon as possible. Maintenance has been notified of this.
PRLU or OLTC
Visit Compliance Report
Buildings and grounds conducted. Clients are out of school for the summer but were engaged in activities inside the facility due to extreme heat. All areas observed in appropriate staff/Client ratios. Cafeteria area observed to be clean and sanitary. Kitchen clean and sanitary with fire extinguisher. 3 halls observed to be clean, safe, and in good repair. Bathrooms clean and sanitary. One of the six bathrooms had slightly tattered shower curtain as if it is being pulled too hard off the rings which was replaced during visit. Grounds observed to be clean and free of safety hazards. Clients rights posted. Electronic MAR (Credible) check for: [REDACTED] all entries up to date.
PRLU or OLTC
Acute Placement, Notice of Incident
Client was placed in Rivendell acute on 5/17/23 due to an increase in emergency safety interventions and inability to stabilize. Client admitted to Centers Monticello on 3/27/23 and will return to Centers Monticello when discharged from acute. Father agreed with acute placement. Arkansas total care was notified of acute placement. Phone call made 5/18/23 for further clarity of client’s behavior. [REDACTED] stated that client was aggressive towards staff and turned over chairs and tables.
PRLU or OLTC
Visit Compliance Report
Buildings and grounds conducted 5 pm-6 pm. Client seen lining up to go to dinner. Staff client ratio: 2:11. Hall 1 observed. Staff/Client ratio 1:5. Tattered blinds observed previous visit had been removed and new ones have been ordered. All areas observed to be furnished, safe, clean, and in good repair except for one bathroom had a torn shower curtain. The shower curtain looked relatively new and was clean but had about a 4-Foot tear in it. Staff were notified and observed replacing shower curtain with a new one. Staff indicated this tear was relatively new, as they had not noticed it earlier. Hall 2 observed. Staff/Client ratio: 1:3. All areas observed to be furnished, safe, clean, and in good repair. Bathrooms observed to be clean and sanitary. Hall 3 observed. No clients present. All areas observed to be furnished, safe, clean, and in good repair except for one bathroom had a torn curtain. The shower curtain looked relatively new and was clean but had about a 3-Foot tear in in. Staff were notified and were to replace shower curtain with a new one. Outside grounds area observed to be clean and free of safety hazards. MAR checked for [REDACTED]. All entries up to date. Regulations needing technical assistance: 911.6 – shower curtains were being replaced during today’s visit. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Acute Placement, Notice of Incident
Client was placed in Rivendell acute on 04.20.2023 due to extensive emergency saftery interventions and inability to stabilize. Client admitted to Centers Monticello on 03.20.23 and will return to Centers Monticello when dischraged froma cute. Guardian is DCFS, [REDACTED]. DCFS agreed to acute placement.
PRLU or OLTC
Technical Assistance, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Review of the agency’s current mandated reporter policy revealed a concern with the Licensing Unit. Please ensure facility policy is updated to reflect the need of all staff to report directly to the child abuse hotline without delay. The updated policy shall be submitted to the Licensing Unit by 04/14/23 and all applicable staff shall be retrained on the updated policy within 2 weeks of the enactment of the updated policy at the agency.
- TA –
- 110.9 – Any owner/operator, employee, foster parent, or volunteer in a child welfare agency shall immediately notify the Child Abuse Hotline if he or she has reasonable cause to suspect that a child has been subjected to child maltreatment, died as a result of child maltreatment or if they observe a child being subjected to conditions or circumstances that would reasonably result in child maltreatment.
- 102.3.h -Child Maltreatment/Mandated Reporter policy; according to Arkansas law, including, procedures to ensure that alleged, suspected, or witnessed incidents of maltreatment are reported to the Child Maltreatment Hotline, and documented as required by these or other applicable rule or laws.
PRLU or OLTC
Technical Assistance, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Review of the agency’s current mandated reporter policy revealed a concern with the Licensing Unit. Please ensure facility policy is updated to reflect the need of all staff to report directly to the child abuse hotline without delay. The updated policy shall be submitted to the Licensing Unit by 04/13/23 and all applicable staff shall be retrained on the updated policy within 2 weeks of the enactment of the updated policy.
- TA –
- 110.9 – Any owner/operator, employee, foster parent, or volunteer in a child welfare agency shall immediately notify the Child Abuse Hotline if he or she has reasonable cause to suspect that a child has been subjected to child maltreatment, died as a result of child maltreatment or if they observe a child being subjected to conditions or circumstances that would reasonably result in child maltreatment.
- 102.3.h -Child Maltreatment/Mandated Reporter policy; according to Arkansas law, including, procedures to ensure that alleged, suspected, or witnessed incidents of maltreatment are reported to the Child Maltreatment Hotline, and documented as required by these or other applicable rule or laws.
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Buildings & Grounds conducted from 11am – 12:30pm. Census: 23. Areas observed: 2 classrooms, Hall 1, Hall 2, Hall 3, and outside play area. MARs checked for 5 residents. Maintenance and staff will address citations.
- Regs out of compliance –
- 910.1 – Broken foam cup debris on the ground outside in the play area.
- 911.6 – Tattered window blinds (Hall 1, bedroom 1).
- 912.4 – Waste basket had grime build up at the bottom (Hall 3). Paint chips from the wall have begun to stick to bathroom floor (Hall 3).
PRLU or OLTC
Medical, Notice of Incident
- Medical
- Client was eating an apple and started showing signs of distress and difficulty breathing. Staff initiated back blows and abdominal thrusts until object (apple core) was dislodged.
- Licensing follow-up: Client remains at the facility, will continue to monitor.
PRLU or OLTC
Children's Records Review, Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Licensing reviewed records for 10 clients using Credible software. All items per minimum licensing standards were accounted for.