"He just punched it, and crack, I went down," she said in an interview at her home in Blackwood, Camden County. Afterward, Costello said, staff refused to let her call home, telling her parents that she had fallen.

A DHS inspection report in 2002 found the center was struggling to "safely and effectively manage the behavior" of the kids from Philadelphia.

By 2003, police complaints about the center's teens were stacking up, and a hospital reported a spate of High Pointe kids showing up injured at its emergency room.

But DHS continued to rely heavily on High Pointe. In 2003, Philadelphia kids occupied more than half the institution's 130 beds.

It took the death of Jerry Trivett for regulators to pay attention.

The 15-year-old from Johnstown, Pa., was born with a slew of conditions that had damaged his lungs, twisted his body, and gave him rages that were hard to control.

Just 4 feet tall, Trivett had been through more than 20 foster homes before landing in a Cambria County shelter in 2003. Social workers called 57 centers before they found one willing to take him: High Pointe.

Less than three months later, another resident slammed the boy to the ground.

Trivett was having trouble breathing and asked to go to the hospital. The staff told him, "Not today - maybe tomorrow," according to an Oklahoma investigative report.

Later, his lips turned blue. But staff didn't call an ambulance until he went into convulsions.

By the time he arrived at the hospital, Trivett had stopped breathing.

Five nurses were disciplined for failing to provide adequate care. One, it turned out, had spent five years in prison for drug dealing.

While Philadelphia did move some children right away, the last one did not leave until High Pointe was forced to close nine months later.

Evans wouldn't comment on DHS's actions before he took over. Former Commissioner Alba Martinez said that during her tenure, the agency also had regularly visited centers and moved children if one was found unsafe.

She did not recall the specifics surrounding High Pointe but, like Evans, said it was difficult to find spots for the most damaged children.

"I was not happy with the lack of alternatives so we could remove kids from facilities that were not good for them," she said.

Splintered oversight

Philadelphia has a fractured system of oversight, with responsibility for evaluating juvenile centers split among a patchwork of social-service offices.

The city's mental-health agency mostly makes sure facilities offer therapy and are licensed and accredited.