Disability Rights Arkansas

Perimeter Behavioral of the Ozarks / Woodridge of the Ozarks

*Photos taken by DRA staff during onsite monitoring visits. Photos reflect the most recent conditions observed by DRA staff but may not reflect the current conditions at the facility. If you are associated with a facility and have updated information or photos you would like to share, please contact DRA at [email protected]

Location: Springdale, AR                   Population Served: Adolescent girls ages 7-17

# of residents per unit: Up to 12 Residents per room: 2 Capacity: 32

Contact with family (Calls and visit schedule): Weekly calls up to 3x/week for 10 minutes, intervention call available 1x/week for 10 minutes. Visitation available 2x/week for 30 minutes if previously scheduled. Zoom available if in person is not possible.

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? Yes 

Treatment Components:

Clinical Director: LCSW                    Therapists: 2 full-time therapists (1 LMSW, 1 LAC)

Treatment modalities offered: Facility declined to identify any specific modalities available.

# of individual therapy sessions/week: Varies by client, most clients receive one individual therapy session per month

# of group therapy sessions led by a licensed mental health professional/week: 3

 

DRA Monitoring/Investigations

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PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client approached nursing staff with scratches on both forearms. No staff witnessed the self-harm event. Nurse cleaned client’s arms and covered the scratches after client’s shower. Observation level modified from Q15 to LOS constant. Client will process with her therapist.
    • Licensing follow-up: Licensing observed client within LOS of staff during facility visit and verified current safety precautions.

PRLU or OLTC

Monitor Visit, Self Report Visit, Visit Compliance Report

  • Licensing Specialist: Michele Sutton.
  • Unannounced licensing visit completed. Licensing verified safety plan precautions were documented and observed for multiple residents, reviewed staffing sheet documentation, spoke to CEO regarding resident, and observed comfort room area. Licensing viewed camera footage for 2 self-harm incidents, with no concerns noted. Per CAA agreement, Licensing viewed environment of care maintenance logs (no concerns noted) and requested the new HR director attend the unit regulatory check training on 04/26/23. Licensing also followed up on a report from DSPQA IOC team that mail with confidential information was left outside unsecured at their time of visit; CEO reported she is in contact with USPS to explore options for securing mail, and Licensing requested this be completed by 03/31/23.
  • Regs out of compliance –
    • 912.4 – Box that toilet is in (bathroom 301) has trash, debris, and space for contraband on either side of the toilet. Facility plan is to place foam in the area, let it protrude, then cut/seal it (Complete by 03/15/23).

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-harm
    • Client became escalated while in the quiet room and began to self-harm with her fingers. Staff intervened and emergency medication was administered due to client’s inability to regain a state of calm. Client calmed down and was released. Client will continue 1:1 LOS for safety.
    • Licensing follow-up: Client was on 1:1 constant LOS and programming separately from peers during licensing visit. Facility has made several acute care referrals.

PRLU or OLTC

Notice of Incident, Suicide Attempt

  • Suicide Attempt
    • Client entered her room for quiet time and staff continued down the hall unlocking doors for peers. Approximately 1 minute later as staff was returning down the hall, staff checked client’s room and client was seen lying on the floor with a piece of material tied around her neck. Staff called for assistance and the material was removed. Client was seen breathing, conscious, and tearful but refused to verbally process. Nurse noted red area on neck where material had been tied. Orders received for 1:1 observation during wake hours while wearing paper scrubs. Client will sleep in the dayroom area for optimal supervision/safety. Therapist will continue to process with client and an individualized safety plan will be developed with therapist.
    • Licensing follow-up: Licensing reviewed camera footage of incident and confirmed that client entered her room at around 11:40 am and was discovered by staff at around 11:41.5 am. Staff reported the material client used was an intact sweatshirt. During licensing visit, client was observed 1:1 with an MHT.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client picked scabs on her arm that resulted in minor bleeding. Client then attempted to attack a peer who verbalized that she would pull the fire alarm; Client pushed a staff member while trying to get to the peer. Client was placed on 1:1 observation due to increased self-harm behaviors and aggression.
    • Licensing follow-up: Unannounced visit conducted this date. Acute care referral was made for client on 02/27 but she was not accepted due to staff shortage. At time of visit, client was observed 1:1 with staff and programming separately from other clients. CEO stated client is being taken outside separately for breaks and recreation.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client used fingernails to reopen an area on her cheek from a previous self-harm attempt. Minimal bleeding noted and the area was cleaned. Client will remain on self-harm precautions until safe behavior is observed.
    • Licensing follow-up: Licensing reviewed documentation to confirm current self-harm safety plan is in place for client.

