DISABILITY LAW CENTER INVESTIGATION REPORT
CHAMBERLAIN INTERNATIONAL SCHOOL – MIDDLEBORO, MA
I.

Introduction

The Disability Law Center (DLC) is a private, non-profit organization which is
designated to provide protection and advocacy (“P and A”) services to individuals with
mental illness, pursuant to a congressional mandate under the Protection and Advocacy
for Individuals with Mental Illness Act (PAIMI), 42 U.S.C. §§ 10801 et seq.; protection
and advocacy services to individuals with developmental disabilities, pursuant to the
Protection and Advocacy for Individuals with Developmental Disabilities Act (PAIDD), 42
U.S.C. §§ 15043 et seq.; protection and advocacy services for individuals with
disabilities who do not qualify for services under either the PAIMI or the PAIDD
Programs, pursuant to the Protection and Advocacy of Individual Rights Program of the
Rehabilitation Act of 1973, (PAIR), 29 U.S.C. §§ 794e et seq.; and for individuals with
traumatic brain injury, pursuant to the Protection and Advocacy for Individuals with
Traumatic Brain Injury (PATBI), 42 U.S.C. § 300d-53. Pursuant to these federal
mandates, DLC is authorized to investigate incidents of alleged abuse and neglect of
people with disabilities throughout the Commonwealth of Massachusetts.
In May 2015, DLC received a complaint from a parent of a student, as well as a
videotaped complaint by the student, regarding the treatment of students at the
Chamberlain International School (CIS, Chamberlain or the School), located in
Middleboro, Massachusetts. Soon thereafter DLC also received a complaint from a
former student alleging additional concerns at the school. After interviewing these
individuals and reviewing records that were provided, DLC contacted CIS and informed
them that DLC had received a complaint to the system and requested to visit the School
and speak with staff and students during this visit to investigate the serious allegations
that had been made. DLC explained its legal authority to visit the campus to interview
staff and students pursuant to these Protection and Advocacy Laws. DLC’s letter to CIS,
dated May 11, 2015, sought to visit the school on Friday, May 15. There was a series of
communications between DLC and CIS about whether CIS would allow DLC to visit the
school to commence its investigation, but DLC’s efforts to obtain access to the campus,
staff and students through direct negotiation were ultimately unsuccessful. DLC filed a
lawsuit in federal district court, seeking a preliminary injunction ordering the school to
provide DLC access to conduct its investigation. The suit alleged that the refusal of CIS
to afford DLC access to conduct interviews of students and staff at the school

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 improperly prevented DLC from being able to fulfill its federal mandate to investigate
allegations of abuse and neglect of people with disabilities.
II.

BACKGROUND

After the suit was filed, the parties entered an initial agreement whereby CIS
would allow DLC to begin its investigation with a visit to the campus on June 12, 2015.
On that date, school staff gave DLC a tour of the campus of the school, but the parties
could not reach agreement concerning DLC’s request to interview students enrolled in
the school. After much discussion and debate about whether DLC could conduct
student interviews, CIS then agreed to allow student interviews to begin on July 13,
2015. After the first day of interviews, there was further discussion and debate
concerning the timing and manner of additional student interviews. Ultimately a second
and third day of student interviews occurred on July 27 and July 28, 2015. In total, DLC
conducted interviews of 43 students. DLC also conducted approximately a dozen
interviews of CIS staff on July 20, 21 and 23, 2015. At the same time, in response to
DLC’s request, CIS provided contact information for existing students at the school. On
July 31, 2015, using the contact information provided by CIS, DLC sent a letter to each
of the families of students explaining the nature and scope of the investigation and
asking families whether they had any information, positive or negative, that they wished
to share with DLC. In response to that letter, many families did contact DLC and shared
information about their experiences with the school. Some families expressed real
satisfaction with the school, while others were quite critical of the school. Over the
course of its investigation, DLC spoke with 26 parents of current or former students, as
well as a half dozen former students.
Throughout the fall, there was much discussion and debate concerning DLC’s
access to student records. In late September, DLC made the requisite procedural
finding under the federal PAIMI regulations, which established the basis for DLC to seek
records of certain students at CIS. A process was ultimately agreed upon by the parties
and in December, DLC sought the records for twenty students, which CIS did provide.
The School had sought an opportunity to meet with DLC staff in order for CIS to
be able to explain, rebut, or put into proper context any concerns that DLC may have as
a result of their investigation. In advance of that meeting, DLC provided the school with
a list of issues of concern and provided the names of student exemplars. On June 21,
2016, CIS staff and their counsel came to DLC and had an opportunity to respond to the
concerns that had been identified to date. Counsel for CIS also asked that some of the
initial allegations received by DLC that had been cited in the original federal court
complaint that had not been substantiated be corrected in the pending federal court
complaint. DLC agreed to amend its complaint to reflect the fact that the substance of
some of those initial allegations had not been substantiated and that DLC was
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 continuing to investigate other allegations concerning the school. A second discussion
of DLC’s identified concerns occurred on August 4, 2016 with Chamberlain and its
counsel.
III.

LEGAL AUTHORITY

Protection and Advocacy systems, such as DLC, have express authority under
the Protection and Advocacy laws to gain broad access to records, facilities and
residents to ensure that vulnerable individuals with disabilities are afforded access to
protection and advocacy services. DLC, as the designated Protection and Advocacy
System for Massachusetts, is authorized under the PAIMI statute to “investigate
incidents of abuse and neglect of individuals with mental illness if the incidents are
reported to the system or if there is probable cause to believe that the incidents
occurred.” 42 USC § 10805(a)(1)(A).1 As noted above, this investigation was
commenced based upon a “complaint to the system.”
The PAIMI regulations define the terms “abuse” and “neglect” as follows:
Abuse means any act or failure to act by an employee of a facility rendering care
or treatment which was performed, or which was failed to be performed,
knowingly, recklessly, or intentionally, and which caused, or may have caused,
injury or death to an individual with mental illness, and includes but is not limited
to acts such as: rape or sexual assault; striking; the use of excessive force when
placing an individual with mental illness in bodily restraints; the use of bodily or
chemical restraints which is not in compliance with Federal and State laws and
regulations; verbal, nonverbal, mental and emotional harassment or any other
practice which is likely to cause immediate physical or psychological harm or
result in long term harm if such practices continue.
42 C.F.R. § 51.2.
Neglect means a negligent act or omission by an individual responsible for
providing services in a facility rendering care or treatment which caused or may
have caused injury or death to an individual with mental illness or which placed
an individual with mental illness at risk of injury or death, and includes but is not
limited to acts or omissions such as failure to: establish or carry out an
appropriate individual program or treatment plan (including a discharge plan);
1

As noted above, this investigation was initiated under PAIMI, PAIDD, PATBI and PAIR. Although the substantive
provisions of these laws are substantially the same, some of the procedural aspects concerning investigations (e.g.,
the particular methods and requirements for obtaining parental or guardian consent) vary among the various P
and A programs. Counsel for CIS argued that PAIMI was the most applicable statute. Without conceding the
correctness of that position, but in order to avoid further delay and move the investigation forward expeditiously,
DLC agreed to follow the PAIMI requirements.

