Report: Vivant Behavioral Health - Brighter Path - Formerly Known as Sequel - continued
March 2018: A former patient of Red Rock Canyon School sued the school for negligence for failure to protect him. The basis of the suit was that the man, who was only 13 when he was admitted to the facility, was sexually abused by then-employee Diarra Niccole Fields. [23] Fields was criminally prosecuted and sentenced in 2014 for sexual abuse of three juveniles.
May 8, 2018: Iowa state inspectors received an anonymous complaint which stated that Clarinda Academy had kept eight residents, ages 13-17 in seclusion for one month following an incident in which the teens eloped the facility, injuring two staff members—this is despite facility procedures which call for residents only be secluded for up to 72 hours in they posed a threat and an additional 72 hours if the behavior continued. The complainant also reported that when one of the teens refused to write a statement admitting he was responsible for the assault on of the staff members, he was slammed to the floor and restrained. None of the teens was informed of what they could do to work their way back into the general population.
After this situation was reported to the state, Clarinda staff members created documents to make it appear that they possessed the required services plans for the teens and had forged student signatures on the documents. [24]
June 12, 2018: Starr Albion Prep has been the subject of nearly 60 investigations since 2014 by the state’s Department of Health and Human Services. Reports show that staffers in 2018 restrained youths unnecessarily and used unapproved techniques, in one case breaking a child’s thumb. [25]
On August 22, 2018, Amanda Renee McCool, 39, a staffer at Lakeside Academy Kansas (not to be confused with Sequel’s Lakeside Academy in Kalamazoo, MI), was arrested on three counts of unlawful sexual relations involving a juvenile. Sequel responded by issuing a statement that Lakeside’s administrator had received a report about McCool, who was then placed on unpaid administrative leave, and thereafter resigned. [26]
October 2018: The patient advocacy group Disability Rights Washington (DRW) released a report stating that Washington state foster youth sent to Clarinda Academy were physically abused and largely segregated from the outside world. The report contended that the Academy is run like a correctional institution: children are painfully and routinely physically restrained, not allowed to have cellphones, are not allowed routine trips into town, and were prohibited from speaking to members of the opposite sex. In response to the report, the Washington Department of Children, Youth and Families stated that it would stop placing children at Clarinda. In interviews, the Washington children independently reported to DRW consistent allegations of verbal and physical abuse. Though many of the students feared retaliation by staff if they became too involved in the investigation, three of the students opted to allow DRW to access and review their records—which included restraint records. Children told investigators that staff "put their hands on you and force you to the ground," The kids separately and independently demonstrated how staff pull their elbows behind their backs and then force them to the ground by putting pressure on the backs of their knees. [27]
"Every student reported that restraints they experienced were physically painful and frequently resulted in back, shoulder, and neck pain for several days or weeks," according to the report. When asked if they receive medical attention, the kids stated that no one complains because they are told “you shouldn’t have gotten put in a restraint.” [28]
One such student was Jesus Lopez, who was a 17-year-old foster kid who had been through more than two dozen placements. Stressed about his future, he was excited at the prospect of admission to Clarinda, as he was assured he’d receive vocational training there. Instead, he discovered he couldn't leave the campus. Alone and intimidated by the other kids, he felt, he said, like he was in juvenile detention. He tried to escape and was restrained by staff, who took turns pulling his arms back and then throwing him down on the floor. His head hit the floor several times, he said, before he fell unconscious. According to Iowa Dept. of Human Services records, he suffered severe bruising on his forehead, as well as bruising on his arms, legs and back. [29]
November 2018: The Des Moines Register “Watchdog” (investigative journalist) reported that in the previous five years, more than 30 police reports were made involving students and staff at Clarinda Academy—including assaults, fights, forcible sodomy, and rape by staff members, including the following:
- In February 2016, a student reported that a 40-year-old night staff member, Antonio DeJesus Aranda, sexually abused her when she was 17. Aranda was charged with three felony sex charges and pleaded guilty to sexual misconduct. He was sentenced to ten years’ probation. [30]
- In September 2016, a 19-year-old student said he was sexually fondled by a 39-year-old staff member, Jennifer Gay, who threatened him not to tell or he would go to jail, according to a police report. The charges were dropped when the resident, who was charged with several felonies after he’d been released from Clarinda, did not cooperate with Gay’s prosecution. Gay made self-incriminating statements to police. However, these were suppressed on the basis that she made them in response to police misrepresentations that she could lose custody of her children.
- In July 2016, staff member Sara Honnald reported being assaulted by a Clarinda patient. Honnald suffered a broken nose and cuts to the forehead. The patient does not appear to have been charged.
