Disability Rights Arkansas

Delta Family Services / Delta Family and Fitness Center for Children

*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

Treatment Components:

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

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PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Facility visited from 9:30AM-12:00PM. Annual Review/Policy PRTF checklist completed. All items on Annual Review/Policy PRTF checklist accounted for.

Camera footage reviewed for the early morning hours of 11/3/23 and 11/4/23.

Staff observed awake and moving throughout hallway but did not walk the full length of the hallway to conduct checks for a 37-minute interval. Facility cited 907.6: Supervision during sleeping hours shall include a visual check on each child at least every thirty (30) minutes.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Building & Grounds conducted from 10:30am – 12:00pm. Classrooms, sleeping areas, bathrooms, and grounds viewed. MARs checked for 5 residents.

Facility cited 9.911.6: Room in Hall 6 had water spots on ceiling tiles. Hall 2 had broken/sagging ceiling tile.

Video was reviewed for the early morning hours of 10/15/23 and 10/16/23; All night visual checks viewed were conducted within 30 minutes.

PRLU or OLTC

Complaint Survey with POC, Revisit Survey

Complaint #AR00030833 was not in compliance, all or in part, with deficiencies cited at N128 and N132.

N128: Facility failed to ensure a physical restraint was implemented without injury for Client #1.

N132: Facility failed to ensure a physical hold was performed in a safe manner for Client #2.

Plan of Correction: All staff were retrained on proper CPI techniques and CPI Instructor/Dept. of Education Director will review camera footage for a minimum of 3 restraint holds per week and document findings until licensing unit determines deficiency is corrected and goal of 100% compliance is met for 4 consecutive months.

A revisit was conducted on 12/13/23, for all deficiencies cited on 10/11/23. All deficiencies have been corrected, and no new noncompliance was found.

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.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Chelsea Vardell.

Licensing and staff met to discuss the progress of the current Corrective Action Agreement made on 3/22/23. Due to recent citations involving the use of inappropriate behavior management by staff, the current CAA will be extended an additional 3 months. Two new requirements were made on the CAA. Staff have been retrained on their restraint hold procedures prior to today’s meeting.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Client accused staff of hitting him during a physical hold. Nurse noted redness and swelling on client’s face. The Child Abuse Hotline was then called and staff went home. Staff will not be coming back to work until a safety plan for him and client is in place and has been approved.

Licensing Specialist: Clayton DeBoer.

Licensing visited facility and interviewed client and roommate. Client stated he received injuries to his face “because we was fighting”. When asked, client stated he was fighting staff and could not remember what exact movement by staff resulted in him sustaining injuries to his face. Client’s roommate stated that client did not have any injuries to his face prior to this altercation with staff. His roommate stated that staff struck client “3 times in the face…with a closed fist… was on the ground on his back and [staff] was on top of him” and that client had blood coming out of his ear.

The following regulations were cited:

– 905.4.g: Staff inflicted physical injury to client during a restraint.

– 907.2: Two staff member failed to assist a third staff member calling a code yellow, asking for assistance, which resulted in the injury of a client.

Licensing and CACD complaint substantiated. Licensing was informed that staff was terminated as of 11/10/23.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

On 9/15/23, client was placed in a restraint by staff. Client said the staff member came into the classroom, told her he was tired of her and was going to punch her in the face. Client said staff grabbed her by the arm to take her to a timeout, pulled her out of her chair, slammed her into two desks and then onto the ground. Client said she later noticed a bruise on her thigh and attempted to show the nurse, who told her she could not do anything about it.

Licensing Specialist: Clayton DeBoer.

Licensing visited the facility and viewed video of the incident. Staff is seen approaching the desk client is sitting in, takes client out of her seat, over a desk that falls over and to the ground for a hold. Additional staff are seen assisting with the hold.

A staff witness was interviewed who stated stated that upon arriving to the classroom, the staff member made a threatening statement to client referencing being quiet. Staff then asked client to go to timeout and client refused, and at this time the physical confrontation ensued.

CACD and Licensing investigations were substantiated. Staff member was terminated.

Facility cited 9.905.4.g: Client sustained injury from physical confrontation with staff.

Facility cited 9.905.10: Staff initiated a restraint on client without client being a threat to herself, others or property.

Police Report

Elopement

Officers responded to the facility in reference to 3 juveniles who escaped. The staff member that had been with the juveniles stated he became distracted with something else when the juveniles decided to go over the fence. He and another staff member attempted to follow them but were unsuccessful. Police assisted in search.

At approximately 1:20pm, an ambulance unit spotted the juveniles and police responded. The juveniles were handcuffed and transported back to the facility.

PRLU or OLTC

Elopement, Notice of Incident, Visit Compliance Report

At 10:40am, residents were getting ready to return inside from an outside activity when three residents jumped the fence. Police were notified and staff members attempted to pursue the residents. Staff saw them run across the highway down a trail that led to a creek. The residents were later found and returned by police at 1:12PM. All were assessed by nursing and placed on precautions.

Licensing Specialist: Clayton DeBoer.

