summary: While in a restraint, a resident tried to pull his arms free and hit his head on the door frame.

raw_content:
(staff) and Chris Franklin (staff) was called to assist to get and Jaylen off the unit due
to them being the target.
Interim Action Narrative: staff member is currently suspended
pending the investigation.
Narrative: AV is AO is staffmember . PRFC
is mother is inpatient at Methodist Family Health Behavioral
Facility. It was reported that on Wednesday night, left his hallway and went into
another hallway and attacked another patient in his sleep. and the same patient got
into a fight yesterday morning about the previous night?s incident, and then while in the
cafeteria waiting for group therapy went up to the patient and punched him in the
face. This morning 1/3/25, left his hallway and attempted to enter the other
patient?s hallway again. Staffmember Shawanda stopped him and asked him what he was
doing. said he was just going to the other hallway to chill. Shawanda told him they
weren?t going to do this this morning, and then came over to help. told
to go back to his hallway and put a hand on him to guide him. slapped
hand off him and then pushed away from him. then became
combative and and another staffmember, Jaylen, had to restrain him. started
spitting in face, so and Jaylen began trying to adjust their restraint on
continued to be combative during the adjustment, and his head was hit against the
doorframe. Jaylen and kept restrained until a coordinator arrived on scene,
after which they released him. immediately made allegations that had
intentionally hit his head into the doorframe during the altercation. then took off his
jacket and swung at Jaylen, missing him and hitting . and Jaylen then restrained
again. and Jaylen were then allowed to leave the scene to try to get to
calm down. When the nurse asked if she could assess him for injuries, told her ?fuck
you?. did allow the coordinator to check him for injuries, and no injuries were
reported though there was a red mark on his head where he hit the door frame. The camera
footage was reviewed and no malicious intent was observed, just being combative
during the attempt to adjust the restraint and hitting his head. is inpatient due to
aggressive behaviors against his mother, and he does have a probation officer.
Licensing Narrative: Licensing informed of complaint by facility via telephone. Facility
provided an email with the referral number, corrective action plan, and plan to request an
ICA. The facility's corrective action plan is to complete a CPI in-service for the staff and
complete and ICA requesting for the staff to work on a different floor. 1/6/2024, checked

for . Licensing will request permission from the to
contact the facility. Licensing will inquire about camera footage, safety precautions, bed
checks, and witness statements. Facility reported resident went to on
1/3/2025. Licensing inquired about safety plan when resident returns from .
Facility reported, residents were placed 10ft from each other. Resident will be placed in the
middle school classroom and the peer will be in the high school classroom so they will stay
separated at all times. Licensing Specialist Horton will view camera footage 01/07/2025.
01/07/2025 Licensing viewed camera footage and is not prepared to leave a finding at this
time. 1/8/2025, licensing requested restraint packet. Facility reported requested
documentations to Licensing via email. Documentation uploaded. The ICA for staff was
reviewed by the PRLU and denied. 2/5/2025, per is still . 2/19/2025,
per . Licensing Specialist informed. Licensing Specialist
reviewed/received information. 02/26/2025 Facility reported employee training document
the document was uploaded. This complaint has been unfounded by Licensing. 2/27/2025,
Program Coordinator reviewed case and contacted the facility regarding the ICA. 3/3/2025,
Case and documentation reviewed. Complaint unfounded by licensing. Case complete.


state: AR

facility_name: United Methodist Children's Home - Little Rock

summary: A resident reported that a staff member picked up another resident and threw him on his bed.

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: 026585
Date of Incident: 1/1/2025
Date Received: 1/3/2025
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Dual
Report Description: , who is an
and DHS placement. (client) reported to his therapist,
that (staff) went into room picked him up and threw
on his bed. .
.
Interim Action Narrative: was called and staff member involved is suspended
pending the investigation.
Narrative:
Licensing Narrative: Licensing informed of incident via telephone. Facility provided more
information via email. Facility provided their corrective action plan, to complete a CPI in-
service, retrain on intensive teaching phases 1, 2, and 3 of tantrum management, and
complete an ICA requesting for the staff to work on a different floor. 1/6/2025, licensing will
follow up with facility on the date of incident, camera footage, and witness statements.
. Staffed with the administrator the
status. Facility reported the incident happened on 1/1/202 but the resident did not report
the incident to his therapist until 1/3/2024. Licensing requested
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

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: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Arlene Horton
Person In Charge: Sherika Williams
Record Visit Date: 1/8/2025
Home Visit Date: 1/8/2025
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time: 9:00 a.m. – 10:00 a.m.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 29
Licensing received a provider reported incident on 01/01/2025 for ELS Case #026585.
Licensing Specialist reviewed camera footage for this provider reported incident with Sherika Williams.
Facility reported to Licensing the incident happened on 1/1/2025 but the resident did not report the incident
until 1/3/2025. Licensing Specialist viewed video footage with a start time of 6:10 p.m. – 6:19 p.m. The
facility reported that the AV reported it to another resident and this resident reported it to his therapist that the
incident occurred in the resident’s room.
Licensing observed on video staff standing in the hallway outside the AV’s room. Licensing Specialist
observed and heard the staff telling the AV (resident) to stop self-harming. Licensing could hear via video
audible the AV (resident) yelling and screaming that he was not self-harming and he made comments towards
the staff. Licensing observed the AV threw items from his room as he yelled and screamed at the staff.
Licensing observed the staff was replaced by another staff member at 6:20 p.m. to monitor outside the AV’s
door in the hallway and due to a fire drill.
Licensing observed staff appeared to be monitoring the facility for safety purposes for staff and residents.
Licensing is not prepared to leave a finding at this time.
***** Pursuant to A.C.A. § 9-24-406(e) (3-4): If you believe that the Department’s notice of noncompliance
is in error, you may ask for reconsideration. The request for reconsideration must be in writing and delivered
to the Department by certified mail within twenty (20) business days of receipt of the notice of
noncompliance. The request must specify the parts of the notice that are alleged to be in error, explain why
you believe those parts are in error, and include documentation to support the allegation of error. Once
received the Department shall issue a decision on your request within twenty (20) days after receipt of the
request.
Provider Comments:
CCL Staff Signature : Date: 1/8/2025
Provider Signature : Date: 1/8/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Notice of Incident


summary: A resident complained of left foot pain after an altercation with a peer. An x-ray was ordered due to swelling of the left foot.

raw_content:
for any concerns with regulation 907.2 and 907.3. Licensing inquired of the facility nursing
note. Licensing did not find any concerns with regulations 907.2 and 907.3.


summary: A resident reported to staff that his peer grabbed his arms from behind and made him bend over. A 10-foot precaution was enacted for these residents.

raw_content:
AR KANS A S&S
DEPARTMENT OF

i¢ SERVICES

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: 026379
Date of Incident: 12/22/2024

Date Received: 12/23/2024

Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115

Incident Type: Licensing

Report Description: On Sunday December 22nd Client

assaulted him. MB ceported that
" bend over" in front of client

GB grabbed his arms from behind and made

. Right now we are waiting for the

; ti‘si‘*@ A 10ft precaution was set for these clients.

Interim Action Narrative:
Maltreatment Narrative:

Licensing Narrative: 12/26/2024 Licensing Specialist Horton enquired of the facility was
the Re: Is there camera footage to review? What is the safety plan for the
residents? Facility reported to Licensing that the residents are being separated to keep them
away from each other. Licensing is scheduled to view camera footage on 12/31/2024.
Licensing Specialist viewed camera footage and minimal licensing standards were met.

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

m ARK AN S A S
) DEPARTMENT OF

IN, HUMAN
y "a SERVICES

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: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Arlene Horton
Person In Charge: Sherika Williams
Record Visit Date: 12/31/2024
Home Visit Date: 12/31/2024

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time: 9:30 a.m. — 10:30 a.m.

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 1 of 2

Census: 34
Licensing received a provider reported incident on 12/22/2024 for ELS Case #026379.

Licensing Specialist reviewed camera footage for this provider reported incident with Sherika Williams at the
facility.

This alleged incident was reported to Licensing on 12/23/2024. Licensing observed according to the camera
footage, the incident occurred at about 6:19 p.m. and ended at about 6:19:40 p.m. The ratio was 3:10. The
residents involved in this incident were watching television in the designated area at the facility. Licensing
observed by viewing the video the resident that reported being assaulted by another resident in the facility
noticed an item that he (AV) wanted from the resident (AO). Licensing observed the AV walking towards the
resident (AO) then reaching for the item the resident had in his hand and said, “why are you raping me, he
grabbed me from my back.” The resident (AO) did not make a comment but moved away from the AV still
trying to hold on to the item.