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 provide adequate nutrition, clothing, or health care; and the failure to provide a
safe environment which also includes failure to maintain adequate number of
appropriately trained staff.
42 C.F.R. § 51.2.
IV.
A.

Factual Findings

Serious Self-Injurious Behavior

DLC originally received complaints in May of 2015 that the Chamberlain School
failed to provide students with medical attention after a suicide attempt. While DLC did
not find evidence to validate this allegation, DLC did find evidence to support a finding
of neglect on Chamberlain’s part to prevent and properly respond to student suicide
attempts or other acts of serious self-injurious behavior. Under the federal regulations
cited above (page 3), neglect includes acts or failures to act by a caretaker that put
students with mental illness at risk of injury or death. See 42 C.F.R. 51.2.
Chamberlain states on its website that it provides “comprehensive and intensive
therapeutic programming.” DLC acknowledges that many of the students at
Chamberlain have complicated needs and profiles. However, that is precisely the
reason why many of them are attending Chamberlain. DLC did speak to some parents
who felt their child did well at Chamberlain, and DLC reviewed the records of one
student who appeared to do well at the school. This student had previously been in a
more restrictive setting, and seemed to attend Chamberlain without any notable
incidents. Nevertheless, DLC found that Chamberlain had actual notice that these
students in the examples below had histories of self-injurious behavior, suicidal ideation
and in some cases, past suicide attempts. Further, with many of these students, they
had expressed suicidal ideation to Chamberlain staff before their attempt. As
described in the examples below, some students used the very same means for
attempts multiple times.
There have been multiple suicide attempts at Chamberlain in the past year and a
half. Many students told DLC they were concerned about students jumping out of
windows. According to the school, their “close watch” policy is a “heightened level of
supervision in response to a student expressing feelings of self-harm.” This plan is for
students who do not meet the level of need for the “at risk” of suicide policy, but still
need heightened supervision due to self-injurious threats or actions, symptoms of
depression or even health issues. If a student is put on “close watch,” protocols include
having staff keep the student in sight, conducting increased bed checks at night, and
keeping bathroom breaks short and having staff monitor outside the door. This is
different from Chamberlain’s “at risk” plan which is a higher level of supervision and
concern for a student who is at risk of suicide. Under this plan, the protocols include the
following: students receive a heightened level of care including supervision by direct
care staff at all times, being searched for dangerous materials, not receiving access to
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 cleaning materials, and not allowing the student to lock or fully close the bathroom door.
Chamberlain also has an internal investigation protocol that states the school “conducts
internal investigations of any serious incident involving health and safety of students.”
Student 1
One student jumped out of a second story dorm bathroom window after asking
staff to take a shower. This student had a history of previous suicide attempts and
suicidal ideations, including one where the student received treatment after jumping off
buildings into the snow. This student had also previously tried to jump off the second
floor of a residence at Chamberlain, but was prevented by staff. In the incident in
question, the student sustained serious injuries after the jump out of the window and
required treatment at a Boston hospital. The student never returned to Chamberlain
following this incident.
Chamberlain informed DLC that they do not characterize this incident as a suicide
attempt because the student jumped into a pile of snow and reportedly told staff he or
she2 thought the snow was deeper. While DLC understands that position, a review of all
the circumstances, both before and after the jumping incident, causes DLC to conclude
that in fact this student’s actions were an attempt to cause serious self-harm. Review of
the student’s file revealed that this student had a history of suicidal ideation before
attending Chamberlain. In addition, other events that happened at Chamberlain leading
up to this incident, and the treatment the student received at other facilities after this
jumping incident, makes DLC conclude that the view that this incident was not an
attempt at serious self-injury is not correct.
Based upon review of the student’s records, DLC found that the student had a past
history of several suicide attempts, including at Chamberlain prior to this incident where
the student ingested shower products while in the bathroom, and in another incident
attempted to wrap a cord around his or her neck then ran from staff stating he or she
was going to jump over the balcony on the second floor of the residence. The student
then expressed to staff that he or she wanted to be hospitalized. Further, one and half
months before this window jumping incident, the student left a suicide note that was
found by staff. The student was placed on “close watch” after staff discovered the note.
The student also requested to go to the hospital after this incident. Residential notes
reflect the student then expressed feeling hopeless and expressed suicidal ideation.
Six days before the student jumped out of the window, the student told staff that he or
she should just die. Five days before the incident, the student again told staff that he or
she did not want to live anymore. DLC did not find any documentation that the student
was placed on close watch after making these comments. Lastly, the hospital where
the student was treated after the incident found the student needed care and an
inpatient stay after being medically cleared. As a result, DLC finds it concerning that
the student was not assessed as a suicide risk. According to the review of the records,
Chamberlain did notify EEC of the incident, but DLC did not find any record that EEC
2

In order to protect the students’ privacy, DLC has made all references without identification of the students’
gender.

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 investigated this incident. DLC did not find records that Chamberlain conducted an
internal investigation following this incident.
Student 2
Five months after the above incident, another student jumped out of the very same
bathroom window as the student in the example above. This student also had a history
of self-injurious behavior and suicidal ideations, including some while at Chamberlain.
DLC found in the student’s records that one of the student’s outside providers wrote a
letter stating this student requires constant supervision to ensure the student’s safety.
However, DLC only found one time that the student was placed on “close watch” status,
and this was more than a year before the jumping incident. DLC was not able to find
the “close watch” plan in the student’s file, only notes in the residential log and school
log that report the student was on “close watch” status. It is not known from the records
why the student was placed on “close watch” at that earlier time. There were several
incidents of suicidal ideations and self-harm attempts where the student was not placed
on “close watch.”
The day this student jumped, he or she had multiple outbursts earlier that same
day. In their notes, staff described the student as very emotional that day. Despite
these facts, DLC finds it concerning that DLC was unable to find any note that the
student saw his or her therapist on the day he or she jumped, nor was DLC able to find
documentation that the student was placed on “close watch” status. The student also
left a suicide note in the bathroom before jumping out the window. This student was
transferred to a Boston hospital by medical helicopter following this incident and
sustained serious, lifelong injuries. Again, a record review reflects that Chamberlain did
notify EEC of the incident, but DLC did not find any record that EEC investigated this
incident. DLC also found that Chamberlain notified DESE of this incident. Notes by
staff indicate that only after this second incident did Chamberlain adjust the window
opening. DLC did not find records that Chamberlain conducted an internal investigation
following this incident.
The day this student jumped, he or she had multiple outbursts earlier
that same day. In their notes, staff described the student as very
emotional that day. Despite these facts, DLC finds it concerning that
DLC was unable to find any note that the student saw his or her
therapist on the day he or she jumped, nor was DLC able to find
documentation that the student was placed on “close watch” status.

