*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: Hamburg, AR Population Served: Youth Ages 11-17
| # of residents per unit: up to 8 | Residents per room: Up to 2 | Capacity: 23 |
Contact with family (Calls and visit schedule): Calls up to 2x/week for 5-15 minutes depending on Level. In person visits depends on the parents\family member\guardian (no additional details were provided).
| Restraint utilized? Yes | Chemical Restraint utilized? Yes | Seclusion utilized? No |
Clinical Director: LAC/CRC Therapists: 2 full-time therapists (1 LAC, 1 LCSW)
Treatment modalities offered: CBT, TF-CBT
# of individual therapy sessions/week: 1x\week
# of group therapy sessions led by a licensed mental health professional/week: 1x/week
PRLU or OLTC
Elopement, Notice of Incident, Self-Harm
While at the emergency for a self-harm incident, a resident walked out of the ER and ran. Police were contacted at 5:30 pm. Police located the resident and returned her to the facility at 8:10 pm. The resident remains at the facility with a safety plan of elopement precautions, 24/7 observation, and physical aggression precautions.
PRLU or OLTC
Notice of Incident, Self-Harm
A resident became upset and began punching the wall with her left hand. After punching repeatedly, the resident had a golf ball-sized knot on her knuckle. The resident was evaluated and then sent to Ashley County Medical Center for an x-ray.
PRLU or OLTC
Notice of Incident, Physical Maltreatment, Visit Compliance Report
A complaint was entered after a resident’s family observed a bigger-than-quarter-sized lump on his head during a visit. The resident stated the injury happened during a restraint when he was pushed down and his head hit the floor. The resident also stated the staff member hurt him and twisted his arm behind his back.
Licensing Specialist: Clayton DeBoer
LS DeBoer visited the facility in response to this complaint. The facility was asked for restraint packets for the time period in question. Video during the incident was reviewed. The video shows staff and resident entering and exiting the resident’s room but does not show the restraint. Staff was interviewed and stated they had used the green pad under the resident’s head, so he would stop banging it on the floor. Staff will be retrained on CPI.
Complaint was Unfounded by Licensing and Unsubstantiated by CACD.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
LS DeBoer performed a Buildings and Grounds walkthrough. Census: 20. Classroom 1 ratio – 3:10. Classroom 2 ratio – 2:8.
Shower areas were clean and sanitary. A baseboard trim needs to be glued down outside Room 67. Room 62’s wall covering was picked away and broken. A hole in the wall was observed in the bathroom of Room 4. Almost all Boys Hall 2 bathroom ceiling tiles were missing or broken. Grounds were clean and free of safety hazards. MARs were checked. All were initialed and up to date.
Facility was cited for 911.6 for issues noted in the walkthrough.
PRLU or OLTC
Notice of Incident, Self-Harm
Resident swallowed a drywall screw she possibly obtained from another room. She was transported to the ER for evaluation at approximately 6:30 pm. At 9:30 pm, she eloped from the hospital. Police were notified and returned the resident to the hospital by 9:40 pm. Resident remained at the hospital while staff looked for an acute placement to send her to.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Buildings & Grounds follow-up conducted to inspect previously noted deficiencies.
All sharp or raised edges on all plywood in all rooms below 6 ft. have been sanded down. Many rooms and bathrooms have added plywood to cover previously identified holes. All added plywood has been painted to match. Some paper towel dispensers have been removed and replaced with plywood. Loose wallpaper has been covered with latus strips. New door was ordered and installed for separating door. New light covers were installed in several rooms. Light switch cover plate replaced in two rooms. Missing baseboards replaced. Broken corner panel was replaced. New floor and ceiling tiles installed.
Additionally, Director and Maintenance did a thorough walkthrough and fixed other identified issues that were observed during today’s visit.
PRLU or OLTC
IOC Report
No deficiencies were cited during the Inspection of Care (IOC) conducted on 09/23/24.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist:Clayton DeBoer
Children’s Records reviewed. All items are present in a hardcopy file except for daily/nightly observations, which were present in a separate file.
