Pennsylvania Protection and Advocacy, Inc. (PP&A), the non-profit organization designated by the Commonwealth of Pennsylvania pursuant to federal law to protect the rights of and advocate for adults and children with disabilities, conducted a thorough investigation of SummitQuest Academy (SummitQuest), a residential treatment facility for youngsters with serious emotional disorders, in response to allegations of abuse and neglect of the youngsters in its care.

            Based on our review, it appears that SummitQuest inappropriately restrains the youth in its care in lieu of appropriate behavioral interventions, resulting in both abuse and neglect.  PP&A recommends that the Department of Public Welfare (DPW), which is responsible to license SummitQuest, intervene to:  (1) require SummitQuest to move to a restraint-free environment and to implement alternative approaches to address behavioral issues, and (2) have an independent child psychiatrist evaluate SummitQuest residents to determine whether it is the appropriate environment to meet their needs and to provide alternative options to those residents for whom SummitQuest is determined to be an inappropriate placement and those who desire alternative options.

II.        What Is SummitQuest?

            SummitQuest is a 129-bed residential treatment facility located in Ephrata, Lancaster County.  Currently operated by ViaQuest, SummitQuest is licensed by DPW’s Office of Children, Youth, and Families and its Office of Mental Health and Substance Abuse Services.   SummitQuest has four treatment programs for adolescent and pre-adolescent males who have primary psychiatric disorders and difficulties in functioning in the community due to behavioral or emotional programs.  Two of the four treatment programs focus on adolescents and pre-adolescents with histories of reactive sexually abusive or sexually problematic behaviors.  The per diem rate for placement -- which is primarily funded through the Medical Assistance program -- is approximately $260.

III.       What Triggered This Investigation?

            On December 14, 2006, PP&A received an incident report from DPW that indicated that, J.W.,  a 17-year-old resident of SummitQuest, died on December 12, 2005.  The report indicated that he collapsed following a gym class at 7:36 p.m. and was taken to a community hospital, where he died at 8:25 p.m.  Although the death has been attributed to the youth’s enlarged heart, PP&A had been unable to secure the autopsy report nor had it been able to determine whether SummitQuest should have been aware of the youth’s condition.

            On February 7, 2006, PP&A received an incident report from DPW that indicated that G.A., a 16-year-old resident of SummitQuest, had died on February 4, 2006.  According to the report, the youth was verbally threatening staff and “violently jumping toward female staff’s face.”  As a result, staff escorted the youth to a room at 3:53 p.m.  Staff reported that they could not safely maintain an escort in the room due to the youth’s struggling.  Staff thus initiated a restraint and notified nursing staff who arrived at approximately 3:56 p.m.  At the 10-minute mark (4:03 p.m.), staff initiated a switch-out.  At this time, the resident became limp and unresponsive.  Staff called 911 and another nurse.  Paramedics arrived at 4:13 p.m., and the resident was transported to the community hospital at 4:34 p.m.  SummitQuest reported to DPW at 7:35 p.m. that the resident died.

            Based on these reports of the deaths of two young males while in SummitQuest’s care and custody, PP&A had probable cause to conclude that abuse and neglect, i.e., inappropriate restraints and inappropriate care, had occurred at the facility and that further investigation was warranted to assess whether there are systemic issues at the facility that place the residents at risk of abuse and neglect.

III.       Scope of PP&A’s Investigation

            PP&A undertook a number of steps to assess the care and treatment provided to residents at SummitQuest, focusing on issues relating to restraints.  Those steps included the following:

 ♦          PP&A interviewed Ellen Whitesell of DPW’s Office of Children, Youth, and Families (OCYF), who was acting to coordinate the reviews of SummitQuest by DPW’s OCYF, Office of Medical Assistance Programs (OMAP), and Office of Mental Health and Substance Abuse Services (OMHSAS) and Pennsylvania’s Department of Health (DOH). 

♦          PP&A interviewed with Orlando Hernandez, of DOH’s Division of ICFs, which is responsible under Medical Assistance law to survey DPW-licensed Medical Assistance programs, such as Summit-Quest, to assure their compliance with federal regulations for psychiatric residential treatment facilities (42 C.F.R. §§ 483.350-483.376). 

♦          PP&A requested and received records concerning DPW’s actions following G.A.’s death. 

♦          PP&A reviewed DOH’s results of its survey of SummitQuest. 

♦          PP&A conducted a site visit of SummitQuest on March 8, 2006, during which PP&A staff interviewed administrative staff, reviewed the files of J.W. and G.A., interviewed 45 residents using a standardized interview format, and informally met with residents during lunch.

