Severe reports

During the inspection, the investigator determined that the provider failed to summon emergency medical services for a minor client who was rendered unconscious and sustained severe head and facial injuries during a physical assault. Rather than summoning emergency medical transport, the provider elected to call a non-medical transport company to take the client to the hospital, delaying medical treatment

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(4) Provider shall protect clients from abuse, prevent abuse.

[Staff 1] later reported BHTs provide medication administration as BHTs punch out the medications from the pharmacy-provided multi-dose packaging, place them into a cup, and give to residents. [...] The MAR stated “… Count off by 2 … 5/22/25 7:58 Chlorpromazine 25 given two to equal 50mg gave, nd [sic] two 25 mg at bedtime … 5/23/25 8:00am Chlorpromazine 25 given 50mg wrong dosage given.” 16. [...] In an interview, [Staff 1] stated the medication errors were “staff errors.” 23.

From the state's report. Deficiency cited, complaint. Cited: R9-10-718.B.3.a-b. Medication Services B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that .... "[...]" 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 former client reported having an inappropriate sexual relationship with a staff member that started at the facility and continued after the client left. The facility rules strictly forbid staff from having personal or sexual relationships with clients. Our summary of the state's report. The state's own wording follows.

"Staff members who engage in romantic or sexual relationships with clients are abusing their power and can be seen as taking advantage of their clients." [...] "Employees are prohibited from engaging in a personal relationship, including any type of sexual contact, with clients." [...] Mid Year Employee Evaluation completed by the DON and dated 8/12/25 included, "...does have 4 medication errors at the present time...completed medication review refresher in 3/2025...has been challenged to stay focused and focus on his responsibilities." [...] He informed Staff #1 to not contact him anymore on 9/12/25 because he felt like Staff #1 hadn't loved him and only wanted a sexual relationship; [...] Based on what [Former client 5] had informed him in September 2025 (exact date unknown) Staff #1 and [Former client 5] had an inappropriate relationship that began while the client was at the facility and continued after the client was discharged;

From the state's report. Deficiency cited, annual and 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.

In plain words: The state found multiple safety and health problems at the program. Issues included privacy violations, medication errors, improper seclusion room use, and many building hazards like mold, broken windows, and unlocked cleaning supplies. Our summary of the state's report. The state's own wording follows.

Compliance issues included HIPPA violation, timeliness of physicals, using a room for seclusion and not following the seclusion use requirements, not meeting the seclusion room physical requirements, seclusion room documentation, and medication errors resulting in a child receiving the wrong dosage.Maintenance concerns with some, needing to be addressed with expeditious correction to mitigate the risk for harm or injury, included: a broken window, mold in a bathroom ceiling and rafters, cluttered laundry room, missing door jams with nails protruding, sharp metal pieces in a window sill, cleaning supplies and other hazardous items in an unlocked closet due to locks not working, missing smoke detectors, laundry stacked against a gas water heater, bathroom door with only one hinge causing the door to not open/close/swing properly, missing floor vents, missing cabinet faces in the kitchen, an oven door that does not close completely, a loose doorknob in the bathroom, significant peeling paint in the bathroom, excessive holes in the walls throughout the house, wires protruding from a removed thermostat, sticker type weeds in the yard, a partially removed window well grate cover.

From the state's report. Deficiency cited, provisional license. Cited: 16.04.18.102.04 DISPOSITION OF APPLICATIONS. 04. Provisional License. A provisional license may be issued to an organization when a licensing standard is not ....

On child A did not receive the appropriate medical treatment or evaluation for injuries received during the restraint on . Child A did not receive medical attention until days after the tape review, when a child abuse report was also called into the hotline on the same day. Child A did not receive medical attention until January 28, despite staff person A's assertions that all children were medically assessed on the day of the incident.

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

On child A did not receive the appropriate dental treatment needed for Child A was involved in a restraint resulting in both of upper front teeth being broken off, exposing the root in . The child was not taken to the dentist immediately following the incident.

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

The operation failed to obtain timely medical care for a child after they ingested over the counter medication during an unauthorized departure.

From the state's report. Risk level: High. Cited: 748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain.

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.

A child in care suffered self-inflicted cuts to her arm on 08/24/2023 and was not seen by a medical professional until 08/28/2023 where the determination was made to admit her into a behavioral hospital for evaluation.

From the state's report. Risk level: High. Cited: 748.125(e)(1)(A) - You must immediately refer a child to a MH professional for a suicide risk assessment if screening finds child to be at a high risk for suicide..

In plain words: A child in the program reported having sex with another child in the game room and closet while a staff member sat nearby with their back turned. The report also states that a staff member threw a water bottle and bumped into a child with her body. Our summary of the state's report. The state's own wording follows.

"it would be different staff." Interview on 3/28/22 with client #6 revealed: -had a hickey from her boyfriend; -client #5 was her boyfriend; -had sex with client #5 in the game room; -client #4 was with them; -staff was at the table in front of the entrance to the game room; -staff had their back to them; -had sex twice in the game room closet with client -second time staff were in the same place when she and client #5 had sex; -don't remember what staff was working; -in the closet for five minutes both times. [...] Clients #1, #2, #3, #4, #5 and #6 displayed behaviors which included sexualized behaviors, substance abuse, aggression, self-harm, suicidal ideation, impulsivity, poor boundaries and criminal activity. [...] Staff #3 threw a water bottle and bumped into client #2 with her body.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 293. "[...]" marks text left out between sentences.

It was substantiated that on Child # 1 attempted suicide at the facility and Staff Member A was made aware of the incident. [...] Staff Member A was indicated for abuse under the CPSL law on for causing serious physical neglect of a child for failure to provide medical care/treatment.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights. "[...]" marks text left out between sentences.

In plain words: State inspectors found the facility failed to provide proper treatment, keep continuous watch during sleep hours, and follow its licensed capacity limit. The facility also failed to create plans to address behaviors such as running away, sexualized actions, and self-harm. Our summary of the state's report. The state's own wording follows.

Based on observation, interview and record review the facility staff failed to provide intensive, active therapeutic treatment and interventions to ensure safety and to minimize the occurrence of behaviors, failed to assure staff were providing continuous supervision during sleep hours and failed to operate within the scope it was licensed for by admitting a 5th client while it was operating at its licensed capacity of 4 clients affecting 2 of 2 current audited clients (#1 #2), 2 of 2 current unaudited clients (#3 #6) and 2 of 2 former clients ([Former client 4] [Former client 5]). [...] Based on interview and record review, the facility failed to develop and implement strategies and interventions within a treatment plan to address behaviors of elopement, sexualized behaviors and self injury affecting 1 of 2 former clients ([Former client 4]).

From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. Cited: V 293} 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" 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.