PRLU or OLTC
Complaint Survey
Complaint #AR00033801 was in compliance.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Resident gave staff members a letter that included suicidal ideations. A short time later, the resident was found in the bathroom with a pair of pajama pants wrapped around her neck. Staff members restrained the resident and retrieved the pants.
The resident was placed on Suicide Precautions and 1:1 ratio unil further notice.
PRLU or OLTC
Elopement, Notice of Incident
Resident eloped during a trip to the Ankle and Foot Clinic in Little Rock.
Resident returned to the facility on 7/26/2024.
Police Report
Police Report
Officers responded to the facility in reference to a resident taking medications she had been pocketing. Officers assisted as Pro Med Ambulance Service evaluated and transported the resident to the hospital.
PRLU or OLTC
Notice of Incident, Suicide Attempt, Visit Compliance Report
Staff attempted to wake the resident up, but she was groggy and couldn’t stay awake for very long. It was determined that the resident had been “cheeking” medication and took several medications at one time. The resident was transported to the Emergency Room via Emergency Medical Services (EMS) for treatment.
Licensing Specialist: Clayton DeBoer
Facility was visited in response to incident. Camera footage was reviewed. Some, but not all clients were viewed opening their mouths after medication was administered.
Inservice training on sweeping the mouth after medications are taken was provided to Licensing by the Director of Nursing.
Facility was cited. 907.2.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist (LS): Clayton DeBoer
Personnel Records reviewed. All items present in files. No citations.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Client was told to wash her hands and line up for lunch. Staff felt she was in the bathroom too long and went to the bathroom to check on her.
Staff found her on the floor with a sheet wrapped around her neck. The client did not require any medical attention and was placed on 2:1 (two clients, one staff).
PRLU or OLTC
Notice of Incident, Self-Harm
Client was placed on 2:1 with staff due to threats to harm herself earlier in the day.
Around 1910 hours, staff found her in her room, making movements under her covers. When staff members asked her what she was doing, the client stated, “nothing.” Two staff members went into the room and pulled the covers back. The client had taken off her pants, attempting to pull them up to her neck. She was placed in a personal restraint so the pants could be removed.
Client continued on 2:1 (two clients to one staff).
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Licensing Specialist conducted an after-hours visit. Census: 18. Staff/client ratio: 4:18.
Hall 1 staff/client ratio: 1:5
Hall 2 staff/client ratio: 1:7
Hall 3 staff/client ratio: 1:6
All staff alert, awake, and attentive. Night visual check logs were observed. MARS checked. All initialed and up to date.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Two allegations of abuse were made regarding client and two staff members. Client alleged a staff member poked her ring into the Client’s arm during a personal restraint, approximately a year ago. Client alleged a second staff member twisted her arm during a restraint on 4/24/24.
Licensing Specialist: Clayton DeBoer
Licensing Specialist visited facility. There is no video of alleged incidents as video recorder does not go back to 4/24/24. No nursing note or restraint incident report could be found for that date. Client interviewed. Client stated that staff member twisted her arm during a personal retraint and another staff member called her “dot to dot”. All staff will be given in-training on professionalism with clients.
Complaint has been determined to be UNFOUNDED by Licensing.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Client took the metal from the paper towel dispenser, and cut herself up pretty good. All superficial, but numerous cuts. Police and Ambulance are here, and she is being sent to the ER, then acute.
Email sent to facility to notify licensing if/when client returns to Delta from acute and what safety plan will be.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
On 3/13/24, client reported to staff, “roommate was right next to her bed last night during the night when she turned around. Client stated roommate then kissed her on the cheek, got in her bed with her then asked if she wanted to have sex”. Client stated “NO” and put her covers over her head. Client stated peer tried to kiss her on the mouth, pulled her shirt up and felt her breast. Client stated “I just I cant go through this tonight again.” Clients were separated that night (03.13). A report was made to the AR Child Abuse Hotline and accepted.