Licensing observed it appeared that the staff monitored the residents for their safety and redirected the AV
when needed.

The facility met the minimum licensing standards.
Provider Comments:

CCL Staff Signature : Date: 12/31/2024

Provider Signatu Date: 12/31/2024

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


summary: A resident tripped while playing basketball in the gym. A knot on his ankle was observed when he was assessed by nursing. An x-ray was ordered.

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: 026383
Date of Incident: 12/20/2024
Date Received: 12/23/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description:
He was playing basketball in the gym with his peers when peer
tripped when he was running to shoot the ball. He was assessed by Nurse
Stephanie Smith, there was a finding of a knot that had developed on his ankle during her
assessment. The APRN order for an x-ray to be completed. X-ray was completed on Friday
night resulting in no fracture or dislocation, the x-ray was normal.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/26/2024 Licensing Specialist Horton inquired of the facility nurse's
notes. Was the trip intentional or accidental? The facility reported to Licensing more of
horse playing than the intent to harm. Facility to provide Licensing nurse's notes and x-ray.
Document received via email from facility. Document uploaded.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident injured her hand by punching the walls during a self-harm incident. An x-ray was ordered.

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: 026210
Date of Incident: 12/15/2024
Date Received: 12/17/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description:
and private placement was upset after visitation with her mom. She refused to follow
any prompts or instructions. attacked staff by grabbing their badge and choking
the staff. She kicked staff when staff was attempting to intervene to prevent client from self-
harming. transitioned to unit and continue to punch the walls, bang her head on
doors and bite herself. Client was assessed by the nurse finding bruising to her right
knuckles due to punching the wall. An x-ray was ordered on 12/16/2024 due to client
complaining of pain in her right hand and completed on 12/16/24 finding no fractures,
normal appearance of the joint spaces and growth plates.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/18/2024 Licensing Specialist Horton inquired of the facility why
was this incident not reported on 12/16/2024? Please provide the nurse's note. Was the
resident placed on any safety precautions? Facility reported to Licensing on 12/15 during
the nurse assessment there were no swelling, bruises or signs that indicated an injury.
complained of pain on 12/16, the x-ray was ordered by the doctor on 12/16 and
completed on 12/16. Per Licensing policy The agency shall notify the Licensing Unit by the
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

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. The facility reported it completed the ELS on 12/17, unless
something has changed on the timeframe to report, we are still in compliance. Facility
reported to Licensing that the resident was currently on suicide precautions, assault
precautions no sharps, spork watch and line of sight 24/7 precautions. The facility reported
to Licensing that the resident was ordered to continue these precautions until behavior
improves. The facility to provide Licensing the nursing note for the resident regarding the
x-ray she received on 12/16. Facility provided documents via email to Licensing.
Documents uploaded.


summary: A resident reported that a staff member told the resident, “I will beat you with this walkie,” and then hit her on the side of the face with the walkie. The physical maltreatment allegation has been UNFOUNDED by Licensing. The verbal maltreatment allegation has been FOUNDED by Licensing. The facility was cited 905.4.g and 110.9.a for this incident.

raw_content:
AR KANS A S&S
DEPARTMENT OF

4 HUMAN
<a\ SERVICES

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: 025996
Date of Incident: 12/8/2024

Date Received: 12/10/2024

Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115

Incident Type: Dual

» who's in
native was involved in an incident on 12/9/2024 with i

fF (staff member). Clients were on their way back upstairs from dinner when
(client) were giggling walking upstairs from the cafeteria.

a

(staff) asked I what they were laughing at, JJ responded, "You!".
HE than responded, "girl find you someone else to play with your own age". | |
threatens [by stating, "I will punch you dead in your face". JJ responded, "I
will beat you with this walkie too". MM began laughing. I redirects

| stay out of it and says ic "you ain't going to punch me in my face", as
she goes to open the door for the other clients. | | responds, I will too". i opens

the door two clients walk out of the door as P| is standing at the door, HE states,
"if I wanted to I could" and ia responds, "I'm glad you don't hunny". As i:
walking through the door, she turns around and attacks J. on the camera, you can see

7 glasses fly off her face but cannot see the full incident. MB alleged that
hit her on the side of the head with the walkie.

Report Description:

has been suspended
until pending investigation is completed.

Interim Action Narrative: Staff placed on leave pending investigation. ICA was not
approved.

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

Licensing Narrative: 12/10/2024 Program Coordinator checked
Licensing Specialist Horton inquired of the permission to contact
the facility. fT granted Licensing permission to contact the facility. Licensing
inquired of the facility if there is camera footage for Licensing to review. Licensing
requested witness statements and inquired of the facility if this incident happened on
12/8/2024, why was it not reported on 12/9/2024? 12/11/2024, Program Coordinator
inquired about date of incident 12/8/2024 or 12/9/2024. Facility reported incident happened
on 12/8/2024 and was i 12/12/2024 Licensing is
scheduled to view camera footage 12/12/2024. Facility was cited on this visit for 905.4.9 and
110.9.a. This complaint has been FOUNDED by licensing. 12/16/2024, facility inquired
about an ICA for the staff member named in this complaint. 12/18/2024, Program
Coordinator spoke wi iii
this complaint. Program Coordinator followed up with facility on ICA. Program Coordinator
spoke with Sherika about submitting an ICA. 12/20/2024 Facility provided document
regarding Mandated Reporter Training to Licensing via email. 1/3/2025, per case is
still pending. Program Coordinator spoke with Ms. Williams regarding the ICA. Facility
informed that the case was on the outcome from the

regarding the staff member named is

before a decision could be
made to lift the ICA. Facility provided training documentation for the staff member named

in this complaint and it has been uploaded. 1/16/2025- Program manager reviewed the case
and lifted the ICA for the staff to return to normal job duties as the

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: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Arlene Horton
Person In Charge: Kaylynn Barnett
Record Visit Date: 12/12/2024
Home Visit Date: 12/12/2024

Purpose of Visit: Complaint Visit

Regulations Out of Compliance:

Regulation Number: 900.905.4.g
Regulation Description: The following actions shall not be used, including as discipline:

Finding Description: Licensing determined the staff engaged in using the threat of bodily harm towards a
resident when they stated, "I will beat you with this walkie too".

Action Due Date: 2024-12-27

Action Due Description: Staff MJ shall be retrained on appropriate communication and de-escalation
techniques with residents.

Comply Date:
Sub-Regulation Level 1 Description: Physical injury or threat of bodily harm;

Action Due Description: Staff JJ shall be retrained on appropriate communication and de-escalation
techniques with residents.

Regulation Number: 100.110.9.a

Regulation Description: Any owner, operator, employee, foster parent, or volunteer in a child welfare agency
shall immediately notify the Child Abuse Hotline if they have reasonable cause to suspect that a child has

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

Finding Description : J
Action Due Date: 2024-12-27

Action Due Description: Staff iijanc [I shall be retrained on mandated reporting.

Comply Date:

Sub-Regulation Level 1 Description: Been subjected to child maltreatment

Action Due Description: Staff J anc J shall be retrained on mandated reporting.

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time: 9: 30 a.m. — 10:30 a.m.

Census: 34
Licensing received a provider reported incident on 12/10/2024 for ELS Case #025996.

Licensing Specialist reviewed camera footage for this provider reported incident with Kaylynn Barrett and Sherika Williams
staff members of the facility. The ratio was 2:1. The incident occurred at about 5:28:34 p.m. and ended at 5:28:57 p.m.

This alleged incident was reported on 12 /08/2024. Licensing viewed the camera footage and observed the incident occurred
as the residents were walking up the stairs from the cafeteria on their way back from dinner. It was reported by the facility
that a staff member asked two residents what they were laughing at and one of the residents responded “You.” The facility
reported that the staff member responded with an inappropriate response of “girl find you someone else to play with your own
age.” It was reported by the facility that the client made a threat to the staff member with a comment of "I will punch you
dead in your face". The facility reported that the staff responded by saying "I will beat you with this walkie too". It was
reported by the facility that the resident and staff both made inappropriate comments to one another and the comments were
heard by the specialist during video review. Licensing viewed the resident walk through to enter another room when a pair of
glasses were viewed in the air, but the camera footage did not provide an angle to view what was taking place between the
resident and the staff member.