- In August 2017, forcible sodomy and lascivious conduct with a minor was reported involving a 37-year-old staff member and 18-year-old student.
- On Dec. 5, 2017, a 15-year-old male student alleged a female staff member performed oral sex on him. Iowa Court records show that the woman was never charged. [31]
February 2019: Representatives from the Iowa Department of Human Services interviewed five children at Clarinda, each of who reported feeling unsafe. They all reported a recent increase in youth-to-youth physical assaults and felt the staff was ill-equipped to manage. [32]
February 2019: The Tennessee Department of Children’s Services (DCS) removed 18 juveniles from Kingston Academy and announced that it had suspended admissions to the facility. DCS’ stated concern was the facility’s physical condition. Sequel gave no further specifics, other than that DCS raised concerns about some of the physical surroundings and that an interior renovation was in-progress when DCS pulled the children.
March 2019: Kingston Academy closed.
April 28, 2019: A riot erupted at Red Rock Canyon School in St. George, Utah. Media reported that 25 students were injured and received medical treatment. Five had to be transported to the hospital for more serious treatment, including one student who required staples to close a gash on the back of his head. Twenty additional students and three facility staff members were evaluated but declined medical treatment. Five students were arrested and jailed on charges of assault, criminal mischief and inciting a riot. Another seven were detained but not arrested. The riot is reported to have been the result of a fight between two students which escalated to involve additional students. Police, medical and SWAT responded to the incident, which lasted two hours. [33]
July 12, 2019: Following a local TV news investigative report on Sequel Pomegranate, Franklin County Children Services (FCCS) conducted a surprise inspection on the facility which uncovered repeated incidents of teen-on-teen, staff-on-teen, and teen-on-staff violence, along with substantiated allegations of sexual abuse and repeated documented events of teens escaping. The news agency also reviewed roughly 400 police dispatches to the facility since 2017 for incidents including fights, disturbances, assaults and allegations of sexual abuse. [34]
July 2019: Red Rock Canyon School closed after being found in violation of more than ten rules and regulations, as uncovered in a state investigation following the April 2019 riot at the facility. The state Department of Human Resources issued a plan of correction to the facility, calling for 16 situations to be corrected within 90 days and putting it on a conditional license. Though the facility reported that it had completed 15 of the 16 actions, and expected it would handle the final one, it nonetheless closed in August 2019, admitting in a news release that "Over the last few months, in working with the Utah Department of Human Services, we have recognized that we have not consistently delivered on our mission." [35]
August 19, 2019: Madison City Council (Alabama) revoked the business license of Sequel’s TSI Madison youth facility (also known as Three Springs Detention Center) after a series of escapes, including two juveniles who are charged with murdering a construction worker after having eloped from the facility. Three Springs management complied with the revocation, issuing a statement indicating that it was seeking to relocate the 51 children in its care at that time. [36]
August 22, 2019: Inspectors from the Ohio Department of Mental Health & Addiction Services cited Sequel Pomegranate following an unannounced visit to the facility, during which they uncovered issues with children being improperly restrained and noted that the facility had failed to report a sexual assault allegation made during June 2019. The Department required Pomegranate to review all incident reports going back to July 1, 2018, to ensure that the facility staff did not fail to report other issues. [37]
August 2019: Days after the announcement that Sequel was closing Red Rock Canyon School, it announced it would be closing Mount Pleasant Academy, also located in Utah. Sequel asserted that the closure of Mount Pleasant was not related to the state health authority’s citing of numerous allegations of physical and sexual abuse of patients. [38]
November 2019: Liz Spellman, a Sequel Pomegranate mental health technician, was placed on administrative leave and later fired following an October incident in which she laid on top of a teen during an improper restraint and also shoved the teen afterward. She admitted to media that “Improper restraints happen every day in there.” A four-page letter from the Ohio Department of Mental Health and Addiction Services to Pomegranate alleged that a nurse at the facility kicked and punched the girl while she was being restrained. That nurse admitted to media that she had done it and that it was a mistake. The letter also cited another nurse who failed to render aid. Later media reported that the nurse was also fired. [39]
