Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.5.19.
Medicaid Inspection of Care
Inspection of Care Report
Police Report
False Alarm, Fire Alarm
False alarm.
Police Report
Battery, Juvenile, Staff Attacked
Staff member reported that he was responding to assist other staff towards whom juvenile was being verbally and physically aggressive. When staff asked juvenile to exit the restroom, juvenile shoved and hit him in the face at least 3 times. Staff stated juvenile has completed the program and the facility has been attempting to contact DHS to get him, and they need a report made in order to force DHS to get juvenile.
Police Report
Juvenile, Missing Juvenile, Missing Person
Metro Police called in reference to a missing juvenile; They spoke to the juvenile’s mother and wanted to make sure juvenile is at facility. Officer confirmed juvenile is at facility and is fine.
Police Report
EMS Assist, Juvenile, Medical Call, Medical Emergency
Juvenile wheezing and vomiting, possible asthma attack. MEMS responded and transported juvenile to hospital.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Resident tied two of her roommate’s shirts around her neck during hygiene time. Staff intervened and removed the shirts immediately. Resident was noted to have some redness on her neck but no further injuries were assessed by the RN on duty. Resident was alert and talking to staff, her vitals were within normal limits. Resident stated that she sees bloody demons that tell her to kill herself and also stated another resident told her to self-harm in the shower. Actions Taken: Physician was notified and ordered Resident to be placed on suicide precautions, level of observation was increased to 1:1 at all times, and placed in paper scrubs until able to contract for safety.
PRLU or OLTC
Special Visit, Technical Assistance, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 12:30pm – 1:30pm. Census: 18. Licensing attended Handle with Care training at facility to ensure staff are being trained according to the facility’s policy on physical restraints and to ensure the policy complies with the minimum licensing standards.
- Review of the agency’s current mandated reporter policy determined it does not comply with A.C.A. 12-18-402 nor the Minimum Licensing Standards. Please ensure facility policy is updated to reflect the need of all staff to report directly to the child abuse hotline without delay. The updated policy shall be submitted to the Licensing Unit by 04/13/23 and all applicable staff shall be retrained on the updated policy within 2 weeks of the enactment of the updated policy.
- 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
Complaint, Notice of Incident, Visit Compliance Report
Staff members cursed at children and talked about meth. My daughtewrs medicine was increased without my consent or notification, when their handbook states they must have consent for psychiatric drug changes. Licensing Specialist reviewed this complaint on 3/27/2023. This complaint was reported to have taken place on the PRTF side. After reviewing the residents’ chart, Licensing Specialist determined that the resident was admitted on the acute side from 3/16/23 to 3/22/23. Licensing Specialist: Kendra Rice.
PRLU or OLTC
Children's Records Review, Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 11:15am – 2pm. Census: 18. Licensing reviewed 5 residents’ files and 5 personnel files. All files reviewed complied with the minimum licensing standards.
Police Report
Juvenile, Medical Call, Medical Emergency
Juvenile passed out in the gym, is unresponsive but breathing. Transported to ER.
PRLU or OLTC
Children's Records Review, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 12:15pm – 2:30pm. Census: 18. Licensing reviewed 5 residents’ files.
- TA –
- 902.13 – Licensing encouraged facility to follow-up on legal documents after a request has been made. Requests were made for copies of residents’ social security cards and immunization records.
Police Report
Disturbance, Juvenile
Caller advised juvenile was being irate and would not go inside the facility.
Police Report
Medical Call, Medical Emergency
Juvenile having difficulty breathing; Transported to ER.
PRLU or OLTC
Medical, Notice of Incident
- Medical
- Client started complaining of chest pain while playing in the gym. Client was assessed and an ER visit was ordered. Diagnosis: Chest pain, unspecified and GERD. Client returned to the facility.
- Licensing follow-up: No licensing concerns noted.
Police Report
Medical Call, Medical Emergency
Juvenile complaining of congestion; Transported to ER.
PRLU or OLTC
Accidental Injury, Notice of Incident
- Accidental Injury
- While playing football with peers, client was running with the ball and when a peer tried to stop her, client fell to the ground. Client was sent to the ER and diagnosed with an ACL tear. Client returned to facility with a brace and crutches and will have a follow-up appointment to determine if surgery is required. Upon her mother’s request, client discharged home for recovery. Residents will no longer be allowed to play football and will not be allowed to run unless they have the appropriate shoes.
