Disability Rights Arkansas

Millcreek Behavioral Health / Habilitation Center, Inc.

*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 rstanford@disabilityrightsar.org

Location: Fordyce, AR                   Population Served: Youth ages 6-17

# of residents per unit: Up to 20 Residents per room: 2-3

Capacity: 162 (111 Arkansas Medicaid PRTF beds, 51 Residential beds used for out-of-state resident PRTF placement or AR contract beds).

Contact with family (Calls and visit schedule): Family visits vary on a case-by-case basis. Phone Calls are allowed on 4 days of each week and are limited to 10 minutes unless otherwise specified.

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

Treatment Components:

Clinical Director: LPC                    Therapists:8 full-time therapists (LPC-S, 5 LPC, 1 LCSW, 1 LMSW)

Treatment modalities offered: 1 EMDR, TF-CBT

# of individual therapy sessions/week: 1

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

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PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Medical Center (DCMC) for outpatient assessment following his involvement in a physical confrontation. During the confrontation, he was punched in the nose by a peer. On-site nursing referred him to DCMC for a laceration to the nose. The laceration was closed using DermaBond. A CT scan of facial bones was performed out of precaution. He was released to return to the facility.

On 6/26/23, CT report received. Revealed a slightly displaced left nasal bone fracture. Follow up with ENT is forthcoming.

Licensing narrative:

  • Millcreek who stated there was video footage of this incident. Visit scheduled for 6/27/23.
  • Facility visited 6/27/23 and video reviewed of the incident which occurred at pine ridge on 6/24/23. Staff/Client ratio visible in video 2:8. The fight itself appears to take place out of video view, but the aggressor can be seen punching something (which later in the video is revealed to be client). As soon as the aggressor begins to punch, two staff are seen intervening. As soon as the staff intervene, another altercation is seen at which point the same two staff intervene in that altercation. Staff are seen using the phone and the nurse is seen entering Pine Ridge a couple minutes later. Client then appears in video bleeding, using a towel to wipe the blood. Both staff observed in video intervene seemingly as fast as they possibly can in both altercations.

Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Personnel Record Review, Visit Compliance Report

Personnel records review conducted for staff: [REDACTED] all items per minimum licensing standards accounted for. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was sent to Dallas County Medical Center for outpatient x-rays. He reported pain in his thumb as a result of him hitting it against the wall during a moment of horseplay. X-ray report reveals no fracture. He was released and returned to facility.

PRLU or OLTC

Maltreatment, Notice of Incident

Alleged victim is [REDACTED], alleged offender is [REDACTED], who is a staff member at Millcreek Behavioral Health. Client has been at Millcreek since 2019 for mental health. Since December 2022 until now, there have been 6 or more phone calls from staff stating has been injured due to an altercation. This past weekend, (6/10-6/11), a nurse reported alleged victim tried to run away, and the alleged offender tried stopping him. Alleged offender “accidentally” kneed in the mouth. The caller believes that something more may be going on at the facility and doesn’t understand how a staff person’s knee could accidentally make its way to the child’s mouth. It is believed that alleged victim does have injuries but the exact level of injury is unknown.

Licensing narrative:

  • Phone call made to facility on 6/13/23 to confirm client still resides at Millcreek.
  • Facility visited 6/14/23, client was interviewed. Client stated that they liked everything about Millcreek and reported that he had never been hit nor kicked by staff at Millcreek.
  • Received email on 7/13/23 that maltreatment report was unfounded.

PRLU or OLTC

Medical, Notice of Incident

Per Dr. Walley, the patient was sent to Dallas Medical Center (DCMC) for a CT scan due to having blood-tinged sputum/stool for a couple of days. Patient returned from DCMC with orders not to eat or drink after midnight just in case they need to do another CT scan with contrast. Follow-Up appointments will be scheduled as necessary.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was sent over to Dallas County Medical Center for x-ray due to him limping, patient stated he had tripped over something a couple of days ago.

