While an investigation cleared Chad of blame in the death, New York and Tennessee stopped sending children to the residential treatment center.
But Philadelphia, despite a drumbeat of warnings that children were being violently subdued and injured, continued to send emotionally troubled children to Chad.
The city's Department of Human Services stuck with Chad even after a top DHS official concluded that "residents were being harshly and improperly restrained."
Not until the June death of 17-year-old Philadelphian Omega Leach did the city finally lose faith.
In a physical restraint gone wrong, Leach died after Chad staff pushed him face-down to the floor, apparently cutting off his air, investigators say.
When done safely, restraints can calm youths who are out of control and prevent children from hurting themselves or others.
But when they go wrong, these "holds" can be brutal. They can dislocate a shoulder, split a chin or snap an arm. In extreme cases, they can kill.
On the day Leach died, Philadelphia had 44 children and teens in Chad, all under DHS oversight. The Philadelphians - some from abusive homes, others with arrest records - made up the biggest share of 85 residents who slept, attended school and got therapy at Chad.
Since 2001, the city has sent scores of youngsters to the center, saying it has been forced to do so because no Pennsylvania facility would take them. It has paid Chad $6 million in the last three years.
Arthur C. Evans Jr., the acting DHS commissioner, took command late last year after Mayor Street ousted its top official following an Inquirer investigation into a string of child deaths in Philadelphia.
"A good facility should not rely on restraints," Evans said. "This is really unacceptable."
Further, he said, his agency's oversight of Chad was also unacceptable.
