comprehensive quality review report baltimore city juvenile justice center (jan 2011)

7/31/2019 Comprehensive Quality Review Report Baltimore City Juvenile Justice Center (Jan 2011)

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OFFICE OF QUALITY IMPROVEMENT

Comprehensive Quality Review Report

Baltimore City Juvenile Justice Center

January 20, 2011


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DJS QI Report Page i of 81

BCJJC


Quality Review Report


Evaluation Dates: December 1 - 10, 2010

TABLE OF CONTENTS

EXECUTIVE SUMMARY .............................................................................................. 1

Facility Strengths ............................................................................................................ 1QI Review Ratings Scale ................................................................................................ 2

QI Rating Percentage ...................................................................................................... 2

Executive Summary of Results ....................................................................................... 4Methodology ................................................................................................................... 5

SUMMARY OF FINDINGS & RECOMMENDATIONS............................................ 6

SAFETY AND SECURITY ............................................................................................. 6

Incident Reporting .......................................................................................................... 6Senior Management Review ........................................................................................... 8

De-Escalation & Restraint ............................................................................................ 10

Contraband & Room Searches ...................................................................................... 12Seclusion ....................................................................................................................... 14

Room Checks During Sleep Period .............................................................................. 16

Perimeter Checks .......................................................................................................... 18

Staffing .......................................................................................................................... 20Control of Keys, Tools & Environmental Weapons ..................................................... 22

Youth Movement & Counts .......................................................................................... 25

Fire Safety ..................................................................................................................... 27Post Orders .................................................................................................................... 29

Staff Training ................................................................................................................ 31

Admissions, Intake & Student Handbook ..................................................................... 32Classification................................................................................................................. 34

Pending Placement ........................................................................................................ 36

Behavior Management .................................................................................................. 37Structured Rehabilitative Programming ....................................................................... 40

Self Assessment ............................................................................................................ 41BEHAVIORAL HEALTH ............................................................................................. 42

Intake, Screening & Assessment ................................................................................... 42Informed Consent.......................................................................................................... 43

Psychotropic Medication Management......................................................................... 44

Behavioral Health Services & Treatment Delivery ...................................................... 45Treatment Planning ....................................................................................................... 46

Transition Planning ....................................................................................................... 47


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BCJJC




Evaluation Dates: December 1 - 10, 2010

TABLE OF CONTENTS(Continued)

SUICIDE PREVENTION .............................................................................................. 48Documentation of Youth on Suicide Watch ................................................................. 48

Environmental Hazards ................................................................................................. 50

Clinical Care for Suicidal Youth................................................................................... 51EDUCATION .................................................................................................................. 52

School Entry.................................................................................................................. 52

Curriculum & Instruction .............................................................................................. 54

School Staffing & Professional Development .............................................................. 56Screening & Identification ............................................................................................ 57

Parent, Guardian & Surrogate Involvement .................................................................. 59

Individualized Education Programs .............................................................................. 60Career Technology & Exploration Programs ............................................................... 62

Student Supervision ...................................................................................................... 63

School Environment & Climate .................................................................................... 64

Student Transition ......................................................................................................... 65MEDICAL CARE........................................................................................................... 66

Health Care Inquiry Regarding Injury .......................................................................... 66

Health Assessment ........................................................................................................ 68Medication Administration ........................................................................................... 71

Dental Care ................................................................................................................... 73

Medical Records Retrieval ............................................................................................ 75Special Needs Youth ..................................................................................................... 76

Availability of Medical Services .................................................................................. 79


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BCJJC

January 2011




EXECUTIVE SUMMARY

A quality improvement assessment and evaluation of the Baltimore City Juvenile JusticeCenter was conducted December 1-10, 2010 by DJS personnel who are subject-matter

experts in the areas reviewed. The areas that were evaluated have been identified asthose having the most impact on the overall safety and security of youth and staff. The

evaluation was based on information gathered from multiple data sources such as staff

interviews, youth interviews, document review and observations of facility operations,

activities and conditions.

