State Agencies & Govt'l Affairs-Senate and House
Video
Transcript
3 documents
Machine transcript
May contain errors. Verify important quotations against the official video.
About transcript accuracy
- Source
- Whisper
- Model
- ggml-large-v3-turbo.bin
- Processing date
- October 5, 2026
Representative Jimmy Gazaway
Unverified
1:00
Thank you.
sees is hereby called to order chair sees a quorum first order of business are comments by the chairs i've spoken with senator flippo and i think we've agreed to waive our comments at this time and i'm going to yield my time to representative in it which means the first order of business is a consideration of a motion to approve the october 8th 2025 minutes all of you should have a copy of those and so i'll give you an opportunity to review those quickly they hear a motion to approve motion to approve your second all those in favor say aye
all those opposed guys have it minutes are approved first item on the agenda today is a discussion of a death that occurred at the southeast arkansas human development center we have representatives here from the department of human services specifically chief of staff Laurie McDonald and the director of the division of developmental disability services Jennifer breeze and I'm sure I said that incorrectly we appreciate the two of you being here you guys would come to the table
if you would each state your name
Chair
Unverified
3:03
for the record hi good morning Melissa Weatherton I'm the division director over specialty populations Jennifer
Speaker 14
3:10
Brzee director of the division of developmental disability services hey good morning Laurie
Speaker 15
3:15
McDonald chief of staff DHS all right thank you
Representative Jimmy Gazaway
Unverified
3:19
all for being here this morning I think you understand the purpose behind why we we called the meeting and so I want to begin by giving all of you and and whoever of the three of
you would like to begin an opportunity to address the situation and the the incident that resulted in this
Speaker 14
3:50
meeting being called today. Yes, thank you, Mr. Chair. So we have prepared a summary overall of what the HDCs do for our state. And then specifically, I know you had asked some questions about the recent death
at the Southeast Arkansas Human Developmental Center. We are also, you
Speaker 22
4:10
know, we feel very, I mean, it's just been a really hard time. Do you want me to just read through this? Let me ask that one time. Okay.
Speaker 24
4:24
Chairman Gaisway, I know that the handout
Chair
Unverified
4:29
we got you that has the summary, we do not want to reread this to you guys. if you
Speaker 28
4:38
specifically want us to comment on the recent settlement?
Representative Jimmy Gazaway
Unverified
4:43
So I think it would be helpful if you would just address the incident that occurred, the death at the southeast facility that is the reason why we're here today, the reason this meeting was called, if you'll address that incident specifically. And then if you want to give some information generally about human development centers, what your policies and procedures are, what training that you have in place. And then when you're finished making
those statements, I'm going to give Representative Ennett an opportunity to make a statement as well.
Speaker 27
5:16
Okay, sounds good. I'm going to let Director Brzee, we have it prepared to
Speaker 14
5:26
have an overview on Mr. Moore. Zachary Moore was born December 31, 2003, and admitted to the Conway Human Developmental Center on May 28, 2019. He was then transferred to our Southeast Arkansas HDC on February 12, 2025. Zachary suffered from severe intellectual disability with limited speech as well as autism spectrum disorder.
Zachary passed on September 7, 2025, at the age of 21 years old. Zachary died after being restrained in a prone position on the ground by multiple Southeast Arkansas HDC staff members for an extended period of time at approximately 13 minutes. Zachary was unresponsive when they ended the restraint at 6.52 p.m., and it is doubtful that he was breathing. Despite this, a Southeast Arkansas HDC nurse administered a chemical injection to Zachary some 12 minutes later at 7.04 p.m.
It is not until after this chemical injection that staff attempted to perform CPR or any other life-saving procedures. Zachary had a history of aggressive behaviors towards staff and others. We entered into a settlement with the family for $725,000. We terminated 13 staff members as a result of this, and we changed the administration at the Southeast Arkansas HDC.
As part of directed plan of corrections that we are currently under with the Office of Long-Term Care, we also brought in a consultant that we've been working with for the last several months to review all of our policies and procedures, do retraining of all our staff on multiple levels, as well as conducted a root cause analysis of the event. As of to date, at least five individuals of the 13 have been criminally charged with felony
Speaker 22
7:32
charges, and there is an ongoing criminal investigation into other staff, from
Allison Guthrie
Unverified
7:46
my understanding. We just wanted to share an overview about the HDCs. So
Speaker 14
7:51
the Human Developmental Centers, which we call HDCs, are intermediate care facilities and are operated by the Department of Human Services Division of Developmental Disability Services. They are licensed by the Office of Long-Term Care on behalf of the Centers for Medicare
and Medicaid Services, or CMS, and subject to continuous monitoring and surveying, we are also fully accredited by the Council on Accreditation of Rehabilitation Facilities, or CARF. As of March 30, 2026, we had a total of 819 residents across all five HDCs. On the prepared document that you all have, we've listed out several statistics of our population of individuals with intellectual and developmental disabilities showing that our population has very
complex medical behavioral health as well as developmental disability needs and require varying levels of supervision and medical care and interventions for multi-disciplinary team of professionals including physicians, APRNs, psychologists, speech, PT, and OT, and other specialist. 368 or 44 percent of our residents are functioning at the profound level of deficits and adaptive functioning, meaning that their IQs and cognitive abilities are very low.
308 or 38 percent of our residents are classified as having fragile health conditions. 561 or 68 percent of our residents have to have a modified diet, meaning they are completely dependent on staff to chop or puree their food and every meal that they eat to minimize choking risk and constantly have to monitor food intake to ensure proper nutritional needs are being met. 681 or 81 percent of our residents have a mental or behavioral health diagnosis along with their
intellectual and developmental disability. 438 or 54% of our residents have complex behaviors that lead to aggressive, destructive, or self-injurious behaviors. 368 or 45% of our residents are completely non-verbal, meaning they have to rely on behavioral cues or special communication devices to interpret their needs of those residents. 406 or 50% of residents have a history of current or active seizure disorder.
318 or 38% of residents have vision impairment or blindness. Also provided is a chart of the last 10 years of the deaths that we had across all five HDCs. Just noting that Conway does have the greatest amount because it is the largest. And so Conway, we house over 400 individuals there, which is almost three times larger than our other HDCs.
They also have a 24-7 infirmary that's certified by the Department of Health. All of our sickest residents that require enhanced medical care are at Conway. They also admit the most medically complex residents, which allows us to meet residents with IDD needs in lieu of often sending them to a nursing home level of care. A hundred percent of our deaths are investigated by our trained HD staff, as well as reported to the Office of Long-Term Care and the Attorney General's Office via our incident reporting system and email communication.
Additionally, we have procedures and processes in place. We have an HDC mortality review committee to specifically ensure that current HDC practices and standards are maintained, prevent deviations of care from practices at the HDCs to the extent possible, evaluate current HDC care processes for effectiveness, and to present any issues to our DDS Quality Improvement Committee. Our committee reports, This committee reports to the Quarterly Quality Assurance Committee as required by Arkansas Code 2010-2201-2204.
Members of the Mortality Review Committee also include representation from the DDS Director's Office, the DDS Quality Improvement Committee, and is comprised of medical professionals that are not connected with the resident's original care, the HDC Superintendent, and HDC Registered Nurse. The required medical records are reviewed by medical professionals not involved in the resident's care, and a conclusion is made that the quality of care was followed or that the quality of care was not followed
and recommendations are made to the specific HDC or, if applicable, to all HDCs during the quality committee. And with that, I will take questions. All right.
Representative Jimmy Gazaway
Unverified
13:02
Thank you for that. At this time, Representative Ennett, you're
Representative Denise Jones Ennett
Unverified
13:13
recognized. Mr. Chairman, members of this committee, I'm here today because a young man named Zachary Moore is dead, and the state of Arkansas was responsible for his care when he died.
On September 7, 2025, Zachary, a 21-year-old with intellectual disabilities, his mother, Angela Stevens, who is here in the audience, she was told that she was supposed to be in some dialogue with the department to see how we can make these things preventable for the next person, and she told me that she was not updated on these meetings, and so I would like to ask about those as well.
Let's see. I am a mother. I have a 17-year-old son with special needs, and I am his advocate every day. This issue is not abstract to me. It is personal, and that is exactly
why I'm here asking questions for every family in the state, and they deserve answers.
Allison Guthrie
Unverified
14:20
Thank you. Thank you, Representative Innit. I personally was not aware that we needed
Speaker 14
14:25
to involve the parents, but I'm more than happy to speak to the mom and include her. We're still going through a lot of work with our
consultants and our directed plan of correction with the Office of Long-Term Care, and so there's
Speaker 22
14:39
just a lot of things going on right now, but more than happy to
Representative Denise Jones Ennett
Unverified
14:53
include her and talk to her. You're recognized. Does the Department of Human Services currently have a written standardized
Speaker 14
15:03
restraint protocol? We do, and that's something the consultants are also looking at and working with our teams on.
I'm very proud to report that the work with the consultants has identified even better opportunities for training and helping our staff understand better ways to deescalate without needing those restraints as often. So where are you in
Representative Denise Jones Ennett
Unverified
15:26
the process? Is it on the website that can we look and see what those procedures are?
I don't believe that they're publicly posted but be
Speaker 14
15:37
more than happy to share those with with y'all. We are aiming aspirationally to
Speaker 22
15:42
have our work wrapped up with the consultant
group and finishing out the rest of the directed plan of correction by the end of June at which time the office of
Speaker 14
15:54
long-term care will come back out and validate everything that we said we were going to do. Okay I
Representative Denise Jones Ennett
Unverified
16:00
have another question so when you employ the employees can you walk me through how you
train your employee I'm sorry I'm getting nervous um can you walk me through on how you
train the employees to deal with restraints so we we hire
Speaker 14
16:21
people to become certified nursing assistants they go through a two-week phase class which includes CPI so crisis prevention institute is the program that we use to do physical holds on individuals then we also do a lot of Extensive training on our mechanical strength restraint device that we also use during that two-week phase class as well as
behavioral interventions and de-escalation processes and procedures during that two-week phase class and then in that phase class period these individuals also Receive a lot of what we call on-the-job training and so they're going into houses with mentors and Individuals really you know learning what the job is and getting to know our residents And then CNA school is after that, so it's an additional certification and training program where we have our own nurse trainers on site that do all of the things that you have to do to become a CNA, which leads to these individuals being able to then take that test for a CNA certification.
