Severe reports

(Continued on page LIC9099-C) The investigation revealed on February 7, 2022, several non-resident female juveniles were able to enter the facility and physically assault [Child 1]. [...] The Department has determined a lack of supervision contributed to the physical assault by juvenile non-residents on [Child 1].

From the state's report. Substantiated. Cited: 87078(a)(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.

A staff unnecessarily grabbed, pulled, and pushed a child as a means to get the child to comply.

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.

It was reported to Community Care Licensing (CCL) that staff #1 threw an object at [Child 1] and [Staff 1] mishandled [Child 1] with an inappropriate restraint. [...] Confidential staff interviews reported that [Staff 1] then threw a plastic bottle of soda at [Child 1]. [...] The preponderance of evidence standard has been met, therefore the allegations that [Staff 1] threw an object at [Child 1] and [Staff 1] mishandled [Child 1] with an inappropriate restraint is found to be Substantiated.

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.

The facility is found in noncompliance for the use of corporal punishment as evidence supports Staff 1 engaged in corporal punishment when he placed his feet under Youth A causing him to fall in what appears to be an attempt to cause a negative consequence to stop his attempted kicking.

From the state's report. Violation established, special investigation. Cited: R 400.158 Discipline.

Documentary evidence revealed that Staff #1 caused an injury to Client #1 in the form of a red handprint on [Child 1]'s back which is consistent with statements that [Staff 1] "slapped" [Child 1] on the back.

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.

On , child A was mistreated by staff member A. Staff member A made an attempt to strike a resident by throwing a punch towards the resident during an altercation.

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

A staff member hit a child in the chest after the child had a verbal altercation with the 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..

Staff pushed child and was observed on camera doing so.

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.

Therefore, there was a preponderance of the evidence that physical abuse of [the alleged victim] occurred.

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

Community Care Licensing received information on November 01, 2021 alleging that Facility Staff handled child in a rough manner, more specifically that Staff # 1 ([Staff 1]) had kicked Child # 1 ([Child 1]). [...] According to confidential information, [Staff 1] was observed to have pulled and kicked [Child 1] during an incident which occurred inside [Child 1]'s cottage on surveillance video. LPA Mena was shown surveillance video where [Staff 1] is observed kicking [Child 1] near the exit door while [Child 1] was laying on the ground. [...] Based on interviews and information gathered during the investigation, the preponderance of evidence standard has been met and the Department has determined the allegation that Facility Staff handled child in a rough manner, more specifically that Staff # 1 ([Staff 1]) had kicked Child # 1 ([Child 1]) is substantiated.

From the state's report. Substantiated. Cited: 87072(d)(11). "[...]" 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.

Confidential interviews reported that the incident involved [Staff 1] not letting [Child 1] keep a slime and [Staff 1] ended up dragging [Child 1] and putting [Child 1] in restraint that was not appropriate.

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.

Caregiver struck a 14 year old child with a shoe.

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..

Both staff were aware of concerns of Youth A being physically hit by Staff 2 and there was no report made to Child Protective Services.

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

The records and the interviews indicated that a staff member did choke the minor through the improper use of a manual restraint.

From the state's report. Substantiated.

In plain words: A child in the program reported that a staff member pinched and kicked them following a restraint. The state reviewed video and interviews and found evidence that the staff member appeared to kick or try to trip the child. Our summary of the state's report. The state's own wording follows.

Supervisor reports that she was emailed Sunday evening (did not read until on duty Monday) regarding an unauthorized restraint and staff pinching the client. [...] The email stated, "Hi was rounding today by phone [unidentified person] and [Client #3] (A) made an allegation that a staff [Staff #2] pinched him and put him a restraint yesterday. have not given a restrain order this weekend and wanted to pass this along for administration to check on it ... [...] Incident (s): The [Client #3] met with his [therapist] on 3/21/22 and reported that a staff member [Staff #8] kicked him following a restraint on 3/18/2022. [...] Conclusions: Based on interviews with staff, consumer, and review of the video there is evidence to show that staff member [Staff #8] placed her foot out appearing to kick or try to trip the consumer. [...] "[Staff #8] kicked me." Interview on 05/04/2022 with Staff #6 revealed:

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.

Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.

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.

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.

During the investigation of staff physically abused minor, staff verbally abused minor, staff threatened minor and staff broke minor's toy.

From the state's report. Substantiated. Cited: 84072(d)(11).

A child in care was so distraught after the staff member pushed the child into their room and closed the door that the child began banging loudly on the door to her room.

A staff member pushed a child two times causing the child to fall.

From the state's report. Risk level: High. Cited: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child; 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..

Several children indicated staff threatened to physical harm children in care.

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.

