During the 2025 legislative session, the Arkansas General Assembly passed HB1653, now Act 636. You can read AACF’s testimony against this piece of legislation here.
This law allows the number of psychiatric residential treatment facility (PRTF) beds in Arkansas to increase to a total of 900 beds. In addition, it classifies a PRTF as a “long-term care facility” and moves the oversight of PRTFs from the Child Welfare Agency Review Board to the Department of Human Services’ (DHS) Office of Long Term Care. Importantly, the law also removes quality of care standards for PRTFs that had previously existed in state statute. However, it tasks DHS with promulgating rules to implement the new law, to include “components that ensure quality of care, health and safety of residents and facility staff, and compliance with all educational requirements.” The “Psychiatric Residential Treatment Facility Services for Under Age 21”rule became effective on June 20, 2025 via an emergency rule.
But AACF submitted the following public comments during the regular promulgation process as DHS determines how the law will be implemented long term.
July 21, 2025
Melissa Weatherton
Medicaid Specialty Populations Director
Arkansas Department of Human Services
P.O. Box 1437
Little Rock, Arkansas 72203
Via Electronic Submission: ORP@dhs.arkansas.gov
Dear Director Weatherton,
Thank you for the opportunity to provide comments regarding the proposed rule for “Psychiatric Residential Treatment Facility Services for Under 21” that establish the licensure manual for psychiatric residential treatment facilities (PRTFs) and the companion Medicaid Provider Manual for PRTFs.
Arkansas Advocates for Children and Families (AACF) commends the Department of Human Services for working to establish performance management and quality assurance mechanisms for children who require the intensive mental health treatment provided within PRTFs. Given the relative dearth of research showing that PRTFs produce positive outcomes for childreni – and with some reports indicating PRTFs can have a detrimental effect on childrenii – establishing trackable data outcomes will be helpful to assessing effectiveness of these facilities in Arkansas. We are also encouraged to see the requirement for all PRTF common areas to have video cameras as well as the monthly reporting mandates for psychotropic medication data and the use of various restraints.
However, we recommend some revisions to strengthen performance management efforts and ensure that the quality assurance provisions outlined in the rule are implemented consistently statewide. We also request consideration of changes regarding the admission of children younger than twelve years of age into these highly restrictive placement environments. These recommendations are described below.
On-Site Inspections of Care
While the proposed rule requires PRTFs to “submit to, and cooperate with, regular and unannounced inspection surveys and complaint investigation surveys in order to receive and maintain a license,” there is only one annually required On-Site Inspection of Care for PRTF providers. Given the number of child abuse hotline reports involving PRTFs and past issues with a lack of quality treatment provided in these facilities, we would recommend a minimum of bi-annual On-Site Inspection of Care visits. At one point when the Placement and Residential Licensing Unit oversaw PRTFs, quarterly site visits to PRTFs were required. As such, there is a precedent for more frequent reviews of PRTFs.
In addition, while the rule acknowledges the possibility of unannounced visits, it does not require unannounced visits with any prescribed frequency. Even traditional foster homes require at least one annual unannounced visit. There are of course many children placed in PRTFs who are not in state custody, so we recognize that the needs for unannounced visits to foster homes and PRTFs differ. Nonetheless, requiring an annual, unannounced visit to each PRTF still seems prudent given the mental and behavioral health needs of children placed in these facilities, as well as the previously noted concerns regarding PRTFs.
Finally, it is encouraging to see that the rule clearly states that an Inspection of Care must include “personal contact and observation of each Resident in the Psychiatric Residential Treatment Facility” along with a “review of each Resident’s medical record.” However, we want to verify that this is truly all residents and that appropriate training regarding this change is provided to PRTFs as well as OLTC staff and any contractor conducting Inspections of Care. It is critical for all involved parties to understand that each PRTF resident must receive an Inspection of Care given that past inspections have only been limited to “active Fee for Service Medicaid” clients. The most recent publicly available documentation of this practice is noted in an inspection summary dated August 19, 2024.iii This previous practice is extremely concerning since the vast majority of Arkansan children placed in PRTFs are covered by a PASSE rather than Fee for Service Medicaid.