On 6/15/23, x-ray report stated that due to the right foot pain, there is a fracture to the distal third metatarsal neck. On 6/15/23, licensing phoned [REDACTED], Risk Management Coordinator for Millcreek, to confirm that the x-ray was completed on 6/14/23, not 6/8/23. The incident that caused the client pain happened on 6/8/23.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Medical Center for assessment following a physical confrontation. Onsite nursing observed a laceration near right eye. The patient received three staples and returned to the facility. Follow-Up appointments will be scheduled as necessary.

Licensing narrative: email sent to facility 6/7/23 to inquire if there is video footage of incident. Received 6/7/23 that altercation took place outside and there in not footage. Both clients interviewed on visit 6/7/23. No licensing concerns at this time. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Medical Center (DCMC) for assessment. He was referred for swelling noted to his eye following a physical confrontation that happened the previous day. He was assessed at DCMC and released to return to the facility. The eye was irrigated only. If necessary, further treatment could be provided by Primary Care Physician.

Phone call made to [REDACTED] of Millcreek 5/31/23 who stated that there is no video of the altercation. Facility visited 6/2/23 in response to self-report incident of client being punched in the eye. Clients interviewed. Client stated that two staff were presented when they were “attacked” and that they intervened “pretty quickly”. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

During a camera review of a physical restraint of patient [REDACTED], it was determined that two staff members did not perform the restraint in compliance of facility expectations. Staff hit client in the face as a response to being bitten on the arm. The other staff member can been seen pulling the client’s shirt over their face. No injuries were sustained by the patient.

A report of these findings was made to the Arkansas Mandated Reporter portal. Reference ID: [REDACTED] both staff members were placed on administrative leave, pending termination. Received text message 5/25/23 from [REDACTED] of Millcreek that maltreatment report was accepted. Received email from licensing 5/25/23 that maltreatment report was accepted. Facility visited 5/25/23 and video reviewed of incident. Both staff have been suspended pending certain termination from employment by Millcreek. All Millcreek staff will be retrained on Acadia zero tolerance for abuse and neglect.

Regulations out of compliance: 109.1.G – two staff are seen aggressively pulling client’s shirt off during a hold. One staff seen striking client with a fist. 905.4.G – two staff are seen aggressively pulling client’s shirt off during a hold. One staff seen striking client with a fist.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was sent to Dallas County Medical Center (DCMC) for assessment after a recreational injury. He and staff member inadvertently bumped into each other while going for a ball, causing client to fall to the ground, hitting his head. He was assessed at DCMC and released to facility. Client was diagnosed with a hematoma and needs no further medical treatment.

PRLU or OLTC

Notice of Incident, Peer Sexual Contact, Visit Compliance Report

On 5/21/23 at 1945, client reported to the nurse that a peer was in his room being sexually inappropriate. On 5/24/23 while in a family session with his therapist, client reported that he was raped by a peer. Client was asked to explain by his therapist, and he stated that the peer bent him over and stuck his penis in his butt. Client stated that the peer asked him to be his bitch.

On 6/13/23, alleged victim was interviewed by Investigator Garcia, and disclosed that 2 months ago he was raped in the bedroom that they shared together. When asked about that, client disclosed that [REDACTED] pulled down client’s pants and underwear and put his penis in client’s butt twice on the same day. Facility was phoned by Licensing 6/13/23 to inquire about when this incident was reported and when it was reported to licensing. [REDACTED], Risk Management Assistant, gave no reasonable explanation as to why was not called until 6/9/23 for an incident that was reported 5/24/23. [REDACTED] did state that the clients were separated. [REDACTED] was moved to Tiger Hall. [REDACTED] remained at Magnolia Hall. [REDACTED], Risk Management of Millcreek was phoned, who was on vacation who could provide no reasonable explanation as to why the was notified untimely.

Follow up visit conducted 8/2/23 of Magnolia Hall to verify client sleeping area. [REDACTED] bedroom is room 2 of Magnolia Hall. Three beds present, with only one furnished. Room appears as though one client occupies it. Regulations out of compliance: 110.9 – this incident was reported by client to Millcreek staff on 5/24/23. Millcreek notified the child abuse hotline on 6/12/23. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Medical Center (DCMC) for assessment after a physical confrontation with peers. Nursing assessment reflected 10/10 mouth pain resulting from being punched in the mouth. Assessment revealed that teeth were intact but displaced. After assessment at DCMC, he was referred to Arkansas Children’s Hospital (ACH).

