summary: Licensing visited the facility to conduct a Children’s Records review. The facility was given Technical Assistance for 902.3 due to a missing immunization record.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 7/24/2024
Home Visit Date: 7/24/2024
Purpose of Visit: Children’s Records
Regulations Out of Compliance:
Regulation Number: 900.902.3
Regulation Description: Each child shall have proof of current immunizations; a letter of exemption in
accordance with the Arkansas Department of Health or a scheduled appointment within one (1) week after
admission.
Finding Description: No immunizations for available for review.
Action Due Date: 2024-08-07
Action Due Description: Immunizations for will be located and added to file.
Comply Date:
Action Due Description: Immunizations for will be located and added to file.
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Children's Record Review conducted for:
All items viewed electronically except for immunizations for Form showing that immunizations were
requested from guardian viewed. These were requested in February of 2024. T/A given for 902.3.
Immunizations for will be provided to licensing by 8/7/24.
Provider Comments:
CCL Staff Signature : Date: 7/24/2024
Provider Signature : Date: 7/24/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


state: AR

facility_name: Centers for Youth and Families - Monticello

summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility was cited 911.15.f for strings found in four bedrooms.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Eric Knowles
Record Visit Date: 7/15/2024
Home Visit Date: 7/15/2024
Purpose of Visit: Subsequent Building and Grounds
Regulations Out of Compliance:
Regulation Number: 900.911.15.f
Regulation Description: Areas used by children shall be designed, constructed, and furnished to reduce risk of
suicide and assault including, but not limited to:
Finding Description: Waistband draw strings found in boy's rooms 3, 9, 10 and 13.
Action Due Date: 2024-07-16
Action Due Description: Staff will inventory all clothing and remove strings if found. Strings found during today's
visit removed on site.
Comply Date:
Sub-Regulation Level 1 Description: Children’s personal items that contain cords, pull-ties, strings, or other
parts that could be used to inflict self-injury shall not be left in the child’s room unless the dangerous component
has been removed.
Action Due Description: Staff will inventory all clothing and remove strings if found. Strings found during today's
visit removed on site.
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Buildings & Grounds conducted from 9:00AM-10:00AM. Census: 18
Cafeteria staff/client ratio: 2:7
Outside play area staff/client ratio: 2:5
Hallway staff/client ratio: 1:5
Outside area clean and free of safety hazards. Cafeteria clean and sanitary.
Girls Hall clean, safe and in good repair. Bathrooms clean and sanitary with functioning sinks, showers and
toilets.
Boys Hall clean and in good repair. Bathrooms clean and sanitary with functioning sinks, showers and toilets.
Waistband draw strings found in boy's rooms 3, 9, 10 and 13. All drawstrings removed on site during visit.
Drawstrings will be removed, and clothing items returned. Facility cited 911.15f. Staff will conduct inventory
on all clothing items to check for strings and removed them.
Emergency escape diagrams, client rights and fire extinguisher observed. Fire and Severe Weather drills
observed.
MAR checked electronically for:
All initialed and up to date.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

Provider Comments:
CCL Staff Signature : Date: 7/15/2024
Provider Signature : Date: 7/15/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3

doc_type: Compliance Report


summary: A resident was taken to a local clinic after falling while racing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022160
Date of Incident: 6/21/2024
Date Received:6/21/2024
Facility Name: The Centers for Youth and Families Monticello
Facility Number:159
Incident Type: Licensing
Report Description: Kids were having outside time. Two kids racing, one child fell on
shoulder in an awkward position. Taken to the local clinic, fractured clavicle and will see
specialist on Monday 06.24.24.
Interim Action Narrative: Resident was taken to a local clinic and will follow up with a
specialist on 6/24/2024.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist will follow up with facility on Monday,
6/24/2024, for more details. 6/24/24-Reviewed for licensing concerns. Phone call made to
night nurse at Centers Monticello to ascertain that client's name is
Received email from of Centers Monticello: He
just returned from his follow-up. No surgery or cast. Can't lift anything over his head or
raise his arm. Next follow-up 07.15.2024.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: Licensing visited the facility to conduct an after-hours visit. All areas observed were clean and in good repair.

raw_content:
ARKANSAS
DEPARTMENT OF

> HUMAN
~=a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: The Centers for Youth and Families Monticello

Facility Number: 159

Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657

Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 5/17/2024

Home Visit Date: 5/17/2024

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

After hours visit conducted from 6:30AM-7:30AM. Census: 23. Staff/client ratio: 5:18

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Nurse KqMJ greeted licensing at the front door in approximately one minute after ringing the intercom.

5 staff, including Nurse } | awake, alert and engaged in morning activities such as waking clients up and
escorting to restrooms. All areas observed to be clean and in good repair. Grounds clean and free of safety
hazards.

MAR checked on computer for:

All electronically initialed and up to date.

Provider Comments:

CCL Staff Signature : Date: 5/17/2024
ky,
“),
AW
Provider Signature : Date: 5/17/2024

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident reported that a staff member placed his hands around the resident’s neck, attempting to choke him. This complaint was UNFOUNDED by Licensing.

raw_content:
immediately placed on administrative leave is a
Visit scheduled for 5/17/24. 5/17/24-Facility visited. No
citations. 5/30/2024-Licensing complaint is closed as unfounded.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 5/30/2024
Home Visit Date: 5/30/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Licensing complaint021298 has been investigated and determined to beunfounded.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

The ICA for the staff may be lifted and they can return to normal job duties.
Provider Comments:
CCL Staff Signature : Date: 5/30/2024
Provider Signature : Date: 5/30/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to conduct a Personnel Records Review. No deficiencies cited.

raw_content:
521 Visit Compliance Report

Licensee: The Centers for Youth and Families Monticello

Facility Number: 159

Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657

Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 5/1/2024

Home Visit Date: 5/1/2024

Purpose of Visit: Personnel Records

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Personnel Records training portion review for:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

ARKANSAS
) DEPARTMENT OF

> HUMAN
~=a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Page 1 of 2

Training portion for staff reviewed through Credible online monitoring system, which is also how staff
complete training. All traming accounted for.

Provider Comments:

CCL Staff Signature : Date: 5/1/2024

Kk)
Ni
Py

/
4} |
i
MIRC

Provider Signature : Date: 5/1/2024

f (Mame ph)

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to conduct a Personnel Records Review. The facility was issued Technical Assistance for 105.13.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 3/19/2024
Home Visit Date: 3/19/2024
Purpose of Visit: Personnel Records
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Number: 100.105.13
Regulation Description: Documentation verifying annual training shall include the date, number of hours, the
name of the source, and the topic/title.
Finding Description: All licensing requirements listed in today's visit were not readily present in each employee
file and did not include the date, number of hours, name of the source, and the topic or title.
Action Due Date: 2024-05-01
Action Due Description: All licensing requirements listed in today's visit shall be present in each employee file,
whether paper or electronic, by 5/1/24 and must include the date, number of hours, name of the source, and the
topic or title.
Comply Date:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Action Due Description: All licensing requirements listed in today's visit shall be present in each employee file,
whether paper or electronic, by 5/1/24 and must include the date, number of hours, name of the source, and the
topic or title.
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Personnel Record Review attempted. Centers is transitioning from paper to "Credible" online training
completion verification. Some verification on paper, some in "Credible". Neither listed the number of credit
hours for completion. T/A 105.13: Documentation of annual training shall include thedate, number of hours,
the name of the source, and the topic or title. As to document a list of everything that needs to be
documented in each Personnel File which shall include the date, number of hours, name of the source, and the
topic or title:
105.4: Preservice training shall include:
a) Confidentiality
b) Resident Grievance process
c) Fire and disaster plans
d) Suicide awareness protocol
e) Behavior management
f) Crisis intervention management
g) Agency policies and procedures
h) Child maltreatment/mandated reporter policy
j) Minimum licensing standards for their license type
105.5: Childcare staff shall have CPR/First Aid within 90 days of hire.
105.8: All full-time childcare staff shall have 30 hours of job related in-service or workshop training each
year. CPR may be included.
105.9: Childcare staff working 24 hours a week, or less shall have at least 15 hours of job related in-service or
workshop training each year. CPR may be included.
105.10: All childcare staff in PRTF's shall complete 10 hours of psychiatric specific training BEFORE being
counted in the staff/child ratio.
105.14: The Administrator, Social Services Director, caseworkers, and therapists shall have 24 hours of
job-related continuing education each year.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

