Severe reports

In plain words: The state found that the administrator failed to keep the required log of unauthorized absences for at least 12 months. The complaint stated that a resident ran away after a fight and later passed away, and that other residents also ran away after fights. Our summary of the state's report. The state's own wording follows.

Based on documentation review, record review, and interview, the administrator failed to maintain a log of unauthorized absences for at least 12 months after the date of a resident's absence to include the name of a resident absent without authorization, name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report. [...] The complaint alleged a resident (later identified as [Resident 2]) had an unauthorized absence and later passed away. [...] The email stated "[Resident 2] and two other [residents] ganged up fought another [resident] and afterwards they ran away." 7. [...] The text message stated "[Resident 3] fought another [resident] then ran away." 8. [...] The text message stated "[Resident 4] ran away at 8:00 am [sic] after fighting another resident." 9. The Compliance Officer requested to review the facility's written log of unauthorized absences.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that includes the .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Additional Non-Compliance Found During Investigation: Improper restraint conducted on a resident.

From the state's report. Found during a substantiated complaint investigation. Cited: 340:110-3-154.2(d) Physical restraint. Restraint may only be used when less restrictive interventions, according to facility policy, have ....

On , Child A was involved in 3 restraints in which they sustained injuries and was not medically assessed until the following day.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.k Specific Rights.

The client was transported by EMS to the hospital; Individual's Condition Before & After the Incident: Physically fine before the incident but became upset during the incident. [Resident 1] was crying and in pain after the incident; Description of any Medical Services Received: EMS transported [Resident 1] to the hospital where [Resident 1] was treated for first degree burns to [Resident 1's] chest." 2. [...] 3. In an interview, [Staff 1] and [Staff 2] reported the first peer who threw water on [Resident 1] used hot water and the second peer used cold water, after [Staff 1] and [Staff 2] investigated the incident. [Staff 1] and [Staff 2] reported removing the peer who threw hot water from the facility and relocating the peer who threw cold water.

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

It was reported by staff, it was the concern of administration, that another staff was believed to have choked a youth during a restraint. cinding: |

From the state's report. Evidence supports non-compliance, DFS notice. Cited: Chapter 3, Section 3 Abuse and/or Neglect Reporting.

The provider was out of compliance with this rule by failing to report multiple allegations of verbal and physical abuse to the applicable investigative agencies. During the investigation inspection, interviews disclosed allegations of verbal and physical abuse by staff members.

During an investigation inspection, multiple interviews substantiated that a staff member made verbal threats to a client and punched a hole in a hallway wall.

From the state's report. Out of compliance, focus inspection. Cited: R495-876-6(1)(a)-(g) Client rights.

On , child A was not treated with fairness, dignity, and respect by staff member A. Specifically, the child was provoked by staff, shoved to the floor and was carried in an unapproved restraint.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.c Specific Rights.

It was found during the investigation that a child in care received significant bruising to their shoulder after a short personal restraint.

From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.

Specifically, it was reported that two staff members threatened to spank [Child 2] and [Child 3].

From the state's report. Substantiated. Cited: 84072(d)(10). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Video surveillance shows staff pushing a child.

From the state's report. Risk level: High. Cited: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment.

Through interviews with staff and children in care, it was determined that a staff member slammed a child in care to the ground when performing a restraint on the child.

From the state's report. Risk level: High. Cited: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force.

In plain words: A former client said two staff members sexually assaulted her while they were trying to get her phone back. The report says there is no documentation of an investigation or of protective measures being put in place. Our summary of the state's report. The state's own wording follows.

