Dillon Kindling was 14 when the state took custody of him and placed him in institutions it had licensed to shelter and treat troubled teens.

Steve Mellon, Post-Gazette Dillon Kindling's mother tried to photograph the damage to his left arm, ring finger, shoulder and collar bone that occurred while he was in an Allegheny County group home and a residential treatment facility. In this collection of her snapshots, she tries to show his inability to straighten the arm completely and the scar running from his elbow nearly to his shoulder, a result of the compound fracture of his arm and surgery to repair it. Click photo for larger image. Day One One boy's history of broken bones Drug convictions no bar to working with abused and neglected kids Juvenile home incident-report flow rapped About the series and author Summaries of the incident reports reviewed for this series Inside the complaint system Day Two Who's telling the truth? Inside the complaint process Day Three Use of physical force on troublesome kids unchecked Restraints applied even when unneeded Hands-off policies ward off abuse Day Four Sex abuse is the product of a volatile mix Preventing group home runaways a daunting task Chaos often takes over in residential facilities Foster care more effective, safer than group homes Online discussion Read the transcript of an online discussion with series author Barbara White Stack.

Over the next eight months, while Kindling's safety was the responsibility of the state, his left arm, left ring finger and left clavicle were broken and his left shoulder was separated, all in separate incidents.

The first fracture occurred in a fight with another boy outside a Spectrum Family Network group home in East Liberty while the institution's solitary worker cooked inside.

The last, a fractured clavicle, occurred just after Kindling turned 15, when a worker knocked him to the floor while trying to restrain him at Southwood Psychiatric Hospital's residential treatment facility in Upper St. Clair.

After that, a judge gave Kindling back to his parents. He hasn't been injured since.

Kindling's experience is an extreme example of what happens routinely in the 961 institutions the state licenses to house and care for abused, neglected, unruly, delinquent and mentally ill children. Youngsters get hurt; they're sexually assaulted; they run away.

The Department of Public Welfare is responsible for ensuring the safety of the 8,890 Pennsylvania children living in institutions at a cost to taxpayers of more than $1 million a day. That's because it licenses group homes, residential treatment facilities, reform schools and detention centers.

But the imprecise way that the DPW gathers information about injuries at the institutions, the disorganized manner in which it stores that information and its failure to analyze it with even the simplest of computer programs all mean that the DPW grants licenses without having crucial data about safety.

It doesn't know, for example, how many children in state-licensed homes were physically restrained last year or how many children's bones were broken in those restraints; how many children ran away from institutions and how many of them were killed or injured after fleeing; how many youngsters had sex with other institutionalized youngsters or how many of those incidents were forced.

The Pittsburgh Post-Gazette was able to piece together a partial picture, which shows at least 77 children were injured or molested by workers at homes run by 13 Allegheny County institutions over the past seven years.

But those figures include only incidents in which the DPW determined that institutions had violated state regulations. That's a tiny percentage of the total number of children hurt or assaulted because it doesn't include hundreds of cases in which the DPW decided the circumstances did not violate state rules. None of Kindling's injuries are included, for example.

The DPW's licensing system is focused solely on the physical, whether the water temperature is too high or the bedrooms too small, while completely ignoring end results, whether a child was better or worse after his stay in the home. While the DPW is required by state law to examine an institution's physical characteristics, nothing forbids it from going a step further and evaluating the quality of treatment, particularly in institutions that call themselves residential treatment facilities.

Assessing quality, however, would add work to a licensing system that's already overwhelmed. DPW inspectors for children's homes carry immense workloads and have paltry enforcement sanctions compared with inspectors for nursing homes.

DPW inspectors rarely determine that agencies have violated state rules.

They checked all four of the incidents in which Kindling was injured, and decided neither institution had done anything wrong. Despite that conclusion, Kindling won civil settlements from both places.

Outmoded tools
The inspectors work with obsolete tools -- pens, paper and manila folders. They don't have the most basic computer programs that would enable them to track problems, automatically flagging where they occur, how often and who repeatedly injures children.