The Department received a complaint on December 17, 2021, that staff #1 physically abused [Child 1] while in care. [...] Additional confidential interviews revealed that [Staff 1] had kicked [Child 3]. [...] Confidential interviews indicate that [Staff 1] did not push [Child 2].***CONTINUED on LIC C***** Additional confidential interviews revealed that [Staff 1] did not kick [Child 3]. Based on confidential interviews that staff #1 physically abused [Child 1] while in care is Substantiated as the preponderance of evidence standard has been met for the allegation.

From the state's report. Substantiated. Cited: 87072(11). "[...]" 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.

A staff member grabbed a child by the arm and dragged them off a couch and down a hallway.

From the state's report. Risk level: High. Cited: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child.

Staff received an RTB for physical abuse and neglectful supervision.

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 July 30, 2021, Community Care Licensing (CCL) received information that alleged facility staff pushed a child while in care. [...] Based on witness interviews and records review, the preponderance of evidence standard has been met, and the allegation facility Staff #1 pushed Client #1 is substantiated.

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.

During the course of this investigation, it was determined that a child in care was improperly restrained and not documented.

From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.

While reviewing the video, it was observed that staff immediately put a child in a choke hold without attempting a proper restraint.

From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.

On August 31, 2021, CCLD received an allegation reporting that on August 29, 2021, Staff member #1 physically assaulted Client #1 causing injuries to [Child 1]'s neck area and possible rib fracture (See LIC811, dated March 29, 2022). [...] It was revealed on August 29, 2021, an incident occurred involving [Child 1] who reportedly displayed behavior outburst resulting in [Child 1] being restrained by Staff member #1 and law enforcement being called. [...] Based on information obtained, the preponderance of the evidence standard has been met, therefore the allegation of physical abuse is Substantiated.

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 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.

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.

An employee was observed on video forcibly picking a child up from his chair and dragging him by his pant leg, and in another video, pushing this same child in care out of his chair onto the floor and hitting him.

A staff member used physical force to push, punch, drag and twist a child’s arm behind their back as an inappropriate response to behaviors demonstrated.

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.

Based on interviews, record reviews and the facility tour, it was determined that the facility staff handled youth in a rough manner, the facility staff did not prevent youths from engaging in physical altercations and the facility serves inadequate and poor quality food.

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

Based on the information obtained there is preponderance of the evidence to prove the facility staff shoved the minor in care and improperly restrained minor.

From the state's report. Substantiated.

The facility is in violation of the rule, as Supervisor 1 punched Youth A during this altercation.

From the state's report. Repeat violation established, special investigation. Cited: R 400.158 Discipline.

It was determined that a caregiver placed a child in a chokehold.

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.

A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401 when the caregiver put a child in care at risk of physical harm when he slammed the child to the ground.

A caregiver slammed a child in care to the ground as a form of discipline which caused the child physical pain.

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; 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child.

During the course of the investigation, a youth alleged that [Staff 1] hit them with a belt one evening while in their own room and out of sight of cameras at the facility. [...] The facility was cited for Personal Rights 87072(a)(11) as children have the right to be free physical abuse, intimidation, threat, ridicule, and coercion. On at least one occasion, [Staff 1] struck a youth in care with a belt. [Staff 1] also disclosed to a staff that they had punched a youth in the stomach.

From the state's report. Substantiated. Cited: 87072(a)(11). "[...]" 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 alleged that staff are physically abusive to a facility client, facility client sustained injuries while in care, and staff are not giving a facility client medications as prescribed.

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

Video footage shows Staff D threw two punches toward Youth D’s face and chest.

From the state's report. Violation established, special investigation. Cited: R 400.158 Discipline.

All residents interviewed stated they have either been hit by the staff or witnessed the staff hit another resident.

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..

13 year old child in care was slapped by a caregiver and a 14 year old child was grabbed by the throat and slammed to the floor by the same 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.

A child in care was subjected to corporal punishment when a staff member used physical discipline as an inappropriate response to the child's behavior.

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.

A caregiver pushed a child to the ground.

From the state's report. Risk level: High. Cited: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child.

Specifically, it was reported that [Staff 1] threatened to hit [Child 1] and also called [Child 1] "bitch".

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.

Excessive force was used during a 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.

A caregiver used hitting as a method of discipline.

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..

All residents interviewed stated they have either been hit by the staff or witnessed the staff hit another resident.

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..

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.

Two children in care expressed that a staff grabbed a child in care around the neck and threw him onto the couch to stop them from potentially fighting.

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.

Based on interviews and record review, there is a preponderance of evidence to prove that [Staff 1] hit [Child 3] with the door to staff office and that staff instigates incidents involving minors, therefore the allegations are substantiated.

From the state's report. Substantiated (one of several allegations). Cited: 87072(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.