Abraxas I

Citation, renewal inspection : 55 Pa. Code § 3800.51 Child Abuse and Criminal History Checks

Staff member C obtained a FBI clearance on 08/10/2020 and was required to obtain a new one within 60 months by 08/10/2025. A review of the personnel record showed that staff member C did not obtain a new FBI clearance until 08/14/2025 (four days late).

Citation, renewal inspection : 55 Pa. Code § 3800.132.a Fire Drills

The facility did not conduct an unannounced fire drill at least once a month. A review of the fire drill logs for Seneca Dorm did not contain a documented fire drill for the months of July and August 2025.

Citation, renewal inspection : 55 Pa. Code § 3800.132.e Fire Drills

The facility did not conduct a fire drill during sleeping hours at least every 6 months. A review of the fire drill logs revealed that the only overnight/sleeping fire drill occurred on 12/29/2025. There was not one documented prior to this.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff persons A, B and D did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter. These three staff persons were not in compliance as outlined below: Staff Person A = Personnel record was missing a health statement. Staff Person B = Bi-annual physical next physical (20 days late). Staff Person D = Bi annual physical next physical (5 days late).

Citation, renewal inspection : 55 Pa. Code § 3800.184.b Medication Log

It should be noted that only six months of Med Administration Records (MARs) for each resident file reviewed were provided for this inspection. The medication logs for children A, B, and C had many squares on their med administration records (MARs) that were blank and it was unable to be determined from them if the medication was given and, if so, who passed the medication. The total blank squares for each resident are below: Child A = 68 Child B = 91 Child C = 5 TOTAL Blank squares for Explorer Dorm = 164

Citation, renewal inspection : 55 Pa. Code § 3800.184.c Medication Log

As explained in 184b, the medication logs for children A through C was incomplete and had blank squares. If medication was given, these logs were not completed at the same time each dosage of medication was administered.

Citation, renewal inspection : 55 Pa. Code § 3800.185.a Medication Errors

Due to blank squares on multiple MARs for children A through C, it cannot be determined if these residents received their medication as prescribed on numerous dates throughout the six months of MARs reviewed. The medication logs did not include documentation of medication errors that occurred including any explanations as to what happened.

Citation, renewal inspection : 55 Pa. Code § 3800.185.b Medication Errors

On numerous dates over the six month period reviewed, the MARs of children A through C had multiple blank squares and it was unable to be determined if these residents received their medication as prescribed. The medication logs did not contain follow-up actions taken to prevent future medication errors for any of these dates.

Citation, complaint inspection : 55 Pa. Code § 3800.32.b Specific Rights

On FY] Child A was restrained unnecessarily by Staff A. According to the complaint, Child A was sitting in | desk in the classroom and humming. Staff A attempted to redirect Child A to stop humming or to leave the classroom, but Child A continued| 7 Staff A reportedly (osc composure, walked over to the child, and restrained on the floor. The child was not injured during the incident. By doing so, the staff "mistreated" the child.

Citation, complaint inspection : 55 Pa. Code § 3800.202.a Appropriate Use of Restrictive Procedures

On Child A was unnecessarily placed in a restrictive procedure that was used by Staff A. According to the complaint, Child A was sitting in his desk in the classroom and humming. Staff A attempted to redirect Child A to stop humming or to leave the classroom, but Child A continued behavior. Staff A reportedly lost composure, walked over to the child, , and restrained on the floor. The child was not injured during the incident. At no time during the video did it appear that Child A was a threat to himself or anyone else in the classroom, thus making the restraint unnecessary. Abraxas leadership reviewed the video and confirmed that the restraint was unnecessary.

Citation, renewal inspection : 55 Pa. Code § 3800.51 Child Abuse and Criminal History Checks

Staff Person B was hired on . The clearances required in this section according to the CPSL are to be updated at least every five years. Upon review of his clearances maintained in his personnel record, the most recent Pennsylvania State Police clearance was dated . As of the date of the inspection, this staff member had not obtained a new one yet.

Citation, renewal inspection : 55 Pa. Code § 3800.144.a Dental Care

There was no documentation in Child A's record to support that received the initial dental exam, nor could the agency produce any.