PRLU or OLTC

Notice of Incident, Self-Harm

  • Self-Harm
    • Client pulled an outlet out of the wall to self-harm with, and when redirected by staff, client continued to find contraband to self-harm with.  After some time, client was placed in a physical restraint. After the restraint, client was assessed by the nurse and no abnormalities were found. Client processed with her therapist and was placed on self-harm precautions with constant LOS.
    • Licensing follow-up: Camera footage was reviewed. The incident occurred in the corner of the dayroom in a camera blind spot, however, staff was with client for most of the hour of footage viewed. When staff left to check on other tasks, they always circled back to check on client within 5 minutes. Licensing also checked the area where the incident occurred, and no loose or poorly fitted outlets were observed in the area. No licensing concerns noted.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client used fingernails to reopen an area on her cheek from a previous self-harm attempt. Minimal bleeding noted and the area was cleaned. No further incidents occurred. Client will remain on self-harm precautions until safe behavior is observed.
    • Licensing follow-up:Unannounced visit conducted this date. Licensing verified documentation was in place for current self-harm precautions.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Michele Sutton.
  • Unannounced facility visit. Areas viewed: All units (blue, orange, green), classrooms, cafeteria, and grounds. Two residents on the green unit were refusing school and in bed, with a staff member in the dayroom. Licensing verified staff Q15s (supervision) were completed/current for both residents (neither resident was on an LOS safety plan). MARs reviewed for 5 residents.
  • Licensing reviewed self-harm incidents and verified all have documentation for LOS precautions, and all were observed within LOS of staff. Residents had several outings this week, and facility plans to offer increased outings as incentives for positive behaviors.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client used her fingernails to create a raw/reddened area on her cheek. Client was placed on self-harm precautions with constant line of sight until she can be assessed by her therapist. No nursing care was rendered for reddened area; Client was instructed to wash area with soap and water.
    • Licensing follow-up: Unannounced visit conducted this date. Licensing verified documentation for current self-harm precautions, and client was observed within LOS of staff.

PRLU or OLTC

Notice of Incident, Self-Harm

  • Self-Harm
    • Client bit her hand during phone call time. Nurse assessed, and no skin was broken or bleeding. Client processed with staff and was placed on self-harm precautions x7 days.
    • Licensing follow-up: Unannounced visit conducted this date. Licensing verified documentation for current self-harm safety plan, and client was observed within LOS of staff.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Staff reported to nurse that client had been attempting to bang her head, and upon nurse arrival, client was scratching her forearm. Client was taken to the comfort room to process. Nurse noted a quarter size knot to client’s forehead, no complaints of pain.
    • Licensing follow-up: Unannounced visit conducted this date. Client was observed within LOS of staff during visit, and client has not had any other attempted self-harm episodes this week. Facility continues to address her behaviors using interventions on her individualized behavior management plan.

PRLU or OLTC

Notice of Incident, Sexual Contact

  • Peer Sexual Contact
    • Client reported to staff that peer inappropriately touched her private area in their room on the night of 2/17/23. Corrective Action Plan: Therapeutic group to be conducted by therapist on peer-to-peer boundaries, reeducate no touching by residents to each other on the unit, residents were separated units for safety, reeducate staff on appropriate supervision throughout the night, and residents will process with their therapist.
    • Licensing follow-up: Unannounced visit conducted this date. The allegation was screened out by the Child Abuse Hotline. The peer involved is on “bed block” status, meaning no other children can share a room with her until facility clinical staff determines safety.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client attempted to self-harm with a comb, and the comb was removed by staff. Client then began to bite her hands and rubbed off scabs on her arm, causing them to bleed. Client processed with staff and her picked scabs were covered and cleaned. Client was given her PRN anxiety medication and self-harm precautions were initiated x7 days.
    • Licensing follow-up: Unannounced visit conducted this date. Client was receiving individualized help with schoolwork in the cafeteria due to behavior issues in the classroom today, within LOS of 2 staff. Licensing verified client had current LOS safety plan documentation.  

