Walkthrough conducted and 6 MARs reviewed. No issues noted.
PRLU or OLTC
Visit Compliance Report
PRLU or OLTC
Visit Compliance Report
Walkthrough conducted and 5 MARs reviewed. No issues noted.
PRLU or OLTC
Visit Compliance Report
- Conducted employee record reviews on-site.
- Regs out of compliance –
- R103.1 – Background checks were pulled, and 26 staff members did not have background checks present in packet. Due to absence of HR worker, Acadia employee stated she would follow up and send email no later than 11/15/21 whether individuals are employed and if background checks need conducted.
PRLU or OLTC
Visit Compliance Report
Walkthrough conducted and 3 MARs checked, no concerns noted. Watched video of classroom; Ratio was correct in videos. Overall facility in order and good repair.
PRLU or OLTC
Visit Compliance Report
- Completed building and grounds walkthrough; Census is 52. MARs reviewed for 5 residents.
- Regs out of compliance –
- R914.6 – No fire escape diagram posted in “Bass” unit. Staff reports a plan to put diagrams in plexiglass and mount them to the walls.
PRLU or OLTC
Notice of Incident
- Complaint
- Specialist received complaint of facility being short staffed and poor management. Complaint stated that staff are forced to stay against their want. Staff has charges on background and talks down to kids and staff. A kid was recently choked by a staff member and staff all lied to save the staff member and sent the boy home. They want this staff member back on the floor. There is almost never an interpreter in the deaf classroom. Not enough direct care or case managers.
- Follow up was done with background check unit and background check was completed for staff member. Ratios at random check at facility was within standards. No further follow-up details.
PRLU or OLTC
Corrective Action Agreement
- Non-compliance areas cited since 07/01/21 –
- 905.9 Behavior Management – Cited for staff failing to use the minimal time and force necessary after initiating a restraint hold for 3 incidents.
- 907.2 Ratio and Supervision – Cited for staff not providing the level of supervision, care, and treatment necessary to ensure the safety and well-being of each child at the facility for 2 incidents.
PRLU or OLTC
Visit Compliance Report
No regs noted out of compliance.
PRLU or OLTC
Notice of Incident
- Complaint
- Specialist received complaint that 2 therapists resigned, leaving only the clinical director to provide therapy services to the residents. Residents are reportedly not receiving therapy services.
- According to the individual who made the complaint, the therapists left due to unprofessional contact, mistreatment of staff, and mistreatment of residents. The reporter also mentioned that the staff who resigned were asked to “stay on paper” so that it would not appear as though the agency did not have any therapists on staff.
PRLU or OLTC
Notice of Incident
- Assault
- Client was upset and began to attack staff. Peer became upset client was attacking staff, so they charged at client and knocked them into a wall.
- Client noted to have slight bleeding around gum line of left central incisor and left lateral incisor with both teeth noted to be loose. Client has appt on 8/31/21 for dental evaluation. The dentist notes that no further treatment is needed.
PRLU or OLTC
Notice of Incident
- ER Visit – Possible Appendicitis
- Client was complaining of severe stomach pain, so she was sent to the ER due to possible appendicitis. No follow-up details.
PRLU or OLTC
Technical Assistance, Visit Compliance Report
Specialist discussed with staff regarding a needed interim corrective action for staff involved in an incident; Discussed reporting incidents that violate Licensing Standards even if they are screened out from the Child Abuse Hotline. Management had several questions regarding what standards in the Minimum Licensing Standards apply to them; Further discussion will take place as soon as all needed parties are available.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Therapist blocked resident in corner from trying to fight peer. Resident began to push the therapist back so the BHA staff took the resident to the ground. BHA staff then attempted to put his hand around the resident’s neck and therapist intervened and removed the BHA staff away from resident. When asked later, the resident denied the BHA staff squeezed his hand around his neck. Witnesses reported staff did squeeze his hands around his neck.
- Staff placed on Administrative Leave as of 8/20/21 and returned to work on 8/24/21 to receive de-escalation training. After specialist reviewed camera footage, a new hotline call was placed and accepted so the staff was placed on office duties with no direct or unsupervised contact with residents until investigation is completed. Unsubstantiated.
PRLU or OLTC
Technical Assistance, Visit Compliance Report
- Specialist discussed a report sent to the specialist involving a previous resident and staff member. Specialist is not prepared to leave a Licensing finding at this time due to the ongoing CACD investigation. Specialist reviewed 5 children’s records.
- TA –
- R904.1.h – The charts of 3 residents were noted to be missing required legal documents.
- R110.9 – Specialist discussed with staff what reasonable cause means in mandated reporting and educated staff on expectations of staff to report any suspected child maltreatment or neglect to the Child Abuse Hotline immediately.
- R905.17 – A restraint documented in a resident’s chart was noted to not have the names of staff involved in the restraint listed.
