Pine Haven Boys Center

Non-compliant, complaint visit : He-C 4001.10(p)(2) The applicant, licensee, or any child care staff shall not falsify any documents, other written information, or reports issued by or ...

REPEAT CITATION PREVIOUSLY CITED ON MARCH 4, 2026. The department's review of the DHHS Restraint & Seclusion Reporting form for the incident that occurred on June 15, 2026, revealed that staff falsely stated that a restraint was initiated after Resident A became physically assaultive towards staff, including throwing punches and kicking staff repeatedly. This did not align with the video footage of the incident. Staff also failed to document a supine restraint completed by Staff A and Staff B, and a prone restraint completed by Staff B, both of which were observed on the video footage. The staff completing the DHHS Restraint & Seclusion Reporting form falsified the document when omitting information and when erroneously reporting the progression of the incident, which was verified in the footage of the incident.

Non-compliant, complaint visit : He-C 4001.23(a) Licensees shall ensure that program staff complete all reports and comply with reporting requirements for uses of restraint and seclusion, in ...

REPEAT CITATION PREVIOUSLY CITED ON MARCH 4, 2026. The department's review of the DHHS Restraint & Seclusion Reporting form for the incident that occurred on June 15, 2026, and video footage of the incident revealed that a supine restraint and a prone restraint were initiated by staff, but were not recorded for reporting purposes. As a result, the report was incomplete and staff did not comply with the reporting requirements.

Non-compliant, complaint visit : He-C 4001.22(e) Program staff shall use seclusion and restraint in accordance with RSA 126-U and He-C 901.

REPEAT CITATION PREVIOUSLY CITED ON MARCH 4, 2026. The department's review of the DHHS Restraint & Seclusion Reporting form, review of video footage, and interviews with staff revealed that there was no evidence that Resident A's behavior posed a substantial and imminent risk of physical harm to themselves or others, and therefore the physical restraint of the resident was not justified pursuant to RSA 126-U:5. Further, on June 15, 2026, staff did not utilize the least restrictive strategies for which they were trained when interacting with Resident A. Staff B engaged Resident A in a restraint after Resident A rolled into a prone position, which is prohibited in RSA 126-U4.

Non-compliant, complaint visit : He-C 4001.22(g) Restraint techniques used shall be consistent with the curriculum required in (f) above and be reviewed at least annually with program staff to ...

REPEAT CITATION PREVIOUSLY CITED ON MARCH 4, 2026. The department's review of the DHHS Restraint & Seclusion Reporting form, video footage and staff training documents revelealed that Staff A and Staff B did not use techniques consistent with CPI, as the least restrictive strategies were not used.

Non-compliant, complaint visit : He-C 4001.22(b)(11) Program staff shall not use rough handling on residents, including but not limited to, grabbing, pushing, pulling, and dragging.

Staff B reported they reviewed camera footage and witnessed Staff C push Resident A. Staff D reported they witnessed Staff C shove Resident A into their bedroom during the overnight shift from May 20 to May 21, 2026. The camera footage provided by the program showed Resident A leaning against the wall in the hallway near their bedroom, facing Staff C. Staff C grabbed Resident A's arm between the elbow and shoulder and roughly turned Resident A's body away from Staff C. Staff C then pushed Resident A's arm from behind so that Resident A was completely turned away from Staff C. Resident A is moved from their original position but did not lose their balance or fall during the interaction.

Non-compliant, complaint visit : He-C 4001.19(a)(1) Program staff shall relate with residents in a professional, respectful manner.

The complainant stated that Resident A reported that during the overnight shift from May 20 to May 21, 2026, Staff C had threatened to punch Resident A in response to Resident A telling Staff C that they were going to punch Staff C in the face. Resident A stated that Staff A had also been present, and told Staff C, "That's not helpful." Resident A and Staff A confirmed the complainant's report. Staff C admitted to telling Resident A that they would hit Resident A back if struck, although they indicated that they had no intent to hit the resident.

Non-compliant, complaint visit : He-C 4001.10(p)(2) The applicant, licensee, or any child care staff shall not falsify any documents, other written information, or reports issued by or ...

