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

Maltreatment, Notice of Incident, Visit Compliance Report

  • Maltreatment (2)
    • Client stated that 3 staff members tried to have peer fight client. Client stated they were kicked in the head by peer and the staff were aware the fight was happening. Client stated no one broke up the fight until the end. Client also stated staff told them to kill their self and wouldn’t remove Lysol from room when client asked them to. Client then said he drank the Lysol and is now stuttering and has an upset stomach and has not received medical treatment. All 3 staff members were placed on administrative leave pending investigation.
    • Child Abuse Hotline was called and accepted, unsubstantiated. Licensing follow-up on 7/11/22: Witness statement from Direct Care Staff stated that client was upset after receiving directive from staff, and client walked to nightstand that staff was using and sprayed cleaning product in their mouth while staff attended to another resident. Witness statement from nurse indicates client was assessed after spraying Lysol in mouth. Client interviewed: When asked about issues with staff, client stated that the 3 staff members, on separate occasions, all approached client with their fists balled up and other staff stopped them. During interview, client made a complaint to Risk Management regarding another staff member. No definitive evidence of licensing concerns voiced during this complaint.

PRLU or OLTC

Licensing Compliance Record, Self Report Incident Response

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 9am – 11am regarding 06/25/22 incident, in which client eloped from facility by pushing unit door open and jumping the fence. The client was located by Magnolia PD on 6/26/22 and was returned to the facility.
  • Licensing observed door that client eloped from to be locked from both inside and outside, requiring a key, but noted the door did have “a little give” when pushed and/or pulled. Licensing interviewed client, who stated that previously, the door was able to be opened by pushing on it, even when locked. Client stated after eloping, he walked about “15 miles” which took him about 2 hours, then he got on a stationary train which shortly began to move. Client stated he jumped from the moving train (no injuries reported) and a guy helped him to get to Magnolia (by hitch-hiking) where he was recognized by police and returned to Millcreek. When given the opportunity to voice issues or concerns, client voiced complaints about staff. Licensing confirmed client was aware of how to follow protocol for reporting facility complaints. Staff contacted maintenance, who stated that a replacement door is being ordered. No deficiencies in minimum licensing standards noted regarding this incident.

PRLU or OLTC

Elopement, Notice of Incident

  • Elopement
    • At approximately 1156, client pushed the unit door open and eloped from Magnolia Hall. The client jumped the fence and ran into a wooded area. Staff followed but were unable to locate client. On 6/26/22, Fordyce PD informed facility that client was in the custody of Magnolia PD. Millcreek obtained custody of client and client was returned to facility at 1417. Client was placed on elopement precautions. No follow-up details.

Police Report

Second Degree Escape

At approximately 12:15pm, Nurse provided officers with description of missing juvenile and advised that the last time staff saw him, he was running into a wooded area. On 06/26/22 at approximately 8:38am, officer was advised that the juvenile was located. The juvenile was transported to the police department and the facility made arrangements to pick him up.

PRLU or OLTC

Licensing Compliance Record, Self Report Incident Response

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited regarding 06/12/22 incident, in which client reported a staff member slapped them in the face. Facility investigation: Staff member denies the allegation. Nursing Report indicated no injuries to the client. Another employee states they witnessed the incident and did not see staff member slap client. Three peers confirmed they witnessed staff slap client, and three other peers reported they witnessed the entire incident and staff did not slap client. Another peer reported they were the one that slapped client and it was not staff. Additional staff confirmed that the peer slapped the client in the face. Staff placed on administrative leave pending investigation. Licensing reviewed witness statements and interviewed client. No definitive evidence to support nor refute claim. Licensing is not prepared to make a finding at this time.

PRLU or OLTC

ER Visit, Notice of Incident

  • ER Visit (Peer Altercation)
    • While outside during recreation, a peer chased and then pushed client, causing client to fall and hurt their ankle. Nurse assessed and the client was transported to the ER. X-ray results: Distal fibular and tibial epiphyseal fracture. The injury was splinted, and follow-up was scheduled for 1-2 days with PCP. No follow-up details.

PRLU or OLTC

Complaint Survey with POC, Revisit Survey

  • Complaint #AR00028297 was unsubstantiated, with deficiencies cited.
  • Regs out of compliance –
    • N 156 – Facility failed to ensure a physician’s order for a physical restraint was signed for 1 client.
    • N 178 – Facility failed to ensure guardians were notified of the use of a physical restraint for 1 client.
    • N 209 – Facility failed to ensure a serious occurrence was reported to the required agencies and the report was maintained in the medical record for 1 client who sustained an injury requiring outside medical care.
  • Plan of Correction –
    • DON surveyed patient charts, audited charts, in-serviced staff regarding physician orders, debrief protocol, guardian notification; DON will audit charts weekly. Director of Risk Management updated index as to what qualifies as a serious occurrence & reviewed serious occurrences from the last 6 months to ensure compliance and will review all incidents to ensure appropriate reporting has occurred.
  • A revisit was conducted on July 25, 2022, for all deficiencies cited on June 14, 2022. All deficiencies have been corrected, and no new noncompliance was found.