FACILITY STRENGTHS

BCJJCs strengths lay in the foundation laid through the federal oversight process. Staffand managers learned and practiced youth supervision and recognition of violence

triggers and continue to practice those skills today. BCJJC youth are busy, with a myriadof activities and programming that fills idle time. The Boys Club, begun by the Boys and

Girls Clubs of America, is housed inside BCJJC and brings relevant, strengths-based

programming to the predominantly African American male population. Youth areconnected from BCJJC into their communities when they leave through the community

Boys Club. Mental Health staff provide counseling services, send youth out for referrals

when needed and are a strong part of the team at BCJJC. The Intensive Services Unit(ISU) provides structure to youth who cannot manage themselves on their unit; it also

provides a respite for staff from the most difficult youth. The friendly kitchen staff serve

delicious and nutritious meals and create meals for special occasions. The Case Managersprepare detailed court reports. Incident reports are organized and seclusion use must beauthorized and is within short timeframes. The unit and shift managers have detailed

knowledge of and concern for the youth who they supervise and a good working

knowledge of the policies DJS has established; they take pride in having established amore professional, youth-centered environment in what can be a difficult setting.


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QUALITY IMPROVEMENT REVIEW RATINGS SCALE

Superior Performance Strong evidence that all areas of practice consistently exceed the

standard across the facility/programs; innovative facility-wide approach

is incorporated sufficiently so that it has become routine, accepted

practice.

Satisfactory Performance Performance measure is consistently met across the facility/program;

any gaps are temporary and/or isolated and minor; documentation is

organized and readily available.

Partial Performance Expected level of performance is observed but not facility-wide or on a

consistent basis; implementation is approaching routine levels but

frequently gaps remain; facility had difficulty producing documentation

in some areas.

Non Performance Little or no evidence of adequate implementation of performance

measure; the required activity or standard is not performed at all or

there are frequent and significant exceptions to adequate practice;

documentation could not be produced to substantiate practice._______________________________________________________________________________________________

At the last QI Review of BCJJC in March 2009, 45 standards were evaluated. Following is a briefsynopsis of the results from that review:*

Rating # within rating % of total in rating

For this review, a total of36 standards were evaluated with the following results:*

Rating # within rating % of total in rating

* The DJS Quality Improvement Performance Ratings are aligned with best practices and optimal standards of care. Therefore,while the facility practice may be in full compliance with minimum constitutional standards, the facility may still receive partialor non performance ratings as a result of QI reviews.

Superior Performance 0 0 %

Satisfactory Performance 18 40 %

Partial Performance 25 55 %

Non Performance 2 5 %

Superior Performance 1 3 %

Satisfactory Performance 18 50 %

Partial Performance 15 42 %

Non Performance 2 5 %


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BCJJC Performance Comparison

0%

10%

20%

30%

40%

50%

60%

3/20/09 1/20/11

Dates of Review

P

ercentage

Superior Performance Satisfactory Performance Partial Performance Non-Performance


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Executive Summary of Results

SuperiorPerformance

Satisfactory Performance Partial Performance Non Performance

Student

Supervision

Incident Reporting

Seclusion

Perimeter Checks

Fire Safety

Behavior Management

Structured Rehabilitative

Programming

Documentation of Youth onSuicide Watch

Environmental Hazards

Curriculum & Instruction

School Staffing & ProfessionalDevelopment

Parent, Guardian & SurrogateInvolvement

Individualized EducationPrograms

Career Technology &

Exploration Programs

School Environment & Climate

Health Care Inquiry RegardingInjury

Medication Administration

Dental Care

Medical Records Retrieval

Senior Management Review

De-Escalation & Restraint

Contraband & Room Searches

Room Checks During Sleep

Period

Staffing

Control of Keys, Tools &Environmental Weapons

Youth Movement & Counts

Post Orders

Staff Training

Admissions, Intake & StudentHandbook

Classification

Screening & Identification

Student Transition

Health Assessment

Availability of Medical Services

School Entry

Special Needs Youth


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OFFICE OF QUALITY IMPROVEMENTBaltimore City Juvenile Justice Center

METHODOLOGY

I. Pre-EvaluationPrior to the evaluation, the facility received a document request list from theDJS Office of Quality Improvement. This list detailed various documents in

the areas of safety and security, medical care, mental health care and

education that would be reviewed by the QI Team.

II. Entrance Interview with SuperintendentA formal entrance interview was not conducted with the Superintendent on

the first day of the review, but discussions and interviews were conductedthroughout the review with the Superintendent, Assistants and key leadership

personnel. Members of the QI Team asked and discussed with the

Superintendent targeted questions related to safety and security, behavioral

health, behavior management, education, medical and many other areas offacility operation.

III. Primary InterviewsA total of 13 youth were interviewed individually and several more in groupsabout a range of areas across the QI review spectrum. This represented 10% of

the total population at BCJJC that week. Interviews were also conducted with

facility staff, administration, medical, case management and education staff.In addition, 12 staff were interviewed specifically about the target areas of the

review as well as their general feelings about the operation of the facility.