 IV.       Findings of PP&A’s Investigation

             Based on our investigation, PP&A has identified the following relevant facts concerning the care and treatment of youth at SummitQuest.

             ♦          G.A.’s death was the subject of investigations by the Ephrata Police, Lancaster County Children and Youth, DPW, and DOH.

            ♦          Eight or nine SummitQuest residents were removed from the facility following G.A.’s death. 

♦          As a result of its investigation, DPW’s Office of Children, Youth, and Families banned admissions to SummitQuest on February 17, 2006, though it appears that such a ban will be lifted. 

♦          DPW’s Office of Children, Youth, and Families has recommended that DPW place SummitQuest on a provisional license, which would generate closer oversight and monitoring, but that recommendation is currently under review by DPW’s Office of Legal Counsel. 

♦          DOH’s survey of SummitQuest concluded that the quality of service was “unacceptable” and recommended that DPW OMAP initiate an action to terminate SummitQuest’s eligibility for participation in the Medical Assistance program, and, concomitantly, its Medical Assistance funding, within 90 days (known as a “90-day termination notice). 

�          DOH’s survey found:  (1) that SummitQuest failed to ensure that restraints were utilized in an appropriate and safe manner in order to prevent serious harm to individuals; (2) that SummitQuest failed to assure that a resident was not subject to restraint as a means of coercion, discipline, convenience, or retaliation; (3) that SummitQuest failed to assure that an emergency safety intervention was implemented in a manner that was safe and appropriate to the resident’s medical condition; (4) that SummitQuest failed to conduct appropriate post-restraint debriefings, including analyzing whether alternate techniques could have prevented the use of a restraint; (5) that SummitQuest failed to ensure that staff were trained in the safe and appropriate use of restraints and cardiopulmonary resuscitation annually; and (6) that SummitQuest failed to report the death to CMS’s Regional Office, DPW, and PP&A. 

            �          Although DOH recommended that OMAP issue a 90-day termination notice, CMS’s procedures allow SummitQuest the opportunity to submit a Plan of Correction to DOH.  If DOH approves SummitQuest’s plan of correction, DOH will re-survey the facility after the plan is implemented.  At that time, if DOH determines that SummitQuest remains non-compliant, DOH will recommend to OMAP continuation of the 90-day termination process of SummitQuest’s participation in the Medicaid program.  To date, PP&A has not seen any plan of correction from SummitQuest.

 ♦     29 of the 45 residents interviewed reported that SummitQuest staff subjected them to restraints.

                         �          19 of those 29 residents reported that they were restrained on more than one occasion,  including four residents who stated
                                      that they were restrained more than 10 times and another four who were restrained at least five times.

                        �          Residents reported that the restraints lasted from 1-2 minutes to up to 90 minutes.

�          Residents consistently described the restraints used by SummitQuest staff as prone restraints, i.e., SummitQuest staff placing residents face-down on the floor or other surface with the residents’ arms pulled up behind their backs and staff holding their arms and legs.  Residents reported that staff often placed their knees on the residents’ back or neck.  If residents struggled, staff applied even more pressure is used and some residents reported that they had difficulty breathing while under this restraint.

�          17 of the 29 residents who reported that they were restrained stated that they suffered injury as a result -- from bruising and muscle aches to one resident who stated that the blood vessels in his eyes popped and another stated that he choked on his own blood after he hit his nose on the ground during the takedown.

�          A few of these youngsters stated that the restraints followed provocations by the staff.  

�          15 of the 29 residents who reported that SummitQuest staff restrained them stated that staff had not made any efforts to de-escalate the situation before instituting the restraints. 

�          Residents reported that after G.A.’s death, SummitQuest staff ceased using prone restraints.  Residents report that staff now use supine restraints and escorts and that such measures are implemented only by a “crisis response team” and are used with less frequency that the type of restraints used prior to G.A.’s death. 

♦          35 of the 45 residents interviewed reported taking medications, with eight reporting negative results, and four stating that they did not see any difference.

                     SummitQuest uses a behavioral intervention policy grounded in a five-level system in which the residents earned higher levels   
            with more privileges based on compliant behaviors.  Residents at “level one” have no privileges, must go to bed early, are not   
            allowed off-grounds or provided home passes, are permitted only one phone call per week, and must wear uniforms.  At “level
            five,” residents have an array of privileges.

V.        Recommendations

            Based on our investigation, PP&A recommends that DPW, as the relevant licensing agency, take the following steps: