Severe reports

During the investigation, LPA interviewed staff and clients which revealed that staff handled minor in a rough manner.

From the state's report. Substantiated.

During the investigation, there were multiple accounts of a caregiver pushing a child in care.

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..

The department received information that Staff D physically abused a resident in response to the resident's behaviors.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(b)(1) Program staff shall not abuse or neglect residents..

The agency is found in non-compliance as interviews and video footage verified that Staff 1 pushed Youth A to the ground.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4157 Behavior management.

The Department received a complaint on September 21, 2023, alleging staff pushed child. [...] Confidential interviews revealed that [Staff 1] admitted [Child 1] came towards [Staff 1] and in self-defense [Staff 1] pushed [Child 1] away and [Child 1] fell and hit [Child 1]'s back. Based on interviews and record review, the preponderance of evidence standard has been met and the Department has determined that [Staff 1] pushed [Child 1].

From the state's report. Substantiated. Cited: 84072(c)(15). "[...]" 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.

The agency is found in non-compliance as per video review, youth interviews, and staff interviews, Staff 1 punched Youth A in the face which is prohibited.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

In plain words: A staff member bit a child on the shoulder to make the child let go of the staff member thumb. The child reported that the staff member put him in a chokehold and threw him on a bed, and that the child bit the staff member to get away. Another staff member called the police, and the child went to the hospital. Our summary of the state's report. The state's own wording follows.

Staff #1 bit Client #1 on the left shoulder to get Client #1 to release his bite on Staff #1's right thumb. [...] "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Vv 514 iss Mir flo( MX 25, hon (Kasi yeahs CDK911 If continuation sheet 5 of 9 Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed: [...] Called the police and Client #1 was transported to a local hospital for a mental health evaluation for his aggressive behavior [...] In an attempt to get Client #1 to release his bite, Staff #1 bit Client #1 on the left shoulder.

"He (Client #1) said [Staff #1] pulled him by the shirt and threw him on the bed, breaking the bed, then he (Client #1) grabbed a piece of wood from the broken bed and defended himself against [Staff #1]." "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Client on Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed:

From the state's report. Deficiency cited, complaint survey, Type A2 violation. Cited: V514 ugetn; V 514) 27E .0102 Client Rights - Prohibited Procedures Vv 514. "[...]" marks text left out between sentences.

Based on confidential interviews, observations, and record review, including review of police investigation report and interviews with alleged victim and suspect, it was alleged that a staff member hit a resident with an open hand on the face.

From the state's report. Substantiated.

A staff slapped a child in care.

A child in care was slapped by a staff member.

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.; 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

The Incident Report noted the caregiver finding "pooled blood" on the floor of the room where the assault took place, and the child sustained a knot on their head, a bloody nose, as well as bruising.

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.

During the review of this investigation, interviews reported that a staff member slapped a child in care during a restraint.

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 state report found that a staff member dragged, kicked, and pulled the hair of a child in the program. The state substantiated these allegations of rough handling based on interviews and file reviews. Our summary of the state's report. The state's own wording follows.

On March 15, 2024, the Department received the allegation that staff dragged and kicked minor in care. [...] A confidential interview stated that [Staff 2] attempted to grab on to [Child 1]'s arm for a hold, however, [Staff 1] grabbed and dragged [Child 1] into the garage. A confidential interview maintained that staff kicked and stepped on [Child 1]'s foot during the dragging. Based on confidential interviews, the preponderance of evidence standard has been met, therefore, the allegation that [Staff 1] dragged and kicked [Child 1] in care is substantiated.

It was further reported that [Child 1] stood up and charged back at [Staff 1] and [Staff 1] grabbed [Child 1] by the hair and yanked [Child 1]'s head back. [...] Based on confidential interviews and file reviews, the preponderance of evidence standard has been met, therefore, the allegation that [Staff 1] handled [Child 1] in care in a rough manner is substantiated.

From the state's report. Substantiated; Substantiated (one of several allegations). Cited: 80072(a)(1); 80072(a)(3). "[...]" 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.

The following narratives are regarding two incidents at Cove Secure/White Deer Run LLC with the same violations for each incident: On child A was mistreated after being head butted and inappropriately restrained by staff member A. Video review of the incident clearly shows child A standing in the doorway alone.

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

At approximately 0:12 seconds in, [Resident 1] tried to exit the room again and [Staff 1] forcefully extended [Staff 1]'s and pushed [Resident 1] towards the middle of the room.

From the state's report. Deficiency cited, complaint. Cited: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises ...; B. An administrator shall ensure that: 2. A resident is not subjected to: a. Abuse;. 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 staff member pushed the child in care's chin during the restraint.

