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, Suicide Attempt

  • Suicide Attempt
    • Client picked and scratched at her arms with her nails, then ripped off a piece of her shirt and wrapped it around her neck. Staff intervened and removed object; Reddened area noted to client’s neck. Client admitted she wanted to hurt herself and agreed to wear paper scrubs. Client scored high on C-SSRS and will be on suicide precautions x 7 days.
    • Licensing follow-up: Facility visited on 12/29/22. Licensing inquired why the client was not assessed for self-harm if she was considered “high risk”; DON reported that the attempts were believed to be client’s response after she was unable to reach her parents on the phone during the holidays. Once the client was able to reach her parents, she has not had another self-harm event.

PRLU or OLTC

Notice of Incident, Self-Harm Attempt, Visit Compliance Report

  • Self-harm Attempt
    • Client was dysregulated and grabbed a screw off the cafeteria doorframe. Client placed it in her mouth and threatened to swallow it, before giving it to a staff member. Client processed 1:1 with staff and returned to the unit. No injuries occurred.
    • Licensing follow-up: Licensing visited facility on 12/29/22. Staff reported they originally thought the screw came from the doorframe, but the screws appear different, so they are unsure where it came from. Licensing discussed self-harm precautions with staff.  Facility was cited for several safety issues (see 12/29/22 Visit Compliance Report).

PRLU or OLTC

Technical Assistance, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Licensing completed intent training with POTO staff. Areas in the classroom and on the milieu need to be repainted. The Incident Log was reviewed and copies of 6 incidents were taken to be reviewed and follow up will occur to address any concerns.

PRLU or OLTC

Technical Assistance, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Visit conducted from 1:30pm – 4:30pm. Licensing presented intent training to 2 groups of staff and collected sign-in sheets for all staff in attendance. The training covered sections 107, 108, 109, 110, and the entire 900 section of the Minimum Licensing Standards.

Police Report

Call Report, Medical

Caller reported juvenile has passed out twice, BP is 86/58 and pulse 118. Juvenile transported to hospital.

Medicaid Inspection of Care

Inspection of Care Follow Up Report

  • Included: IOC (follow up report), CAP
  • Multiple deficiencies noted. CAP must be completed within 30 calendar days (CAP submitted and approved).

PRLU or OLTC

Complaint, Notice of Incident, Visit Compliance Report

  • Complaint
    • Complaint received stating client was given the incorrect dose of medication which lead to increased aggression and harm to others. Client was then discharged, and parents were notified via email that they had 72 hours to pick the patient up, 15 hours away. No aftercare plans were made.
    • Licensing follow-up: Licensing reviewed client records. Client was admitted on 11/28/22 and arrived with limited paperwork and bottles of pills (a 60 mg bottle and 80 mg bottle). The nurse assumed the 80 mg bottle was the current dosage, but the actual dosage prescribed was 140 mg. The APRN signed off on the medications after reviewing and adjusting them the following morning. The guardians were notified of the adjustments but were not provided a full list of current meds which would have reflected the lower dose of the specific medication she arrived with. Client exhibited violent behaviors throughout her stay, prompting an emergency 72-hour discharge on 12/20/22. The guardians were then provided a list of medications upon discharge, and they discovered the incorrect dose of medication. CEO advised that the client had several aggressive/violent behaviors at her previous facility, therefore, the facility does not believe the medication changes caused behavior prompting emergency discharge. Licensing investigated this complaint and provided TA on 01/04/23 regarding standard 902.10.f. Licensing complaint unfounded. DON stated that moving forward, the facility plans to complete a nurse review and medication reconciliation for each new resident to ensure meds/dosages are correct and will follow-up with guardian to ensure accuracy.

PRLU or OLTC

Notice of Incident, Property Damage

  • Property Damage
    • Client damaged the fire sprinkler resulting in the fire alarm being triggered, and widespread flooding through the units/milieu. All residents were taken to the back courtyard until deemed safe by the fire department. Once back inside, client stated she planned to elope but was unable to do so. Client was placed on attempted elopement precaution safety plan with constant line of sight, and property destruction safety plan.
    • Licensing follow-up: Facility visited on 12/29/22 and camera footage reviewed. The client is observed escalating and begins destroying and throwing items, then picks up a Lysol bottle that was left out and proceeds to get on a chair and hit the sprinkler with it. Client gets on and off the chair 2 times, hitting the sprinkler both times, before getting on the chair the third time and activating the sprinkler and fire alarm.
    • The facility was cited for 910.1: Lysol was left unattended, allowing the client to obtain it. TA was provided for 905.10: Staff did not intervene while the client attempted to damage the fire sprinkler multiple times before she was successful.