Senator Scott Flippo
Unverified
17:34
Senator Filippo. Thank you, Mr. Chairman. So, Jennifer, I just want to go back to something that Representative Innes said. I did not know that this young man's mother was in the audience today, and my sympathies and prayers are with you, ma'am, and your family. You mentioned that this lady whose son was recently passed, she was told by somebody in DHS that she was going to be involved in a meeting or in discussions about something, and, Jennifer, you're saying that you're not aware of that, correct? Correct. I was not made aware of that.
Okay. Okay. So how does that work when somebody in your department tells a family member who just lost a loved one and it does, is there like a policy procedure that you all have for when somebody dies in state custody, you know, custody, that this is exactly how we handle this from A to Z? Because you've got a grieving family here that obviously wants to know, and I think that's, any one of us could relate and identify with that. But it's hard for me a bit, like, it's hard for me to sit with somebody when you don't know what's being said by the people underneath you. When it comes to loss of life and the state's culpability or role that somebody employed by the state might have within that, this is really problematic.
Speaker 70
18:50
This is really, really problematic. I mean, this lady
Senator Scott Flippo
Unverified
18:53
who has just lost her son has now got to go through, and one person that works for this state is saying one thing, and the person above them obviously is saying, I am unaware of that. Because I want to stop right now and let you all answer, what is your policy when somebody dies in state custody and you're communicating with their family, their next of
Speaker 21
19:13
kin, what is that policy? I don't, thank you, Senator Filippo, appreciate that for sure. We do have
Speaker 22
19:18
a specific procedure for how we notify families, and I can get that to y'all.
Senator Scott Flippo
Unverified
19:23
I do not have that with me today. Did this lady follow that procedure? As far as I'm aware, but I would have to. lady this person followed that procedure this employee you know who's visited with
Speaker 22
19:38
the family with this young man's mother did they follow that procedure it's something I'll have
Senator Scott Flippo
Unverified
19:41
to look into and I will get back with you for sure so here's now a problem you knew this meeting was coming today this is something that if I'm this would be like a ground zero of where I'm starting what communications have we been
Speaker 27
19:59
having with this family if i may because we were involved in active litigation the communication um as of recent
has been between legal counsel when when we are involved in active litigation which we have been and we just entered into a settlement um we do not have open communication with our with our team with families okay so is so I
Chair
Unverified
20:22
that in what meeting they were referring to but I will assure you that we will get to the bottom of this
Speaker 78
20:30
yeah um because I don't think that it's isolated to this specific
Senator Scott Flippo
Unverified
20:35
case either that I'm aware of instances in my
district where things have been said by somebody employed by DHS that somebody above them says no we are not in a position to do that or we can't do that, why would this person say that? I mean, like, there needs to be this very solid policies, procedures, and that so that if that is not followed, there absolutely needs to be some, you know, some consequences to the person that breaks said policies and procedures. I mean, again, I know you ladies would be good people who truly care about, you know, the people of this state and the children of Arkansas, and I don't want to sit up here
and convey anything differently, but there has to be accountability. And I'm not saying that somebody that violates a policy procedure in every aspect deserves to lose their job or some significant, but it needs to be addressed, and the public needs to know that it's getting addressed and that we're not going to accept that because I can't even imagine in the time when you've lost a child how to watch my parents lose their only daughter, and it was not relevant to this. But it's a tough time for a parent.
And so it just concerns me when they're hearing one thing from state government, and then, you know, we have a meeting and we're hearing a different, which is I'm unaware. So, you know, I'm just disappointed that we're here today having this meeting, and nobody can tell me whether or not this conversation even took place or even what the context of the conversation
Representative Julie Mayberry
Unverified
22:07
was. We just don't know. Thank you, Mr. Chairman. Representative Mayberry, you're recognized. Thank you. So the majority of the care for
the person, the individual in the HDC, is by the CNA.
Would you agree with that statement? I would. Okay. Can you tell me what the
Speaker 22
22:26
CNAs are making? Our CNAs start out at $39,000 a
Speaker 42
22:29
year. Okay. the that's actually a little higher than what I thought
Representative Julie Mayberry
Unverified
22:37
you were going to say so that that that does make me feel a little better but it brings to the issue that most often the care for individuals with disabilities in the
state are being provided by some of our lowest paid people working in the state of arkansas and so a lot of families and and and i'm not i'm trying to kind of make a point that this is not just a one issue thing there is a bigger problem that we all as legislators here need to understand we all we have a role in this because families when they have the child
who has these profound aggressive behaviors they sit on a waiting list now that we we eliminated in 2020 but now there's 2,000 people sitting on this waiting list waiting for care in their own home so that they can keep their loved one with them but they're waiting for that care now and so many are having to make the decision, I can't provide that care in my own home, and so they then put
them in a human development center for that care. And even when you have the care at home, if you get off this waiting list and the money is there for the care, you can't find the caregivers. You can't find a direct care provider that you trust to have in your home. As one who has had a daughter at home, I went through six, six people in my home to provide care.
They wouldn't show up on time. They didn't provide the right care. I can go through a long list of things. so this is a real problem and I believe a lot of it starts with the funding that we're giving your department to provide this care and I realize I'm trying to get to a question but I'm also trying to make a point that there's a bigger issue and we as legislators have an opportunity to try to fix some of this maybe in 2027 by providing a way for people to get off of a wait list so they can
keep their child at home if that's what they want but then also to um make sure that we're compensating the people who are providing the care enough so that we can reach out to higher quality folks um would you agree with any of that or do you have anything to add to that thank you representative mayberry the direct care providers what i i believe lee johnson had a bill
that that is looking at the rate of what we're paying those where are we
Speaker 10
26:00
with that we are it was a rate report for services provided underneath our past
Speaker 27
26:05
program for certain behavioral health and idd services and we are moving forward with implementing that rate report in January. Okay. And you
Representative Julie Mayberry
Unverified
26:17
are in agreement that there's 2,000 waiting on this list for care right now. You can confirm that with everybody? Yes. Okay. And any idea how quickly
any of those people would come off that list? Because that list was at zero in 2020, and now we're up to 2,000. So if we don't do something to help those families, that list is going to continue to i mean in five years we've gone up 2 000 so another i mean is that kind of
Speaker 22
26:52
the rate that we're seeing so right now the last uh group to be first on the waiting list became eligible in july of
Speaker 88
27:02
2023 okay would you agree that there is a shortage of quality workers to provide the
Speaker 22
27:07
care for these individuals and that is what our providers and parents continue to to share with us yes okay thank you representative woldridge
Representative Jeremy Wooldridge
Unverified
27:25
you're recognized thank you mr chair and i'd like to join my colleague senator flippo by extending my sympathy and my prayers to the family who are here and I can see obviously that the agency is grieved by this tragedy and I appreciate you being here
so you were talking about deaths across all facilities every year and obviously you know that got me thinking about natural cause of death versus an incident like this how often does something like this happen or take place is that something I mean I would think to Senator Flippo's point you've got a process in place hopefully that process is rarely to never used but how frequently are there accidents like this that are taking place thank you representative
Speaker 21
28:09
Wooldridge so across the 10 years we've identified four cases
Speaker 22
28:12
where it appears the quality of care was potentially not met and happy to talk to those as much as I can okay well I appreciate
Representative Jeremy Wooldridge
Unverified
28:23
that and follow up if i can mr chair um when you look at those four incidences are they all restraint related incidences i know you said you utilize cpi and i didn't know if it was cnr or cpi or pmt or what you utilize from a
Speaker 22
28:45
restraint practice who authorizes restraint um so c cms
But in real time, in practice at the facility, it's the professional staff. So emergency holds can be done, you know, to immediately prevent someone from hurting themselves or hurting other people. But then you're quickly notifying the nurses and the administrator and the doctors who's on call. And what shift did this occur on? I believe this occurred in the evening. So it was around 6 p.m. 6 p.m. so
Representative Jeremy Wooldridge
Unverified
29:17
what is the staffing situation look like there are they working 12-hour shifts are they working
Speaker 22
29:23
three i'm not i'll have to look but our nurses do work um some you know different shifts sometimes they work 10 hours sometimes we have some 12-hour shifts and then uh oftentimes in the evenings it is more of an on-call status so there's not a requirement for there to be a nurse on site 24-7 But, of course, given our population, we try as best we can to have RNs on site. I do know in Zachary's case there was an LPN that was present during the intervention,
and there was communication with the RN, the APRN. Okay. Well, and again, you
Representative Jeremy Wooldridge
Unverified
30:00
know, I'm not here to point fingers after the fact. This is a tragedy, and I'm grieved by it as well as I know you are and every member sitting up here. But I do want the agency to learn from it, to Senator Filippo's point. there needs to be an ironclad process because when a family suffers a tragedy like this the state creating a second tragedy with how we handle the process is unacceptable and i think that the agency can do better there and i hope that the family will accept our apology on however this has
manifested itself and that we can move forward and improve on that so thank
Representative Jimmy Gazaway
Unverified
30:37
you for being here today thank you. Representative Beatty, you're recognized. Thank
Representative Howard M. Beaty, Jr.
Unverified
30:42
you, Mr. Chair. I'll echo the comments of my colleagues. We're deeply moved, and you
have our sympathies for the loss of your son. My question's for, and I hope I say your name right, Brise, and the question's also for Ms. Weatherton. How long have you been at DHS? How long have you been in your current role,
And what are your specific duties related to
Allison Guthrie
Unverified
31:08
those areas? Thank you, Representative Beatty.
