Disability Rights Arkansas

Perimeter Behavioral of West Memphis / Woodridge of West Memphis

Location: West Memphis, AR

Population Served: Adolescents aging from 12-17 (there is also an Acute onsite for ages 6-17)

# of residents per unit: Up to 18 Residents per room: 3 Capacity: 36

Contact with family (Calls and visit schedule): Family calls 2-3 times per week.

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

Treatment Components:

Clinical Director - LPC

Therapists: 6 therapists (1 LMSW, 1 LPC, 1 LCSW, 3 MS) that cover the PRTF and 36 bed acute side

Treatment modalities offered: DBT, CBT

# of individual therapy sessions/week: 1-2

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

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PRLU or OLTC

Personnel Record Review, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 12:45pm – 3:00pm. Census: 16. Licensing Specialist reviewed 3 personnel files.
  • Regs out of compliance –
    • 1.103.1 – FBI results needed for 3 staff. Due date: 09/16/22.
    • 1.103.3 – Child Maltreatment Registry needed every 2 years for 1 staff. Due date: 09/16/22.
    • 1.105.13 – Documentation of annual training to include number of hours, the name of the source, and/or topic/title for 3 staff. Due date: 09/16/22.
    • 1.105.15.g – Functional job description for 1 staff. Due date: 09/16/22.
    • 1.105.15.h – Three (3) positive personal references from nonrelatives for 1 staff. Due date: 09/16/22.
    • 1.107.4 – Documentation that staff have been made aware of the need to protect the confidentiality of children in the use of social media for 2 staff. Due date: 09/16/22.

Police Report

Alarm, Call Report

Staff advised it was a false alarm, someone knocked down the fire exit.

Police Report

Runaway Complaint call report

Officers responded in reference to a runaway juvenile. Upon arrival, officers were advised by staff that juvenile was being loaded onto a transport van when he fled from staff. About 20 minutes later, Juvenile returned to the scene, crying and apologizing for running away from staff. Juvenile was transported to Crittenden County Detention Center.

Police Report

Call Report, EMS Assist

Officers dispatched to assist in transporting juvenile having an allergic reaction to the hospital.

PRLU or OLTC

Accidental Injury, Notice of Incident

  • Fracture (Accidental Injury)
    • Resident complained of left foot pain, stating they almost tripped in classroom and hit their toe. Resident could not remember the timeframe of the incident. X-ray confirmed fracture of 5th toe, and resident’s foot was placed in an Unna boot. Follow-up appointment was scheduled for 9/12/22, and resident was informed to report all injuries, no matter how small.

PRLU or OLTC

Maltreatment, Notice of Incident

  • Maltreatment
    • Resident reported that over the last few days, peer had become sexual with resident. Resident reported things started off with kissing on the mouth, laying between peer’s legs, and kissing on the neck. Resident reported peer pulled their pants down and performed oral sex and fondled resident sexually. When asked if resident ever said no or state they did not want that to happen, resident stated “I didn’t say no, but I did not want this to happen.” Residents were separated from each other, and both were placed on Peer Separation Precaution. Peer was placed into a blocked room until they discharge.
    • Child Abuse Hotline was called and accepted. Investigation pending.

PRLU or OLTC

Personnel Record Review, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Licensing Specialist reviewed 10 personnel files.
  • Regs out of compliance –
    • 1.103.1 – No FBI check verification printouts for 5 staff.
    • 1.105.4.j – No signed verification that staff was made aware of the minimum licensing standards for their license type for 1 staff.
    • 1.105.5 – No verification of CPR/First Aid completion for 1 staff.
    • 1.105.14 – For 2 staff, verification of 24 hours job-related continuing education was not observed.
    • 1.105.13 – No documentation of annual training for 5 staff.
    • 1.105.15.d – No documentation of annual training for 5 staff.
    • 1.105.15.g – No functional job description in 1 staff’s file.
    • 1.105.15.h – 3 staff did not have 3 personal references or were not verified.
    • 1.107.4 – No documentation that staff was made aware of the need to protect the confidentiality of children in the use of social media for 2 staff.

Police Report

Call Report, EMS Assist

Juvenile had a seizure and was unconscious. EMS transported juvenile to hospital.

Police Report

Medical Call

27 y/o female vomiting, blood loss, lethargic. Transported to hospital.