The facility will be cited for the following:

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

905.4.g “The following disciplinary actions shall not be used: (g) Physical injury or threat of bodily harm” due to the staff
member stating to the resident “I will beat you with this walkie too”.

110.9.a "Any owner, operator, employee, foster parent, or volunteer in a child welfare agency shall
immediately notify the Child Abuse Hotline if they have reasonable cause to suspect that a child has: (a) Been

subjected to child maltreatzen" ll

A/O is currently on leave pending the investigation.

Siaft NN and es
, Shall be retrained on mandated reporting by 12/27/2024.

Complaint findings:

109.1.g- Licensing was unable to determine if the staff struck a resident with a walkie talkie (engaging in
behavior that could be viewed as physically harmful to a child). -Unfounded

905.4.g- Licensing determined the staff engaged in using the threat of bodily harm towards a resident when
they stated, "I will beat you with this walkie too". -Founded

110.9.a
-Founded

Provider Comments:

CCL Staff Signature : Date: 12/12/2024

Provider Signature : Date: 12/12/2024

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

521 Visit Compliance Report

A RM AN SB ASE
) DEPARTMENT OF

V4 HUMAN
ot SERVICES
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

y

Licensee: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Arlene Horton
Person In Charge: Sherika Williams
Record Visit Date: 2/19/2025
Home Visit Date: 2/19/2025

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

- 521 for ELS Case #025996

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

Page 1 of 2

No in-person licensing visit was completed 02/19/2025.
Licensing received a complaint on 12/10/2024 for ELS Case #025996.

This complaint has been founded by Licensing.

***** Pursuant to A.C.A. § 9-24-406(e) (3-4): If you believe that the Department’s notice of noncompliance
is in error, you may ask for reconsideration. The request for reconsideration must be in writing and delivered
to the Department by certified mail within twenty (20) business days of receipt of the notice of
noncompliance. The request must specify the parts of the notice that are alleged to be in error, explain why
you believe those parts are in error, and include documentation to support the allegation of error. Once
received the Department shall issue a decision on your request within twenty (20) days after receipt of the
request.

Provider Comments:

05.1.0, 07 wend, 405.4.9 OnANO.F.a woe Wsth fpyroleol

CCL Staff Signature : Date: 2/19/2025

[antl Nabi

Provider Signature : Date: 2449/2025
PCat, uev> apes
J

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


summary: On 12/1/24, a resident reported to her mother that she punched a wall with her right hand. The resident’s mother emailed the therapist about the incident. An x-ray was ordered.

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: 025861
Date of Incident: 12/2/2024
Date Received: 12/3/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On 12/1/24 client reported to
her mother while mother was visiting that she punched a wall from the weekend with her
right hand. Mother emailed the therapist about the incident and the therapist let the
treatment team know of the situation. Medical Director emailed nursing to ask for an x-ray
to be ordered. An x-ray was ordered on 12/2/24 and results show "no acute fracture" Client
will be placed on suicidal precautions, until behavior improves.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/03/2024 Licensing Specialist Horton inquired of the facility nurse's
note, x-ray results, and email from parent. 12/04/2024 The facility provided documentation
to Licensing via email. The documentation has been uploaded.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident alleged that a staff member slapped him in the face. The complaint was UNFOUNDED by Licensing.

raw_content:
AR KANS A S&S
DEPARTMENT OF

4 HUMAN
<a\ SERVICES

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: 025778
Date of Incident: 11/26/2024

Date Received: 11/26/2024

Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115

Incident Type: Dual

Report Description: on 11/26/24 Client J age
| alleged that staff member slapped him in the face when client was
going to the bathroom to wash his hands. You see staff open door and stand in the doorway
and does not go towards the client, you hear a faint sound and then client starts to cry and
blame staff for "hitting him" and then the staff leaves area to grab another staff member

lwas suspended until investigation is over.

Interim Action Narrative: es suspended until investigation is over.

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

Licensing Narrative: Program Coordinator checked I IR Ti
11/27/2024, Program Coordinator checked 3 RT ZT 7 as of today.
Licensing Specialist Horton requested permission from J EEE to

contact the facility. Licensing Specialist inquired of the facility camera footage to be saved
for review, nurse's note, and witness statements. Licensing Specialist viewed camera
footage on 11/27/24. Licensing is not prepared to leave a finding at this time. 12/02/2024
Facility reported to Licensing that there were no witness statements. 12/3/2024- Licensing
received an ICA for the staff to work under supervision with no contact with the AV.
Licensing approved the request. 12/04/2024 Facility provided documentation, and the
documentation has been uploaded. 1/3/2025, ro iii 01/24/2005
Licensing found case# 025778 to be UNFOUNDED and worker can return to normal job
duties. 1/28/2025, documentation reviewed, case unfounded, and complete.

mh AR MANS AS
) DEPARTMENT OF

IN, HUMAN
= “1 SERVICES
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: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Arlene Horton
Person In Charge:

Record Visit Date: 11/27/2024
Home Visit Date: 11/27/2024

Purpose of Visit: Self Report Visit

Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time: 11:30 a.m. — 12:30 p.m.

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 1 of 2

Census: 35
Licensing received a provider reported incident on 11/26/2024 for ELS Case #025778.
Licensing Specialist reviewed camera footage for this provider reported incident with Ms. K. Barrett.

This alleged incident was reported on 11/26/2024. The staff and the resident appeared to be calm and
interacted well. The staff and the resident started talking with each other where their communication could not
be heard on the video for Licensing.

Licensing did hear the staff tell the resident to go to the bathroom to wash his hands. Licensing observed the
resident walk into the bathroom while the staff walked to the door of the bathroom. It appeared the staff stood
at the door and turned on the light, a noise was heard from the video, and then the resident could be heard
crying and screaming.

Licensing is not prepared to leave a finding at this time.

Provider Comments: Om ‘A712 ed neceived a phere call dhe neoidonk

urrlhat, Se nepoTttd Urat He Weoiolert tard Por Wak the cotald um ler
Mn 'h Unik dren We 40 Ris uerrothwr that She warverad at the pene LN
CCL Staff Signature: Qyeearat votaly, Warrwlenahinn — Date: 11/27/2024
eer DOC WU?
Wore.

Date: +4/27/2024—
\ 23 [au

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

BS ARKANSAS
) DEPARTMENT OF

IW) HUMAN
» “at SERVICES

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: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Arlene Horton
Person In Charge: Kaylynn Bamett
Record Visit Date: 1/24/2025
Home Visit Date: 1/24/2025

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Licensing received a complaint on 11/26/2024 for ELS Case #025778.Complaint has been UNFOUNDED by
Licensing. Worker may return to normal job duties.

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

Provider Comments:

CCL Staff Signature : Date: 1/24/2025

Date: 1/24/2025

lala 2

Brgy er Snee :

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

Page 2 of 2


summary: A maltreatment report received states that a staff member put his hands around a resident’s neck and performed an improper hold by holding the resident down with his arms and knee in the resident’s chest. The complaint was FOUNDED by Licensing. The facility was cited 109.1.g and 907.2 for the incident.

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: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Arlene Horton
Person In Charge:
Record Visit Date: 11/27/2024
Home Visit Date: 11/27/2024
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulation Number: 100.109.1.g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Finding Description: A male staff member was observed being inappropriate during camera review.
Action Due Date:
Action Due Description:
Comply Date:
Sub-Regulation Level 1 Description: Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.
Action Due Description:
Regulation Number: 900.907.2
Regulation Description: Child caring staff shall be responsible for providing the level of supervision, care, and
treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s
age, individual differences and abilities, surrounding circumstances, hazards and risks.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Finding Description: A female staff member did not provide adequate supervision to ensure safety of the
resident.
Action Due Date:
Action Due Description:
Comply Date:
Action Due Description:
Regulation Number: 100.109.1.g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Finding Description: A male staff member was observed being inappropriate during camera review.
Action Due Date:
Action Due Description:
Comply Date:
Sub-Regulation Level 1 Description: Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.
Action Due Description:
Regulation Number: 900.907.2
Regulation Description: Child caring staff shall be responsible for providing the level of supervision, care, and
treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s
age, individual differences and abilities, surrounding circumstances, hazards and risks.
Finding Description: A female staff member did not provide adequate supervision to ensure safety of the
resident.
Action Due Date:
Action Due Description:
Comply Date:
Action Due Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