Speaker 22
31:11
So in June, I'll have been with DHS for two years. I don't know how much of my background you want to hear, but I'm a licensed certified social worker with the state of Arkansas. Our division not only oversees the five human developmental centers operationally wise, we oversee the CES waiver and autism waiver. We act as subject matter expert on all IDD programs and services, including autism services,
OTPT, speech that are from a habilitative nature, and the private ICF world, as well as the
Chair
Unverified
32:00
state-run ICFs. Hi. Hi. Yes, sir. Thank you. I've been in this role for two and a half years. This current position oversees the specialty populations, which is over the Division of Developmental Disabilities, the Office of Substance Abuse and Mental Health, the Division of Aging and Behavioral Health, and also over our licensure unit.
so the Division of Provider Services and Quality Assurance. Follow-up, Mr. Chair. Now, my question
Representative Howard M. Beaty, Jr.
Unverified
32:35
is, I heard you speak about a consultant that's been hired to come in, and it was for
policy review, training. So my question to either one of you, whose responsibility is it between the two of you for policy review and training
Speaker 14
32:58
So, specifically in regards to the consultant's work, they have very directed actions that
Speaker 22
33:06
they were required to take under the Office of Long-Term Care, and so they're fulfilling those actions as well as continuing to help us in several different ways. On the policy side, each HDC has their own quality assurance committees and leadership that review policies, but a lot, and I mean, almost all of them relate back to policies
specifically around what the Office of Long-Term Care and CMS require when it comes to the operations and running of an intermediate care facility.
Representative Howard M. Beaty, Jr.
Unverified
33:40
Okay, I'm going to ask that again, make it real simple. Which one of the two of you review
the policies to make certain that the policies are proper, and who reviews the
Speaker 22
33:56
have not been directly involved in the policies that were created prior to my entering DHS.
Speaker 14
34:03
And then the trainings, also, I have not been directly involved with prior to my role. I
Chair
Unverified
34:10
would say the short answer is each, the division directors are ultimately responsible for their
Speaker 27
34:16
division. And I supervise four division directors. I'm actively engaged, but that's how the chain goes up. And we are working on each division director signing off on the policy. And then it comes to me if we need assistance. So
Representative Howard M. Beaty, Jr.
Unverified
34:31
for two, two and a half years, policy's been in place.
I looked through some of the data on deaths. It's so small, I thank goodness for technology with the phone that I could zoom in and see. But it looks like we're having 15 to 20 on an average each year in deaths. And granted, I guess you guys do the review to decide if it was quality of care or if there was something else outside. I'm certain there's an outside agency that also reviews that. But do you think maybe it would have been prudent to review the policies and procedures and make certain that the training and everything was up to date on the employees that are in these centers?
Chair
Unverified
35:11
So Jennifer, I think she's just getting a little nervous. Jennifer Reed did the way that they do the Mortality Review Committee about a year and a half ago. So that's that independent committee that has MDs on it that have nothing to do with the person's care that reviews every single death at the HCC. And before this committee, we thought we were coming on the 24th, I asked and personally reviewed every single death that the mortality reviewed.
we had 190 people pass away the last 10 years um and out of 190 four were flagged
Speaker 27
35:51
as possibly not meeting quality of care one of course being uh Mr. Morse of course and then unfortunately y'all remember that we had an individual pass away at Boone Bowl he was on that list um there was two others um that we are looking at it had nothing to do with restraints it actually had to do with the way that their food was chopped up and so um but yes I I think there there are
processes in place in terms of long-term care comes out attorney general comes out if they find something to be suspicious um obviously criminal prosecution comes out when it's something that they feel like was criminal like it was in this case um and then this mortality review committee which is an independent body reviewing them and making policy recommendations their role really isn't to say you did something specific to that death the role is really to say how did we miss what was the miscommunication that this person did not understand that this needed to
be pureed right like why why did they miss it and so that's the purpose of that committee um and so we don't ever want anybody to daw because of something that we because of a quality of care issue at one of any of our seven facilities that we run um so yeah this um this is awful i'm sorry that somebody said to her that we would reach out to her and we didn't and i'll speak to her after this and last question mr chair
Representative Howard M. Beaty, Jr.
Unverified
37:25
so when when was the last time the policies were reviewed for this center and when was the last
time that those 13 plus members received training on restraints we'll get that get you that information see that's what we don't want to hear you knew what you were coming here to talk about and you heard the frustration from senator flippo you've heard the frustration from other members we show up at these meetings the only reason we're having this meeting is dhs and you come in here
and you don't have information for us and you can say you're sorry and you you can you can try to
say the right things but in the end you're not even prepared for this meeting so i don't even
Chair
Unverified
38:18
know why we're asking questions um i'm through senator beady if i may i i can oh i'm sorry
Speaker 27
38:23
um i can confirm that when the young man died in boonville that all policies across all hdcs
were reviewed in 2021 and I can also confirm that the staff at HCC's historically received annual training on restraint that's mandatory all right I have a couple
Representative Jimmy Gazaway
Unverified
38:48
of questions I want to just kind of drill down on this specific incident that we're talking about been a lot of talk in generalities Um, but I, and I realized there was a little synopsis that was given at the beginning
about the incident that brought us here today, but this was a death that occurred at the Conway facility. Is that correct? No, the Warren facility. That's right. I'm sorry. The Warren facility and the name of the individual who is deceased. Zachary Moore, Zachary Moore. What was the cause of death? What was ultimately determined to be the cause of death? i don't know
i believe it was asphyxiation all right and and to be clear the your answer was i believe it was asphyxiation as representative debate he said you guys have known for a long time we were going to have this meeting today this is the central issue that we came here to talk about specifically Mr. Moore's death why it
happened how it happened the policies that are in place how it can be avoided in the future and I asked the cause of death and it's I believe it was asphyxiation do you not know
Speaker 27
40:18
i have not looked at the death certificate um we're not getting a lot of information right now due to the ongoing criminal investigation and the charges the felony charges it's hard
Representative Jimmy Gazaway
Unverified
40:27
for me to believe that a state agency who was charged with the care of this individual who died in your custody you would not know the official cause of death it's just hard for me to believe but you
Chair
Unverified
40:40
don't know I have not seen the death certificate for the official cause
Representative Jimmy Gazaway
Unverified
40:49
of death no sir okay you believe it was asphyxiation you know my understanding is is that we were here to discuss the policies surrounding restraints and how they're used in these facilities is that correct that's what we're here to discuss today in part was the policies surrounding restraints and their use in the human development facilities is that correct yes sir that's correct all right and
what specific policies or procedures that are to be used in the human development facilities when you're dealing with individuals like mr moore were violated in this instance so our consultant group has done a
Speaker 22
41:35
root cause analysis that we are happy to share with the group well i'm asking i'm not trying to
Chair
Unverified
41:48
the the young man should never have been put in a in a prone position during a restraint that is the long and the short of it it was completely against policy the staff were not trained on such and in fact they were told not to do that so that was the root of what occurred the chemical injection should never have been given at the point it was given and they never should have put him in a prone restraint
Speaker 27
42:13
and that's why you saw that 13 people were immediately terminated okay so I
Representative Jimmy Gazaway
Unverified
42:20
thought I heard you say two things that the staff were told not to do that
Chair
Unverified
42:24
but then that they didn't know not trained they were not they were trained not to put people in that type of restraint so they were specifically they they went against what we trained them to do in the cpi training furthermore not only was that done incorrectly when a when a client is calm not not just at an hcc any long-term care facility when a client is calm you do not then come in and give someone a chemical restraint so two major violations occurred that night and that's why you
Speaker 27
43:00
saw so many people terminated because there were so many people involved in kind of the different aspects that should have been either not doing what they were doing or supervising differently so that was the large numbers behind
Representative Jimmy Gazaway
Unverified
43:13
it okay well let's talk about those different aspects specifically give me every one of the aspects where there was a failure in this particular case to follow training and proper procedures
Speaker 14
43:31
yeah go through that that's detailed so through our root cause analysis process it was identified that mid managers and professional
staff did not provide constant oversight of the incident we also
Speaker 22
43:44
did not implement policies and procedures on restraint by the DSPs, which are the direct support professionals in nursing. There
Speaker 14
43:55
were other individuals that witnessed the incident. Sorry, this was part of the fishbone diagram, and so translating it verbally is a little bit different.
This was some of the issues that happened, which also contributed to this. So there was a helmet he was supposed to have on his head. It wasn't used. There was a humane wrap, which is our physical restraint. It arrived late to the incident. When it did arrive, the wrap was the wrong size, and staff did not use a mat to put down on the floor for the individual. Problems were that the individual could not communicate verbally
and that the staff did not communicate among themselves about the incident oversight and responsibility. The nurse physician did not communicate to the continued need of the medication. Other contributing factors, the use of floating staff, so staff not regularly assigned to that house. Staff were inattentive. Staff did not respond as trained. The fact, as Melissa stated,
that he was restrained in a prone position and then implementation of the restraint was not appropriately monitored. There was also found to be improper use of medical equipment,
Representative Jimmy Gazaway
Unverified
45:38
specifically the AED device. Okay. So it wasn't just one failure to follow policies. It was multiple. Yes, sir. Involving numerous levels of individuals in the chain of command of care,
if you will. Is that right? That's right. All right. Now you're saying that these individuals had been trained and just failed to follow the training? That's correct. Okay. And then I understood you to say that there are some of these individuals that are criminally charged currently. Is that right? That is
Speaker 14
46:14
my understanding. And what are they charged with? I believe it's manslaughter, although I can't
Representative Jimmy Gazaway
Unverified
46:20
speak to the technical legal. Okay. So recklessly causing the death of another person.
Okay. I mean, to be clear, there's a clear distinction between manslaughter and murder. No one's saying that anyone did this intentionally. They're saying that their conduct was reckless in causing the death. Is that correct? From my
understanding, yes, sir. Okay. All right. How many individuals are charged
Speaker 22
46:48
with manslaughter in this case? There are currently five, but my understanding is they're still looking and investigating. Five.