November 2019: Former Red Rock Canyon School staffer Atonio Kavea was arrested on charges of having a sexual relationship with a 15-year-old girl and fathering a child with her. The girl, who had been a patient at the facility, began an online relationship with Kavea after she was discharged. Kavea would make monthly visits to the girl (then only 14 years old) in Tulare County, CA and take her to motels rooms for sex. He was charged in with two felonies (unlawful sexual intercourse and lewd act upon a child) and was taken into custody of Tulare County Sheriff. The website of the California Department of Corrections and Rehabilitation shows that he was imprisoned at the California Correctional Institution on October 27, 2020 and will be eligible for parole in May 2023. [40]
On November 21, 2019, The Salt Lake Tribune reported that a 15-year-old Oregon boy who had been placed as a foster child at Red Rock Canyon School had filed a lawsuit against the Oregon officials who sent him to the facility. The suit alleges that Red Rock staffers knew the boy was being bullied but did nothing to stop it; staff encouraged patient-on-patient violence; hired unqualified staff; did not conduct background checks, resulting in the hiring of a convicted felon; did not properly train staff; allowed students to restrain each other, including choke holds; and staff mistreated the children. [41]
December 2019: The Ohio Department of Mental Health and Addiction Services (OHMAS) notified Sequel Pomegranate that it was seeking to revoke its license. A hearing before OHMAS was set for mid-January 2020 for Pomegranate to respond to allegations and defend its license. Franklin County (Ohio) Children Services was also at that time reviewing 11 complaints of alleged neglect and physical or sexual abuse leveled at the facility since August 2019. Following this, Pomegranate’s CEO stepped down. [42]January 2020: Franklin County (Ohio) Children Services (FCCS) stopped sending children in their custody to Sequel Pomegranate due to concerns about the how children were being restrained there, as well as concerns over violence and sexual abuse over the previous months. [43]
February 2020: A lawsuit demanding $4.5 million was filed on behalf of a minor child, alleging that while the child was hospitalized at Kingston Academy, he was repeatedly and violently raped by in the bathroom by a Kingston Academy employee and another patient. The case, filed in Roane County, Tennessee is, as of February 2022, still active, with a pre-trial conference scheduled for April 20. [44]
February 2020: Sequel Pomegranate entered into a settlement agreement with the Ohio Department of Mental Health and Addiction Services (OHMAS) to avoid having its license revoked. The agreement required Pomegranate to hire an outside expert to review its operations, submits routine reports to the state, pass a survey by the state Dept. of Health and, after reducing its patient population to zero, but suspend admissions for 120 days. [45]
March 2020: The patient advocacy agency Disability Rights Ohio, the statewide advocacy group for people with disabilities, called on OHMAS to further investigate Sequel Pomegranate following a pattern of abuse allegations and environmental conditions that the group says have not improved over the past several months, based on its own on-site inspections between July 2019 and January 2020. The group began its own investigation of the facility following a local TV investigative report which initially uncovered violence, sexual abuse, and escapes from the facility. In speaking with youth at the facility, the majority interviewed reported:
· Painful holds that resulted in harm/injury
· Being bullied by peers
· Being demeaned, sworn at, called derogatory names by and being bullied by staff
· Youth having to jump in to intervene in physical altercations because staff do not
· Staff failure to intervene during patient self-harm or peer-to-peer aggression
Disability Rights wants OHMAS to conduct its own complaint-based survey of Pomegranate patients. [46]
April 30, 2020: Sixteen-year-old foster child Cornelius Frederick lost consciousness, urinated, and went into cardiac arrest after being restrained by several staff at Sequel’s Lakeside Academy in Kalamazoo, MI, because he had tossed a sandwich onto the floor. The restraint was carried out over approximately ten minutes, during which Frederick was reported to have screamed “I can’t breathe!” as staff members placed their weight upon his chest. He died in the hospital the following day. [47]
The manner and cause of Frederick’s death was ruled a homicide. “In my opinion, the complications of him being restrained, on the ground in a supine position by multiple people, is ultimately what led to his death,” said Kalamazoo County Medical Examiner Dr. Ted Brown. [48]
Following his death, The Michigan Center for Youth Justice (MCYJ), a non-profit that advocates for a more fair and effective justice system for the state’s youths, called for Lakeside to close. Mary Kind, MCYJ’s executive director, stated that the Center had joined a national campaign with the National Juvenile Justice Network, which launched a petition urging governors to ban Sequel from serving youth. [49]
“We believe that both those who were involved in the restraint, as well as the facility Lakeside Academy, need to be held accountable for Cornelius Frederick’s death,” King said. “We think that there should be an investigation that is made public. We believe Lakeside Academy, which is operated by the national for-profit group Sequel Youth and Family Services, needs to be closed.” [50]