All of these items for every employee of Centers Monticello need to be ready for review by 5/1/24. If an
extension is needed to continue the transition from paper to online training verification, licensing must be
notified.
Provider Comments:
CCL Staff Signature : Date: 3/19/2024
Provider Signature : Date: 3/19/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident reported that a staff member was rough with her and pushed her to the wall, causing bruises on her face, leg, and arms. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 019333
Date of Incident: 2/21/2024
Date Received: 2/22/2024
Facility Name: The Centers for Youth and Families Monticello
Facility Number: 159
Incident Type: Dual
Report Description: Secondary DHS caseworker, Kia Smith completed a monthly contact
visit on 02.21.2024, with . Ms. Smith stated that had made an
allegation that she had bruising and a red scratch on right cheek due to an emergency safety
intervention. Ms. Smith took pictures of cheeks and bruising.
Interim Action Narrative: Hotline called and call accepted. Staff placed on leave pending
investigation.
Maltreatment Narrative: AV is . AO is . AV,
, reported that AO, , employee of Centers, allegedly got rough with
her and pushed her to the wall causing bruises on the face, leg, and arms. stated that
she got the bruises on her face, arms, and legs from a behavior hold at Centers. FSW Smith
immediately took pictures of the bruises. Karen, employee of Centers, has security camera
footage of the behavior hold and additional information. 2/27/24-Received email that A/O
was . 3/1/24-Received email from CACD Investigator Stephanie
Britton: The investigation against at Centers in Monticello has been closed
today, Unsubstantiated!
Licensing Narrative: Program Coordinator requested permission to contact the facility.
Investigator Brittion granted permission. Resident's DOB is . 2/22/24-Facility
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

visited. CACD Investigator Stephanie Britton present. Emergency Safety Intervention
nursing notes reviewed for Camera footage of restraint holds for client reviewed for
2/18/24, 2/19/24 and 2/20/24. Licensing not prepared to make a finding as of 2/22/24.
3/1/24-Received email from CACD Investigator Stephanie Britton: The investigation
against at Centers in Monticello has been closed today, unsubstantiated.
4/29/24-Received email that the investigation against was closed as
unsubstantiated.

Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 019350
Date of Incident: 2/22/2024
Date Received: 2/22/2024
Facility Name: The Centers for Youth and Families Monticello
Facility Number: 159
Incident Type: Licensing
Report Description:
Additional Information State police
completed an interview today, 02.22.24, at the advocacy center. stated that she did not
know who was and that it was . Clayton with licensing and
Stephanie with state police came at 1:30 today, 02.22.24, and reviewed videos. Both decided
to talk with before they left at 3:30. stated that she could not eat a banana and
had broken bones in her face. DHS contacted, came, and got her to have an X-ray at the
doctor's office. When she got to the doctor's office, she told them that she had blurred
vision and was weak. The doctor?s office sent to the local ER for CAT Scan.
02.22.2024, 06:30 pm, Told ER nurse she could not eat or see. 02.22.2024, 6:50 pm, still at ER
with DHS. and were placed on administrative leave. Disability will
be notified.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 2/22/24-While interviewing client for complaint, client reported
broken bones in her face. Karen Walker of Centers Monticello stated she would have x-
rayed. Karen Walker phoned licensing and stated that reported dizziness and blurred
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

vision so was taken to the ER for a CT scan. 2/22/24-8:37PM received email from Karen
Walker: Doctor reported CT scan normal.

DHS Placement and Residential Licensing Unit
Office of the Secretary
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 019391
Date of Incident: 2/22/2024
Date Received by PRLU: 2/26/2024
Facility Name: The Centers for Youth and Families Monticello
Facility Number: 159
Incident Type: Licensing
Report Description: Update 02.26.2024: , DOB
County Drew Memorial Hospital, Drew County DHS,
02.22.2024, 08:26 pm notified us that CT scan had been read and came back negative for any
damage or issues.
Interim Action Narrative:
______________________________________________________________________________
Maltreatment Narrative:
Licensing Narrative: Follow up to prior incident. No licensing concerns noted.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility for an annual review of policies and a buildings and grounds walkthrough. The facility was cited 908.8 for medication marked “missed” on the Medication Administration Record due to an entry error.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 1/11/2024
Home Visit Date: 1/11/2024
Purpose of Visit: Agency Checklist
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Annual Review/Policies PRTF completed. All items on checklist accounted for.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Provider Comments:
CCL Staff Signature : Date: 1/11/2024
Provider Signature : Date: 1/11/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough and an annual review policies checklist. The facility was cited 110.11 for a missing child abuse hotline log.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 11/13/2023
Home Visit Date: 11/13/2023
Purpose of Visit: Agency Checklist
Regulations Out of Compliance:
Regulation Number: 100.110.11
Regulation Description: The agency shall maintain a log or file of all calls to the child abuse hotline.
Finding Description: Facility did not have a child abuse hotline log or file.
Action Due Date: 2023-11-13
Action Due Description: Child Abuse Hotline log was created by Karen Walker of Centers Monticello during
today's visit.
Comply Date:
Action Due Description: Child Abuse Hotline log was created by Karen Walker of Centers Monticello during
today's visit.
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Annual Review/Policies PRTF document checklist completed today. All items on checklist accounted for
except there was no current log or file of all calls to the child abuse hotline. A file was made by Karen Walker
of Centers Monticello during today's visit. Facility cited 110.11: The agency shall maintain a log or file of all
calls to the child abuse hotline.
Provider Comments:
CCL Staff Signature : Date: 11/13/2023
Provider Signature : Date: 11/13/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted on 10/02/23. All deficiencies overturned.

raw_content:
October 05, 2023
REVISED: November 14, 2023
The Centers for Youth & Families
936 Jordan Dr
Monticello, AR 71655-5728
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations are listed below for the inspection conducted at the following service site on the following date:
The Centers for Youth & Families
Provider Medicaid ID:
Onsite Inspection Date: October 02, 2023
Onsite Inspection Time: 9:27 AM
Inspection of Care Summary
Facility Tour:
Upon arrival at the facility, AFMC staff was promptly greeted at the main entrance by a The Centers for Youth
and Families staff member. AFMC was immediately taken to a conference room where they were met by the
Program Director. AFMC staff was given the completed and signed consent form listing approval for access to
the AFMC portal.
A tour of the facility was completed with the Program Director for the residential unit. The facility environment
was clean, well-organized, and in good repair. Educational classes were in session. Several staff members were
observed interacting calmly with clients in the classroom setting. Staff were able to answer questions regarding
the facility. There were no issues noted during the facility tour.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, no deficiencies were noted.
Personnel Records – Licenses, Certifications, Training:
There was a total of ten personnel records reviewed, four (26%) professional and six (26%) paraprofessional.
During the review of the personnel records, no deficiencies were noted.
Observations:
AFMC staff reviewed the final document request form with the Chief Executive Office, the Chief Operations
Officer, and the Risk Manager at the completion of the on-site Inspection of Care. The provider signed the
acknowledgement of manual requirements that were made available in the provider’s policy and
procedures. AFMC staff explained that these findings were preliminary and there was still an off-site portion to
be completed.
Clinical Summary