The department’s review of the DHHS Restraint & Seclusion Reporting forms for incidents that occurred on February 1, 2026, February 9, 2026, February 15, 2026, February 16, 2026, and February 22, 2026, revealed that the staff who completed the reports provided false information when the staff reported the use of an escort, which is not the action that the staff took, and none of the reports include that the staff also secluded Resident A. Additionally, the descriptions in the reports did not aligned with the images seen in the video footage.

Non-compliant, complaint visit : He-C 4001.23(a) Licensees shall ensure that program staff complete all reports and comply with reporting requirements for uses of restraint and seclusion, in ...

The department’s review of the DHHS Restraint & Seclusion Reporting forms for incidents that occurred on February 1, 2026, February 9, 2026, February 15, 2026, February 16, 2026, and February 22, 2026, revealed that all the reports identified the use of an escort, which is not the action that the staff took, and none of the reports include that the staff also secluded Resident A.

Non-compliant, complaint visit : He-C 4001.22(b)(11) Program staff shall not use rough handling on residents, including but not limited to, grabbing, pushing, pulling, and dragging.

The administrative staff of the program reported non-compliance to the department after completing a general administrative review of multiple incident reports regarding Resident A and determining that multiple holds were not being done in accordance with policy and that seclusion events did not meet the criteria for seclusion. The department’s review of incident reports, video footage, and interviews with staff and Resident A revealed that on February 1, 2026, February 9, 2026, February 15, 2026, February 16, 2026, and February 22, 2026, three program staff roughly handled Resident A when they held Resident A’s wrists above Resident A’s head, at times carrying Resident A when their feet were not touching the floor, or dragged Resident A by their suspended arms when Resident A did not walk along with staff, dragged Resident A by their legs and one arm, carried Resident A by their right arm and right foot so that they were suspended entirely off the floor, dragged Resident A by one arm, and dragged Resident A by their arms down hallways and torso down the stairs. By rough handling Resident A as described, staff created a significant risk of injuring Resident A.

Non-compliant, complaint visit : He-C 4001.22(e) Program staff shall use seclusion and restraint in accordance with RSA 126-U and He-C 901.

The department’s review of incident reports, video footage, and treatment plans, and interviews with staff and Resident A revealed that on February 1, 2026, February 9, 2026, February 15, 2026, February 16, 2026, and February 22, 2026, program staff secluded Resident A in a manner that was not in accordance with the provisions of RSA 126-U. Specifically, staff held a door closed or sat outside the closed door, which was not equipped with unbreakable observation windows or equivalent devices to allow the safe, direct, and uninterrupted observation of every part of the room, as required in RSA 126-U:5-b. In addition, as required in RSA 126-U:5-b, a co-regulator was not designated to monitor Resident A and a plan was not developed to help Resident A manage their state of regulation and their return to a less restrictive setting when Resident A was in seclusion, and on February 16, 2026, the seclusion lasted for more than 30 minutes without staff checking on Resident A. Additionally, at no point did any of the staff utilize the least restrictive strategies for which they were trained when interacting with Resident A, and there was no evidence in any of the incidents that Resident A’s behavior posed a substantial and imminent risk of physical harm to themselves or others, which is contrary to the requirements in RSA 126-U:5-a.

Non-compliant, complaint visit : He-C 4001.22(g) Restraint techniques used shall be consistent with the curriculum required in (f) above and be reviewed at least annually with program staff to ...

The department’s review of incident reports, video footage, and staff training documents revealed that the staff members involved in the rough handling and seclusion of Resident A as described herein did not use techniques consistent with CPI. At no point did any of the staff utilize the least restrictive strategies for which they were trained, and the manner with which they moved Resident A, as described under He-C 4001.22(b)(11) herein, did not constitute a restraint in any of the incidents. All four staff involved have completed initial and refresher training in Nonviolent Crisis Intervention with Advanced Physical Skills taught by a CPI certified instructor.

Non-compliant, complaint visit : He-C 4001.14(a) Program staff shall provide care and supervision at all times to ensure that residents are safe and that their needs are met according to their ...