June 20, 2020: Following the death of Frederick, Michigan Governor Gretchen Whitmer issued a public statement ending the state’s relationship with Sequel Youth & Family Services: “Protecting our most vulnerable is a top priority of my administration, and the senseless death of a youth at Lakeside…in Kalamazoo is intolerable and heartbreaking. We will take steps to prevent tragedies like this from occurring in the future and make sure there is accountability. Today I directed Michigan Department of Health & Human Services Director Robert Gordon to take every step necessary to ensure Sequel Youth and Family Services — the company that provided staffing for Lakeside for Children where the 16-year-old died — no longer provides services for facilities licensed by the department.” [51]
June 24, 2020: Three staff members of Sequel’s Lakeside Academy in Kalamazoo, MI, were criminally charged in the restraint-related death of 16-year-old Cornelius Frederick. Michael Mosley, 47 and Zachary Solis, 28, were charged with involuntary manslaughter for restraining Frederick in a grossly negligent manner. Each was also charged with two counts of child abuse. Heather McLogan, 48, Lakeside’s Director of Nursing, was charged with involuntary manslaughter and one count of child abuse for her failure to seek, obtain, or follow through with timely medical care. [52]
July 4, 2020: The 107-year-old Michigan social services agency Starr Commonwealth ended its contract with Sequel Youth & Family Services following the death of 16-year-old Cornelius Frederick at Sequel’s Lakeside Academy facility in Kalamazoo on April 29th. Starr Commonwealth had contracted for the past six years with Sequel to provide services in its Starr Albion Prep facility, located in Albion, MI, where it had 135 children under Sequel care. [53]
July 6, 2020: The Alabama Disabilities Advocacy Program (ADAP, which is part of the nation’s federally funded patient Protection & Advocacy system), sent a ten-page public letter to the Commissioners of several state agencies, to call their attention to the conditions inside Sequel’s four Alabama facilities (Sequel Owens Crossroads, Sequel Courtland, Sequel Tuskegee, and Sequel Montgomery) and to urge corrective action. “These facilities are violent and chaotic places where youth are physically and emotionally abused by staff and peers, subjected to wretched living conditions, provided inadequate supervision and medical care, and subjected to illegal seclusion and restraint, all in violation of their Fourteenth Amendment constitutional right to protection from harm, and of state and federal laws and regulations,” the letter begins. “Despite…federal and state prohibitions, Sequel engages in a pattern and practice of using violent force against children. During ADAP’s in-depth interviews, residents described Sequel staff slamming residents against walls, punching and slapping residents in the face, using chokeholds, and laying on top of residents who are lying face down on the ground. Staff violence against youth has resulted in serious injuries, including head trauma, lacerations, hematomas, and loss of consciousness, not to mention trauma to their mental well-being.” The letter also addresses Sequel staffs’ verbal abuse against children; denial of needed medical and dental care; unsafe living conditions; and generally chaotic and non-therapeutic environment in Sequel facilities. ADAP called upon all relevant state agencies to conduct their own immediate and comprehensive inspections, suspend further admissions, and revoke all licenses, among other things. [54]
July 2020: Cornelius Frederick’s family filed a wrongful death lawsuit in Michigan Circuit Court against Lakeside Academy, Sequel Youth & Family Services and its related corporations. [55]
September 17, 2020: The Ohio Department of Mental Health and Addiction Services ordered Sequel Pomegranate to immediately relinquish its license and announced that it would bar Sequel from reapplying for a license to operate a residential psychiatric facility for teens for nearly a year. This order came after a series of investigations beginning in July 2019, which found teenage residents of the facility had been exposed to repeated incidents of violence and improper restraints, as well as substantiated cases of sexual abuse and residents escaping from the supposedly secure facility. Additionally, there 16 reports submitted to the state of children who had harmed themselves at Pomegranate – many of whom required hospital visits or stitches through either cutting themselves with things like pieces of broken toilets or swallowing foreign objects including batteries. [56]
May 14, 2021: The State of Illinois announced that it was removing all children in its care from Sequel’s Northern Illinois Academy, following a report that found serious concerns regarding staffing, incident reporting, elopements, treatment planning, the use of seclusion and isolated time-outs, and improper restraints. Children interviewed in the investigation reported that the “nurses never believe us” and staff frequently shoved and slammed them onto the ground and on their beds. Other observations noted in the report showed that minors were frequently not supervised, which resulted in youths engaging in undetected inappropriate activities. Additionally, staff would take away personal items from minors as punishment for not listening, including pictures of family members. [57]