Time: 10:00 a.m. – 11:00 a.m.
Census: 35
Licensing received a provider reported incident on 11/23/2024 for ELS Case #025730.
Licensing Specialist reviewed camera footage for this provider reported incident with Ms. K. Barrett. The
incident took place in the boy’s foyer unit with a ratio of 2:1.
It was reported on 11/23/2024 at around 4:53 p.m. the resident was observed laying and crawling on the floor
of the boy’s foyer. Ms. Barrett reported to Licensing that the resident was in the boy’s foyer area for being
disruptive. The resident could be heard on the video making loud annoying noises as he moved around in the
boy’s foyer.
Licensing observed the resident moving close to the staff member’s personal space. The staff member and the
resident were viewed having a physical altercation.
Another staff member did come in the foyer when the resident began yelling and screaming but failed to seek
additional assistance during the incident.
The facility was issued two citations. 109.1.g a male staff member was observed being inappropriate and
907.2 a female staff member did not provide adequate supervision to ensure safety of the resident.
Provider Comments:
CCL Staff Signature : Date: 11/27/2024
Provider Signature : Date: 11/27/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: Licensing performed a Personnel Records and Background Check review at the facility. No deficiencies cited.

raw_content:
521 Visit Compliance Report

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

Licensee: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Arlene Horton
Person In Charge: Fatima Stepps
Record Visit Date: 11/21/2024
Home Visit Date: 11/21/2024

Purpose of Visit: Personnel Records

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time: 9:00 a.m. to 11:30 a.m.

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

Page 1 of 2

Census: 38

Licensing Specialist Horton was assisted by Ms. Fatima Stepps and Ms. Shannon Rouse for personnel record and background check
reviews for United Methodist Children's Home Little Rock Campus.

Licensing observed the FBI, Arkansas State Police, Child Maltreatment, and verifications in each file.

Licensing Specialist reviewed personnel records and background checks for staff members during this visit.

Licensing Specialist Horton reviewed ten personnel. The ten were:

Personnel Job Title

A Avery, Jr. Behavior Instructor

D Barker Behavior Instructor

K Barrett RTC LR Director

Willie M Davis Behavior Instructor

A Garner Behavior Instructor

E Hayes Behavior Instructor Lead
M Johnson Behavior Instructor Lead
S McCraw RN

C Ragland Behavior Instructor Lead

M Young Teacher

DOB

Hire Date
11/13/2023
01/17/2007
10/21/2019
10/16/2023
09/03/2024
09/03/2024
03/08/2021
05/02/2022
04/17/2013
08/10/2010

All staff members’ backgrounds were complete, current, and met minimal Licensing standards.

Provider Comments:

CCL Staff Signature :

| ,

Provider Signature :

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

Date: 11/21/2024

Date: 11/21/2024

Page 2 of 2

doc_type: Compliance Report


summary: A Medicaid Inspection of Care review was conducted at the facility in response to a complaint received.

raw_content:
• Medication Administration Policy
• Medication Error Policy
• Medication Errors for the previous three months
• Quality Assurance Meeting Minutes
• Incident Reporting Policy
• Chart Audit Policy
• Chart Audit Tool
Summary of Findings and Resolution:
Below are findings based on a review of the facility’s policies, procedures, and documents and an extensive
conversation with the Corporate Compliance Specialist and a telephone conversation with the Nurse Manager. No
deficiencies were noted during the reviews.
• Medication Errors are reported to the Nurse Manager via a medication error form. That information is
then submitted to be reviewed at each quarter’s Quality Assurance Meeting.
• Upon review of the Quality Assurance Meeting Minutes for the prior year it was determined that there
has only been one medication error in the last year on November 29, 2023, at 11:00 a.m.
was ordered by the
physician. The nurse accepting the order did not transcribe the medication orders to the Medication
Administration Record, so the client did not receive either medication for a total of twenty-seven doses.
• The following is the process verbalized by the Nurse Manager that the nursing staff follow with all new
physician orders:
o The physician gives the new order to the staff via verbal order, telephone order, or by email. The
physician does not enter any of their orders in the electronic health record. The nurse manager
states that the physician must sign the orders within 48 hours of the original order time which is
per the Documentation of Time Frames Policy.
o The nursing staff have a nursing group email that is utilized to share the physician orders as well
as any other information regarding the clients’ care and behaviors. If the order is not received by
email from the physician, the nurse will email the order in a nursing group email which includes
the Nurse Manager as well as the staff nurses. There was an agency nurse working on one of the
units who AFMC staff spoke to regarding this process. They stated they did not have access to
this nursing group email therefore, they rely on another nurse to give them the updates regarding
each client.
o The nurse who receives the order or a nurse who has access to the nursing group email enters the
order into the electronic health record system.
o If the order includes a medication that is new, changed, or discontinued the order is entered into
a different computer system that houses the Medication Administration Record. The Medication
Administration Record is printed for each day and the nursing staff document on the printed
Medication Administration Record when administering medications. If medication orders are
received after the Medication Administration Record is printed, then all new medication orders
are handwritten on the Medication Administration Record.
o After the orders are transcribed onto the Medication Administration Record the outsource
Pharmacy (Omnicare) is called by the nurse and those orders are relayed to the pharmacist to fill
for each client. AFMC staff asked if the orders were only called via telephone or were they also
faxed since the order that is entered into the computer can be printed. The Nurse Manager stated
that they only “call in” the medication orders to the pharmacy. Omnicare fills the medication
order in a 30-day blister pack for each single medication with the client’s information as well as
the prescribed medication information labeled on each blister pack. If the medications are
discontinued before the 30-day blister pack is completed, then the pack is disposed.
o Once the client is discharged, the Medication Administration Records are scanned into the actual
health record.
o The above steps are not reflected in the facility’s Medication Administration Policy.
United Methodist Children’s Home – Little Rock, AR – IOC Report 2 | P ag e

• AFMC staff asked the Nurse Manager how the staff verified that each medication order was completed.
The Nurse Manager stated that they have a 1530 Form that is completed on the 15th and 30th of each month
and they have implemented a chart audit process that is done every 30 days on each chart.
o Upon review of the 1530 Form, AFMC noted this is a medication reconciliation form. This form
is utilized to suffice Regulation CFR 42 456.610(b)(1) which states the attending physician
reviews prescribed medications at least every 30 days in psychiatric facilities.
o Upon review of the new chart audit process, AFMC staff were informed that this process has a
form that is placed in the front of each chart. The Nurse Manager stated that chart audit tool also
has instructions for completion in the front of each chart. AFMC staff were unable to find the
instructions for the chart audit tool. Facility staff emailed the instructions the following day to
AFMC staff.
o AFMC staff reviewed several active client charts for this form and found that the Nurse Manager
is the one who is completing the chart audit process monthly. This form is a checklist to ensure
that the chart contains all the required forms upon admission as well as documentation is
completed as per the regulation requirements. There is one check box that states “Orders” and the
instructions state to “verify that orders in the computer have been noted properly.”
o AFMC staff asked the Nurse Manager and nursing staff that were on duty the day of the IOC if
there were any type of audits that were occurring every shift or every 24 hours to verify that all
orders were completed and all nursing staff answered that there were no other checks and balances
completed on charts to verify that all orders are completed, and all medications are given as
ordered.
Summary of Findings and Resolution:
• AFMC staff discussed with the facility’s Corporate Compliance Specialist the lack of evidence of any
type of daily chart check to ensure that all orders received from the physician were completed each day.
Daily chart checks are not only a nursing standard of care but considered the best practice. These chart
checks should be performed daily and noted in the chart once each chart check is completed. Auditing
charts daily ensure that all orders have been completed correctly and will prevent medication errors
from not only occurring but also continuing for days and even weeks before being found.
• Prevention of medication errors should include double check/triple check procedures. Nurses must
ensure that not only are the orders reviewed every shift but also communicate new orders to incoming
shift staff.
• Unsafe medication practices and errors are the leading cause of injury and avoidable harm in the health
care system. Safe medication administration involves the implementation of safe medication procedures
to bridge critical communication gaps from the time the order is given until the order is carried out. The
facility is encouraged to review all steps of the medication administration process and bridge any gaps
in their process of ordering, transcribing, dispensing, administering, and monitoring medications for
their clients.
• The more steps in prescribing medications will equal more risk of error. Ensuring the five rights of
medications as well as institutional policies related to medication transcription are followed will help
prevent medication errors. This facility is encouraged to review all steps they are currently utilizing for
medication administration and update their policy to reflect their current practice.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
United Methodist Children’s Home – Little Rock, AR – IOC Report 3 | P ag e

doc_type: IOC Complaint Report


summary: A report received states that the facility currently has no teachers on staff as of 9/6/2024. The facility is reportedly using substitutes to make up for the lack of teachers.

