The Commonwealth of Massachusetts Pm Executive Of?ce of Health and Human Services Office of Child Care Services 15 Mulberry Street, Spring?eld, Massachusetts 01105 Date: AMENDED INVESTIGATION REPORT C01nplaint/Incident#: 20212 Facility 490096 Name of Facility: Frederick L. Chamberlain School Address: 3 Pleasant Street, Middleboro, MA 02346 I. Incident Summary AMENDED On May 10, 1999, the Of?ce received a mandatory incident report from the Frederick Chamberlain School in Middleboro regarding the alleged consentual sexual intercourse between a female resident and a staff person. The report alleged the following: year old resi dent (Child M) reported that on May 5, 1999 she had consentual '1 ?sexual intercourse with a male staff person (Staff Staff A has denied the allegations. The program has noti?ed and Staff A has been suspended until completion of pending investigations. II. Summary of Investigation Activity The case was assigned to this Investigator on May 7, 1999 and received on May 10. 1999. Note: This Investigator was assigned a case at the same facility involving the death of a child which took priority over this case. This Investigator also went on a two week vacation from June l~11, 1999 which further delayed completion of this case. An investigation was conducted between May 24, 1999 and June 16, 1999. An investigation occurred at the site on June 16, 1999. An entrance interview was conducted with the Clinical Director. The investigation brochure was not distributed because the site had received it several weeks earlier. The investigation activities included a review of program policies and procedures, a limited inspection of the dormitmy, and interviews with the Program Director, Staff B, Staff C, Staff D, and Staff E. Staff A had terminated employment with the program and was not available for an interview. The residents were not interviewed because they had been interviewed by the Investigator and the information was shared with this Investigator. Child A's record (incident reports) was brie?y reviewed. An exit interview was conducted I wwith the Clinical Director at the time of the visit. Additional investigation activities included extensive contact with the. Investigator and an attempt to contact Staff A via telephone. Summary of Findings 1. This Investigator learned the following information from the - Investigator. Interview with Child A: Child A reported that Staff A began talking to her in a sexually inappropriate manner approximately six months prior to the incident of sexual intercourse m. Staff A would discuss his own sex life and question Child A about her sex life with her boyfriend (Child B). Child A further reported that Staff A began touching her inappropriately prior to the incident, such as brushing his arm against her chest while_they were walking. Child A reported other inappropriate interactions with Staff A, such as being slapped, punched, and kicked by Staff A as well as other horseplay. Staff A also encouraged Child A (and other residents) to kneel on the floor with outstretched arms and say "Hail King (Staff up to twenty times. The relationship between Child A and Staff A became more intense after Child A Approximately a week or two prior to the alleged incident, StaffA and Child A engaged in consensual kissing and fondling. During the week before the incident, Child A stated that Staff A attempted to put his hands down her pants while in the laundry room, but she stepped him because she was menstruating. Child A described the incident in question. Child A stated that she had planned to have sexual intercourse with Staff A but a staff scheduling change occurred which presented a better opportunity. Child A reported that Staff A entered her bedroom t? and woke her up between 11:30 pm. and midnight. Staff A indicated that he wanted to have sexual intercourse. Child A told him that she was mensturating, but Staff A stated that he did not care. Child A and Staff A entered the staff room where they had sexual intercourse on the bed. Staff (second overnight staff) was resting downstairs at that time with a headache. Child A reported that the sexual intercourse occurred for approximately twenty minutes. Staff A next made a telephone call to his live?in girlfriend. At approximately 1 :00 am, Staff A and Child A entered the laundry room and had sexual intercourse a second time. Child A estimated that they were in the laundry room for approximately thirty minutes. Staff continued to be downstairs while this was occurring. Child A went to bed after the completion of the second act of sexual intercourse. Interview with Staff A: Staff A admitted that he engaged in two acts of sexual intercourse with Child A on the evening 0. Staff A stated that Child A is eighteen years old and the sex was consensual. Staff A did not perceive Child A as a disabled person because she will shortly be graduating from the program and has plans to be hired as a nanny. Staff A also admitted to acts of horseplay which included slapping and kicking Child A in a playful manner. Staff A denied hitting or kicking Child A in a hurtful manner. Staff A admitted to other horseplay, such as wrestling with Child A during recreational trips. Staff A reported that the "Hail King? thing was his invention and described it as a joke. Staff A denied any favoritism on assigning points to the residents. interview with other residents Child B. Child C. Child D. and Child Several residents (Child B, Child C, and Child D) stated that they observed ?irting behavior and inappropriate sexual discussion between Staff A and Child A. Child recalled hearing Staff A telling Child A that "she had an awesome body" and "he wanted her? sometime around Residents also con?rmed that this behavior intensi?ed after Child Child and Child reported that Staff A spent alot of time alone with Child A in the laundry room and room time after the? vacation. Five residents reported observing the "Hail King" behavior by Child A to Staff A. One resident reported that Staff A would have a ?power thing? where he would require Child A to do between ten and twenty "Hail Kings" in order to get a cigarette. Three residents (Child B, Child C, and Child E) reported that Staff A was unfair in the manner in which level points were given to residents. Child stated that Staff A would unfairly subtract points from him (punishment) because of his relationship with Child A. Child stated that she would get points from Staff A which she did not deserve and believed it was done so she would not disclose her knowledge of the relationship between Staff A and Child A. Interview_with staff: Staff was the second staff on the overnight shift Staff .initially stated that she had gone downstairs for only fifteen minutes on the evening in question. Staff later amended her statement to say that she had stayed downstairs for approximately two hours because of an allergy-related headache. Staff stated that she had been contacted by Staff A when the allegations first came forth and he requested her to say she was only downstairs for ten to ?fteen minutes. Staff admitted that she initially lied to administration, but later decided to be truthful. Staff reported that she was downstairs from around midnight to 2:00 am. StaffB stated that most of the room checks were conducted by Staff A on that evening. Staff is the Head House Parent for the dormitory where the incident occurred. Staff reported observing no unusual behavior from Staff A before the incident occurred. Police investigation: The Middleboro Police Department conducted an investigation into this incident. The investigation resulted in no charges being brought against Staff A because the girl (Child A) was of age and the sex was consensual. The case has been closed pending ftutlier information that would warrant reopening the case. 2. This Investigator interviewed the Program Director to get an overview on policies and procedures. The dormitory in question has ten female residents. There are currently two awake staff timing the overnight shift. This is a relatively recent change in staf?ng. There previously was one awake staff person and one asleep staff person assigned to the shift. The staff normally conduct fifteen minute room checks which are documented in a log. Staff werk out their own schedule on how these room checks occrn between two persons. The overnight staff also calculate the student points for the following day. There is an overnight administrator who ?oats between the dormitories and makes unannounced visits to determine whether overnight staff are following procedures and/or need assistance. This Investigator questioned whether there are any rules speci?c to male staff supervising female residents. The Program Director stated that a female dormitory must always have a female staff person on shift. The female staff person can be located anywhere in the building. Male staff persons are allowed to be alone with residents on the floor. Male staff are allowed in female bedrooms for room checks, etc. Gender appropriate staffing occurs for such things as toileting, showering, and dressing. The Program Director stated that horsepiay between staff and residents is not allowed. Staff are also not allowed to engage in kissing and frontal hugs. The Program Director stated that some of this information is contained in "Behavioral Guidelines for Employees" and more detailed information is given during boundary training for staff. The boundary training is not mandatory for staff, but staff are encouraged to attend this training. The Program Director stated that she has responded to the incident by increasing training on boundary issues and child supervision with the overnight staff. The agency is considering other areas of corrective action, such as the use of technology to monitor staff/student interactions. 3. This Investigator interviewed Staff B. Staff admitted that she violated program policy by being downstairs for two hours during the overnight shift. Staff stated that she had limited interactions with Staff A prior to the incident because she had only worked with him when he was an asleep staff. Staff stated that she never observed an inappropriate interactions between Staff A and any of the residents. 