As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There were no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client
interviews were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in the classroom setting. Staff were calmly interacting
with residents and providing a therapeutic environment for learning.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was onsite.
Due to the observation of non-Medicaid clients not being compliant with the HIPAA minimal necessary rule, no
medication pass was observed. AFMC RN visited with the facility medication nurse who was able to show
AFMC RN the facility policies and procedures regarding medication administration, narcotic
count/reconciliation/handling, and medication discrepancies.
The facility nurse was able to verbalize the step-by-step process of medication delivery including the
demonstration of the five rights of medication administration, documentation of medication delivery,
verification of client taking medication including mouth/cheek checks, and how clients are educated about each
medication. Facility nurse also verbalizes the process utilized when a client refuses medications. Tour of
medication room completed no discrepancies with medication storage, cleanliness of medication room, and
knowledge of medication dispensing found.
Clinical Record Review Deficiencies:
There were no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
The Centers for Youth & Families – Monticello, AR – IOC Report 2 | P ag e

October 05, 2023
The Centers for Youth & Families
936 Jordan Dr
Monticello, AR 71655-5728
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations and any deficiencies noted are listed below for the inspection conducted at the following service
site on the following date:
The Centers for Youth & Families
Provider Medicaid ID:
Onsite Inspection Date: October 02, 2023
Onsite Inspection Time: 9:27 AM
A summary of the inspection and any deficiencies noted are outlined below.
The provider must submit a Corrective Action Plan (CAP) designed to correct any deficiency noted in the
written report of the IOC. Accordingly, you must complete and submit to AFMC a Corrective Action Plan for
each deficiency noted. The Corrective Action Plan must state with specificity the:
(a) Corrective action to be taken.
(b) Person(s) responsible for implementing and maintaining the corrective action; and
(c) Completion date or anticipated completion date for each corrective action.
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report. Please
follow the link provided in the email notice to submit either a Reconsideration or CAP for the inspection, all via
AccessPoint.
The contractor (AFMC) will:
(a) Review the Corrective Action Plan.
(b) Determine whether the Corrective Action Plan is sufficient to credibly assure future compliance; and
(c) Provide the Corrective Action Plan to the Division of Provider Services and Quality Assurance (DPSQA).
Please see § 160 of the Medicaid Manual for an explanation of your rights to administrative reconsideration and
appeal. Additionally, the imposition of this Corrective Action Plan does not prevent the Department of Human
Services from prescribing additional remedial actions as may be necessary.

Inspection of Care Summary
Facility Tour:
Upon arrival at the facility, AFMC staff was promptly greeted at the main entrance by a The Centers for Youth
and Families staff member. AFMC was immediately taken to a conference room where they were met by the
Program Director. AFMC staff was given the completed and signed consent form listing approval for access to
the AFMC portal.
A tour of the facility was completed with the Program Director for the residential unit. The facility environment
was clean, well-organized, and in good repair. Educational classes were in session. Several staff members were
observed interacting calmly with clients in the classroom setting. Staff were able to answer questions regarding
the facility. There were no issues noted during the facility tour.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, the following deficiencies were
noted:
Regulation Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2; HR records did not indicate that all direct The provider lacked documentation in HR
CFR 42 482.130, care personnel are currently certified in records that all direct care personnel are
483.376 cardiopulmonary resuscitation (CPR). currently certified in cardiopulmonary
resuscitation (CPR).
Personnel Records – Licenses, Certifications, Training:
There was a total of ten personnel records reviewed, four (26%) professional and six (26%) paraprofessional.
During the review of the personnel records, the following deficiencies were noted.
Personnel Rule Credential Outcome Reviewer Notes
Record Validated
Number
SR015053 Medicaid IP Sec. 2: CPR training Failed No file received.
221.804C
Observations:
AFMC staff reviewed the final document request form with the Chief Executive Office, the Chief Operations
Officer, and the Risk Manager at the completion of the on-site Inspection of Care. The provider signed the
acknowledgement of manual requirements that were made available in the provider’s policy and
procedures. AFMC staff explained that these findings were preliminary and there was still an off-site portion to
be completed.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There were no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client
interviews were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in the classroom setting. Staff were calmly interacting
with residents and providing a therapeutic environment for learning.
The Centers for Youth & Families – Monticello, AR – IOC Report 2 | P ag e

Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was onsite.
Due to the observation of non-Medicaid clients not being compliant with the HIPAA minimal necessary rule, no
medication pass was observed. AFMC RN visited with the facility medication nurse who was able to show
AFMC RN the facility policies and procedures regarding medication administration, narcotic
count/reconciliation/handling, and medication discrepancies.
The facility nurse was able to verbalize the step-by-step process of medication delivery including the
demonstration of the five rights of medication administration, documentation of medication delivery,
verification of client taking medication including mouth/cheek checks, and how clients are educated about each
medication. Facility nurse also verbalizes the process utilized when a client refuses medications. Tour of
medication room completed no discrepancies with medication storage, cleanliness of medication room, and
knowledge of medication dispensing found.
Clinical Record Review Deficiencies:
There were no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA, and may result in other remedial actions, by
DPSQA, if warranted.
* For more details on the individual related deficiencies, please log into the portal.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
The Centers for Youth & Families – Monticello, AR – IOC Report 3 | P ag e

doc_type: IOC Report


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. No deficiencies cited.

raw_content:
The Centers for Youth and Families Monticello
936 JORDAN DRIVE
MONTICELLO AR 71657

ARKANSAS
DEPARTMENT OF

DN HUMAN
—=a\ SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Clayton DeBoer
Donaghey Plaza

P.O. Box 1437

Little Rock, AR. 72203

Facility Visit Compliance Notice

Facility#: 159

Date of Visit: 9/28/2023
Visit Type(s): Monitor Visit
Time: 10:00 AM - 10:28 AM

Visit Comment :

Buildings & Grounds conducted from 10:00AM-11:00AM. Census: 21

Classroom observed staff/client ratio: 2:8.

Outside area observed to be safe and free of safety hazards. Staff/client ratio: 2:8

Wall brackets which house fold-up tables all inspected today. A significant amount of force was pulled on all
four brackets. The brackets did not budge and seemed to be securely fastened to the wall.

All sleeping areas observed to be clean, safe and in good repair.

Bathrooms all clean and sanitary with functioning sinks, showers and toilets. All shower curtains intact today.

MAR checked for:

Page 1 of 2

All initialed and up to date.

CCL Staff Signature :

5

Provider Signature :

vy,
/

4 ~ J Hf

XY UI/

Date: 9/28/2023

Date: 9/28/2023

Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with

it.

Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing

Requirements or contact your Licensing Specialist.