ACH diagnosis: Open fracture to tooth and displacement to tooth. He was ordered to receive the care of a dentist as soon as possible. This visit is scheduled to occur on 05.22.23. Phone call made 5/22/23 to [Redacted] of Millcreek who stated there is video of the hallway, but that the fight takes place in a client bedroom.

Facility visited 5/23/23 in response to self-reported incident of client being assaulted by peers resulting in dental injury. Video reviewed of hallway of incident. Staff are seen in the hallway then entering the dayroom entry way, seemingly to address something taking place in the dayroom. No video of inside this dayroom available. 3 staff are seen in the video, 2 staff escorting client out of the dayroom. Another video review yields client continuing being escorted by the two staff and being attended to by 2 nurses in the hallway.

Client was reassigned living quarters from Tiger Hall to Pebble Creek after this incident. Client could not be interviewed during today’s visit due to reported current, ongoing, dysregulated behavior from client today. Per risk management, [Redacted], several attempts have been made to assign client living quarters that will ensure his safety. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Client was slapped on the left cheek by staff member. A candy sucker had fallen to the ground and [REDACTED] attempted to pick it up. As he did, he was slapped by [REDACTED]. Nursing assessment reflected redness on the left cheek. The staff member was immediately placed on administrative leave and removed from the living unit by supervisory personnel. The incident was reported to the child abuse hotline. Reference number: [REDACTED].

No return correspondence has been received, reflecting if the report was accepted for investigation. Based on the findings of the internal investigation, Millcreek will terminate the employment of [REDACTED]. Termination is scheduled for 05/22/23. As a follow-up, zero tolerance in-service training was conducted with employees of the living unit. Received notification 5/22/23 that the first call for this incident was screened out.

This incident was re-reported to the 5/23/23 by Licensing Specialist Clayton DeBoer, ref#[REDACTED]. Received confirmation 5/24/23 that call was accepted. Received notification 7/24/23 that ref#[REDACTED] was unsubstantiated.

Regulations out of compliance: 905.4.G – staff [Redacted] is seen slapping client. 109.1.G – staff [Redacted] is seen slapping client.

PRLU or OLTC

Visit Compliance Report

Program coordinator met with CEO [REDACTED] and regional CEO [REDACTED] to discuss the Corrective Action Agreement put in place between Millcreek of Arkansas psychiatric residential treatment facility (PRTF) and the placement and residential licensing unit. The plan was discussed, agreed upon, and signed by all parties. The Program Coordinator informed the facility that, while it is not required, their attendance at the CWARB meetings over the period of the Corrective Action Agreement is encouraged so they may discuss their progress towards the goals for correcting areas of non-compliance. CEO will provide the Program Coordinator with dates and times that would be good for the agency to conduct an intent training with the licensing unit. Licensing Specialist: Chelsea Vardell.

PRLU or OLTC

Corrective Action Agreement

The following non-compliance areas have been cited during the past 3 months:

  • 109.1.g (Unprofessional Conduct) – Facility received a citation on 03/03/23 regarding the inappropriate discipline given to a resident based on their age, development, and history.
  • 905.3 (Behavior Management) – Facility received a citation on 03/13/23 regarding the inappropriate discipline given to a resident based on their age, development, and history.
  • 905.4.f (Behavior Management) – Facility received a citation on 03/13/23 regarding inappropriate behavior management.
  • 905.4.g (Behavior Management) – Facility received a citation on 03/17/23 regarding inappropriate behavior management.
  • 907.2 (Ratio & Supervision) – Facility received citations on 01/03/23, 01/17/23, 03/03/23, and 03/13/23 regarding the failure of staff to provide adequate supervision to residents.

