The Hughes Center

Non-compliance, DBHDS inspection : 12VAC35-115-110. C. (4) The provider's duties. 4. Providers shall not use seclusion, restraint, or time out as a punishment or reprisal or for the convenience ...

"Seclusion" means the involuntary placement of an individual alone in an area secured by a door that is locked or held shut by a staff person, by physically blocking the door, or by any other physical or verbal means, so that the individual cannot leave it. 4. Providers shall not use seclusion, restraint, or time out as a punishment or reprisal or for the convenience of staff. Per the provider's investigation conducted through staff admissions, witness statements, witness credibility, and video camera review. Employee #1 pushed on the bathroom door to not allow Individual #1 to exit, thus substantiating seclusion.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings conducted through witness statements, witness credibility, and video camera footage it appears that staff did not provide an appropriate level of supervision, allowing Individual #1 and Individual #2 to engage in fellatio.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the findings of the OHR Region 3 Advocate during document review. Treatment plans have listed for residents that they would have weekly medical visits with the resident physician. However, these weeklies did not always occur, and some were completed by other medical professionals (PMHNP-BC) versus the licensed physician as documented. This appears to be a systemic issue.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: 2. Assault or battery; Per the provider's investigative findings conducted through witness statements, witness credibility, and video footage, Employee #1 was seen pushing Individual #1 forcefully off of the nurses station, thus substantiating physical abuse.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

The Hughes Center "Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the findings of the OHR Region 3 Advocate during document review. Treatment plans have listed for residents that they would have weekly medical visits with the resident physician. However, these weeklies did not always occur, and some were completed by other medical professionals (PMHNP-BC) versus the licensed physician as documented. This appears to be a systemic issue.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings conducted through witness statements, witness credibility, and video camera review Individual #1 was not supported appropriately by Employee #1 and Employee #2 in order to stop a peer-to- peer altercation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings conducted through witness statements, witness credibility, and video camera footage it appears that staff did not provide an appropriate level of supervision, allowing Individual #1 and Individual #2 to engage in fellatio.

Non-compliance, DBHDS investigation : 12VAC35-46-660. H. Entries in a resident's record shall be current, dated, and authenticated by the person making the entry. Errors shall be corrected by ...

During an unannounced complaint investigation on 7/29/26, the department noted that the following individuals did not have documented individual therapy three times per week as stated on their treatment plans: Individual #1 did not have evidence of individual therapy three times per week the week of 6/1/26 and 6/15/26. Records only reflected individual therapy those weeks on 6/1/26, 6/3/26, 6/15/26, and 6/17/26. Individual #1 record did not contain evidence of individual therapy being provided after 6/15/2026. Individual #3 record did not contain evidence of individual therapy provided after 7/16/2026. Individual #4 record did not contain evidence of individual therapy three times per week the week of 6/8/26 and 6/29/26. Record only reflected individual therapy those weeks on 6/10/26, 6/12/26, 6/29/26, and 7/1/26.

Non-compliance, DBHDS investigation : 12VAC35-46-840. I. Each resident's health record shall include or document the facility's efforts to obtain treatment summaries of ongoing psychiatric or other ...

During an unannounced complaint investigation on 7/29/26, the department noted that the following individuals did not have documented medical/psychiatric care once per week as stated on their treatment plans: Individual #1 record did not have evidence of medical/psychiatric care the week of 6/1/26 and no evidence of medical/psychiatric care after 7/14/26. Individual #2 record only had documentation of medical/psychiatric care in June on 6/8/26 and 6/15/26.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings conducted through witness statements and witness credibility, neglect was substantiated as Individual #1 and Individual #2 did not have proper supervision; which, allowed Individual #1 and Individual #2 to engage in sexual activity.

Non-compliance, DBHDS investigation : 12VAC35-46-660. H. Entries in a resident's record shall be current, dated, and authenticated by the person making the entry. Errors shall be corrected by ...

During an unannounced inspection on 2/26/2026, resident records did not contain documentation of therapy was being provided as stated in the residents' treatment plans. Individual #1 record only contain evidence that therapy had been provided on 2/2/26, 2/3/26, and 2/4/26. Individual #2 record did not contain any documented evidence that therapy had been provided in February at all. And Individual #3 record did not contain evidence of therapy being provided since 2/18/26.

Non-compliance, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

CHRIS Number: 20250033 Date/Time of Discover: 09/28/2025 12:30AM Enter Date/Time: 09/29/2025 5:19PM Reporting Delay: 16:49:00 Location Name: The Hughes Center

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: 2. Assault or battery; Based on the provider investigative findings conducted through video camera review, witness statements, and policy review abuse was substantiated based on the preponderance of evidence, that Employee #1 did push Individual #1 through the door in a malicious manner, causing Individual #1 to fall to the floor.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings conducted through video camera review and staff admissions, neglect was substantiated as Individual #1 and Individual #2 did not have proper supervision, which, allowed Individual #1 and Individual #2 to engage in sexual activity in the group room.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: 2. Assault or battery; 5. Use of excessive force when placing a person in physical or mechanical restraint; Per the provider's investigative findings conducted through video camera review and staff admissions, abuse was substantiated as Employee #1 is seen pushing Individual #1. Employee #1 also put their hand around Individual #1's neck, when attempting to put Individual #1 in a PRT hold, in an excessive manner when initiating the restraint.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-300. B. (1) The records of each employee shall include: 1. A completed employment application form providing the individual's name, address ...