Representative Jimmy Gazaway
Unverified
46:57
Wow. All right. And, um, so we know where the failures were in this particular case. It sounds like, sounds like you guys identified a lot of violations. What are you doing
Speaker 14
47:15
to ensure that this never happens again? We're attacking this from multiple
Speaker 22
47:19
fronts, including enhanced retraining, looking at everyone's behavior support plan. So that is a list of activities and interventions very specific to the individual making sure those are very
person-centered and very easily understood by the CNAs and the staff caring for the individuals we are doing like we've mentioned before extensive retraining on multiple fronts with our staff on seclusion restraints on abuse reporting on behavior interventions on autism that we can provide that list to you if requested for sure. We also replaced the leader of the Human Developmental Center with a
new superintendent who has been doing a fantastic job and our consultants have been extremely helpful in being on site almost every week helping monitor. They're doing extensive checking to make sure that the training sticks. So not only are they helping lead the trainings, they're going on campus and walking around and just offhandedly getting people and saying, hey, do you remember what this meant? Or do you remember how to do this? And so we're putting multiple things in
place to verify and recheck that the training is sticking in folks' heads. And they're there, yeah they're there multiple times every week oh yeah sorry also also DDS leadership has been on site
Representative Jimmy Gazaway
Unverified
48:58
all right representative in it you're
Representative Denise Jones Ennett
Unverified
49:02
recognized thank you mr. chair was the mortality review board dismantled before the death of Zachary Moore so it hasn't been
Speaker 14
49:11
dismantled just letting you know that we reorganized that so our mortality review committee prior to and I believe it was during the summer was comprised of some community partners and the group had just gotten really large so what we did is a reorganization we reinstituted our behavioral consultation committee which is comprised of community partners then we implemented a specific quality review committee
for all five hdcs where we're tracking specific measures in all avenues in all realms of quality as well as creating a public forum to discuss policy and procedures together and that is where our mortality review findings will be brought before that committee to implement policy program changes as needed. The mortality review committee itself has basically stayed the same so it's that core group of people along with that medical professional who was not originally involved
Speaker 53
50:20
in that resident's care to have a more unbiased opinion. Okay I was
Representative Denise Jones Ennett
Unverified
50:26
a little confused so was it dismantle or was it not this? No, it was not dismantled. Okay. Um, I have another question with the wrongful
loss. I hope I'm saying this right. Wrongful loss, um, death, um, settlement. Sorry. How much money has the state of Arkansas paid out on these wrongful death settlements? This
Chair
Unverified
50:51
is the only, um, I'm sorry, there's been two in 10 years. Um,
I think I just saw it post. It just went through Claims Commission and got approved. I'm not sure it's
Speaker 27
51:02
been paid out of our account yet on this one, to be honest. The other one was from the death in
Chair
Unverified
51:10
Boonville in 2020, and we ended up paying $400,000. That one actually went to trial and was litigated, and that was what Claims Commission and the
Speaker 27
51:20
legislative body came that that was the price of
Representative Denise Jones Ennett
Unverified
51:24
the payout. Okay, I have another question. So with that $400,000-plus, if that was invested in getting some quality training for these
employees, would that be justified if that
Speaker 156
51:35
can happen so we won't have these deaths occur? So, Representative, this
Speaker 157
51:40
is money we pay that leaves our department. We paid them
Chair
Unverified
51:45
$400,000. We paid a family $400,000, and we'll pay this family $750,000. money going out our door yeah well I guess what I'm trying
Representative Denise Jones Ennett
Unverified
51:55
to say is so we can prevent deaths in the future is it more prudent to have a good protocol
together so this won't happen again so we don't have to pay out this amount of money to the families yeah but
Chair
Unverified
52:16
more importantly regardless of the money just so we don't have people pass away yes this is a priority for us for
Representative Jimmy Gazaway
Unverified
52:31
sure representative wayne long you're recognized thank
Representative Wayne Long
Unverified
52:34
you mr chairman i was wondering what's
an autopsy performed to to come up with
Speaker 22
52:42
a cause of death i'm not sure there may have been we don't we don't get a copy of that autopsy unless the
Speaker 165
52:52
long i can answer that question an autopsy was performed um and and i want to go back something that you had asked representative guys away um on mr moore's death certificate his manner of death was listed as a homicide cause of death is physiologic physiologic stress associated with struggle
and prone restraint and just a couple more clarifications there have been six individuals charged with manslaughter
Speaker 164
53:20
and neglect of a vulnerable person out of Bradley County my second question
Representative Wayne Long
Unverified
53:27
was how many total staff were involved in this as an incident so 13 okay it just seems sort of odd that none of these professionals thought to perform any sort of resuscitation is like that
correct that no one performed resuscitation or at least not initially when it was discovered that the was not breathing
Speaker 20
53:54
yeah so they did start CPR just too late how late was
Chair
Unverified
53:58
it again 13 minutes okay thank you very much senator hammer you're
Senator Kim Hammer
Unverified
54:08
recognized thank you mr. chairman and to the family want to express condolences but
also please understand some of the questions that may be getting asked today or to give us a holistic view while you may feel that
it might not be relevant to your loved one's death it does help us understand things at a larger scale so please take that in consideration first question the litigation regarding the death because there is a settlement that part of it is concluded is that correct so anything is being said today could not change what has already been agreed upon as far as payout to the family correct correct but there is an
active active investigation going on with regards to criminal charges and the things that are being said in here today now in the open maybe could be achieved through depositions but now that the things that have been said here today those will be able to be accessed by prosecutors to be used in their
Chair
Unverified
55:15
case am I correct in that I mean I see what you're
Senator Kim Hammer
Unverified
55:23
saying Senator Hammer yes I mean this is now public so okay the regarding the consultants they
were brought in at what time frame in relation to the death of the loved one They weren't actively present on the campuses at the time of the death. They were brought in afterwards. Is that
Chair
Unverified
55:49
correct? So since it's a long-term care facility, the Office of Long-Term Care investigates these on behalf of the federal government. They have multiple choices when they go in and something has happened, like a death.
in this instance they came in and said we aren't going to allow you warren htc to come up with your own plan we're going to come in and self-direct your plan and we're going to tell you exactly what we think you need to do to to not this not to happen again and so they came in and in there what they call a a directed plan of care that they gave
Speaker 27
56:31
warren they said you must do the following things and several things and one of those was immediately hire a consultant
to come in do this root cause analysis figure out how this happened and then have them work with you to change all of these policies not only at Warren but then implement these policies across the other
Senator Kim Hammer
Unverified
56:54
five other four sorry okay the And I guess part of it is the
consultant then was directed by the federal government, not by
Chair
Unverified
57:04
y'all? They're directed by long-term care, and they're our federal surveyors.
Senator Kim Hammer
Unverified
57:09
Okay, and I'm just wondering, were they involved prior
to the situation happening that they did not sound alarm bells prior to this event happening so that maybe this could have been prevented? Were they just not present? Was what they were being offered ignored? Or through your testimony today, it wasn't that it wasn't there. It was just that it wasn't being followed.
Chair
Unverified
57:36
We have to report across all of the facilities.
So many things are called reportable events, incidents, accidents, way beyond just deaths, right? And they're out all the time. So the CMS, OLTC surveyors, this was just a day, Senator Hammer, where, you know.
Senator Kim Hammer
Unverified
58:01
Perfect showroom, everything went wrong. All right. But did they, were they not sounding the alarm bells prior to this? So all the policies that needed to
be in place that the consultants would have been involved in prior to the event happening,
The policies that the consultant said you guys ought to be safe. If you do these things those things were all in place in yes, sir Okay. All right A couple of quick ones the labor pool in the area where it happened in order to have adequate staffing Is the labor pool in the area where it happened sufficient to be able to meet the needs of that facility there?
Speaker 14
58:47
so we are working to recruit individuals and in Warren specifically it is and has been one of our areas where we've been challenged in hiring CNAs okay and and
Senator Kim Hammer
Unverified
59:08
so does that contribute to the overall ability of the facility not being able
to fulfill what the consultants and the policies that are in place so as
Allison Guthrie
Unverified
59:24
identified by their root cause analysis it means we have to use sometimes
Speaker 14
59:29
float staff to help with coverage in those float staff may not be as familiar with the individuals and that's something we're actively working to address okay and and is that
Senator Kim Hammer
Unverified
59:42
systematic across all the other locations as well or is this uh are there others that are in the same similar situation because if it could happen at one because a labor pool is not
sufficient to meet the needs as required by the policies substantiated
by the consultants then are the other facilities also at risk for the same thing
Speaker 14
1:00:07
so i can just speak to float staff we have to maintain coverage in our our residents have varying levels of supervision needs and so when people are on vacation or call in sick we do have to utilize staff from other houses
Allison Guthrie
Unverified
1:00:23
to cover and make sure that our individuals
are supervised adequately okay and
Senator Kim Hammer
Unverified
1:00:29
then last question DHS attorney not
here today is that am I observing it right and if if not why is the DHS attorney not here to sit with y'all to answer questions there are y'all the
Chair
Unverified
1:00:52
mean honestly we didn't know we
needed to bring one of them okay with us okay all
Speaker 138
1:01:02
right that's it for now thank you representative Rye you're recognized yes sir thank you
Representative Johnny Rye
Unverified
1:01:12
sir you know this has probably been coming home for a long time and I just can't understand it it looks like that you've got all these stats but we don't have a coroner's report I mean it looks like that would
Speaker 27
1:01:29
have been sent to the people on the committee no miss McDonald corrected that just a second ago because she got some information from our our office correcting that do
Speaker 164
1:01:47
you want to talk about it yeah representative Rob we we wouldn't have that
Speaker 165
1:01:52
so what I had said is that his death was there was a death certificate issued obviously and his manner of death that was listed was a
homicide I'm sorry I'm just not exactly sure where you're going with this well Well, I'm
Representative Johnny Rye
Unverified
1:02:10
just saying that, you know, anyone that dies, you get a coroner's report from that. And I would have thought that all of the things that we've mentioned throughout this whole meeting would have been included with a
coroner's report to let everyone know
Speaker 164
1:02:32
aware of us ever receiving a coroner's report on anything like this.