Page 2 of 2


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility was cited 911.6 for issues noted during the review.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 8/17/2023
Home Visit Date: 8/17/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulation Number: 9. 911. 6
Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.
Findings Description: Hall 1 bathrooms had two torn shower curtains. Hall 2 right bathroom toilet had gaps at the
base between toilet and floor and needs to be reset.
Action Due Date: 8/24/2023
Action Due Description: Maintenance will be notified. Deficiencies shall be corrected within a week.
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Regulations Not Correctable:
Narrative:
Building & Grounds conducted from 10:00AM-12:00PM. Census: 20.
2 classrooms observed, staff/client ratios: 2:9, 2:9.
Bathrooms have hot water and functioning sinks and toilets. Sleeping areas furnished, clean and free of safety
hazards.Facility grounds clean and free of safety hazards. All buildings safe, clean and in good repair except
for two torn shower curtains in Hall 1. Hall 2 right bathroom toilet functioning, but needs to be reset to the
floor, as there is a gap showing at the base of the toilet. Facility cited 911.6: All buildings shall be clean, safe
and in good repair.
MAR checked for:
JW 12/14/12
LB 4/14/14
AJ 9/28/10
MW 9/17/13
KE 9/21/15
All initialed and up to date.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was transported to Drew Memorial emergency room after a table fell on him and injured his wrist. The facility was cited 911.6 for the unsecured table box.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/12/2023
Date Received by DCCECE: 8/13/2023
Facility Name: The Centers for Youth and Families Monticello
Facility Number: 159
Incident Type: Licensing
Report Description: On 08.12.2023, due to the extreme heat, a male group was in the
cafeteria area playing basketball. This area has 4 cafeteria tables that fold up to the wall to
provide room for the inside basketball goal to be utilized. The group had been playing
basketball for approximately an hour. At 3:37 03.21.2023, (custody of DHS,
Randolph County, 870.609.6062) went to the side of the metal box holding the table and
pulled. Once pulled the metal box holding the table, the table fell from the wall
landing on top of . The nurse and staff immediately came to his aid. Staff lifted the
table over allowing to move. complained of wrist hurting. was
immediately taken to Drew Memorial Emergency room to be evaluated. Drew memorial
stated a possible break. On call DHS worker for Drew County was notified. Primary DHS
on call worker as well as Pulaski County DHS notified. was transferred to
Children?s Hospital. Children?s determined had a break located on the thumb side
of the hand, lying laterally in the lower arm. A cast and sling were secured. returned
to Centers at 5:10 am on 08.13.23. Over the counter pain medications if needed for pain.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing received facility report on 8/13/23 that on 8/12/23 client
injured his arm while playing basketball and was transported to Drew
Memorial Emergency Medical Center. was then transferred to Children's Hospital, and
it was determined that had a break on the thumb side of the hand, lying laterally in the
lower arm. A cast and sling were secured. Facility visited 8/17/23 and video reviewed of
incident. Client is seen playing basketball, inside, in the cafeteria, The cafeteria tables
are folded up against the wall. Staff/client ratio: 2:7. The area where these tables are folded
up against the wall inspected during today's visit. The tables fold up and can be secured
inside a box which is fastened to the cafeteria walls with hex bolts connected to a concrete
wall. The box was securely fastened to the wall today. Continuing in the video, pulls on
a table which is secured in a box against the wall. The box and the table fall on client .
The box was not securely fastened to the wall. Facility cited 911.6: All buildings and
furnishings shall be clean, safe and in good repair. There would be no indication that these
boxes are not securely fastened to the wall unless pulled. Additional hex bolts will be added
to the fold-away table boxes as soon as possible. Maintenance has been notified of this.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 8/17/2023
Home Visit Date: 8/17/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulation Number: 9. 911. 6
Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.
Findings Description: Fold-away table box was not securely fastened to the wall resulting in the injury of a client.
Action Due Date: 8/24/2023
Action Due Description: Additional hex bolts will be added to the fold-away table boxes.
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Licensing received facility report on 8/13/23 that on 8/12/23 client injured his arm while playing basketball and was
transported to Drew Memorial Emergency Medical Center. was then transferred to Children's Hospital, and it was
determined that had a break on the thumb side of the hand, lying laterally in the lower arm. A cast and sling were secured.
Facility visited 8/17/23 and video reviewed of incident. Client is seen playing basketball, inside, in the cafeteria, The
cafeteria tables are folded up against the wall. Staff/client ratio: 2:7. The area where these tables are folded up against the wall
inspected during today's visit. The tables fold up and can be secured inside a box which is fastened to the cafeteria walls with
hex bolts connected to a concrete wall. The box was securely fastened to the wall today. Continuing in the video, pulls on
a table which is secured in a box against the wall. The box and the table fall on client . The box was not securely fastened
to the wall. Facility cited 911.6: All buildings and furnishings shall be clean, safe and in good repair. There would be no
indication that these boxes are not securely fastened to the wall unless pulled. Additional hex bolts will be added to the
fold-away table boxes as soon as possible. Maintenance has been notified of this.
Provider Comments:
CCL Staff Signature : Date: 8/17/2023
Provider Signature : Date: 8/17/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


raw_content:
ARKANSAS
DEPARTMENT OF

> HUMAN
=a! SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: The Centers for Youth and Families Monticello

Facility Number: 159

Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657

Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 6/29/2023

Home Visit Date: 6/29/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted. Census: 22. Clients are out of school for the Summer but were engaged in
activities inside the facility due to extreme heat today.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Classroom | staff/client ratio: 1:3
Classroom 2 staff/client ratio: 2:6
Hallway staff/client ratio: 1:1
Dayroom | area staff/client ratio: 1:6
Dayroom 2 area staff/client ratio: 1:5

Cafeteria area observed to be clean and sanitary. Kitchen clean and sanitary with fire extinguisher.

3 Halls observed to be clean, safe and in good repair. Bathrooms clean and sanitary. One of the six bathroom
had slightly tattered shower curtain as if it was pulled too hard off the rings which was replaced this visit.

Grounds observed to be clean and free of safety hazards.

Client rights posted.

Electronic MAR (Credible) checked for:

All entries up to date.

Provider Comments:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 8/17/2023
Vi Al a

Provider Signature : Date: 8/17/2023

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was transported for acute care due to an increase in emergency safety interventions and an inability to stabilize.

raw_content:
suicidal or self-harming. Phone call made 5/18/23 for further clarity of client's behavior. Ms.
Walker stated that client was aggressive towards staff and turned over chairs and tables.


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility received technical assistance for 911.6 due to torn shower curtains.

raw_content:
ARKANSAS
DEPARTMENT OF

x

HUMAN
SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: The Centers for Youth and Families Monticello

Facility Number: 159

Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657

Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 5/2/2023

Home Visit Date: 5/3/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Number: 9. 911. 6

Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.

Findings Description: Halls 1 & 3 had clean, relatively new but torn shower curtains.
Action Due Date: 5/2/2023

Action Due Description: Shower curtains were being replaced during today's visit.
Comply Date:

Sub Regulation Description:

Regulation Not Applicable:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

Page 1 of 3

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted 5:00PM-6:00PM. Census: 21

Client seen lining up to go to dinner. Staff/client ratio: 2:11.

Hall 1 observed. Staff/client ratio: 1:5. Tattered blinds observed previous visit had been removed and new
ones have been ordered. All areas observed to be furnished, safe, clean and in good repair except for one
bathroom had a torn shower curtain. The shower curtain looked relatively new and was clean but had about a
4-foot tear in it. Staff were notified and observed replacing shower curtain with a new one. Staff indicated this
tear was relatively new, as they had not noticed it earlier.

Hall 2 observed. Staff/client ratio: 1:3. All areas observed to be furnished, safe, clean and in good repair.
Bathrooms observed to be clean and sanitary.

Hall 3 observed. No clients present.All areas observed to be furnished, safe, clean and in good repair except
for one bathroom had a torn shower curtain. The shower curtain looked relatively new and was clean but had
about a 3-foot tear in it. Staff were notified and were to replace shower curtain with a new one.

Outside grounds area observed to be clean and free of safety hazards.

MAR checked for:

All entries up to date.

Facility given Technical Assistance for torn shower curtains, 911.6: All buildings and furnishings shall be
clean, safe and in good repair.

Provider Comments:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 6/6/2023

=

Provider Signature : Date: 6/6/2023

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was transported for acute care due to extensive emergency safety interventions and an inability to stabilize.

raw_content:
AR KAN S A S&S
DEPARTMENT OF

+4 HUMAN
<a¥ SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident

Date of Incident: 4/20/2023

Date Received by DCCECE: 4/20/2023

Facility Name: The Centers for Youth and Families Monticello
Facility Number: 159

Facility Type:

Incident Type: Licensing

Report Description: ee; was placed in Rivendell acute on

04.20.2023 due to extensive emergency safety interventions and inability to stabilize.
admitted to Centers Monticello on 03.20.23 and will return to Centers Monticello
when discharged from acute. Guardian is DCFS, Thuli Dimini, iii Highway
, Woodruff County. DCFS agreed to acute placement.

Summit Community Care was notified of acute placement.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Client 3 ITZ was placed in Rivendell acute on 04.20.2023
due to extensive emergency safety interventions and inability to stabilize.

admitted to Centers Monticello on 03.20.23 and will return to Centers Monticello when
discharged from acute.