- Licensing Specialist was asked to sit in on a meeting occurring with Tracie Schnider with Behavioral Health and Aging, who was there to discuss options for a deaf Arkansas DCFS foster child to be place at the facility. Specialist explained that the child shall not be admitted prior to the approval of the CWARB.
PRLU or OLTC
Notice of Incident
- Staff Sexual Abuse
- Alleged offender (previous staff) has been accused of having sexual intercourse with a previous resident during his time at the facility from Jan. – Mar. 2021. It is reported that the facility once reprimanded the employee for giving candy to this resident then conducted their own investigation into the sexual abuse allegations, but never called this report into the hotline, and that 2 other employees were aware of this situation and failed to report it.
- Staff is no longer employed at the facility as of 3/31/21. On 8/17/21, Specialist received response from facility staff confirming they had knowledge of the accusation but did not find substantial evidence during their own investigation. Staff was terminated from employment on 3/31/21 after a no call no show. On 8/18/21, Specialist discussed with facility representatives the incident and appropriate mandated reporting. No further details.
Police Report
Sexual Assault First Degree
Caller from CAC stated that the child abuse hotline had received a report of alleged sexual assault that had taken place between a Juvenile and Staff member in February 2021. Juvenile has since returned home and Staff member was terminated in April 2021. Juvenile’s Mother found explicit photos in Juvenile’s phone from Staff. Mother advised hotline that Juvenile stated he and staff member had engaged in sexual intercourse while he was a patient at facility and she has been sending him money on cashapp.
PRLU or OLTC
Notice of Incident
- Complaint
- Specialist received an email reporting concerns about the facility. Individual reported she is aware of at least 2 times when a resident was assaulted by peers and 1 time she was sexually assaulted by peers. Individual also reported that “uncertified restraints happen all the time” and “*redacted* and *redacted* cover it up”. Individual stated she felt so strongly that wrongdoing by management was occurring that she left her job there.
- *Redacted* of resident also reported multiple concerns regarding supervision at facility resulting in sexual activity and self-harm, the use of inappropriate restraint holds, resident able to use staff cell phones to make unauthorized calls, facility not following ICPC agreement regarding medications and incident reporting, objects found in facility to use for self-harm, and inappropriate comments from staff.
- Specialist reviewed the chart of the resident named in the complaint to check for all correspondence documentation. No further details.
Police Report
Medical
No info.
PRLU or OLTC
Visit Compliance Report
- No site visit conducted on this day.
- Regs not correctable –
- R907.2 – Incident report received on 7/14/21 from event that occurred regarding resident and a staff member shows staff did not provide the level of supervision, care,and treatment necessary to ensure the safety and well-being of each child at the facility.
- TA –
- P110.12 – Ensure that all child abuse hotlines made against the owner/operator, employee, volunteer, or other person in the child welfare agency are reported to the Licensing Unit by the next business day.
PRLU or OLTC
Notice of Incident
- Other – Client Unsupervised
- Staff left client on the unit alone for 18 minutes.
- Staff member placed on administrative leave as of 7/14/21. Child Abuse Hotline was called, not accepted.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Staff can be seen on camera breaking up an altercation between peers and slamming resident to the ground.
- Staff member was placed on administrative leave on 7/14/21. Child Abuse Hotline was called and accepted.
PRLU or OLTC
Visit Compliance Report
- Specialist reviewed incident report/video footage involving a staff member and resident. Staff out of ratio and has one arm in cast.
- Regs not correctable –
- R905.9 – Staff member did not use minimal force, did not use proper restraint hold, and resident was not posing a risk to himself/others when restraint was initiated.
- R907.3 – During the time of incident, the staff member can be seen out of ratio 1:7.
- Regs out of compliance –
- R912.4 – Bathrooms in A1, C1, and C2 need cleaned; Sinks were visibly dirty with grime and hair, toilet areas had visible urine on the ground and a strong odor. Staff were called to clean the restroom immediately.
- R914.6 – Need new emergency evacuation diagram in the cafeteria and C1.
PRLU or OLTC
Notice of Incident
- ER Visit – Abnormal ERG
- Resident was taken to ER after a normal checkup at facility showed abnormal ERG results.
PRLU or OLTC
Notice of Incident
- Injury – Accidental
- Resident was playing outside and complained of calf pain to the staff on 7/2/21. Nursing staff did muscle stretches and gave the resident Ibuprofen. The resident then began to complain of pain again on 7/4/21 so an x-ray was ordered.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Resident was agitating a peer, and when resident ran to attack peer, staff extended his arm to stop him. Resident ran into staff’s arm, neck first. Resident began hitting staff several times so staff grabbed the resident by the shirt and flung him to the ground. Resident kicked and bit staff while on the ground. Staff then kicked the resident in the knee and proceeded to hold the resident firmly to the ground.
- Staff was placed on suspension 7/2/21. Child Abuse Hotline was called and accepted.