COMMONWEALTH OF MASSACHUSETTS SUFFOLK, ss DEPARTMENT OF EARLY EDUCATION AND CARE } In Re: Residential Group Care License Nos. 9017891, 9017894, 9017895, } 9017896, 9017897, 9017892 and 9017893.) EEC DOCKET NO. Issued To: Eagleton School, Inc.; Eagleton) R&P 16-023 School - White Birch 1; Eagleton School— ) White Birch 2; Eagleton School - White) Birch 3; Eagleton School - White Birch 4, ) Eagleton School — Upper 23; end Eagleton ) ‘School ~ Intensive Program 2 ) Licensee: Eagleton School, Inc. ) 446 Monterey Road ) Great Barrington, MA. 01230-1454 ) ) ORDER TO PROTECT CHIL} ': NOTICE VOCATI NOTICE OF SANCTIONS AND NOTICE OF INTENT TO FINE In January 2016, the Department of Barly Education and Care ("EBC") learned from law enforcement officials and others that there were allegations of a significant pattern of physical and emotional abuse of residents by some Eagleton staff, eliciting concems for residents” health and safety. EBC has been monitoring Eagleton School, Inc.; Eagleton School - White Birch 1, Eagleton School - White Birch 2; Fagleton School ~ White Birch 3; Eagleton School ~ White Birch 4; Eagleton School — Upper 23 and Eagleton School- Intensive Program 2 (collectively hereinafter "Eagleton”) and its ability to provide for the safety and well-being ofits residents, ‘and to report health and safety related incidents appropriately and timely. As a result of EEC’s ‘of Sanetions and initial review of the allegations, it issued an Order to Protect Childe. Notice of Intent to Fine ("Sanctions Order") on February 17, 2016. Since issuing the Sanctions ‘Onder that EEC imposed for the immediate protection of the residents, EEC has learned of newregulatory violations, demonstrating tha! the continued operation of Eagleton poses a risk to the hhealth and safety of children. At the same time, Eagleton has failed to comply with provisions of the Sanctions Order and residents have disclosed several recent instances of abuse or neglect of residents by Eagieton staff to state oversight agencies. Due to the breadth and scope of these health and safety concems, violations of the Sanctions Order, and other regulatory violations, EEC is exercising its anthority to issue this Order to Protect Children: Notice of Revocation. Noi is and Noti ‘Intent to Fine (“Onder”) against the Eagleton Residential of Saneti Group Care Licenses (#9017891, 9017894, 9017895, 9017896, 9017897, 9017892 and 9017893), which expire on May 14, 2016. I. FACTS AND REGULATORY VIOLATIONS 1, Bagleton has seven residential group care programs licensed by EEC on its school campus located at 446 Monterey Road, Great Barrington, Massachusetts. The total capacity of these seven group care programs is for 76 residents, consisting of boys and young men from 9 ~2i years of age. Alll Eagleton residents have developmental disabilities, behavioral and psychiatric diagnoses and/or are cognitively impaired. 2. All: Eagleton residential group care programs licenses are held in the name of Eagleton School, In. (hereinafter the “Licensee”), a Massachusetts for profit conporation with a mailing address of 446 Monterey Road, Great Barrington, Massachusetts. Bruce Bona is the President, Treasurer and Secreiary of the Licensee, 3. The intetim Residential Program Director for Eagleton residential group care programs is presently Michael Adams, Eagleton has searched for a new Program Director since the 5. 222 201,On January 29, 2016, BEC was informed by law enforcement officials of allegations of criminal conduct by several Eagleton staff members. Based on this information, search ‘warrants were issued and executed by law enforcement officials at the school on January 30, 2016. Based on this investigation, Mj Eagleton staff members were arrested on charges that included assault and battery of Eagleton students. Afier EEC reviewed the then available information, EEC issued a Sanctions Order to Eagleton in hand on February 17, 2016. EEC is attaching the Sanctions Order and incorporates it here by reference in its entizety. See Exhibit i ~ Sanctions Order. The Sanctions Order required that Eaglefon fulfill sanctions lettered A through Q as described in Section III of the Sanctions Order. 1d. Section IV of the Sanctions Order permits Fagieton to request an extension of any sanction deadline after demonstrating extenuating circumstances, Extension requests must be placed in writing at least seven (7) days prior to the sanction due date, and must include the reason for the request with an anticipated completion date. Jd. On February 17, 2016, EBC provided the Sanctions Order to Eagleton administrators in person at a meeting attended by EEC, the Department of Elementary and Secondary Education ("DESE"), and Eagleton, EEC was represented by Commissioner Tom Weber, Deputy Commissioner for Field and Legal Operations Carmel Sullivan, and Deputy General Counsel Felicia Sullivan. Present from DESE were General Counsel Rhoda Schneider, Legal Counsel Anne Berry Goodfellow, Chief of Stail Helene Bettencourt, and Assistant Director of Program Quality Assurance Services Joe Drolette. The following individuals were present on behalf of Eagleton: Owner Bruce Bona, Attorney10. Janine Brown-Smith, Attomey Kate McCormick, Interim Program Director Michael Adams, a parent of an Eagleton resident, and Attorney Roderick MacLeish, who participated by phone. During the meeting, EEC's Deputy Commissioner read through the entire Sanctions Order and answered questions as they arose. In particular, EEC reviewed Sanction L, which required that staff not have unmonitored contact with residents, Faglcton's attorney asked the Interim Residential Program Director if Sanction L was feasible. Mr. Adams replied yes, but noted that there are sometimes staff who have to chase after residents. EEC's Deputy Commissioner replied that Eagleton has the ability to request administrative reconsideration of any sanetion if there are concems with Eagleton’s ability to comply. Section VI of the Sanctions Order permitted Eagleton to file a request for administrative reconsideration of the Sanctions Order by February 24, 2016, but Eagleton never submitted such a request. Id. On February 26, 2016, a meeting occurred with EEC, DBSE, and Eagleton’s potential consultant, Charles Conroy, Ed.D. Present on behalf of EEC were Residential and Placement Supervisor Tim Keane, Licensor John Riley, and Deputy General Counsel Felicia Sullivan, DESE was represented by Assistant Director of Program Quality Assurance Services Joe Drolette, Dr. Conroy was present with Attorneys Brown-Smith and MacLeish, who participated by phone, During the meeting, BEC and Eagleton reviewed the Sanctions Order and Eagleton’s attorneys and Dr. Conroy asked questions. ‘The following information was reviewed during the meeting: a. Eagleton's attomeys acknowledged that they missed the deadline for filing a request for administrative reconsideration.b. Eagleton’s attomeys verbally confirmed that they would seek an extension of the timelines and EEC explained that requests to extend timelines had to be in writing and in advance of the deadline. c. Attomey Macl.eish stated that Eagleton would be moving forward