And DPW inspectors rarely impose the few sanctions they've got. In the past five years, Allegheny County's Office of Children, Youth and Families suspended admissions to nine institutions for brief periods while CYF awaited proof the homes had resolved problems as serious as child safety and as technical as car insurance. The state hasn't done it once. And that means other counties and states continued to send children to the very institutions CYF deemed substandard.

In this licensing environment, serious problems recur. The Post-Gazette discovered by conducting a computer analysis of DPW records and gathering information from other sources that children suffer repeatedly. For example:

Two years after a worker broke Kindling's clavicle, another staff member at Southwood injured a child by picking him up and carrying him by the neck.

In April, May and June 2002, a worker at a Holy Family Institute group home in Emsworth sexually abused a 16-year-old girl. Six months later, another staff member was charged with sexually assaulting a 15-year-old girl.

In May 2004, a worker at Pressley Ridge, a non-profit social service agency operating group homes, was criminally charged with breaking the arm of a 14-year-old. In May of this year, another Pressley Ridge staff member was criminally charged with breaking both of a 14-year-old's arms.

In January 2000, at the Auberle group home in McKeesport, a child's ear was so badly lacerated in a restraint that it required stitches. In January 2003, an Auberle worker punched a child during a restraint, followed six months later by a worker choking a child during a restraint.

Also at Auberle, a staff member was convicted of involuntary deviate sexual intercourse for having sex with a 16-year-old group home resident in 2002. Six months later, another girl told her therapist she'd had improper sexual contact with a staff member, a report that state investigators believed.

In October 2002, three girls ran away from the Three Rivers Youth's Dithridge Shelter. In October 2003, eight girls ran.

In 1999, a staff member at what is now a FamilyLinks facility got in what the DPW called a street fight with a child, with the two punching each other. In 2002, a FamilyLinks staff member and child engaged in a shoving and punching match.

In an interview earlier this month, DPW Secretary Estelle Richman didn't defend the agency's regulatory record. She wants improvements.

When she took over in January 2003, she said, she found the DPW's Office of Children, Youth and Families, called OCYF, to be in particularly poor shape.

"As I got into DPW and began to look at the different departments, OCYF looked as if it had not been managed in many ways for quite a while," she said.

She wants a computer system. She wants institutions evaluated based on quality of services. She wants strict enforcement and serious penalties imposed for violations.

But she's far from achieving these goals. She hasn't even named a director for OCYF since the previous one left in April.

Extra care required
When states take custody of children such as Dillon Kindling, they assume special obligations, said Madelyn DeWoody Freundlich, a lawyer and expert on child welfare issues who serves as policy director for the national advocacy organization, Children's Rights.

"States have a heightened level of responsibility for the child's safety when they contend they've taken the child to protect him from parents," she said.

A federal court has ruled that states bear that obligation even when the child is delinquent. Detention centers have "a duty to protect detainees from harm (whether self-inflicted or inflicted by others) and provide, or arrange for, treatment of mental and physical illnesses, injuries and disabilities," the 3rd U.S. Circuit Court of Appeals ruled last year in a Luzerne County case.

Freundlich found it incredible that the DPW gathers information on children in homes but doesn't analyze it to determine how many times children get into fights and which institutions have the most incidents.

"How can these questions not be answered if the system is truly accountable?" she asked.

"Why isn't the state asking these questions?"

A challenging group
Children in the institutions the DPW licenses almost always have something in common with Dillon Kindling -- behavior problems or mental illness. Often they've been rejected by a series of foster parents. They're the difficult ones.

For that reason, institution directors say, child injuries are virtually unavoidable.

Still, the entire purpose of a group home or residential treatment center is to deal with the hard cases. And they're paid well for it. While foster parents get $25 to $30 a day or twice that for a child with problems, group homes and treatment facilities are typically paid $130 to $500 a day per child.

John Patrick Lydon, chief executive officer at Auberle, one of the largest institutions in Western Pennsylvania, says 99.9 percent of group home workers love children and want to do right by them. "I have had staff say to me that they would sooner hurt themselves than a child," he said.

