Punched. Stomped. Whipped.

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Twenty Chester County Devereux staffers allegedly harmed children — or kept quiet about the abuse — since 2018. The company says it's continuing its reforms.

When a 16-year-old with severe autism ran naked into the living room of his residential facility at Devereux Advanced Behavioral Health’s campus in West Chester one early evening in September, a staffer turned off the lights and advanced on the boy.

Four times the man punched the teenager — in his head, his ribs, his groin. The boy, who is nonverbal, put up his hands to try to block the blows.

After the teen broke free and fled, the staffer, Olasoji Satimehin, turned the lights back on, looked up at a surveillance camera, then calmly sat down, according to a criminal complaint. Police say he did not know the camera was equipped with night vision.

Satimehin’s October arrest was the most recent in a string of criminal cases at Devereux.

Since July 2018, prosecutors have charged 20 staffers in connection with alleged physical abuse of 18 different children at Devereux’s three residential campuses in Chester County: Leo Kanner in West Chester, Brandywine in Glenmoore, and Mapleton in Malvern, according to an Inquirer review of court records.

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LAUREN SCHNEIDERMAN / Staff Photographer
“He would try to punch himself in the head and he would say, ‘I was bad,’ and ‘Don’t tell.’”
Chris Oram, speaking of her son Seth
Hear their story

One staffer whipped three girls with a phone charger cord, raising welts on the arms of two of them. Another repeatedly struck a nonverbal girl with cerebral palsy and autism with a hairbrush, laughing during the attack. Two other Devereux employees made two boys engage in a bloody fistfight. In all three cases, other staffers watched — and didn’t intervene, court records show.

Devereux leaders would not answer questions about specific incidents, citing litigation concerns and privacy laws. In a statement, they said: “These incidents are heartbreaking and unacceptable, and we must always ensure we’ve learned from the past and are constantly driving change in our organization and industry. Every provider in the field must deal with the issue of employees who, despite thorough training, support, and supervision, do the wrong thing in complicated situations.

“At Devereux, we hold ourselves to the highest standards — we know there is still important work to be done and we are committed to protecting those in our care.”

Devereux senior vice president and chief strategy officer Leah Yaw acknowledged that more of its staffers have been arrested for abuse than those at other providers. She attributed that to “our really excellent use of video and reporting and catching incidents and being able to provide evidence so that when people need to be prosecuted, they are successfully prosecuted.”

Jonathan Rubin, who oversees state-licensed residential facilities for children as a deputy secretary in Pennsylvania’s Department of Human Services (DHS), recently said Devereux’s use of video technology was “ahead of the curve” compared to other providers.

Facilities that care for children with disabilities are not immune from incidents of abuse. It is a recognized problem in the industry. Devereux, which specializes in treating children with intellectual and behavioral disabilities, mental disorders and trauma, holds itself out as “best in class.”

Devereux leaders say that since January 2018, when CEO Carl Clark II took the helm, the Villanova-based nonprofit has increased direct staff pay, upgraded video camera technology and implemented random reviews of surveillance footage, and beefed up training and oversight to hold staff accountable and protect children. Devereux said it plans to spend up to $6 million to add more cameras in hallways, stairwells, and outdoor areas at its 15 residential campuses in nine states.

As changes rolled out, incidents still took place. Several Devereux employees didn’t report suspected child abuse to authorities even though they are legally mandated to immediately do so; Devereux supervisors sometimes minimized the severity of a child’s injuries, and failed to tell parents that a staffer was suspected.

In some cases, staffers who witnessed the abuse did nothing to intervene and kept quiet. They either failed to file a required incident report when a child got hurt or was restrained, or they lied in the report. And Devereux supervisors who reviewed the reports accepted the staffers’ accounts.

After The Inquirer published an investigation in August about how Devereux staff sexually assaulted at least 41 children over the last 25 years at facilities in Pennsylvania and seven other states, the company hired former U.S. Attorney General Loretta Lynch to conduct an independent audit of child safety. It is ongoing.