No documentation of an investigation into the allegations made by Former Client (FC) #7 that Staff #3 and Staff #4 sexually assaulted her on No documentation to support systems were put MHL0601558 Be WING 01/03/2024 in place to protect clients during an investigation after sexual assault allegations were made against Staff #3 and Staff #4 on 10/20/2023. [...] Description: Client ([Former client 7]) stated that staff (Staff #3 and Staff #4) were sexually assaulting her when staff were trying to get the phone back from the client. [...] Type of incident: Client/Staff Sexual Assault Allegation. Synopsis of incident: On Friday 10/20/2023 Client ([Former client 7]) stole staff phone and ran into her bathroom... and was making statements that staff (Staff #3 and Staff #4) were sexually assaulting her while she was in the bathroom. [...] The allegation of sexual assault incident with [Former client 7] occurred on 10/20/2023.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 132 G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Interviews conducted with children had similar statements and stated that a staff grabbed and pulled a child's hair and staff punching a child in the back after children threw water and condiments at staff. [...] Staff stated there was an incident that occurred where a child threw soap and water at a staff.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

Child in care was hit by a staff member.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

During an investigation inspection, staff and client interviews and provider documentation substantiated that a staff yelled at a client, grabbed the client by their shirt, shook the client, and hit the client in the forehead with an open palm.

From the state's report. Out of compliance, focus inspection. Cited: R495-876-5(1)(a)-(m) Code of conduct.

On ma. child A was in an inappropriate physical altercation with staff member A. Staff member A is seen on video pulling back multiple times to punch the child in the midsection.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.

A child in care was hit and choked by a staff member.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

Upon review CHRIS entry A- 20230020; the provider's investigation includes review of cameras and eyewitness statements which revealed that Employee # 1 had inappropriate sexual conversations and exchange letters with sexual content with Individual #1.

From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 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..

As a result, [Child 1] was found unconscious from an overdose and later passed away. [...] As a result, [Child 1] suffered an overdose and loss of life while under the direct care of STRTP [Staff 4]. Pursuant to the Enhanced Civil Penalty law, the Health and Safety Code 1548 (e)(3) states a violation the Department determines "resulted in the death of a person receiving care through a short term residential therapeutic program" the Department will issue an immediate civil penalty of $7,500.00. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the administrator.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Based on confidential interviews and record reviews, the allegation of sexual abuse had maintained consistent through multiple interviews. [...] The allegations were also investigated by the Alameda County Sheriff's Office. [...] Based on the confidential interviews and record review, the allegation that staff sexually abused a youth in care has met the preponderance of doubt and is therefore substantiated.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

A caregiver shoved a child in care on the shoulder during an argument.

From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..

Based on LPA's observations, record review, and interviews, a resident in care sustained bruising on their arm following an improper restraint performed by staff.

From the state's report. Substantiated.

Resident reported small abrasion on her palm side next to her thumb from the restraint, petechiae around her eyes and cheeks that were not observed on 10/25/2023. [...] I did not get up as I was eating dinner. [QBHP #1] took her to the seclusion room and called me to take his place. [Client #1] was kicking, screaming, scratching, drew blood from my hand from scratches, and banging her head. [RN #1] brought a pillow.

The Policy "Use of Seclusion-Intensive Residential" (Reviewed 07/24/2023), read in part, "...Seclusion is utilized to protect the patient from injuring self or others...

From the state's report. Deficiency cited, complaint survey. Cited: N 132 PROTECTION OF RESIDENTS N 132; N 172 MONITORING DURING AND AFTER N 172. "[...]" marks text left out between sentences.

During the investigation of staff had inappropriate relationship with youth, LPA toured the facility with LaKeisha Carter, Director on 8/29/23 and with Kim Robinson Assistant Director on 9/13/23. [...] LPA's Jean Stidman and Stephannie Verna conducted interviews with the reporting party, two staff, one resource parent and three clients on 8/29/23, 9/13/23, 9/14/23 and 11/9/23.Two out of two youth interviewed reported the staff had an inappropriate relationship with youth.

From the state's report. Substantiated. Cited: 84072(d)(10). "[...]" marks text left out between sentences.

During the course of an investigation, it was determined on /2023 that Staff Member A engaged a verbal conflict with Child A, including using profane language, and staff pushed the back of the child's chair, causing to fall to the ground.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.

The referral reported staff ([Staff 1]) allegedly raped a former client, who is now an adult (A1).

From the state's report. Substantiated. Cited: 87072(c)(15). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Based on the information obtained, there is a preponderance of the evidence to prove that staff handled minor in care in a rough manner.

