Severe reports

Medication was not kept inaccessible other than employees responsible for storing the medication, as a child was able to obtain 6 bottles of medication and ingested an unknown amount of medication, requiring that child to be hospitalized.

From the state's report. Risk level: High. Cited: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication.

In plain words: A child in the program received a head injury during a physical restraint. The facility failed to make sure the restraint did not cause the injury, and the child was sent to the emergency room for a scan. Our summary of the state's report. The state's own wording follows.

Based on record review, the facility failed to ensure a physical restraint did not result in injury for 1 (Client #1) of 1 sampled client who received a head injury during a physical restraint. [...] 6. List any revisions for the resident's plan of care, treatment, or services: Sent to ER [Emergency Room] [Hospital]...Description of injuries: R had silver dollar size hematoma on R [right] lower occipital lobe @ [at] base; Description of Treatment: APRN [Advanced Practice Registered Nurse] notified resident sent to [Hospital] for CT [computed tomography] scan of head..." b.

From the state's report. Deficiency cited, complaint survey with poc. Cited: N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.

The residents returned to the facility and shared pills amongst each other and several residents were rushed to the hospital due to ingestion.

From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.

In plain words: A child in the program got a cut requiring stitches after a staff member took them to the floor. Witnesses and a discipline document stated that the staff member used excessive force and an unapproved technique. Our summary of the state's report. The state's own wording follows.

A. Maltreatment: On January 5, 2022, [the alleged victim] sustained a cut on his/her chin and received stitches after being taken down to the floor by [the staff person]. [...] However, P1 was in the timeout room at the time of the incident and stated that the way [the staff person] took [the alleged victim] to the floor was “excessive” and that s/he noticed blood on [the alleged victim]’s face after the incident; P2 watched the video and said that [the staff person]’s actions were not consistent with his/her training; and [the staff person]’s Staff Discipline Document stated that [the staff person] used “excessive force” when taking [the alleged victim] to the floor, using a technique that was not approved by the facility.

From the state's report. Maltreatment determined as to neglect and physical abuse of an alleged victim by a staff person.. "[...]" 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 investigation found the facility failed to properly supervise young people, leading to emergency hospital care for two clients. The state issued a civil penalty for physical abuse resulting in serious injury. Our summary of the state's report. The state's own wording follows.

The complaint, which was conducted by CCL Investigations Branch, alleged that the facility failed to properly supervise clients resulting in emergency attention and hospitalization for two clients. [...] The Department determined issuance of Civil Penalty per Health and Safety Code 1548 (f)(C)(i) For a violation that the department determines constitutes physical abuse, as defined in paragraph (2), or resulted in serious bodily injury, as defined in Section 243 of the Penal Code, to a person receiving care at, but not limited to, short-term residential therapeutic program. [...] A copy of this report, Confidential Names Form, Appeal Rights, and form UC 421-D(CRP) for a Civil Penalty Assessment- Death/ Serious Bodily Injury/ Physical Abuse were provided to Facility Representative.

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

On August 31, 2021, Community Care Licensing Division (CCLD) received complaint allegations concerning Staff member #1 who reportedly hit resident Client #1 with a vehicle while dropping minor off at school (see Confidential Names form LIC811, dated March 29, 2022). [...] Information obtained revealed enough evidence to prove the alleged, as [Staff 1] admitted that [Staff 1] was distracted and unintentionally hit [Child 1] with the vehicle as [Staff 1] was backing up while attempting to exit the parking lot at the School after dropping off facility clients on August 25, 2021. [Child 1] was taken to the hospital to be treated for injuries.

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: A child in the program was found asleep in bed with a staff member outside the door. A deputy later took the child to the hospital for an evaluation after a reported suicide attempt using shoelaces tied to a door. Our summary of the state's report. The state's own wording follows.