Philadelphia’s Department of Human Services and Community Behavioral Health conducted its own inquiry. Six weeks later, city officials said they would remove all 53 children it had placed at Devereux facilities, saying that staffers “weren’t doing their jobs” and lapses in supervision put vulnerable children at risk. To date, 34 remain at Devereux, in part because parents chose to keep their children there and because they are among the most difficult to relocate.

Darlene St. John, of Philadelphia, said she opted for her 17-year-old grandson to stay at the West Chester campus, where he’s lived for two years. “He feels loved — he feels nurtured there,” she said.

The Pennsylvania DHS, which inspects, monitors, and licenses residential treatment facilities for children, also launched a review into Devereux’s safety practices, including unannounced visits. The abuse of the 16-year-old boy with autism occurred in the midst of that review, which remains open.

Two days after Satimehin allegedly assaulted the teen, a nurse at the center noted “mild swelling” to his skull. The next day, a Devereux official alerted police. Devereux also fired Satimehin, and contacted the boy’s parents to tell them what had happened.

It was a shock, said the father of the boy, who is unnamed in police and court records.

The boy has lived at Devereux for about five years. The father said he and his wife had no reason to think he wasn’t well-treated there.

Their son has autism and intellectual and behavioral disabilities that require 24-hour attention. The couple tried to care for him at their Philadelphia home, but by age 10, he had become too difficult to manage, running outside into traffic and getting aggressive with younger siblings, he said.

The father said he hopes to soon find a new facility for his son, but agonizes over his safety. “If someone beats [him] or does anything… [he] could not tell anything — nothing.”

Reports pile up

DHS said it has received 254 reports of suspected child abuse and neglect on Devereux’s three Chester County campuses from Jan. 1, 2018, to Nov. 16, 2020, through ChildLine, the state’s 24-hour hotline to report child abuse. DHS officials said they cannot reveal how many children are involved or how many of the reports were founded because the state’s Child Protective Services Law bars them from releasing that information.

But during a state legislative committee hearing in September, Rubin, of DHS’s Office of Children, Youth and Families (OCYF), testified that state investigators confirmed a total of four incidents of physical abuse at Devereux’s three Chester County campuses since 2018.

Of the 20 criminal cases, OCYF issued violations to Devereux in just four of them: The bloody staged fight between two boys that had become so well-known among staffers that some nicknamed it “fight club.” The staffer who took a hairbrush and chair to a girl. The foot stomping of a 15-year-old boy’s head. And Satimehin’s alleged abuse of the 16-year-old boy with autism, according to an Inquirer review of state inspection summary reports.

In response to reporters’ questions about why only four of the 20 criminal abuse cases are reflected in public licensing records, state DHS officials said prosecutors have more leeway under criminal law to bring charges in alleged cases of child abuse, while DHS investigators, by statute, must prove that a staffer “intentionally, knowingly, or recklessly” injured a child or created a situation where a child could have been injured, via “any recent act or failure to act.”

Under the regulations, Devereux is required to remove the alleged perpetrator, immediately report the incident to the state, and fully cooperate with investigations. If the company does so, state DHS officials said they weigh those factors favorably during a licensing review.

DHS officials say they do consider complaints of child abuse when deciding to renew a facility’s annual license.

But an Inquirer review of summary inspection reports shows an agency focused more on the nuts and bolts of building maintenance and paperwork — expired waffle mix, a burned-out refrigerator light, uncovered trash containers, missing documentation of staff training, incomplete health records of children’s annual eye and hearing exams — and less on rooting out suspected child abuse.

“We have a child protective services system that is not working to protect children,” said Marci Hamilton, founder of CHILD USA, a nonprofit think tank at the University of Pennsylvania dedicated to preventing child abuse and neglect through reform.

DHS has the power to pull a license or put institutions on warning with a provisional license, which could deter parents or government agencies from sending children to programs that can cost as much as $84,000 per child per year.

The state, however, rarely wields this power. Even as criminal convictions piled up, DHS did not alter Devereux’s licensure.

“To the department’s knowledge, there have been no recent failures among Devereux’s leadership to address concerns and take appropriate action,” DHS spokesperson Ali Fogarty wrote in an email to The Inquirer last month.