Police Report

Alarm

Keyholder requested dispatch for burglary alarm. Building secured.

PRLU or OLTC

Notice of Incident, Self-Injury, Visit Compliance Report

  • Self-inflicted Injury
    • Client reported self-harming in the shower using a shampoo bottle. Superficial scratches noted to right forearm. Body and room search completed, and client was placed on self-harm precautions including LOS showers x 7 days.
    • Licensing follow-up: Licensing visited facility on 12/29/22. Licensing discussed ways facility can ensure staff are following all doctor’s orders regarding self-harm safety plans and the option of using paper cups for hygiene products to ensure residents do not use bottles to self-harm with. Facility was cited for several safety issues (see 12/29/22 Visit Compliance Report). The facility was also cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).

PRLU or OLTC

Buildings and Grounds, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 9:30am – 10:30am; Census: 30. Blue Unit, Green Unit, and classrooms viewed. Licensing was informed that the new CEO will be starting on 01/04/23. MARs reviewed for 5 residents. No licensing concerns noted.

PRLU or OLTC

Notice of Incident, Self-Harm, Visit Compliance Report

  • Self-harm
    • Client was involved in several verbal altercations with peers and was placed in a restraint after becoming dysregulated and attempting to damage property. Client calmed but became angry again after she was told she could not join her peers in the cafeteria for dinner. Client entered the hygiene closet and locked herself inside. Staff remained by the door and attempted to make entry until client decided to open the door. Client was placed in another restraint, during which she began banging her head on the floor and bit staff on the ankle. Client received a chemical restraint, after which she calmed down. No injuries noted. Client was placed on assault precaution safety plan.
    • Licensing follow-up: Facility visited on 12/29/22. Licensing discussed with staff alternative ways to ensure the hygiene door cannot lock from the inside. Staff reported a mechanism on the inside of the lock can be disabled; This will be completed by 12/30/22. The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).

PRLU or OLTC

Notice of Incident, Self-Injury, Visit Compliance Report

  • Self-inflicted Injury
    • Client self-harmed with light socket cover on her forearm. The wounds were superficial and cleaned with soap and water. Client placed on self-harm precaution x 7 days.
    • Licensing follow-up: Licensing visited the facility on 12/29/22 and observed the resident’s bathroom light socket was replaced. Licensing discussed self-harm precautions with staff, and the facility was cited for several safety issues (see 12/29/22 Visit Compliance Report). The facility was also cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).

PRLU or OLTC

Buildings and Grounds, Visit Compliance Report

  • Licensing Specialist: Michele Sutton.
  • Unannounced buildings and grounds visit completed. Licensing viewed green, blue, and orange units and grounds. Blue unit was recently painted and the unknown black substance around the skylight was removed and painted over. Shower drains have been repaired and tested to ensure they were draining properly. No citations in areas viewed.

PRLU or OLTC

Notice of Incident, Self-Injury, Visit Compliance Report

  • Self-inflicted Injury
    • Client used fingers to create superficial wound on her left arm. Wound was washed with soap and water. Client was placed on self-harm precautions x 7 days.
    • Licensing follow-up: The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).

Police Report

Alarm

Caller requested dispatch. “Got sent to the hotline that is 24/7”; “Building secure.”

PRLU or OLTC

Notice of Incident, Self-Injury, Visit Compliance Report

  • Self-inflicted Injury
    • Client hit head against wall for a short period resulting in a small circular bump in center of forehead. Client refused treatment for injury. Client placed on self-harm safety precautions.
    • Licensing follow-up: The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).

Medicaid Inspection of Care

  • DMS imposes the following sanctions, based on findings from 10/21/22 Inspection of Care, and monitoring visits on 03/29/22, 07/20/22, and 10/13/22:
    • Placement in high priority monitoring status;
    • Submission of a Corrective Action Plan that addresses the deficiencies related to the missing treatment plans, to be submitted to DMS within 30 days of receipt of this notice;
    • DMS will be reporting the facility to its accrediting agency.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 11:30am – 1:15pm; Census: 26. Licensing inquired about de-escalation training that the CEO was waiting on approval from corporate. Interim CEO reported that the CEO is no longer employed at the facility and that all staff get de-escalation training during their SAMA training and annually. A roster was provided of staff that completed SAMA and annual training. No licensing concerns noted.

