Liberty Point Behavioral Healthcare Secure Residential Treatment

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-590. B. The interior and exterior of all buildings shall be safe, properly maintained, clean, and in good working order. This includes, but is not ...

During the recent inspection, it was noted that interior walls and ceilings throughout the facility were dirty and marked with scuffs and graffiti, including inappropriate drawings and curse words. The provider failed to ensure that the interior of all buildings was maintained in a safe, clean, and properly functioning condition.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (9a) - The provider's duties. 9. Providers shall comply with all applicable state and federal laws and regulations, certification and ...

Providers shall comply with all applicable state and federal laws and regulations, certification and accreditation standards, and third-party requirements as they relate to seclusion and restraint. CHRIS A#20260015 Provider substantiated for restraint not in compliance with standards based on the following: • Individual #1 was standing on a chair and hitting a light while another individual was involved in a restraint. • Individual #1 then jumped off the chair and attempted to hit Employee #1. • Employee #1 then placed Employee #1's hands on Individual #1's shoulders/upper arms and then moved Individual #1 forward down the hallway which is not in compliance with provider's standards (Entity #1). Failing to comply with provider standards specific to the requirements of Entity #1 is a violation of 12VAC35-115- 110(C)(9).

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. CHRIS A#20260012 Provider substantiated for abuse based on the following: • Employee #2 and Individual #1 reported that Employee #1 struck Individual #1 in the face. • Employee #1 reported that Employee #1 accidentally struck Individual #1 in the face when attempting to block Individual #1 from hitting Employee #1. Employee #1 striking Individual #1 in the face was an act that was performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm or injury to Individual #1 and is a violation of 12VAC35-115-50(B)(2).

Non-compliance, DBHDS human rights inspection : 12VAC35-115-60. B. (2) The provider's duties. 2. Providers shall ensure that all services, including medical services and treatment, are at all times delivered ...

Providers shall ensure that all services, including medical services and treatment, are at all times delivered in accordance with sound therapeutic practice. CHRIS A#20260013 Provider substantiated for violation of sound therapeutic practice based on the following: • Employee #1 and Employee #2 attempted to perform a therapeutic guide on Individual #1 that did not follow provider policy and was not delivered in accordance with sound therapeutic practice. Employee #1 and Employee #2 failing to ensure that all services, including medical services and treatment, are at all times delivered in accordance with sound therapeutic practice is a violation of 12VAC35-115-60(B)(2).

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. CHRIS A#20260011 Provider substantiated for physical abuse based on the following: • Review of video footage revealed the following: ◦ Individual #1 can be seen going down the hallway and attempting to aggress toward Employee #1. ◦ Employee #1 immediately raised up arm and drew arm back and then forward toward Individual #1. ◦ While video footage was not clear if Employee #1 made physical contact with Individual #1, Employee #1's action was performed knowingly, recklessly, or intentionally, and that might have caused physical harm or injury to Individual #1 and is a violation of 12VAC35-115-50(B)(2).

Non-compliance, DBHDS human rights inspection : 12VAC35-115-60. B. (2) The provider's duties. 2. Providers shall ensure that all services, including medical services and treatment, are at all times delivered ...

Providers shall ensure that all services, including medical services and treatment, are at all times delivered in accordance with sound therapeutic practice. CHRIS A#20260010 Provider substantiated for Services violation based on the following: • Individual #1 was kicking doors and making inappropriate statements to other individuals on the unit. • Employee #1 was asked by another staff to assist with redirecting Individual #1 away from other individuals to avoid peer-on-peer altercations. • When Employee #1 redirected Individual #1 to walk off the unit to the courtyard, Individual #1 started walking toward the hallway and quickly turned around, almost running into a chair. • Employee #1 then placed Employee #1's hands on Individual #1's upper body and moved Individual #1 forward in the direction of the hallway. • Provider indicated that Employee #1 should have carried out a therapeutic guide (Handle With Care) or requested further assistance from other staff. Employee #1's action of moving Individual #1 forward was not in line with provider policy and failed to deliver services in accordance with sound therapeutic practice which is a violation of 12VAC35-115-60(B)(2).

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (6) The provider's duties. 6. Providers shall not use a restraint that places the individual's body in a prone (face down) position.

CHRIS A#20250033 Providers shall not use a restraint that places the individual's body in a prone (face down) position. • While Individual #1 was experiencing a behavioral crisis, Employee #1 and Individual #1 fell to the floor causing Individual #1 to land on Individual #1's stomach and Employee #1 to fall on top of Individual #1. • Employee #2 and Employee #3 both observed Employee #1 remain on top of Individual #1 while Individual #1 was on Individual #1's stomach in a prone position, and then proceed to perform a headlock/choke hold on Individual #1. • Employee #3 then immediately pulled Employee #1 off Individual #1 and removed Employee #1 from the area and away from Individual #1. Employee #1 remaining on top of Individual #1 while Individual #1 was on Individual #1's stomach and performing a headlock/choke hold move was using a restraint that placed Individual #1's body in a prone (face down) position and, therefore, is a violation of 12VAC35- 115-110(C)(6).