Student 3
A student jumped off a second story fire escape at a residence while reportedly
being watched closely by staff. This student also had a past history of suicidal ideations
and hospitalizations. A couple of months before the student jumped, the student had
told staff that he or she was contemplating suicide. This student’s records show that his
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 or her team at Chamberlain met almost one month to the day before he or she jumped
to discuss his or her suicidal ideations. In this meeting, Chamberlain notes that the
student is unable to make any consistent progress recently due to ongoing emotional
crisis. Yet, despite these facts, the student was never placed on “close watch” status
the entire time the student attended Chamberlain. Under the School’s policies, it would
seem that having suicidal ideations would meet, at the very least, the close watch
standard discussed above -- if not the suicide “at risk” policy in such instances.
Additionally, three weeks prior to the jumping incident, this student had run away
from the school and was found by police. The student left the residence by using the
same fire escape from which the student later jumped. There was no alarm on the fire
escape at that time. The student was found by police and brought to the local hospital
after making suicidal comments to the officers. The local hospital sent the student back
to Chamberlain. The student was not placed on “close watch” status at that time.
In the day before the student jumped, the student’s parent had been calling staff
about concerns the student was accessing non-approved material on the internet
including social media sites. Even though this student was not on “close watch” status,
staff was reportedly checking on the student frequently leading up to the incident. If the
student had been on close watch status, staff would have been required to have the
student in sight at all times during the day and evening. Chamberlain’s internal
investigation references a video that reportedly shows staff checking on the student five
times in the 30 minutes prior to when the student jumped. Just prior to jumping, the
student reportedly called out to staff, who was in the TV room down the hall, saying he
or she was going to kill themselves by jumping. The staff member was reportedly too
far away to get to the student in time before he or she jumped. There was no alarm on
the fire escape door at this time. After jumping, this student was transported to the local
hospital for medical treatment before being transferred to a Boston area hospital for
further medical and treatment. This student sustained serious injuries.
Chamberlain investigated this incident and found that they provided appropriate
supervision and that they did not have any warning the student would jump. There was
no corrective action plan issued. In addition to the concerns that the student was never
placed on “close watch” and that there was no alarm on the fire escape door, it is
concerning to DLC that staff notes did not address the fact that the student attempted
suicide, but instead state that the student was transported to the hospital due to being
upset about the denial of social media access and not leaving the program. DLC feels
this minimizes the seriousness of the issue. EEC investigated this incident and found
that there were no regulatory issues and no remedial plan needed.
Other Incidents
Student 4
Another student ingested bleach and was transported to the hospital. This student
was upset and had originally put a bag over his or her head, but was stopped by staff.
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 After staff took the bag away, staff let this student go into the bathroom on his or her
own where the student was able to ingest the bleach. Significantly, this was not the first
time this student ingested bleach. About six months prior, the student had locked him
or herself in the bathroom and sprayed bleach into his or her mouth. It is particularly
concerning that this student had previously used bleach to self-harm and that the school
had not established more specific protective measures such as ensuring that cleaning
products like bleach were removed, or that such products were securely locked away
from the students. This student had also previously attempted to jump out a window at
the school, but was stopped by staff.
Student 5
Another student ran from campus and jumped into a river nearby while repeatedly
saying “goodbye” to staff who were nearby. This was the second incident in a couple of
weeks involving this student attempting to jump or jumping into the river. In the first
incident, the student went out of a bathroom window in the residence and made it to the
river before staff was able to stop him or her from jumping in. The student was
hospitalized after this incident and, when he or she returned to campus, Chamberlain
did not create a written plan to help prevent future incidents. The student then left the
residence within a week of returning to campus and did jump in the river this time.
Although a staff person jumped into the river to attempt a rescue, it was not successful.
The student had to be rescued by the Fire Department by boat. EEC did investigate
this series of incidents and found non-compliance.3 EEC found that Chamberlain
subsequently responded to each of the compliance issues satisfactorily.
Student 6
There are many examples where Student 6 made self-harm or suicidal threats
over the weekend but then was not assessed by a clinical staff until Monday. As
Chamberlain explained to DLC, clinicians only work typical school hours. There is an
on duty residential supervisor and on call administrator that staff can call if they have
mental health concerns about a student. The on duty supervisor is not a clinician. The
administrator on call may be the clinical director, but is not always the clinical director.
The administrator on call can then make the decision of whether they should call the
psychiatrist to discuss hospitalizing a student. However, DLC rarely found records that
staff utilized the on call system, and often the non-clinical, residential staff were
addressing these mental health issues and sometimes incidents of serious self-injurious
behavior with the students before the students were assessed by a clinician the next
business day.
For example, there was one Saturday when Student 6 self-harmed even though he
or she was on “close watch” status. Student 6 then told staff that he or she needed help
due to mood swings he or she can’t control and that the student felt he or she needed
3

This incident is discussed in more detail in the “Inadequate Supervision” Section, IV,B.

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 more support to be safe. Then, the following day on Sunday, despite being on “close
watch” status, the student attempted to choke him or herself, and said he or she wanted
to die. The student was not sent to the hospital on either day, and records show the
student did not see his or her therapist until Monday. DLC did not find records that the
on-call administrator was called. Another time, the student told staff he or she was
suicidal and needed to go to the hospital. Staff did not send the student to the hospital,
DLC did not find records that an on-call administrator was contacted, and the student
was not assessed by the therapist until the following Monday which was a full two days
after this incident.
As part of Chamberlain’s self-injury plan and policy, they keep sharp objects such
as knives and scissors locked up. However, this student was repeatedly finding broken
glass under the residence deck or surrounding the residence. This student then would
use the glass to self-harm. He or she had 37 documented incidents of self-harm while at
Chamberlain and was hospitalized 13 times.4 This student had to go to the hospital six
times for stitches following self-injurious behavior, one time even receiving eleven
stitches. DLC also found a pattern with this student where he or she would tell staff
they needed to go to the hospital, staff would not send him or her, and then an incident
would occur and the student would end up hospitalized anyway for harming him or
herself or others.5
DLC found this occurring in the student’s records several times. For example,
the student once required hospitalization after cutting him or herself with glass that
required six stitches, and ended up being hospitalized for seven days. The student had
told staff the day before this incident that he or she needed to go to the hospital.
Another time the student said he or she wanted to go to the hospital because he or she
wanted to kill themselves. Staff convinced the student to go on a field trip instead. Then
the student cut him or herself on the field trip. Staff requested immediate assistance
from a supervisor but were told to wait for word from management. The student later
talked to management and was taken to the hospital via ambulance where he or she
stayed for several days.
One day the student asked to go to the hospital as he or she was leaving
campus and going into the woods. Staff refused to discuss this until the student came
back to campus. The student then proceeded to walk into the woods until he or she
was 1 mile from campus and cut him or herself extensively on the arms, legs, hands,
feet and face. The student then reportedly attacked staff multiple times when they tried
to restrain him or her and bring the student back to campus. The student reportedly
punched, bit and attempted to choke staff. Chamberlain did not send the student to the
hospital after this incident, nor did DLC find records that the student was put on “close
watch” status. The residential notes from this date also note that the student had
4

This student did attend the school for many years. However, in one year alone, this student had sixteen
documented incidents when he or she cut themselves.
5 There were many other times the student requested to go to the hospital. We are not including every
incident, only ones that were serious and not assessed.