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.

During the inspection, it was reported by witnesses that a teacher mistreated a client by pushing the client when the client was acting out in their class.

From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.

While a child was being restrained by staff, another staff choked the child.

A staff threw away a child's food in response to the child spitting at their feet.

A child received a bloody, swollen nose during a restraint due to a staff member banging their head on the ground.

From the state's report. Risk level: High. Cited: 748.2461(b)(3) - Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing; 748.2307(14) - Other Prohibited Punishments-withholding food that meets the child's nutritional requirements; 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force.

During a restraint, a staff used excessive force to take a child to the ground, causing the child to chip a tooth upon impact.

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.

A caregiver intentionally pushed and hit a youth in care during an altercation.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.

It was found that a caregiver dragged a child to the restroom and hit the child repeatedly in the head.

It was found that a caregiver used corporal punishment with a child in care.

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; 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..

The facility is found in non-compliance as per video review, Youth A and Staff 1’s interview, Staff 1 pushed Youth A into his room.

From the state's report. Repeat violation established, special investigation. Cited: 400.10107 Employment policies and procedures; establishment.

In plain words: A staff member placed his hand on a youth’s face, pushed the youth’s head back, and then pushed the youth backward by the shoulders near the neck, causing the youth to fall into a chair and hit the floor. Our summary of the state's report. The state's own wording follows.

Non-compliance is also found in the courtyard when Staff Person 1 placed his hand on Youth A’s face and pushed Youth A’s head back, Staff Person 1 used one hand and pushed Youth A on his back, and Staff Person 1 placed his hands on Youth A’s shoulders by his neck moving Youth A backwards, which caused Youth A to back in to a chair and fall to the ground.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions..

He came in my office last Friday and showed me and he said she (staff #1) choked me said we talked last week, and you said you were playing.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect.

(continued on LIC 9099c) Specifically, it was stated that [Staff 1] grabbed [Child 3] by the shirt and pulled [Child 3] towards to [Staff 1] and [Staff 1] made an inappropriate statement to [Child 3].

From the state's report. Substantiated. Cited: 87072(c)(1). 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.

" called her ‘an old hag’ again and she (staff #1) said, ‘why don't you run (hit) to your old hag (repeated this twice).' asked her, ‘are you talking about my grandma?" " started crying. [Staff #2] had moved to the left side of her (staff #1). started yelling at [staff #1], ‘you do not know who you are messing with.' She (staff #1) pulled at her pants, like she was Cc squaring off (getting into a fight stance) and said, ‘you messed with the wrong one today.’ Then she (staff #1) said something, don't remember what she said, but it triggered me. punched her in her cheek. was aiming for her eye. thought had punched her in her eye but later heard her telling [Staff #2] hit her on her cheek." [...] "l walked down the hallway and yelled to [Staff #1], ‘I'm sorry [Staff #1], didn't want to hit you, _ didn't want to hurt you but you scared me.' She (staff #1) didn't respond."

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512 27D .0304 Client Rights - Harm, Abuse, Neglect V.512 Tame diate \y ‘. "[...]" marks text left out between sentences.

Staff 2 used corporal punishment by punching and pushing Youth A. This was evident in the video watched at the facility and confirmed by both Staff 1 and Staff 2.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

It was alleged Staff hit youth. [...] On 03/08/2024, the Department received a complaint alleging that a staff hit youth. [...] [Staff 1] stated that she did not slapped or punch the youth. [...] [Child 1] stated that he spat on [Staff 1] again and [Staff 1] slapped him again. [Child 1] stated that he spat on [Staff 1] for a third time and [Staff 1] punched him on the face and kicked the PS5. [Child 1] stated that there was another staff that got there just before [Staff 1] punched him and the other kids were in the van. A second staff worker who was present and witness the incident stated that [Staff 1] punched [Child 1] on the face.

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.

A caregiver used excessive physical force by hitting a 9-year-old child with a shoe approximately three times.

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.

The agency is found in non-compliance as Staff 2 adamantly reported he witnessed Supervisor W punch Youth A in the face and did not report it as required per child protection law.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4131 Compliance with child protection law; development of plan required..

A child in care was choked and punched by a staff member

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..

A child in care was slapped by a caregiver in the face which caused a bruise.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.

Individual #1 was placed in a prone restraint that caused bruising and a bloody nose to Individual #1. [...] Based on the provider's investigative finding, there is a preponderance of evidence to support a substantiated finding of physical abuse.