IV. Document ReviewDocuments were reviewed that were requested by the QI Team and provided

by the facility staff in support of facility operations and program services.The documents included medical records, incident reports, logbooks, program

schedules, seclusion and suicide watch documentation, staffing reports,

training records and statistical data, as well as other documents from areas in

fire safety and youth supervision.

V. Observations of Facility Operations Youth movement Structured programming Recreation Unit activities Leisure Time Classroom Activities

VI. Review of Quality Improvement ReportThe facilitys previous QI Report was also reviewed to determine what areas

needing improvement at the last review were improved or were still in need ofattention.

VII. Exit ConferenceAn exit conference was conducted on December 10, 2010.


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SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY

INCIDENT REPORTING RATING: Satisfactory Performance

STANDARDWritten policy, procedure and practice document that all incidents that involve youth

under the supervision of DJS employees, programs, or facilities, including those owned,

operated or contracted with DJS, are reported in detail and in accordance with

departmental guidelines.

SOURCES OF INFORMATION

41 Facility Incident Reports Jun-Nov 2010 Youth grievances from 2010 Staff Training Histories Report OIG investigations Interviews with youth Interviews with staff

REFERENCESDJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management

(CPM) Techniques Policy (RF-02-07); DJS Video Taping of Incidents Policy (RF-05-

07); DJS Youth Grievance Policy (MGMT-01-07)

SUMMARY OF FINDINGS

The IR files in every case contained both written and electronic copies. IRs are filled in entirely with few blank areas. There were no unreported incidents discovered (only one that was discovered and

reported late) and staff seem very clear that all are to be reported.

The narrative portion of the IR included all four parts and all four werecompleted.

Child abuse allegations were reported to CPS as required. Precipitating events were described as required. Descriptions of uses of force (when applicable) were good. Staff gave

descriptions of which arms/hands they used in most cases. However some staff

put hands on youth to remove them from areas when they are being non-compliant with directives which violates DJS policy.

Narratives were generally noted as good. The reader could get a good idea abouthow an incident occurred from reading the IR. One deficiency: sometimes the

video of the same event showed that key information was left out of the IR. In

some, the lack of a bathroom break or the extent of a youths aggression in order


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to justify handcuffs, were important details left out by staff. Staff should be

encouraged to fully document all important aspects of each incident.

Also, staff must use clear words to describe what they did. A couple of examplesthat were problematic were: Staff wrote that I disregarded his lunch tray when

staff actually threw away his lunch tray. Staff wrote that two youth who were

separated re-approached each other when they actually ran and went after eachother in the gym and fought (this was listed incorrectly as an Inappropriate

Conduct rather than a Youth-on-Youth Assault). Issues such as this give theimpression that vagueness is used to cover for what actually did occur. If goodsenior management follow-up is accomplished, this can be resolved.

All of the IRs contained shift commander comments. The quality of thosecomments is indicated in the next section entitled Senior Management Review.

Notifications sections were complete. Detail on exactly where staff were posted was present in 83% of the IRs reviewed

which is very good.

All IRs reviewed had all or most youth witness statements present. Nearly all of the IRs had all staff witness statements present. The most common

missing staff witness statement was the staff who arrived to assist. They often did

participate in at least some of the event but few offered witness statements.

In 100 % of incidents the youth(s) were evaluated by the nurse for injury.GRIEVANCES

There were 18 youth grievances in the past 6 months at BCJJC. Half of thecomplaints were about points. The resolution of these grievances appeared to be

prompt and fair.

The Youth Advocate picks up grievances in 1.5 days on average; every youth saidthey knew where to find and file grievance forms and would do so if they had a

complaint. On a walk through of all three pods, one unit each was checked forstocked grievance forms; there were stocked grievance forms accessible to youth

on 2 of the 3 units (none were on Unit 41).

RECOMMENDATIONS

In order to reach Superior Performance status in this area it is recommended that thefacility:

Especially encourage staff to give full and complete details about the incident,including all actors, what each did or did not do. Ensure no vague words are used.Encourage them that when describing a restraint they did, to include youth

compliance, what was being said by all parties, whether the youth was calm, and

whether the restraint was successful and if not, why not. This kind of information

can be used to assess whether further or different training is needed or to confirmthat staff did all they could in a difficult situation.

Retain witness statements from all staff present during the event including thosewho come to assist.