Representative Jimmy Gazaway
Unverified
1:02:37
I'm just not aware of that. Thank you. Thank you, sir. Thank you Mr. Chairman. All right just to follow up on Representative Rye's question I think his point is and you know as I asked earlier with the central issue here that we're here to discuss today is Mr. Moore's death and the policies and procedures that are in place that surrounded that at the time and what's changed since then and so on and so forth and so central that discussion is how did he die what was the cause of death and what was the manner of death the manner of death
as you repeatedly say, was homicide. That's a general category. You know, was it an accident? Was it natural causes? Was it or homicide? I mean, the manner of death is a very general classification, but the cause of death is the specific, you know, exactly the mechanism that caused the death. And she's discussed that as well. I think we know what that is. But the point is, is that we needed to know that in order to really have a discussion around what policies and procedures you had at the time or that you have now to prevent this specific type of thing from happening again.
Okay. And I think that's what Representative Rice is getting at there. I'm not speaking for him, but Representative Beck, you're recognized. Thank you, Mr. Chair. Just listening
Representative Rick Beck
Unverified
1:04:01
to the conversations, I want to, you know, in almost
all of our emergency, like I've been on fire departments and so on and so forth, you know, there's always someone who's in charge, and this is the one person that's in charge.
Now, that might change in the incident depending on who shows up later or whatever. And I'm not being critical here. I'm just asking the question, is there actually, when this occurred, was there somebody there who was in charge that the other 13 people eventually were involved with this would have looked at and said, okay, what's, you know, maybe not suggesting what should have happened because your testimony that this shouldn't have been done and this shouldn't have been done. and that it seems like there were a lot of things that shouldn't have been done
and there were other people there that maybe didn't feel like they either had the authority to tell that person don't do that or do this or whatever. It just seems like there was a lot of confusion that resulted in this. So does your policy have like a chain of command at an instant? This is the person, it's not named by name, but the person in this position would be charging this and doing that. Is that in your actual policies?
You mentioned root cause analysis, and that's the first thing, root cause analysis,
Speaker 22
1:05:32
who was in charge? Thank you, Representative Beck. Yes, 100% that is what our root cause analysis identified is that the staff on scene did not know or did not feel empowered to be in charge of the situation. And so what we have done is clarify that and we've created crisis teams so that there's exactly what you're saying, clear chain of command and who is saying what and who is
Representative Rick Beck
Unverified
1:05:58
leading the situation. Just a brief follow-up. So you're saying that no one felt like they were in charge. So, are you saying then, in this incident, there were people there who, your statement kind of implies that there were people there who maybe thought maybe this was not a good idea or maybe we should be doing that, but they didn't feel authorized to make that
Chair
Unverified
1:06:28
call? I think there's a difference in what Director Brzee is saying.
Ultimately, I want you to know that the person in charge of each HTC is the superintendent, and they hold a nursing home administrator license. And at this facility, after this incident, that person was terminated. Second, every single shift has a shift coordinator, so they know who's in charge. I think what was happening, you know, we went back and looked at the footage and went through all of this. there was you know there was different levels involved in this there was cna levels there was
like a cna supervisor there's an lpn there was an rn in and out and at some point um there was a supervisor for the house and i think you know what they were explaining in this root cause analysis was when you have all these different levels if you have an rn is because they're the highest clinician are they now in charge right or is the house supervisor always in charge i mean so it was that it's that kind of detail not that they didn't know who was the person on charge for the campus but they weren't running in and out of this house right all these other people were um and so
you know that was one of the things we watched of why didn't that person step in right there and stop this well when you when they talked to him it's like well there was a was a person in the room that was a higher level than me well they were a higher level than you because we were having a medical emergency and we've got people coming in and out of this house
Speaker 27
1:07:59
so it's that retraining of going okay the supervisor's in charge of the house but when something like this occurs you know this is the person that you look to this is the person that's going to run this type of
emergency situation and so that's what the consultant is doing and
Representative Rick Beck
Unverified
1:08:15
just one so with your statement just yes or no your new policy now
has the chain of command very it's laid out as to who would be in charge
Chair
Unverified
1:08:28
in situation they're drafting it that's right in
Representative Jimmy Gazaway
Unverified
1:08:31
an emergency situation all right
Representative Ryan A. Rose
Unverified
1:08:35
thank you representative Rose you're recognized thank you mr. chairman along with the rest of my colleagues, to Mr. Moore's family, sincerest condolences. It's terrible and I'm very
sorry. For the benefit of the committee, when Representative Gasway asked about the cause of death, I simply did a Google search with his name and cause of death and found the information that was publicly available in multiple news reports of what that cause of death was. So I'll echo Representative Beatty's frustration, and I've experienced this in other committees, where we come before all of us together to have a very serious conversation, and very
basic preparation hasn't been done. So that's frustrating. And I don't know if that's a defensive tactic to avoid some of the harder questions, or it's some other reason. But I want to reread what the news report listed. And I apologize to the family for having to reread this. But Moore's death certificate listed his manner of death as homicide and his cause of death as physiologic stress associated with struggle and prone restraint. And again, for the benefit of the committee,
physiologic stress is a prohibited form of torture by international law in the Geneva Convention just to kind of establish a baseline. Something else that was said or was unknown, we heard from different individuals at the table here that it was five individuals who were charged, and thank you, Ms. McDonald, you corrected the record and said that it was six. And how many individuals were fired? Was it 12 or was it 13? 13. Okay, because we've heard both of those as well. And so this causes challenges for those of
us sitting at the table to know whether we're getting the full truthful or accurate information from this case. And looking at the report that you provided us, I see that it's just over 10.5% of what would be your labor force. Those positions are currently unfilled. So in the eight months since this event took place in September. Have you dramatically changed policies on quality and quantity of hiring
so that incidents like this
Speaker 27
1:11:12
don't happen again? - We've had some pretty extensive conversations that many of y'all have been involved with around hiring and retaining staff at the human development centers and the use of on-call, the high utilization of on-call contracts. So I think I saw Representative Painter in here earlier about some of those conversations
around how we're hitting those contracts right now because we're not, we don't have as many FTEs as we need to not hit those contracts. So in short, yes, we are having extensive conversations around what that looks like. We have drafted a plan. We're in the internal approval processes around that plan currently, and we hope to be able to
Chair
Unverified
1:12:06
publicly make that plan available.
Representative Ryan A. Rose
Unverified
1:12:09
So we're at eight months since that happened, a little over eight months. So how much longer until the discussions and the draftings and all those things are made available? It's, I can't,
Chair
Unverified
1:12:22
I'm not going to promise you a date that I can't keep. We're working actively internally on approvals. A year from now, will we know? Surely it would not take that long. I just don't want to give you an arbitrary date and give you, say, two weeks.
And I can't promise that because I'm not
Speaker 133
1:12:43
sure. But we're actively working on internal approvals on this retention and
Representative Ryan A. Rose
Unverified
1:12:49
recruitment plan. Follow-up, Mr. Chair. So the one thing I have heard definitively is that we have instituted contracts and hired consultants. Is
Speaker 126
1:13:02
that correct? We have utilized contracts
Representative Ryan A. Rose
Unverified
1:13:06
for many, many years. I'm talking about this. Since this incident, we have employed consultants?
Yes. Okay. So we don't, with the help of these consultants, we don't have a definitive timeline yet of when a public plan will be available or when conversations will move, but we are paying consultants. We are doing that for this
Speaker 157
1:13:29
specific thing, correct? So I think we're getting two things conflated. The consultants are in here to analyze the horrible
Chair
Unverified
1:13:36
event that happened at Warren, do this analysis for us, work on all of our policies, and greatly improve the care at that particular facility that we then hope to spread to the other four.
the htc recruitment retention plan although related honestly i mean obviously is a plan for all of the centers to understand better you know what why we are not why we are continuing to have issues keeping hiring and keeping staff and why we are hitting the on-call contract so heavily so the plan that i'm talking about is the plan that would be a recruitment plan for all five not not in particular
Speaker 27
1:14:17
to what has gone on at Warren nor what the consultants are looking at
Representative Ryan A. Rose
Unverified
1:14:23
I think I follow some if not most of that and me not following the rest is probably my fault not yours but what I will say just to conclude is that we are eight months later and it does sound like there's a lot of talk and maybe ideas but there's nothing actionable in terms of making sure employees like this are not hired again, making sure we're not 10, 11% understaffed. It's, it's just up in the air at this, at this time. And there's no definitive timeline of when you're going to have decided to improve it
Chair
Unverified
1:14:57
officially. Is that correct? I'm going to ask, uh, Director Brzee to give you, uh, more comprehensive documents on where we are with the consultant. I think it's coming across like a lot of talk, but there has been a lot of work completed the last eight months that is actionable and in place right now i think one of the things to be frank that we are seeing is when they're looking at stuff then they're turning over the rock and then there's something else and does that make sense so
Speaker 157
1:15:26
what we're doing what they came in to
help us look at you know we continued to then go well we need to look at this issue now right so but i don't want
Chair
Unverified
1:15:38
it to appear that dds and the hasn't they have are not making significant progress um we have comprehensive updates from the
Speaker 27
1:15:45
consultant showing what they have done that we can provide you thank you mr chair representative
Representative Jimmy Gazaway
Unverified
1:15:51
beaty you're recognized thank you mr chair i
Representative Howard M. Beaty, Jr.
Unverified
1:15:57
kind of want to go back i know you know just from doing a couple of searches
there was like 148 page investigative report uh based on the the events and we've heard what happened um and and kind of looking through some of those that you and you mentioned here a ban on prone restraints and that's face down holding someone face down on the ground for 13 minutes until they're not breathing so we're not going to do that anymore um uh actually pre-restraint protocol training you know try to de-escalate um it's kind of what i've been doing to myself over
here a little bit and then chemical restraint review and oversight of when you can use that it also pointed out vital sign monitoring that we're going to include that in some of the training and then administrative overhaul policy monitoring that now that's required and then a system-wide application outside of what I just identified through the review of this consultant that's coming in to to to make a plan and most of the time you know the consultants come in when they
find a problem they're reporting it to you can you report to us any other changes or rules or implementations that you made uh systemically through through all five of the hdcs based on the results uh and information from the consultant because we don't wait until we get a final report i hope to implement these changes because they could be life-changing changes so could you update us on something other than what you know came out of the long-term care report that y'all have implemented to make these these facilities safer and to better provide for arkansans
Speaker 22
1:17:41
so speaking about warren specifically the consultants have brought in nursing they brought and behavioral specialists. We have a team, they're just fantastic with a ton of experience in working with IDD and they've been at Warren almost every week helping do training, helping doing reviews of our person-centered plans as well as our behavior support plans and then rewriting them.
And so working very closely with our behavioral health and psychology staff to update those plans, to make them more plain language, to make them very person-specific with actionable items so that the layperson, a CNA, can implement those actions and steps for that specific person's behavioral health behavior needs. We are super excited about their interventions
and reducing the use of restraints and very much look forward to implementing the things that they're working with right now across all five HTCs. I think, and I understand where you're coming, Representative Beatty, but we're still in the thick of it and getting everything where it needs to be at Warren, and then we are 100% going to start translating those things and activities and policies across all five. So just a
Representative Howard M. Beaty, Jr.
Unverified
1:19:10
follow-up to make certain that I understood what you just said.
is right now the focus is just on Warren because that's where we had the death. So all the focus is there, and if there's information gleaned and there are things that we could change, we're going to implement that later at these other four HDCs? Or as
these areas are identified, are you implementing change systemically through all
Speaker 22
1:19:41
five HDCs? We are sharing that information 100%. For example, one of the things is they introduced a new version of the person-centered service plan,
and so we've been sharing that with other HDCs. But Representative Betty, you want to share, our other HDCs, we're constantly doing trainings, retrainings. The Office of Long-Term Care comes in regularly. They're all actively doing things
Speaker 53
1:20:07
to prevent this from ever happening. I understand that. My question is,
Representative Howard M. Beaty, Jr.
Unverified
1:20:12
have you seen anything or have they identified anything that is something that I don't – sharing is one thing, but mandating that this is the practice and procedure
that you're going to follow at these HTCs to prevent a death or other injury, have you gained any of that information, and have you implemented that? not just share it but to mandate it by policy procedure memo operating procedures have you done anything with that are you waiting on this consultant's
Chair
Unverified
1:20:45
final report represented babe from the updates that jennifer's been keeping me on this particular facility was not on par with the
rest of them and so what what they're having to do is i mean they're in there i mean redirecting how they're doing med passes um it's they had policies that weren't right that they should have been updated they had behavior plans that were not specific to people that were completely against how we trained them to do it um we have asked the other hccs to pull and ensure that
they're not doing the same failed practices at this point though i mean it's really isolated what we're finding so far just at that facility um because the other ones what what they're finding that's happening there is not happening at the other one so you know like it's not a um a shared practice where we go this is a great idea go call conway because they need to do this too that's not what we're seeing we're seeing that they
Speaker 157
1:21:55
were not following what the other four have have been
following and we're just trying to get warren
Representative Howard M. Beaty, Jr.
Unverified
1:22:02
to there okay so that that takes me
back to the first question i asked y'all is who's responsible for oversight and looking after these hdcs if you had warren not following the rules and procedures that you've identified whose job was it
to identify that they're not and to make certain that we don't have a death down there i mean
who's who ultimately was the final word in that that should have been looking at these sites.
Speaker 224
1:22:32
So the first line of defense who's in charge of that
Representative Howard M. Beaty, Jr.
Unverified
1:22:36
is the superintendent. I'm not asking first line of defense I'm talking about from that staff position up to the high rank at DHS who is ultimately responsible that these folks are following procedures. If the superintendent's not doing it who at DHS knows they're not following the procedures who knows that they're not handing the meds
Chair
Unverified
1:22:56
out properly dude i mean there is an assistant director underneath director brisee that is the liaison to the hdcs um at the same time that um the superintendent
was let go um that person retired um and then that that's
Speaker 27
1:23:12
the chain so it last question have y'all taken the
Representative Howard M. Beaty, Jr.
Unverified
1:23:17
training classes have you taken the restraint and the training classes that these hdc's take i took
Speaker 157
1:23:25
restraint training uh yeah at boonville but it was in uh 2015. well maybe maybe that's a
Representative Howard M. Beaty, Jr.
Unverified
1:23:31
good place to start with taking this training that your folks are taking to see if it's sufficient that they understand that holding somebody that face down for 13 minutes is
Speaker 30
1:23:40
unacceptable i did go through the training
Representative Howard M. Beaty, Jr.
Unverified
1:23:46
just sharing that so uh and and then have you made visits to all five HDCs since the death.
Allison Guthrie
Unverified
1:23:53
Yes, sir. Me and my team, we are regularly having contact and visiting the HDCs in person. All right.
Representative Howard M. Beaty, Jr.
Unverified
1:24:01
Thank you. Again, I apologize for getting riled up, but I mean, we're talking about human life. And if we're waiting on a study to implement
changes. That's unacceptable. Thank y'all. Senator Clark Tucker, you're
Representative Jimmy Gazaway
Unverified
1:24:17
recognized. Thank you, Mr. Chair. I want to
Senator Alan Clark
Unverified
1:24:22
join my colleagues in offering my condolences to the family. We've had a lot of conversation here today about what changes can be made at the agency level, you know, moving forward and rightly so. My question is really a follow-up to a point representative mayberry was making earlier what do you need out of the legislature to make sure
that we can avoid tragedies like this from occurring in the future because i can assure you we want to make sure we want to do our part to make sure that we
Speaker 10
1:25:09
prevent tragedies like this from occurring thank you senator Tucker you
Chair
Unverified
1:25:14
know we always appreciate it when members of the legislature take an interest in any of our facilities and I know I think some of y'all recently been to the state hospital right so we just we appreciate you um giving us grace
Speaker 27
1:25:31
and understanding what we're trying to do and then supporting those efforts um in in multiple arenas right in these spaces so
Chair
Unverified
1:25:40
i would say that that is that would be our request i think the other is is that
many times we do have to hit contracts we've
Speaker 27
1:25:50
always had to to maintain not always i hate saying that word we have for many years um even before covid i had to utilize some contracts to make ratio um it's it's going to take time to to shift that um over
Chair
Unverified
1:26:07
um because that's been a that's been a long-standing practice um and so i think just um if we could just give
Speaker 27
1:26:14
us some Kindness around the process knowing that we are working on that
Senator Clarke Tucker
Unverified
1:26:22
As you continue your review of this process if if you think there are laws that would help or specific funding
Representative Jimmy Gazaway
Unverified
1:26:34
measures I hope you'll let us know. Thank
Senator Kim Hammer
Unverified
1:26:36
you Senator hammer you're recognized. Thank you of the Of the 13 that were fired who was at the highest level of being fired
Speaker 74
1:26:46
Not the name, but the title. The superintendent of that facility, the nursing
Senator Kim Hammer
Unverified
1:26:51
home administrator. Okay. And fired or retired?
Did I misunderstand something a while ago? Fired. Fired, okay. And all 13 of them were fired. None of them were given the
option to retire. Is that correct? No, sir. Okay. And then on the go back to the area that's in question, you know, you could pay 50, 60,
$70,000 in some areas, but that's not going to put the bodies in a geographical area in order to meet the needs.
the consultants and part of their job is that to do an assessment of just that facility or all facilities and maybe you already have that information available as far as the manpower shortage in the area where the facilities are located is that speak to that for just a second please so
Allison Guthrie
Unverified
1:27:47
the columbus group came in specifically for warren and for this incident and directed plan of correction okay how does that
Senator Kim Hammer
Unverified
1:27:55
help you go ahead you want to add to it so
Allison Guthrie
Unverified
1:28:02
they're not there to evaluate our staffing levels or the community staffing levels but do you have
Senator Kim Hammer
Unverified
1:28:08
that somewhere in any of the reports that you have done or is that something that needs to be done because I understand the floating concept but a floating concept is a temporary fix to a long term problem is that a fair statement yes sir okay so do you have a report out there are you working on a report that shows in the geographical location where
these facilities are the ability to staff appropriately and sufficiently so as to help prevent this from happening if staffing is an issue as I think has been stated here so
Chair
Unverified
1:28:51
I think I briefly mentioned that I think to representative rose so we have we have drafted an overarching retention recruitment plan specifically for the human development centers it's not broken down
geographically because some of the issues I believe are very universal to all five that is the that's the plan that we're going through internal approvals on right now okay because I know and you know
Senator Kim Hammer
Unverified
1:29:19
separate issues you you know we take a look at some of our prison facilities and they're having to bus employees in in order to be able to staff them and I'm just curious as to whether or not that is done and if that that is being done how are you going to channel that up to us as a legislative body so we can have an opportunity
to look at that you're going to send it to state agencies or when will that be done where we can take a look at that and maybe that goes back
Speaker 165
1:29:52
to that question a year yeah senator hammer i think that that report will go to alc
Senator Kim Hammer
Unverified
1:29:56
okay and and you anticipate so is that report then in the works or when would you expect is that i think that that's what representative
Speaker 165
1:30:02
rose was was inquiring about and you hope it's not going to be a year it'd be sooner than
Senator Kim Hammer
Unverified
1:30:06
a year right pretty sure it won't be a year yes
sir okay with regards to the rate study that was mentioned while ago
last question mr. chair regarding the
rate study that was mentioned a while ago refresh my memory the rate study is that is that completed or it's about to be complete refresh my memory when
Speaker 224
1:30:33
that's done or not just to clarify so this is the this
Chair
Unverified
1:30:40
is the right study that was um a piece of legislation went through remember um and it's for um specific services under the past program so idd and behavioral health and
we are working to implement it
Senator Kim Hammer
Unverified
1:30:58
january 1. okay january 1 of
27. yes sir okay um so will that rate study that was that the numbers that that rate study produced and is that going to address the areas that have been problematic in this situation is that rate study specific to like the
Chair
Unverified
1:31:20
cnas and the all those folks are not no no unrelated so that rate study is for providers that um provide like in for the dd providers that
provide supportive living so people who were on the waiver um getting that service in their home supportive living that that rate is in this rate study a lot of in-home and school-based behavioral health services are in this rate study but it's not um it's not like clinical like we're not going in and saying cnas need
Speaker 233
1:31:48
to be paid this or it's not that kind of rate study it's for those specific services under the PASS program. Okay, and just refresh my memory. I'm sorry that
Senator Kim Hammer
Unverified
1:32:00
it might not be as good as it needs to be, but with regards to what the
CNAs need to be paid, where they are, and where they need to be gotten to, what do we have that shows what that number is? Do you have the study out there? Is that part of a rate
Speaker 10
1:32:17
study somewhere or what? No, sir. So that was part, they're state employees at the HTCs, of course. So that
Chair
Unverified
1:32:22
was part of the pay plan that went into effect last summer that now we pay them, what did you say, $39? $39, right.