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: 025492
Date of Incident: 11/7/2024
Date Received: 11/7/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: A report was received that the facility does not currently have any
teachers on staff as of 9/6/2024. The facility is reportedly using substitutes to make up for
the lack of teachers.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: The program manager emailed the facility to inquire if the facility has
any teachers on staff. 11/14/2024- The program manager received a response from the
facility confirming they do not currently have any teachers on staff and are using staff who
have bachelor's degrees as substitutes until a new teacher begins. The new special
education teacher is set to begin her orientation with the agency on 11/25/2024 and they
plan to hire an additional three teachers. 11/20/2024- Further questions were asked by
licensing of the agency to include, how many classrooms are they operating, how are they
splitting up the resident to provide classroom instruction, what type of bachelor's degrees
do the staff have that are currently teaching the children, will the new special education
teacher be teaching all the children or will the other substitutes continue to teach under her
supervision, and how many children are on IEPs or 504 plans. The questions were answered
as follows: 4 classrooms are in operation, 2 classrooms per floor with 10 girls per classroom
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

and 9 boys for each of the other 2 classrooms, the staff has a bachelor's degree in Family
and Consumer Science and is in the process of obtaining a teaching degree, the new special
education teacher will be providing oversight of the other staff once she begins, and they
have 9 on IEPs and 2 on 504 plans. The facility is continuing to provide education to the
residents pending the hire of the new teacher.


summary: A resident was transported to Arkansas Children’s Hospital after she was injured in an unprovoked attack by a peer.

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: 024926
Date of Incident: 10/24/2024
Date Received: 10/24/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: on 10/24/24 Client ,
and was in line in the cafeteria about to transition upstairs. Another client
jumped out of her seat and attacked unprovoked. The other client hit and pushed
into the door and hit her head above her eyebrow on the door causing an inch
gash on her head. Staff quickly responded and separated the two clients. was
transported to the ER by mems due to the gash and bleeding and to receive treatment from
Arkansas Children's Hospital. Corrective action taken place. Clients will be placed on 10 ft
restrictions from each other, and nursing will monitor for further treatment.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/25/2024 Licensing Specialist Horton asked facility if there is
camera footage of this incident and requested nursing note and ACH documentation.
Licensing is scheduled to view camera footage on 10/28/2024. Camera footage viewed by
Licensing on 10/28/2024. See inspection. Nursing note has been attached. ACH
documentation has been attached.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that a staff member hit her in the mouth, causing her lip to bleed. The facility was cited 109.1.g for unprofessional conduct related to 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: 024668
Date of Incident: 10/8/2024
Date Received: 10/11/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: , who is an
and reported to her therapist that (staff) hit her in the
mouth. After reviewing camera footage, was going for the staff clipboard that was
left on the couch in the dayroom. Staff ran over to the couch attempting to beat to
the paperwork. grabbed the clipboard before could get the paperwork.
There were books and other items on the ottoman that tried to grab one of the
items and tried to get prevent her from getting the item.
pulled her away from the item while was swiping the item from the couch.
is on her knees due to crawling to the ottoman on the floor. While they are preventing her
from getting the item, some type of way she gets hit in the mouth. did not
intentionally hit her in the mouth like she reported. I only saw them going in for the item
while resulted in her lip bleeding. They took her to the nurse immediately. The therapist
The report
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 10/14/2024 Licensing Specialist Horton requested from the facility the
nursing note and if there is camera footage to review regarding J
. 10/21/24-Reviewed for licensing concerns. Facility visited and camera footage
reviewed. Facility cited 109.1g. 10/22/24-Training for both staff involved provided to
licensing.


summary: Licensing conducted a buildings and grounds walkthrough of the facility. No deficiencies cited.

raw_content:
521 Visit Compliance Report

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

Licensee: United Methodist Children's Home Little Rock Campus

Facility Number: 115

Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

Licensing Specialist: Arlene Horton
Person In Charge: Shannon Rouse
Record Visit Date: 10/8/2024
Home Visit Date: 10/8/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time: 9:15 am — 10:30 am

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

Page 1 of 2

Census: 38

Licensing Specialist Horton and Program Coordinator Slade completed buildings and grounds for Methodist

and was escorted by Shannon Rouse.

This is a two-level building occupied by female residents on the first floor and males on the second level.
Licensing Specialist viewed two classrooms, ratio was 2:8 and, 2:7. There was a class in the gymnasium, the
ratio was 2:7. On the girls’ floor there were residents and a staff member, ratio was 1:2.

Clients’ bedrooms, bathrooms, dayroom area, and dining area were all maintained.

Licensing Specialist reviewed the MAR on the residents listed below at the nurse’s station:

All initialed and up to date.

Provider Comments:

CCL Staff Signature :

Provider Signature :

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

Date: 10/8/2024

Date: 10/8/2024

Page 2 of 2


summary: A resident was injured after punching a mattress he had placed against the wall. An x-ray was ordered.

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: 024121
Date of Incident: 9/19/2024
Date Received: 9/20/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: ON 9.19.24 Client
was in his bedroom, Client got upset at a peer and began to punch
his mattress that he placed against the wall with his right hand. Staff heard the noise and
investigated. Asked him to stop, he complied. He was assessed by nursing. An x-ray was
ordered.
(1-2 weeks ) Client will be placed on suicidal and assaultive precautions,
line of sight 24/7, no sharps spork watch
Interim Action Narrative: Resident was assessed by the nurse and x-ray completed.
Resident will be placed on suicidal and assaultive precautions, line of sight 24/7, no sharps
spork watch.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concenrs.
Program Coordinator will request documenation for this incident. 9/24/2024, facility
provided the nursing note and it has been uploaded. Nursing note reviewed.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Reported to AR Child Abuse Hotline: A resident had a piece of paper and refused to give it to staff, and the staff member grabbed her arm and tried to remove the paper from her hand, scratching the resident with her nails. 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
R
Notice of Serious Incident
Case Number: 024061
Date of Incident: 9/18/2024
Date Received: 9/18/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Dual
Report Description: On 9/18 arrived at the RTC. To the
Director, Kaylynn Barrett, the stated, "I guess you know why I am here." The
Director denied knowing a report was made to the regarding one of
our residents and a staff member. reported that
had alleged that grabbed a paper
from her and scratched her with her nails. The Director inquired about the date it happened
and the did not have a date. The Director informed the that
was on the unit self-harming at the moment. Director retrieved from the
unit and escorted her to the Intake room. As we were walking down the hallway,
purposely ran into a male staff member and nudged him aggressively. As she passed the
Consultant, she stated, "What the fuck are you looking at?" The Director let in the
Intake Room and informed the that she would be in the lobby area to wait until
the interview was finished. Not long after the Director sat in the lobby, yellling was heard
from the Intake Room. The came out and stated that she was done. The
Director verbally requested that follow her back to the unit so she could get lunch.
refused to leave and sat in the chair with her arms crossed and a frown on her face.
The Consultant entered the Intake room and attempted to verbally get to return to
the unit. It was observed that had blood running down her arm. The
reported that picked at her arm in front of her and arm began to bleed.
was verbally disrespectful and hostile toward the Consultant and the
Another staff member was called to assist in escorting back to the unit. The
Director lead the to the lobby area where the observed the
Consultant and another BI escorting back to the unit. The reported
that said that she was mad because her mother gave her the jacket that was taken
from her. The Director informed the that the jacket was taken because
was using it to hide self-harm. The informed the Director that the report would
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

be closed out on this date. The requested the licensing agent's name which the
Director did provide. The also interviewed the staff member that had the
allegation. safety plan is for client to be on unit restriction until behavior improves, body
mark checks per shift by nurse to ensure safety, remove items that can cause harm or items
she can hide selfharm from. Suicidal Precautions, no sharps spork watch, finger food tray,
line of sight 24/7
Interim Action Narrative: Staff member was suspsended.
Maltreatment Narrative:
stated that she had a piece of paper and
staff member tried to take the paper from her. She refused to give it and asked why
the staff member wanted it. Staff then grabbed her arm and tried to remove the paper from
her hand and in the process of that the staff member dug her nails into the AVs arm and
hand. AV has fingernail marks/cuts on her arm that are starting to scab over. She did not
say what day this occurred on, but it was recent.
Licensing Narrative: Facility contacted Licensing in regards to this complaint and was
encouraged to enter it in ELS. Program Coordinator reviewed this complaint and will follow
up with the 9/19/2024, Program Coordinator requested more information via
email from and looked up more information in Per report the date of
the allegation is unknown. 9/23/2024, Program Coordinator spoke with and
received permission to contact facility via telephone. informed and emailed
Program Coordinator of case finding. Per case found unsubstantiated. Case
completed.