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SENIOR MANAGEMENT REVIEW RATING: Partial Performance

STANDARDWritten policy, procedure and practice document that incident reports are reviewed and

critiqued by shift commanders and critical documentation, such as incident reports,

suicide watch and seclusion paperwork, are routinely audited by senior managers within

DJS timelines and corrections are made by staff timely.


41 Facility Incident Reports Jun-Nov 2010 Review of 15 videotaped incidents Interviews with staff Review of OIG Investigations Review of seclusion documentation Review of suicide watch documentation Staff Training Histories Report

REFERENCESDJS Policy MGMT-03-07 Incident Reporting Policy (MGMT-3-01); ACA 3-JDF-3B-10and 3-JTS-3B-11

SUMMARY OF FINDINGS

All of the IRs contained Shift Commander comments. Most of the shiftcommander comments were critiques (as is required); there is still a portion of the

shift commander group who do not offer and coaching or follow-up on IRs.

One Pod Manager and several Shift Commanders offered exceptional critiqueand incident follow-up. Their efforts included identification of the supervisionissue, documented critique to staff, documented counseling of staff and

documented further follow-up to ensure an action was taken. These middle

managers are the most important day-to-day staff in facilities and BCJJC is

fortunate to have some with these very high level skills and obvious dedication toaccountability.

Policy requires senior administrative review of incident reports within 72 hourswhich, on average, is accomplished. Audits are completed by all three Pod

Managers, one of the two Assistant Superintendents, and one RA Supervisor incharge of the ISU.

Only a small portion of the incidents are audited however. Restraints, seclusionuse, and other critical incident types are not audited but administrative review ofthese incidents is required by policy. Of the 15 videos reviewed regarding 15

incident reports, only 5 had been audited; and in 13 of them, some issue presented

that would have warranted comment by Administration if reviewed on video.

Though Inappropriate Conduct incidents on their own are not required to beaudited by policy, the number reviewed by QI with sometimes substantial issues

in terms of either incorrect incident type or video reviews that showed concerns


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were large enough in number to make QI strongly encourage their audit as well.

Two of the fifteen videos showed employee conduct that led QI to refer to OIGbut were not previously caught be management. Some were actually fights but

were incorrectly listed as Inappropriate Conduct.

Video review of an incident is only accomplished for assaults. And even then, thedocumentation of that video review showed that only about half of the assaults arevideo reviewed. Though it is likely that the video indeed was reviewed in many of

those cases by Shift Commanders in floor control, there was no documentation tosupport that.

Seclusion sheets showed no evidence of auditing in most cases. Suicide watch documentation is not audited. The Office of the Inspector General (OIG) completed 15 investigations in the past

year, 5 of which were sustained. All seemed to be thorough and gave a goodaccounting of the facts. The OIG investigators at BCJJC are extremely diligent.

RECOMMENDATIONS

In order to reach Satisfactory Performance status in this area it is recommended that the

facility:

Require all shift commanders to critique staff and to share their comments withstaff so that staff can learn from the management review. Ensure all shiftcommanders understand the mechanics of a critique and know what supervision

points to catch when they review an incident.

Ensure regular audits of suicide watch sheets. Ensure seclusion forms are audited along with the IR. See that Shift Commanders document in the Video Review Tracking Log when

they have reviewed a video.

Consider adding video review of Inappropriate Conduct incidents to ensure theyare correctly designated and are not actually assaults.

Begin auditing all IRs to ensure issues are spotted and if necessary, discipline isaccomplished.

Assign all managers equally so that the task is manageable.


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DE-ESCALATION & RESTRAINT RATING: Partial Performance

STANDARDWritten policy, procedure and practice document the use of verbal crisis intervention

techniques to de-escalate a situation prior to the use of physical restraints. Physical

restraints are used only when necessary and the least restrictive physical restraint is used

first. Incidents involving physical restraints are video taped.


41 Facility Incident Reports Jun-Nov 2010 15 videotaped incidents Staff Training Histories Report Interview with Superintendent Interview with Assistant Superintendents Interviews with youth Interviews with staff

REFERENCESDJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management

(CPM), Techniques Policy (RF-02-07); DJS Videotaping of Incidents Policy (RF-05-07);ACA 1-SJD-3A-14-15

SUMMARY OF FINDINGS

Descriptions of uses of force in written IRs were good. Staff explained in gooddetail what they did. There was no evidence that restraints went to the floorimmediately; standing restraints were most common.

There were 3 occasions where staff seemed to lose their cool due to the youthsbehavior (spitting, for example). Other staff were quick to move in to remove the

agitated staff from the situation. But more often, BCJJC staff showedprofessionalism and calmness in what were extremely heightened situations. Uses

of force on youth are last resort methods but when they have to be used,

evidence showed that the BCJJC staff do a good job maintaining control and aprofessional demeanor with youth.