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 suicidal ideations. Then, about one week after this first incident, the student again
escalated and attempted to assault staff. It was not until after this second incident that
the student was sent to the hospital where he or she remained for twelve days.
Student 7
Another student was also frequently finding broken glass and other sharp
materials surrounding the residence. This student then would use the glass and other
objects to self-harm. This student, who has a long history of self-cutting, was left in the
bathroom for 20 to 30 minutes in two separate incidents that occurred within two weeks
of each other. In both incidents, a staff person was outside the bathroom the whole
time and suspected the student was cutting him or herself. Each time, this student had
cut him or herself repeatedly while in the bathroom. DLC did not find documentation
that the student met with his or her therapist following these incidents, or that the
student was put on “close watch” status.
Also, with many of these self-injurious occurrences, this student did not see his or
her therapist until the following day, similar to Student 6 in the example above. This
student put a seatbelt around his or her neck on two separate occasions while staff was
driving. A non-clinical staff person then “processed” with him or her. DLC did not find
any notes that the student talked to the therapist following these incidents. This student
also had an incident where he or she had a knife and then, later in the day, wrapped a
curtain around his or her neck. The student was not assessed by his or her therapist
until the next day. Another example is a day when staff noted this student was acting
strange. The student had poured shampoo all over the bathroom, self-injured, and was
found sitting on his or her bed with his or her hands covered in blood. There was blood
on the window sill in the bathroom. DLC did not find any records that an on-call
administrator was called, no record that the student was evaluated by his or her
therapist, and no record that the student was put on “close watch” status.
DLC did find records that show what had been an appropriate response by
Chamberlain. This student escalated one day and assaulted his or her teacher. After
the student calmed down, he or she met with his or her therapist, and put on “close
watch” status. The student also met with his or her psychiatrist two days later.
Chamberlain reports they created their policy related to self-injurious behaviors
with the help of a well-known expert. Part of this plan requires staff to ignore or not
overly react to a student’s self-injurious behavior in order to not provide the students
with the secondary gain or attention they are seeking.6 DLC understands this strategy,
but remains concerned about things such as the pervasive presence of broken glass
that is accessible on the campus. Chamberlain informed DLC that students who want to
find broken glass will find it and that sometimes it bubbles up from the ground from
6

Chamberlain reports it is their policy for staff to provide the students with first aid or a visit to the nurse if
needed.

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 years ago. Chamberlain also reported that when students break windows, maintenance
will clean it up immediately. DLC is concerned that Chamberlain appears to minimize
the nature or seriousness of the student suicide attempts by not classifying them as
suicide attempts. DLC understands that it is not possible to always prevent self-injury or
know the precise mindset of a student, but DLC is concerned that many of these
students are having serious self-injurious behaviors and suicidal ideations and not being
assessed by clinical staff. Instead, students are assessed by non-clinical staff if it is
after school hours or on weekends. It is also concerning to DLC that students were
having these behaviors and ideations and yet not put on “close watch” or even
assessed for “close watch.” An additional concern involves the failure of CIS to
establish or create an appropriate individual program or treatment plan to address these
significant needs for each student.
DLC understands that it is not possible to always prevent self-injury or
know the precise mindset of a student, but DLC is concerned that many
of these students are having serious self-injurious behaviors and
suicidal ideations and not being assessed by clinical staff. Instead,
students are assessed by non-clinical staff if it is after school hours or
on weekends. It is also concerning to DLC that students were having
these behaviors and ideations and yet not put on “close watch” or even
assessed for “close watch.”
B. Inadequate supervision enabling students to run away
DLC received complaints that, due to inadequate supervision of students by
Chamberlain staff, students had been able to run away from the Chamberlain School
campus, resulting in actual or potential harm to the students. DLC investigated this
allegation by reviewing the school records of approximately twenty students, talking to
students and parents, obtaining and reviewing records from the Middleboro Police
Department (MPD) and reviewing documents from the Department of Early Education
and Care (EEC). After completing its investigation, DLC found that there was a
significant number of instances of students being able to run away from the
Chamberlain School campus, validating the concern that there was inadequate
supervision of the students by CIS staff. The following examples illustrate the problem
of inadequate supervision resulting in a failure to provide a safe environment:




One student walked off campus and was found by staff at a traffic rotary, where
several major highways intersect, almost three miles away; the same student ran
away and was returned to the CIS campus by police; that same student ran away
from the School and into the street, where there were multiple cars coming; and that
same student, when on a school field trip in Boston, disappeared and was not found
for over three days;
One student ran into the woods and, after threatening to hurt staff, ran into the road.
Because the staff was not watching him or her, the same student managed to leave
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 

