Disability Rights Arkansas

Perimeter Behavioral of West Memphis / Woodridge of West Memphis

*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: 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 10am – 2:45pm. Census: 16. Licensing reviewed 9 personnel files.
  • Regs out of compliance –
    • R103.1 – FBI background check being approved for 5 staff.
    • R103.2 – No Child Maltreatment Central Registry results for 5 staff.
    • R103.7 – AR state police check shall be completed every 5 years (1 staff).
    • R103.8 – Required checks were not initiated within 10 days of hire for 3 staff.
    • R105.4 – No pre-service training for 4 staff.
    • R105.5 – No CPR/First Aid training within 90 days of hire for 3 staff.
    • R105.10 – No documentation of completed 10 hours of psychiatric specific training before being counted in the staff/child ratio for 5 staff.
    • R105.13 – No annual training to include the date, number of hours, the name of the source, and the topic/title for 5 staff.
    • R105.14 – Social Services Director, Caseworkers, and therapists shall have 24 hours of job-related continuing education each year (5 staff).
    • R105.15.b – No date of hire documentation for 3 staff.
    • R105.15.c – No verification of qualifications for 3 staff.
    • R105.15.e – Regulatory checks (3 staff).
    • R105.15.f – Staff not made aware of being a mandated reporter of suspected child maltreatment and have been given information on how to make a report (1 staff).
    • R105.15.g – No functional job description for 3 staff.
    • R105.15.h – One reference verified for 2 staff; No references verified for 3 staff.

Police Report

Call Report, Medical

Caller reported juvenile experiencing chest pain, radiating down the left arm and in the back; Insulin resistance. Juvenile transported to hospital.

Police Report

Call Report, Medical

Caller reported juvenile having seizures; Juvenile’s medical history is extensive. Juvenile transported to hospital.

PRLU or OLTC

Complaint, Notice of Incident, Visit Compliance Report

  • Complaint
    • Licensing received an anonymous report, stating the facility is working with unlicensed therapists. The caller reported at least 3 therapists are not licensed in Arkansas.
    • Licensing follow-up: HR informed Licensing that a few therapists license had expired. Licensing visited facility on 12/28/22 and reviewed files of active therapists. Of the 5 full-time therapists, 2 were verified to have an active Arkansas license while the other 3 were in the process of getting licensed. One of the PRN therapists is also in the process of getting licensed, and the other PRN therapist reportedly is licensed in Tennessee, but not Arkansas. Licensing met with DHS legal counsel and determined the facility is meeting standard 906.1.d by having 1 or more therapists currently licensed as a mental health professional in the state of Arkansas as recognized by Arkansas Medicaid. The complaint is unfounded for any licensing violations.

Police Report

Call Report, Medical

“BP has dropped to 80/50”; Juvenile transported to hospital.

PRLU or OLTC

Buildings and Grounds, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Buildings & Grounds conducted from 11:30am – 2pm. Census: 16. Walkthrough completed of units 3 & 4. MARs reviewed for 5 residents. No licensing concerns noted.

PRLU or OLTC

Complaint, Licensing Follow Up, Notice of Incident, Visit Compliance Report

  • Licensing (Complaint)
    • A former employee reported that staff provoke children to fight each other, staff curses at children, and facility allows 12 y/o girls to be on the same unit as 17 y/o girls. Complainant reported a former male staff member who molested a child of which the state may already be aware of. Complainant also reported that a 16 y/o beat a 13 y/o and staff were not watching the children. Her concerns were brought to the supervisor, and nothing was done about the staff’s conduct.
    • Licensing Specialist spoke with complainant, who gave additional information:
      • Residents are mistreated (unnecessary holds, cursing, yelling, and being snatched up), intimidated, and manipulated by staff and nurses.
      • A former male staff molested a resident and they were corresponding through a book. Staff allow a resident to prey on younger girls.
      • A resident spat on a staff member, and he put her in an aggressive hold.
      • Nursing staff overdosed a resident on medication.
      • A resident was sat on by 6 male staff members as a form of restraint on Unit 3.
      • A fight between older and younger residents happened on 10/08/22 around 6pm, and staff did nothing (reports there is video footage).
      • The residents’ charts are filled with lies and staff are falsifying information.
      • The residents do nothing but sit in rooms all day and some don’t have TVs.
      • Acute: On 09/09/22 around 10:30pm, a staff member was asleep and 2 other staff were not in their designated area. A male resident entered a female resident’s room and was there for almost 30 minutes (reports there is video footage).
      • On 10/27/22, Licensing completed a record review on 3 personnel and 3 residents. The following regulations were cited: 902.13, 904.1.k, 105.15.c, 105.15.d, and 105.15.g. 105.15.h cannot be corrected.
      • On 11/15/22, Licensing reviewed 2 resident’s charts, including restraint documentation. Facility was cited for 902.3 (residents did not have current immunizations, letter of exemption, or scheduled appt in their file) and 902.13 (residents did not have copy of birth certificate or social security card).
      • Licensing complaint is unfounded.

PRLU or OLTC

Children's Records Review, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 11am – 2pm. Census: 15. Licensing reviewed 5 children’s files with no licensing concerns noted.

PRLU or OLTC

Notice of Incident, Rape Allegation

  • Dual (Rape Allegation)
    • CACD accepted a report involving foster child: Child believes to be pregnant as a result of rape that occurred at facility in February or March of 2022. Child does not possess a vagina or uterus. This occurred in her room, and she did not have a roommate at the time. Child claims her belly started growing and requested a pregnancy test, and believes she is 7-8 months pregnant. Reporter believes that the rape may be psychosis related. Child stated she is cramping and bleeding from her privates.
      • Licensing follow-up: The incident was determined to have happened on the acute side of the facility. Licensing does not issue a license for acute hospitals.

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.

PRLU or OLTC

Licensing Follow Up, Notice of Incident, Overdose

  • Licensing (Overdose)
    • Client and peers pushed their way into staff’s office. A peer took medicine (acetaminophen) out of locker while client distracted staff by stealing coffee condiments. Peer hid pill bottle under desk, and while staff was distracted with another client, peer poured pills in client’s hand and client swallowed them. Client was taken to the ER, and after acetaminophen levels were decreased, client was discharged with recommendations to follow up with PCP.
    • Licensing follow-up: Specialist viewed camera footage of incident and observed residents and staff in classroom (ratio 3:1). Residents pushed past staff into the BI office and began going through things. Staff attempted to get residents out of the office with many distractions. Specialist observed client opening something and swallowing but was unable to identify if they were pills or coffee condiments. Outcome: Founded.

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. Licensing was informed the residents have been separated, with the alleged offender being placed in a blocked room (room by herself) and line of sight.

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.