Handcuff use at BCJJC is prevalent. DJS policy requires that handcuffs be onlyused to assure secure movement of youth. Though the BCJJC Superintendent

indicates that handcuffs are used as often as they are for safety (per theSuperintendent, they are safer than an extended physical restraint), there was little

evidence on the video tapes to suggest that handcuffing a youth to walk him avery short distance to his room was always necessary. Other facilities do not usehandcuffs as often and do not have any higher incidences of youth or staff injury.

In one incident of handcuff use, a youth was found to be in handcuffs more than15 minutes without further authorization and without constant supervision (youth

in handcuffs 32 minutes). Most times handcuffs are off within the first 15 minutesbut any restraint use must be audited and scrutinized.


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Of the 15 videos reviewed, most showed uses of force that were reasonable, non-aggressive and safe. Staff used CPM techniques and when they did not or could

not, used safe alternatives.

An RA Supervisor indicated that he uses restraints in order to move youth fornon-compliance which is not permitted by DJS policy or by COMAR. All staffshould know this is not permitted. This same issue was also brought to the

attention of the facility by the Juvenile Protection Division of the Public

Defenders Office via a November 3, 2010 email. Just 27 of 108 staff (25%) were compliant with Crisis Prevention and

Management semi-annual training (when reviewing CPM compliance overall,

53% had had CPM at least once in the prior year.)

Mechanical restraints are not covered in training.RECOMMENDATIONS

In order to reach Satisfactory Performance status, it is recommended that the facility:

Ensure all staff are trained twice yearly in CPM, including mechanical restraints. Ensure all staff are aware that moving a youth for non-compliance is not

permitted by DJS policy or by COMAR. Ensure they have other methods they can

apply in these situations and that this use of restraint is not tolerated by

management.

Monitor handcuff use and ensure they are only used when absolutely necessary.Most youth having to be taken from the unit dayroom to a downstairs roomshould not require handcuffs.

Ensure all staff who are agitated by youth are processed about the incident andhave strategies to employ next time in order to remain calm.


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CONTRABAND & ROOM SEARCHES RATING: Partial Performance

STANDARDWritten policy, procedure and practice document searches of rooms, youth and any

contraband found. Incident Reports are written for contraband found in accordance with

DJS policy.

SOURCES OF INFORMATIONUnit Logbook

Interview with Staff

Observation at the facility

REFERENCESDJS Searches Policy (RF-06-07); Incident Reporting policy (MGMT-03-07); ACA 1-SJD-3A-16

SUMMARY OF FINDINGS

DJS written policy and procedures require that sleeping rooms be searched aminimum of once per week for contraband and the search be documented in therespective units log book. A review of randomly selected unit log books

indicated inconsistencies with documenting the required searches as pursuant to

DJS policy.

Staff interviews along with a review of FOPs indicated that staff are required tosearch sleeping rooms for contraband at least twice a day (i.e. 1 st and 2nd shifts).

Each room search is to be recorded on a Shakedown Form. A review of randomly

selected Shakedown Forms for the period of August 2010 to November 2010,revealed inconsistencies with staff documenting at least two room searches per

day.

Three of ten staff interviewed indicated that they are not given enough time orassistance to realistically search each sleeping room.

A review of the DJS Incident Reporting Database for the period of January 1,2010 to December 7, 2010, revealed that the facility reported 37 incidents

involving contraband.

A QI team search of several sleeping rooms revealed several plastic drinkingstraws, a pen, paper clip and pencils hidden under mattresses. Also, a pen and a

pack of pencils were left attended in a unit dayroom.

Several of the sleeping rooms had gang graffiti written on the walls and/or floor.One sleeping room had a collection of inappropriate pictures of females posted on

the wall. Staff immediately removed the pictures from the room.

Observations revealed that youth are not consistently frisked for contraband uponmovement from the dining hall and school. Of the three movements observed,

youth were frisked only during only one. During one observation, a staff was in

the process of escorting a youth from a classroom and was instructed by a

supervisor to search the youth before leaving. The staff responded by asking whatwas he supposed to be looking for.