Senator Kim Hammer
Unverified
1:32:29
All right, so that is the rate that we should be paying them in order to be able to recruit them.
So we're back to the question of do you have the people in the area to recruit if that is the market, fair market rate that we
Chair
Unverified
1:32:44
should be paying. Is that correct? Yeah, and sir, that's a very fair question. I will say that we see a great discrepancy, the amount of CNAs applying for a job in Conway versus the amount of CNAs applying for jobs in the other areas. Conway, we're getting so many applicants because of where it's located. Where it's located. All right, thank you.
Representative Jimmy Gazaway
Unverified
1:33:07
Representative David Ray, you're recognized. Thank
Representative David Ray
Unverified
1:33:10
you, Mr. Chairman. First of all, everything that has been said, Extending sympathy and condolences to the family, I echo that. And I also echo what Senator Tucker said a minute ago about if there are things that the legislature could assist with to help prevent a tragedy like this in the future, please let us know. There was one thing that you said a moment ago, Ms. Weatherton, that caught my attention.
and you made a remark about the standard at this facility in Warren not being up to the standard at the other four centers. And I know when you have a high-profile tragedy, whether it's 9-11 or the airplane collision at Reagan National Airport last year or anything like that, once an investigation has been done, There's usually, in hindsight, we can usually find warning signs that, in a perfect world, would have been recognized and addressed sooner.
Were there warning signs at this center? I'm curious how you came to the conclusion that the standard was not up to the other four centers, were there warning signs that maybe were missed all right thank you for the question representative ray
Speaker 27
1:34:41
I think the consultants have very much showed us at the standard when they went in for the deep job that the standards were not
with what was expected nor at the other four centers and I understand what you're saying on on if there weren't warning signs why weren't there warning
Chair
Unverified
1:35:00
signs um i mentioned earlier and i just i hate to get into personnel stuff openly like this but i will happy to talk to y'all but again um changing out the superintendent and then and then changing the person that was the representative in the central office that was the sole responsibility
was to oversee these facilities um and go out there and check this sort of thing um has also changed um guard and i agree
Chair
Unverified
1:35:36
superintendent then it's this then it's this other assistant director that reports directly to jennifer whose job is to ensure that those superintendents and those facilities are maintaining the standards that are expected and
so and then that assistant reports up to Jennifer so changing both of those positions I think we will see a different outcome the person that we are that is going to be permanent at Warren has been there as interim but she has she's a long-standing superintendent for
Speaker 27
1:36:14
us from arkadelphia who lives in warren and has been commuting to arkadelphia for us for years and
she's a strong woman and she is cleaning house and
Chair
Unverified
1:36:27
one of the reasons where we're also seeing problems with hiring in warren is because she has a very different standard of who she wants working for her and so we are experiencing very high turnover at that facility since she has been there the past eight months so but I agree with you we should have seen warning signs if the facility
Speaker 27
1:36:51
was not performing to the expectations okay
Representative Jimmy Gazaway
Unverified
1:36:55
thank you I want to follow up on that just quickly so with regard to warning
signs is there an independent or outside agency that audits these facilities and and if so who is that yes
Speaker 27
1:37:12
sir so the office of long-term care um goes into these facilities and audits them um they're there regularly okay so
Representative Jimmy Gazaway
Unverified
1:37:21
with regard to the warren facility what did you know about the audits that long-term care had performed about the warren facility prior to
Speaker 112
1:37:30
this event happening we and we um we are
Speaker 27
1:37:38
privy to every uh on-site survey that they do at all facilities we get copies of all of those documents there was nothing of this caliber um or related to these kind of failed practices leading up to this event okay
Representative Jimmy Gazaway
Unverified
1:37:51
um i understand that there may not there may never have been an event like this but just because there's never been an event like
it doesn't mean that there aren't things to look for that would indicate that an event like this would be possible or might be more probable based on say employee evaluations performance evaluations of the employees that didn't go well or I mean you I think in as you said in response to representative ray you knew the warren facility was underperforming or was it worse essentially than the other facilities something led you to that conclusion oh no oh no sir that's
Chair
Unverified
1:38:32
that's not what i said i said that the consultant group has when they came in after that after the death we identified the deficiencies that were occurring at that facility that was what i was trying to express Representative Ray, there were not warning signs that went up the chain of command between the superintendent, the assistant director, Jennifer, and then to me. Those warning signs did not flow up. But for the fact that this occurred and the consultant came in is when we've
Representative Jimmy Gazaway
Unverified
1:39:07
uncovered deficient practices. So the consultant clearly identified them after the fact. Do you think the office of long-term care is not doing their
Speaker 27
1:39:20
the sole responsibility of the division of developmental disability services this is the office and ultimately that comes up through me so i'm not
Representative Jimmy Gazaway
Unverified
1:39:27
trying to throw her under the bus my point is why would they not have found if the office of long-term care does these audits and they're thorough why would they not have found the same deficiencies that the consultants seem to very easily find
Chair
Unverified
1:39:41
after the fact the office of long-term care is not charged with coming out and pulling individual client files and saying why in the world do all your behavior plans look exactly alike right so what happens is there's a reportable event it gets reported it gets keyed they send nurses out to do the survey they're looking at that right so this is more of a program policy review that would be under the purview of DDS, they're coming out to look at incidents, accidents, complaints,
not widespread, you know, you have a
Speaker 112
1:40:15
policy and your policy's not good. The Office of Long-Term Care is doing
Representative Jimmy Gazaway
Unverified
1:40:18
this more generalized. They do more, I would say they do more specific. Okay, if there's an event, then the Office of Long-Term Care comes out. Yes, sir. I'm talking about like a yearly audit similar to what the consultant ultimately did. Is there someone who does that on a regular basis? some entity no that's
Speaker 250
1:40:42
something that we need to look at doing I see okay because
Representative Jimmy Gazaway
Unverified
1:40:49
those that might have identified the warning signs before an event like this ever happened all right very good yes representative
Representative Jack Ladyman
Unverified
1:41:01
ladyman you're recognized thank you mr. chairman
and I'm not a member of this committee I I appreciate you letting me ask a question. I'll try not to talk too long, but I was not going to ask a question, but I have to. This discussion, and ma'am, the mother of the young man that passed away, I'm very sorry.
You know, it doesn't matter how perfect the system is, there are failures. And I was going to say I couldn't imagine how you feel, but I can. Because, you know, we had a couple, we had an individual that passed away in Jonesboro, just a few, a good friend of mine, his son passed away. There was nothing bad about that. But I talked to the individuals that was there and how they handled that.
And, you know, they did everything right. But that doesn't always happen. And, you know, I have a son in one of the facilities. And this discussion has been very good. A lot of people have left, and they won't hear what I have to say. But many people have asked what we can do to prevent this from happening at other facilities. And I'm very interested in that since my son is in one of these other facilities.
And I know that these sites get inspected more than once, long-term care. There's another organization that does an inspection. My wife, Linda, and I were on the committee that reviewed incidents in the Jonesboro facility, and there are a lot of them, a lot more. This is a failure of the system, but there are a lot of incidents that the system worked, and it prevented this kind of thing. And you talk about, what's the term, restraints.
Well, let me tell you, you have to use restraints at times. I sit in my living room with my knee on my son's throat to keep him from hurting himself until the police got there. And these individuals working at these sites, they have to make quick decisions just like I did. And it's difficult to remember your training. But talking about the training, it cost $2,000 to train one CNA at an HDC.
You know how many were trained last year at the Jonesboro HDC? $400. $400. $2,000. There's a turnover. There's a reason for that. Now, we can say we're paying these people adequately. And we are paying them based on the rate study, what other states pay. But this is a group of people that we are responsible to make sure that they're taken care of. There are many things. The questions have been asked.
What can we do as a legislative body? I had two bills that died in committee during fiscal session. Representative Lee has a bill that's not been passed. There are many other bills. We have people working out of house trailers. You know, if you were working out of a house trailer and somebody offered you a better job in a nice office, wouldn't you take that? That's why we have turnover. I mean, it's go to these places and look and you'll see what the problem is. We had a bill.