PRLU or OLTC

Elopement, Notice of Incident, Visit Compliance Report

  • Elopements
    • At approximately 4:08 pm, Client 1 conspired with peers to pull the fire alarm with a set of keys she had stolen. Client 1 entered the employee breakroom and stole car keys and the wallet of a staff member, then fled facility grounds in staff’s car with Client 2. Client 3 eloped from the facility separately. Police were notified. Clients 1 & 2 were picked up by Conway PD and transported to JDC; Client 1 did not return to the facility and was picked up by AR DHS, and Client 2 returned to the facility and was placed on elopement precautions, line of sight, and placed in paper scrubs. Client 3 was located by Springdale PD 2-3 hours later; She returned to the facility and was placed on elopement precautions and line of sight.
    • Licensing follow-up: Facility visited on 11/29/22 and camera footage reviewed. Licensing was informed that when the resident pulled the fire alarm and ran out of the gym, staff did not follow her but informed other staff and called the police. The resident then entered the breakroom and stole the keys and wallet. The other 2 residents eloped after being escorted outside due to the fire alarm. No licensing concerns noted.

Police Report

Missing Person, Runaway, Theft of Vehicle

At 1614 hours, staff called to report a child missing after the fire alarm was activated and doors unlocked; Shortly after, staff advised all children were accounted for. At 1637 hours, staff advised dispatch a juvenile fled the facility. Upon officer’s arrival, staff stated there were 2 missing juveniles. Staff stated J1 pulled the fire alarm and grabbed a wallet, backpack, cigarettes, and a lighter, then walked outside and left in a staff member’s vehicle. Staff later noticed J2 was missing and were unsure how she left the facility. At 1739 hours, staff called dispatch to advise of another missing juvenile that ran out of the facility when the fire alarm was pulled. J3 was located by police at approximately 8:10pm. At approximately 2319 hours, J1 & J2 were located by State Police near Plumerville.

PRLU or OLTC

Complaint Visit, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 10:15am – 12:30pm; Census: 24. Licensing inquired about boundary training, and the CEO reported that all staff have completed boundary training (Maintaining Healthy Boundaries) except for 3 PRN staff members. CEO stated those staff will not be able to work until they have completed the training. Copies of the sign-in sheets were provided. No licensing concerns noted.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

  • Maltreatment
    • It was reported by residents and staff that 2 residents were allowed to use a vape by a staff member while on transportation to an outside medical facility. The staff member was terminated from the facility on 11/22/22, and the staff member who reported it received a verbal and final written warning. Residents and their belongings were searched and nothing was found.
    • Licensing follow-up: Licensing spoke with staff, who stated the 2 residents were being taken to the ER for a stomachache and strep throat. The alleged staff member transported them, along with a new staff member who reported the incident. When asked about the incident by management, the alleged staff member stated “something like that may have happened” and refused to discuss it further. The staff member was immediately terminated. A sweep of the facility was conducted and no vape pen was recovered. Child Abuse Hotline call was screened out. Licensing was provided with the discharge papers for the ER visits, witness statement from staff, phone numbers of the staff members, and corrective action plan. Facility was cited for 907.2 (staff failed to provide the level of supervision to ensure the safety and well-being of the residents).

PRLU or OLTC

Notice of Incident, Suicide Attempt, Visit Compliance Report

  • Suicide Attempt
    • Client was sleeping in the dayroom due to safety precautions. When staff approached to do a safety check, client had 2 socks tied together and was making gestures to put it around their neck. Staff removed the socks and client was assessed. Suicide precautions were extended. 
    • Licensing follow-up: Licensing viewed camera footage on 11/23/22 and observed 4 residents sleeping in the dayroom due to being on precautions. Due to the camera angle, licensing was only able to observe client’s lower extremities under the covers, moving around on her mattress. No licensing concerns noted.

Police Report

Disorderly Conduct

Caller stated they needed an officer “right now”, stating a client was fighting staff (at approximately 1945 hours). Yelling could be heard in the background of the call. Officers responded to facility. A juvenile was transported to ER after complaining of stomach pain.