The department’s review of video footage of an incident on February 1, 2026, and of Pine Haven’s incident report, revealed that three staff members secluded Resident A. According to the incident report, while in seclusion Resident A urinated in their pants, completely soaking themself. One staff member required Resident A to first clean the seclusion room and mop the floor, which took approximately 10 minutes, before permitting Resident A to leave the room and clean themselves.

Non-compliant, renewal visit : He-C 4001.31(b) Prior to the start date and every 5 years thereafter, an employee, volunteer, household member, or other individual who will be working in the ...

The licensing coordinator's review of the current direct care staff list revealed that there were four staff members active within the program without a valid background check.

Non-compliant, renewal visit : He-C 4001.14(l) The program director or designee shall conduct fire drills at varying times, including night time hours, once each month in each building that ...

Two licensing coordinators' review of program documents revealed that monthly fire drills were not conducted in August 2024 and February 2025.

Non-compliant, complaint visit : He-C 4001.22(b)(1) Program staff shall not abuse or neglect residents.

On March 20, 2025, program staff reported an incident in which a staff member may have abused a resident. Staff A reported that they had heard Child A yelling from downstairs at the cottage while Staff A was upstairs at the cottage, requesting Staff B not to touch them. Staff A reported that they went downstairs and witnessed Staff B backing out of the “Chill Zone,” where there are no cameras. Staff A reported seeing visible red marks on Child A’s neck while Child A was in the “Chill Zone,” and that Child A had stated “he [expletive] choked me.” In a forensic interview, Child A disclosed that Staff B had pushed Child A into a chair and choked Child A while in the “Chill Zone.” Video footage confirmed that Staff B had pushed Child A into a chair with force while in the TV room, and that Staff B had entered the “Chill Zone.” A photograph of Child A’s neck confirmed that there was a visible mark on Child A’s neck following the incident, indicating that Staff B, who was the only person present, had forcible contact with Child A during the altercation.

Non-compliant, complaint visit : He-C 4001.20(a) Program staff shall provide care and supervision at all times to ensure that residents are safe and that their needs are met according to their ...

REPEAT CITATION PREVIOUSLY CITED ON DECEMBER 11, 2023 AND MARCH 26, 2024. The program self-reported a possible lack of supervision during a community outing with residents on September 2, 2024. Two staff members and six residents participated in the outing. Three residents reported to the program that during the outing, they had engaged in sexualized behavior while out of sight of staff. Staff B stated that on September 2, 2024, Staff A had been supervising one of the residents in the restroom, while Staff B supervised the other 5 residents. Staff B stated that they had stood outside the bottom level of a two-story play structure inside a building, between the building and an adjacent playground, while the residents ran in and out of the building, and to the playground. Staff B stated that at times the residents were in tunnels on the bottom level of the building, and on the top level of the building, and were therefore out of view of the staff.

Non-compliant, complaint visit : He-C 4001.20(a) Program staff shall provide care and supervision at all times to ensure that residents are safe and that their needs are met according to their ...

Program staff self-reported to the Division for Children, Youth, and Families in regard to a concern for a lack of supervision resulting in sexual contact between two residents, which occurred during an outing on December 3, 2023. Staff at the program confirmed that both children had attended the outing. Neither Staff B nor Staff C, who had been present during the outing, had witnessed inappropriate interactions between the two children. Staff B reported that they had been driving and that it had been dark on the return drive. Staff C reported that they had been sitting in the back with the children but had not witnessed any misconduct from the children. Staff A reported that the program has had previous concerns about Staff C providing adequate supervision, specific to Staff C being on their personal cell phone when working. Staff D confirmed that Child B has a history of sexual contact with other residents at his previous placement facility, while Child A’s history was specific to the opposite gender. Child A disclosed that the interaction had taken place in the van while returning to the program during an in-person interview conducted on December 11, 2023. Child B was not willing to participate in an in-person interview, however, they disclosed the interaction to program staff on December 6, 2023, as documented in a Log Entry and Critical Incident Report provided by the program. Child C confirmed that Staff C had been riding in the back of the van and reported that they ...