Of the 20 cases, 14 unfolded on Devereux’s West Chester campus, where 10 dormitory-style residences, a small zoo, a swimming pool, and a job training center are spread out on a sloping hill off Boot Road. As of late December, 141 children with severe cognitive and behavioral challenges lived there.

Abuse complaints on this campus are investigated by the West Whiteland Township Police Department. Detective Michael Buchmann handles nearly all of them. He said he investigates at least 75 child abuse complaints a year. Very few complaints result in criminal charges, Buchmann said. He worries only a fraction gets referred to him.

“That’s my big stress,” Buchmann said. “If no one makes a report, I would never know.”

Fight club

It was just after 6:30 p.m. July 5, 2018, when Devereux staffers Anthony Merrick and Rayne Portela cleared furniture in a common area and pushed two boys toward each other to engage in a vicious, bare-knuckled brawl.

Merrick and Portela laughed as Merrick videoed the boys punching and kicking each other, according to a detailed police account of the video. One boy tried to run away, but Merrick grabbed his shirt and pushed him toward the other child to keep fighting. Portela wiped blood off one boy’s back. He used a white rag to wipe his bloody nose.

Merrick shared the recorded fight with friends on SnapChat.

None of the staffers told the boys’ parents, or reported the abuse to authorities. Staffer Dyneisha Kellogg, who witnessed the fight, would later say she tried to get Merrick, Portela, and the boys to stop, but they would not listen. She later told Buchmann that she had emailed her supervisor about the incident. It’s unclear what, if anything, the supervisor did about it.

The incident only came to light three months later with the intervention of Joel Secundy. He had grown increasingly concerned about seeing bruises, cuts, and scrapes on his son, who has autism, ever since he went to live and get treated at Devereux about two years earlier.

During a visit in October 2018, his son told him that a staffer had twisted a towel around his neck and choked him.

Secundy called the police and the case landed on Buchmann’s desk. Most investigations are hampered by victims who can’t articulate what happened, staffers who lie and cover for one another — and above all, a lack of video evidence, Buchmann said. “Video is key,” he said. “It’s very hard for people to say it didn’t happen when it’s on video.”

The choking incident was not captured on video, so Buchmann had to tell Secundy he could not move forward.

There’s something else you should know, Secundy told the detective. Three months earlier, Devereux employees had orchestrated a fight between his son and another boy. “They got that on camera,” Secundy said.

Buchmann said he called ChildLine, and was told no report had been made about the fight.

When he asked Devereux’s quality control manager about the incident, she cited the date of it right away, and provided a 32-minute video.

When Buchmann interviewed Merrick and Portela later that fall about the July fight, both were still employed by Devereux, he said.

By the time they were charged in December, the two had been fired. They later pleaded guilty to conspiracy and simple assault, and in July 2019 were sentenced to two years’ probation.

DHS inspectors wrote a blistering summary report: They found that Devereux failed to protect the “health, safety and well-being” of the children by allowing them to fight. That staff videotaped the degrading incident. That they failed to report it. That Devereux’s program manager didn’t do her job.

DHS required Devereux to submit a “plan of corrective action.” Devereux assured state officials that it would retrain staffers on reporting laws and ways to keep children safe and ensure their rights are not violated. And the agency renewed Devereux’s license.

In two years after the fight club incident and retraining, at least 16 more children at Devereux’s Chester County facilities have allegedly been physically abused, court records show.

Devereux, which receives about 95% of its $497 million in annual revenue from government programs, including Medicaid, is governed by a board of trustees. Rhea Fernandes, senior vice president and chief operating officer, said the board is made aware of the criminal cases and executives are held accountable.

‘None of that is borne out’

Devereux frontline staff, called direct care professionals, need to have a high school diploma, but aren’t required to have worked with special-needs youth, although some do. The starting hourly wage is about $15.

Each time they have to restrain a disruptive child, they must file a report with facility managers. Devereux says this incident reporting system protects kids from harm. But in 2018, that safety net had holes.