summary: A resident was injured while going down a zip line. The resident was transported to Arkansas Children’s Hospital for evaluation.

raw_content:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Program Coordinator requested a copy of the nursing note. 9/6/2024, facility provided
requested documentation.


summary: Client was transported to Methodist Behavioral Health due to her ongoing aggressive behavior, and while there she accused staff of choking her. This 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
R
Notice of Serious Incident
Case Number: 023715
Date of Incident: 8/29/2024
Date Received: 9/4/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Dual
Report Description: Client
Client was transported to Methodist Behavioral Health due to her ongoing
aggressive behavior. Client accused staff of choking her, a
was called and accepted. the referral number is: . Client was in the girls foyer
not following instructions. Client became irate and started to attack staff. Running around
the foyer lunging herself towards staff. Staff walked away to get away from client. Client
then grabbed her sweater that was on the floor, and began to wrap it around her neck. The
staff quickly tried to remove the sweater from the clients neck that was wrapped around
multiple times. The client accused staff member that he had choked her.
The staff was only removing the sweater. After review of camera footage from 3 supervisors,
it was determined that this did NOT happen. The reason the ELS is being sent today is
because we heard of the allegation.
Interim Action Narrative: ICA submitted and approved by licensing.
Maltreatment Narrative:
is currently
inpatient acute. She reported on 8/29/2024 she was chased around the facility before being
thrown on a couch and choked with one hand by " " at approximately 6-7pm.
is currently a staff member at Methodist Children's Home.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Facility contacted Program Coordinator about complaint and was
encouraged to enter complaint into ELS. Facility was informed to submit an ICA for the
staff member involved. Program Coordinator will schedule a day and time to review camera
footage. Program Coordinator requested permission to contact the facility. Permission
granted to contact the facility. Facility informed a decision on the ICA would be made after
camera review. 9/5/2024, Program Coordinator met with and reviewed
camera footage. Facility provided a copy or nursing note and reported that was the only
restraint that resident had been placed in on day of incident. ICA approved by Licensing.
9/26/2024, per case unsubstantiated. Case complete.


summary: During an incident with an aggressive resident, a staff member was observed grabbing the resident’s sweatshirt and pushing her to the ground.

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: 023810
Date of Incident: 8/29/2024
Date Received: 9/6/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description:
. On 9/3/2024, camera footage was reviewed of an incident with
On 8/29/24 was observed banging her head on the walls and floor. She
aggressively went toward a much younger peer, age 9. began going after, spitting
on, and attacking staff. At approximately 7:52pm was moving aggressively toward
(staff), slapping at was observed grabbing
sweatshirt and push her to the ground. A was completed was completed for this
incident on 9/3/24 at 3:17pm, confirmation number was given for the report. We
haven't received an email with the referral number or a decision if the report will be
accepted or not.
Interim Action Narrative: Facility called the .
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed camera footage of this incident for
another case and was informed of the call being made. Program Coordinator will
inquire if call was accepted. 9/19/2024, Program Coordinator followed up with the facility.
It is unknown to the facility if the was accepted. 9/23/2024, Program Coordinator
suggested for staff member named to be retrained. Facility reported staff member will be
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

retrained in CPI and documentation will be provided. 9/25/2024, Program Coordinator
inquired about training documentation. 9/26/2024, facility provided training
documentation, and it has been uploaded. 11/21/2024- Information received revealed that
the original report may have listed the A/O as another child at the facility. This is incorrect;
therefore another . 11/22/2024, Program
Coordinator checked for referral number. Referral was screened out.


summary: No deficiencies were noted during the complaint triggered Inspection of Care (IOC) review conducted on 08/08/24.

raw_content:
August 13, 2024
United Methodist Children’s Home
2002 S Fillmore St
Little Rock, AR 72204-4909
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:
United Methodist Children’s Home
Provider Medicaid ID:
Onsite Inspection Date: August 08, 2024
Onsite Inspection Time: 8:49 AM
A summary of the policies reviewed, and finds are noted below:
Inspection of Care Summary
Health and Safety-Policy Review
This additionally ordered inspection was triggered by a complaint against United Methodist Children’s Home.
Based on the nature of the incident, the following were requested for review:
• Policies
• Staffing Schedules and Daily Census from July 1, 2024, until date of IOC
• Personnel Records
• Client file of the alleged victim
Health and Safety Deficiencies:
Upon review of the site’s policies, procedures, and certification requirement, no deficiencies were noted.
Observations:
Upon arrival at the facility, AFMC staff was promptly greeted at the entrance by a United Methodist Children’s
Home receptionist in the main lobby. AFMC was immediately taken to a conference room where they were met
by the Compliance Director and the Corporate Compliance Specialist. AFMC staff received the completed and
signed consent form listing approval for access to the AFMC portal prior to arrival to the site visit. Facility staff
were given the Document Request Form, and AFMC staff discussed the requirements for the Inspection of Care.
A tour of the facility was completed with the Corporate Compliance Specialist and the Nurse Manager. Areas
toured included the boys’ and the girls’ units including the dayrooms and clients’ rooms, the seclusion rooms,
medication room, cafeteria, gymnasium, and outdoor courtyard. The facility environment was extremely clean,
well-organized, and appeared to be in good repair. Therapeutic group activities were in session on both units.
Staff were able to answer questions regarding the facility.

Upon entering the girl’s unit, AFMC staff noted one female adolescent client sitting quietly at a table drawing.
AFMC noted the only visible staff member present on the unit at this time was a housekeeper. AFMC staff
asked the Nurse Manager who was giving the tour if it was facility policy for clients to be left in the care of
housekeeping. The Nurse Manager did ask the housekeeper where the staff responsible for the client was
located, and the housekeeper stated the Behavioral Instructor (BI) was in the bathroom. The Nurse Manager
stayed with the client until the BI returned. Upon personnel file review it was noted that the housekeeping staff
was not properly trained to supervise clients. They did not have current CPR nor restraint and seclusion training.
While visiting with the facility nurse in the medication room, AFMC staff observed the alleged victim come to
the window of the medication room inquiring about getting treatment for a wound on their foot. Staff nurse
excused herself from the conversation to take care of the wound. AFMC staff observed the alleged victim take
flip flops off and lay across the furniture. No dressing was noted on the wound of their right foot.
Additional Health and Safety Policy Review:
Based on the nature of the incident, the following additional policies were requested for review:
• Incident Reporting Policy
• Critical Incident Logbook
• Skin and Wound Assessment Policy
• Nurse On-Call Policy
• Vital Signs Policy – Per facility staff, there is no policy regarding frequency of vital signs.
• Staffing Policy
• BI Job Description
• Nurse Job Description
Personnel Records – Licenses, Certifications, Training:
There was a total of nine professional personnel records reviewed. There were no deficiencies noted during the
personnel record review.
Clinical Record Review Deficiencies:
AFMC was provided with the alleged victim’s file for review.
The provider uploaded records which were then reviewed for compliance with licensure standards. Based on the
review of clinical components of licensure requirements, the following deficiencies were noted:
Record Rule Deficiency Statement Reviewer Notes
Number
RR0035188 IP Psych Restraint or seclusion intervention was Upon review of the restraint and seclusion
221.702 used as a means of coercion, discipline, log, numerous incidents of restraint and
convenience or retaliation. seclusion have been utilized on this client
since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych Physician order was not specific to the Multiple incidents of restraint and seclusion
221.702, acute incident requiring the use of have been utilized on this client since
221.703, restraints or seclusion. 24 admission. No restraint or seclusion
221.704 documentation submitted for review.
RR0035188 IP Psych A face-to-face assessment of the Upon review of the restraint and seclusion
221.703 physical and psychological well-being log, numerous incidents of restraint and
of the resident was not completed seclusion have been utilized on this client
within 1 hour of the initiation of the since admission. No restraint or seclusion
emergency safety intervention by a documentation submitted for review.
physician or other licensed practitioner.
United Methodist Children’s Home – Little Rock, AR – IOC Report 2 | P ag e