During an unannounced inspection on 7/1/25, Employee #1 personnel record did not contain evidence of an employment application or resume.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-300. B. (2) The records of each employee shall include: 2. Educational background and employment history, including dates of employment for each ...

During an unannounced inspection on 7/1/25, Employee #1 personnel record did not contain evidence of educational verification that matched the requirements on the job description.

Non-compliance, systemic, DBHDS unannounced inspection : 12VAC35-46-300. B. (3) The records of each employee shall include: 3. Professional references;

During an unannounced inspection on 7/1/25, Employee #1 personnel record did not contain evidence of personal reference check results. This regulation is being cited as non-compliant systemic as provider was cited during the 2024 and 2025 inspections.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-300. B. (5) The records of each employee shall include: 5. Annual performance evaluations;

During an unannounced inspection on 7/1/25, Employee #1 personnel record did not contain evidence of annual performance evaluations. Last documented evaluation was completed on 11/13/2023.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-310. B. (2) Required annual retraining: 2. All staff who administer medication shall complete annual refresher medication training.

During an unannounced inspection on 7/1/25, Employee #1 personnel record did not contain evidence of medication administration training for EpiPen administration.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-420. E. The buildings and physical environment shall provide adequate space and shall be of a design that is suitable to house the programs and ...

During an unannounced inspection on 7/1/25, Educational Room 101 was missing multiple ceiling tiles from the drop ceiling which left exposed rails and electrical wiring; roughly 10 tiles were missing.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-480. F. Each child shall have a separate, clean, comfortable bed equipped with a clean mattress, clean pillow, clean blankets, clean bed linens ...

During an unannounced inspection on 7/1/25, several beds in all four wings of the facility were missing sheets on the beds.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: 2. Assault or battery; Per the provider's investigation conducted through witness statements and video camera review Employee #1 was seen pushing Individual #1 with force to where Individual #1 fell, causing Individual #1's shoulder to separate.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-60. A. Each individual receiving services shall receive those services according to law and sound therapeutic practice.

Per the provider's investigative findings and through video camera review by OHR Region 3 Advocate, Employee #1 did not provide sound therapeutic practices by not practicing the least restrictive intervention when taking crayons from Individual #1, as Individual #1 was breaking crayons, but not bothering surrounding peers.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-300. B. (3) The records of each employee shall include: 3. Written references or notations of oral references;

During an unannounced inspection on 7/15/24, Employee #2 personnel record did not contain evidence of reference checks completed before hire.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-310. A. (1) Required initial training: 1. Within seven days following their begin date, each staff member responsible for supervision of children ...

During an unannounced inspection on 7/15/24, Employee #1 and #2 personnel records do not contain evidence that they successfully passed the behavior intervention training. Records only contain evidence that a competency checklist had been completed but not verification that the employee passed the training course.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-310. A. (8) Required initial training: 8. Before administering medication, all staff responsible for medication administration shall have ...

During an unannounced inspection on 7/15/24, Employee #1 and #2 records do not contain evidence that they successfully passed medication training required to administer EpiPen when needed. Records only contain documentation of a competency checklist but not if they passed the training.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-710. A. Admission shall be based on evaluation of an application for admission. The requirements of this section do not apply to court-ordered ...

During an unannounced inspection on 7/15/24, Individual #1 and #2 records did not contain evidence that the applications for admission had been evaluated to determine appropriateness of placement.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: 2. Assault or battery; Per the provider's investigative findings conducted through video camera footage review and witness statements, abuse was substantiated for Employee #1 as Employee #1 placed Individual #1 in a headlock and proceeded to throw him. Furthermore, such techniques are not appropriate and/or taught.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: 5. Use of excessive force when placing a person in physical or mechanical restraint; Per the provider's investigative findings conducted through the review of video camera footage and the credibility of witnesses, Employee #1 was found to have used a restraint in an excessive manner as Employee #1 was seen to have picked up Individual #1 and threw him on the ground, causing him to break his wrist.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-70. A. (1c) - Each individual has a right to participate meaningfully in decisions regarding all aspects of services affecting him. This includes ...

Per a review of records, the guardian of Individual #1 did not consent to medication #1 being administered at the time of the order.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (13b) - The provider's duties. 13. Providers may use seclusion or mechanical restraint for behavioral purposes in an emergency only if a ...

Per the review of OHR staff the restraint could have been avoided as all peers were removed from the area, while the peer was being aggressive. At one point, staff exited to the room and then returned, where Individual #1 was seen to have spit on Employee #1. Employee #1 placed the individual in a restraint, but should have allowed time to the individual to de-escalate by himself prior to re-entering the room. Furthermore, Employee #2 participated in the restraint in an excessive manner.