We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A review of the facility’s mandated reporter policy revealed a concern with the Licensing Unit. The facility received technical assistance for 102.3.h and 110.9 due to the concern.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 3/31/2023
Home Visit Date: 3/31/2023
Purpose of Visit: Technical Assistance Request Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Number: 1. 102. 3 .h
Regulation Description: The following policies of the agency shall be current and available to all employees of
the agency and the Licensing Specialist:
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 110. 9
Regulation Description: 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
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

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.
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Review of your agency's current mandated reporter policy has revealed a concern with the Licensing Unit.
Technical assistance was provided to the agency on Arkansas mandated reporting, R102.3.h, and R110.9.
Please ensure that your current policy is updated to reflect the need of all staff to report directly to the child
abuse hotline without delay. All reports will be screened by the Child Abuse Hotline to determine if they meet
criteria for investigation. The updated policy shall be submitted to the Licensing Unit by 4/14/23 and all
applicable staff should be retrained on the updated policy within two weeks of the enactment of the updated
policy at the agency.
Provider Comments:
CCL Staff Signature : Date: 3/31/2023
Provider Signature : Date: 3/31/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility was cited 910.1, 911.6 and 912.4 due to issues observed during the review.

raw_content:
521 Visit Compliance Report

Licensee: The Centers for Youth and Families Monticello

Facility Number: 159

Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657

Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 3/7/2023

Home Visit Date: 3/7/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulation Number: 9. 910. 1

_ ARKANSAS
) DEPARTMENT OF

«| SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Regulation Description: The grounds of the facility shall be kept clean and free of safety hazards.

Findings Description: Broken foam cup debris on the ground outside in the play area.

Action Due Date:

Action Due Description:
Comply Date:

Sub Regulation Description:

Regulation Number: 9. 911. 6

Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.

Findings Description: Tattered window blinds in Hall 1, bedroom 1.

Action Due Date:
Action Due Description:
Comply Date:

Sub Regulation Description:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

Page 1 of 3

Regulation Number: 9. 912. 4
Regulation Description: The bathroom shall be clean and sanitary.

Findings Description: Waste basket had grime build up at the bottom. Paint chips from the wall have begun to
stick to bathroom floor.

Action Due Date:

Action Due Description:
Comply Date:

Sub Regulation Description:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:
Buildings & Grounds conducted from 11:00AM-12:30PM. Census: 23
2 classrooms observed. Staff/client ratios: 2:10, 3:12.

Halls 1, 2 and 3 observed to be furnished, clean, safe and in good repair except for tattered blinds in Hall 1,
Bedroom 1. Bathrooms observed to be clean and sanitary except for Hall 3, left bathroom. Paint has chipped
off the wall. The paint chips have begun to stick to the floor of the bathroom. Hall 3, left bathroom trash
basket had grime build up at the bottom of the trash basket.

Outside play area observed to be safe and free of safety hazards. Broken foam cup debris observed on the
ground.

The last fire drill documented to be held on 2/23/23.

MAR checked for:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

Staff and housekeeping to be addressed today regarding broken foam cups and dirty bathroom waste basket.
Maintenance has been informed of the tattered window blinds and paint chips on the bathroom floor.

Provider Comments:

CCL Staff Signature : Date: 3/7/2023
Provider Signature : Date: 3/7/2023
I!

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident began showing signs of distress and difficulty breathing. Staff initiated back blows and abdominal thrusts until an apple core was dislodged.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 3/1/2023
Date Received by DCCECE: 3/2/2023
Facility Name: The Centers for Youth and Families Monticello
Facility Number: 159
Facility Type: Residential
Incident Type: Licensing
Report Description: , . Parent, contacted on 03.01.23
at 1935. On 03.01.23 at 1845 client was in classroom eating snack (apple) and started to show
signs of distress and difficulty breathing. Staff initiated back blows and abdominal thrusts
until object (apple core) was dislodged. Incident report forwarded to risk management.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:On 03.01.23 at 1845 client was in classroom eating snack (apple) and
started to show signs of distress and difficulty breathing. Staff initiated back blows and
abdominal thrusts until object (apple core) was dislodged. Incident report forwarded to risk
management. Client remains at facility. Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to review children’s records. All files reviewed complied with Minimum Licensing Standards.

raw_content:
521 Visit Compliance Report

Licensee: The Centers for Youth and Families Monticello

Facility Number: 159

Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657

Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 2/15/2023

Home Visit Date: 2/15/2023

Purpose of Visit: Child Record Review Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Client Records Review for:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year

ARKANSAS
) DEPARTMENT OF

|\-7 HUMAN
» "2 SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

y

Page 1 of 2

Records review conducted by viewing Credible software. All items per minimum licensing standards
accounted for.

Provider Comments:

CCL Staff Signature : Date: 2/15/2023
Lf
Ay
Provider Signature : Date: 2/15/2023
| thin

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to review personnel records. All files reviewed complied with Minimum Licensing Standards.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 1/12/2023
Home Visit Date: 1/12/2023
Purpose of Visit: Personnel Records
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulations Not Correctable:
Narrative:
Personnel Records Check conducted from 10:00AM-12:00PM for Centers Monticello staff:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 1 of 2

All items per Minimum Licensing Standards accounted for.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 2 of 2


raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: The Centers for Youth and Families Monticello
Facility Number: 159
Licensee Address: 936 JORDAN DRIVE
MONTICELLO AR 71657
Licensing Specialist: Clayton DeBoer
Person In Charge: Karen Walker
Record Visit Date: 1/6/2023
Home Visit Date: 1/6/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulations Not Correctable:
Narrative:
Buildings & Grounds conducted from 10:00AM-11:30AM. Census: 23
Classroom observed to have staff/client ratio: 3:10
Outdoor area observed to have staff/client ratio: 2:10
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 1 of 2

Units 1 & 2 observed to be clean, safe, furnished and in good repair. Bathroom clean and sanitary with hot
water, functioning sinks and toilets.
Residential sleeping area (3 provisional beds) observed to be clean, safe, furnished and in good repair.
MAR checked for:
All initialed and up to date.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 2 of 2


facility_name: Delta Family Services

summary: A complaint received alleges that a nurse is observing naked children while they are in the shower.

raw_content:
R
Notice of Incident
Case Number: 031502
Date of Incident:
Date Received: 7/22/2025
Facility Name: Delta Family Health and Fitness for Children
Report Description: Nurse is observing children while naked in the shower. a. Three residents said
they had experienced a nurse doing ?shower checks? and one said they had heard the nurse do it to
another child, but had not experienced it personally. All four described the process as the nurse
telling residents to open the curtain and then looking to make sure she can see soap everywhere.
Two of the residents stated this process has also involved being instructed to turn around, bend
over, or spread their legs. b. Clinical Director confirmed that nurses do ?soap checks? that involve
viewing the residents in the showers from time to time to address hygiene issues. All residents
indicated to that there was only one nurse that does this and identified her as Nurse .
When shared this information with the Clinical Director, in particular that according to
residents only one nurse was doing this, she did not ask which nurse had been identified.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Complaints # AR00039471 and #AR00039478 were found not in compliance. A Corrective Action Plan was submitted and approved.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
July 31, 2025
Dean Hill, Administrator
Delta Family Health And Fitness Center For Childre
815 E St Louis
Hamburg, AR 71646
Dear Mr. Hill:
On July 18, 2025 a Complaint Investigation survey was conducted at your facility by the Office of Long
Term Care to determine if your facility was in compliance with Federal requirements for Psychiatric
Residential Treatment Facilities participating in the Medicaid (Title XIX) Program. This survey found
that your facility had deficiencies requiring correction/substantial correction prior to a revisit as
specified in the attached CMS-2567.
Plan of Correction
A POC must be submitted within 10 calendar days of you receipt of the Statement of
Deficiencies. Failure to submit a POC may result in termination. Include a completion date for each
deficieny cited.
Stephanie Lester, Reviewer
OLTC, Survey & Certification Section
PO Box 8059, Slot S404
Little Rock, AR 72201-4608
(501) 396-6013
email to stephanie.lester@dhs.arkansas.gov.
Your Plan of Correction must also include the following:
a. Address how the corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
b. Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
c. Address what measures will be put into place or systemic changes will be made to ensure that the
deficient practice will not recur;
d. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop plan for ensuring that correction is achieved and sustained. This plan must
be implemented, and the corrective action evaluated for its effectiveness.
Dean Hill - Delta Family Health And Fitness Center For Childre - - (AOLTC - PRTF OTC) Page 1 ]

