Protection & Advocacy, Inc.
of SummitQuest Academy
Residential Treatment Facility
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 DPWs 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 youths 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 youths 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 staffs 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 youths 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 SummitQuests 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&As 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 DPWs Office of Children, Youth,
and Families (OCYF), who was acting to coordinate the reviews of SummitQuest by DPWs OCYF, Office of Medical Assistance Programs
(OMAP), and Office of Mental Health and Substance Abuse Services
(OMHSAS) and Pennsylvanias Department of Health (DOH).
PP&A interviewed with Orlando Hernandez, of DOHs 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 DPWs actions
following G.A.s death.
PP&A reviewed DOHs 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
Findings of PP&As Investigation
Based on our investigation, PP&A has identified the
following relevant facts concerning the care and treatment of youth
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, DPWs Office of Children, Youth,
and Families banned admissions to SummitQuest on February 17, 2006,
though it appears that such a ban will be lifted.
DPWs 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 DPWs Office of Legal Counsel.
DOHs survey of SummitQuest concluded that the quality of service
was unacceptable and recommended that DPW OMAP initiate an action
to terminate SummitQuests eligibility for participation in the
Medical Assistance program, and, concomitantly, its Medical
Assistance funding, within 90 days (known as a 90-day termination
DOHs 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
residents 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 CMSs Regional Office, DPW, and PP&A.
Although DOH recommended that OMAP issue a 90-day termination
notice, CMSs procedures allow SummitQuest the opportunity to submit
a Plan of Correction to DOH. If DOH approves SummitQuests 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 SummitQuests participation in the
Medicaid program. To date, PP&A has not seen any plan of correction
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
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
more privileges based on compliant behaviors. Residents at level
one have no privileges, must go to bed early, are not
off-grounds or provided home passes, are permitted only one phone
call per week, and must wear uniforms. At level
have an array of privileges.
Based on our investigation, PP&A recommends that DPW, as
the relevant licensing agency, take the following steps:
Prohibit SummitQuest from using prone restraints and any and all
Require SummitQuest to adopt a sanctuary (i.e.,
non-physical) model of treatment.
3. Require SummitQuest to secure recommendations from an expert
(e.g., Gordon Hodas) concerning how to provide
trauma-informed care and proven and effective de-escalation
techniques and to immediately implement such recommendations and to
provide training to SummitQuest staff to enable them to implement
the recommended care and intervention strategies.
Require SummitQuest to discontinue its use of a point/level system
and to replace that system with strength-based individualized
positive behavior plans for each resident.
Have an independent child psychiatrist evaluate each SummitQuest
resident to determine whether SummitQuest is appropriate to meet his
needs and, if not, to identify what services and supports the
6. Develop an appropriate discharge plan for those SummitQuest
residents who (a) are determined not to need the level of care
provided by SummitQuest, or (b) desire an alternative placement and
whose placement at SummitQuest is not court-ordered. The discharge
planning process should include families, counties, and independent
Establish a plan to decrease the census at SummitQuest within two
Establish a Youth and Family Advisory Board at SummitQuest to
present concerns, make recommendations for change and growth, and
monitor progress and restraint data. The Youth representatives
should be chosen by their peers.
9. Increase SummitQuests residents opportunities to access the world
outside the facility, including a greater array of engaging and
relevant leisure activities.
Require SummitQuest to prominently post information about rights and
advocacy in all buildings, including all living units and schools.
Appoint a master to oversee the facilitys implementation
of corrective action plans.