the CIS campus and, by hiding in a nearby barn, was missing from 4:30 pm until 11
a.m. the next day – the student was only found through the use of the police canine
unit and an amber alert; the same student had approximately 22 different incidents
where that student either ran into the woods, into the road, or to another location off
campus;
According to a state investigation and report, one student had climbed out of a
bathroom window and ran from the campus, but when staff went outside to look for
the student, they were unable to find the student for 20 minutes and called police for
assistance. One hour after the student left the building the student was found under a
bridge, next to a river. That student had taken off his/her shoes and was about to
jump into the water, when the student was stopped. The student was taken by
ambulance to a hospital for evaluation. The student was hospitalized for two weeks.
Less than one month later, when that same student was back on campus, he or she
refused to go to class, walked around the campus and wound up going into a
maintenance shed that had been left unlocked. Staff convinced the student to return
to school, but the student refused to go to class. The student ran from campus later
that day. Multiple police departments were called, and the student was found by the
police and returned to campus. Later that very same day, the student got away a
second time, ran down the road and into a nearby field, and towards the tree line at
the far end of the field, behind which is a river. That student was standing in the river,
dunking his/her head in the water and repeating “good bye.” The student began to
float down river towards the bridge, where the student was ultimately rescued by a
first responder in a kayak.
o After an investigation of the incident by EEC, a report was issued that
expressed a number of concerns about this incident, including: (a) it found
it concerning that despite the fact that the same student had attempted to
jump into the same river only sixteen days earlier, which resulted in a twoweek hospitalization, no safety plan was implemented to prevent the
student from leaving the campus or from heading toward the river upon
the student’s return to the school; (b) the agency also found disconcerting
that there was no general safety plan in place by which staff are informed
of geographic risk areas, such as the river; (c) staff who were monitoring
the residence on the day of the second river incident stated they were not
aware of any prior incident in which the student had attempted to injure
him or herself or attempted to jump into the river, despite the fact that the
student had only returned six days earlier from the hospitalization resulting
from the prior river incident; and (d) the absence of a preventative plan
authorizing staff to physically intervene was also a concern identified by
the agency. As explained by the agency, although attempting to reduce
restraints is admirable, when a resident’s pattern of behavior puts a
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student at risk of harm, a preventative plan must be in place. Once a
resident has attempted a particular methodology to self-harm, an
individual safety plan needs to be developed to protect that resident from
engaging in that particular behavior.
o CIS was directed to ensure that a team will identify residents’ needs and
develop individual service plans for meeting those needs, including safety
and behavior management needs. CIS was required to explain all service
plans and updates to all staff providing care to students and responsible
for implementing the service plan on a daily basis. CIS staff should also be
aware of the path of the river and woods and instructed to remain
cognizant of the potential risk of those areas to residents in emotional
distress. Subsequently CIS did respond satisfactorily to each of those
outstanding compliance issues.
One student ran out of the house, could not be located, so CIS called the police.
The student was not found for over 90 minutes; that same student ran out of the
house with another student and when the student was not found the police were
called, but the student was not located for 45 minutes; the same student ran out
of class, into the woods and when the student was found the student had multiple
scratches due to briers in the woods; the same student ran out of the house, CIS
staff searched for him or her in a vehicle and he or she was found later heading
north on Route 18; on a different day that same student rode off on his or her
bike away from his or her 1:1 aide and onto Route 495. After the student was
missing for 20 minutes CIS called the police who found the student three hours
later.
One student ran out of the residence a significant number of times, at least 12 of
which involved leaving the residence and going either into the woods, the road, a
field, another building on campus or to a van where the student locked him or
herself inside of the vehicle. One student ran from the school and was AWOL for
a day.

When DLC discussed the issue of inadequate supervision which allowed
students to run away from the CIS campus, the School responded that it was the
unfortunate consequence of having an open campus. The school further suggested that
they would be unable to physically restrain a student from leaving the campus, even if it
might result in the student getting into harm’s way. While one can certainly appreciate
the challenges presented by having an open campus in such a setting, where woods,
fields and a river are nearby, the pattern of multiple escapes and runaways, particularly
with respect to certain students who have exhibited such patterns repeatedly, imposes
upon the school the obligation to take reasonable and effective protective measures. As
13

 EEC has noted in its report, when a resident’s pattern of behavior puts a student at risk
of harm, a preventative plan must be in place. After a resident has attempted a
particular methodology to self-harm, an individual safety plan needs to be developed to
protect that resident from engaging in that particular behavior. As further noted by the
licensing agency, if staff members were not made aware of prior similar actions done by
a student, then the school has failed in its obligation to keep its staff informed of such
essential information. The failure to establish and maintain an adequate level of
supervision and undertake effective steps to reduce or eliminate such risks results in an
unsafe environment for students, exposing those students to actual or potential harm.
This constitutes “neglect” under the PAIMI regulations.

The failure to establish and maintain an adequate level of supervision and
undertake effective steps to reduce or eliminate such risks results in an
unsafe environment for students, exposing those students to actual or
potential harm. This constitutes “neglect” under the PAIMI regulations.

C.

Medication Issues

DLC received allegations about medication errors and the improper administration of
medication. DLC first received such complaints in May of 2015, and then subsequently
received additional complaints during the course of its investigation. DLC investigated
this by reviewing twenty student records and talking to over two dozen students and
parents. After completing our investigation, DLC found several errors in administering
or failing to administer medication to students. DLC would note that Chamberlain does
administer a lot of medication to over 100 students without any error7, however, the
errors that DLC found are concerning for student health and safety. Remedial action is
necessary to prevent similar issues in the future, and as noted below, some
improvements are already underway. Here are some examples of medication errors
that were found:
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7

One student was mistakenly not given his or her anti-depressant medication for
over two months. This was only discovered after the student required
hospitalization following the two months without medication. It was determined
that the pharmacy failed to send the medication to Chamberlain. Chamberlain
reports it added additional procedures and safeguards after this incident.
One student was found unresponsive and sent to a local hospital before
transferring to a hospital in Boston for four days. It was discovered the student
had a strong anti-psychotic medication in his or her system that had not been
prescribed for that student. It is unclear how the student got this medication,

Chamberlain reports that it has an overall 0.01% error rate in administering medication.

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however there was at least one student in the school who was taking this
particular medication at that time.
One student was mistakenly given his or her dose of medication twice within 30
minutes. One staff person administered the medication early but failed to note
that he or she had done so. After the shift change, another staff person
administered the medication at the regular time not knowing the student already
received the dosage since the prior administration of medicine had not been
documented. The student then became extremely tired, was seen by the school
nurse, and was sent to the hospital.
One student received four times his or her prescribed dosage of psychiatric
medication seven times in a three week period. The student was originally
receiving three pills at 25 mg (75 mg total). The doctor then increased the
dosage to one, 100 mg pill. Some staff however continued to think that the
student was getting 25 mg pills due to an error on the medication administration
record and thus gave the student four, 100 mg pills in error. This added up to a
total of 2100 mg of extra medication that was mistakenly administered to this
student.
One student was sent home for a school break without any medication including
seizure medication. The student realized this several days into the vacation after
reportedly having a seizure and notifying Chamberlain.
A different student was also sent home for a break without his or her medication.
Another student was sent home for a school break with the wrong medication.
DLC found notes in several students’ files where medication was not available for
several days.

In response to concerns about the medication errors, Chamberlain has taken a
number of remedial steps. Chamberlain has informed DLC that it has decided to hire
additional nurses to administer medication on nights and weekends. Chamberlain
reports its intent is to only have licensed nurses administer medication instead of lay
staff and reports that it has already posted advertisements for these jobs and started
interviewing candidates. Chamberlain also made a staffing change and is set to have a
new Director of Nursing start in September. Once this new nurse starts, Chamberlain
plans to review its staff training procedures, packaging of medications and other
protocols. DLC believes these steps will help avoid future mistakes and errors.
D.