e. Include dates when corrective action will be completed. The corrective action completion dates must
be acceptable to the State. Your facility is ultimately accountable for its own compliance. The plan of
correction will serve as the facility’s allegation of compliance. Unless otherwise stated on the PoC, the
last completion date will be the date of alleged compliance.
Informal Dispute Resolution
In accordance with 42 CFR § 488.331, you have one opportunity to question deficiencies through an
informal dispute resolution (IDR) process. To obtain an IDR, you must send your written request to
Health Facility Services, Arkansas Department of Health within ten (10) calendar days from receipt of
the Statement of Deficiencies. The request must state the specific deficiencies the facility wishes to
challenge. The request should also state whether the facility wants the IDR to be performed by a
telephone conference call, record review, or a face-to-face meeting.
If the facility will be represented by an Attorney, please notify ADH in your IDR request and provide the
name and contact number for the Attorney. Additionally, please notify DHS, at
OLTC2@dhs.arkansas.gov, of your intent to be represented by an Attorney. Failure to do so may result in
a delay of your hearing.
An incomplete informal dispute resolution procedure will not delay the effective date of any
enforcement action or the requirement for timely submission of an acceptable plan of correction.
Informal dispute resolution in no way is to be construed as a formal evidentiary hearing. It is an
informal administrative process to discuss the findings.
Please submit your request to:
IDR/IIDR Program Coordinator
Health Facilities Services
5800 West 10th Street, Suite 400
Little Rock, AR 72204
Phone: 501-661-2201
ADH.HFS@Arkansas.gov
If you have any questions, please contact your Reviewer.
Sincerely,
for Jeff Rosenbaum
Stephanie Lester, RN QA Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
sl
cc: DRA
Dean Hill - Delta Family Health And Fitness Center For Childre - - (AOLTC - PRTF OTC) Page 2 ]

Dean Hill - Delta Family Health And Fitness Center For Childre - - (AOLTC - PRTF OTC) Page 3 ]

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
August 6, 2025
Dean Hill, Administrator
Delta Family Health And Fitness Center For Childre
815 E St Louis
Hamburg, AR 71646
Dear Mr. Hill:
On July 18,2025 we conducted a complaint survey at your facility. You have alleged that the
deficiencies cited on that survey have been corrected. We are accepting your allegation of compliance
and have approved your plan of correction and presume that you will achieve substantial correction by
August 8, 2025.
If you have any questions, please contact your reviewer: Stephanie Lester at 501-396-6013 or email
to: stephanie.lester@dhs.arkansas.gov.
Sincerely,
for Jeff Rosenbaum
Stephanie Lester, RN QA Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
sl
Dean Hill - Delta Family Health And Fitness Center For Childre -- -- (AOLTC-14) Page 1

doc_type: Complaint Survey


summary: A resident was transported to the hospital for treatment.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029706
Date of Incident: 5/13/2025
Date Received: 5/13/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
05/12/2025 around 9:00-9:15 after having a . She has now been
cleared and returned to the facility about midnight.
Interim Action Narrative: Resident taken to and treated at hospital.
Narrative:
Licensing Narrative: 5/13/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported swallowing a metal shaving found in her food. The resident was taken for evaluation. All questionable food was thrown away, and the can opener will no longer be used.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029658
Date of Incident: 5/11/2025
Date Received: 5/12/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
was taken to the last night due to
reporting she swallowed a metal shaving she found in her food. She turned in a piece, but it
is uncertain if she actually had the piece in her mouth. A few other metal shavings were
found in food, and food was thrown away from clients. It is believed the metal shavings
came from the can opener. The can opener will not be in use. While at was
completed, and it was clear. returned to the facility last night.
Interim Action Narrative: Can opener and questionable food thrown away. Resident taken
to .
Narrative:
Licensing Narrative: 5/12/25-Reviewed for licensing concerns. Phone call made to Misty
Winters of Delta who stated that the can opener has been thrown away and will not be in
use anymore. As indicated in report, all questionable food that day was immediately thrown
out. As a precautionary measure, resident was taken to which found
nothing abnormal. This incident was staffed with Program Coordinator Kendra Slade.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: During the admittance process, a resident hit the front door several times causing the lock to loosen and the door to open. The resident was able to run from the facility and into the road. Police were called. Officers located and returned the resident to the facility approximately 20 minutes later.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029583
Date of Incident: 5/7/2025
Date Received: 5/7/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
on 05.07.2025 at approximately 12:45pm to be admitted to our facility. She completed
all required paperwork and was legally signed in to our facility. Approximately 1:00p --
1:10pm, hit the front door several times, causing the magnetic lock to loosen
opening the door. A code was called. was notified. She ran
from staff. Staff members followed. She then attempted to run into a large truck, similar to a
garbage truck. Staff grabbed her and pulled her
back out of the road. were able to locate her, her, and she was returned to
the facility approximately 20 minutes later. Due to this situation, is being sent to
acute care, She will be leaving by in the next 30-
45 minutes. It is undetermined if she will be returning to our facility at completion of her
acute stay. I will notify licensing as soon as possible either way.
Interim Action Narrative: Police notified. Resident sent to acute.
Narrative:
Licensing Narrative: 5/8/25-Reviewed for licensing concerns. Report indicates that facility
will notify licensing if/when resident returns to facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported being choked and grabbed on the neck by a staff member during a physical altercation. The complaint has been UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029458
Date of Incident: 5/1/2025
Date Received: 5/2/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: Resident was admitted to tonight from Delta Family Center RTC
program. Resident states being physically aggressive with RTC staff today. Resident has red
marks under her neck and on the left side of her neck. Resident states being
choked/grabbed on the neck by a staff member during the physical altercation. Resident
admits to hitting the staff member on the face, saying staff member was trying to place the
resident in a restraint. Resident states "I took her to the ground. " Resident states the staff
member was aggressive towards her so that's why the resident was aggressive back. The
resident states the staff member did not hit her. Pictures were taken of the injuries on
resident's neck.
Interim Action Narrative: Staff member has been suspended pending outcome of the
investigation.
Narrative:
Licensing Narrative: Licensing requested an ICA for the staff member mentioned in this
complaint. Facility provided licensing with an ICA. Per facility, they were made aware by
the Program Manager Lead Therapist that there had been a complaint filed against the staff
member. The staff member is currently off duty until further notice and will not be returning
to work until an ICA is approved and/or incident determined to be unfounded. 5/5/25-
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Email sent to for further information.
Resident
will not be returning to facility. Email sent to facility to inquire if there is video of the
incident 4/30/25. Received email from with further information. 5/5/25-Restraint
packet and nursing note reviewed. Nursing notes state there was redness to the neck area.
Visit scheduled for 5/6/25 to review camera footage. 5/6/25-Facility visited. No citations.
Licensing complaint is unfounded. 5/23/2025, case and documentation reviewed. Licensing
reviewed camera footage on 5/6/2025. Complaint unfounded by licensing. Approved by
Program Coordinator. Case complete. 6/13/25-Sent email inquiring about staff's
employment status. 6/16/25-Received email from facility as follows: staff has been on
medical leave as well. She contacted us this morning noting that she received her letter
today stating allegations were unsubstantiated. She has not been to work since the incident
due to her medical injury. She will continue medical leave until at least 6/20, when she
returns to They may determine medically she cannot return yet.


