Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.
Medicaid Inspection of Care
Corrective Action Plan, Inspection of Care Report
PRLU or OLTC
Visit Compliance Report
Monitor visit conducted today to review timely night supervision checks. Halls A,B,C,D reviewed for the early morning hours of 7/16/23 and 7/17/23.
7/16/23: Hall A checks conducted at 1:08 AM, 1:14 AM and 1:28 AM. Hall B checks conducted at 1:15 AM, 1:30 AM and 1:34 AM. Hall C checks conducted at 1:02 AM, 1:20 AM and 1:32 AM. Hall D checks conducted at 1:00 AM, 1:15 AM and 1:30 AM.
7/17/23:Hall A checks conducted at 1:27 AM, 1:43 AM and 1:57 AM. Hall B checks conducted at 1:18 AM, 1:30 AM and 1:45 AM. Hall C checks conducted at 1:00 AM, 1:16 AM and 1:31 AM. Hall D checks conducted at 1:15 AM, 1:31 AM and 1:45 AM. All night supervision checks done within 30 minutes. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Accidental Injury, Notice of Incident
On July 11th, client was in the gym playing in rt where client “Twisted” his ankle. An x-ray was ordered and performed and the results are “No acute fracture”. Licensing narrative: no licensing concerns noted from this incident.
PRLU or OLTC
Notice of Incident, Staff Neglect, Suicide Attempt, Visit Compliance Report
On June 30 2023, about 6:45 am, client was on the unit in active tantrum, yelling, screaming, attacking staff. Staff removed other clients from the hallway, and during this client went into her bedroom and grabbed a pair of pants and wrapped them around her neck, stating “I want to kill myself”, staff intervened and removed the pants from the clients neck. Client was assessed by the nurse and no markings were found. Client, later in the morning, was transported by MEMs to the behavioral hospital in Maumelle.
Licensing narrative: Facility visited 7/5/23 in response to self-report incident of client demonstrating suicidal behavior. Video reviewed of incident. Around 3 minutes go by with ligature wrapped around client’s neck before staff enter the hallway and remove ligature. Staff can be seen from hallway camera sitting, not looking in on client. Regulations out of compliance: 907.2 – staff failed to supervise an escalated client for 3 minutes while client made suicidal gesture. 907.3 – no staff were present nor supervising an escalated client for 3 minutes. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Visit Compliance Report
Buildings & grounds conducted. 2 day rooms observed. Staff/Client ratio 4:17 and 2:9. Milieu observed staff client ratio 1:2. Halls a, b, c, and d observed to be clean, safe, and in good repair. Bathrooms were clean with functioning sinks, toilets, and showers. One bathroom was closed due to having a clogged toilet and staff report that maintenance had been notified. The bathroom/Client ratio was still within licensing limits. Hall b, room 2218, one client was laying down in her bed. No staff were present on the hall b. Staff was immediately notified who reported that the client was ill and being checked on every 15 minutes. Staff were advised that client needed to be supervised within ratio. Client was immediately moved from the bedroom to the dayroom for direct staff supervision. Cafeteria and gym observed to be clean, safe, and in good repair. Two fire extinguishers observed in the kitchen which was clean and sanitary. MAR checked for: [REDACTED]. All initialed and up to date. Regulations out of compliance: 907.3 – a client was laying down in her bed in hall b, room 2218. No staff were present on hall b. Licensing Specialist: Clayton DeBoer.
Police Report
Runaway
Officers responded to the listed location for a runaway report. Upon arrival officer made contact with staff, who advised that a juvenile ran away from this location. Officer entered juvenile into ACIC entries and deletions as a runaway/Missing person.