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A review of the DJS Incident Reporting database revealed that staff searches andobservations have resulted in the recovery of various contraband items (i.e. cell

phones and chargers, batteries, a sexuality explicit magazine, a mirror, a MP3player, headset, tobacco substances, [suspected] marijuana, lighters, matches,

sharp objects, seeds, Zantac pills, pens, pencils, etc.) It is admirable that

these items are found, but the type and number of incidents is concerning,especially when it is unclear how these items entered detention without being

discovered. DJS Security staff utilize a walkthrough metal detector and handheld wand to

scan visitors and employees for contraband prior to entering the secured area ofthe facility.

Frequent searches of general areas appear to occur as pursuant to DJS policy.RECOMMENDATIONS

In order to reach Satisfactory Performance status in this area it is recommended that thefacility:

Ensure staff are familiar with their responsibility to conduct and record roomsearches as required by policy.

Ensure staff under the importance of being thorough and consistent whenconducting frisk searches upon movements.

Have maintenance eradiate all graffiti from the walls and floor of sleeping rooms. Have staff carry or secure pens/pencils and not leave them about day room/unit.

If staff lends a pen/pencil to a youth, they should record that in the logbook and

get the pencil back.

Review contraband incidents reports to discover the source of contraband andprevent its reoccurrence.


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SECLUSION RATING: Satisfactory Performance

STANDARDWritten policy, practice and procedure provide that youth confined to a locked room, not

during sleeping hours, shall be observed often and have those observations documented,

shall only be placed in seclusion if they present an imminent threat to others or an

imminent threat of escape, and shall be treated humanely and with concern and care soas to safely maintain the youth until he can be released in the least amount of time.


Facility Seclusion Log Interview with Superintendent Interview with Assistant Superintendents Incident Reports from June-Nov 2010 Seclusion sheets Interviews with youth and staff

Observation at facility

REFERENCESDJS Seclusion Policy RF-01-07; COMAR 16.18.02

SUMMARY OF FINDINGS

Documented seclusions at BCJJC are as follows:Month # of seclusions Average Daily Population Rate

August 73 117 2.01September 99 122 2.70October 125 124 3.25

November 56 123 1.52

There was a rise in October and a fall in November that could not be explained bythe Administration so it is unclear what if anything was responsible for these

changes.

The average length of stay in seclusion is relatively short. For the month ofNovember 2010, the stay averaged 3.34 hours.

Seven (7) documented episodes of seclusion were reviewed. Checks on the sheetsby line staff showed few concerns. Most staff made all checks (and listed youthbehaviors displayed) as required. In two cases, staff wrote missed check when

they missed checks of youth due to other unit duties. This is excellent practice andgives their checks even more credibility.

There was no documented auditing of the seclusion log or observation sheets; theSuperintendent indicated they had stopped doing so but were going to reinstitute

the practice. BCJJC used to also track seclusion use and lengths of stay; this also


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is no longer occurring but the Superintendent indicated he will re-institute this as

well. There is no random video review of seclusion episodes.

The shift commander comments (reasons for youth not being released fromseclusion) were good.

The facility requires senior administrative approval of seclusion use. In every documented case, medical staff appropriately documented observations. In every documented case, shift commanders visited the youth and made checks

timely.

Youth were individually processed and not all released at one time, an indicatorthat seclusion is not being used as punishment.

Seclusion use for lack of staff (staff shortages) was documented in the seclusionlog as required which is excellent practice.

The use of early bed violates DJS seclusion policy. There was one indicationby staff (IR# 86971) that a youth had to go to bed at 6:30 due to his behavior. The

youth was angry and an incident resulted. This was not caught by the

Administration. These kinds of instances can increase exponentially if not caughtand staff not counseled that early bed is not permitted. Staff must follow the BMP

when imposing consequences for youth.

RECOMMENDATIONS

In order to reach Superior Performance status in this area it is recommended that the

facility:

Ensure that the auditing process includes seclusion sheets and the seclusion log ifa seclusion episode occurs.

Ensure all staff are aware that early bed is not permitted. Institute random video review of 5-10% of seclusions monthly to ensure staff

checks are happening as expected. Track seclusion lengths of stay by rate and ensure all Administrators are aware of

seclusion patterns and any burgeoning overuse.


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ROOM CHECKS DURING RATING: Partial Performance

SLEEP PERIOD

STANDARDWritten policy, procedure and practice document that staff visually check the safety and

security of each youth at least every 30 minutes during the sleep period, unless instructed

to check more often due to the status of the youth. Room checks during sleep perioddocument the youths name and the time the check was conducted


Interviews with staff Logbooks Guard Tour documentation

REFERENCESDJS Youth Movement and Counts Policy RF-02-06; ACA 3-JDF-3A-04 and 3-JTS-3A-

04

SUMMARY OF FINDINGS

BCJJCs FOP requires that staff conduct a visual check of each youth at leastevery 30 minutes during bedtime hours and record the observed behavior of theyouth at the time of the check. Interviews and a review of FOPs revealed that the

facility utilizes the Guard Tour System to electronically record each check during

the bedtime hours.