8:16 pm: "Consumer assessed for 1:1 at 1950 (7:50 pm) - asleep in bed with staff outside door. [County Sheriff's Deputy] arrived at 2016 (8:16 pm) to transport consumer to [hospital] ED (emergency department) for IVC (involuntarily commitment) evaluation. [...] Reason for admission included self harming behaviors, suicidal ideations, physically and verbally aggressive. [...] As a result of those behaviors and attempted suicide attempt (SA), [Former client 13] was IVC'd. nterview on 3/7/22 [Former client 13]'s MCO Care Coordinator stated: [...] On 12/6/21 he received a call at 7 pm froma acility and told [Former client 13] was being sent to the hospital. [...] He recalled being informed during morning rounds that [Former client 13] attempted to hang herself with some shoe laces tied to a door.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 314. "[...]" 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 continued to put resident at risk by allowing another resident to restrain and hit the resident numerous times without removing either from the situation, resulting in the resident receiving a black eye due to the other resident striking him in the face with no intervention from Staff. [...] Due to the severity of the situation, resident was transported to the hospital because he had major cuts on his arm and lost a lot of blood.

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. "[...]" marks text left out between sentences.

LPA Yamamoto met with the facility representative named above and discussed the following: On 1/25/21, the Department received an incident report that on 1/23/21, a client in placement was found unresponsive at the facility after staff exited a bathroom. Staff called 911 and first responders arrived. Client was taken by paramedics to the hospital where client later died. On the same day, the Department received a complaint alleging neglect/lack of supervision resulting in a client's death. [...] A copy of this signed report, Confidential Names Form (LIC 811), Form LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse and Appeal Rights were provided to the facility representative.

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

The Department received a complaint alleging that a client, who was left unsupervised, choked on food resulting in client's death. [...] Staff called 911 and was instructed to perform chest compressions by the 911 operator. [...] Client passed away at the hospital.

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

In plain words: The state investigated a complaint that a staff member failed to properly supervise a fifteen-year-old resident before the child died. The state determined the violation resulted in the resident's death and issued an immediate seven thousand dollar fine to the program. Our summary of the state's report. The state's own wording follows.

On July 23, 2021, the Department concluded a complaint investigation alleging that staff #1 (See the Confidential Names List, LIC 811, dated September 3, 2021) neglected to provide the supervision necessary to meet the needs of fifteen-year-old client #1, prior to [Child 1]'s death. [...] Pursuant to the Enhanced Civil Penalty law, the Health and Safety (H&S) code section 1548 (e)(3)(A) 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 be issuing an immediate civil penalty of $7,000.00." An exit interview was completed and appeal rights discussed. Copies of this report, the Confidential Names List, Appeal Rights and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the executive director.

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.

Caretakers at the operation did not provide proper supervision to a child in care allowing for the child to cause a self injury to themselves requiring hospitalization

From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.

On December 27, 2020, CCLD received a complaint referral alleging Neglect / Lack of Supervision as Child #1 reportedly had access to hazardous items and [Child 1] ingested hazardous items while in care (see Confidential Names form LIC811, dated 5/28/2021). Information obtained during the investigation including interviews and review of related medical records for [Child 1] indicates in part, numerous hospitalization's for [Child 1] due to ingesting foreign objects and being placed on involuntary psychiatric holds between August 2020 and February 2021. [Child 1] was hospitalized on 12/14/2020, for "foreign body ingestion" of glass. Records indicate [Child 1] ingested two fistfuls of glass shards. On 08/31/2020, [Child 1] was admitted to the hospital emergency room with complaint of swallowing glass and ingesting a metallic screw seen on x-ray. [...] On 10/04/2020, [Child 1] was admitted to the emergency room for ingesting window screws.

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.

Staff #1 conducted an inappropriate restraint on client #3 face down on the couch. Client #4 was injured during the physical altercation and required six stitches for a laceration above her eye.

From the state's report. Deficiency cited, follow-up survey, Type A1 violation. Cited: {V 293}.