From the state's report. Substantiated.

The Penal Code Section 11165.6 defines child abuse or neglect as a physical injury or death inflicted by other than accidental means upon a child by another person. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the Facility Director.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

Staff was observed on video hitting a child in the face with a closed hand.

From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..

In plain words: A report noted several serious incidents in the program, including a medical emergency from suspected drug use, aggressive physical restraints by staff that caused injuries, sexual misconduct, criminal activity, and a child leaving without permission. Our summary of the state's report. The state's own wording follows.

These incidents included a client medical emergency as a result of reportedly smoking methamphetamine, an unnecessary and aggressive physical restraint that resulted in serious client injury, a physical restraint in which a staff punched a client in the face multiple times that resulted in client injury, 5 incidents of client sexual misconduct, criminal activity, and an AWOL incident.

From the state's report. Out of compliance, complaint, focus inspection. Cited: R501-1-11(2)(a)-(f) Licensed Program Complaints and Critical Incidents.

Child B was mistreated by Staff member A when staff member A dragged the child by the arm briefly during an escalated incident.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.

On May 22, 2023, Community Care Licensing (CCL) received two allegations alleging due to a lack of care and supervision minor (Child #1) overdosed while in care and Minor ([Child 1]) did not receive medical treatment in a timely manner. [...] Confidential interviews and medical records note overdose as cause of [Child 1] being found unconscious. [...] Based on confidential interviews and record review the allegations alleging due to a lack of care and supervision minor (Child #1) overdosed while in care and Minor ([Child 1]) did not receive medical treatment in a timely manner are substantiated.

From the state's report. Substantiated. Cited: 87078(a). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

[Staff 1] offered [Child 1] the bottled water, poured water on [Child 1]'s face causing [Child 1] to escalate, attacking [Staff 1] and bit [Staff 1]'s leg.

From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The evidence substantiated that a staff member bit a client during a physical restraint incident in response to the client aggressively engaging with the staff; the client incurred an injury as a result.

From the state's report. Out of compliance, focus inspection. Cited: R495-876-5(1)(a)-(m) Code of conduct.

It is alleged that an organization staff member used and unapproved restraintAtransport technique, dragging a youth on the floor to a timeout room.

From the state's report. Evidence supports non-compliance, DFS notice. Cited: Section 25 Emergency Safety Interventions; Section 23 Child and Family Rights.

A youth in care was found to be physically abused by a caregiver.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

On , Child A was not treated with fairness, dignity and respect by Staff Member A. Surveillance footage showed Child A was carried in an unapproved restraint causing Child A to fall out of clothing.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.c Specific Rights.

[Staff 2] reported to have written incident reports on "two or three" occasions regarding [Resident 1]'s unwanted sexual misconduct behavior allegations by another resident towards [Resident 1].

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose .... The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Additional Non-Compliance Found During Investigation: Behavior Management: Staff member used improper restraint techniques in dealing with a resident's behaviors.

From the state's report. Found during a substantiated complaint investigation. Cited: 340:110-3-154.2(d) Physical restraint. Restraint may only be used when less restrictive interventions, according to facility policy, have ....

According to SIA Birk's report, based on confidential interviews and documentation there were multiple consistent statements of multiple clients being sexually assaulted and/or inappropriately touched while at the facility.

From the state's report. Substantiated. Cited: 84072(d)(10).

On June 16, 2023, Community Care Licensing (CCL) received two allegations alleging Staff ([Staff 1]) sexually abused a minor ([Child 1]) in care and staff ([Staff 1]) bribed minor ([Child 1]). Specifically, it was reported when [Child 1] resided at the facility, [Staff 1] propositioned [Child 1] for sexual activities in exchange for items including drugs, candy, and things unavailable at the facility. Consistent confidential interviews and record review provided a preponderance of evidence of [Child 1] being sexually abused by [Staff 1] by [Staff 1] bribing [Child 1] to participate in sexual activities. Based on record review and confidential interviews the allegations alleging Staff ([Staff 1]) sexually abused a minor ([Child 1]) in care and staff ([Staff 1]) bribed minor are substantiated.

