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.
  • 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.

PRLU or OLTC

Personnel Record Review, Visit Compliance Report

  • Specialist reviewed personnel records for 5 staff; Census 21.
  • Regs out of compliance –
    • R105.4.b – Specialist could not locate training verification of resident grievance processes for two staff.
    • R105.15.h – Two staff members only have one of three needed reference checks in their charts.
  • TA –
    • R105.10 – Ensure any training considered psychiatric specific is labeled as such so they can be counted in the required 10 hours of psychiatric specific training required.
  • Regs not correctable –
    • R105.14 – Case manager only completed 2 hours of continuing education for 2020-2021 and 14 hours in 2019-2020.

Police Report

Call Report, Disturbance

Officers responded in reference to verbal altercation; One party went inside the residence, the other stayed outside. No action taken.

Police Report

Alarm - General, Call Report

Accidental; Staff stated a nurse hit the alarm in error.

PRLU or OLTC

Visit Compliance Report

  • Completed buildings/grounds walkthrough, reviewed MARs and 5 children’s records.
  • Regs out of compliance –
    • R914.6 – No escape route diagram located in the educational building; Staff placed a paper copy on the wall until a new plastic copy can be ordered (Corrected on-site).
  • TA –
    • R102.11 – Specialist discussed recent administration changes including a new CEO. Specialist was provided with a new organizational chart. Specialist advised the agency is required to report any changes of Administrator, Social Services Director, or Clinical Director to Licensing within 5 days.

PRLU or OLTC

Visit Compliance Report

  • Specialists conducted unannounced visit, reviewed buildings and grounds with no issues. Reviewed MAR for resident.
  • Regs not correctable –
    • R908.8 – Medication was not documented at time of medical given. Night nurse needs to be retrained on use of MAR and sent to Licensing Specialist when completed. Expected completion date: 10/05/21.

PRLU or OLTC

Notice of Incident

  • ER Visit – Self-Harm 
    • Resident reported to staff on 08/23/21 that she punched a wall on 08/21/21. An assessment was done on her hand and the nurse noted swelling. Resident was taken to ER for further evaluation. No follow-up details.