Police Report
Non Police Incident
Officers were advised that the accident happened on the highway. Officers called ASP to assist. No further action was taken.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Client was in the classroom refusing to go sit at his desk. Staff began using the teaching family model to teach to the youth behavior, but continue to ignore her instructions. [REDACTED] sat in the chair in front of [REDACTED] and [REDACTED] began going back and forth with each other. One client ([REDACTED] involved himself attempting to take up for [REDACTED] getting in [REDACTED] face and [REDACTED] hit him in the face. Staff got between [REDACTED] and [REDACTED] to separate the clients. [REDACTED] took [REDACTED] out of the room, while [REDACTED] is separating that incident [REDACTED] and [REDACTED] is still going back and forth. Client gets involved trying to attack [REDACTED] and [REDACTED] intervene by stepping in front of the client. Client gets up a second time walks in [REDACTED] personal space and [REDACTED] kicks him. As [REDACTED] and [REDACTED] is separating the [REDACTED] and [REDACTED] charge toward [REDACTED] and kicks him. The staff goes to break the two clients the client goes over to [REDACTED] and spits on him. [REDACTED] intervene by guiding out of the room. [REDACTED] walks over to the bookshelf, staff runs over stating “Don’t touch”, [REDACTED] grabs the clients from the back pushing him against the shelf making him hit his head. [REDACTED] then slung over on the desk, [REDACTED] then punches her in the face. [REDACTED] is now trying to prevent client from hitting her, staff comes over to help separate the [REDACTED] from [REDACTED] still have a hold of shirt while staff is trying to place him in a hold. [REDACTED] then grabs one of legs, at this time [REDACTED] is on the floor. [REDACTED] release his leg yelling “Calm down”. Client runs up kicks [REDACTED] and pour water on him. A report was called in and accepted. The report number is [REDACTED]. Licensing narrative: licensing received complaint 6/23/23 that on 6/22/23 staff shoved client during an incident. Child abuse hotline was called, ref#[REDACTED]. Corrective action plan: staff was terminated. We will do an in-Service with and other staff members on tantrum management and the crisis development model. 6/26/23- program coordinator emailed the investigator for permission to contact the agency. Facility visited 6/27/23 in response to complaint that staff had inflicted physical harm to a client during an altercation. Video reviewed of classroom where incident took place.
Staff was given in-Service retraining from UMCH staff sherika williams on 6/23/23. Staff was terminated from employment at UMCH following this incident. 8/3/2023- maltreatment case is still open and pending. 9/5/23-Maltreatment case unfounded. Regulations out of compliance: 905.4.D – client called staff a b*Tch and staff responded “It takes one to know one”. 905.4.G – staff seen pushing client into a metal bookshelf, putting her hand on the back of client’s neck and pulling their leg during an altercation. 109.1.G – staff shoved client into a metal bookshelf, grabbed him by the back of the neck and grabbed and pulled at his foot during an altercation. 907.2 – staff does not prevent a peer from kicking client. Licensing Specialist: Clayton DeBoer.
Police Report
Runaway
Officers responded to a runaway juvenile report at 2002 Filmore St. Upon arrival officers made contact with Methodist Children Home manager. Manager advised at approximately 1 PM, a juvenile exited the back door of the facility and fled west toward university. Manager advised the juvenile told one of the residents that they were going back to [REDACTED]. Officers notified supervisor and broadcast juvenile’s description and last known direction of travel. Officers circulated the area with negative results. Officers completed supplement form after completing search of the area. On June 2, 2023 officers located juvenile as a part of a separate disturbance and returned juvenile back to methodist children home.
PRLU or OLTC
Elopement, Notice of Incident, Visit Compliance Report
Client was on the unit with staff having conversations. Client mentions that she likes staff’s keychain and complements it. Shortly after client grabs the keychain and runs off with it through the unit, into the courtyard. Another client runs after the first. First client jumps fence and throws keys back over to the second client. The second client returns the keys one minute later. Local police were notified immediately, and are still looking for client. Licensing narrative: facility visited 6/20/23 and video reviewed of elopement. Staff/Client ratio in video 1:3. Client is seen and heard having conversation with staff about her keys, when grabs keys from staff and use key fob to exit area, another peer following behind him. The other peer had grabbed staff’s radio and pushed door closed behind him when exiting area. Staff immediately tried to chase clients but was unable to exit door to pursue them. Clients are seen in video exiting the hallway then into the courtyard where a key fob would have granted them access out of the courtyard. The peer with is then seen using the key fob to re-Enter facility and giving the keys back to staff. Staff did not fail to supervise clients until clients eloped during video reviewed. Staff did not properly secure keys/Key fob while supervising clients. Staff will complete in-Service on importance of key/Key fob control.