From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

LPA's observation, interviews conducted, and records reviewed were consistent that a facility employee inappropriately handled a client in care when the client was shoved. Evidence, including interviews, incident and Law Enforcement reports, video footage, and the facility's completed internal investigation, revealed that a facility employee ([Staff 2]) shoved a client during an incident on 06/21/2023. Additionally, the video footage obtained and reviewed clearly shows the alleged staff forcefully shoving a client.

From the state's report. Substantiated. Cited: 87072(c)(11). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The complainant’s statement that Resident A reported to emergency room staff that a peer sexually assaulted them.

From the state's report. Non-compliant, complaint visit. Cited: 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 ....

Behavior Management: Staff member threw a resident to the ground.

From the state's report. Substantiated complaint. Cited: 340:110-3-154.2(b)(1) shaking, striking, spanking, or other cruel treatment;.

In plain words: The state found that two staff members, a house manager, and the licensee neglected the needs of two former clients after one reported being sexually assaulted by the other. Staff did not get medical care for the victim and doubted the report. Our summary of the state's report. The state's own wording follows.

Finding #5: Evidence Staff #1, Staff #5, the HM, and the Licensee neglected [Former client 2] and [Former client 3]'s needs after an allegation of sexual abuse made by [Former client 2] against [Former client 3]. [...] "Allegation of sexual abuse reported 9/10 (9/10/23) ...Additional steps of safety plan were taken. [...] No medical care or evaluation completed after an allegation of sexual assault and vaginal penetration with a make-up brush. [...] On 9/9/23 between 9:30 pm and 1:00 am "She [Former client 3] raped me. ..." [...] Reported the sexual assault on 9/10/23 to Staff #1 and Staff #5, "They didn't really believe me." [...] Had [Former client 2] and [Former client 3] write a grievance and spoke to both of them about the alleged sexual assault. [...] Reported the sexual assault grievance made by [Former client 2] to the HM on 9/11/23. [...] On 9/10/23, Sunday, [Former client 2] said to her '[Former client 3] raped' her ... told her she had to talk to [the Licensee] ..."

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

On July 28, 2023, Community Care Licensing (CCL) received the allegation that staff handled minor in a rough manner. [...] Based on confidential interviews, the allegation that [Staff 1] handled [Child 1] in a rough manner is SUBSTANTIATED because the preponderance of evidence standard has been met.

From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: An administrator failed to notify the state in writing within one working day about a resident's death from a reported drug overdose. Our summary of the state's report. The state's own wording follows.

Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. [...] The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [Resident 1] was seen smoking a unknown substance at a QT off [street name] and [Resident 1] was taken to the emergency room where [Resident 1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of [Resident 1]'s death.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Staff #1 grabbed Client #1 by the shirt from behind with one hand and walked him over to a chair, then shoved him down into the chair; [...] Staff #1 grabbed Client #1 by the wrist, then tried to grab his other hand, Client #1 was moving around, Staff #1 then took about 2 steps and dragged Client #1 while Staff #1 was walking, he stopped and tried to get Client #1 to stand up on his feet, Client #1 was moving all around on the floor; [...] Staff #1 started to walk toward the outside door while he held Client #1's wrist, Client #1 fell to the floor and Staff #1 took about 6 steps while dragging Client #1 on the floor; [...] The allegations include The Village House staff choking and neglecting clients at the YMCA." [...] Staff #1 "dragged" client #1 out of the pool; [...] Staff #1 dragged the client (#1) out the back door.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences.

It was determined that physical abuse occurred (any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means.

From the state's report. Maltreatment determined as to physical abuse of an alleged victim by a staff person..

In turn, [Resident 1] became intoxicated and had to be transported to the local hospital for assessment. [...] 4. In an interview, [Staff 1] acknowledged, as a result, [Resident 1] ingested alcohol, which caused [Resident 1] to be under the influence, where [Resident 1] was transported to the hospital for a medical assessment.

From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.