The start of each youths bedtime is between 8pm and 9:30pm and correspondswith the youths BMP level. Wake up time is at 5:30am. A review of Master

Control logbook(s) indicates that Master Control usually announces around10:30pm that units are to begin wanding rooms. The announcement suggeststhat some units may be starting their room checks after 10pm., which is two hours

after the level one youth are required to be in locked in their rooms for bed. A

review of the Guard Tour data revealed that some units did not start conducting

room checks until after 10pm.

A review of 132 randomly selected sleep periods (excluding units 42 and 43)revealed that there were:

o Ten (10) incidents in which room checks were not checked/documentedduring the sleep periods;

o Sixty-five (65) incidents in which room checks were not conducted priorto 10pm;

o Twenty-eight (28) incidents in which room checks ended two to five hoursprior to wake up time; and

o Twenty-one (21) incidents in which gaps between checks ranged from 90minutes to 275 minutes.


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DJS and BCJJC FOPs require that staff members who are conducting roomchecks record the observed behavior of the youth at the time of the check. Staff

did not record the observed behavior of any youth while conducting checks.

Units 40 and 41 consistently documented the required checks from the beginningto the end of the sleep period, however, they did not document the behavior of theyouth.

The facility did not provide documentation regarding any malfunctions with theelectronic Guard Tour system.

BCJJCs Tour Guard FOP requires Pod Managers to confirm weekly that roomchecks are being completed as required. The randomly selected room checks

from August 10, 2010 to December 12, 2010, revealed that the deficiency by staff

to record the observed behavior of youth as well as the gaps in checks has gone on

unabated.

RECOMMENDATIONS


facility:

Require the shift commanders to verify that staff are conducting the requiredroom checks and documenting their observations of youth throughout their shift.

Shift Commanders/Pod Managers should randomly review Guard Tour data forverification.

Any discrepancies or failures by staff to properly perform room checks shouldbereported to the Facility Administrator or designee for corrective action.


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PERIMETER CHECKS RATING: Satisfactory Performance

STANDARDWritten policy, procedure and practice document daily security checks of the perimeter to

include, at a minimum: a check of all locks, windows, doors, fences, gates, security

lighting, security devices, and a check of outdoor areas, gates and security fences to

ensure they are secure, free from contraband and have not been tampered with.

SOURCES OF INFORMATIONFacility Tour

ObservationsLogbooks

Interviews with staff

REFERENCESDJS Perimeter Security Policy RF-09-07, Maryland Standards for Juvenile Detention

Facilities; ACA 3-JDF-3A-12, 2G-02, 3-JTS-3A-12 and 2G-02.

SUMMARY OF FINDINGS

DJS policy requires that at least one perimeter check be conducted daily.Interview with staff along with a review of documents revealed that at least one

interior perimeter check is conducted during each shift with only a fewexceptions. DJS Security Officers frequently inspect the external perimeter of the

facility on a daily basis.

The Shift Commanders are required to document the interior perimeter checks ona check-off form; however, the time of the check is not indicated. The form onlyindicates the shift (i.e. 6a-2p, 2p-10p, etc.) at the time of the perimeter check.

A review of Master Controls logbook(s) revealed that interior perimeter checksare not consistently documented in the logbook. One entry in the logbook

indicated that the perimeter check was completed via camera.

During a tour of the facility, three security doors were discovered unlocked (ahallway door, one of the health suites sally port doors and a school door.)

DJS Security utilizes a walkthrough metal detector and handheld wand to scanvisitors and employees for contraband prior to entering the detention area of the

facility.

A review of the Visitors logs (i.e. civilians, Community Case Managers, etc.)revealed that 13 % of the visitors between July 1, 2010 and December 6, 2010 did

not sign out upon leaving the facility.


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RECOMMENDATIONS

In order to reach Superior Performance status in this area it is recommended that the

facility:

Ensure visitors are signed-out when leaving the facility so that their whereaboutscan be accounted for in the event of an emergency.

Ensure all doors are kept locked when not in use. Ensure Shift Commanders indicate the time of each perimeter check on the form

and actually conduct a physical check of the perimeter.


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STAFFING RATING: Partial Performance

STANDARDThe facility maintains a current staffing plan that ensures a sufficient number of staff is

present to provide an environment that is safe, secure and orderly.