with Dr. Conroy as Eagleton's consultant. d. Eagleton's atlomeys claimed that Eagleton had already complied with several of EEC's sanctions, stating that the Licensee had removed Daye Farrell from its Board of Directors, ensured that there is an administrator on site, and prohibited staff from having unmonitored contact with residents. Atiomey Brown-Smith stated that Eagleton sent a memo to staff notifying them of the requirement to have no ‘uunmonitored contact with children. Since the issuance of the February 17th Sanctions Order, the following provisions have been violated by the Licensee on several occasions: a, Sanction L: The Licensee shall ensure that ail direct care staff will not have any unmonitored contact with residents pending the completion of EC's investigation. i, On March 9, 2016, the EEC Investigator observed an Eagleton staff member escorting a resident across campus, There were other Eagleton staff and residents walking across campus or on the basketball court; however, no one appeared to be monitoring this particular staff member with this resident. ii, On the same date, Fglet n's i wes walking residents to and from interviews until EEC’s Investigator informed him that the Sanctions Order prohibited staff from having unmonitored contactwith residents. Thereafter, residents were accompanied to and from interviews by Jaw enforcement. iii, On March 10, 2016, law enforcement present at Eagleton observed a single staff’ | member transporting approximately three to four Eagleton residents in a vehicle | without an additional stafff member present. Law enforcement immediately | reported their observations to the EEC investigator, iv. On the early afternoon of March 10, 2016, the BEC Investigator and a Department of Children and Families ("DCE") Investigator together witnessed four separate incidents during which an Eagleton staff member was walking a resident on campus outside the presence of additional staff. During one of the incidents, the investigators observed the staff person retrieve a resident from one Eagleton residence aud walk the resident across campus to another Eagleton residence. v. Three DESE staff members informed EEC that they separately observed violations of the Sanctions Order while present at the Eagleton campus after February 17, 2016. DESE staff members observed Eagleton staff alone with residents outside of the buildings on campus and inside at least two of the residences. b. Sanction M: The Licensee shall ensure that any allegations regarding physical abuse, emotional abuse, or any mistreatment of residents will be immediately reported to DCF or DPPC ("Disabled Persons Protection Commission"), to DESE as applicable, and to EEC. "immediately" shall mean no later than twelve hours from the time of the incident's occurrence. " Additionally, EEC ws dotermiced thet III tas not competed BEC's entire background record check process in violation of Sanction K.1. On March 7, 2016, EEC was notified that a 51A report was filed with DOF regarding an incident that allegedly occurred on Mare 3, 2016 during which a resident was left unsupervised undemeath a bed between fifteen and forty minutes. The resident was supposed to have a one-to-one staff. DCF learned about the incident from a third party not associated with Eagleton. Eagleton had notified EEC on March 4, 2016 at 9:58AM that a resident was found hiding under his bed. EEC responded to Eagleton's notification at 11:29AM on the same day and recommended that Eagleton contact DCF if it appeared that the resident was subjected to abuse or negiest. EEC also requested more detail about the incident, including the staif people involved and the timeframe. Eagleton responded to EEC's March dth inquiry on March 8, 2016 reporting the names of four staff involved in the incident, confirmed that the incident occurred on March 3, 2016, and noted that Eagleton had contacted DCF. EEC was later informed that Eagicton had not filed a 51,A report with DCF until March 8 2016. (EEC Complaint No. 73281). 12, BBC has learned of the following allegations of abuse or neglect by Eagleton staff members against Eagleton residents allegedly inflicted after the issuance of the February 17th Sanctions Order: a, On February 22, 2016, a 51A report was filed with DCF alleging neglect of a resident. The allegations were that on February 19, 2016, a witness spoke with a MMR 52x ofd Eagleton resident on the telephone. After the witness hung up the phone the witness's phone rang reflecting 2 call back from the Eagleton residence. When the witness answered the only sound discemible was screaming and crying inthe background. This information was reported by the witness is ME £€ Complaint No. 73317). . On March 7, 2016, EEC leamed that a 51 report was filed alleging neglect of an Eagleton resident by Eagleton staff after the resident was left unattended under a bed between fiiteen and forty minutes. See supra paragraph 11(b)(1); (EBC Complaint No, 73281). On March 8, 2016, Interim Program Quality Insurance ("PQI") Manager Chad Astore notified EEC that a report was filed with DPPC on behalf of an [IM year old. resident, Bagleton staff bad alleged that they observeid a staff member who was verbally abusive to a resident on more than one occasion. Eagleton did not permit the staff member to work another shift after learning of the allegations. (EEC Complaint No, 73450). ‘On March 14, 2016, Interim PQI Manager Chad Astore notified EEC that a resident grabbed a pizza and ran out of his residence, An Eagleton staff member followed and claimed that the resident started spitting and punching at the staff member. When a second staff member arrived to assist, Eagleton staff conducted a physical hold of the resident, After the incident, the resident alleged that he was placed in a headlock bythe first staff member. Both Eagleton staff members denied a headlock occurred, but Mr. Astore stated he would review the video footage and place the staff who the resident accused of the headlock in a position with no unmonitored contact with residents, (EEC Complaint No. 73499). . On Match 15, 2016, EEC was copied on five letters from Eagleton's Interim Education Program Director Kurt Garivaltis to out-of-state placing agencies, requesting emergency terminations due to these residents posing a clear and present threat to the health and safety of themselves, other students and staff. Mr. Garivaltis stated in each letter that Eagleton is not able to provide these students with the services they now require and therefore it is not equipped to meet their needs. On March 15, 2016, Eagleton notified EEC that a 51A Report was filed with DCP afler a staff member and the school cook left aI) year old resident alone, unattended in an Eagleton residence for approximately forty minutes while they ‘transitioned residents to the school, Interim Residential Program Director Michael Adams recovered the student who appeared unharmed. Eagleton I «211 062: incident. (EEC Complaint No. 73523). . On March 16, 2016, EEC received a complaint from a third party that on March 15, 2016, a resident reported that he witnessed a teacher shaking another student because the teacher was frustrated with him, which made the resident feel unsafe. The resident reported that this incident happened within the past week, EEC was also notified that this resident alleged that Eagleton’ makes him feel uncomfortable. (EEC Complaint No. 73534).1B. During its investigation into the factual and regulatory violations contained within EEC's Sanctions Oréer, new facts came to light regarding some of the previously reported incidents described in the Sanctions Order: a. DCF supported afinding of abuse and neglect by EE on Eagleton staf? member on Pebruary 1, 2016 as to his restraint of a II year old Eagleton resident in EE. See Exhibit 1 at section'T, paragraph 15. Subsequently, a EE Jeamed that the other EN veer old Eagleton resident was forcibly given his medication, during which I) egeressively placed his hands on the resident's neck and head area while an Eagleton staff member and i pried his, ‘mouth open. ‘The resident receiving the medication struggled with staff as his neck. ‘was pulled back, and his nose blocked, resulting in the student being restrained by. ER. © :¢ BE v2 014, observing the other resident struggling and then placed in a restraint, punched [IE on the back of the neck in an effort to assist the other resident, EEC determined thal Eagleton underreported the severity of the incident; the entirety [III was not released to EEC and DCF and HEEB ivpplicated at least two additional staff in the incident, (EEC Complaint No, 72654). b, EEC received a complaint on January 28, 2016 that stati member EE stuck his finger in 2) year old resident's eye during a restraint on January 29, 2016. ‘The resident who was restrained suffered swelling and bruising as a result of the incident. See Exhibit 1 af Section | paragraph 16. EEC discovered that staffhad 10submitted misleading incident and restraint reports regarding this particular incident (EEC Complaint No. 73142). ¢. EEC was notified by a third party on February 3, 2016, that on January 1, 2016, a HB yee old Eagleton resident in [I was subject to intimidation and coercion by (III, an Eagleton employee who ripped up the resident's "star" card, reflecting good behavior and privileges earned. See Exhibit 1. ‘The resident stepped towards fj J and was brought to the ground by four staff members, including INF. The resident was punched several times and suffered 2 HH 20d black swollen eyes during the restraint. There were several witnesses to the incident but this matter was not reported timely to DPPC or EEC. (EEC Complaint No.73205), L. Video footage viewed by FEC directly contradicted staff statements referenced in Eagleton’s investigation report of the January 1st incident. Meanwhile, Eagleton's internal investigation report did not list all residential staff who were involved in the restraint, and only noted the presence of school employees. ii, Eagleton's restraint report for the Janmary }st incident did not contain signatures ofall staff involved, did not include the titles of the staff involved in the restraint, did not document a review by the Restraint Coordinator, Nursing Staff, or Clinical Staff of the restraint that occurred, and the report was not signed off by the Restraint Coordinator. iti, BEC’s review of the nursing log related to EEC Complaint No. 73205 reflects that on January 1, 2016, the resident's severe injuries were cleaned and treated with ‘ointment, The resident went to the nurse every day between January 2 through u14. January 6, 2016 to address complaints of knee pain but was only provided with ME, 10 Freeze compress, and a sieeve for his knee. In reviewing the telephone conversation report, EEC noted that there were no contact notes for the resident's family EE regarding the January 1, 2016 restraint or the injuries sustained by the resident, During investigations conducted after EEC issued its Sanctions Order, EEC learned that ‘two residents had broken bones wale attending Eagleion that were not reported to EEC or DPPC. One resident broke a IM on September 27, 2015 anda second resident suffcred (MM on July 9, 2015. (EEC Complaint No. 73149). ince issuing its February 17, 2016 Sanctions Order, FEC has received new allegations of physical abuse by Eagleton staff occurring prior to February 17, 2016: a, On January 29, 2016, dM year old resident disclosed that he was pushed into a wall and injured by staff membe within the prior weeks. ‘was not removed from duty ancl continued to have unsupervised contact with children following the incident. EEC was informed by Eagleton that J’ 2 Corn lsint No. 73317). b. On February 3, 2016, EEC learned of an incident where a resident kicked a teacher and staff member III intervened by grabbing the resident's arm and twisting, it, The resident's arm was twisted so badly it appeared to witnesses to the incident that it was going to break and the resident had tears in his eyes. (EEC Complaint No. 73204), 12c. OnFebruary 4, 2016, BEC received a complaint that a fj year old resident reported mistrust of Eagleton staff, The resident reported thai unnamed Eagleton staff stole his TV cord, denied him phone privileges, and pulled a sweat shirt over his face causing injury to the resident's I. which were not immediately fixed by Eagleton, As of February 5, 2016, the resident was due i (Bu: it was believed that the resident's J had been broken for quite some time. (GEC Complaint No, 73210) * d. On February 9, 2016, EEC received a complaint that a EM year old resident disclosed that two staff people in his dorm have threatened him and stated they will come after the resident if he told anyone. (EEC Complaint No. 73226). ©. On February 11, 2016, Bagleton filed a SLA report with DCF and notified ERC that an Engieton staff member bit « QNMMMMyear old resident during a restraint on the day prior while the resident was attempting to move toward the road. The resident was seen by the nurse and there was a mark on the resident's hand and back. Interim Residential Program Director Michael Adams is es SR (25C Complaint No. 73244). £. On February 17, 2016, Interim PQI Manager Chad Astore reported the following four incidents to ERC, and stated that notification of these incidents was delayed because Mr. Astore believed he did not need to rept aa | i. On February 3, 2016, a report was made to Mr. Astore that a few months prior, SR 2llecedly yelled and swore at a vear old resident and 13pushed the resident into a chair white other staf - I — sp r2205 resid Sai. AIL staff members allegedly yelled at or pushed the resident if he "doesn't nove rsh, 3 Eagleton filed a 1A report on February 21, 2016. (EEC Complaint No. 73317). ii, On February 5, 2016, 2 [I year old resident reported that approximately one year and a half ago Eagleton staff member I cllegedly stuck his finger in the resident's eye during a restraint, Bagleton informed EEC that RE © is next scheduled work day. spoke with Mr. Astore about 2: 52s | scheduled to be on a one-to-one with a resident that day. EEC expressed concer with this decision and Mr. store i 2220 Complaint No. 73282). iii.On February 7, 2016, aE year old resident reported that on that day Eagleton staff member EEE allegedly threw him into a ceiling and hithim in the head with a radio, Eagleton reported that fl] Hl (EEC Complaint No. 73280). iv. On February 15,2016, al year old resident reported that Eagleton staff member {EEE had allegedly kicked the resident. (BEC Complaint No. 73281). “4g, On February 22, 2016, EEC was informed of a 51A report that was filed on behalf of a MMB ex old former Eagleton resident. The resicent I chat while at Eagleton, the resident suffered strikes to his face, abdomen, and other body parts, A staff member allegedly twisted the former resident's arm, breaking the resident's J The former Eagleton resident claimed staff would threaten the resident by showing photographs of deceased gang members who had been killed and stated that staff was part of a gang. The matter is under investigation. (EEC Complaint No, 73306). 