The facility is required to complete the following:

  • Present an intent training for all facility staff regarding the Minimum Licensing Standards sections 109, 110, and all of 900.
  • Conduct a minimum of once per week camera reviews of 3 separate locations in facility to ensure staff are appropriately supervising residents.
  • If a discovery is made of staff failing to supervise or participating in inappropriate behavior management, the facility will report it to the Licensing Unit by the next business day.
  • Retrain all child caring staff on behavior management policy.
  • Continue daily leadership rounding program to ensure all doors required to be locked are secured, looking for safety concerns, and any environment of care issues.
  • Proceed with training all direct care staff on the topics of Nurtured Heart Approach, Improving the Milieu, De-escalation with Highly Aggressive Patients, and Processing with our Clients.

PRLU or OLTC

Visit Compliance Report

Buildings & grounds conducted from 9:45 AM – 11:00 AM. Kangaroo and Eagle halls observed to be clean, safe, and in good repair except for wooden flooring that had holes in them. CEO [REDACTED] indicated during this visit that floors were being repaired facility-wide, and that the floors would be replaced in the near future. Bathrooms were clean and sanitary with functioning showers, sinks, and toilets. Outdoor basketball area was free of safety hazards.

MAR checked for 5 clients, all initialed and up to date except one AM medication for the date 5/16/23.

Regulations out of compliance: 908.8 – one client’s AM medication was not initialed for 5/16/23. Regulations needing technical assistance: 911.6 – Kangaroo and Eagle halls had holes in wooden flooring. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Notice of Incident, Self-Harm

Client was sent to Dallas County Medical Center for outpatient x-rays following an episode of self-injurious behavior where he punched a wall. X-ray results indicate that no fracture was present. He was returned to the facility without treatment.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was referred to Dallas County Medical Center for outpatient x-rays as she reported pain in her ankle from a recreational injury. No fracture found. She was returned to the facility without treatment.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to the Dallas County Medical Center for assessment following a physical confrontation with a peer. He was punched in the face and received a superficial laceration above his left eye. Dermabond was applied to the wound, and he was returned to the facility. No further treatment was necessary.

Facility visited 5/16/23 and video reviewed of this incident. Visible staff/Client ration in video 2:11. Client sits in a chair that [REDACTED] seems to disapprove of. Client then punches [REDACTED]. Staff immediately intervene. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Accidental Injury, Notice of Incident, Visit Compliance Report

Client was sent to the Dallas County Medical Center (DCMC) for assessment of a head injury. He was picked up and dropped by a peer while standing in line to leave the living unit. When he was dropped to the floor, he struck the back of his head on the floor. On-site nursing assessed and referred to DCMC as a precautionary measure and for further assessment. DCMC determined that no treatment was necessary. He was released to return to the facility.

Facility visited 5/10/23 and video reviewed of this incident. Peer is seen attempting to lift client. This does not seem to be aggressive. Peer is seen lifting client then dropping them accidententially. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client reported to the Medical Director that he had pain in his right arm from when he fell during a recreational game. Client previously fractured his right arm on 01/18/23. Out of precaution, he was referred to Dallas County Medical Center for outpatient x-rays. The x-ray report indicates that there is no fracture.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Medical Center for outpatient x-rays. He received an on-site nursing assessment following a physical confrontation with a peer where he was kicked in the face. X-ray report indicates an acute comminuted and displaced nasal bone fracture, greater on the right. The doctor determined no follow up treatment is necessary. He was released to return to the facility. Interim Action Narrative: Resident was moved to the Tiger Hall.

Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Client reported that Millcreek staff members performed a personal body search on her while they were looking for contraband. During the search, an unnamed staff member rubbed her hand against the client’s breast. Facility visited on 5/1/23. 4 staff were present during the search, all staff present were interviewed. Client stated that 4 female staff were present during the search. All staff corroborate the same story, client was asked to remove some clothes for the search, but staff never asked client to remove their undergarments. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Medical Center ER for assessment of injuries following a physical confrontation that involved him being punched by a peer. He was assessed and released back to the facility without signs of distress. ER report indicated minimal swelling on the right side of his nose. No further injury noted.

Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Notice of Incident, Self-Harm

Client was sent to the Dallas County Medical Center Emergency Room for x-ray of her right hand. Medical Director instructed her to be sent for assessment following the patient punching a wall. X-ray report indicates normal alignment with no displacement seen. No fracture or deformity indicated. She was released to return to the facility.