Additionally, as had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home as placed in a therapeutic foster home after she was discharged from American Children’s Home abruptly, June 2018. [...] Additionally, HB hes had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home. was placed in a therapeutic foster home after she was discharged from American Children's Home abruptly, June Initially, ME cclimated well to her foster family. [...] For recipients identified as high risk for dangerous é or self injurious behaviors the discharge/transition fan includes admission to the appropriate level of care. [...] New behaviors have arisen this month. i had sneaked a railroad spike to the home and started self-harming. [...] 2/19/2019- Recently participated in self-harming behaviors which has led to her be hospitalized.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 296 anything management staff will be asked to put. "[...]" marks text left out between sentences.

In plain words: Video footage showed a staff member pushing one child into a room and blocking the door with a chair. The staff member also pulled another child by the shirt and blocked a third child, causing that child to fall. Finally, the staff member dragged the first child by the ankle across the floor. Our summary of the state's report. The state's own wording follows.

Per video surveillance footage review, Staff Member A is scon pushing Child # 1 into his/her coom and placing a large wooden chair In front of Child # {'s door and sits in the chair, which is blocking Child # 1 from exiting the room. [...] Regulation- 3800.32(b)- A child may not be abused, mistreated, threatened, harassed or subject to corporal punishment morning of 10/20/19, Staff Member A is seen pushing Child #1 into his bedroom, pulls Child #2 backwards by his shirt while the Child #2 is attempting to walk down the hallway, and is physically blocking Child #3 from walking down the hallway which makes Child #3 fall to the floor. [...] Child #1 falls to the floor and Staff Member A grabs Child #1’s foot/ankle and picks his leg up, Staff Member A takes a couple of steps while holding Child#1’s foot/ankle and drags Child#1 on the floor for approximately 2-3 feet.

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

(1719) [5:19 p.m.] pt being sent to ER [emergency room] for evaluation of pain to R shoulder..." d. [...] Then he started to try to count to ten and started to bite one of them and I told him don't bite, don't bite." RN #1 and LPN #1 were asked, "Was he fighting?" LPN #1 stated, "He was trying to come up with his body and his legs were coming out of the restraint, so just kinda wiggle wormed." RN #1 and LPN #1 were asked, "Is bruising normal during a restraint?" LPN #1 stated, "You can get some bruising right there in the crease [indicating crease between the junction of the upper arm and shoulder], that is pretty normal, but not to that extent." Both RN #1 and LPN #1] stated, "Not to that extent." RN #[ and LPN #1 were asked, "Was it caused by undo pressure on his shoulder?" LPN #1 stated, "Yeah, I never seen a restraint look like that." e.

From the state's report. Deficiency cited, complaint survey. Cited: N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.

In plain words: A child in the program stole a school laptop from the office to contact men and then ran away from the group home. Staff found her, talked to her about the dangers of contacting older men, and she agreed to follow safety rules before running away later that shift. Our summary of the state's report. The state's own wording follows.

One elopement noted in September 2017. [...] Due to hospitalization between 03/06/18 and 03/21/18, client #8 was not able to be interviewed. [...] 02/25/18, client had been caught inappropriately using her alternative school laptop...client had stolen her school laptop from the staff's office and was attempting to utilize in her bedroom to facetime men...staff discovered Cc client using the laptop during a routine check and retained the tablet..staff educated the client on the dangers of seeking older men, giving out her personal information such as the residential placement's address and attempting to link up with men to be sexually active... client was able to contract for safety and agreed not to steal electronics, utilize face book again to contact men and to really focus on her school work...later in the shift, client eloped from the group home. [...] She was hospitalized in that area.

From the state's report. Deficiency cited, complaint survey. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.. "[...]" marks text left out between sentences.