16, EEC’ investigation revealed that Eagleton's administrative procedures are incomplete i and do not comply with EC's regulations: a. Cerfain Eagleton administrators had the authority to contact the video surveillance company and request that specific video footage be downloaded to the Eagleton | server. Former administrators and staff appear to have manipulated video footage that ‘would have revealed serious incidents that occurred during Eagleton's operations. fj | =. b. Restraint reports are not being completed ine manner required by EEC regulations. | Many restraint reports are either missing or are incomplete and lack specificity or detail about the restraints. EEC discovered that a restraint report had been falsified after observing two restraint reports written by staff about the same incident that were drastically different. Many restraint reports do not have the review and signature of the Restraint Coordinator or contain evidence that the resident was able to comment in vaiting following the completion of a restraint, 15c. While reviewing documentation related to several of the aforementioned incidents, BEC discovered that staff were not writing authentic incident reports. EEC also observed that nursing logs and telephone conversation seports are not xegularly signed off by the staff who entered them. d. On March 14, 2016, EEC learned from the New York Justice Center that Eagleton. had not notified the agency of allegations of abuse or neglect on New York residents. The agenoy indicated that the contract hetween Eagleton and the placement agency is mandated by New York law to contain an affirmative reporting requirement to the New York Justice Center to enable them to appropriately investigate the allegations. 17. On March 10,2016, Bagleton’s attorney requested that EEC waive the requirement that a {ull background record check (specifically the fingerprint-based check of the federal and state criminal history databases) be completed prior to employment, as required by Sanction J. See E-mail dated March 10, 2016. 18, EEC was informed by Eagleton that staff roc es I, LEGAL BASIS FOR OCATION EEC is issuing a revocation of Eagleton’s residential group care licenses because the Licensee's failure to comply with the regulations of the Commonwealth demonstrates that itis not capable of providing an environment that ensures the safety and well-being of residents in its care. See 102 CMR 1.07(4)(@)1. Despite the serious allegations facing several current amd former Bagleton staff, EEC provided the Licensee with the opportunity to address EEC's concems with the issuance of its Sanctions Order, See Exhibit 1. Eagleton has demonstrated that itis incapable of complying with provisions of said Sanctions Order, which are independent 16grounds for issuing further legal action. See 102 CMR 1.07(4)(a)1. Additionally, EBC has identified numérous regulatory violations throughout its enhanced monitoring and investigation into Bagleton, warranting the escalation of legal action in this matter. See id ‘The specific regulatory violations are as follows: A. ‘The Livensee has failed to comply with specific sanctions. ‘The Licensee has failed to comply with provisions contained within EEC’s Sanctions Order issued to Eagleton on February 17, 2016. EEC may issue scinctions to one or more programs upon leaming of deficiencies with compliance with EEC’s regulations. See 102 CMR. 1.073). Faiture to comply with any sanction issued in « legal order constitutes a violation of EEC's enforeement regulations and may result in additional legal action, including suspension, and/or revocation of a license, See 102 CMR 1.07(4)(a)1. One of the most concerning violations of the Sanctions Order hes been a repeated violation of Sinction L, requiring that no staff member have unmonitored contact with residents. See Exhibit 1. BEC imposed this senction to protect the health and safety of all residents remaining in the care and custody of Eagleton. At the time BEC imposed is Sanctions Cr, es imposed this sanction to ensure that staff were monitored and supervised and so that the likelihood of additional allegations of abuse or neglect by staff at Eagleton would be negligible. Since February 17, 2016, there have been numerous allegations of abuse or neglect filed with various state agencies demonstrating that residents remaining in the presence of a single Eagleton staff member preseuts a reel risk of harm. For exemple, when the Interim PQI Manager called EEC on February 17, 2016 to report three seperate allegations of abuse or neglect made by residents, each incident alleged misconduct by staff who are still employed by Eagleton. One 7incident alleged [urrent Eagleton staff members holding a resident captive and abusing the resident on February 3, 2016; a report alleged that on February 15, 2016 another resident was. abused by the same staff member who led an assault on a resident on February 3, 2016; and a final incident where a resident asserted that on February 7, 2016, another current staff member allegedly threw the resident against a ceiling and threw an object at the same resident. All incidents were aggressive and abusive acts against residents, and appear to have occurred in instances in which stuff had unmonitored contact with residents. ‘The Licensee has not informed EEC that it has had difficulty complying with the requirement that staff have no unmonitored contact with residents. On February 17, 2016, BEC ppfesented the Sanctions Order fo Eagleton administrators in-person and went over each sanction one by one. There was no comment made during the presentation of the Sanctions Order that the Licensee was incapable of fulfilling its obligation. In fact, Eagleton's attomey inquired of Eagleton administration present at the meeting as to whether they could fulfill the sanction, Further, the Licensee was reminded of its eblity to address any concem(s) through a request for administrative reconsideration, but elected not to submit such a request. Despite the Licensee providing staff with a memo regarding the sanction, itis evident that this sanction has not been enforced because state agency authorities, during the course of their on-site monitoring and investigations and since the imposition of the Sanctions Order, have observed at least ten instances