The Virginia Department of Behavioral Health and Developmental Services Office of Licensing opened an investigation into Kempsville Behavioral Health Center after a doctor from North Carolina called to report that “a resident’s parents complained about [their] loved one being sexually abused during [their] stay at Kempsville location.”
The doctor also informed the Office of Licensing that “[North Carolina] is moving forward to removing all NC residents from The Pines facilities.”
In its investigation, the Office of Licensing reviewed records of the following incidents during the North Carolina resident’s stay:
1st incident: Prior to 11/14/10 incident where roommate flashed resident;
2nd incident: On 11/14/10, resident report another resident touching him in private area. Provider indicated that this was during “horse playing”.
3rd incident: On 1/23/11, resident reported that another resident touched him in private area. Provider founded this inappropriate behavior.
The Office of Licensing determined that the facility failed to report and document these incidents appropriately, noting that the “[p]rovider failed to properly report [these] incidents to the Office of Licensing… [T]he incident that occurred on 1/23/11 is not documented anywhere in the Therapy notes or in the staff progress notes. … Parents not notified until 1/25/11. Provider failed to follow their own [policies and procedures] regarding appropriate notification of sexual related incident.”
Documents also revealed that the resident’s discharge summary listed “placement successful” as the reason for discharge. In fact, the resident’s parents had indicated via letter that “We made the decision to not wait any longer to remove [him] from The Pines and picked him up.”
Following an on-site inspection, the Office of Licensing determined the facility had violated four residential treatment regulations. These included the requirement to report serious incidents to guardians within 24 hours, the requirement to have services coordinated by a case manager, the requirement for accurate discharge summaries, and the requirement to have a structured program of care with clear measures of progress.
To address these deficiencies, the Office of Licensing required the facility to submit an acceptable Corrective Action Plan.