When 16-year-old Shanttia Nelson tried to leave from her residential unit on West Chester’s campus on a September 2018 afternoon, Devereux staffer Christina Borden said she first tried to reason with the girl with intellectual and behavioral challenges. But Shanttia attacked her, Borden said in a report she filed. She said she had to place the girl in a “bear hug,” a minimal restraint that Devereux staffers are trained to use.

Next, Borden escorted Shanttia to the staff nurse for an exam — a “body check” for any possible restraint-related injuries, which is standard at Devereux. Inside the nurse’s office, the girl complained of some arm pain and the nurse gave her an ice pack. Borden explained how she was forced to restrain Shanttia after she got violent. The teen echoed Borden’s account.

Borden put this all in her incident report. That likely would have been the end of the story, if not for the throbbing pain that brought Shanttia to tears the next day and her grotesquely swollen elbow.

Devereux took Shanttia to a nearby hospital, where an X-ray revealed a fractured arm. At that point, a Devereux employee alerted ChildLine of suspected abuse.

Law enforcement authorities reviewed video of the incident.

The video shows Shanttia near an exit door. Borden runs over and yanks the girl by her arms. Borden puts her in a bear hug and places the girl in her room, holding the door shut so she can’t leave. Once Borden walks away, Shanttia emerges. Borden attacks her from behind, hurling her down. Shanttia is on all fours as Borden knees her, again and again, each time the girl tries to stand, according to court records.

Borden’s earlier restraint report was a work of fiction, according to police.

“In the incident report, Christina said that Shanttia assaulted her, that she was being aggressive, pulling at her clothes, trying to bite her, was hitting her and that she charged at her,” said Erin O’Brien, a prosecutor with the Chester County District Attorney’s Office. “None of that is borne out by the video. It’s just not.”

Marian Grischott with her daughter, Rose, at their home in Lebanon County. While at Devereux, a staffer whipped Rose with a cell-phone charger cord.
LAUREN SCHNEIDERMAN / Staff Photographer
Marian Grischott with her daughter, Rose, at their home in Lebanon County. While at Devereux, a staffer whipped Rose with a cell-phone charger cord.

“There’s no oversight — the way that the incident reports are written and submitted, no one ever would have pulled the video [to check] if Shanttia hadn’t had that serious injury,” O’Brien said.

Borden had even convinced the girl that she was to blame, causing her to parrot the words that Borden used in her false report. Shanttia repeatedly told authorities she was sorry for her bad behavior, O’Brien said.

The video also reveals two staffers, Monique Scott and Solgie Barbar, watching Borden batter the girl, court records show. They don’t intervene or report the abuse.

Four hours after she assaulted Shanttia, Borden whipped three girls, ages 12, 16, and 18, with a cell-phone charger cord. Again, staffer Scott watched as Borden chased the terrified girls in and out of their rooms. Borden took off a shoe and cornered one girl in a bedroom closet, then threw her shoe and the girl’s doll, hitting her in the head and making her cry, according to police records. On the video, Scott appeared to egg Borden on, O’Brien said.

It was only by chance that evening that a Devereux nurse visited the floor to see another child and noticed the welts on the girls’ arms before they faded and made a report to ChildLine, O’Brien said.

Referring to this case, O’Brien said, “I think just the culture of Devereux at that facility is, or was at that point, just not to get involved, just to mind your own business.”

A judge sentenced Borden to a maximum of 23 months in prison. Scott pleaded guilty to child endangerment; Barbar pleaded guilty to failure to report child abuse. Both got probation.

The mother of Rose Grischott, one of the three girls whipped by Borden, said she wasn’t alerted to the abuse by Devereux officials, as state law mandates, but from Buchmann.

Marian Grischott said her daughter had just turned 18 and was back living in the family’s Lebanon County home when the detective called.

The Grischotts had adopted Rose at age 2. She was born with fetal alcohol syndrome and Cornelia de Lange syndrome, a genetic disorder that slows growth and causes intellectual disabilities. Doctors later diagnosed her with autism, pica and self-harming obsessive-compulsive disorder.

After talking to the detective, Grischott sat down and talked to her daughter. Rose told her that Borden often tormented her and ripped up her drawings of horses and tore family photos. She said Borden took away her puzzles, coloring books and the sensory “fidgets” she used to keep from picking at her skin, her mom said.

Rose identified Borden as her attacker during the criminal trial. The girl sobbed after leaving the courtroom with her parents. “I didn’t want to talk about her,” she wailed, Grischott recalled.

In a recent interview, Devereux’s Fernandes acknowledged that there was a “cluster of incidents in 2018,” including “fight club.” Since then, Devereux has tightened oversight: For example, supervisors now try to match all incident reports of restraints to video footage, if available, to check that they line up, Fernandes said.

‘They let it happen’

When Devereux staffers and supervisors fail to report abuse to authorities, the burden falls squarely on the parents’ shoulders.

On Jan. 6, 2020, Tom Hackenberg was on his job trimming trees near Pittsburgh when a Devereux supervisor called him around 2:30 p.m. to tell him that his 15-year-old adopted son, Wayne, had to be restrained at the Glenmoore campus.

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LAUREN SCHNEIDERMAN / Staff Photographer
“There was nothing but blood and bruises…. There was this other mark where they basically curb stomped him.”
Tom Hackenberg
Hear their story

Wayne had a few bruises on his face from going to the floor, he recalled the supervisor telling him, and Hackenberg wasn’t overly worried about what was portrayed as minor injuries.

“He said he might have a small concussion and he wanted Wayne to go to the hospital to get checked out, but Wayne was refusing to go,” Hackenberg recalled.

Hackenberg asked him to put Wayne on the phone. “I don’t want to go nowhere with nobody,” he said his agitated son told him. “I don’t want anyone around me.” Pleading, Hackenberg finally convinced Wayne, who has autism and an IQ of 50, to go to Brandywine Hospital with a female Devereux staffer the boy trusted.

This photo of Wayne Hackenberg was taken the night of Jan. 6, 2020 after a Devereux staffer allegedly stomped on his face after he threw Wayne against a brick wall, causing the boy to fall to the floor.
Courtesy of The Hackenberg Family
This photo of Wayne Hackenberg was taken the night of Jan. 6, 2020 after a Devereux staffer allegedly stomped on his face after he threw Wayne against a brick wall, causing the boy to fall to the floor.

Crying as he drove east, Hackenberg arrived at the hospital around 6:30 p.m. when Wayne was getting X-rays. “It’s really bad,” Hackenberg said the Devereux staffer told him. “What happened to him should have never happened.”

When he saw his son, Hackenberg was aghast. “A boot print was across his face, all the way down,” Hackenberg recalled. “There was nothing but blood and bruises…. There was this other mark where they basically curb stomped him.”

Hackenberg dialed 911 for the West Brandywine Police, something Devereux staff had not done. A police officer came to the hospital.

Wayne Hackenberg was allegedly assaulted by a Devereux staffer on Jan. 6, 2020. This photo was taken the night Wayne was taken to the hospital for treatment.
Courtesy of The Hackenberg Family
Wayne Hackenberg was allegedly assaulted by a Devereux staffer on Jan. 6, 2020. This photo was taken the night Wayne was taken to the hospital for treatment.

Tina Hackenberg called her husband around 9:30 to tell him she reported the assault to ChildLine. Tom Hackenberg informed the staffer, who excused herself from the hospital room, saying she had “to make some calls.” About an hour later, Tina Hackenberg said a ChildLine worker called her to say Devereux had just made a report — around nine hours after the assault.

Hackenberg signed Wayne out of Devereux that night.

The video shows a 26-year-old staffer named Tahir Carr pushing Wayne down a hallway, according to court records. Carr then throws him backward, causing Wayne to fall face first into a concrete block wall. After he falls to the floor, Carr stomps him in the face.

Carr has been charged with aggravated assault, simple assault, and endangering welfare of a child. Carr did not respond to a message seeking comment.

His attack on Wayne was “corroborated by several witnesses who were standing in view of these events,” according to the criminal complaint. “All the staff members who watched and turned away did it to him as well,” Hackenberg said. “They let it happen.”