Citation, renewal inspection : 55 Pa. Code § 3800.146.b Hearing Care

The facility was unable to provide documentation showing Child B had a hearing screening within 30 days after admission or record of prior exam in accordance with the periodicity schedule recommended by the American Academy of Pediatrics.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff Person A did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter. The last physical exam contained in Staff Person A's personnel record was dated . This is THREE exams behind what is required.

Citation, complaint inspection : 55 Pa. Code § 3800.32.b Specific Rights

On October 2, 2024, it was determined that child A was by staff member A. Occurring on multiple occasions, during July and August 2024, staff member A with Child A.

Citation, complaint inspection : 55 Pa. Code § 3800.53.b Director

This regulation states that the director shall be responsible for administration and management of the facility, including the safety and protection of the children, implementation of policies and procedures and compliance with this chapter. The Director of the facility is responsible for ensuring that restraints are not done only when necessary, but done properly as well. Regulation 205(b)(3) requires that proper use of restrictive procedures be taught in training. While it appears as though this is occurring during training, multiple interviews during this complaint investigation revealed that staff member A did not implement the procedure as trained. Specifically, child A and two other staff members present reported that staff member A's hands were up high, between the shoulder blades. Child A reported feeling thumbs pushing into back and there were subsequent marks on upper back that support the placement of hands between the shoulder blades. Child A also reported being pushed forward to the point of being somewhat bent over, with head close to lap at times. To this writer's knowledge, neither of these positions/techniques are taught during SCM certification. While there were injuries from the restraint, the staff member does not appear to have been acting in a manner where he was knowingly, recklessly or intentionally causing said injuries.

Citation, complaint inspection : 55 Pa. Code § 3800.202.b Appropriate Use of Restrictive Procedures

Child A was subject to a restrictive procedure that was being utilized for reasons other than to prevent a child from injuring or others. On March 14, 2025, child A was placed in a restrictive procedure in bedroom. According to all parties involved in the complaint process, child A was kept back from school and was to be sitting in the common area of the unit due to being placed on restriction. During time in the common area, child A would use that time to complete schoolwork and assignments. Child A was refusing to sit in the common area and was in room instead, refusing to comply and leave. One of the unit staff members used a "touch prompt" on child A's shoulder to try and move along and child A responded by hitting this staff member's hand away. The response by child A was seen as physical aggression towards staff and as a result the restraint was initiated. If child A was to complete work in the common area as part of being on restriction, it is unclear why this same task could not have occurred in bedroom. At the time the staff member placed hand on child A to use a "touch prompt," child A was not a threat to himself or anyone else. became agitated and aggressive after the "touch prompt" was used, which resulted in the restraint.

Citation, complaint inspection : 55 Pa. Code § 3800.213 Restrictive Procedure Records

Child A was subject to a restrictive procedure on March 14, 2025. Staff member C was not physically involved in the procedure and was observing the restraint as part of the medical staff and was to have completed an observation form. The investigation into this complaint included a review of child A's file. No observation form could be located. When asked if this document was completed, this writer was informed that the observation form was completed by staff member B, who was a participant in the restraint. Administration was already aware of this and acknowledged that it is incorrect and against policy.

Citation, complaint inspection : 55 Pa. Code § 3800.184.c Medication Log

The medication log for child A was not completed at the same time each dosage of medication was administered.

Citation, complaint inspection : 55 Pa. Code § 3800.185.a Medication Errors

Child A reported that Staff A gave him both nighttime and morning medications on 03/22/24. A MAR review was completed. The review was unable to determine if Child A received multiple doses of medication on 03/22/24, but multiple medication administration documentation errors were identified.

Citation, complaint inspection : 55 Pa. Code § 3800.32.b Specific Rights

or iii child A was engaged in an intervention by staff member A. During this intervention staff member A utilized inappropriate techniques by’

Citation, complaint inspection : 55 Pa. Code § 3800.32.b Specific Rights

On FY staff member A also utilized improper physical techniques iin The agency shall submit a written plan of correction which identifies how they will ensure that all staff use appropriate techniques for physical intervention. This could include additional training and mentoring regarding awareness of inappropriate physical techniques, and the professional courage to intervene if inappropriate behavior by staff is identified.