summary: A resident was transported for acute care after hitting a staff member four times.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029404
Date of Incident: 4/30/2025
Date Received: 4/30/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: Ouachita County DHS DCFS
-- arguing with a staff about what staff are supposed to do. Walked up
and hit staff member 4 times. She was placed in a personal restraint, given a chemical
restraint at 1755 and released from personal restraint. contacted.
She will be leaving here via Ambulance about 9.30pm and should arrive
at by 11.30pm
Interim Action Narrative: Resident sent to .
Narrative:
Licensing Narrative: 5/1/25-Reviewed for licensing concerns. Email sent to facility to
notify licensing if/when resident returns and what safety plan will be. Received email that
resident will not be returning to facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for acute care after she became upset, punched a wall several times, attacked a nurse, self-harmed, destroyed property, and threatened others.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028847
Date of Incident: 4/7/2025
Date Received: 4/8/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: Izard County DHS, Susan Hale, FSW
She was placed at today. She became upset yesterday, punched the
wall several times, was placed in a personal restraint, unable to keep her calm so she was
given a chemical. Afterward, she attacked the nurse, hitting her and pulling a chunk of hair
out. This morning, she has been being aggressive, hitting walls with close fists, threatening
to "tear the place up" and grabbed a picture frame off the wall, slung it down breaking it,
and threatening to hurt others with it.
Interim Action Narrative: Resident sent to acute placement.
Narrative:
Licensing Narrative: 4/8/25-Reviewed for licensing concerns. Email sent to facility to
notify licensing if/when resident returns to facility and what safety plan will be or if resident
discharges.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that staff members held her down, put an elbow on her throat causing difficulty breathing, and bruised her arms during a restraint. This complaint has been UNFOUNDED by Licensing and Crimes Against Children Division (CACD). Staff will receive retraining.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028892
Date of Incident: 4/5/2025
Date Received: 4/10/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: . AO is age/name unknown. AV is in DHS
care and is currently at in Little Rock, Arkansas and will be until her release
on 25. AV had been residing at Delta Family Center in Hamburg, Arkansas until
25 when she was taken to . AV reported that on 25 she was
placed in a restraint and then held down by four to five staff members. When questioned
why so many staff were holding her down, AV stated that they needed that many to restrain
her. AV reported that there was one staff member who took it too far and bruised her as well
as putting their elbow in her throat and pushing down so that she couldn?t breathe. AV does
have three green bruises on her right arm and 2 bruises on her left arm. When discharged
from AV will not be returning to the Delta Family Center.
Interim Action Narrative: A/V sent to placement 028847 reported to licensing.
Narrative:
Licensing Narrative: 4/9/25-Recieved phone call from who provided further
information. A/V is at and will not be returning to Delta. No A/O's named
at this time. A/V scheduled for forensic interview today. Phone call made to of
Delta who stated there was video of incident. Visit scheduled for 4/15/25. 4/10/25-Received
licensing complaint report and reviewed for licensing concerns. Report states incident
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

occurred 4/5/25. Phone call made to of Delta. Incident occurred 4/6/25. A/V
was in no restraint nor had any incidents 4/5/25. Video has been saved for licensing to
review. Email sent to . No A/O's have been named at this time. Visit scheduled for
4/15/25. 4/14/25-Received email from that two A/O's were named during
. Complaint against A/O 2 reported to have happened about 4 months ago
Complaint against A/O 1 refers to this complaint. Email and phone call made to facility to
inform them that A/O's will need before being allowed to work until investigation is
complete. Phone call made to of Delta. Both named A/O?s are on leave pending
approved or close of investigation. 4/15/25-Facility visited with 4/15/25. Video
reviewed of recent incident. Documentation provided of reported complaint from 4 months
ago. No citations. Licensing complaint unfounded. 4/18/25- for both A/O's denied.
5/2/2025- for staff reviewed and lifted so that he may return to normal job
duties. 5/7/25- for staff lifted. Retraining sent to licensing.


summary: A resident reported that a staff member threw her on the floor to restrain her, busting her lip. The resident also reported being bitten by ants in her bed and not being given the toothpaste she received at a dental appointment.

raw_content:
R
Notice of Incident
Case Number: 031102
Date of Incident: 4/1/2025
Date Received: 7/10/2025
Facility Name: Delta Family Health and Fitness for Children
Report Description: About a month after March 6, 2025, when she was admitted into Delta RTC.
A male staff member came into her room by himself and threw her onto the floor to restrain her.
She burst her lip and blood was everywhere. She still has the scar where the AO?s fingernails went
into her skin. She was not being aggressive to cause this. She said the AO said, ?it was about to be a
code yellow.? It was asked in front of her guardian and therapist if an incident report was completed
and no one responded. The case manager asked her guardian if an incident report was done. Her
guardian said that when she heard about the restraints, she went down to Delta to talk to them
about it. She had not been previously made aware of the details until shared them on
7/8/2025. She did ask why she had not given these details to her. said it was
because at Delta, was in the room and she knew would twist
her story and say she was lying and exaggerating. said no report had been called in the
about this and says the staff at Delta act fake when DHS is present. She also says she has
been eaten by ants being in her bed that it was a horrific amount of ants on her sheets. However,
when a nurse and staff went in to see they only saw one or two ants and said she was exaggerating.
She was given a -250 for exaggerating. On 07/07/2025 had an Orthodontist appointment
. When she returned to Delta she was told she
could not have bands that she may put them around her neck. She was also told the Colgate
toothpaste she received at the appointment could not get the job done, that she could not have it.
said that at DHS had given her some squishy pens and a squishy animal. Delta
asked where they came from she told them, and the staff said she was lying. says she has
been at Delta for a while and is ready to go, everyone else is being discharged and she has been there
the longest. She does feels she has made progress and is ready to go back to .
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An annual review was conducted. All items were accounted for in hard copy files. No deficiencies were noted.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 3/25/2025
Home Visit Date: 3/25/2025
Purpose of Visit: Agency Checklist
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Annual Review conducted. All items accounted for in hard copy files.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Provider Comments:
CCL Staff Signature : Date: 3/25/2025
Provider Signature : Date: 3/25/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident began self-harming by biting her right and left hand. The facility was cited for late reporting.

raw_content:
AR KANS A S&S
DEPARTMENT OF

i¢ SaRVICES

Placement and Residential Licensing Unit
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident
Case Number: 027556
Date of Incident: 2/11/2025

Date Received: 2/13/2025

Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing

Report Description: On 02.09.2025, she bit her right hand. Later she bit her left hand. She
was already 1:1 with staff due to previous statements of suicidal ideation. On 02.10.2025, our
psychiatrist ordered fF sssisi*@*S She was placed 1 ii on

HB .2025. The current plan is for her to return to our facility once she is discharged from

Interim Action Narrative:

REE No :2tve:

Licensing Narrative: 2/13/25-Reviewed for licensing concerns. Received email that "she"
in the report refers to client IE EE Placement. Facility
cited 110.17. Phone call made to Dean Hill of Delta who stated that staff responsible for late
reporting has been counseled regarding this incident and reminded tha 3
need to be reported to licensing by the next business day.

We Care. We Act. We Change Lives.
humanservices.arkansas.gov

_ ARRAN GAS
i DEPARTMENT OF

a1 SERVICES

c . Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Delta Family Health and Fitness for Children

Facility Number: 172

Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

Licensing Specialist: Clayton DeBoer

Person In Charge: Dean Hill II
-Record Visit Date: 2/13/2025

Home Visit Date: 2/13/2025

Purpose of Visit: Desk Review

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Regulation Number: 100.110.17

Regulation Description: The agency shall notify the Licensing Unit by the next business day of serious injuries
requiring emergency medical treatment, agency vehicle accidents, arrests, elopements, suicide attempts, or
deaths, and maintain documentation of the incident and notification.

www.arkansas.gov/dhs -
a ane gees 4
Serving more than one million Arkansans each year : Page 1 of 2

Finding Description: Received provider reported incident that on 2/11/25 client as placed in acute care.
Facility did not notify licensing until 2/13/25.

Action Due Date: 2025-02-13

Action Due Description: Staff responsible for late reporting counseled and reminded that acute placements must
be reported to licensing by the next business day.

Comply Date:
Action Due Description: Staff responsible for late reporting counseled and reminded that acute placements must
be reported to licensing by the next business day.

Narrative:

Received provider reported incident that on 2/11/25 clientffvas placed in acute care. Facility did not notify
licensing until 2/13/25. Facility cited 110.17. Staff responsible for reporting this late has been counseled and
reminded that acute placements have to be reported to licensing by the next business day.