Bruises, burns, and wounds

In May 2019, Devereux supervisors provided staffers with enhanced training on client abuse and neglect, with an emphasis on their duty to immediately report any suspected abuse to ChildLine. DHS regulators reviewed the beefed-up training, which grew out of the 2018 “fight club” incident, and signed off on the plan.

But two months later, another incident went unreported.

On a hot, sunny Saturday in July 2019, 16-year-old Ava left Devereux’s West Chester campus and went home for a visit. Ava’s mom, Angie Coggin, discovered a dark purple bruise on Ava’s left foot from her ankle to her toes.

“What on earth happened?” Coggin asked. Ava, who has cerebral palsy and autism, can only communicate by typing or clicking on suggested words that are converted into computerized speech on her iPad.

“I got hit,” Ava replied on her device.

When Coggin called Devereux for answers, “they were trying to tell me her shoe was too tight.” Coggin, a nurse, knew that couldn’t explain the injury.

A few days later, the principal at Ava’s school told Coggin that she had heard a woman, recorded on Ava’s talking device, threaten to push the girl in her “motherf— face.” The principal told her it was very disturbing.

Buchmann, the detective, obtained surveillance video from July 26, 2019. It shows staffer Andrene Bennett-Wint pushing Ava, striking her with a hairbrush, and shoving a chair into her knees and waist, court records show. Staffers Cecelia Gbor and Tyrena Adams witnessed the assault, but did not report it.

At Devereux, Buchmann was unable to communicate with Ava. “She came to the interview without her talking device and she appeared very lethargic and out of sorts,” he said. “She could barely keep her eyes open.”

Bennett-Wint told the detective she didn’t hurt Ava, that Ava was abusing her. Then Buchmann played the recording on Ava’s iPad. Bennett-Wint was shocked to hear her own voice. She started to sweat and placed her shaking hands on her lap, according to the affidavit of probable cause.

Buchmann then played the nine-minute video of her assault, and Bennett-Wint changed her story: She struck Ava on the “spur of the moment.” Last month, Bennett-Wint pleaded guilty to endangering the welfare of children and was sentenced to three years’ probation. Adams was sentenced to two years’ probation for failure to report. The case of Gbor, also charged with failure to report, remains open.

About a month after the assault, and after Buchmann had confronted Bennett-Wint with the video and audio, Coggin saw a scab on Ava’s foot that looked like the result of a serious burn.

Using her iPad, Ava told her that a staffer had scorched her with a curling iron, Coggin said, according to police. When she called Devereux, she said she was told, once again, that Ava’s shoes must be too tight. When Buchmann investigated, he said that Devereux supervisors told him that they were unable to retrieve the video from the time period he requested.

Then not long after, Coggin noticed a wound in the middle of Ava’s back. Coggin said a Devereux staffer told her that Ava had rolled around in gravel. But the girl told her mom she was outside at a picnic table when a staffer scraped a fork down her back. Coggin called ChildLine. When he investigated the alleged incident, Buchmann said he was told there was no video coverage of that area.

Since the string of incidents, Ava has regressed drastically, Coggin said. She has escaped from Devereux at least five times, and sometimes was found rolling on an asphalt road. “At school she went from straight A’s to where they couldn’t even keep her in class,” she said.

Her daughter started eating feces and attacking other kids and staff at her school. “She hadn’t had any incidents of aggressive behavior, but when this happened, it was like, boom!”

Coggin is trying desperately to find another residential treatment center for her. She’s been told the only facility willing to take her is in Ohio.

“At school she went from straight As to where they couldn’t even keep her in class.”
— Angie Coggin

“Just because she has aggressive behavior disorder, it doesn’t give anyone the right to treat her the way she’s been treated,” she said. “Bottom line is she’s a child with a disability. If you choose to do this as your career, you have to go in with the mindset that you’re going to help these kids, not harm them.”

ChildLine has been alerted at least three times that Ava allegedly was abused, Coggin said.

“If I had done this, I would have lost my nurse’s license, lost my kids,” she said. “I’d have someone at my house that very day. They wouldn’t let it go on three times. They wouldn’t need video evidence. I’d lose it all.”