Bullying

One of the recurring complaints DLC found during its investigation was peer on
peer bullying. DLC found evidence of this in student records and also received
complaints about bullying from multiple students and parents. Massachusetts
regulations define bullying as follows:
the repeated use by one or more students of a written, verbal or electronic
15

 expression or a physical act or gesture or any combination thereof, directed at a
target that:
(a) causes physical or emotional harm to the target or damage to the target's
property;
(b) places the target in reasonable fear of harm to himself or herself or
damage to his or her property;
(c) creates a hostile environment at school for the target;
(d) infringes on the rights of the target at school; or
(e) materially and substantially disrupts the education process or the
orderly operation of a school. Bullying shall include cyberbullying.
603 C.M.R. § 49.03
DLC found extensive documentation that one student repeatedly reported to staff
that he or she was bullied. This happened over several months before the records
show documentation that staff met with this student to discuss the bullying. The student
first told staff that other students were constantly making derogatory comments to him
or her. Then three days later the student reported to staff that he or she was being
bullied. Four days after that, the student told staff he or she continued to be bullied at
school. Two days later, this student told staff he or she was anxious because he or she
continued to be bullied at school and other students were spreading rumors about him
or her. The next day, the student’s parent called Chamberlain about this bullying. A
few weeks later, staff noted that the student was on the phone with his or her parent
and was crying telling the parent that other students were calling the student names and
saying he or she was the ugliest person on campus. Two days after that phone call, the
student told staff that a particular student was targeting him or her. Six days after that,
the student reported that the same student was targeting him or her and telling people
not to be friends with him or her. The following day, the student reported to staff that
this same student called the student derogatory names in class. Five days later, staff
note that other students were writing mean things about this student on a school table.
The next day the student again reported that the students were again bullying him or
her and stole his or her hat at lunch. It was only at this point, almost two months after
initially reporting the bullying, that the records reflect staff finally sat down with this
student to address the bullying.
DLC finds that Chamberlain did not follow the Massachusetts anti-bullying law
and regulations in the above instance. DLC found records that staff reported these
reports of bullying to a supervisor in one of the instances explained above. DLC did not
find records that they were reported in the other instances. Chamberlain’s bullying
policy requires that all reports of bullying should be made to the Program Director.
Further, its policy requires that staff “report any rumors of bullying.” (Emphasis in
original). Staff are also required to complete a written incident report if they receive
information about bullying or witness bullying. DLC did not find any records that these
instances were investigated to determine if bullying had occurred and, if so, what the
school could do to stop it and what services they could offer to help the student. These
16

 are all required actions under the Massachusetts anti-bullying law, which states that
schools must promptly report and investigate reports of bullying.
DLC also reviewed two other students’ records where it found dozens of bullying
incidents where these two students were the bullies, but did not find any bullying
investigations or any specific plan to address and reduce these behaviors.
Another student reported that he or she was continuously bullied by one student
in his or her residence. This bullying reportedly included statements with anti-Semitic
slurs. The student reported this to staff, yet felt staff did not do anything to stop the
bullying. The student was then physically attacked and had to change residences after
this incident. When these incidents were raised with a Chamberlain administrator, he or
she reportedly said that the alleged victim had started the fight. In this case, the
reported incident would qualify as both bullying under Massachusetts law and
discriminatory harassment under federal law.
DLC found many other examples of bullying at the school. Here are additional
examples:
 One student had three classmates put feces on his or her pillow. The student
reported to staff that these three classmates had been picking on him or her.
This same student was later physically assaulted by other students twice in
one week. This student reported he or she had to move residences more
than once due to bullying.
 Yet another student had over twenty concerning bullying incidents as
recorded by staff. The student was choked by one peer, and the same peer
also made multiple threatening comments to the student. This student was
often the target of physical attacks by peers, was slapped by peers, and
verbally targeted by peers. The student’s parent even reported to staff that
other students were making anti-Semitic comments while the parent was
there on a visit. The student reported to staff that he or she was being
bullied, but DLC could not find evidence of follow up by the school. Further,
there was no evidence in this student’s file that Chamberlain ever conducted
a bullying investigation.
 One student was repeatedly called fat by classmates. This student had a
history of being bullied at his or her previous school. The student later saw
graffiti in the bathroom discussing him or her. The student’s parent also
contacted Chamberlain staff to report his or her concerns that their child was
being bullied. Records show that this student spoke to his or her therapist
about the bullying and that the therapist encouraged the student to ignore
the other students as a coping mechanism. DLC did not find any records of
a bullying investigation by Chamberlain.

17

 Since there are a significant number of concerning incidents and no record of
investigations having been done, DLC finds Chamberlain’s lack of response to such
bullying constitutes a failure to provide a safe environment and thus meets the definition
of neglect under the PAIMI regulations. Further, DLC finds that Chamberlain did not
follow Massachusetts law related to bullying both in their actions and policy.
Chamberlain must broaden its view and definition of what
constitutes bullying, aligning it with Massachusetts law and take
timely and effective proactive and remedial actions to stop
bullying on its campus.
DLC did discuss its bullying concerns with Chamberlain. Chamberlain
responded that they do have an anti-bullying policy, but that many of these incidents
were not bullying because there was no imbalance of power between the students.
Chamberlain’s written Bullying Policy also reflects this narrower view of what constitutes
bullying, citing an imbalance of power. As made clear by the regulatory definition of
bullying cited above, Chamberlain’s much narrower construction of bullying is not the
full scope of what constitutes bullying under Massachusetts law. Chamberlain must
broaden its view and definition of what constitutes bullying, aligning it with
Massachusetts law and take timely and effective proactive and remedial actions to stop
bullying on its campus. In addition, Chamberlain’s bullying policy states that “the
administration will investigate all reports/complaints where appropriate.” DLC finds this
part of the policy is too broad. There is no definition of when a complaint is appropriate
and this gives the administration too much discretion about whether they have to
investigate a bullying allegation. As described above, this has resulted in no bullying
investigations in the sample of records DLC reviewed, despite many bullying
complaints. This part of Chamberlain’s policy must be fixed.
E.

Restraints

DLC originally received complaints in May of 2015 regarding inappropriate and
excessive restraints at the Chamberlain School. Throughout its investigation, DLC
continued to receive additional complaints of inappropriate and excessive restraints, as
well as restraints using excessive force. State law provides protections to prevent
children from being unlawfully physically restrained while attending school. Under 603
CMR § 46.03, physical restraint can only be used when non-physical interventions
would not be effective and should be considered “an emergency procedure of last
resort.” Id. In addition, the student’s behavior must pose a threat of imminent, serious,
physical harm to self and/or others. Physical restraint cannot be used as a means of
punishment. Nor may it be used as a response to property destruction, disruption of
school order, a student’s refusal to comply with a school rule or staff directive, or verbal
threats that do not constitute a threat of imminent, serious, physical harm. These laws
exist to protect all children and specifically to protect children with disabilities.