Email sent to facility 9/5/23 for incident details: Staff on break outside facility notified Hamburg Police Department when they saw clients jump the fence. Clients asked staff to retrieve balls inside the fenced area before traversing fence. Staff/client ratio at the time of this incident was 2:8. No supervision issues noted from report.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Facility visited and video reviewed for the early morning hours of August 28th, 29th and 30th, 2023.

Facility cited for regulation 907.6: 37 minutes in between night visual checks (Supervision during sleeping hours shall include a visual check on each child at least every thirty(30) minutes).

PRLU or OLTC

Notice of Incident, Self-Harm, Suicide Attempt, Visit Compliance Report

[REDACTED] was upset with a peer’s behavior; [REDACTED] went into his room and hit his wall numerous times. When the shift leader attempted to redirect, he punched staff in the face and he was placed in a physical restraint. Once the restraint was over, a behavior coach was doing visual checks and noticed client sitting on the bed attempting to tie his sheet around his neck. The shift leader came to assist and client proceeded to go into his bathroom. Once the shift leader opened the door, [REDACTED] had his head in a sink of water and his sheet around his neck. The shift leader was able to remove the sheet and [REDACTED] was evaluated by the RN. [REDACTED] was placed on 1:1 precautions and sent to an acute facility on 8/8/23. Once released, client will return to facility.

Licensing Specialist: Clayton DeBoer.
Facility visited 8/9/23 in response to facility reported incident that on 8/7/23 client made a suicide attempt. No video footage was available to review as incident occurred in client’s bedroom. Staff most directly involved in this incident were interviewed with no issues noted by Licensing.
Facility cited 110.17 for late reporting: This incident occurred on 8/7/23 and was reported to Licensing 8/9/23.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Facility visited and camera footage reviewed for the early morning hours of 7/31/23, 8/1/23 and 8/2/23 (Halls 1, 2, and 6).
Facility cited 907.6: On 7/31/23, staff conducted night visual checks at 1:16AM, and the next one at 1:49AM, 33 minutes apart (supervision during sleeping hours shall include a visual check on each child at least every 30 minutes). Staff will be retrained/counseled on night supervision checks by 8/2/2023.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Revisit Complaint regarding staff supervision: Facility visited and video reviewed of early morning hours of 7/9 and 7/10.
Facility was cited 907.6 (video of Hall 1 on 7/9 showed 43 minutes in between staff conducting checks). Staff will be counseled on the importance of nightly visual checks being conducted in a timely manner.

Buildings and Grounds conducted from 12pm – 2pm. Halls 1, 2, and 6, cafeteria, bathrooms, and grounds observed. MARs reviewed 5 residents (all initialed and up to date).
Facility was cited 911.6 for the following issues:

  • Hall 1, Room 2 had a hole in the bathroom door and a hole in the bathroom wall.
  • The seal around the A/C unit was not completed (addressed during visit).
  • Hall 1, Room 6 had a torn baseboard trim around the corner of the entrance.
  • Hall 2, Room 23 had a hole in the bathroom wall.
  • Hall 6, Room 69 had a broken light switch cover in the bathroom (no wires exposed).
  • Ceiling drop tile was missing over the School Hall due to a recent leak that was currently being worked on.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Revisit Complaint regarding staff supervision: Facility visited and video reviewed of Halls 1, 2, and 6 for the early morning hours of 6/23, 6/24, and 6/25 for hall checks conducted. All checks observed today were conducted within 30 minutes.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Revisit Complaint regarding staff supervision: Facility visited and video reviewed of Halls 1, 2, and 6 for the early morning hours of 6/10, 6/11, and 6/12 for hall checks conducted.
Facility was cited 907.6 (visual check was conducted over 30 minutes on Hall 6 on 6/10) and 907.3 (staff member left Hall 6 on 6/12 for an extended period of time and nurse was not watching hall while staff member was absent).

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Revisit Complaint regarding staff supervision: Facility visited and video reviewed of Halls 1, 2, and 6 for the early morning hours of 5/26, 5/28, and 5/30 for hall checks conducted. No licensing concerns noted.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Buildings and Grounds conducted from 8:30am – 10:30am. Girls Halls 1 & 6 and Boys Hall 2 observed to be furnished and in good repair. Bathrooms observed to be clean and sanitary with functioning showers. Cafeteria, classroom, and outdoor areas observed in ratio, clean, and free of safety hazards. MARs were viewed for 5 residents: All initialed and up to date.

Revisit Complaint regarding staff supervision: Video was reviewed of Halls 1, 2, and 6 for the early morning hours of 5/15, 5/16, and 5/17 for hall checks conducted. All checks observed within licensing standards timeframe.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Revisit Complaint regarding staff supervision: Facility visited from 3:30pm – 4:30pm. Video reviewed from the early mornings of 4/28/23, 4/29/23, and 5/1/23 for hall checks conducted. No licensing violations seen during video reviewed this visit.

PRLU or OLTC

Visit Compliance Report

Facility visited 4/18/23 from 9:00AM-10:30AM. Census: 18. Video reviewed from the early morning hours of 4/14/23, 4/15/23 and 4/16/23. All staff seen awake (moving) during video reviewed.

