Physical restraints that broke kids’ bones, at least one suicide attempt and sexual contact between unsupervised patients prompted the rare reprimand of a Little Rock psychiatric center for children and teens.
At special meetings held in late May and early June, Arkansas’ Child Welfare Agency Review Board agreed to issue a letter of reprimand to Elizabeth Mitchell Centers — the formal name for a 12th Street residential treatment site run by The Centers for Youth and Families — related to several incidents, some of which sent kids to the hospital.
The quality-of-care failings span months and go beyond a one-time slip in supervision or a negligent staff member, according to documents, video and emails that the Arkansas Democrat-Gazette obtained under the state’s public-records law. The records describe a series of potentially traumatic events affecting children, all on the watch of adults who were supposed to be healing them.
The state Department of Human Services’ written recommendations for a letter of reprimand, a corrective action agreement signed by the facility’s top administrator and other files outline reported issues in more detail. Among them:
• Since August, the facility staff broke or fractured four youths’ bones during physical restraints.
• The facility failed to immediately report to a state licensing unit two events during which children were hurt.
• Four incidents of sexual contact between young clients.
In one of those four, a child alleged that three other youths “sexually assaulted him” in a facility bathroom, state agency records show. A Centers spokesman said “it is our understanding there was no corroborating video and no evidence [that] the allegation was founded.”
Reports from the Arkansas State Police division that investigates child sex-abuse cases aren’t typically made public.
Through a written statement provided by a spokesman, Centers’ chief executive Melissa Dawson said the time period that the state reviewed is “is not reflective of our legacy of high-quality client care and community service.” The covid-19 pandemic “amplified” stress, disrupting routines and family visits for kids with “extreme emotional and psychological trauma.”
Eight workers were fired as a result of incidents recounted in Centers’ corrective plan with Arkansas regulators, the statement said. More staff was hired, existing staffers were retrained and new leadership meetings have been implemented, according to the statement.
Admissions were paused but have resumed, according to Dawson.
The Little Rock-based Centers pushed back on the reprimand through a June 15 letter to the board via attorney Ashley Hudson of the Kutak Rock law firm. The lawyer appeared before the board while it considered the reprimand, introducing herself as the corporate compliance officer for Centers.
The board misapprehended the events’ timeline, and the state’s corrective plan had not had time to work at the point of the reprimand, wrote Hudson, who is also a Democratic state representative from Little Rock.
Internal emails show that regulators’ increased focus on Centers goes back to at least mid-April, when Disability Rights Arkansas forwarded to state officials an investigative report on an “alarming uptick” in harmful incidents at Centers. The newspaper also obtained a heavily redacted version of that report, with 21 of its 48 pages blacked out.
Department of Human Services communications chief Amy Webb said in an email that a failure to report issues is a “major concern” for the agency. Children’s safety is its top priority, she wrote, and state inspectors will continue increased monitoring of Centers.
The state depends on Centers to provide “expert-level” care “safely and effectively,” Webb wrote. “It’s not as simple as things were fine, the pandemic hit, and the results were beyond Centers’ control.”
Centers’ reprimand is only the second time since at least 2009 that the child welfare board issued such a letter, which is not an official action against the care center’s license to operate. The letters — both of which were sent this year — instead serve as a caution to get in line with state standards or face the prospect of harsher penalties.
Board members decided on the reprimand after a recommendation from the Department of Human Services unit that inspects such facilities.
The unit’s monitors have “serious concerns with the broken bones at the facility, the number of suicide attempts, the number of elopements and the peer-to-peer sexual activity,” Placement and Residential Licensing Unit program manager Ebony Russ told board members, adding that she wasn’t sure if a letter of reprimand “is enough.”
Days after regulators met with facility officials to discuss the problems and a corrective plan, a child’s bone was broken during a physical restraint, Russ said. Centers hadn’t yet had time to retrain the staff after the discussion, its officials told the board, and Centers’ spokesman later said the staffers involved were terminated.
A May 3 email from Disability Rights Arkansas advocates to Human Services officials drew attention to the same event. Disability Rights is federally mandated to monitor the treatment of people with disabilities.
“This time it was a 10-year-old little girl,” the advocate, Disability Rights Arkansas staff attorney Reagan Stanford, wrote of the incident. “To our knowledge, no other [psychiatric residential treatment facility] has administered restraints that resulted in broken bones in the last year.”
On 12th Street, it was the fourth fracture in 10 months.
