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

Patient reported a fading bruise. When questioned on the origin of the bruise, he stated, “[REDACTED] did it.” Client explained that last week (unable to give an exact date/Time), he and a peer engaged in a physical confrontation. [REDACTED] picked up a chair to throw at the peer. Staff member got the chair away from and stepped in between the two patients, grabbing them on the upper part of the arm. Client continued to explain that the incident was over once [REDACTED] separated them. Nursing report indicates that [REDACTED] has a brownish-green bruising on his left bicep. The allegation was accepted for investigation by referral id: [REDACTED]. Staff member was immediately placed on administrative leave, pending the results of the investigation. Licensing narrative:

  • 7/27/2023- Program Coordinator determined that no investigator with [REDACTED] has been assigned to this case yet. Licensing is unable to obtain permission to contact the agency at this time.
  • 7/27/23-Phone call made to [REDACTED] of Millcreek who stated there was no video of the incident.
  • 7/27/23-Phone call made to investigator [REDACTED] who gave permission for licensing to interview alleged victim. Investigator scheduled a visit with licensing at Millcreek for 9:00 AM 7/28/23.
  • Facility visited 7/28/23 in response to complaint that staff grabbed clients arm causing a bruise. Licensing attended interview with investigator and alleged victim. Witness statements from staff and client reviewed. Neither indicated unprofessional behavior on the part of staff. Licensing is not prepared to make a finding at this time.
  • 8/31/23-Maltreatment report closed as unsubstantiated. 8/31/23: maltreatment report for case#[REDACTED] closed as unsubstantiated. Staff suspended 7/26/23 immediately following incident.
  • Received email 9/1/23 from [REDACTED] of millcreek that staff is still employed at Millcreek and received “Restraint training (Breaking up fights with minimal force)” 8/10/23 and was returned to work 8/10/23. This was not approved by licensing. Chris Butler of Millcreek reminded of licensing regulation 110.10 – any interim action measures shall be approved by the licensing unit.

Regulations needing technical assistance: 905.9 – client reported that staff bruised his arm during a restraint. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Resident became non-compliant when prompted to get out of bed, and later reported on a phone call to her parents that she was dragged out of her bed and beaten up by staff member. Resident reported she was dragged by her wrists and ankles, and her hair pulled to the point that strands broke off. A pin-point red area was noted to resident’s inner ankle and her knee. This was reported to the hotline and accepted for investigation. Staff member was placed on administrative leave pending the investigation.

Licensing Specialist: Clayton DeBoer.
Facility reported there is video for the day in question (7/23/23), but the resident has since stated the incident happened a week, a couple weeks, or maybe a month ago.
Facility visited 7/26/23 and interviews conducted. Resident reported that about 2 weeks ago, staff member pulled her hair and then apologized. Resident reported that about 1 week after this, staff member grabbed her arm and leg and dragged her off her bed, stating 2 staff members witnessed this. Licensing reviewed a witness statement related to the first incident, in which a peer does state that staff member pulled resident’s hair when attempting to pull her jacket hood.
Two staff were interviewed who stated they have never witnessed the alleged staff member get physical with any resident.
Licensing unfounded complaint. Crimes Against Children Division (CACD) investigation was unsubstantiated.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Resident reported that on 7/14/23, a staff member engaged in a verbal confrontation with him, calling him a “bitch” and his mother a “hoe”. Resident also reported that after this, another staff member grabbed him by his shirt and swung him between 2 beds. This was reported to the hotline and accepted for investigation. Both staff members were placed on administrative leave pending the investigation.

Licensing Specialist: Clayton DeBoer.
Facility visited on 7/18/23 and video reviewed. Facility reported there is video of client interacting with staff, but no video footage of where the incidents took place (laundry room and bedroom). Licensing observed what appeared to be a verbal confrontation occur between resident and staff member over a basket of laundry. Four peers were interviewed and denied female staff cursing or being physical with them, but stated the following regarding the male staff member:

  • Staff “throws us across the room”.
  • Staff “flicked me in the mouth…twisted my arm…pushed me down on the court”.
  • He had seen staff “grab a kid by his arm…nothing bad”.
  • Staff “twists arms” and had done this to him. Staff does this until it hurts and resident is unable to get away from the hold.

Licensing made a separate hotline report regarding the allegations made by 3 residents interviewed (accepted for investigation). After the interviews were conducted, the facility reported the male staff member’s suspension will be moved to termination.

Licensing unfounded complaint. Both Crimes Against Children Division (CACD) investigations were unsubstantiated. Facility reported the male staff member’s last day of employment was 7/21/23, and the female staff member is no longer employed and her last day was 7/14/23.

PRLU or OLTC

Notice of Incident, Peer Altercation

Client was sent to the Dallas County Medical Center for assessment following a physical confrontation with a peer. She was punched in the face, receiving a small laceration above the left eye. The laceration was treated with Dermabond and she was released to return to the facility.

Licensing narrative: Facility visited 7/18/23 and video reviewed of the altercation involving [REDACTED] from 7/13/23 which occurred in penguin hall. Hall video reviewed which shows one staff standing and one sitting. One client aggressively enters a bedroom. Within seconds staff present respond by following. The client who appears to be the aggressor leaves the bedroom. The client who seems to have been attacked by the aggressor exits her room aggressively as to retaliate. At this point, 7 additional staff are present and briefly restrain this client. All staff viewed in video seem to respond to this incident as fast as possible.