Licensing Specialist: Clayton DeBoer.
Per facility report, a power surge 3/7/24 damaged cameras for Hall 1, where the alleged incident occurred. Facility is waiting for the cameras to be repaired or replaced. Night checks reviewed for 3/11/24-3/12/24 between 8:00pm – 12:00am. All checks conducted according to print out. Client interviewed. She reported that alleged incident occurred in between staff checking on her room.
Facility cited 110.12: Staff reported this incident to licensing late. Email from facility received stating there was no valid reason for late reporting. She got busy and forgot.
CACD investigation was unsubstantiated. Licensing investigated this complaint and determined it to be unfounded.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings & Grounds conducted from 9:30am – 10:30am. Census: 19. Hall 6 observed. MARs checked. All initialed and up to date. Background checks review completed for all employees.
Facility cited 911.6: Room 67, had a loose toilet seat, Room 68 bathroom had a torn hole in wallpaper, and Room 70 had two droopy ceiling tiles. Maintenance notified during today’s visit.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Annual Review/Policies/PRTF checklist completed. All items accounted for. Background checks reviewed for 20 personnel files. All background checks accounted for.
Police Report
Battery
Police were dispatched to Delta Family Center where a juvenile subject was detained on the ground. Upon arriving police placed the subject into custody and de-escalated the situation. Police spoke with staff who stated she would look for a detention center to place the juvenile.
While standing at the entrance, staff advised that the juvenile grabbed Mrs. Kesee’s shirt and was pushing her around. Staff advised that before he could punch Mrs. Kesee, they took him to the ground and restrained him. The juvenile’s case worker who was on the scene advised that they would take the subject back to where he was previously placed. Staff were speaking amongst themselves stating several things that were visibly upsetting the child and had the potential to re-escalate the situation.
Ms. Tanksley advised that the Juvenile could be taken to the police department. He was transported to the police department until they could find placement. Mrs. Tanksley contacted police and advised they could not place the juvenile and that Delta Family Center had filled out an affidavit over the incident. The juvenile was remanded into the custody of his case worker who transported him back to Sebastian County, in the custody of DHS.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Buildings & Grounds conducted from 10:00 AM – 11:30 AM, Census: 20. Classroom 1 staff/client ratio: 2:7, Classroom 2 staff/client ratio: 6:12. Sleeping areas, showers, bathrooms, cafeteria, and grounds observed. MAR checked. All initialed and up to date.
Facility cited 911.6: Torn/missing tile behind toilet in room 23. Maintenance notified.
Facility cited 912.4: Bathroom in room 25 had strong urine odor and stain behind toilet. Housekeeping notified.
Video camera footage reviewed for the early morning hours of 12/4/23 and 12/5/23. All night visual checks conducted within 30 minutes.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Upon reviewing a physical restraint completed on client on 11/13/2023, it was observed Behavior Coach did not utilize proper restraint procedures. He intervened solo, grabbed his neck and slammed him on the floor. The critical incident indicated the resident threw a desk, but this did not occur, as observed in review of video today. He laid the desk over on the floor and was no danger to self or others.
Licensing Specialist: Clayton DeBoer.
Facility visited 11/21/23 in response to provider reported incident that staff had used or initiated an inappropriate hold with client. Video reviewed. Client is seen sitting in a desk, periodically getting up with an object. After what appears to be a brief exchange between staff and client, staff walks towards client, grabs his arm, and used his left arm, palm flat on client’s back and guides client to the ground. Other staff are present for entire incident and are seen immediately assisting staff in hold by securing client’s extremities.
Facility cited 905.10 for staff initiating physical restraint whilst client was not, at that point, a threat to himself, other people or property. Staff will be retrained on initiation/intervention of holds and level of holds. Staff is currently on suspension and will complete training before returning to work.