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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Police Report

Disorderly Conduct, Radio Log

Officer was dispatched in reference to a fight. Upon arrival, staff member was arguing with a juvenile. Staff stated juvenile was upset due to a fight that happened involving other residents. The physical fighting had dispersed by the time officers arrived.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Program Coordinator: Chelsea Vardell.
  • Visit conducted from 9:45am – 12:00pm. Census: 161. Licensing Specialist and Program Coordinator completed walkthrough of Flamingo Unit, Deerfield, the cafeteria, and the school building. Licensing discussed the progress the facility is making on correcting issues with their regulatory checks noted by the DHS regulatory check unit. The facility reported they are approx. 30% completed on all checks and are on track to have all completed by 8/31/22. MARs reviewed.
  • Regs out of compliance –
    • 9.908.8 – The administering of all medications, including over-the-counter, shall be logged at the time the medication is given, by the person administering the medication.
    • 9.911.15.d – Areas used by children shall be designed, constructed, and furnished to reduce risk of suicide and assault.
    • 9.911.15.f – Areas used by children shall be designed, constructed, and furnished to reduce risk of suicide and assault.
    • 9.912.4 – The bathroom shall be clean and sanitary.
  • TA –
    • 9.914.6 – There shall be an emergency evacuation plan diagramed and posted in each building used by children.

PRLU or OLTC

Notice of Incident

  • ER Visit (Accidental Injury)
    • Client’s face collided with the back of a peer while playing basketball. Nurse assessed and noted bleeding to nose and small knot to side of nose. On 7/29/22, the client was transported to the ER for an x-ray. X-ray revealed a non-displaced fracture of the distal tip of the nasal bone. No follow-up details.

PRLU or OLTC

Maltreatment, Notice of Incident

  • Maltreatment
    • Client reported that during restraint, staff member dropped client, causing them to hit their head on the ground. Nurse noted knot to back of client’s head. Staff member denied allegation, and stated the restraint was necessary to prevent self-injurious behavior and escalation of peers. Six resident witnesses were interviewed, and each reported that client was punching staff member and struggling against staff as the restraint was initiated. Three residents indicated they saw client’s head hit the ground, but that staff member was not attempting to harm client. Staff member was placed on administrative leave pending the investigation.
    • Child Abuse Hotline called and accepted. Licensing follow-up on 8/18/22: Specialist visited facility and conducted interviews. Staff members involved stated that at no time did client’s head hit the ground. Two residents who witnessed the incident stated they did not see client’s head hit the floor, and one resident stated the alleged staff member lifted client and slammed him into the floor headfirst. Facility was cited 110.9 (Risk Management was made aware of the incident on 8/10 but did not report to the hotline or Licensing Unit until 08/11). CACD investigation was unsubstantiated. Licensing complaint unfounded. 

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Not listed.
    • Facility visited from 11:00am – 12:30pm regarding incident reported to Licensing on 7/10/22, in which client alleged that multiple staff members tried to have a peer fight him and allowed him to drink Lysol. Witness statement reviewed and 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. No definitive evidence from witness statements or interview yield licensing concerns.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

  • Maltreatment (1)
    • Client reported that while being placed in a restraint, client was kicked in the face by staff. The staff member was immediately removed from the vicinity by another staff member. Facility Investigation: Staff member denied allegation. Three staff members confirm the events as reported by the client. Nurse assessment revealed no injury, but noted prior to the restraint, facial redness and petechia to lips. On 7/11/22, client reported pain in nose area. X-ray at ER revealed no fracture. Staff was terminated on 7/12/22.
    • Child Abuse Hotline was called and accepted, unsubstantiated. Licensing follow-up on 7/12/22: Facility level investigation determined the allegation to be founded. Facility cited 109.1.g, 907.2, and 905.4.g (staff struck client in face). 

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.