  • 4/14/23: Hall 1 checks were seen conducted at 1:07 AM, 1:21 AM and 1:33 AM. Hall 2 checks seen conducted at 1:16AM, 1:19AM and 1:30 AM. Hall 6 checks seen conducted at 1:06 AM, 1:22 AM and 1:36 AM
  • 4/15/23: Hall 1 checks conducted 2:10 AM, 2:16 AM and 2:30 AM. Hall 2 checks conducted 2:18 AM, 2:42 AM and 3:04 AM. Hall 6 checks conducted 2:00 AM, 2:15 AM and 2:30 AM.
  • 4/16/23: Hall 1 checks conducted 4:26 AM, 5:10 AM and 5:27 AM. Hall 2 checks conducted 4:00 AM, 4:40 AM, 4:48 AM and 5:12 AM. Hall 6 checks conducted 4:00 AM, 4:15 AM and 4:34 AM was staff on Hall 1 on 4/16/23 and had a gap between checks from 4:26 AM-5:10 AM. was staff on Hall 2 on 4/16/23 and had a gap between checks from 4:00 AM-4:40 AM.

Delta has had a Proxiguard Patrol Management system installed which requires staff to wave a wand in front of a sensor at the beginning and end of the hall. [REDACTED] viewed the data from the Proxiguard system which confirmed the gaps in hall checks. Licensing Specialist: Clayton DeBoer.

Regulations out of compliance: 907.6 – Supervision during sleeping hours shall include a visual check on each child at least every thirty (30) minutes.

PRLU or OLTC

Corrective Action Visit, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Licensing visited facility to conduct intent training regarding the Minimum Licensing Standards: Section 900. The training is part of the Corrective Action Agreement with the facility and the PRLU. All remaining staff who were not able to attend will be trained by management using the slideshow provided.

PRLU or OLTC

Technical Assistance, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Review of the agency’s current mandated reporter policy determined it does not comply with the current law in Arkansas nor the Minimum Licensing Standards. Please ensure facility policy is updated to comply with A.C.A. 12-18-402 and the Minimum Licensing Standards by 04/12/23 and provide a copy to the Licensing Unit for review. Staff shall be retrained on the new policy within 2 weeks of the new policy going into effect.
  • 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

Corrective Action Agreement

  • The following non-compliance areas have been cited during the past 6 months:
    • 907.2 – Citations on 02/13/23 and 03/01/23 regarding staff being asleep and failing to supervise the residents.
    • 907.5 – Citation on 02/13/23 regarding the overnight shift staff failing to remain awake and provide appropriate supervision of the residents.
    • 907.6 – Citations on 02/13/23 and 03/01/23 regarding staff failing to conduct visual checks during sleeping hours on each child at least every 30 minutes.

PRLU or OLTC

Corrective Action Visit, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Census: 19. Licensing visited facility to discuss the initiation of a formal Corrective Action Agreement between the facility and DHS. The facility reported new sensors have been installed on the end of each resident unit, and staff have a wand that they must carry to the end of each hall and wave in front of the sensor to log that staff were present on the unit. The information is then saved for review to ensure that staff complete their required visual checks during sleeping hours. The facility has also installed motion sensors at the end of the halls to alert staff when a resident has come off a unit. The facility has completed 2 in-service trainings for staff on the importance of documentation and supervision of the residents on 02/16/23 and 03/01/23.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted from 8:45am – 11am. Census: 19. Licensing observed Girls Halls 1 & 6, Boys Hall 2, outdoor grounds, and 2 classrooms. When staff present in the classrooms were asked how many kids were present, they stood up to count before replying. Video was reviewed from 03/20/23: In Hall 1 from 1:35am – 2:15am, staff was not on the hall nor doing proper checks. In Hall 6 from 2:25am – 3:35am, staff was not present on the hall in between checks. Licensing discussed building repairs with staff and the importance of staff being aware of the number of clients they are supervising. Staff reported that occasionally the nurse would work in ratio with the direct care staff, and Licensing informed staff that the nurse would have to be on the unit with visual of the residents to be counted in ratio.
  • Regs out of compliance –
    • 912.4 – Middle shower (Boys Hall 2) and toilet (room 23) were not clean.
    • 911.6 – Bathroom had a partially removed light switch cover and broken ceiling drop tile (Girls Hall 1 room 5). Middle shower was not clean (Boys Hall 2). Ripped mattress and area behind toilet seat was not clean (Boys Hall room 23). Bed to floor bracket loose enough to be removed by a client to potentially self-harm or harm others (Boys Hall room 30).  
    • 911.15.f – String sewn into pants (Girls Hall 1 room 6).
    • 907.2 – Night staff observed not present on the hall nor doing appropriate checks.
    • 907.6 – Night staff observed not present on hallway nor doing appropriate checks.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Licensing completed a monitor visit during the early morning hours on 03/15/23. New sensors have been installed at the entrance of each hall; Once the alarm is set, if anyone goes past the sensor, the alarm will sound with a flashing light in the foyer area. Nightly logs were viewed on both female logs and were current until 1am. MARs reviewed for 3 residents.