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

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.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Building & Grounds conducted from 10:30am – 11:30am. Census: 24. Licensing reviewed areas where deficiencies were cited on 9/20/22 and noted repairs made to multiple rooms/areas and repairs still pending.

PRLU or OLTC

Recertification Survey

A validation survey was conducted from 10/3/22 – 10/7/22. No deficiencies were cited.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted from 12pm – 1pm. 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 checked for 5 residents.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 1:15pm – 3:45pm. MARs checked with no concerns. Progress visits will be conducted as to ascertain improvements are being addressed.
  • Regs out of compliance –
    • 9.911.6 – Window trim and holes in wall in rm 2. Hole under A/C unit and broken door handle in rm 4. Light switch needs replaced and wall is rotten in rm 5. Broken sink shroud, smoke detector hanging from ceiling, and holes in drawers in rm 6. Hole in the wall in the bathroom and broken toilet seat in bathroom in rm 8.  Loose board over vanity in rm 23. Broken door to bathroom, A/C unit needs a screen, and silver wall plate is missing exposing a screw and wires in rm 28. Screw poking out of wall and A/C unit needs cover in rm 29. Missing floor tile in rm 30. Top to toilet is broken, hole in wall, and A/C not fitted to wall in rm 63. Screws poking out in bathroom in rm 65. A/C vent cover is missing in rm 67. Wallpaper is pulled from the wall above headboard in rm 68. Missing floor tile in bathroom in rm 69. Ropes on dressers are dirty and shall be replaced to all the drawers to be used designed. Boys and girls shower areas have broken doors. Wood/metal picnic tables in outside area broken with sharps exposed (wood or metal is sharp). Cracked/broken dirty clothes baskets shall be replaced. Broken and sagging ceiling tiles shall be replaced.
    • 9.912.4 – Boys and girls shower areas have stained mats outside of showers, rust on black metal below the showers, black mats have white build up on them.
    • 9.913.5 – Several bedrooms were missing pillows. All bedframes shall be secured to the floor to prevent them from moving (beds are screwed into the floor).
    • 9.911.15.d – Exposed tv/electronic wires need to be covered and/or neatly wrapped up in rm 22 (Dayroom).

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 6:00pm – 7:00pm. Census: 19. MARs checked for 5 residents. No licensing concerns noted during visit.

PRLU or OLTC

Buildings and Grounds, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • An unannounced visit was conducted from 12:30pm – 1:30pm. Census: 17. MARs checked for 5 residents. No licensing concerns noted during visit.

PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 10:30am – 11:30am. Census: 20. MARs reviewed for residents. No licensing concerns noted during visit.

PRLU or OLTC

Children's Records Review, Personnel Record Review, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Specialist visited facility from 11:30am – 2:30pm. Records reviewed for 5 residents and 10 staff; No licensing concerns noted.

PRLU or OLTC

Complaint Survey with POC, Revisit Survey

  • Complaint #AR00027919 was unsubstantiated.
  • Regs out of compliance –
    • N 120 – Facility failed to meet the requirements for Condition of Participation by failing to ensure a policy and procedure related to the vaccination of staff, appropriate interventions were in place to mitigate the spread of Covid-19, and only 53 percent of staff were vaccinated.
    • N 156 – Facility failed to ensure a Physician’s order for a physical restraint was signed by the physician for 1 client who was physically restrained.
  • Plan of Correction – Policy was implemented (IC35/Employee Health COVID Control Plan) and database developed to track vaccination status of staff. The attending physician was retrained regarding CMS guidelines and DFC Policy PC 11, and DocuSign program was purchased and activated to expedite signatures. The Director of Nursing will in-service all nursing staff on policies and DocuSign application and will review each seclusion and restraint to ensure signatures.
  • A revisit was conducted on April 19, 2022, for all deficiencies cited on March 10, 2022. All deficiencies have been corrected, and no new noncompliance was found.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client disclosed that staff member roughly placed her in a restraint, resulting in client having a black eye, scratches to the neck, and bruises to the arm. Client still has the scratches/bruising on her arm, but the black eye has faded (she could not see out of her eye for “awhile”). Staff members have been calling her “Chucky” and client is not allowed to have unsupervised phone calls with her DHS caseworker (a therapist must be present). Reported to DCCECE on 2/24/22.
    • Child Abuse Hotline was called and accepted. Agency’s Corrective Action: “Clients who were arguing separated.” Specialist visited facility on 2/28/22. Report indicated that client’s belongings were removed after client threatened staff. Video was reviewed which showed no inappropriate holds. The incident was reported to Licensing 2 days after facility was aware of the hotline call. Facility was cited for 110.12.

PRLU or OLTC

Visit Compliance Report

Census: 22. Buildings and Grounds conducted; No regs out of compliance. MARs checked for 5 residents.