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 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.

PRLU or OLTC

Special Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Licensing conducted follow-up visit to address PM staff staying awake and doing bed checks per licensing standards. Camera footage was reviewed of Girls and Boys Halls. During review, a staff member did not check 2 of the 4 rooms she was supposed to be checking, and another staff member was observed doing checks 35 minutes apart. It should be noted that facility policy is that staff perform checks every 10 minutes.
  • Regs out of compliance –
    • 907.2 – PM staff did not perform checks within 30 minutes. One PM staff seen not checking on all clients she was supposed to be.
    • 907.6 – PM staff did not check on all clients within a 30-minute timeframe.

PRLU or OLTC

Self Report Visit, Visit Compliance Report

  • Licensing Specialist: Sharra Singleton-Litzsey.
  • Licensing completed an afterhours visit from 11:45pm – 12:30am. Community showers were observed to be clean and in good repair, and halls were within ratio. Each bedroom has an alarm, and if clients are moving around in the bedroom while the alarms are set, a chime is heard, and the alarm must be disarmed and reset.

PRLU or OLTC

Notice of Incident, Sexual Contact, Visit Compliance Report

  • Peer Sexual Contact
    • At approximately 3:18 am, client snuck off Hall 6 and entered a peer’s room on Hall 2. Client was found in peer’s room at 7:10 am by staff, and both reported they had consensual sexual intercourse. Child Abuse Hotline was called, but not accepted. In statements taken, peer also reported another resident was across the hall watching them while masturbating. All residents involved stated staff were sleeping. Staff were sent home on leave pending the investigation.
    • Licensing follow-up: Facility visited on 02/13/23 and video footage reviewed. Both staff members in Hall 2 and Hall 6 were observed sleeping when client snuck into peer’s room around 3:16 am. At around 4:00 am, staff member on Hall 2 awakens and appears to do periodic rounds. Staff discovered client in peer’s room at 7:11 am. Ten-minute check charts were reviewed for both residents; Some were initialed, and some had a line drawn through to indicate the same checks were being conducted. Licensing called the hotline again, and that report was screened out as well. Facility reported the client has appointments to receive pregnancy tests and effective birth control. Doctor’s plan: “I suggest we educate clients about contraceptives – pregnancy etc. and recommend girls on contraceptives, separate gender group education, health unit consultation (for the female client), provide reading materials per health units and then, it is up to them and guardians and parents.” 
    • Facility cited 907.2, 907.5, and 907.6 – Staff (2) are clearly seen asleep in the video viewed, not conducting ten-minute checks.
    • Licensing revisit on 02/23/23: Program Director was unavailable, and video was unable to be viewed as no staff present had access to camera. Nightly check logs for the 2 staff involved were provided. Preventative measures for night staff sleeping during shifts and medical follow-up visits for female client were discussed.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted from 5:30 pm – 6:30 pm. Census: 17. Boys and Girls Halls viewed, and MAR checked for 5 residents.
  • Regs out of compliance –
    • 911.6 – Missing A/C vent in room 66 (repair by 2/15/23).

PRLU or OLTC

Children's Records Review, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Licensing reviewed 10 client records. No licensing concerns noted.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted from 11am – 12pm. Census: 19. MARs checked for 5 residents.
  • TA –
    • 9.911.6 – Hole in bathroom wall and tile chipped in hallway. Maintenance was present and indicated they would work on these areas immediately.

Medicaid Inspection of Care

Inspection of Care Report

  • Included: IOC
  • No deficiencies noted.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted; Census: 22. All deficiencies noted on 9/20/22 have been repaired. MARs checked for 5 residents. No licensing concerns noted

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted from 10am – 11am. Census: 23. Licensing reviewed areas where deficiencies were cited on 9/20/22 and noted repairs made to multiple rooms/areas and repairs still pending. MARs reviewed for 5 residents.