of Eagleton staff being alone on campus with one or more residents. Another important provision of the Sanctions Order that has been violated is Sanction M, requiring that the Licensee ensure that any allegations of physical abuse or neglect or mistreatment be immediately reported to DCF, DPPC, EEC, and DESE within twelve hours of the occurrence of the incident. See Exhibit 1, On March 7, 2016, BEC leamed from a source 18other than Eagleton, that a resident had been left under a bed by Eagleton staff between fifteen and forty minutes on March 3, 2016, Although an Eagleton administrator verbally notified EEC of the March 3, 2016 incident on March 4, 2016, there was insufficient detail about the incident. EEC requested that follow up be provided and instructed the reporting Eagleton administrator to inform DCF of the incident if it was alleged that there was abuse or neglect of the resident. Instead, the Licensee did not report the matter to DCF until March 8, 2016, and EEC was officially notified of the incident through DCF on March 7, 2016. This is a significant failure on the part of the Licensee, because one of the most serious concerns raised by BEC in its Sanctions Order was a systemic failure to report allegations of abuse or neglect to state authorities. See Exhibit 1. The recent failure to report this incident demonstrates a continued lack of appreciation for the reporting requirements under G.L. ¢. 119, § SIA. B. The Licensee has continued to employ staff who engage in abusive and cruel behavior and conduct improper restraints, resulting in injury to Eagleton residents. Since the issuance of EEC’s Sanctions Order on February 17, 2016, there have been ‘numerous allegations that Eagleton staff continue to place residents at risk by utilizing physical force and unwarranted restraint techniques to control emotionally and mentally disabled individuals. During the course of EEC's investigation, EEC has become aware of several serious allegations of staff abuse or neglect of residents that occurred within the past couple of months. Although the Sanctions Onder required the removal of Eagleton staff implicated and arrested for the abuse of residents, residents have identified several additional staff members as responsible for inflicting harm. EEC regulations prohibit employees, staff, or any other person with ‘unsupervised access to residents from inflicting any form of abuse or neglect upon a resident in Eagleton's care and custody. See 606 CMR 3.071). Programs are also responsible for ensuring that residents do not suffer from abuse, neglect, cruel, unusual, severe or corporal punishment, or 19verbal abuse. See 606 CMR 3.07(7)(g). EBC has received at least seven complaints of abuse or neglect of residents, iucluding five 51A reports filed with DCF elleging abuse or neglect of residents by Eagleton staff since February 17,2016, There remains a genuine concern thet the Licensee is still placing residents at risk of harm. Several of the inéident reports assert that Eagleton staff inflicted physical force against residents, and there have been at least two separate claims that residents were threatened and intimidated by Eagleton staff members. One resident expressed his lack of trust of the Eagleton staff. The volume of the complaints received demonstrate that the incidents are not isolated and there is an increasing concern for the welfare of the Eagleton residents. EEC has leamed of several disquieting events in which residents were injured during the course of restraints at Eagleton, Restraints may not be used for purposes of punishment or for ‘the convenience of others, and licensees must assure that the restraints used on residents are the least intrusive means necessary to protect the resident, other residents and program staff. See 606 CMR 3.07(7)(j)2 and 7. In November 2015 a resident was injured during a restraint J 8 ciety" restraint was inflicted on a resident in the presence of several staff members on January 1, 2016; on February 2, 2016 a staff member used a restraint to abuse a resident; a resident alleged that a stati’ member bit a resident during a restraint on February 11, 2016; and on February 5, 2016, a resident disclosed that a staff member poked him in the eye during a restraint one year and a half prior. There is evidence that frequently the restraints at Eagleton have been used for punishment and have resulted in serious injury to residents. The staff appear to fack the training and appreciation for how to utilize appropriate behavior supports. EEC's investigation hs revealed that Eagleton staff members frequently injured residents, and in doing so, the Licensee and its administration either 20negligently failed to accurately document the incidents that occurred, or was complicit or active in covering up evidence of staff misconduct towards residents, ‘The Licensee failed to report to EEC ot DPPC that two residents had broken bones while attending Eagleton, in violation of 606 CMR 3,04(5)(2) and 606 CMR 3,04(5)(6). The Licensee failed to report to EEC that an Eagleton staff member grabbed a resident's arm and twisted it so badly that it appeared to witnesses it was going to break. See 606 CMR 3.04(5)(g) and. 606 CMR 3.04(5)(e). The Licensee failed to properly document end provide information to EEC when an Eagleton staff member stuck his finger in a J year old resident's eye during a restraint, in violation of 606 CMR 3.103) and 102 CMR 1.06(3). The Licensee's lack of supervision of its staff and residents has resulted in two recent allegations of neglect by Eagleton staff. Licensoes are mandated to supervise residents in a ‘manner that protects residents from abuse or neglect. See 606 CMR 3.07(1). On March 3, 2016, Eagleton staff left a resident unsupervised in a residence between fifteen and forty minutes, even though the resident's treatment plan requires that he receive one-to-one care. On March 15, 2016, Eagleton reported that its staff again left a resident unsupervised in a residence for approximately forty minutes, while staff members were transitioning residents to the educational program, Both incidents reflect a lack of basic supervision of the residents and placed residents at risk of harm, C. The Licensee continues to fail to comply with state law regarding reporting allegatic abuse and neglect of children. EEC remains concerned that the Licensee is failing to report all incidents of suspected abuse or neglect to DCF, which was part of EEC's legal basis for issuing its Sanctions Order. See Exhibit 1 at Section II, paragraph B. Eagleton staff are considered mandated reporters under G. L.c. 119, §S1A, See G.L. c. 119, §21 (including "... home or program funded by thecommonwealth or licensed under chapter 15D that provides child care or residential services to children" (emphasis added). Under §51A of G.L. e. 119, mandated reporters must immediately communicate allegations of abuse or neglect of a child to DCF and send a report within forty-eight hours of learning of the incident. EEC regulations require that licensees include in their policies a written plan for staff to file a report of abuse or neglect with DCF. See 