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

CHRIS A#20250033 "Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Provider substantiated for physical abuse based on the following: • Individual #1 alleged that, on November 30, 2025, Employee #1 choked Individual #1 and hit Individual #1 several times. • Individual #1 was in the cafeteria with Employee #1 when Individual #1 experienced a behavioral crisis. • Employee #1 reported that Individual #1 hit Employee #1 in the face several times causing visible injuries to Employee #1's face. • Employee #3 arrived first to assist Employee #1 with Individual #1. • Employee #3 reported that Employee #3 thought that Employee #1 was attempting to initiate a restraint with Individual #1 when Employee #3 observed Employee #1 and Individual #1 fall to the floor with Individual #1 landing on Individual #1's stomach and Employee #1 landing on top of Individual #1. • Employee #2 reported that Employee #2 arrived to see Employee #1 on top of Individual #1 and Individual #1 was lying on Individual #1's stomach in a prone ...

Non-compliance, DBHDS human rights inspection : 12VAC35-115-60. B. (2) The provider's duties. 2. Providers shall ensure that all services, including medical services and treatment, are at all times delivered ...

A#20250028 Providers shall ensure that all services, including medical services and treatment, are at all times delivered in accordance with sound therapeutic practice. As part of an investigation provider determined that there was a violation of sound therapeutic practice based on the following: • During a crisis situation, Individual #1 climbed up on a pipe structure in the gym. • While Individual #1 was on the pip structure, Individual #1 was making inappropriate comments/insults towards staff. • Employee #1 made a statement to Individual #1 in attempt to get Individual #1 down off of the pipe structure, however the statement was not in accordance with sound therapeutic practice and is therefore a violation of 12VAC35-115-60(B)(2).

Non-compliance, systemic, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

Liberty Point Academy This regulation was NOT MET (SYSTEMIC) as evidenced by: CHRIS Number: 20250027 Date/Time of Discover: 07/29/2025 7:39PM Enter Date/Time: 08/01/2025 8:09AM Reporting Delay: 36:30:00 Location Name: Liberty Point Academy CHRIS Number: 20250028 Date/Time of Discover: 07/29/2025 7:45AM Enter Date/Time: 08/01/2025 8:24AM Reporting Delay: 48:39:00 Location Name: Liberty Point Academy Note: As this is provider's second step in the Progressive Citation Cycle for the same regulation within a one-year period, measured on a rolling basis, provider has demonstrated systemic noncompliance. Provider was previously cited for late reporting • The first citation was issued on 9/18/24 and is now non- compliant.

Non-compliance, DBHDS investigation : 12VAC35-46-920. (5) The following actions are prohibited: 5. Any action that is humiliating, degrading, or abusive;

Based upon the review completed for the investigation of serious incident CHRIS report #20250018, including video evidence and Individual #1's reports; the provider failed to prevent the prohibited actions that were humiliating, degrading and abusive to Individual #1.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

CHRIS A#20250018 "Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. * Use of language that demeans, threatens, intimidates, or humiliates the person. Provider substantiated for verbal abuse based on the following: • Individual #1 requested to Employee #1 to make an additional phone call. • Employee #1 had just previously assisted Individual #1 with making a phone call and reminded Individual #1 of that, along with informing Individual #1 that other individuals needed to use the phone first. • Individual #1 continued to request a phone and not respond to redirection from Employee #1. • Individual #1 then requested again and asked why not and Employee #1 responded with, "Because I fucking can." Employee #1's language toward Individual #1 is use of language that is demeaning, threatening, intimidating or humiliating and meets the definition of verbal abuse. This is a violation of 12VAC35-115-50(B)(2).

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

CHRIS A#20250017 "Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Provider substantiated for sexual abuse based on the following: Review of camera footage revealed the following: On May 3, 2025, at approximately 9:36am, Individual #1 and Employee #1 entered the cool down/sensory room. Employee #1 and Individual #1 engaged in inappropriate touching, to include Individual grabbing Employee #1's waist band, slapping/smacking Employee #1 on the bottom several times, and Employee #1 grabbing/caressing Individual #1's face. Employee #1 and Individual #1 were seen kissing multiple times. Individual #1 then attempted to take Employee #1's pants off, but Employee #1 pushed Individual #1 away. Employee #1 then performed oral sex on Individual #1 three times. While Individual #1 is behind the door and mostly off camera, Employee #1 can be seen on camera kneeling in front of Individual #1 with one hand on the door. Additionally, Individual #1's hand can be seen grabbing the back of Employee #1's head and Employee #1's ...