Police Report

Medical Call

Juvenile having a seizure; EMS transported juvenile to hospital.

PRLU or OLTC

Children's Records Review, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Facility visited from 11:00am – 2:00pm. The Licensing Specialist and Program Coordinator reviewed 5 children’s records.
  • Regs out of compliance –
    • R902.3 – No immunization records were found for 5 residents. Due date: 08/14/22.
    • R902.13 – Birth certificates and social security cards could not be located for multiple residents. Due date: 08/14/22.
  • Regs not correctable –
    • R903.4 – Three residents did not have a master treatment plan in their file even though it has been more than 30 days since their admission.

PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Facility visited from 12:30 – 14:00. Census: 24. Showers were viewed in all resident bedrooms and no tiles were found to be loose.
  • TA –
    • R911.6 – Please ensure that peeling paint is corrected and repainted throughout each unit.
    • R913.5 – Two resident mattresses on blue unit (102 and 103) and one mattress on orange unit (201) need to be replaced. All resident bedrooms should be checked to ensure that no additional mattresses need to be replaced. 

Medicaid Inspection of Care

Inspection of Care Report

  • Included: IOC Report
  • Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
  • DPSQA PR has provided multiple outreach attempts since to assist provider in completing, however CAP has not been received.

PRLU or OLTC

ER Visit, Notice of Incident

  • ER Visit (Swallowed Pen)
    • Resident was taken to the ER after swallowing a pen.
    • Licensing follow-up on 6/21/22: Licensing found the incident report in the mail room of the county office. The date marked on it is “received 6/9/2022” via fax. Licensing was not made aware of the fax. Licensing reached out to the facility and informed them to send all incident reports through email and if that was not available, to notify the Program Coordinator when any paperwork is faxed to the county office.

Police Report

EMS Assist

Staff advised they have a child that is unresponsive, unknown medical history. Transported to ER by EMS.

PRLU or OLTC

Children's Records Review, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Facility visited from 12:40 – 16:00. Census: 18. Children’s record review completed for multiple residents and personnel record viewed for 1 staff member.
  • Regs out of compliance –
    • R902.13 – Multiple residents did not have a copy of their legal documents or documented attempts to receive them from the guardian in the chart within 30 days following admission. Due date: 6/17/22.
  • Regs not correctable –
    • R903.4 – Multiple residents did not have a treatment plan in their chart within 30 days following admission.
    • R103.3 – Staff member is overdue for his child maltreatment registry check. Staff report that the check has now been initiated but is in a pending status.
    • R904.1.p – Multiple residents did not have any individual therapy notes documented within the past 30 days.
    • R105.8 – Staff member did not receive 30 hours of continuing education in 2021.
    • R902.3 – Multiple residents did not have a copy of their immunizations or a documented appointment to receive them within 7 days following admission.
    • R105.13 – Some documentation of annual training was found on a written log in staff members file, but the log did not document the required items listed in the standard.

Police Report

Call Report, Juvenile Complaint

Caller reported juvenile destroying personal property by punching vehicle and leaving a dent. Caller stated juvenile was battering him. Juvenile will be readmitted.

Police Report

Call Report, Runaway

Staff advised at approximately 2:15pm, all juveniles went outside in the back yard for recreational time. Staff stated at approximately 2:35pm, she believes the 2 juveniles ran away from the facility. The 2 technicians supervising the juveniles stated the gate in the backyard was not secured, allowing juveniles to leave on foot. On 4/12 at approximately 11:49pm, J1 was found at a Walmart. He was placed in custody and transported to CCJDC. J2 ran away from officers at Walmart.

Police Report

Call Report, Medical

Juvenile unresponsive, still breathing; History of seizures.

PRLU or OLTC

Background Check Review, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Census on RTC: 18. Visit conducted from 14:00 – 16:30 and from 18:30 – 19:30. MARs reviewed for 4 residents; Background checks reviewed for 25 employees.
  • Regs not correctable –
    • R908.8 – Two medications were not initialed as administered on [date] for one resident.

Police Report

Call Report, Medical

Juvenile hit brick wall, head injury. Juvenile transported by EMS to hospital.

Police Report

Call Report, Fight Call

Manager advised there is a group of females fighting; Parties separated. Unknown if juveniles or staff.