606 CMR 3.04(3)(). In its Sanctions Order, EEC mandated that the Licensee report allegations of abuse or neglect to DCF within twelve hours from the time of the occurrence because Eagleton was consistently failing to report incidents in a timely manner. See Exhibit 1. Eagleton has failed to take measures to ensure that its staff are abiding by their obligetions as mandated reporters, despite EEC's sanotion, See Exhibit 1. D. Eagleton continues to lack sound administration,» EEC remains concemed with the soundness of Eagleton’s administration. Residential ‘group care programs are designed to provide children with services thet meet their immediate and basic needs and foster the optimal growth and individual development of the residents in its care, See 606 CMR 3.04(1)(a). Licensees are mandated to ensure that a residential program is soundly administered by qualified persons designated with specific administrative and program responsibilities. See 606 CMR 3.03(3), 3.046). Additionally, it is expected that a licensee provides a fiscally and administratively sound program with clearly conceived policies and practices; is able to meet the short-term, immediate, and emergency needs of residents; is capable of planning for the resident's long-term needs; and provides for each resident's health, nutrition, individuality and interaction with peers and adults, before it attempts to satisfy each resident's more complex needs. See 606 CMR 3.01(a)-(c). Evidence retrieved during EEC’s investigation demonstrates that the Licensee has failed to meet the goals of residential group care. BEC hasleamed that Eagleton's nursing staff has not appropriately provided care for at least one resident and failed to notify a parent or guardian of an injury sustained by a resident during « January 1, 2016 restraint occurring at Eagleton. EEC leamed during its investigation that two separate residents’ injuries had not been timely reported to EEC. EEC leamed independently that residents had suffered broken bones while at Eagleton, one on July 9, 2015 and one on September 27, 2015. Pursuant to EEC regulations, licensees are mandated to report to EEC any serious injuries to a resident, and if requested, supply EEC with a written report of the injury. See 606 CMR 3.04(5)(g). The Licensee failed to notify EEC of the incidents, and it was not until EEC conducted its own. investigation that it leamed about the residents’ injuries. Based on a concem for the safety of residents, EEC required that the Licensee complete several sanctions to increase the stability of the residential group care programs. See Exhibit 1. Due to the circumstances outlined in the Sanctions Order, EEC required that several Eagleton staff be removed, including several key administrators and mandated that several essential positions be hired to ensure the safety of residents attending Eagleton, The Licensee has had difficulty hiring additional staff in compliince with the Sanctions Order, and has failed to request an extension within the timeframe required by the order or appeal any of the deadlines. As documented above, EEC’s investigation has uncovered allegations so significant and far-reaching that sanctions are not sufficient to ensure the health and safety of Eagleton residents. ‘There have been two recent incidents demonstrating that the Licensee is having difficulty managing its residents and administrative obligations. In two separate incidents, Eagleton left residents alone in a residence after losing track of them during a transition period. The fact that both incidents occurred demonstrates that the Eagleton administration is having 23trouble keeping track of its high needs residents. The delay in reporting the March 3rd incident to DCF further reflects that the administration is having difficulty fulfilling its reporting obligations. There has also been evidence revealed during EC's investigation demonstrating a significant concern whether the Licensee has historically been accurately reporting information to BEC and demonstrating that there has been at least one false or misleading report supplied to EEC. Provision of a false or misleading statement or report to EEC is independent grounds for revoking a residential group care license. See 102 CMR 1.07(4)(a)3. As noted in EEC's Sanctions Order, Eagleton administrators had difficulties reporting incidents to FEC and persistently failed to notify BEC of all the facts and circumstances surrounding restraints ot injuries to residents. See Exhibit 1. EEC also leamed that video tape evidence has been withheld from EEC. See id. During EEC's recent investigation, EEC has learned that the misconduct perpetrated by Eagleton staff was more extensive than previously known. EEC learned that, Eagleton staff manipulated videotapes and submitted investigation reports that were contradicted by the authentic video footage. An e-mail between Eagleton administrators acknowledged that an incident occurred; however, the investigation reports provided to EEC were completely contrary to the administrator's account,which downplayed the gravity of the situation Licensees are required to supply EEC with complete information as requested by EEC to enable EEC to make an accurate determination as to whether a licensee is in compliance with all BEC regulations. See 102 CMR 1.06(3). When a program provides false or misleading information to EEC it interferes with EC's ability to monitor the health and safety of a program. EEC has also leamed that the Licensee has failed to maintain complete and accurate documentation of incidents and restraints. During EEC's investigation, it was leamed that 24Eagleton staff members manipulated video footage which would have disclosed serious incidents that occurred during Fagleton’s operations. In addition to the manipulated video footage, it was discovered that restraint reports were either missing or incomplete, with at least one misleading restraint report in violation of 606 CMR 3.07(7)@)I4. Licensees are required to document all restraints occurring at a residence and maintain a report related to the restraint in the resident's, file, See 606 CMR 3.07(7)()14. The licensee must also maintain legible, dated, and signed records and logs that are signed by the individual making the entry that are consistently updated and maintained in the resident's file. See 606 CMR 3.10(3). BEC has learned during its investigation, that Eagleton has failed to maintain such logs, has not appropriately signed off on ‘nursing logs, or properly notated when nursing has had interactions with residents, EEC hes also learned that the Licensee has failed to report allegations of abusé or neglect of residents to New York, a referring state, In addition to notifying EEC, licensees ere required to notify a referral source or other state agency immediately after learning of an allegation of abuse or neglect against «resident that occurs during program activities. See 606 CMR 3.04(5)(c).. EBC licensure does not relieve a residential program of its duties to comply with any other state or local reporting requirement, or requirements included within a program's contract with a referral source. See 606 CMR 3.11(1). The New York Justice Center is the social services agency that oversees all New York residents placed in facilities outside of New York state. To receive New York residents, Eagleton signed a contract with a New York referral agency and pursuant to New York law, Eagleton is required to notify the New Yorke Justice Center of any allegations of abuse or neglect of residents. See Article 11 of the New York Social Services Law, §490.5. In speaking with the New York Justice Center, EEC learned that Eagleton has not 25reported allegations of abuse or neglect involving New York residents. EEC is aware of at least one allegation of abuse or neglect since 2013 that should have been reported, As described above, Eagleton has failed to comply with applicable regulations and has expressly failed to comply with the Sanctions Order. 