And group home directors tell heartwarming stories about teens they help. Three Rivers Youth, for example, continues to support young adults who have moved out of the foster care system at 18 and are in the military or college.

Even so, the question remains: How many aren't helped? How many are hurt? What facilities hurt children more often? Which deserve better funding because they hurt children less often? How many Dillon Kindlings are there?

The DPW doesn't know.

Institutions must tell the DPW when a child dies, attempts suicide, is treated at a hospital, has sex with another child, runs away, gets arrested or experiences a violation of his rights.

But this self-reporting system is faulty.

For instance, the state might never know if an agency conceals an incident by failing to file a report.

And there is clear evidence that agencies don't file reports every time they are required to. For example, Shuman Juvenile Detention Center didn't report that two staff members broke 13-year-old Crystal McDonald's arm on Oct. 24, 2000.

If an institution learns of a problem after the child leaves, it doesn't have to file a report. For example, when a child returned home and told her mother she had been having sexual encounters with a worker at Three Rivers Youth, the agency didn't have to mention it to the DPW.

And finally, an agency might file a blatantly false report. Summit Academy, a Butler County facility that houses mostly delinquent children but takes some abused youngsters, told the DPW this summer that a child was seriously injured when he tripped and fell face first into glass covering a fire extinguisher box. Witnesses have since told police that a staff member shoved the child into the glass.

Few problems found
After it investigates an incident, the DPW rarely concludes there was a problem.

For instance, when Kindling's arm was broken during the fight at the Spectrum Family Network home on Sept. 7, 2000, the home's report said "the staff on duty at the time of incident were Marshall Clark and Eugene Tyler." But Clark would say in a sworn deposition later that he was alone with the boys at the home that afternoon, and, as a result, was not directly supervising them while cooking their dinner.

The DPW found no problem with that.

Over a seven-year period ending in June, among approximately 9,500 reports it received concerning Allegheny County institutions, the DPW found 85 violations at homes run by 13 institutions, a rate of one transgression for every 115 reports.

At another 17 mostly smaller institutions operating homes in Allegheny County, the DPW found not a single violation.

The failure to find any problems over seven years might be explained in part by another figure, the number of inspectors the DPW hires.

There are 13 for the Western Region, which covers 23 counties stretching from New York to West Virginia. They receive an average of 195 reports a month. That means every inspector is responsible for checking 15 incidents a month as well as completing annual licensing inspections for 42 homes, nearly one a week. As a result, DPW inspectors investigate some incident reports with just a telephone call.

The DPW inspectors' average case load of 42 homes compares unfavorably with that of their colleagues at the state Department of Health, who are responsible for an average of six nursing homes each.

Remarkably, the DPW's western regional office took no licensing action against the home that had the most violations by far, Holy Family Institute, which had 20 over the seven-year period.

The next highest was Shuman Juvenile Detention Center, with 15; Auberle, with 12; FamilyLinks, with 9; The Academy, with 8; Cornell programs, with 7; Western Psychiatric Institute and Clinic children's programs, with 4, and Three Rivers Youth with 3, and Pressley Ridge and Spectrum each with 2.

Bradley, Circle C and Southwood each had one violation.

The violation numbers raise the question of why the DPW continues to license the operation of homes with numerous transgressions when others have few or none.

In fact, even when the DPW finds a problem, it rarely uses the few tools it's got in its satchel of sanctions -- suspending admissions, removing children, downgrading a license or revoking a license. Even the weakest action, downgrading a license to provisional, which results in little more than the annoyance of twice-a-year inspections, is rare.

In the past seven years, the DPW issued more than 600 licenses to Allegheny County agencies, but only 24 of those were provisional because of violations. In addition, more than half of the provisional licenses, 13 of 24, went to homes run by one institution, Three Rivers Youth. Several of Three Rivers' provisional licenses were a result of sexual misconduct by one staff member.