PRLU or OLTC

Visit Compliance Report

After hours buildings & grounds conducted for Deerfield from 5:45 PM – 6:45 PM. Staff/Client ratio 2:12. Living area and sleeping area clean, safe and in good repair except bedroom 2 had 4″X4″ hole in laminate tile. Maintenance order was put in to have that piece of laminate tile replaced. All other floor areas in Deerfield in good condition. Bathrooms clean and sanitary with functioning sinks and toilets. Showers had hot water. Grounds outside Deerfield were clean and free of safety hazards. MAR checked for:[REDACTED]. All initialed and up to date.

Regulations needing technical assistance: 911.6 – bedroom 2 of Deerfield had a 4″X4″ hole in laminate tile. Maintenance order was put in to have that piece of laminate tile replaced. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Notice of Incident, Peer Altercation

Client was sent to Dallas County Medical Center for outpatient x-rays after reporting pain in his hand. The injury was a result of a physical confrontation on 7/7/23. X-ray report has not been received at the time of this report. He was released to return to the facility.

Licensing narrative: Received email from facility 7/13/23 that client’s [REDACTED] is [REDACTED] and there is no video footage of the confrontation. Also, x-ray results indicate no fracture was found.

PRLU or OLTC

Notice of Incident, Self-Harm

Client was referred to Dallas County Medical Center for outpatient x-ray after reporting pain in his hand following an incident in which he punched a wall. No fracture was found, and he was released to return to the facility without restriction. Licensing narrative: no licensing concerns noted from this incident.

PRLU or OLTC

Notice of Incident, Self-Harm

Client was referred to Dallas County Medical Center for outpatient x-ray after reporting pain in his hand following an incident in which he punched a wall. No fracture was found, and he was released to return to the facility without restriction. Licensing narrative: no licensing concerns noted from this incident.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was referred to Dallas County Medical Center for outpatient x-ray after reporting pain in his hand following a recreational game of basketball. No fracture was found, and he was released to return to the facility without restriction. Licensing narrative: no licensing concerns noted from this incident.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was sent to Dallas County Medical Center for outpatient x-ray. She reported pain in her wrist after slipping in her bedroom while changing clothes and trying to catch herself when falling. X-ray report indicates that no fracture was found. She was returned to the facility without restriction. Licensing narrative: no licensing concerns noted in complaint. Client remains at the facility.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client reported foot pain after playing a game of kickball. After seeing the medical director, she was referred to Dallas County Medical Center for outpatient x-ray. No fracture was found. She was released to return to the facility without restriction. No licensing concerns noted from this incident.

PRLU or OLTC

Visit Compliance Report

Buildings & grounds conducted from 11:00 AM – 12:00 AM. Zebra and Flamingo halls inspected.

Zebra staff client ratio – 3:16. Flamingo staff/client ratio – 2:5 (some clients on field trip). All buildings and grounds clean, safe and in good repair other than previously addressed holes/tears in laminate tiles, which facility is replacing unit- wide and two showers in Zebra hall. Two showers in Zebra hall had, per staff, not been working for about two days and a maintenance order had been placed for this. Sleeping areas furnished and in good repair. Bathrooms clean and sanitary. Day room’s clean, furnished and in good repair. Clients present in day room areas were engaged in activities. MAR checked for: [REDACTED]. Regulations needing technical assistance: 911.6 – all 3 showers in zebra hall will need to be fully functional. Maintenance order has been placed before today’s visit. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Notice of Incident, Self-Harm

Client was referred to Dallas County Medical Center (DCMC) for outpatient x-ray of his right hand. His injury resulted from an incident where he punched a wall on 06/25/23 after a phone call with his father. X-ray report received on 06/28/23 indicates a fracture but is inconclusive on whether this injury is from the current incident or a previously healed fracture. A follow up appointment with Primary Care Physician is scheduled for 06/29/23.

PRLU or OLTC

Notice of Incident, Peer Sexual Contact, Visit Compliance Report

Alleged victim is [REDACTED]. Alleged offender is a former roommate at Millcreek. Alleged victim communicated that while he was at Millcreek in 2022, his roommate raped him. He reports that he was in the Pebble Ranch cabin, and it occurred after bed checks. It was prior to December of 2022. Alleged victim stated that he told his therapist at Millcreek, but she did nothing about it and “blamed him”. He stated that his roommate climbed into his bed after bed checks, pulled down his pants, and raped him. He stated that his roommate was also older and bigger than him and was “mixed”.

Licensing narrative:

  • Licensing was given approval by investigator via phone 6/26/23 to contact facility.
  • Phone call made to facility 6/26/23 to confirm that was a Millcreek psychiatric residential treatment facility (PRTF) client and that his therapist was [REDACTED].
  • Visit scheduled for 6/27/23.
  • Facility visited 6/27/23 in response to complaint. All therapy notes reviewed for client nothing in therapy notes is indicative of subject matter in complaint. Licensing is not prepared to make a finding at this time. [REDACTED] was client’s last assigned therapist. Therapy notes reviewed included notes from staff/therapists/therapist interns [REDACTED] and [REDACTED].
  • 8/3/2023 – Maltreatment investigation is still open and pending at this time.
  • 9/5/23 – Case#[REDACTED]. Maltreatment complaint unsubstantiated.

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 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.