102 CMR 1.07(4)(a)(1). Eagleton has submitted misleading or false statements or reports required under 102 CMR 1.00 through 8.00 et seq. 102 CMR 1.07(4)(a)(3). As described above, Eagleton has refused to submit any report or make available any records required under 102 CMR 1.00 through 8.00 et seq. 102 CMR. 1.07(4)(a)(4). Any one of Eagleton’s documented failures warrants EEC’s revocation of the Residential Group Care licenses. The nature, scope, severity and frequency of Eagleton’s non- compliances reveal a grave and present risk to the health, safety and welfare of children. TH. REVOCATION Based on the aforementioned information, EEC hereby revokes the Residential Group Care licenses (#9017891, 9017894, 9017895, 9017896, 9017897, 9017892 and 9017893), issued to the Licensee, which expire on May 14, 2016. See G.L. ¢. 15D, §10 and 102 CMR 1.07(4). IV. RIGHT OF APPEAL OF REVOCATION ‘Within twenty-one (21) days of receipt of this Order, the Licensee may file with EEC the enclosed Notice of Claim for an adjudicatory hearing on EEC’s determination to revoke Eagleton’s Residential Group Care licenses. See 102 CMR 1.08(2)(a). The Notice of Claim. should include a written Answer that specifically responds to EEC’s Order by admitting, denying or explaining material facts. The Answer should also include all affirmative defenses, as well as any supporting documentation, Failure to file a written Answer may result in EEC requesting a dismissal of any Notice of Claim. Send the Answer and the Notice of Claim directly to: Department of Early Education and Care, Legal Unit 51 Sleeper Street, Fourth Floor 26Boston, Massachusetts 02210 Attn: Felicia Sullivan, Deputy General Counsel ‘Tais Order to Protect Children: Notice of Revocation, Notice of Sanctions and Notice of Intent to Fine shall be EEC’s Final Agency Decision on its determination to revoke Eagleton’s Residential Group Care licenses if, after twenty-one (21) days, the Licensee fails to file a timely Notice of Claim or otherwise elects not to respond. See 801 CMR 1.01(4). If this Order becomes EEC’s Final Agency Decision, the Licensee may not apply for or qualify for any license, certificate, approval, or any other authorization. from EEC for five years. See 102 CMR 1,07(4)(b)2. V. FAILURE TO COMPLY WITH REVOCATION If an appeal is not timely filed as provided above, and the Licensee provides residential care, in violation of the provisions of G.L. c. 15D, §6(a) and in violation of this Order, EEC may initiate further legal action against the Licensee, including the enforcement of this Notice of Revocation in Superior Court. See G.L. c. 15D, §15(b). In addition, EEC may seek to impose penalties against the Licensee including, but not limited to, fines of up to five thousand dollars ($5,000) for each violation. See G.L. c. 15D, §15(a). VI. SANCTIONS Pending any appeal that the Licensee may file in this matter, the following Sanctions shall be placed on all seven of Eagleton’s Residential Group Care licenses (#9017891, 9017894, 9017895, 9017896, 9017897, 9017892 and 9017893). See 102 CMR 1.07(3). ‘These Sanctions shall take effect immediately. EEC reserves its right to add or amend sanctions based upon information revealed during the course of its investigation or during the investigations conducted 7by other state agencies and/or state and federal law enforcement agencies. These Sanctions may not be modified or rescinded without the express written permission of BEC. A. ‘The Licensee will continue to cease the enrollment of new resideats and shall not re~ enroll former residents, ‘The Licensee shall ensure that the following staff members remain suspended from their duties pending the outcome of EEC's investigaticn: i a Any staff member who has alleged to have abused or neglected a resident must be removed from a position where there is the potential of unsupervised contact with residents pending the outcome of the investigation into the incident. The Licensee will designate Charles Conroy as its Program Monitor, who is responsible for overseeing the reconfiguration of Eagleton's administration and its compliance with the sanctions during the pendency of this Order. ‘The Program Monitor will assess the financiel and operational viability of Eagleton and its ability to continue its operations during the pendency of this Order and will be in constant contact with EEC about Eagleton's ability to manage staff and residents during the pendency of this Order. The Program Monitor will communicate Eegleton's progress with fulfilling the sanctions in ‘the Order. ‘The Program Monitor must act cooperatively with all state agencies ‘monitoring Eagleton, including EEC, DESE, DCF, DPPC, and the Department of Developmental Services ("DDS") to ensure the smooth transition of residents into alternate placements, if necessary. In the event Dr. Conroy does not agree to.act as, Program Monitor, then the Licensee shall hire another individual to do so. The Licensee must provide EEC Residential and Placement Supervisor Tim Keane and EEC 28E, Residential and Placement Licensor John Riley, EEC Western Regional Office, 95 Liberty Street, Suite 1124, Springfield, Massachusetts 01103 with the names and resumes of candidates for the Program Monitor position by March 25,2016. EEC will review the candidates and determine which candidates are approved by EEC, EEC will make the final written determination that the Program Monitor is an approved candidate, and the new Program Monitor must be hired by the Licensee by April 1, 2016. If Dr. Conroy does not act as Program Monitor, then the Licensee will immediately provide, subject to EEC's approval, the name of an individual who will act as interim Program Monitor until the Program Monitor is hired. In addition to the Licensee's regulatory reporting requirements to EEC, the Program Monitor or the person acting in ‘the Program ‘Monitor's capacity will notify the Berkshire County District Attomey immediately of any potentially criminal acts discovered at Eagleton and the Program Monitor or person acting in the Program Monitor's capacity will conduct a joint investigation with the Berkshire District Atorney's Office. Eagleton staff and administrators will not investigate incidents that occurred at Eagleton prior to February 12, 2016. All incidents of