Provider Comments:

CCL Staff Signature : Date: 2/13/2025

Provider Signature : Date: 2/13/2025

 —

www.arkansas.gov/dhs .
Serving more than one million Arkansans each year Page 2 of Z


summary: Licensing visited the facility to conduct a Buildings and Grounds walkthrough. The facility was cited 911.6 for a broken light fixture in one bathroom and ceiling tiles out of place throughout the facility.

raw_content:
ARKANSAS
DEPARTMENT OF

> HUMAN
~a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Delta Family Health and Fitness for Children

Facility Number: 172

Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill I!
Record Visit Date: 2/4/2025

Home Visit Date: 2/4/2025

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulation Number: 900.911.6
Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.

Finding Description: Light fixture in bathroom in room#29 broken and ceiling tiles out of place throughout facility
bathrooms.

Action Due Date: 2025-03-15

Action Due Description: Light fixture replaced and ceiling tiles placed correctly during today's visit. To address
ongoing issue of ceiling tiles, they will be replaced with wooden boards and secured into ceiling.

Comply Date:

Action Due Description: Light fixture replaced and ceiling tiles placed correctly during today's visit. To address
ongoing issue of ceiling tiles, they will be replaced with wooden boards and secured into ceiling.

Regulations Needing Technical Assistance:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:
Buildings & Grounds completed. Census: 19

Classroom | staff/client ratio: 1:5
Classroom 2 staff/client ratio: 3:9

Library staff/client ratio: 1:3
Fire and Severe Weather logs observed and up to date.

Buildings clean, safe and in good repair except Room. 29 had a broken light fixture in the bathroom and
ceiling tiles throughout facility bathrooms were out of place. The broken light fixture was replaced during
today's visit. Ceiling tiles were put back in place during today's visit. Ceilings, especially in bathrooms
continue to be an ongoing issue as clients continue to find ways to push them up, including slamming
bathroom doors hard to create suction which pushes them up. Facility cited 911.6. A corrective action plan of
replacing ceiling tiles in bathrooms with wooden boards will be completed by 3/15/25. Dean Hill and Terry
with maintenance consulted regarding these repairs during today's visit.

Ground clean and free of safety hazards.

MAR checked for:

Provider Comments:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 2/4/2025

Date: 2/4/2025

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was taken to the Emergency Room for dizziness, headache, and coughing up a dime-sized sputum of blood. After the evaluation, the resident was transported back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026778
Date of Incident: 1/12/2025
Date Received: 1/13/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: l Client was taken to
for dizziness, headache and coughed up a dime size sputum of blood. All labs were normal.
Vital signs normal and
discharged with follow up. Followed up this am with PCP and no abnormal findings noted.
Interim Action Narrative:
Narrative:
Licensing Narrative: 1/13/25-Phone call made to Delta to ascertain client's last name
and . Conversation had with of Delta regarding submitting
reports in ELS. Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to the Emergency Room for possible seizure-like activity. After the evaluation, the resident returned to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026777
Date of Incident: 1/11/2025
Date Received: 1/13/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
Interim Action Narrative:
Narrative:
Licensing Narrative: 1/13/25-Phone call made to of Delta (
to gather the following information: On 01/11/2025 was taken to for
possible seizure like activity. Labs normal CT negative and follow requested. Has
appointment with PCP today at 3PM. Conversation had with on submitting
reports in ELS. 1/13/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident walked into the nurse’s station, opened the medication cart, and took medication that did not belong to her. The resident was transported to the Emergency Room for evaluation. The facility was cited for 110.9.a, 110.17, 907.2, and 908.4 as a result of the incident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026707
Date of Incident: 1/1/2025
Date Received: 1/9/2025
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type:
Report Description: , ,
, On January 1,
2025, the nurse was involved in a personal restraint with another client, and was away from
the nurse's station. Other staff were around the nurse's station with . She then
walked into the nurses station without permission, opened the medication cart, and took
medication that did not belong to her. A staff member observed this, went into the station,
and placed in a personal restraint to prevent her from continuing this behavior. The
nurse returned, and it was determined she had taken the same type of medication she is
prescribed. She did take a larger dose than prescribed. As a precautionary measure, she was
taken to the at , where she was given an and
released. There were no medical injuries, therefore this incident was not reported to
licensing at that time. Guardian was notified of the situation. did request in
a report to the 2025, and this was done.
Interim Action Narrative: Resident was taken to the for evaluation. A/O
was placed on leave .
Narrative: Av is who is currently residing at Delta Family
Center. AO is name and age unknown who is a staff member. is currently receiving
treatment at Delta Family Center, Hamburg, AR. On January 1, 2025, the nurse was involved
in personal restraints with another client and was not at the nurse's station. went
into the nurse's station, opened a drawer and took medication that did not belong to her
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: While at the emergency room for a self-harm incident, a resident walked out of the ER and ran. Police located the resident and returned her to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025984
Date of Incident: 12/8/2024
Date Received: 12/9/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
hit her hand on the wall, causing a golf ball sized swollen
place on her left hand. She was sent to the ER at 3.30pm. She was seen for an x-ray, and met
with doctor, who noted it was swollen, . 1728 -- walked out of the
Emergency Room at Ashley County Medical Center, and ran. 911 was contacted at 1730.
ran behind Stonegate Nursing Home, Crossett, AR. At 1745, no police had arrived, so
911 was contacted a 2nd time. Police found in the woods beside the nursing home at
7:06pm, was found by police. She was transported back to the facility, and arrived at
2010, where she was fighting police to keep from coming in the building.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/9/24-Reviewed for licensing concerns. Incident reports for this and
related case#025983 sent to licensing. Phone call made to Misty Winters of Delta to
ascertain completion of report. Client did return to facility and remains at facility with safety
plan of elopement precautions, 24/7 observation (eye contact) and physical aggression
precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Ashley County Medical Center after injuring her hand by repeatedly punching a wall.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025983
Date of Incident: 12/8/2024
Date Received: 12/9/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
On December 8, 15.20pm was upset about being in the
facility. She became upset, and angry. She began punching the wall, twice, with left hand.
After the second time of punching repeatedly, within 3 minutes, she had a golf ball size knot
pop up on her knuckle. Nurse evaluated, and due to concerns she could have broken her
hand, she was sent to the ER at Ashley County Medical Center for an x-ray. Due to a second
incident, another incident report is being completed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/9/24-Reviewed for licensing concerns. Received documentation
from facility
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident’s family reported finding a lump on the resident’s head during a visit. The resident stated the injury occurred during a restraint, when he was pushed down and his head hit the floor. The resident also stated the staff member hurt him and twisted his arm behind his back.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026021
Date of Incident: 12/6/2024
Date Received: 12/10/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Dual
Report Description: Licensing received 12/10/24 as follows: AV is 11yo
. AO is worker at Delata family homes . is a
, While he was on a visit with his pre adopt
family was observed to have a bigger than a quarter size lump on his head behind
his left ear that he told his family was from pushing him down and his head hitting
the concrete floor when the family asked why this happened stated he was being put
in a hold but that she hurt him and then twisted his arm behind his back. The family also
reported that the staff at the facility told to not be talking about what had
occurred the previous day (Friday the 6th) when the family asked him that's when he stated
he was pushed and the discovered the knot on his head. reports that is often
mean to him and his pre adopt family is very concerned.
Interim Action Narrative: Both staff and placed on leave pending
investigation or approved ICA. 12/12/24-ICA for approved by Program
Manager Chelsea Vardell.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 12/10/24-Phone call made, voice message left, and email sent to
asking permission to contact facility and/or AV regarding
this case. No reply at this time. Case staffed with Program Coordinator and Program
Manager. 12/11/24-Facility visited. present for visit. No citations.
Licensing is not prepared to make a finding at this time. 12/12/24-ICA for
approved by Program Manager Chelsea Vardell. 12/19/24-
notices provided by facility for both . 12/20/24-ICA lifted for both
A/O's. 1/2/2025, complaint reviewed and approved. Complaint unfounded by licencing.
Case complete.