Page 1 of Devereux staffer Andrene Bennett-Wint
Contributed to DocumentCloud by James Neff (Philly.com) • View document or read text

DHS cited Devereux for suspected child abuse and failing to report Bennett-Wint’s assault on Ava in the Glenloch building. Once again, Devereux assured DHS officials that Glenloch staffers would be retrained on “interrupting any perceived mistreatment of children,” and “abuse reporting procedures.”

In a Nov. 21, 2019 letter, DHS accepted Devereux’s plan and renewed its license for the Glenloch building.

Broken trust

The abuse of Seth Oram, however, apparently stayed under the state’s radar.

On July 5, 2019, police charged a staffer in the Goldsmith dorm on the West Chester campus with repeatedly punching 17-year-old Seth in the head a month earlier. Three days later, on July 8, Devereux submitted a renewal application for the Goldsmith building.

DHS dropped the license in the mail on July 10, with the regulatory caveat that the agency could pull the license or issue a provisional one, if inspectors later found problems.

DHS inspectors spent three days — July 24, 25, and 26 — at Goldsmith. They found Devereux in violation for allowing one Goldsmith staffer to work with children before completing orientation, according to the inspection summary report. The report didn’t address what happened to Seth.

Seth had been living at Devereux just over a year when his mother, Chris Oram, received an email from a Devereux nurse in June 2019. She wrote that she was called to check on Seth at 9:15 that morning. “He has a 2cm scratch on the top of his head left of center. It is not deep but it did bleed a little. He also has three scratches on his right side-mid back. An investigation is being done to find out how these injuries occurred. I applied Neosporin to the areas and will monitor.”

“It didn’t sound like it was a big deal,” Oram recalled.

A program coordinator called her to say a staff member had hit him, but still Oram didn’t understand the severity until Buchmann called and told her. She started to sob hysterically.

In a video, Seth, 5-foot-8 and only 118 pounds, enters an office, followed by 39-year-old staffer James Summerville. Less than a minute later, Seth leaves the office, visibly upset, holding his head. He runs to staffer Stephanie Boyd. Summerville then exits wiping his hands.

Boyd would later tell Buchmann that Seth was “beet red.” She asked him what was wrong. “I’m sorry,” he told her, and started to cry and cradle his head. He told her it hurt.

Boyd alerted another staffer, who saw that Seth was bleeding from a gash on his head. Boyd later told Buchmann she suspected that Summerville had hit him. Boyd and two other staffers went into an office to discuss how to report the incident, and eventually did so. Seth was with them.

Meanwhile, in walked Summerville. “Who you talking to?” Summerville asked the boy, according to the criminal complaint.

Then Summerville took a closed fist, his middle knuckle sticking out, and punched him in the head, directly into the wound. Seth fell to the floor.

Boyd screamed at Summerville and ordered him to leave the room. Seth crawled toward her and wrapped his arms around her legs.

During the interview with Buchmann, Boyd cried. She later told him it made her “heart drop.”

Chris and John Oram, of Sinking Spring, had taken Seth into their home when he was 10 days old. Born five weeks early, he was one of Chris’ patients in an Ohio hospital where she worked as a nurse in the neonatal intensive care unit.

The Orams would learn that Seth has fetal alcohol syndrome, autism, mild cerebral palsy, feeding problems, seizure disorder, attention deficit disorder, and a severe intellectual disability. With an IQ around 40, he knows his name, but not colors, letters or numbers. He knows about 50 words and can manage sayings like, “I love you, mom,” or “I want pizza,” she said.

Two years ago, his in-home therapeutic support staff was no longer funded, and Chris was battling thyroid cancer while her husband underwent open heart surgery.

“We were at the point we couldn’t care for him anymore,” she said. “That’s why he ended up at Devereux.”

On visits, the Orams noticed that Seth always had a lot of bruises. Staffers told them that Seth was clumsy and tripped a lot.

“I never wanted to think that anyone would hurt my son,” she said. “You put your trust in them. It’s something you don’t want to think about.”