4. All staff interviewed consistently reported never observing any inappropriate interactions between Staff A and any female residents, inclusive of Child A. Staff described Staff A as hard-working, cheerful, and responsible. Some staff described StaffA as occasionally being ?silly? with residents. Two staff observed residents doing the "Hail King? to Staff A, but felt it was only a joke. No staff reported knowledge of Staff A being unfair with the behavior management point system. No staff reported ever receiving a complaint regarding inapprOpriate interactions by Staff A from any other resident or staff person. Several staff reported thinking that Staff A spent alot of time alone with Child A on the second floor doing chores on the week of the incident. Staff stated that they did not think anything unusual at the time, but now realize in hindsight that this may have given Staff A an opportunity to engage in sexualized contact with Child A. 5. This Investigator reviewed the overnight shift log for~ The shift log did not document the names of the staff assigned to the shift. The log documented that ?fteen minute room checks occurred during the entire night. The log does not show which staff person (Staff A or Staff B) conducted each room check. There is reason to believe that documentation of room checks between midnight and 2:00 am. was falsified based on information gained during the staff interviews. 6. This Investigator reviewed Staff A's record. Staff A was hired as a house parent The employee record showed evidence of an application, three telephone reference checks, and a completed criminal record check. A review of the training sheets showed training in Residential Staff Meetings, Adoption, Restraint, Diabetic Management, Working with Parents, Effective Behavioral Management Techniques, Van Safety, Policy and Procedures, Medication Review, and Universal Precautions. There was no training documented in boundary issues. There were no disciplinary action or supervisory concerns documented in the record. 7. This Investigator reviewed an incident report written by Staff B. Staff wrote that she went downstairs to take an aspirin and tea for her headache. She wrote that she stayed downstairs until around 2:00 am, went upstairs to check on the residents, went back downstairs shortly thereafter, and went back upstairs around 5:00 am. Staff 13 wrote that it was "poor judgement? on her part and she was "embarrassed and ashamed". 8. This Investigator noted that the program staff responded appropriately to the incident when it was ?rst disclosed by Child A. A child care worker received the disclosure from Child A and immediately forwarded the information to her supervisor (Staff C). Child A was taken to the Morton Hospital Emergency room for an examination. Staff A was intercepted when he arrived at work, informed of the allegations, and suspended from working with the residents. Notification of the incident was made to Child A's parents, the Middleboro Police Department, and this Of?ce. Staff was questiOne by Staff and asked to make a written report about the evening. It should be further noted that the program took these steps even as they were dealing with the tragic death of a resident in an automobile accident. IV. Non-compliances ESee attaclnnent. Investigator: Judy Pasko Complaint Number: Program Information: Program Program Name: Statement of Non-compliance 20212 Tel: 5089477825 490096 Chamberlain International School 3 PLEASANT ST MIDDLEBORO, MA 02346?1 101 Date of Report: 3/ 2/ 2000 Licensee Information: Tel: 5089477825 1400330 Chamberlain International School Licensee ID: Licensee name: 1 PLEASANT ST MIDDLEBOROMA REGU LATION 3.01 3.04(03) 3.07{01) STATEMENT OF NON-COMPLIANCE PLAN (Describe how, when and by whom, iDate correction has been I will be made. Please be ispecific] Through interviews and a review of written documentation, it was learned that the program does not have adequate policies and procedures to protect female residents from mate staff persons. Thr0ugh interviews and a review of written documentation, it was learned that the overnight log did not show which staff persons made the entries- The overnight log also inaccurately documented bed checks that did not occur. AMENDED: Through interviews and a review of written documentation, it was learned that a staff person engaged in consentual sexually intercourse with a resident in the program. The staff person admitted to engaging in two acts of consentual sexual intercourse with a resident under his so ervision during the evenings staff person also engaged in other inappropriate interactions with this resident, such as slapping her in the face and kicking her in the buttocks. A second . This same? staff person admitted that she failed to follow program procedures by spending the majority of the evening? ?downstairs instead of supervising the residents on the second floor. Print Date: 98012014 iThreugh interviews and a review of written idocumenie?en, it was learned that a staff person did inst consistently follow the program's behavior i imanagemenl system. Residents reported that this i istaff person would take away points unfairly for residents he did not like and give points unfairly to iresidents he chose to favor. Judy Pasko Licensing Specialist I have reviewed the above non-compliances and have speci?ed my plan and date of correction for each non-compliance. LICENSEES SIGNATURE: DATE: Print Date: 913N2014