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 [email protected]

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

Licensing Compliance Record, Maltreatment, Notice of Incident

  • Maltreatment
    • Client reported to staff that staff member picked him up and slammed him on the floor in another client’s bedroom. Nursing evaluation: Nickle size abrasion to left elbow with superficial scab present. Child Abuse Hotline was called and accepted. Staff placed on administrative leave.
    • Licensing follow-up: Facility visited 1/6/22. No camera footage available of incident. Facility cited (110.12: Incident occurred on 12/31/21 and hotline was called and accepted; Licensing was notified on 1/5/22). CACD investigation unsubstantiated. Staff was retrained and brought back, but no longer works at facility for unrelated reasons. 

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported that peer was “feeling her breast and rubbing her elbow and tried to hold her hand” while their group was watching a movie. Client reported during the internal investigation that both girls were fully clothed. The event was alleged to have occurred over a period of 3 minutes. Nurse evaluation: No injury indicated.
    • Child Abuse Hotline was called, not accepted. Specialist followed up on 12/28/21: Staff stated they would research what staff ratio and staff names were during incident. Staff ratio reported to be within licensing standards. No camera footage of area or incident.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client alleged that staff member “bitch slapped” him in the face while intervening in an episode of physical aggression. The primary interview with client showed discrepancies in the alleged events that lead to doubts of the authenticity of the report. A follow-up interview on 12/21/21 matched the original allegation. Interviews conducted with 2 staff and 4 patients revealed that no eyewitnesses corroborate the statements of client being slapped. Nurse evaluation: No redness, swelling, or bruising to the indicated area.
    • Child Abuse Hotline was called and accepted. Staff was placed on leave pending outcome of investigation. Specialist followed up on 12/21/21: Facility’s internal investigation yielded nothing to substantiate report. No camera footage to review for licensing standards.

Police Report

Radio Log, Second Degree Escape

Staff reported missing juveniles at 1739. Staff could not provide complete descriptions. Upon arrival, staff stated they had both subjects in custody (at approximately 1755).

Police Report

Radio Log, Second Degree Escape

Staff reported missing juvenile at 1755 and stated they didn’t know what time he left. Juvenile was located by police at 1841 and was picked up by staff.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client stated that staff member instigated a group of 4 fellow patients to fight her. Internal investigation conducted with 3 staff and 5 patients revealed that no witnesses corroborate the statements of client. It was admitted by alleged staff member that on 12/4/21, client got in her face and slightly pushed her, in which staff pushed client’s shoulder and told her to move. Nurse evaluation: Scratch under and over left eye. Scant amount of bleeding. Small knot to left side of forehead with several scratches. Client had hair pulled out on both sides of head with scant bleeding noted.
    • Child Abuse Hotline was called, not accepted. Staff placed on leave. Specialist followed up via phone call on 12/9/21: Staff emailed the hotline call reference number and stated it had not been accepted. Moving forward, staff will be properly trained that physical injury or threat of bodily harm may not be used when interacting with clients. Facility visited on 12/15/21; Facility cited for 905.4g. Facility cited for staff pushing client.

PRLU or OLTC

Visit Compliance Report

Buildings and grounds completed; Census 221. MARs were reviewed for 6 residents. No concerns noted

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported to his therapist that staff member was trying to protect peer during a physical altercation they had and in the process of separating both patients, staff member slapped client. Client stated he was punched in the left cheek multiple times by peer. Nurse evaluation: Slight discolored area to left cheek bone.
    • Child Abuse Hotline called and accepted. Specialist followed up on 11/18/21: Staff stated clients and staff were interviewed and no camera footage was available of room where incident happened (bedroom). Video of outside of bedroom is being held until staff can view. Staff member has been placed on administrative leave pending outcome of investigation.

PRLU or OLTC

Complaint Survey

Complaint #AR00027389 substantiated, all or in part, with no deficiencies cited.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client stated he was sleeping and woke up to peer 1 penetrating his penis in peer 2s behind. Peer 2 asked what peer 1 was doing, and peer 1 stated nothing and went back to bed. Peer 2 was taken to hospital for assessment.
    • Child Abuse Hotline was called and accepted. Clients have been placed on separate halls and no interaction between clients happens. All recreation, meals, and activity time is separate. Specialist followed up with investigator via email on 11/15/21 regarding findings of incident. No further details.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client stated that sometime between May 27th and June 15th, client woke up with her panties down one night and staff member (unknown) was touching her vagina. Client states she did not tell anyone but then said a female staff was informed. Client stated the female staff told her that she must have been dreaming because they do not allow male staff on the female side.
    • Child Abuse Hotline was called and accepted. Specialist sent email to investigator on 11/3/21 requesting permission to contact Millcreek regarding report (permission granted). Specialist followed up with Risk Manager and they were going to review the information and get back to licensing unit since they had not received the information prior to program coordinator talking to them. No further details.

PRLU or OLTC

Visit Compliance Report

Records review conducted for 10 employees. No issues found.

Police Report

Criminal Mischief First Degree, Radio Log

Staff reported they have 2 male escapees but before police got descriptions they had been found. Staff reported they had 7 clients that were having behavior issues and attempting to damage property. Later staff called back to report juvenile had broken a rear window on staff member’s car with a sign.

PRLU or OLTC

Notice of Incident

  • Injury
    • Client became upset when 2 peers disclosed something that she said to a supervisor; Client entered bathroom and punched the wall with her fist. Client was taken to ER for X-ray: No fracture.
    • No video footage available of the incident.

Medicaid Inspection of Care

On-Site Inspection

  • Included: IOC (revised), Reconsideration Determination Letter
  • Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.

