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

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.

PRLU or OLTC

Complaint, Notice of Incident, Visit Compliance Report

Received complaint 4/13/23 as follows: Member’s guardian [REDACTED] said she’s dissatisfied with Millcreek of Arkansas’ services. Guardian reported that he has had on campus visit withjt he member and each time she has witnessed poor hygiene. Dirty clothes, dirty fingernails, toenails, and brusies. Guardian also reported the member always says he’s hungry during phone calls and appears to be starving whenever she sees him. Guardian also mentioned that when she calls Millcreek of Arkansas she hardly ever gets soemone to answer the phone and that they have only been giving the meber antibiotiucs and medication to help with bowel movements. Guardian said she spoke with the CEO once and he was nice but did mention that they normally don’t take in indcivuals that wear pull ups, who aren’t potty trained, and that the meber is old enough to go to the restroom on his own. Guardian said the CEO was really nice aside from that statement. Guardian said there are no changes in member’s medications and that she was under the impression that Millcreek would be helping the member, but instead his behaviors have worsened.

Licensing Specialist: Clayton DeBoer. Regulations out of compliance: 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.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client engaged in a game of recreational kickball. She slipped and fell while kicking the ball. She reported pain in her right wrist and lower arm. Slight swelling noted. Sent to Dallas County Medical Center for outpatient x-ray. X-ray report indicated no fracture. She was released to return to the facility.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Mecial Center for assessment following a physical altercation. They reported dizziness during his on-site nursing assessment. ER report indicates no loss of consciouness, no vision changes, no neurologic deficits.

Licensing Specialist: Clayton DeBoer. Regulations out of compliance: 907.2 – Child caring staff shall be responsible for providing the level of supervision, care, and treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s age, individual differences and abilities, surrounding circumstances, hazards and risks.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

Client was sent to Dallas County Medical Center following a physical confrontation. He reported pain in his nose during the on-site nursing assessment. He was sent for outpatient x-ray. X-ray report indicates ” CT imaging would best define if needed clinically.” Tylenol was provided for pain. He was released to return to the facility. Licensing Specialist: Clayton DeBoer. Regulations out of compliance: 907.2 – Child caring staff shall be responsible for providing the level of supervision, care, and treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s age, individual differences and abilities, surrounding circumstances, hazards and risks.

PRLU or OLTC

Technical Assistance, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Review of the agency’s current mandated reporter policy revealed it does not comply with A.C.A 12-18-402 nor Minimum Licensing Standards. Please ensure facility policy is updated to reflect the need of all staff to report directly to the child abuse hotline without delay. The updated policy shall be submitted to the Licensing Unit by 04/14/23 and all applicable staff shall be retrained on the updated policy within 2 weeks of the enactment of the updated policy.
  • TA –
    • 110.9 – Any owner/operator, employee, foster parent, or volunteer in a child welfare agency shall immediately notify the Child Abuse Hotline if he or she has reasonable cause to suspect that a child has been subjected to child maltreatment, died as a result of child maltreatment or if they observe a child being subjected to conditions or circumstances that would reasonably result in child maltreatment.
    • 102.3.h -Child Maltreatment/Mandated Reporter policy; according to Arkansas law, including, procedures to ensure that alleged, suspected, or witnessed incidents of maltreatment are reported to the Child Maltreatment Hotline, and documented as required by these or other applicable rule or laws.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Licensing documented employment status of persons not eligible to be employed by a child welfare facility. Offer was rescinded for 3 individuals, 3 individuals were never hired, 1 individual was terminated on 01/23/23, and 1 individual who was on leave since 03/23/23 is scheduled to be terminated on 03/28/23.

PRLU or OLTC

Self-Harm

Client was sent to Dallas Co. Medical Center for outpatient x-rays. Following his punching a closed-door multiple times, he reported pain in his right hand during a nursing assessment. ER Discharge report indicated . The finger was reset, and he was released to return to the facility.

Police Report

Runaway

On Sunday March 20, 2023 at approximately 1300 hours. Officer was dispatched to Darryl’s for a runway juvenile from Millcreek. Dispatch advise it was a [REDACTED]. He was wearing a white t-shirt and black jacket. On arrival I saw the indivual who fit the description of the information I had. Officer spoke with him. He stated that he was trying to go to McDonalds. I called Millcreek to speak with someone about the runaway juvenile and I sated that I will be in route with the juvenile for return.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted from 10:30am – 12pm. Census: 166. Pebble Creek, Rock Hill, Deerfield, and Store observed. Store is for faculty use only at this time. Maintenance will address citations on or before 04/03/23 and Rock Hill flooring repairs will be contracted out. MARs reviewed for 5 residents.
  • Regs out of compliance –
    • 901.3 – No posted client rights in Deerfield.
    • 911.6 – Shower nozzle was broken in bathroom and scattered spots on ceiling in bathroom (Pebble Creek). Chipped paint on bedroom 1 wall, flooring not laid adjacent to the door hinge in bedroom 2 leaving an open area that had collected dirt, missing baseboard in bedroom 4, graffiti on shelf in closet of bedroom 5, missing shower rings in bathroom 2, and flooring in common area had holes throughout (Rock Hill). Baseboards in bedroom 1 tattered and not connecting (Deerfield).

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

  • Maltreatment
    • During a therapy session, client reported that a staff member had threatened to “cut his vocal cords” because he wouldn’t stop humming, made him get under a table and pushed a chair against him, made him “stand up in a corner when it was time to go to bed”, and “poked him with a pen” behind his ear and the side of his head. Nurse noted a healed abrasion with scab behind ear. Child Abuse Hotline was called and accepted. Staff member was placed on administrative leave pending the investigation.
    • Licensing follow-up: Video reviewed on 03/13/23 showed client being directed to stand in the corner from 7:15pm until 9:40pm with brief breaks (on 03/09/23). The office door was open during the entire time reviewed, and a staff member was on her cellphone during most of the video. During further review, a staff member was seen bumping client with her stomach area to direct client back to the corner (Child Abuse Hotline was called separately for this incident) and a client is seen transporting a cleaning agent unsupervised (later determined to be soap).
    • Unfounded: At no time is alleged staff member seen pushing a chair against client or poking him with a pen.  
    • Founded: Client was observed being directed by 2 staff members to stay in corner area until 9:40pm. On 03/17/23, facility indicated staff 1 remains on administrative leave pending certain termination and staff 2 will be retrained on TCI which encompasses appropriate staff/client interaction.
    • CACD investigation was unsubstantiated as of 05/03/23. Staff 1 was terminated on 03/23/23. Staff 2 was retrained and has since been terminated as of 05/22/23.
  • Regs out of compliance –
    • 905.3 – Child stood in the corner from 7:15pm – 9:40pm.
    • 905.4.f – Child stood in the corner from 7:15pm – 9:40pm.
    • 907.2 – Door to the office in video reviewed was open with no staff inside the office for duration of the video. A client is seen transporting what appears to be a cleaning agent unsupervised.
    • 905.4.g – Staff member bumped client with her stomach to direct him back to a corner he had been standing in for an extended period of time.

PRLU or OLTC

Notice of Incident, Peer Altercation

  • Peer Altercation
    • Client engaged in a physical confrontation with a peer and was punched in the nose. Nurse noted slight swelling to the bridge of the nose. Client was sent to the ER, and x-rays indicated no fracture was present. Client returned to facility.