The Centers for Youth and Families has a large presence in mental health care in Arkansas, especially for children. It offers inpatient and outpatient services, and is the designated community mental health provider for low-income people in part of Pulaski County, a role assumed when the Little Rock Community Mental Health Center folded in 2019.
The group’s Elizabeth Mitchell Centers inpatient site in Little Rock is licensed for 49 psychiatric beds and 13 residential beds, according to state documents. A Department of Human Services spokesman said 27 people were being treated in the program on June 1.
Centers’ website touts work serving people with challenging histories, such as kids with behavioral difficulties, kids with learning differences, homeless youths, pregnant and parenting teens, and survivors of human trafficking. Over 90% of the organization’s child clients “have experienced trauma,” a history says.
Documents, however, show a residential facility struggling to maintain a secure and safe environment within the past year.
One client was sitting on the residential facility’s washing machine when a “staff [member] yanked client off the washer resulting in client being injured, twisting her ankle, and hitting the back of her head,” Human Services records show. A staff member was fired, and two others were disciplined as a result.
In another episode, several children ran away, and some were returned by police. A state employee wrote to Centers on Nov. 6, a Friday, to inquire about the escape, emails show.
“I’m following up on a notification we received that Centers for Youth and Families had several elopements (9 children went AWOL) at one time Wednesday night, [redacted] 2020, by pulling the fire alarm,” wrote the employee of the Placement and Residential Licensing Unit, Ezell Breedlove.
“If so, we have yet to receive a report. So, can you verify whether or not the alleged incident did or did not occur.”
Breedlove wasn’t specifically assigned to the facility at the time and “would not have been in the communications loop,” but the incident was reported, a Centers spokesman said in an email. “All but two of the kids were back at The Centers within hours.”
The six-month corrective plan between the state and Centers requires retraining the staff on mandatory reporting connected to two other incidents, which appear not to have been reported the next business day as required. One “resulted in a client having a black eye” and the other involved “a serious injury requiring medical attention after a physical restraint.”
Dawson said in her statement that the events were reported to the Arkansas Child Abuse Hotline “in a timely fashion” but noted a delay in reporting to the licensing unit. The hot line is operated by the Arkansas State Police, while the licensing unit falls under the purview of the Arkansas Department of Human Services.
The agreement also says a system for physical restraints called “Handle with Care” will no longer be used, in favor of a different system. In her written comments, Dawson said the group already had created a restraint reduction plan and that the practices are a “last resort” meant to protect children and staff members from harm.
Told of Centers’ plan to change from one restraints system to another, Mental Health America’s vice president for state and federal advocacy was skeptical. Restraint practices are poorly regulated and physically risky, and their discontinuation requires significant cultural change, the Washington, D.C.-based advocate, Debbie Plotnick, explained.
“It’s a lot easier to just be bigger and stronger and hold people down,” she said. “That is not only not therapeutic — it hurts people, and it creates this escalating cycle.”
Tell us your experiences
The Arkansas Democrat-Gazette would like to talk with current and former patients, family members, foster parents and staff about their experiences at Elizabeth Mitchell Centers and The Centers for Youth & Families. The newspaper understands many of the issues are sensitive and may include personal information about minors.
If you would like to talk with a reporter or to ask for information about sharing documents securely, contact:
Kat Stromquist - (501) 313-3741
Eric Besson - (501) 313-0912
The Child Welfare Agency Review Board is the state’s licensing authority for 103 private providers that either care for children in facilities or place children in new settings.
In this role, the board wields power to suspend licenses or place agencies on probation when they fail to meet licensing standards. Six of its eight gubernatorial appointments are required by law to represent provider groups overseen by the board.
For example, board chairman Andy Altom is president and chief executive of Methodist Family Health, which offers a suite of programs that includes a psychiatric residential treatment facility similar to Centers.
Board members decided on the reprimand during 70-minute and 40-minute virtual discussions, during which they posed questions to regulators and Centers’ representatives.
During the initial meeting, Hudson, Centers’ compliance officer, said a “perfect storm” of undesirable circumstances “caused a lot of problems,” particularly last fall. Staff members missed time because of covid-19, the coronavirus spread through the facilities and restless children longed for an outlet, she said.
“This past year was not great, but it wasn’t great for a lot of people for a lot of reasons,” she told the board. “And you put a bunch of teenagers into a communal living situation, and put that stress on top of it, and things happen.”
Thirty-nine clients and 69 staff members have been diagnosed with covid-19 since the pandemic began, Centers’ statement said.