While the DPW docked Three Rivers after the sexual assaults there, it didn't downgrade the license status at other institutions where assaults occurred.

After two sexual assaults that led to criminal charges against workers at Holy Family and one at Auberle, the DPW did not reduce their license status.

Though the DPW doesn't sanction institutions aggressively to begin with, its enforcement efforts are hampered by its inability to impose fines or routinely conduct surprise visits.

The state Health Department, by contrast, almost never provides notice of its inspections of nursing homes and can fine those that violate rules.

The Health Department has another advantage over the DPW as well: Access.

Family members, friends and Aging Department ombudsmen are in and out of nursing homes all the time. Ombudsmen, 464 volunteers across the state, don badges and check nursing homes, unannounced, anytime they please, providing a level of vigilance completely absent in children's institutions.

		The complaint process When children are hurt at group homes, residential treatment facilities and other institutions, the agency directors must report to the state Department of Public Welfare. DPW then investigates these reports, and in instances where it determines a state law or regulation was violated, it writes the institution describing the problem and asking how it plans to prevent a recurrence. The institution then responds to DPW explaining what it did or plans to do to correct the problem. To illustrate this process, here are documents exchanged between DPW and a Pittsburgh group home: The correspondence begins in Dec. 2003 with a letter finding no basis for complaints of verbal and physical abuse, and lack of food at the home. The next summer, a DPW document outlines three violations found during an inspection based on another complaint. These include physical abuse, exposure to a hazardous chemical and use of tobacco. A month later, a follow-up letter notes seven additional concerns in addition to the three violations. Two weeks later, the group home outlines more than a dozen procedural changes in a plan of correction. The Post-Gazette obtained these sets of correspondence from DPW for Allegheny County institutions for the period of 1998 through July 2005 by filing requests under the provisions of the state Right to Know law. DPW redacted the names of children and workers from the files. The Post-Gazette obscured official signatures to deter misuse.

Kurt Emmerling, bureau chief for the Allegheny County Area Agency on Aging, said he felt the same model would work for children's homes. "Eyes on is a good thing to prevent risk," he said.

Richman said she did not approve of timid licensing or sanctioning.

"Why not put your foot down?" she asked. And, she said, she wanted the state to give the DPW the right to fine institutions for children.

The secretary acknowledged the common contention that homes for children can't be closed because of difficulty finding new places for the youngsters. "But you don't let kids get hurt just because someone says there's no place else for the kids to be," she said.

Still, she was unaware of the small number of inspectors her department assigns to do the licensing and sanctioning.

Poor record-keeping
When those inspectors receive incident reports, they don'tshare the information with those responsible for placing children in these homes and they don't catalog the information in easily accessible databases.

That failure allows problems to recur, said Mark Courtney, director of the Chapin Hall Center for Children at the University of Chicago. "The only way to know if there is a problem is if you track and spreadsheet," he said.

The DPW spent about $20 million in state and federal dollars trying to set up a computer program in the late 1990s. The program didn't work, and the DPW ditched it in December 2001.

Just months later, the DPW office of mental retardation began setting up its own computer program to track incident reports at its 500 service providers across the state. Now those institutions can go online and fill out reports and send them electronically to the DPW.

The reports can be analyzed to show patterns of problems. For example, every restraint must be reported, so the office of mental retardation knows there were 400 in the last quarter, and it can easily determine if some places had far more than others.

Richman's staff is checking to see if the mental retardation tracking system can be converted for use by the Office of Children, Youth and Families.

She hopes it can, because she feels computerized information is crucial and doubts the Legislature will give OCYF much more money to accomplish that.

"We want to make the system more accountable, more sensitive," she said, "and a computer system must be part of that. Without data, it is incredibly difficult to manage."

Richman said she'd tried hard in her two years at the DPW to change an entrenched culture at OCYF. Some of those workers, she said, need to be reminded that their mission is improving the lives of children, which can't be done if they're not safe.

"We can't continue to let kids get hurt."

Tomorrow: Officials rarely believe the children.