PRLU or OLTC

Maltreatment, Notice of Incident

  • Maltreatment
    • Client reported a staff member slapped them in the face. Facility investigation: Staff member denies the allegation. Nursing Report indicated no injuries to the client. Another employee states they witnessed the incident and did not see staff member slap client. Three peers confirmed they witnessed staff slap client, and three other peers reported they witnessed the entire incident and staff did not slap client. Another peer reported they were the one that slapped client and it was not staff. Additional staff confirmed that the peer slapped the client in the face. Staff placed on administrative leave pending investigation.
    • Child Abuse Hotline was called and accepted (called on 06/14/22 when the incident was suspected of maltreatment). Licensing follow-up on 6/17/22: Licensing visited facility, reviewed witness statements, and interviewed client. No definitive evidence to support nor refute claim. Licensing is not prepared to make a finding at this time.  

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Not listed.
  • Facility visited from 9:00am – 11:30am. Census: 160 or 162, both listed.
  • 06/01/22 incident: Client alleged that staff slams him down hard during restraints, and that staff has threatened to “drop” him multiple times. Licensing interviewed client, who stated he didn’t know why the report was made and no staff had hurt or threatened to hurt him. No evidence to support this claim. Licensing is not prepared to make a finding at this time other than unfounded.
  • 06/03/22 incident: Client alleged that staff member grabbed him during a restraint, leaving a bruise on his hip. Licensing interviewed client, and client lifted shirt to indicate bruised area (no longer visible bruise). No evidence to prove or refute claim. Licensing is not prepared to make a finding at this time. Risk Management reports that staff member will be in-service retrained in TCI following this incident.
  • 05/30/22 incident: Client stated he was in an altercation with a peer and when peer told staff, client “cussed” and “pushed” staff. Client alleged that staff then pushed him to the ground. Client stated it did not seem that staff was doing this to hurt him and stated the hold staff was performing did not hurt him. No definitive evidence to support or refute claim. Licensing is not prepared to make a finding at this time.

PRLU or OLTC

Licensing Compliance Record, Notice of Incident

  • Maltreatment
    • Client reported to a nurse that he had been grabbed by a staff member. Client stated that he started banging his head on the wall because he was mad about a game, and staff grabbed him to assist him to his room. Nursing report indicated a bruised area, approx. 4cm. When interviewed by Risk Management, client stated he was being self-injurious, and he felt that staff was not trying to harm him.
    • Child Abuse Hotline was called, not accepted. Staff will not work in proximity of client. Licensing follow-up on 6/8/22: Facility visited, and client interviewed. Licensing is not prepared to make a finding at this time. Risk Management reported staff will be in-service retrained in TCI.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client stated, “they slam me down really hard to the ground during restraints.” Client stated that staff has threatened to “drop” him multiple times. Client stated he was last slammed down about 3 weeks prior. Staff involved unknown.
    • Child Abuse Hotline was called and accepted. Upon client interview, client stated that he was not thrown by any staff member and was unaware of any events that could have been related to this claim. Licensing follow-up on 6/8/22: Facility visited, and client interviewed. Client stated he didn’t know why the report was made and no staff had hurt or threatened to hurt him.
    • Investigation unsubstantiated.

PRLU or OLTC

Licensing Compliance Record, Notice of Incident

  • Maltreatment
    • Client stated staff member put him in a chokehold. Nurse assessment: Petechia to front and back of shoulders, red scratches to left rib area, redness to left side of back, 2 small bruises to upper left chest, c/o wrist hurting. Tylenol administered.
    • Child Abuse Hotline was called and accepted. Staff placed on administrative leave. Licensing follow-up on 6/8/22: Facility visited, and client interviewed. Client stated staff had pushed him to the ground after he “cussed” and “pushed” staff. Client stated it did not seem that staff was doing this to hurt him and stated the hold staff was performing did not hurt him.
    • Investigation unsubstantiated.

PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 8:30am – 9:30am. Census: 162. MARs checked for multiple residents. No licensing concerns noted during visit.

PRLU or OLTC

Children's Records Review, Personnel Record Review, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 9:30am – 1:00pm. Records reviewed for 10 residents and 10 staff members.
  • Regs not correctable –
    • R904.1.h – Two clients missing legal documents e.g., Birth Certificate and Social Security Card. A request form or correspondence indicating these items had been requested was not present in the files. Admissions staff indicated these were out-of-state clients and that the requests for these documents were sent in the form of an email. Risk Management indicated that all emails are deleted after 30 days. Moving forward, when an email is sent requesting these documents, it will be printed off and placed in the file.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported she was asleep in bed and woke up to her roommate kissing her. Client stated that peer digitally penetrated her vagina. Client stated she went back to sleep and did not immediately report this to staff. Peer stated the events did not occur, and that a staff member was positioned outside her open bedroom door throughout the evening.
    • Child Abuse Hotline was called, not accepted. Licensing follow-up on 5/18: Facility visited, no evidence to refute nor confirm allegation.

Police Report

Second Degree Escape

At approximately 1528 hours, officer was dispatched for 2 runaway juveniles. Staff reported they ran away at about 1458 hours. Officer attempted to locate but was unsuccessful. On 5/7/22, officer was advised that facility had the 2 juveniles back in their care.

PRLU or OLTC

Licensing Compliance Record, Notice of Incident

  • Maltreatment (1)
    • Client reported to a staff member that a peer had pulled his pants down and sucked his penis while playing Hide and Seek. Peer denied incident and stated client was lying to get him in trouble.
    • Child Abuse Hotline was called, not accepted. Both clients were placed on Close Observation (already reside in separate rooms) and an internal investigation is being conducted. Licensing follow-up on 5/11/22: Camera footage reviewed, and client/peer interviewed. Peer stated he plays Hide and Seek often and when asked where staff were he stated, “they don’t pay attention.” Client stated again that peer had sucked his “privates.” No definitive evidence to yield licensing concerns.

PRLU or OLTC

Notice of Incident

  • Maltreatment (2)
    • Facility was notified of an outside report made to the Child Abuse Hotline. Allegation: Complainant picked up client from facility and saw various bruises on his shoulder, back, shoulder blades, neck, and forearms. All bruises were in various stages of healing. Client stated that other children were holding him down and punching him, and that staff knew and told him not to tell otherwise he would get his phone privileges taken away.
    • Child Abuse Hotline was called and accepted. An internal investigation is being conducted. CACD investigation unsubstantiated. 

PRLU or OLTC

Notice of Incident

  • ER Visit (Accidental Injury)
    • Client slipped and fell while playing basketball outside. Client was sent to ER for x-ray due to his wrist hurting. X-ray results: Fracture to right wrist. Client has brace in place to right wrist/hand area.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client disclosed that previously, another child hit him, and a staff member smacked him with an open hand on his face a couple of weeks ago. Client has still not received eyeglasses (requested on 11/2021) and is on waiting list. Client’s hygiene is inadequate, his clothes were dirty, he was disheveled, and he seemed to be wearing the same clothes for multiple days. Client was asked if he bathes and he stated “no, because they do not make him.”
    • Child Abuse Hotline was called and accepted, unsubstantiated. Licensing follow-up on 4/22/22: Clients (3) were interviewed and all reported access to a shower, clean clothes, feeling safe at Millcreek, and how to report to staff if they feel unsafe. Client received his glasses and was wearing them. Client was showered and had clean clothes on. Client’s therapist reported that client frequently refuses to shower or change clothes.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client alleged that staff member punched him in the jaw while being placed into a physical restraint. Internal Investigation: Multiple staff were interviewed, and no report corroborates the allegation. There were no resident witnesses. In client’s incident debriefing, client stated he didn’t want a witness statement because “the staff did not do anything to me.” Client’s initial discussion with therapist indicates discrepancies, as he first indicated that another staff member was the one that punched him.  
    • Child Abuse Hotline was called, not accepted. Alleged staff member remains on leave until completing in-service Therapeutic Crisis Intervention at which time he will be rescheduled for employment, and client/staff interaction will be limited to basketball events. Licensing follow-up on 4/19: Reviewed witness statements and interviewed client. There is no definitive evidence to support that staff struck client.

Medicaid Inspection of Care

Inspection of Care Report

  • Included: IOC
  • No deficiencies noted.

Police Report

Radio Log

ICF – Staff called for update on missing juveniles and officer stated they had not received a call (staff called Dallas County); Staff stated that 2 juveniles had been missing since about 9:30pm. Juveniles were spotted on morning of 4/10 but not found. At 1240 hours on 4/10, the missing juveniles were found and back at Millcreek.

Police Report

Assault Second Degree

ICF – Officer served an affidavit warrant for Assault 2nd Degree with a bond amount of $570.00 on staff member and issued court date.

Police Report

Battery Third Degree, Radio Log

ICF – Caller stated that on 3/27, resident had wanted to call his aunt and while staff was trying to find the phone number, resident began fighting him. Caller stated the staff member had struck the resident in the head during the fight; Child Abuse Hotline was called but refused the report since the resident was 18y/o.