PRLU or OLTC

Notice of Incident

  • Suicide Attempt
    • Client became upset and went to her room; Client remained in her room while unit left for cafeteria. Client took her clothes off, found a phone charge cord in the hallway and tied it around her neck. She stated she did this because she heard a voice telling her to. Upon noticing she was not with the group, staff came back to unit to discover her condition in the bedroom. Client was placed on suicide prevention precautions.
    • Staff members involved were placed on administrative leave as an investigation was conducted. In-services are being completed campus-wide in relation to head counts, documentation, informational handoffs, staff to patient ratio/supervision, cell phone usage/security. Child Abuse Hotline was called, not accepted. No video footage available of the incident.

PRLU or OLTC

Notice of Incident

  • Restraint Injury
    • After client attempted to hit staff with a loose board from the playground equipment, client was placed in a restraint. Client complained of pain to left ankle, originally stating that he twisted his ankle when he fell, and later stated that staff rolled over his ankle while placing him in a restraint. Client stated that he is not sure what happened, but he didn’t think that staff member intentionally hurt him. Client was sent to ER for X-ray: Closed fracture to left navicular bone. Patient placed in short leg cast.
    • After specialist follow-up, facility staff stated that the playground equipment is old and is more than likely going to be removed. Names of staff involved in incident were provided. No camera footage available. Specialist followed up on equipment removal via email.

Police Report

Radio Log, Second Degree Escape

Officers were dispatched for 3 runaway Juveniles from facility. Upon arrival, Officer saw 2 females on the ground with 2 staff members restraining them. J1 was fighting with staff member trying to get free. Officer placed both Juveniles in handcuffs and in patrol unit. J1 stated staff member choked her; Officer advised staff member did not. Officer states staff had J1s arms crossed on her chest and restraining them down on her chest to keep her from escaping again. No marks found on J1. Officer transported the 2 Juveniles back to facility.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported that after jumping into an argument between his peers, staff pushed him, so he pushed staff back. Client stated that staff grabbed him by the neck and slammed him to the floor which led to a restraint joined by the rest of the staff members. Client stated that the staff threatened that he would have him moved to another unit so that other patients would jump him.
    • Staff member was put on leave pending the investigation. Child Abuse Hotline was called and accepted, unfounded. Specialist requested video footage and facility stated that it was saved for review. On 10/14/21, Specialist was advised that staff is still on leave/working in another capacity. No further follow-up details.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client stated that staff member squeezed her in between 2 chairs and that she cried out that she couldn’t breathe. Client stated that staff told her to go to her room and staff came to her room and choked her. Client noted to have slight bruise on left inner foot with small swelling noted.
    • Staff placed on leave pending investigation. Staff remains on leave as of 10/14/21. Child Abuse Hotline called and accepted, unfounded. There is no video footage of the incident. As of 10/14/21, staff advised they were waiting for CACD to finish their investigation.

Police Report

Radio Log, Second Degree Escape, Theft

Officer was dispatched to facility at approximately 2010 hours for 3 runaway juveniles. Staff stated the juveniles ran into the woods. At approximately 2118 hours, Officer was advised that staff with Millcreek stated they had all 3 juveniles back at the facility. Nurse later reported to Officer that individual had called stating her mother’s phone had pinged at Millcreek, and staff then found the phone on one of the runaway juveniles.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance –
    • R911.6 – Plug cover in Penguin Hall day room and shower were inoperable; Baseboard in Flamingo Hall needs to be replaced; Shower inoperable in Zebra Hall; Replace wet and missing ceiling tiles in Deerfield; Hole in bedroom wall in Magnolia Hall; Switch covers loose in rooms 6 and 2 in Rock Hill; Showerhead loose in bathroom #2 and inoperable in bathroom #3 in Pine Ridge.
    • R914.4 – Rock Hill room #3 smoke detector inoperable.
    • R911.15.f – Drawstrings and/or shoestrings were present in Zebra Hall room, Tiger Hall rooms, and Rock Hill room.
    • R912.2 – Only 1 out of 3 showers operable for 16 kids.
    • R9095.4.h – Licensing staff heard a female staff member in Tiger Hall yelling at patient and this led to the escalation of the situation. Staff should be retrained on this standard.
    • R910.1 – Outbuildings on the grounds near cottages need to be secured.
    • R912.6 – Paper towel holders would not close and were empty at the boy’s school.
    • R908.9 – While checking the MAR at nurse’s station for Eagle, Kangaroo, and Tiger wing, MAR was checked for 5 children and proof of meds being given was not present on the 14th of August for 3 of the kids. The nurse was not aware of why this was not documented.

Police Report

Radio Log, Second Degree Escape

Officer was dispatched at approximately 2015 hours for Juvenile that ran from facility. Staff stated that at approximately 7:25pm, Juvenile slammed door and took off running from facility. At approximately 2135 hours, Officer was patrolling area when Millcreek staff flagged him down and advised they had found the Juvenile and were bringing him back to facility. Officer checked on Juvenile, who stated he ran away because he wanted to talk to someone.

Police Report

Battery Third Degree

Caller stated her daughter had been bullied at Millcreek since arriving there on 8/9/21. Juvenile stated that her roommate grabbed both her arms and pulled her off the bed. Juvenile also stated she did an incident report but no one followed up or did anything about it. Juvenile also stated a group of girls came to her yelling that she had chores to do and if she didn’t no one was going to the talent show. Juvenile stated she hasn’t been sleeping or eating, and that she didn’t want to be at Millcreek anymore.