Performance Management
The rule requires that the Office of Long-Term Care (OLTC) and the facility “work collaboratively to develop standards and share data that is needed and required by OLTC to ensure standards and outcomes are met.” It also states that “it is ultimately OLTC’s responsibility to set the performance standards.” We agree that consistent performance standards and outcome data across all PRTF facilities are critical to improving the services provided to children placed in these restrictive settings. However, it appears the standards and data points to be tracked have yet to be developed. If performance standards and required data points are set forth in another document (e.g., contract performance indicators), we would ask that the rule note where said performance standards and data points can be found. If the performance standards and data points are not already listed in another document, specific performance standards should be developed as soon as possible.
While the rule requires each PRTF to submit a monthly status report to OLTC, it is unclear when this process will begin if performance standards have not yet been developed. This is concerning since, under Act 636, existing PRTFs can now expand and new PRTFs can begin operating. The sooner these performance standards and outcome criteria can be developed, the better the health and well-being of youth placed in PRTFs can be ensured.
Quality Assurance
We are encouraged by the requirement for PRTF facilities to maintain a continuous quality assurance plan that is provided to the residents on a quarterly basis. However, the rule only mandates that these plans “be available upon request for review by the Office of Long-Term Care.” Instead, the rule should require that PRTFs submit these plans quarterly to OLTC. In doing so, OLTC could ensure that all PRTF quality assurance plans share basic quality assurance components, which would promote consistency in quality assurance efforts across these facilities. Requiring quarterly submission of the quality assurance plans would also allow OLTC staff to regularly assess how PRTFs are addressing “any identified issues” as required in the quality assurance plan.
Finally, we recommend that, in addition to the PRTF providing the quarterly assurance plan to the residents, the rules should also mandate that parents, guardians, or custodians of the residents receive the quarterly quality assurance plan for the facility in which their child is placed, given that most youth placed in PRTFs are still minors. This information will help improve communication between the facilities and the parents, guardians, or custodians of the residents and empower those who are legally responsible for the youth to take action when necessary.
Minimum Age of Admittance
Setting the minimum PRTF admittance age to ten years of age (beginning 7/1/25) is a step in the right direction to ensure that very young children are not placed in these highly restrictive residential facilities. However, research suggests that children under the age of twelve should be placed in the least restrictive, most family-like setting possible.iv Young children placed in residential facilities are more likely to develop physical, emotional, and behavioral problems that can lead to poor long-term health and well-being outcomes such as homelessness, teen pregnancy, and incarceration.v We recognize that there are ten- and eleven-year-old children who may require significant mental and behavioral health interventions. However, it is crucial that our state enhance community-based mental health systems to meet the mental and behavioral health needs of these young children who are still just elementary school students.
For these reasons, we ask the state to consider increasing the minimum age of admittance to twelve years of age. If this is not possible, then the rule should require a specialized or more intensive review process – other than those already described in the rule – to assess the need for continued placement in a PRTF for those under the age of twelve.
Miscellaneous
It appears there may be typos in the following places:
- Under Section 215.110: Requirements for the Individual Plan of Care, Item C appears to be missing the word “goals” or a similar noun.
- Under Section 241.000: On-Site Inspection of Care “patients” should be possessive.
Thank you again for the opportunity to comment on the PRTF licensure manual and the companion Medicaid Provider Manual established by this rule. We want to support the implementation of high-quality standards of care and performance management to ensure the health and well-being of children who are placed in psychiatric residential treatment facilities. We also look forward to the development of trackable outcomes across all PRTFs in the state that can be shared with the public. Our hope is that children who require this level of intervention will receive the evidence-based, trauma-informed care and support described in the rule that will result in effectively meeting their mental and behavioral health needs. The result should be short-term stays in these facilities, so these children and youth can then return to their communities and thrive.
Sincerely,
Keesa M. Smith
Executive Director
AR Advocates for Children and Families
Christin Harper
Policy Director
AR Advocates for Children and Families