Medicaid Inspection of Care

Corrective Action Plan, Inspection of Care Report

Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.

This IOC visit was upon request of DPSQA (Division of Provider Services and Quality Assurance) to follow up on a recent IOC inspection conducted on 10/6/22 and 12/5/22.

PRLU or OLTC

Children's Records Review, Personnel Record Review, Visit Compliance Report

  • Licensing Specialist: Michele Sutton and Chelsea Vardell.
  • Licensing Specialist reviewed records for 5 children and 11 staff. Licensing viewed fire drills and storm drills; Facility was in compliance with safety requirements. Licensing conducted a brief walkthrough of the milieu area, and facility has implemented a “Shout out” bulletin for staff and residents to write encouraging messages, added wallpaper to common area, and implemented a “Feelings Wheel” on units to assist residents with processing their emotions with staff.
  • Regs out of compliance –
    • 904.1.h – Copy of social security card or documentation it has been requested needed for 1 resident.
    • 904.1.i – Copies of immunizations or documentation they have been requested needed for 1 resident.
    • 105.3 – All pre-service documentation was not documented in all 11 personnel records.
    • 105.13 – Training documentation shall include date, hours, topic, and source. Training records for all 11 personnel only contained the date and topic of training.
    • 105.10 – Each personnel file shall have 10 hours of psychiatric specific training before being counted in the staff/child ratio. All 11 personnel records did not have 10 hours documented.
    • 107.4 – Personnel records should include documentation that they have been made aware of the need to protect the confidentiality of children in the use of social media. Documentation was only found in 1 of 11 personnel files viewed.
    • 103.2.a – AR Child Maltreatment regulatory check was not initiated within 10 days of hire for 1 personnel. (CEO reports this is likely due to termination of HR Director on 01/09/23).
    • 105.15.h – 10 personnel records did not have 3 references from non-relatives in their file.
  • TA –
    • 105.15.c – Please ensure all personnel have some form of verification of their qualifications (high school diploma, GED, or college diploma).

PRLU or OLTC

Notice of Incident, Self-Harm

  • Self-harm
    • RN was called to unit due to client biting her hand; No injuries noted. Client accepted an exit due to peers being loud and spent 30 minutes in the quiet room. Client placed on self-harm precautions x 7 days.
    • Licensing follow-up: Licensing completed visit to facility and observed client within LOS of staff. Client’s safety plan ended on 02/21/23 and there have been no additional self-harm incidents. No additional follow-up needed at this time.

PRLU or OLTC

Notice of Incident, Self-Harm

  • Self-harm
    • Client became upset about having to move units. Client stole a walkie from staff 2 separate times, attempting to self-harm with them; Client was placed in 2 physical holds to retrieve the contraband. Client later attempted to get to the fire alarm on her unit, and staff intervened. Client then grabbed keys from a staff member’s neck, stating she was going to escape; The keys were promptly retrieved by staff. Client was eventually able to regulate emotions, and no injuries were sustained. Client was placed on self-harm precautions with constant LOS, as well as assault and property destruction precautions.
    • Licensing follow-up: Licensing discussed incidents with CEO, who reported the client stole keys by breaking a lanyard and obtained the second walkie after staff had taken them off to complete the restraint. CEO reported the client’s behaviors have stabilized and client expressed she liked her new unit better than she thought she would.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • While in the bathroom, client repeatedly punched herself in the face causing minimal bleeding from nose. Client was physically blocked by staff and was able to process with staff. Client’s face was washed and no visible injury was noted. Self-harm precautions with constant LOS in place.

Police Report

Hang Up

Hang up calls from the front desk with no answer on call back. No emergency.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client became triggered due to another peer self-harming. Client obtained a staple and used it to make superficial abrasions on her forearm. Staff removed the staple, and the abrasions were cleaned. Client placed on self-harm precautions x 7 days. 
    • Licensing follow-up: During facility visit, the CEO confirmed client remains on self-harm safety plan.

PRLU or OLTC

Notice of Incident, Suicide Attempt

  • Suicide Attempt
    • Client became escalated due to multiple triggers and used her shirt to tie around her neck. The shirt was removed by staff and no injuries were noted. Client scored low risk on C-SSRS and was placed on suicide precautions x 7 days.
    • Licensing follow-up: Licensing completed record review at facility and noted client to have updated/current self-harm safety plan and treatment plan.