Record Rule Deficiency Statement Reviewer Notes
Number
RR0035188 IP Psych The order for restraint or seclusion does Upon review of the restraint and seclusion
221.703 not include the date and time the order log, numerous incidents of restraint and
was obtained. seclusion have been utilized on this client
since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych The start and stop times of the Upon review of the restraint and seclusion
221.703 emergency safety intervention were not log, numerous incidents of restraint and
documented. seclusion have been utilized on this client
since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych The name(s) of the staff involved in the Upon review of the restraint and seclusion
221.703 emergency safety intervention were not log, numerous incidents of restraint and
documented. seclusion have been utilized on this client
since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych The documentation of the intervention Upon review of the restraint and seclusion
221.703 was not completed by the end of the log, numerous incidents of restraint and
staff's shift. seclusion have been utilized on this client
since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych The intervention was not conducted Upon review of the restraint and seclusion
221.703 within the time limitations for the log, numerous incidents of restraint and
client's specific age. seclusion have been utilized on this client
since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych The order for the emergency safety Upon review of the restraint and seclusion
221.703 intervention does not include the length log, numerous incidents of restraint and
of time for which the physician or other seclusion have been utilized on this client
licensed practitioner permitted by the since admission. No restraint or seclusion
State and the facility to order restraint documentation submitted for review.
or seclusion authorized its use.
RR0035188 IP Psych The date and time the team physician Upon review of the restraint and seclusion
221.704 was consulted was not documented in log, numerous incidents of restraint and
the resident's record. seclusion have been utilized on this client
since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych There is no documentation of the Upon review of the restraint and seclusion
221.707 facility notifying the resident's parent(s) log, numerous incidents of restraint and
or legal guardian(s) as soon as possible seclusion have been utilized on this client
after a serious occurrence. since admission. No restraint or seclusion
documentation submitted for review.
RR0035188 IP Psych There is no documentation of a face-to- Upon review of the restraint and seclusion
221.709 face post intervention debriefing within log, numerous incidents of restraint and
24 hours after the use of restraint or seclusion have been utilized on this client
seclusion with staff involved and the since admission. No restraint or seclusion
Client. documentation submitted for review.
RR0035188 IP Psych There is no documentation of a post Upon review of the restraint and seclusion
221.709 intervention debriefing within 24 hours log, numerous incidents of restraint and
after the use of restraint or seclusion seclusion have been utilized on this client
with all staff involved. since admission. No restraint or seclusion
documentation submitted for review.
United Methodist Children’s Home – Little Rock, AR – IOC Report 3 | P ag e

Summary of Findings and Resolution:
Below in a synopsis of events for the alleged victim:
• Client admitted to United Methodist Children’s Home on 2024.
• On July 18, 2024, the client became upset after staff took their papers and began kicking doors in the
hallway. The client broke through the magnetic locking doors on hallway and attempted to break through
the magnetic locking doors into the boy’s unit. When the client kicked the door, the client’s toe got stuck
in the magnetic lock and client pulled foot away, injuring the fifth digit of right foot. Initially the client
refused assessment and walked around foyer of unit dripping blood and smearing blood onto walls and
floor. Once the client became compliant with assessment, the wound was assessed and cleaned by nurse
and reported to the APRN who ordered the client to be transferred to
for further evaluation and treatment via EMS. Client returned approximately 6.5
hours later after receiving studies revealing a
Client was placed on for wound. The client also was given an to wear to
protect wound from further injury. Once the client returned to the facility, the client was aggressive toward
staff and tried attacking staff members. Staff had to call the on-call nurse in to facility (licensed nurses
are on-call and not in-house from 10:00p.m. until 6:00a.m. each night) to assist with client behaviors. The
client removed the orthopedic boot and refused to wear it.
• Documentation daily after the client returned from the emergency department stated that the client was
non-compliant with the wound care and refused treatment numerous times. The client would remove the
dressing from the wound and refused to wear shoes throughout the facility. Staff documented numerous
times daily of encouraging the client to put flip flops on. Staff also documented daily that the wound was
cleaned and redressed due to the client removing dressing and that the client was dragging foot across the
floor, carpet, and furniture after removing dressing, and pulling scab off until wound would bleed.
• On July 31, 2024, the RN Nurse Manager assessed the client’s wound to the right fifth toe. In the
assessment, the nurse manager stated that the wound appeared to be worse and had dehisced at wound
edges with greenish-yellow exudate present in wound with some areas of dark discoloration/black
appearing tissue without odor. Tip of right fifth toe appeared red and inflamed. The APRN was called and
updated with wound pictures sent. APRN instructed nursing staff to send the client to
for further evaluation and treatment. The client stayed at for wound
care and and returned to the facility on 2024. Upon returning to facility
the wound had steri-strips applied and covered with dressing. The client continued to remove the dressing
numerous times daily and continued to pick at the wound.
• On August 7, 2024, staff documented the client’s right fifth toe appeared dirty with pieces of hair noted
in the wound. There was dried up yellow tinted discharge and the wound had discolored, darkened areas
suggestive of dead tissue/necrosis observed. The nurse cleansed the wound, removed debris as much as
possible, applied multiple steri-strips firmly, and covered the toe with two bandages. Nursing continued
to document the client’s noncompliance with leaving the dressing on, picking at wound, and not wearing
appropriate shoes.
Below are findings based on review of the critical incident reports:
• Upon review of the critical incident report logbook, AFMC staff noted that there were missing times,
missing details, and follow-up was not documented.
• Critical incident reports were reviewed for the alleged victim during the timeframe of received complaint.
Below is a summary of reviewed incident reports and outcomes:
o On July 16, 2024, at 8:15 p.m. per the critical incident report, the client got upset after staff would
not allow client to take books to their room. The client began yelling and screaming and becoming
aggressive as staff put the client’s books back in the coping skills closet. The client pushed staff
while he was walking out the door. A staff member backhanded the client hitting the client in the
face. Other staff intervened, removing the client from the dayroom. The client continued to be
aggressive toward staff and staff had to hold the client away from the staff member who had the
client’s books. The client continued to hit and punch at staff and hit the staff member holding the
books in the face injuring their nose. The client grabbed their books and kicked their way through
the doors of the unit. The client received a chemical restraint. The client was assessed by the nurse
and was found to have no markings or bruises.
United Methodist Children’s Home – Little Rock, AR – IOC Report 4 | P ag e

o On July 18, 2024, at 6:15 p.m. per the critical incident report, the client asked to be excused during
dinner. The client entered the hallway and crossed over into the dayroom grabbing their book.
The staff told the client that they couldn’t have their book until dinner was over. The client got
upset and refused to respond to the staff, yelling profanities at the staff. The client was kicking at
the magnetic lock door and was able to get to the elevator area. The client heard the elevator
coming and kicked the elevator door. The client then started kicking at the magnetic locked door
to enter the foyer area. While kicking at the door the client cut “pinky toe” on right foot. The
nurse was informed of the incident and the ambulance was called.
o On July 22, 2024, at approximately 6:45 p.m. per the critical incident report, the client got off
task because they couldn’t find their books. The client began to dump out Legos, markers, color
pencils, etc. The client began making verbal threats to attack the staff and throwing objects at
staff. The client threw dominos causing them to break. The client then began to make threats of
cutting with the broken dominos. The client refused to pick up the spilled items and pushed
through staff and began kicking at the door. The client was able to be redirected to sit down and
calm down.
o On July 31, 2024, at 1:08 p.m. per the critical incident report, the client was in the cafeteria and
the client was trying to step on another client’s heel, hitting his “pinky toe” on the edge of the
table. The nurse was notified and put peroxide and a band-aid wrap on the client’s toe.
o On August 4, 2024, time not documented per the critical incident report the client got upset
because he couldn’t play the video game. The client went into a “tantrum” screaming. The client
was observed picking at toe and trying to twist skin off making it bleed.
• AFMC staff spoke with one of the direct care nurses regarding the above incidents. The nursing staff
member was able to verbalize much more details about the above incidents. Nursing documentation also
provided much more detail regarding the client’s behaviors as well as detailed wound assessment and
follow-up care including the client having to be transferred to for continued
care on 2024, and 2024. AFMC staff spoke with the nurse manager and the BI supervisor
who both relayed that the critical incident reports are only completed by the BI. When asked if an incident
occurs that isn’t witnessed by a BI but instead a licensed nurse who fills out the incident report, and the
nurse manager and BI supervisor both stated the BI will still fill out the critical incident report. When
asked if any training was given to staff on how to fill out a critical incident report, the supervisory staff
stated no. AFMC staff did speak with the Corporate Compliance Officer regarding the lack of important
details such as wound assessments, missing times, and no follow-up.
• AFMC staff noted the Critical Incident Report Policy implies that a witness to the incident will fill out
report. The policy states the narrative section will contain a detailed description of the incident and the
use of presumptive descriptors (i.e. patient was aggressive) will not be used. The Policy also states that
the staff will complete the follow-up section and what information must be included.
Below are other related findings based on requested policies:
• AFMC staff requested daily staffing per shift and client census from July 1, 2024, until August 8, 2024.
Facility staff were unable to provide adequate documentation of staffing for each shift and what the census
was each shift to determine if staffing was appropriate based on facility’s staffing policy.
• AFMC staff requested a copy of the On-Call Nurse Policy for review. The facility does not staff an in-
house licensed nurse after 10:00 p.m. until 6:00 a.m. The on-call nurse is required to be available by phone
and must respond to the facility within 30 minutes of receiving a phone call if needed. The on-site staff
will contact the on-call nurse regarding any medical concerns, restraints, or need for physician input on
client behaviors. Once having received a call, the nurse is required to advise on-site unlicensed staff on
medical issues and if needed respond to the hospital to assess or provide care for the client(s).
• AFMC staff requested a copy of the Vital Signs Policy. Routine vital signs to include temperature, heart
rate, respiratory rate, blood pressure, and pain scale is a way to assess for infection and psychotropic
medication reactions. The facility does not have a policy stating the frequency of how often or when it
should be appropriate for vital signs to be taken. AFMC staff visited with the facility nurse who stated
vital signs are taken upon admission and once weekly. Facility nurse also stated the staff try to take all
weekly vital signs on Mondays but sometimes they get missed or the client refuses, so they will continue
daily to try to obtain vital signs, but there is no written standard.
United Methodist Children’s Home – Little Rock, AR – IOC Report 5 | P ag e

Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
United Methodist Children’s Home – Little Rock, AR – IOC Report 6 | P ag e


summary: A Medicaid Inspection of Care review was conducted at the facility. No deficiencies were cited.

raw_content:
August 13, 2024
United Methodist Children’s Home
2002 S Fillmore St
Little Rock, AR 72204-4909
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:
United Methodist Children’s Home
Provider Medicaid ID:
Onsite Inspection Date: August 08, 2024
Onsite Inspection Time: 8:49 AM
A summary of the inspection and any deficiencies noted are outlined below.
Inspection of Care Summary
Facility Tour:
Upon arrival at the facility, AFMC staff was promptly greeted at the entrance by a United Methodist Children’s
Home receptionist in the main lobby. AFMC was immediately taken to a conference room where they were met
by the Compliance Director and the Corporate Compliance Specialist. AFMC staff received the completed and
signed consent form listing approval for access to the AFMC portal prior to arrival to the site visit. Facility staff
were given the Document Request Form and AFMC staff discussed the requirements for the Inspection of Care.
A tour of the facility was completed with the Corporate Compliance Specialist and the Nurse Manager. Areas
toured included the boy’s and the girl’s units including the dayrooms and client’s rooms, the seclusion rooms,
medication room, cafeteria, gymnasium, and outdoor courtyard. The facility environment was extremely clean,
well-organized, and appeared to be in good repair. Therapeutic group activities were in session on both units.
Staff were able to answer questions regarding the facility.
Upon entering the girl’s unit AFMC staff noted one female adolescent client sitting quietly at a table drawing.
AFMC noted the only visible staff member present on the unit at this time was a housekeeper. AFMC staff
asked the Nurse Manager who was giving the tour if it was facility policy for clients to be left in the care of
housekeeping. The Nurse Manager did ask the housekeeper where the staff responsible for the client was located
and the housekeeper stated the Behavioral Instructor was in the bathroom. The Nurse Manager stayed with the
client until the Behavioral Instructor returned. Upon personnel file review it was noted that the housekeeping
staff was not properly trained to supervise clients. They did not have current CPR nor restraint and seclusion
training.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirement, no deficiencies were noted.

Personnel Records – Licenses, Certifications, Training:
There was a total of twenty personnel records reviewed, four (25%) professional and sixteen (26%)
paraprofessional. There were no deficiencies noted during the personnel record review.
Observations:
Upon completion of the onsite portion of the Inspections of Care, AFMC staff reviewed the final document
request form with the Compliance Director and the Corporate Compliance Specialist 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 was 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 on each unit in the dayrooms during group activities. Clients appeared engaged
in ongoing activities. Staff were calmly interacting with clients and providing a therapeutic environment that
was conducive for learning and treatment therapies.
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 complaint 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.
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. The
facility nurse also verbalized the process utilized when a client refuses medication. 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 was 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
United Methodist Children’s Home – Little Rock, AR – IOC Report 2 | P ag e

doc_type: IOC Report


summary: A resident complained of right hand/wrist pain. An x-ray was ordered.

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: 022772
Date of Incident: 7/23/2024
Date Received: 7/24/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On July 23,2024
complained about Right Hand, wrist, and arm discomfort to the
nurse. Client was assessed by nursing and noticed small swelling. Client stated she closed
her arm in a door on accident. An X-ray was ordered and the results are:
No new precautions are ordered for this. She was ordered ibuprofen
for discomfort from the physician.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/24/24- Licensing reviewed for concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident and peer were involved in an altercation. Staff intervened.

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: 022746
Date of Incident: 7/22/2024
Date Received: 7/23/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description:
was off task in the group room by running grabbing staff ankle,
yelling and curing. ran over to the chair where (peer) was sitting and
hit the chair. then got on the floor and began to destroy and throw puzzle that
was on the floor everywhere. became upset she asked (staff) to get
when she was throwing her puzzle pieces. gets up pushes into the chair, then
kicks her, kicked back and then hits (staff) and
(staff) intervenes by getting in between and
.
. Our corrective action plan is placing
and on 10ft from each other, changed room to a different hall, and they will no
longer be in the same group.
Interim Action Narrative: Staff intervened and .
Residents will no longer be in the same group. Both residents were placed on 10 feet
restriction.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns. Progam Coordinator will follow up with facility regarding any injuries.
Facility reported that no injuries were sustained.


summary: A resident injured his ankle participating in a group structure activity. The resident was evaluated, and an x-ray was ordered.

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: 022733
Date of Incident: 7/20/2024
Date Received: 7/22/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description:
was participating in a structure activity with peers in the
game of "guess the behavior/skill", as he was acting out a behavior for his team, he injured
his ankle. stomped on the floor demonstrating a behavior for peers to guess the skill
and came down wrong on his right ankle. Nurse assessed ankle and the on-
call MD ordered for him to get an x-ray. X-ray was completed
Interim Action Narrative: Resident was assessed by the nurse and an x-ray was ordered by
the physician.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident injured his foot by kicking a door while upset. The resident was transported to Arkansas Children’s 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
Notice of Serious Incident
Case Number: 022698
Date of Incident: 7/18/2024
Date Received: 7/19/2024
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description:
. On 7/18/24, became upset due to wanting his book while eating
dinner. had a hard time accepting no, he went into the hallway for no apparent reason.
He was laying on the floor, then he threw his shoe at the ceiling and just being off task
yelling at peers in the cafeteria. He then kicked threw the door into the elevator vestibule.
He was kicking the door continuously. It appears while kicking the door he hits his feet on
the metal mag lock. toe immediately start to bleed, staff took the client to the unit for
the nurse to assessed. was transported to Arkansas Children's Hospital via MEMs due
to needing stitches and further evaluation. He returned to the facility later that
night/morning. was diagnose with
Interim Action Narrative: Resident was assessed by the nurse and transported to ACH via
MEMS.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns. Program Coordinator will inquire about safety precuations and
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

facility reported that resident was placed on assault precautions and unit restriction.
8/1/2024, CEO called Program Manager and informed her that resident was taken to the
ER due to blood being seen through his sock. Resident was admitted into the hospital due
to an infection of the injury. Facility will provide Licensing with documentation from
7/18/2024 to 8/1/2024. 8/19/2024, Program Coordinator attempted to review the resident's
files for nursing note for 7/18/2024. The electronic file had not been updated. Program
Coordinator will request documentation from Nurse McCraw. Facility provided
documentation for this case.