Furthermore, thel child paychiatic evaluation reeds: “Recently [the child] had cut severe enough that fhe/she] required 27 sutures, [The child] reports [he/she] last cut. [...] The child then swallowed the razor blade. According to notes taken by Staff Member 8, the facility's contractad peychiatriat, Child #1 swallowed the blade because “wea hoping H would kill (hinvher].” The faoilty’s internal policy prohiblis penci] sharpeners In the posseasion of childran or present In the facility at any tins. ‘The factity developed an initial written safely plan on fEEEEhch indicated that Child #1 “will be encouraged to utilize [molding clay, lying down, coloring and humor] to cope with negative feelings.” This written safety plan was not developed with methods fo monitor and prevent self-harm, increased general supervision, or othar adequate methods to ensure child safety.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.142. "[...]" marks text left out between sentences.

In plain words: A child in the program told a staff member about thoughts of self-harm, but the facility did not immediately increase supervision. Later that evening, the child attempted an act of self-harm, and the home then increased supervision. Our summary of the state's report. The state's own wording follows.

" Risk: Miiig#has reported suicidal ideation thalglipouchts to self harm Plan: The Therapist processed coping skills thatllll—has readily available and revised lllMeafety pro! ort Min manag M@@B safety. [...] According to Staff Member A's notes from that session, Child #1 Indicated “continued thoughts of self-harm’. During an interview with representatives of the department, Child #1 also expressed that he/she “had urges and flashbacks and wanted to i wrap sheet around neck"on and also stated that he/she expressed this to Staff Member A during the 15 therapeutic i interaction, ‘The facility did not Immediately implement intensive supervision as part of their intemal safety plan procedure protocol. i At6:14 pm or Chitd #1 attempted an act of self-harm. [...] At 9:10 pm the home implemented Increased supervision due to suicidal ideation and self-harm.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.142. "[...]" marks text left out between sentences.

On 3/6/2016, Resident #3 self-harmed with a piece of glass he/she reported to have found near the back doors of hallway A of the _ Expressions unit, Resident #3 was sent (o Ohio Vailey Hospital via ambulance where heishe was ‘reated wilh medical glue for an Injury to hisfhes left arm,

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.87.a.

In plain words: A staff member physically held a child to the floor of a bedroom after the child yelled and got close to the staff member. The child complained of arm pain afterward, went to the hospital, and was diagnosed with a broken arm. Our summary of the state's report. The state's own wording follows.

On 7/6/15 al approximately 8:30 AM, Staff Member A manually restrained Resident # 4 {o the floor In a resident bedroom for yalling and getting Into the face of the staff member, Following the restraint, Resident # 4 complained of left arm discomfort and was transported to a hospital emergency room and was diagnosed wilh a radial shaft fracture to his/her left arm.

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

In plain words: A sixteen-year-old resident sexually assaulted an eleven-year-old resident in their shared bedroom. A staff member later took the younger resident to the hospital, and the older resident was charged with rape and other crimes. Our summary of the state's report. The state's own wording follows.

On 8/7/15 al approximately 2:30 PM, Staff Member B transported Resident #2 to a hospital's emergency room due to the resident belng sexually assaulted by Resident #1 on the evening of 8/6/16, The jocal police department responded {o the hospital at approximately 3:68 PM to investigate (he sexual assault.

On the evening of 8/6/15, Resident #1, a 16 year-old, sexually assavited Resident #2, an 11 year-old, in the residents' shared bedroom #4, Ag a fesullt of the Incident on 8/6/15, Residen! #1 was charged with rape, Involuntary deviate sexual assaull, stalutory sexual assault, aggravated indecent assault, ‘and indecent assault, . [...] Immediate Action: At approximately 12:35 pm on August 7, 2015 Staff B approached Director EEE to inform her that resident 2 had reported 1o SB that he had been sexually assaulted during the previous night (8/6/15). [...] At approximately 1:15 pm, Director HE otified BCCYS regarding the incid ied to [Resident 2]'s agency, Butler County CYS, that he had been transported to the ER,.