- Licensing follow-up: Staff reported that client discharged on 02/19/23 to her guardian. No licensing concerns noted.
Police Report
False Alarm, Fire Alarm
Staff advised there was an alarm malfunction and no fire danger.
Police Report
Call Report, Welfare Concern
Caller requested a welfare concern on juvenile at facility, stating she was in fear of juvenile’s life after attempting to make contact with the facility and getting no answer. Caller advised when the facility called back, the nurse sounded intoxicated and hung up on her. Officer checked on juvenile who was in good health.
PRLU or OLTC
Notice of Incident, Peer Altercation
- Peer Altercation
- Client was involved in a physical altercation with 2 peers. Client was sent to the ER and diagnosed with a nasal bone fracture. Peers were placed on assault precautions and all 3 residents were placed on peer separation.
- Licensing follow-up: Staff reported camera footage is available but Licensing was not able to view due to camera system being down. Staff reported a technician is scheduled to repair it. Licensing reviewed client’s chart in record review.
Police Report
Call Report, Juvenile Complaint
Caller stated juvenile was being admitted to facility and would not exit the vehicle.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 11:45 am – 1:45 pm. Census: 18. Licensing reviewed 10 personnel files. All regulatory checks initialed with some completed and pending. HR staff stated she has requested information on the pending personnel regulatory check.
Police Report
Call Report, Medical
Juvenile having seizure, transported to hospital.
PRLU or OLTC
Buildings and Grounds, Monitor Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 11:45 am to 2:15 pm. Census: 18. Licensing completed facility walkthrough and viewed the following areas: courtyards, gym, butterfly room, comfort room, blue rooms, classrooms, and Unit 4. MARs reviewed for 5 residents. No licensing concerns noted.
- Licensing spoke with staff for update on regulatory checks. Staff reported corporate employee was working on new hires, and an HR Generalist started employment on 01/23/23. Staff reported an estimated 30% have been completed on recent list of employees and hope to have “No Match” completed by 02/07/23. The “Not Approved” employees will be rescheduled to have fingerprints completed, and staff spoke with DCCECE Background Unit regarding Child Maltreatment forms that will be resubmitted.
PRLU or OLTC
Special Visit, Visit Compliance Report
- Licensing Specialist: Chelsea Vardell.
- No site visit conducted on this day. During the course of a complaint investigation on a different matter, it was discovered that the current Clinical Director is not licensed as a mental health professional in the state of Arkansas. Licensing met with facility management on 01/10/23, with the facility reporting that the Clinical Director is licensed out of state and is working on gaining reciprocity in Arkansas. Licensing requested arrangements be made for a therapist licensed in Arkansas to fulfill the role of Clinical Director until the current Clinical Director is licensed.
- Regs out of compliance –
- 906.1.c – Clinical Director not licensed as a mental health professional in Arkansas.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 10am – 2:45pm. Census: 16. Licensing reviewed 9 personnel files.
- Regs out of compliance –
- R103.1 – FBI background check being approved for 5 staff.
- R103.2 – No Child Maltreatment Central Registry results for 5 staff.
- R103.7 – AR state police check shall be completed every 5 years (1 staff).
- R103.8 – Required checks were not initiated within 10 days of hire for 3 staff.
- R105.4 – No pre-service training for 4 staff.
- R105.5 – No CPR/First Aid training within 90 days of hire for 3 staff.
- R105.10 – No documentation of completed 10 hours of psychiatric specific training before being counted in the staff/child ratio for 5 staff.
- R105.13 – No annual training to include the date, number of hours, the name of the source, and the topic/title for 5 staff.
- R105.14 – Social Services Director, Caseworkers, and therapists shall have 24 hours of job-related continuing education each year (5 staff).
- R105.15.b – No date of hire documentation for 3 staff.
- R105.15.c – No verification of qualifications for 3 staff.
- R105.15.e – Regulatory checks (3 staff).
- R105.15.f – Staff not made aware of being a mandated reporter of suspected child maltreatment and have been given information on how to make a report (1 staff).
- R105.15.g – No functional job description for 3 staff.
- R105.15.h – One reference verified for 2 staff; No references verified for 3 staff.