She could rationalize the bruises on his legs. “But I couldn’t understand the ones on his back, the middle of his back,” she said.

The same day that Wayne Hackenberg was assaulted, Chris Oram stood before Judge Jeffrey Sommer in Chester County Common Pleas Court to describe how Seth still blames himself.

“I never wanted to think that anyone would hurt my son. You put your trust in them. It’s something you don’t want to think about.”
— Chris Oram

She told Sommer she’s tried to explain to Seth that being beaten wasn’t his fault. “He just does not have the ability to process that,” she said. “The only thing he would say is, he would try to punch himself in the head and he would say, ‘I was bad,’ and ‘Don’t tell.’

“Those are the only words that we could ever get from him about it. This kind of broke our hearts.”

She wants to know how people like Summerville pass a screening test to work with special needs kids. “I don’t understand what kind of person takes that type of job and has that evilness inside them. Is that why you took the job because you can do this kind of stuff to children who can’t tell anyone?” she said in an interview.

“I want Devereux to be held accountable,” she said. “They need to look at their hiring, training, and monitoring practices.”

Reflecting on her son’s experience, she said: “They need to be upfront with families when the children are hurt. They need to be open and honest. The lack of information makes it worse.”

Devereux declined repeatedly to answer questions about specific cases. The company has noted it has added safety measures since 2018.

After the assault, Seth often had night terrors, and he started to bite his arms again until they bled.

“I could not protect my son from this assault,” she told the judge that January day. “I feel like I…” Unable to finish, she asked assistant district attorney Emily Provencher to read the rest of her victim-impact statement.

“I feel like I have failed as a parent, especially the parent of a special needs child. I feel helpless and inadequate,” the prosecutor read. “After every visit with Seth, I go home depressed and often cry all the way home. I don’t know if I will ever, ever be able to forgive you for assaulting my helpless son. I can’t say that I will be happy with the outcome today, but I am hoping that giving this statement will start the healing process in our household.”

After pleading guilty to simple assault, Summerville was sentenced to three years’ probation.

The Orams moved Seth, now 18, to a group home in a Philadelphia suburb in August.

“I’m scared,” Seth told his mom that day as they celebrated with pizza and cake. “These people could hurt me too.”

The last stop

After the 16-year-old autistic boy was beaten in the darkened living room, his father visited and was heartsick.

“He was like keeping his distance from us,” the man recalled. “It’s something that’s not normal, as if he’s afraid of us.” When a staffer held out a cookie, the boy wouldn’t come closer to take it.

Prosecutors charged Satimehin, of Delaware County, with aggravated assault, simple assault, and child endangerment. He declined to comment after a recent court hearing.

On Sept. 13, a day after Satimehin’s alleged assault, another incident took place in the same dorm. A staffer placed a boy in another child’s bedroom and left to help other children shower. A half-hour later, the boy, whose treatment plan called for 24-hour supervision, “was found laying naked with another child,” according to a state DHS licensing inspection summary.

In each case, Devereux launched an internal investigation and fired both staffers. Devereux also submitted plans of correction to the state; both involved more staff training. Devereux said it would train all staff on a new “client supervision hand off procedure” and institute a “shower plan,” with increased staffing, at that dorm. In the case involving Satimehin, Devereux said it would give all overnight supervisors access to recorded video and increase camera reviews, including “all restraints.”

In a one-paragraph form letter, a DHS regional director deemed each plan “acceptable.”

Meanwhile, Devereux’s Fernandes said of the 53 children that Philadelphia officials had pledged to relocate, only three families now want their children moved. And for those families, options are few, she said.

“Devereux has a long history of taking the most behaviorally intense kids,” she said. “There’s no other provider that will take them.”

The kids who end up at Devereux have “exhausted” other treatment routes. “We,” Fernandes said, “are the last stop for these kids.”

*Former staff writer Lisa Gartner contributed to this article.

Barbara Laker is a reporter on the investigations team who digs deep into a host of topics, hoping to break new ground and uncover injustices. Reach her at blaker@inquirer.com or 215-854-5933.

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