Some board members’ comments during the meetings were sympathetic to Hudson’s perspective. Altom expressed concern over whether state monitors have a “got-you-type attitude” mindset. He later clarified that he was “not trying to be adversarial.”
After agreeing to the reprimand letter, the board tasked the Human Services Department’s licensing unit with creating a rough draft. Board members met June 1 to review and revise it before sending a final version to Centers.
Among the changes were the addition of a line noting Centers’ “long history of compliance with licensing standards” and the addition of the word “recently” before the phrase “failed to maintain substantial compliance” with those standards.
The board also deleted a list of specific infractions, instead referring to the corrective action agreement, which was sent as an attachment. The corrective plan includes specific citations.
Altom, after the edits were completed, suggested sending a letter “of caution” rather than one of “reprimand,” but others on the call expressed confusion over the difference and which one represented a stronger action.
After board member Andrew Watson said he preferred to leave it as is, the board voted to finalize the edits without any audible dissent.
Asked by a reporter last week whether he felt the strongest possible letter was warranted, Altom said the board wants to have “a collegial relationship with providers” in the state.
“If this board gets in the business of putting good providers that maybe stumble out of business, pulling their license, then we really do an injustice to the state in the sense of, ‘Where are those kids going to go,’” Altom said.
“I think the board made the decision to do the letter of reprimand, and they stand behind it,” Altom later added.
Webb, the Human Services spokeswoman, said state licensing officials want to see “progress that is sustainable and real” at Centers.
“If we see that, for example, they are not following the corrective action plan or not using the new de-escalation and behavior modification training they said they would use, then we would go back to the board and make a recommendation for an adverse action,” Webb said.
Centers’ reprimand represents the second time in four months the child welfare board has employed this method of discipline on an Arkansas psychiatric residential treatment facility for youths.
It issued a more detailed letter of reprimand earlier this year to the Piney Ridge Treatment Center, a for-profit facility in Fayetteville. The eight-page document outlines licensing standards violations related to the buildings and grounds, as well as behavior management.
The Department of Human Services staff presented similar recommendation documents to the board for both reprimand letters, Webb said. For Centers, “the board chose to keep the letter brief with a focus on the corrective action plan and expectations about moving forward.”
State licensing staffers visited the Piney Ridge grounds several times during 2020 and noted problems with clogged sinks, dirty bathrooms, shoelaces and charger cords left in children’s bedrooms, and lack of soap and towels, among other violations. In one instance, the facility was cited after a July complaint and told not to use derogatory remarks about “the child, the child’s family, race, or gender” as discipline.
The board voted unanimously Feb. 25 to issue the letter, dated March 3.
The Democrat-Gazette previously reported allegations of abuse and neglect at Piney Ridge, including poor supervision of clients that led to sexual contact — both “forced” and “consensual” among youths, according to a 2019 report from Disability Rights Arkansas that was obtained through an open-records request. At the time, a separate report from the nonprofit Arkansas Foundation for Medical Care confirmed many of the Disability Rights allegations.
Other allegations included excessive use of restraints, poor conditions on the grounds, and housing too many children in the same room without consideration of their mental illnesses and developmental disorders.
Piney Ridge treats children who exhibit sexually problematic behaviors and have mental illnesses. It’s owned by Acadia Healthcare Inc. The center’s chief executive officer at the time resigned at the end of 2019, and the state said fixes were underway for living conditions.
During the June 24 child welfare board meeting, current chief executive officer Justin Hoover told board members that Piney Ridge was “working really hard” to resolve issues, including “a ton” of renovations and repairs to the facility
Additionally, Piney Ridge has implemented staff incentives such as signing bonuses and new employee check-ins to improve retention. It has added more staffers, including a recreational therapist and a chief operating officer, to provide another layer of oversight and more supervision of children, Hoover added.
Since the April 22 board meeting, the state noted problems with providing clean bathrooms, a hole in the wall, missing baseboards, four instances when children ran away, and three injuries. All three were caused by peer-to-peer interactions, and two were accidents, Russ told board members.
In recent interviews, Disability Rights Arkansas executive director Tom Masseau expressed frustration with what he framed as intermittent enforcement of care rules. After “the light gets shined on this one facility” having issues, “we continue to play that game with the state — this one’s bad, [or] this one’s bad,” prompting promises of reforms.
That doesn’t do anything at all to address systemic problems, he said.
“You have bad apples wherever you go,” Masseau continued, “unless you have standards in place to weed them out.”