Staff in-Service training emailed to licensing 6/21/23. Received email from Justin King 6/26/23 of UMCH that client was located and brought to UMCH on 6/25/23. Email received 6/26/23 from UMCH as follows: good afternoon, we don’t have a written safety plan. We have a doctor’s order that we are abiding by. The doctors order are elopement precaution, building restriction, unit restriction and 60K focus. Licensing Specialist: Clayton DeBoer.
Police Report
Runaway
Officers responded to the location and made contact with staff member who advised juvenile 1 ran away from the location. Staff stated that juvenile 1 was inside watching tv and when she went back to check on him he was gone. Staff stated juvenile 1 has a history of running away and was located approximately two hours away the last time. Staff provided a photo of juvenile 1 from just before he left. Officers attached photo to NCIC form.
Police Report
Non Police Incident
Officers were en-route to this call when offices observed a b/F matching the description given at 22nd & Fair Park. Officers transported the b/F and a employee of the address to 2002 S. Fillmore street.
PRLU or OLTC
Elopement, Notice of Incident, Visit Compliance Report
Client was sitting on the unit with a staff member, when client started asking for keys. Client reached over and attempted to grab keys that was on a lanyard around staff’s neck. Staff was holding the keys tightly to prevent client from obtaining them. During the situation the staff member remains sitting and tries to verbally deescalate the situation. Client eventually obtains the key from staff and scanned herself off the unit. Client walks down the stairs onto the boy’s unit. Another staff tries to stop client from going out the door, but the client pushes them back. Client goes through exit door by the classroom. Staff follows her out the door. Client jumps the fence and continues down the road. Staff follow client until she stopped on Fair Park and 22nd street. Staff stay with client until police arrive and bring her back to the facility.
Licensing narrative: Facility visited 5/26/23 in response to incident in which client eloped from UMCH. Video was reviewed. Client elopes around 3 PM and is returned around 4 PM. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Notice of Incident, Suicide Attempt, Visit Compliance Report
Client was in the dayroom and was asked to take a self time-Out after earning correctives for throwing a milk to another client. She went into the hallway, instead of going to the designated area staff assigned and sat in front of the entrance door. The housekeeping staff was inside of the exam room cleaning, housekeeping opened the exam room door to exit the room. Client then stands up, and walked over to the cleaning cart grabbing a bottle with cleaning chemicals off the cart. The housekeeper was trying to prevent the client from grabbing items off of the cart, but the client was able to still grab a bottle. Staff also tries to separate client from the bottle, but was unable to get the bottle before the client unscrewed the lid off of the bottle and drank some of the liquid. Another staff member comes to assist and obtains the bottle from client. Client was transported to Arkansas Children’s Hospital by MEMs around 8:15 AM. Client returned around 10:35 AM and did not sustain any injuries from ingesting the chemicals.
Licensing narrative: Facility visited 5/26/23 and video was reviewed of the incident in which client swallowed an unknown substance from a cleaning cart. Staff/Client ratio observed on camera to be 5:18. Facility protocol is that if a client is acting out, that maintenance does not clean in that area at that time. Client was not acting out, but sitting quietly on the floor and gave no warning before grabbing the bottle. Staff immediately addressed the situation and obtained the bottle from client. Client was assessed by nurse and sent to ACH. Licensing Specialist: Clayton DeBoer.
Police Report
Missing Person
Officer responded to the listed address in reference to a missing person report. Staff advised juvenile 1 left the residence at 2030 hours wearing a grey hoodie, blue jeans, and blue and white shoes. Officers circulated the area and observed juvenile 1 at Adam and Eve lingerie store. Juvenile 1 refused to go into police custody and advised he will return home at 2300 hours. Officers did not observe juvenile 1 to be in distress and left the scene per l33. A broadcast was made and a NCIC supplement form was completed.
