The inspector, Haiying Xi, wrote a report with a candid disclosure: The Department of Human Services, he said, had given him no clear standards to assess whether kids were safe in out-of-state centers.

Still, he gave Lake Grove at Durham a passing grade. On the very same day, May 9, Connecticut announced it would begin pulling its own children out, saying the state's child advocate had found problems in medical care "so grossly serious as to create risk of possible injury or death."

Connecticut said it had informed other states of its intention to move its kids out by Sept. 15, though the facility remains open. Philadelphia moved its three clients in November.

Despite a changeover in management and a spate of improvements at DHS, the Lake Grove files illustrate how the agency still struggles to ensure the safety of vulnerable children placed in out-of-state treatment facilities.

Some of Philadelphia's most psychologically troubled children, sent outside the state for treatment and care, have been killed, sexually assaulted, sent to emergency rooms with broken bones, and entrusted to staff who are former convicts, according to records, lawsuits and interviews.

Since 2000, five children from Philadelphia have died in out-of-state homes or institutions - one of them after an overhaul that began 18 months ago, when The Inquirer revealed the agency's poor record in protecting vulnerable children.

Since then, DHS has undertaken the most sweeping changes in its history. Officials have rechecked kids under their care, cleared out poorly performing contract agencies, and raced to arm caseworkers with better methods to assess when children face danger at home.

And last week, members of an oversight board said DHS had made much progress in how it tackled safety. But some board members, and the state's welfare director, said the city had a way to go to keep kids safe in far-flung institutions.

"This is an issue we're going to take a look at," said Carol Spigner, who leads a DHS oversight panel.

Even today, Philadelphia has kids in a Colorado facility where DHS inspectors found that youngsters were kept in isolation rooms and strapped into a "restraint chair" - the same model that the U.S. government uses to force-feed suspected terrorists in the prison at Guantanamo Bay, Cuba.

The Inquirer began a review of out-of-state facilities used by DHS after 17-year-old Omega Leach, sent to a Tennessee institution, died last summer in a struggle with a staff member.

Documents and interviews show the agency routinely misses critical signs of danger in out-of-state juvenile centers or, worse, notes the problems but fails to do anything about them.

Among the findings:

The city's system for ensuring the safety of kids is fragmented and chaotic, with the responsibility for guaranteeing safety divided among three sets of social workers who rarely communicate.

Philadelphia doesn't check the regulatory files in states that oversee treatment centers it uses. At least twice, records show, other state regulators found institutions unsafe and removed their children - while Philadelphia continued to house kids there.

Even when its own reviews raise serious concerns, DHS is often slow to act. In at least three cases, the city removed children only after someone died, and even then took months to do so.

Acting DHS Commissioner Arthur C. Evans, who took over in late 2006, said the department had taken some important steps, one of them a new committee to comb through reports for signs of overlooked problems.

The department also now requires centers tell it when children die, even if they are not from Philadelphia, and plans to inspect troubled facilities more frequently. This month, an independent agency hired by DHS began to interview kids in institutions.

"If you look at any place in the country, we are doing as much to make sure kids are safe," Evans said.