Citation, complaint inspection : 55 Pa. Code § 3800.32.b Specific Rights

During the course of an investigation, it was determined that Child A, Child B, and Child C were abused by Staff A. These incidents occurred over time, beginning in November 2023 and ending in March 2024. The agency shall submit a written plan of correction which identifies how they will prevent this from occurring in the future. This could include increased training and mentoring of staff regarding recognition of inappropriate interactions, professional courage, and use of appropriate reporting channels when concerns arise.

Citation, renewal inspection : 55 Pa. Code § 3800.58.d Staff Training

Staff person A, B, C, D, and E did not have 40 hours of annual training after the initial year of employment.

Citation, renewal inspection : 55 Pa. Code § 3800.144.a Dental Care

Child B did not receive any dental care since admission date

Citation, renewal inspection : 55 Pa. Code § 3800.224.b Development of the ISP

The ISP dated 11-03-23 was developed and signed by the Clinical Therapist. The counselor and child A] did not sign ISP till 11/29/23 making the ISP late and not inclusive or client centered to the child A.

Citation, renewal inspection : 55 Pa. Code § 3800.17 Recordable Incidents

It was determined that the facility did not have a record of the incident that occurred on 09/14/2023 that involved child E.

Citation, renewal inspection : 55 Pa. Code § 3800.58.d Staff Training

Staff persons A, B, C, D, and E did not have 40 hours of annual training after the initial year of employment.

Citation, renewal inspection : 55 Pa. Code § 3800.243 Content of Records

Child A, B, and C ’s record does not contain identifying personal information such as religious affiliation. Child C and D’s record does not contain identifying personal information such as annual dated photograph.

Citation, renewal inspection : 55 Pa. Code § 3800.243 Content of Records

Staff F did not have a FBI clearance on file. A report of Federal criminal history record information. The applicant shall submit a full set of fingerprints in a manner prescribed by the department. The Commonwealth shall submit the fingerprints to the Federal Bureau of Investigation in order to obtain a report of Federal criminal history record information and serve as intermediary for the purposes of this section.

Citation, renewal inspection : 55 Pa. Code § 3800.58.d Staff Training

Staff persons A, B, and C did not have 40 hours of annual training after the initial year of employment.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff persons D, E, F, and G did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff members D, E, F, and G did not have the proper Clearances to work in the state of Pennsylvania. Pursuant to 18 Pa.C.S. Ch. 91 (relating to criminal history record information), a report of criminal history record information from the Pennsylvania State Police or a statement from the Pennsylvania State Police that the State Police central repository contains no such information relating to that person. The criminal history record information shall be limited to that which is disseminated pursuant to 18 Pa.C.S. § 9121(b)(2) (relating to general regulations) 2. A certification from the department as to whether the applicant is named in the central register as the perpetrator of a founded report of child abuse, indicated report of child abuse, founded report for school employee or indicated report Clearances (continued) for school employee 3. A report of Federal criminal history record information. The applicant shall submit a full set of fingerprints in a manner prescribed by the department. The Commonwealth shall submit the fingerprints to the Federal Bureau of Investigation in order to obtain a report of Federal criminal history record information and serve as intermediary for the purposes of this section.

Citation, renewal inspection : 55 Pa. Code § 3800.58.d Staff Training

Staff person A-B-C-D did not have 40 hours of annual training after the initial year of employment.

Citation, renewal inspection : 55 Pa. Code § 3800.151 Staff Health Statement

Staff person A and B did not have the required statement signed and dated by a licensed physician, certified registered nurse practitioner or licensed physician’s assistant, within 12 months prior to working with children or food service and every 2 years thereafter.

Citation, renewal inspection : 55 Pa. Code § 3800.243 Content of Records

Child A and B's record does not contain identifying personal information such as, religious affiliation. Child B's file did not contain a dated annual photograph.

Citation, complaint inspection : 55 Pa. Code § 3800.202 Appropriate Use of Restrictive Procedures

Child A was subject to a restrictive procedure on 01/27/2024 without evidence of attempts being made to anticipate and de-escalate the behavior and using methods of intervention less intrusive than restrictive procedures.

Citation, partial inspection : 55 Pa. Code § 3800.16.c Reportable Incidents

On , an incident involving child A occurred at the facility which required notification to the Department within 24 hours.