This is a question. We had a procedure where we were paying individuals regionally because we could not hire individuals in that area, which means we were paying people in rural areas more than people in Jonesboro and Conway where we have plenty of people applying. You just mentioned that. That was taken away. I don't remember exactly how that happened but that particular program was helping us recruit people in those rural areas like Boonville and Warren and Arkadelphia. You know we're 75 percent of our
nurses are RNs in Arkadelphia are traveling nurses or they were. I haven't seen the latest numbers. That means we're paying them way more than we are the current nurses because we can't hire nurses there. We have to pay more in those areas to get people to move there and be RNs. That's a very simple solution. We need to look in the mirror, guys, people. We need to look in the mirror. We can't expect them to come to us and tell us what our job is and what we need to do.
We need to be more familiar. We need to go to these sites. If you don't understand and you don't want to vote for a bill that I have to get people out of a house trailer and into an office, come to Jonesboro. I'll show you. I'll show you. And there are other bills. This needs to be a priority in our next session. It does. And these people do not have a lobbyist. The state hospital is another one. We don't have a capital improvement fund for the HDCs or the hospital.
We have it for schools. We have it for prisons. We don't have it. We need to have a capital improvement account set up because if you improve the working conditions, you get better people that follow the policies. Mr. Chairman, I'm sorry I'm talking so long. But my question is, that program I spoke about where we were paying individuals, that was taken down, discontinued. Is that
Speaker 75
1:46:47
correct? So I think you're talking about like a rural shift differential.
When the new pay plan was implemented,
Chair
Unverified
1:46:55
one of the goals behind it was to, because the pay was increasing pretty good, you know that was to get rid of all these different differentials everybody is paying um but but um we have always been told um that um after letting the pay plan settle for a second if we need to come back and request such a thing that it would be considered um so that is something that we are talking about um in our um retention recruitment plan
make sure that we have the the funding to do such
Speaker 27
1:47:31
a thing and then if and seeing that if we think it would substantially help.
Representative Jack Ladyman
Unverified
1:47:39
Some other question so if we could do something like that or maybe another program where we could have full-time employees versus traveling RNs that would save us a lot of is that correct
Chair
Unverified
1:47:54
yes so if a part of putting any kind of I just want to clarify this part of any kind of HCC retention recruitment plan is going to
cost money that's part of the thing but it will be it is will be more cost effective and better for clients if it if we can implement and it costs a bit more money but we still are cheaper than what we're utilizing on these contracts every year right so that's what we're really looking at so though we we present ALC a lot of numbers around these on-call contracts
Speaker 27
1:48:31
for HDC's the line is around we're spending around like 10 million a year
Speaker 75
1:48:37
on on-call contracts if what we're recommending in the recruitment plan
Speaker 27
1:48:42
is less than 10 million a year then this then we want we think it'll be worth it right because part of the value having full-time employees and not using contracted staff or them
Chair
Unverified
1:48:53
getting to know clients better and if you know clients better then you take better care of them and like jennifer said some of the issues with this particular death was we had a lot of floaters
Speaker 233
1:49:04
in the house so we we're looking at all of all of those things um right
Representative Jack Ladyman
Unverified
1:49:09
this second so if we had employees who were full-time employees who stayed at the job longer and i shouldn't say better
trained but maybe uh better at executing their training do do you believe that that would reduce the risk of something like this happening in the future a hundred percent thank y'all
Representative Jimmy Gazaway
Unverified
1:49:40
for being here thanks all right those were excellent points representative ladyman i know you've been very involved in this issue so thank you for that representative in it would you like to make any
Representative Denise Jones Ennett
Unverified
1:49:51
closing remarks thank you mr. chairman i'd like to thank the committee um i know everybody was anxious to get back home after we gobbled out um i'd like to thank everybody for all the questions I was a little nervous presenting today, but I'm glad that all these questions came up. I'd like to also thank the mother for being here. And I think she wants to say a couple words afterwards, if that's permissible.
Can she come up? Okay. I'm hoping in 2027 that this body can come up with some solutions so we can make these places better. Like I stated earlier, I'm a mother of a 17-year-old who has disabilities. And so that pulled at my heartstring. And so I just want to make sure that the people of Arkansas, if they have to put their children or their loved ones in these institutions,
Speaker 62
1:50:55
that they're not going to die. And that's all I have to say.
Representative Jimmy Gazaway
Unverified
1:51:04
Thank you. Thank you, Representative Innet. thank you for bringing this issue to this committee's attention it's very important one that we definitely need to be very serious about addressing in our upcoming session so thank you very much for that
and I do have on the sign-up sheet Miss Angela Stevens Miss Stevens would you still like
to say that make some remarks all right
Representative Jimmy Gazaway
Unverified
1:51:35
miss miss stevens if you would you can just have a seat and you'll need to press the button and when it lights up uh just state your name and then you'll be
Speaker 260
1:51:58
recognized you can make make your remarks hello my name is angela stevens mother of zachary
Speaker 261
1:52:03
moore i want to thank y'all for letting me speak today and being here I appreciate it I know that there has been a settlement said
but money does not bring back Zachary and I'm here because the next Zachary that is in the right now is not safe and that nick zachary needs to be protected for the future and that's why i'm here um to bring up um i know there's a staff shorting i understand that i understand that
is part of what has happened um but from the statement that happened from the the incident there were two cnas that weren't couldn't even pass a cna test that were there that shouldn't have been on the floor if they could not pass a cna test i don't see why they should be on the floor um they're not being trained that dhs had said that they're going through all these training and everything and then cna classes these individuals had not could not pass them yet
they were still there caring for my son and others and another thing they had a chart they have to read to know each individual what their care needs are for the day those staff members did not read and sign that that chart they did not know that zachary had to have his helmet on they did not know the procedures they did not follow so where are the individuals above them that are supposed
to be implementing these procedures so these little things that could have been done to help for the safety of the staff and the safety of the the individuals that are living there for both of them but they're not being implemented um since this incident they said that they have improved um staff coming in yet i don't agree with that because there's been an incident afterwards
where a new hire has put another another resident in a coma for um getting them high or getting drugging them right after the new hires so where's the drug test where's the background test where's the training so these individuals are just this is a new hire so these individuals are coming in there to care for our loved ones that are bringing in drugs to them and and putting them in the hospital so and one more thing on the training it was just notified at Boonville that um the same
day that the settlement was signed for Zachary a manager managing nurse made the decision to place newly recruited uncertified CNA staffs directly on the floor without training without certification her stated justification was committed and communicated to the staff members that was the facility is too short staff to take the time to properly change train the people that were just hired and it was confirmed by the individuals by the staff that were in fact provided care
shortly after without the training they were put on the floor so these training and everything that they're doing none of it got done they said they were too short staffed so they just put newly people had no idea what they're doing no training whatever on the floor to care for people and that would just happen the 27th the day that the settlement was signed so where's the change this is like we all said this has been eight months what has changed what improvements for
the other Zacharies out there are being done. Has there been anything? Zachary paid the price for this to be noticed. So what's going to come of it? Is his death in vain? How can I help you
Speaker 262
1:56:41
all understand and help for the next Zachary not to go through this?
Representative Jimmy Gazaway
Unverified
1:56:49
I think that's it. Thank you. Thank you, Mrs. Stevens. My heart goes out to you, as I know. I think I
can speak for everyone on this committee. Our heart goes out to you in this, what I know, is a very difficult situation. So God bless you. Thank you for being here, and thank you for those remarks. Any other questions or comments from the committee? Representative Bennett, you're recognized.
Representative Denise Jones Ennett
Unverified
1:57:19
Thank you, Mr. Chair. I have a request from DHS that you keep us abreast of all of the, you know, the recruitments, the consultants' reports and whatnot. Also, I have a request that you keep Ms. Stevens, reach out to her and talk to her about the issue that she told me that she was supposed to be, whatever that conversation that she was promised, if y'all can reach out to her and make sure that happens.
Unknown speaker
1:57:55
Thank you. All right. Seeing no further business before this committee, we are adjourned. Thank you all very much.
Agenda
A. Call to Order
B. Comments by the Chairs
C. Consideration of a Motion to Approve the October 8, 2025, Meeting Minutes [Exhibit C]
D. Discussion of Death at Southeast Arkansas Human Development Center [Exhibit D]
E. Other Business
F. Adjournment
Documents
| Title | Type | Pages | Source |
|---|---|---|---|
| Agenda — STATE AGENCIES & GOVT'L AFFAIRS-SENATE, May 6, 2026 | Agenda | 1 | Official source ↗ |
| Exhibit C - Draft Minutes 10-8-2025 | Exhibit | 1 | Official source ↗ |
| Exhibit D - DHS Overview of Human Development Centers | Exhibit | 3 | Official source ↗ |
Speakers
Representative Jimmy Gazaway
Unverified
Chair
Unverified
Speaker 14
Speaker 15
Speaker 22
Speaker 24
Speaker 28
Speaker 27
Allison Guthrie
Unverified
Representative Denise Jones Ennett
Unverified
Senator Scott Flippo
Unverified
Speaker 70
Speaker 21
Speaker 64
Speaker 78
Representative Julie Mayberry
Unverified
Speaker 42
Speaker 10
Speaker 88
Representative Jeremy Wooldridge
Unverified
Representative Howard M. Beaty, Jr.
Unverified
Speaker 138
Speaker 53
Speaker 156
Speaker 157
Representative Wayne Long
Unverified
Speaker 164
Speaker 165
Speaker 20
Senator Kim Hammer
Unverified
Speaker 75
Representative Johnny Rye
Unverified
Representative Rick Beck
Unverified
Representative Ryan A. Rose
Unverified
Speaker 133
Speaker 126
Speaker 224
Speaker 30
Senator Alan Clark
Unverified
Senator Clarke Tucker
Unverified
Speaker 74
Speaker 233
Representative David Ray
Unverified
Speaker 112
Speaker 181
Speaker 250
Representative Jack Ladyman
Unverified
Speaker 62
Speaker 230
Speaker 260
Speaker 261
Speaker 262