Police Report
Runaway, Runaway Juvenile
QRTP – Upon officers arrival, staff advised a juvenile left the premises at 2050 hours and has not returned. Prior to completion of report, juvenile had been located; Officer responded and transported juvenile back to facility. Juvenile stated he runs away from the facility due to bullying.
PRLU or OLTC
Visit Compliance Report
Buildings & grounds conducted from 5-6:30Pm. Cafeteria observed staff/Client ration 3:17. Day room observed staff/Client ratio: 1:4. Foyer observed ratio 2:7. Girls halls a and b bedroom area observed to be furnished, safe, clean and in good repair. Bathroom observed to be clean and sanitary with functioning sinks, showers, and toilets. Clients rights posted at nurse’s station window. Fire extinguishers observed and emergency evacuation plans visible and posted. MAR checked for: [Redacted]. All initialed and up to date. Pm meds had just been distributed and were initialed. Licensing Specialist: Clayton DeBoer.
Police Report
Juvenile Runaway, Runaway
QRTP – Upon officers arrival, staff advised 2 juveniles walked away from the facility at approximately 1854 hours. Officers entered both juveniles in systems as missing. At approximately 2330 hours, officers responded to facility to confirm both juveniles had returned. Juveniles were removed from ACIC.
Police Report
Elopement, Runaway, Runaway Juvenile
QRTP – Upon officers arrival, staff advised 2 juveniles walked away from the facility at approximately 1851 hours. Officers circulated the area and entered both juveniles in systems as missing. On 04/27/23 at 1048 hours, J2 was cleared from systems as actively missing.
Police Report
EMS Assist, Runaway, Runaway Juvenile, Suicide Attempt
QRTP – Upon officers arrival, staff advised juvenile left the location at approximately 1745 hours. Officers circulated the area, located juvenile and returned him to facility. At approximately 1902 hours, officers responded back to the location for the same juvenile attempting to hang himself. Upon arrival, officers located juvenile with a rope wrapped around his neck, pulling on it. Juvenile was placed in handcuffs and officers removed the rope, noting redness and bruising around his neck. MEMS transported juvenile to the hospital.
Police Report
Runaway, Runaway Juvenile
QRTP – Upon officers arrival, staff reported juvenile ran away from the facility. Prior to the completion of the report, an officer located and returned juvenile.
Police Report
Injury, Runaway, Runaway Juvenile
QRTP – Caller reported her son had found juvenile walking down Fair Park Blvd with a black eye and stopped to help him. Facility had also just reported the juvenile missing. Officers responded and spoke to juvenile, who appeared not to want to return to the facility and was lying to officers. Officers transported juvenile to facility and had to assist him inside due to refusing to exit patrol vehicle. Once inside, juvenile became verbally violent and ran out of an unlocked back door. Officers were unable to locate him. Staff made a runaway report.
Police Report
EMS Assist, Non Police Incident
Officers stood by for medical.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
A/V is [REDACTED], lives with mom, dad, and A/O is staff person at Methodist Children’s Home unknown last name. Client stated that today, 4/23, staff and him got into an argument and staff said “we will take this outside” and client stated that he then said “we can fight right now”. Client said staff threatened him and shoved him hard. There are no markings or bruising. Client stated that staff is always bullying him and making threats (unknown what type of threats). Program Manager [REDACTED] viewed video footage of the incident. Video footage showed clients eating breakfast. There were 2 staff present with the clients as they at breakfast. A/V can be seen in getting up in A/O’s face/personal space and evening touching the A/O. As the video goes on, the clients move across the hall to dayroom area with 2 staff. A/V and A/O have a struggle outside the view of the camera in a corner by the day room. A/V pushes A/O, A/O raises his arm to protect himself (never in a motion to hit A/V).
Licensing Specialist: Sharra Singleton-Litzsey.
Regs Needing Technical Assistance: 905.4.g – The following actions shall not be used, including as discipline: Physical injury or threat of bodily harm.
PRLU or OLTC
Visit Compliance Report
Records review for two clients was conducted.