Resident #1's-heallh and safely assessment dated 6/6/15 indicates, "Any concems of the child being a perpetrator of sexual abuse? [...] Whiie not within any staff person's eyesight on the evening of 8/6/15, Resident #1, a 16 year-old, sexually assaulted Resident #2, an 11 year-otd, in the residents‘ shared bedioom #4. As a resull of the Incldent on 8/6/15, Resident #1 was charged with rape, involuntary deviate sexual assault, statutory sexual assaull, aggravated indecent assault, and indecent assault,

Resident #1's health and safety assessment daled 6/5/15 indicates, "Any concerns of the child.being a perpetrator of sexual abuse? [...] While not within any staff person's eyesight on the evening of 8/5/15, Resident #1, a 18 year-old, sexually assaulted Resident #2, an 11 year-old, In the residents! shared bedroom #4, As a result of the incident on 8/6/15, Resident #1 was charged with rape, involuntary deviate sexual assaull, statutory sexual assault, aggravated indecent assault, and indecent assault, “ .

A child may not be abused, mistreated, threatened, harassed or subject to corporal punishment, On the eveniig of 8/6/16, Resident #1, a 18 year-old, sexually assaulled Resident #2, an 11 year-old, in the residents’ shared bedroom erere 4 harged with rapa, Involuntary deviate sexual assault, statutory sexual ee a monitoring process will be documented for each child, Repeat Violation: No

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.16.c; 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.142; 55 Pa. Code § 3800.142; 55 Pa. Code § 3800.32.b. "[...]" 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 3/6/2015, Resident #3 self-harmed with a piece of glass he/she reported to have found near the back doors of hallway A of the Expressions unil, Resident #3 was sent to Ohio Valley Hospital via ambulance where he/she was {reated with medicat glue for an Injury to his/her left arm.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.87.a.

Clients on high supervision must be in direct Vew of tho assigned statt af ai times.” The facility's Observation Record indicated the “ctlont nas had extersive recont inpatient hospitalization, sign‘ficant for suicidal ideutiowplan, saif-harm, and audilury dalfucinallons, Dr. ordered to place client on Hiyh Supervision, af 1:64 PM, as a precaution sue to uncarfamty of ckent's baseline.” On 12/5/14 al approximately 8:30 ?M in Resident ¥ 1's bedioum. Resident # 1 reported to Stall Member A that he/she fell unsate and had Just attempted to self-harm by scratching his/her left wrist Staff Member A lefl Ihe resident's bedroom to notify the medical department and asked Staff Member 8 lo moaitor the resident.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.142.

On 08/04/14, Resident #1 and Resident #2 each ingested multiple tablets of the medications that were obtained by Resident #1 on 8/03/14. This resulted In Resident #1 being taken to the local hospital by facility staff persons and then being transferred by medical helicopter to the regional nospital to receive inpatient treatment, and Resident #2 being taken to the local hospital by facility alatf pereons {o receive oulpalignt treatment on 8/04/14.

From the state's report. Citation, complaint inspection.

Child # 1 was the victim of an indicated case of physical abuse in an assault by Staff Member A that caused Child # 1 to be hospitalized,

From the state's report. Citation, j ‘type of inspection: partial bha docket number: notice: un inspection. Cited: 55 Pa. Code § 3800.32.b.

(b) While Consumer #6 alleged abuse (staff kicked him in the mouth) during the restraint which resulted in his assault charge, the abuse allegation was investigated internally. [...] (c) Consumer #1 was inappropriately restrained by Staff #30 on 3/17/01. [...] The consumer suffered a sprained wrist, requiring a trip to the emergency room, during the restraint. [...] Findings include: (a) Staff #5, according to internal investigation, was negligent in her duty to supervise Consumer #7 when he eloped on 1/29/01.

From the state's report. Deficiency cited, survey. Cited: C 102 64-11-5.2.a. Governing Body. "[...]" marks text left out between sentences.

For example, Consumer #1 hit his head on the wall and cursed staff on 5/6/00, 5/8/00, 5/15/00 and hit himself in the face on 5/21/00. On 5/15/00, the consumer injured himself so badly that he had to be taken to the emergency room of a hospital for treatment of his head injuries.

From the state's report. Deficiency cited, survey. Cited: C 243 64-11-7.3.d. Treatment Plan.