abuse or neglect of residents alleged to have occurred on residents of other states or territories must be reported to the referring state or ageney and the applicable social services agency as required by law. ‘The Licensee shall ensure that all administrators and staff have completed background record checks through EEC before they are allowed o work with residents. A completed background record check consists of: (i) a Criminal Offender Record Information Check that is either clear or found suitable after a discretionary review by the Licensee; (ii) a 29DCF background record check that is either clear or found suitable after a discretionary review by the Licensee; (iii) a Sex Offender Registry Information Check found suitable afier review by BEC; and (iv) a fingerprint-based check of the federal and state criminal history databases found suitable after review by EEC. ‘The Licensee will provide EEC with evidence of its financial capability to operate while ‘the Order isin place within twenty-one (21) calendar days of the issuance of this Order as required by 606 CMR 3.04(4), including (1) a one year operating budget, estimating income and expenses and (2) proof of financial viability for the next three months. Within twenty four hours of the issuance of this Order, the Licensee will provide EEC with a list of staff employed by Eagleton's residential group care programs. Any changes in staff will be provided to EEC daily by 5:00 p.m. This information will be emailed to EEC Residential and Placement Supervisor Tim Keane. Within twenty four hours of the issuance of this Order, the Licensee will provide EEC with a current list of residents. Any changes in residents provided to EED daily by 5:00PM. The list will be emailed to EEC Residential and Placement Supervisor Tim Keane. The Licensee shall ensure that all direct care staff will not have any unmonitored contact, with residents pending the completion of EEC’s investigation. ‘The Licensee shall ensure that any allegations regarding physical abuse, emotional abuse or any mistreatment of residents will be immediately reported to DCF or DPPC as applicable, to DESE as applicable, and to EEC. "Immediately" shall mean no later than ‘two hours from the time of the incident’s occurrence between 9:00AM and 5:00PM, and 30‘twelve hours from the time of the incident’s occurrence during ovemight and weekend shifts. ‘The Licensee shall ensure that an Administrator is present during all residential program shifts, ‘The Licensee has an affirmative responsibility to maintain required staff-to-resident ratios to ensure the health and safety of residents in the programs, In the event the Licensee is unable to maintain appropriate staffing levels, then it must immediately notify EEC Residential and Placement Supervisor, Tim Keane to discuss a potential reduetion in capacity or emergency staffing plans. ‘The Licensee shall provide EEC with a staff retention plan that includes but is not limited to additional compensation or incentives for staff who agree to remain employed at Eagleton during the time for appeal permitted by this Order. The Licensee shall continue to provide timely daily reports to EEC and DESE detailing the status of program and school administration, staffing, and resident status in the format provided by EEC and DESE. VII. FAILURE TO COMPLY WITH SANCTIONS ‘An EEC representative will make frequent monitoring visits to Bagleton's residential ‘group care programs to determine compliance with the Sanctions in this Order. If at any time the Licensee fails to comply with the Sanctions in this Order or with any other EEC requirement and regulation, EEC may suspend Eagleton's licenses or impose any other actions or sanctions that EEC, in its discretion, deems appropriate and in accordance with the law. See 102 CMR 1.07(3), (4) and (5) and G.L. c. 15D, $10. 31VII. RIGHT TO REQUEST ADMINISTRATIVE RECONSIDERATION ‘OF SANCTIONS ‘The Licensee has a right to file with EEC a written request for administrative reconsideration, within seven (7) days of receipt of this Order, of all or part of the Sanctions imposed in this Order. See 102 CMR 1.08(1)(a). The Licensee's written request shall clearly state the reesons(s) why EBC should modify, correct, or rescind the Sdinctions or any part thereof. EEC shall grant, deny, or otherwise act upon such request within fifteen (15) business days of receipt of such request and shall notify the Licensee in writing of its decision. See 102 CMR 1,08(1)(b). The Licensee must send any written request for administrative reconsideration directly to: Department of Early Education and Care ~ Legal Unit 51 Sleeper Street, Fourth Floor, Boston, Massachusetts 02210 Attn: Carmel C. Sullivan, Deputy Commissioner for Field and Legal Operations. Pending notification of EEC’s decision regarding the request for administrative reconsideration, ‘the Licensee must continue to comply with all the Sanctions set forth in this Order. TX. NOTICE OF INTENT TO FINE BEC may levy a fine upon the Licensee if it fails to comply with this Order. Such fine may range from fifty dollars ($50.00) to one thousand dollars ($1,000.00). A separate fine may ‘be imposed for each instance of the Licensee's failure to comply with more than one Order issued by EEC and may result in the assessment of more than one fine. See 102 CMR 1.07(3)(b). X. WAIVER OF RIGHTS If the Licensee does not timely file a Notice of Claim or elects not to submit a request for administrative reconsideration, EEC will deem such actions as a waiver of the Licensee's right to request an adjudicatory hearing or request administrative reconsideration, 32XI. POSTING AND DISSEMINATION OF ORDER ‘The Licensee must post this Order in each of the Eagleton residential group care programs, in a place easily viewed by parents, visitors and employees until further notice from EEC. See 102 CMR 1.09(2)(@). In addition, EEC will continue to post the licensing status of all, Eagleton's residential group care program locations addressed in this Order, as “Sanctions” on the Department's website, along with any other publicly available information regularly posted. EEC will disseminate a redacted copy of the Order to each state agency or orgenization sesponsible for placing each Eaglefon resident, and will also provide a redacted copy of the Order to each resident's parent, guardian or other person with legal authority over the resident, Verification of posting of the Order must be provided to EEC by March 24, 2016. Department of Early Education and Care Carmel C. Sullivan Deputy Commissioner for Field and Legal Operations, By REC Attomey Felicia Sullivan Deputy General Counsel 51 Sleeper Street, Fourth Floor Boston, Massachusetts 02210 617-988-6603 BBO No. 672584 Dated: March 17, 2016 33CERTIFI ERVIC. I, Felicia Sullivan, do hereby certify that on this date the foregoing documents were served in hand upon counsel for Eagleton School, Inc. at EC's Springfield Regional Office: Janine Brown-Smith, Esq. Clark, Hunt, Ahern & Embry 150 Cambridgepark Drive Cambridge, MA 02140 Signed this 17th day of March, 2016 under the penalties of perjury. “ 4 pela i Sillvege Felicia Sullive 34