July 1, 2021: Following an investigative report by the San Francisco Chronicle and the non-profit news outlet The Imprint, which uncovered that the state of California had sent thousands of children to out-of-state Sequel facilities, the state Department of Social Services (DSS) decertified all such facilities and programs—ending the practice of shipping California foster children out of state. The Governor of California, in signing a new state budget bill, effectively banned the practice permanently. California law prohibits judges from sending children to for-profit residential facilities. The Chronicle-Imprint investigation revealed that Sequel skirted the law by managing the campuses while preserving facility ownership under local nonprofits. At these institutions—in Michigan, Iowa, Wyoming, Arizona and Utah—students reported physical abuse and sexual assault at the hands of employees. The violence turned deadly in April 2020, when seven staff members at the Sequel-run Lakeside Academy in Michigan killed 16-year-old Cornelius Frederick by piling on top of him as he cried out, “I can’t breathe.” Since 2017, officials in California and five other states had investigated hundreds of alleged violations or deficiencies at Sequel-run facilities used by California, including complaints that staff members had hit, kicked and assaulted residents, or had placed them in dangerous physical restraints. [58]
July 31, 2021: Heather McLogan, former director of nursing at Sequel’s Lakeside Academy, pleaded no contest to third-degree child abuse in the death of 16-year-old Cornelius Frederick. The other charges against her were dropped as part of the plea agreement. She was expected to testify if necessary against the other two Lakeside staff charged in Frederick’s death. [59]
August 2021: Northern Illinois Academy closed following the removal of all children being housed there under state- or county-funded programs. [60]
September 27, 2021: Heather McLogan, former director of nursing at Lakeside Academy, was sentenced to 10 years’ probation in the death of 16-year old Cornelius Frederick. [61]
September 30, 2021: A second lawsuit was filed against Lakeside Academy and Sequel Youth & Family Services in the death of Cornelius Frederick, seeking $50 million in damages. The suit, which was filed in federal court (unlike the first action, which was filed in county court), included not only Sequel’s related corporations but also ten named Lakeside employees, including McLogan, Mosley, and Solis. [62]
December 1, 2021: Sequel’s Bernalillo Academy in Albuquerque, New Mexico voluntarily relinquished its license to the state. Sequel staff began contacting parents in November 2021 to inform them that the facility was closing down and they would need to find new placements for their children by December 22nd. When parents asked why, staff gave reasons such as “COVID” and “resources.” However, the actual reasons for the closure are detailed in an investigation report issued by the state Children, Youth & Families Department (CYFD), which found the facility didn’t perform adequate background checks or verify employment for many of its staff, with some staff not even meeting the requirements of the job, where they were dealing with severe developmental and behavioral cases in children and teenagers. But other allegations go much deeper — from reports of staff whipping children with tree branches and bark, leaving them with severe bruising and injuries, to countless reports of physical aggression between kids without staff intervention. Detailed in the report, one child said, “I guess they are just waiting for me to die,” while another said he “doesn’t really feel safe here.” CYFD also found instances of sexual aggression between those in the facility’s care, one stating they were afraid they would be molested after another “client” in the care of the facility asked to have oral sex with them. [63]
January 3, 2022: The second of two lawsuits filed against Sequel’s Lakeside Academy by the family of Cornelius Frederick was settled for undisclosed terms. Among the information contained in the Facts section of the family’s civil suit is that Frederick had been restrained “scores of times” during the 18 months he was at Lakeside, including two incidents in January 2020 in which he was restrained “to the point that he was unable to breathe and was rendered incapacitated.” [64]
Police calls for service
Between 2008 and 2013, St. George (UT) Police Department received 127 calls for service to Sequel’s Red Rock Canyon School. These include reports of assault (26), runaways (7), sex offense (6), criminal mischief (3), and child abuse (2).
During 2016, Sheridan County (WY) Emergency Services received more than 55 calls from Normative Services. The facility also had 57 runaways during the same period. [65]
According to the Roane County (TN) Sheriff’s Office, deputies were called to Kingston Academy 135 times in 2018. In just the first two months of 2019, they were called 36 times for complaints including assault, vandalism, and runaways. [66]
There were 77 calls for service to Albuquerque Police to Bernalillo Academy between 2014 and 2019, including the following:
- Disturbance: 13
- Child neglect: 8
- Sexual abuse: 5
- Physical abuse: 4
- Suicide: 4
- Aggravated assault-battery: 2
A WBNS News (Columbus, OH) investigation, which included a review of 400 police calls for service (over a two-year period), 911 calls, police body-cam footage, and state incident reports submitted to both OHMAS and FCCS, found:
- 125 patient escapes
- Police response to 36 assault reports and 14 alleged sexual assaults
- Substantiated cases of teen-on-teen violence and sexual assaults
- 24 incidents of staff being accused of improper restraint. [67]