18

 In the course of its investigation, DLC found evidence of inappropriate or excessive
restraints at Chamberlain in student records and student and parent verbal complaints.
Here are some examples that illustrate DLC’s findings:
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One student had over 50 documented restraints in a 24 month period.
Another student had 116 restraints in the 36 month period of the records DLC
reviewed.
School records indicate that staff used excessive force when one student was
pushed back on the couch and subjected to a seated hold. The student reported
that he or she was thrown on the couch, then taken off camera, punched in the
leg, thrown against the wall and held there.
Another incident of excessive force involved a staff member putting his or her
hands on a student’s neck. DLC also found a similar incident with a different
student. This different student reported to the Chamberlain nurse that he or she
was grabbed by the neck. The nurse noted “two visible reddish blue straight lines
areas on left side of neck.” The next day the nurse noted early bruising in the
area. DLC did not find any records that this was reported to DCF or EEC.
A student complained that staffed pinched him or her. The student was
observed by the school nurse to have “fresh, finger-sized bruises” on his or her
left torso. These bruises were observed both on the front and back of the
student’s torso. The student also had a rug burn under his or her armpit with a
bruise around it about 2 inches by 4 inches. Chamberlain did report this to DCF
and also conducted an internal investigation. This staff member, who had a
previous disciplinary warning, was terminated.
Chamberlain nursing records note one student had two inches of broken
capillaries on the front of his or her neck following a restraint.
Records show that a student fell backwards while being restrained and hit his or
her head on the floor. The student also had marks on his or her chest and both
shoulders after the restraints including broken blood vessels.
One student was put in a physical escort by two staff because he or she was
unresponsive to staff requests. This then triggered the student who escalated
and was then put in a prone restraint for 15 minutes. After the restraint began,
the student became combative. This was an inappropriate reaction to this
student because it was well documented that the student was triggered by
physical touch. Further, it was well documented in the records that physically
touching was a trigger for further escalation for this particular student. The
student also informed staff of this trigger. The student then fell to the ground in
the restraint and was put in a prone restraint for 10 minutes. The student
continued to bang his or her head on the ground, sustained wounds, and needed
to go to the emergency room. This same student was restrained and physically
directed many times despite the documentation that this was a clear trigger. The
student was restrained after becoming aggressive when staff put hands on him
or her when the student was not listening to staff instructions. This restraint
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lasted for 10 minutes. As a remedial measure, the staff person was required to
review restraint protocol after this incident. Another incident involved staff
physically escorting this student. The student then escalated and staff report
they had to bypass a team control hold and go immediately to the prone restraint
position. Yet another time, this student was restrained in the supine position for
10 minutes because he or she did not want to get in the van and then began to
walk to a dorm. There was another incident when staff touched this student’s
shoulder to give directions and this again triggered the student and ended in a
restraint. This student was involved in another questionable restraint. He or she
was not following directions. When the student finally complied and got up to
move to the other room, he or she struck staff. There is no documentation that
the student continued to escalate beyond this one action, was out of control, or
that there was an ongoing safety issue. However, staff still initiated a three
person, supine hold that lasted for fourteen minutes.
DLC found one parent consented to restraint only when the student met the
definition of a run away, yet the student was restrained many times when he or
she did not meet the runaway criterion.
One student reported getting slapped in the face by staff while being restrained.
The staff then reportedly asked other staff to take over the restraint so the staff
would not do something to get themselves fired.
One student reports witnessing a restraint of a peer where the peer was
restrained, pushed on his or her stomach on the sidewalk, and then threw up.
One student reported that some staff are rough when they restrain him or her
and that the restraints are painful. The student reports having his or her arm
pulled all the way back behind his or her back, getting pinched by staff during a
restraint, and not being able to breathe while in a restraint.
One student was restrained after assaulting staff. The restraint resulted in the
student’s face being swollen and red. The student also complained that his or
her whole body hurt. There was no incident report related to this incident in the
student’s records, nor did the residential notes mention it. There were only notes
from the nurse and a summary of the incident from a fax to the student’s home
school district.
One student reported seeing a staff person grab a student by the back of the
neck and knee the student in the back. The staff person reportedly threatened to
punish the student if the student reported the incident.
Another student reported seeing a restraint where the student’s face was pushed
into the rug and the student sustained a rug burn on his or her face.

20

 Another incident of excessive force involved a staff member putting
his or her hands on a student’s neck. DLC also found a similar
incident with a different student. This different student reported to
the Chamberlain nurse that he or she was grabbed by the neck. The
nurse noted “two visible reddish blue straight lines areas on left side
of neck.” The next day the nurse noted early bruising in the area.
DLC did not find any records that this was reported to DCF or EEC.

Overall, DLC found evidence of excessive and inappropriate restraints at
Chamberlain that meet the definition of abuse and neglect under 45 C.F.R. § 1386.19;
42 C.F.R. § 51.2. As illustrated above, DLC found many examples where staff at the
Chamberlain school did not comply with Federal and State laws. Many of these findings
are based on incidents that happened before Chamberlain started implementing their
new behavior management system, CPS.
The Chamberlain School informed DLC that they started the process of going
restraint-free in the fall of 2015. Chamberlain provided DLC with information on the new
program they are using called Collaborative Problem Solving (CPS). Chamberlain
reports that this program change has been approved by its licensors. As a result of this
change, Chamberlain had to arrange for alternate programs for seven students who
they felt could not work with the new program without restraints. According to data from
Chamberlain, they fully implemented the CPS system in January of 2016 and between
then and June of 2016, they only used restraints in nine instances.
Chamberlain is moving forward with making the school restraint free and consulting
with an expert in CPS to help make this happen. DLC finds it is commendable that
Chamberlain is attempting to remedy these issues by going restraint free, but DLC is
concerned that, while the administration appears committed and knowledgeable about
the restraint-free techniques, it might be difficult to change the culture of the staff from
frequently restraining students to a more cooperative and collaborative environment.
F.

Inappropriate Staff Behavior

In the dozens of parent and student interviews DLC conducted, DLC received
many complaints about verbal abuse by staff and other inappropriate staff behavior.
DLC finds much of this behavior meets the definition of abuse under the federal
regulations.
DLC is also concerned about this behavior contributing to a negative culture in
the school for both staff and students, as well as being contrary to the therapeutic
environment and treatment the school wishes to establish. Here are some examples of
the complaints and reports DLC received, which were found to be credible:

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DLC received information of an incident where a staff person tried to physically
attack a student after the student splashed soda on the staff member. Two other
students had to physically hold the staff person back. The staff member told the
students that if they did not hold him or her back, the staff person would have
“beat the s***” out of the other student.
A staff told other students that he was going to “f*** that kid’s [referring to one of
the students in the house] mom and not use a condom” so that the student would
have to see the staff member’s face when he or she sees the child of his or her
mother and the staff member. DLC discussed this complaint with Chamberlain.
Chamberlain reported that they interviewed this staff member and several other
staff members and that no one reported concerns or previous complaints about
this staff member. Chamberlain did not interview any students in the house
where this incident reportedly happened. Chamberlain asked DLC to provide the
name of the reporter so that they could identify which students to interview. DLC
did not provide the name of the reporter, as DLC is required by federal law to
keep the identity of the reporter confidential. DLC has found this reporter’s
information to be accurate in the past, and has no reason to suspect that the
reporter is fabricating or embellishing this incident.
DLC received a report from someone who witnessed a male staff go into a
female student’s bedroom and then drag the student off of her top bunk-bed
because the student was refusing to leave her room. According to the witness,
male staff are not allowed in female students’ bedrooms. The witness reported
this to staff and staff reportedly said there was nothing they could do because the
staff person involved in the incident was a supervisor.
DLC received a complaint that a student was crying on the phone to his or her
parent when a staff member told the student to “shut up and be quiet.” The staff
member then ended the phone call between the student and the parent.
We received more than a dozen complaints of staff swearing at students. Here
some specific examples:
o Staff tell students “I’m going to drop your a**’ or “I’m going to kick your
a**.”
o Staff told a student that “I don’t give a s*** about you, I’m only here to get
paid.”
o Staff told a student that the student’s “a** belongs in jail.”
One administrator told a student they would end up in prison or a mental hospital.
DLC received a complaint that a student was called anti-Semitic slurs by a staff
member. This same staff member then said in a meeting that the student was
the worst behaved student in the house.
DLC received a complaint that a staff member targeted a different student for his
or her Jewish faith. Staff reportedly made holocaust jokes and told this student
that he or she should “burn like a real Jew.”
DLC received a report that staff are often condescending and have said “I don’t
care how retarded that kid is.”
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Student reports about one house manager’s behavior towards the students is
verbally and physically inappropriate, condescending and threatening. Two
students reported that they told this to their therapists but said nothing changed.
DLC discussed this concern with Chamberlain. Chamberlain informed DLC that
they spoke with the staff member’s supervisor and the supervisor reported this
staff member’s style did not fit with the needs of the students of that house. As a
result, the supervisor reportedly moved the staff member to a different role. This
staff member is still employed by Chamberlain, but works in a different area of
the school.
One staff member told another staff member in front of students that if he or she
thought any of the students would ever have spouses, the staff member was as
“crazy as they [the students] are.”
Staff told a student with a phobia of showers that they were disgusting for not
showering.
Staff reportedly told a student “when you’re older and in prison, you won’t be able
to speak because you’ll have a d*** in your mouth.” When a parent reported this
to an administrator, the administrator reported that the staff had snapped
because the students had bullied him or her so much.
Staff wrote in an incident report that when a student would not comply with
directions that the staff began to use a louder tone of voice with the student and
even yelled at the student. The student then became agitated and the incident
ended in the student being restrained.

DLC finds that these complaints meet the definition of abuse which includes
“verbal, nonverbal, mental and emotional harassment.” 42 C.F.R. § 51.2. DLC had a
general conversation with Chamberlain about verbal abuse concerns. Chamberlain
informed DLC that verbal abuse is not tolerated, is strictly against their school policies,
and would be reported to DCF if raised with staff. Chamberlain informed DLC that
sometimes students misconstrue what staff are saying when they are joking, or that
students get upset when staff members set limits or deny them privileges and students
refer to this as verbal abuse. Further, Chamberlain informed DLC that sometimes
certain students don’t understand colloquialisms. DLC finds that many of the
complaints received do not fit within the explanation Chamberlain provided but do fit
within the statutory definition of abuse.
V.

Conclusion

Many of the initial allegations were especially alarming, which precipitated and
necessitated a thorough abuse and neglect investigation. During the course of the
investigation, while the substance of some of those initial allegations was not supported
by the evidence, other concerns were substantiated. In some of the issue areas, CIS
has undertaken remedial steps and made personnel changes to certain senior staff
positions.

23

 As set forth in greater detail in the prior sub-sections of Section III, “Factual
Findings,” DLC has found:
1.

Neglect in the school’s failure to prevent and properly respond to students
exhibiting serious self-injurious behavior;

2.

Neglect in the school’s failure to establish and maintain an adequate level of
supervision and undertake effective steps to reduce or eliminate risks from
students running away from the school’s campus. This results in an unsafe
environment for students, and exposes students to actual or potential harm;

3.

Neglect in the school’s failure to investigate and stop bullying incidents and to
comply fully with Massachusetts’ anti-bullying law, which constitutes a failure to
provide a safe environment; and

4.

Abuse, in the form of verbal, nonverbal, mental and emotional harassment, and
other inappropriate treatment of students by staff.

As set forth in greater detail in the prior sub-sections of Section III, “Factual
Findings,” DLC has found:
1.
Neglect in the school’s failure to prevent and properly respond to students
exhibiting serious self-injurious behavior;
2.
Neglect in the school’s failure to establish and maintain an adequate level
of supervision and undertake effective steps to reduce or eliminate risks from
students running away from the school’s campus. This results in an unsafe
environment for students, and exposes students to actual or potential harm;
3.
Neglect in the school’s failure to investigate and stop bullying incidents
and to comply fully with Massachusetts’ anti-bullying law, which constitutes a
failure to provide a safe environment; and
4.
Abuse, in the form of verbal, nonverbal, mental and emotional harassment,
and other inappropriate treatment of students by staff.

With respect to the other two issues: inappropriate and excessive restraints and
the medication issues, DLC did find that past policies and practices had resulted in
abuse and neglect of students, but CIS has undertaken substantive remedial measures
since the commencement of the investigation. Most notably, in the area of restraints, the
school has announced and undertaken an effort to make CIS a restraint free campus.
As a result, the numbers of restraints have significantly decreased. Since the start of the
Collaborative Problem Solving (CPS) program in January 2016, CIS reports that in most
months, there has only been one restraint. CIS senior staff explained that the full
implementation of that effort will require a several year period, but the initial results
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 certainly show promise. The school will have to work to change the culture of frequent
restraints of students to transition to and achieve a restraint free campus.
In the area of medication administration, the school has announced remedial
steps as well. CIS has stated its intention that all medication administration will be
conducted by nursing personnel. CIS is currently working to hire a sufficient number of
nursing staff. CIS has also changed senior management in the nursing department to
more quickly address the concerns and move the nursing department forward.
Notably, there have been changes to other senior staff positions, including the
Program Director, the Clinical Director, and Director of Student Life.
While recognizing that CIS has made very good progress in some issue areas,
DLC does have concerns about the abuse and neglect at the school, as set forth above.
CIS needs to formulate a remedial plan which addresses each of the above issues
where neglect or abuse was found. That plan, which must be created and submitted to
DLC by November 16, 2016, shall include the following elements:
1. Policies and practices to effectively identify, prevent and treat students who
exhibit or are at risk of serious self-injurious behavior (which should include a
plan to provide timely access to clinical staff on evenings and weekends);
2. Policies and practices to establish and maintain an adequate level of
supervision and undertake effective steps to reduce or eliminate risks from
students running away from the school’s campus (which should include a plan
to address the need for greater oversight of residential staff);
3. Policies and practices to establish an effective anti-bullying program,
consistent with the requirements of the Massachusetts anti-bullying law;
4. Policies and practices to eliminate verbal, nonverbal, mental and emotional
harassment and other inappropriate treatment of students by staff;
5. A process and timeline for periodic reporting to DLC on the continued
progress in moving CIS to a restraint-free campus; and
6. A process and timeline for periodic Reporting to DLC on the continued effort
to address medication issues.

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