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

The provider failed to follow the below Joint Commission standards: Standard CTS.05.06.35 (15) The facility failed to evaluate and report the injury to Youth #3 on 11/18/2023 to external agencies when Staff #1 reported punching Youth #3 three times and gauging at his eyes.

From the state's report. Deficiency cited, complaint inspection.

In plain words: A staff member allegedly slapped and punched a child in the face, causing a bloody nose, and threw the child onto a couch during an incident over a phone call. Our summary of the state's report. The state's own wording follows.

In doing so staff hand hit clients nose causing it to bleed. [...] "[Client #4] said [staff #1] punched me and threw me on the couch and sat on him." [...] "[Client #4] kind of lunged at [staff #1] and brought back his hand to scare [staff #1]. [Staff #1] slapped [client #4] on the face and that caused him to fall back on the couch. Then [staff #1] kept slapping [client #4] in the face a pretty good amount of times.” [...] "He (staff #1) assaulted a minor and now he is working again. [...] Staff #1 hit him with an "open hand." Interview on 4/9/24 with client #4 revealed: [...] Staff #1 then "yanked" the phone out of his hands and his phone call was disconnected. [...] "I guess he (staff #1) thought was going to hit him.” "He (staff #1) slapped me with an open hand 1 time (on his face) and fell back on the couch because of how hard he hit me." [...] "[Staff #11] asked me what happened and told him [staff #1] started punching me."

From the state's report. Deficiency cited, annual and follow-up survey, Type A1 violation. Cited: V512, 27D .0304 Client Rights - Harm, Abuse, Neglect v512 Each staff member was required to review the. "[...]" marks text left out between sentences.

Through interviews with youth and documentation reviewed there was evidence found that Staff 1 hit Youth A during an escalated incident on 02/26/2024.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

"[Staff 2] stopped walking and stiffened his body, mostly [Staff 2]'s arm, stuck out his elbow and [Staff 2]'s elbow hit [Resident 1].

"[Staff 2] stopped walking and stiffened [Staff 2's] body, mostly [Staff 2's] arm, stuck out [Staff 2's] elbow and [Staff 2's] elbow hit [Resident 1].

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises ...; B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. 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.

Behavior Management: Staff member punched resident(s).

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

Through interviews it was confirmed a staff dragged a child in care by the hair to the bathroom to sprayed child off in shower as a form of punishment.

Staff used excessive force when preforming an emergency behavior intervention.

From the state's report. Risk level: High. Cited: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child; 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.

A staff member hit a child in the face as a means to get the child to comply.

Collateral staff confirmed during interviews that the staff member was directed to release the child from the restraint and the child said they could not breathe.

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.; 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso.

Employee #1 used unauthorized physical restraint while de-escalating self-harm on Individual #1.

From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-110. A. Each individual is entitled to be completely free from any unnecessary use of seclusion, restraint, or time out..

ALLEGATION 1 Before six staff arrived to assist him, Staff 1 admitted he used a martial arts chokehold applied from behind Youth B. Choking a youth is considered physical punishment and prohibited by the rule.

From the state's report. Violation established, special investigation. Cited: 400.4158 Intervention standards and prohibitions.

A child in care and collateral residents reported a caregiver had pushed a child on multiple occasions while in care.

From the state's report. Risk level: High. Cited: 748.2307(6) - Other Prohibited Punishments-pinching, pulling hair, biting, or shaking a child.

Client #1 was sitting in a chair in the facility kitchen when staff #1 grabbed her by her shirt and pulled her off a chair causing her to fall to the floor.

From the state's report. Deficiency cited, annual and follow-up survey, Type A1 violation. Cited: V 512.

Review and analysis of the facility surveillance video footage capturing the incident on September 17, 2023, determined that [Staff 1] used excessive force when pushing/forcing the quiet room door open with both hands while [Child 1] was visibly positioned on the opposite side of the door. [...] Based on confidential statements and documentary evidence, the Department has determined substantiated findings for inimical conduct displayed by [Staff 1] using excessive force causing a wrist fracture to [Child 1].

From the state's report. Substantiated (one of several allegations). "[...]" 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.

Through interviews with youth and staff and documentation and video footage reviewed, there was evidence found to show a rule violation in that Staff 1 punched back at Youth A during the escalated incident.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

The facility is found in noncompliance as Staff 4 pushed Youth A, grabbed him, pulled him to the ground then held him to the ground.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Through interviews with youth and staff, video footage and other documentation reviewed, there is evidence to show that Staff 1 punched back at Youth A during an escalated incident and therefore this rule was violated.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

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 ....

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.