SOURCES OF INFORMATIONReview of Facility StaffReview of Facility Logbooks

Interview with staff and youth

Interview with Assistant SuperintendentReview of Seclusion Logs

Observation of facility

REFERENCESACA 1-SJD-1C-03

SUMMARY OF FINDINGS

A review of the seclusion log from October 2010 to December 2010 found seveninstances when youth were on seclusion because of a lack of direct care staff. The

seclusions ranged from a half hour to five hours in length.

A review of the school log book from October 2010 to December 2010 indicatedthat there were six instances when units were held back from first period due to alack of direct care staff.

The Assistant Superintendent indicated that there is a steady flow of overtime atthe facility. He reported that there are staff needed in places that are not built intothe schedule. He reported that there are an abundance of medical runs requiring

two additional staff members per run. He also reported that there has been an

increase in special education students in the self-contained class, requiring an

additional staff member for first shift. Also, during the review both of theOrientation units held 17 youth apiece. This also required two additional staff

members per shift above the scheduled allotment of staff

The Assistant Superintendent reported that there are 9 Resident Advisorvacancies, 2 Resident Advisor Lead vacancies and 3 Resident Advisor Supervisorvacancies at the facility.

At no time during the review were the units observed to be out of the appropriateratio.

Seven of the eight staff members interviewed indicated that they are required todo at least one double shift a week, with five indicating that they are required to

do several double shifts per week. Most of the staff indicated that they dont mindworking the double shifts because of the additional money as long as they are

given enough time to prepare for them.


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RECOMMENDATIONS

In order to reach Satisfactory Performance in this area, it is recommended that the

facility:

Review the current staffing pattern to determine the additional staff that areneeded in light of the needs of the facility.

Continue to recruit to fill all available vacant residential staff PINS.


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CONTROL OF KEYS, TOOLS RATING: Partial Performance

& ENVIRONMENTAL WEAPONS

STANDARDWritten policy, procedure and practice provide for the control of tools and equipment

that could be used as weapons or for other dangerous purposes. There is system that

ensures strict accountability of the receipt, usage, storage, inventory, and removal of alltoxic and caustic materials.


Facility Tour Interview with staff Key Inventory Tool & Sharp Objects Inventory

REFEERENCESDJS Key Control Policy RF-06-05;DJS Perimeter Security Policy RF-09-07, ACA 3-

JDF-3A-22 and 3-JTS-3A-22

SUMMARY OF FINDINGS

DJS policy requires that each facility maintain a working keyboard as the primeissuing point for facility keys issued on a regular basis. BCJJC has a key controlprocess and maintains two keyboards (i.e. Restricted and Working Keyboards) in

Master Control from which keys are issued on a regular basis.

The facility utilizes assigned chits, a Sign-in/out Key Log and frequentinventories to account for facility keys throughout the day. A review of the

restricted keyboard revealed key RK#27 lying at the bottom of the key boxwithout an assigned hook.

DJS policy requires that every assigned hook in a keyboard contain either a key orchit so that it can be readily apparent if a key is missing. An inspection of the

working keyboard revealed 4 vacant hooks. A review of the key log revealed thatthe keys had been signed out. According to MC staff, an administrative chit is

usually placed on a hook if the staffs assigned chit is not available when the key

is issued. No administrative chits were available.

DJS policy requires that a set of facility emergency keys be maintained at a securelocation away from, but near the facility (e.g., another DJS facility, local law

enforcement facility, etc.). Interview with the Facility Administrator and

Assistant Facility Administrative revealed that the Director of DJS Security andMaster Control maintain a set of emergency keys. However, both the Director of

DJS Security and Master Control are housed in the same building as the facility.

A review of the key logs revealed several irregularities with staff recording thereturn of facility keys.

The key logs and Master Control logbook revealed a few instances involving stafffailing to return keys at the end of their shift.


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Not all of the keys to pod doors and sleeping rooms are identifiable by touch. Some keys to the fire extinguisher and unit supply/janitor closets have difficulty

unlocking the locks.

Observation revealed that keys are maintained on a metal key ringsoldered/crimped at the joint to prevent tampering, loss or removal.

Observed key rings have a tag affixed that indicate the hook number of the keyring and the number of keys on the ring.

The Assistant Facility Administrator maintains Back-up keys in a secure locationalong with an inventory listing of the keys.

Policy requires that at least one randomly selected key ring be inventoried daily toverify and record the number of keys attached to the ring. Although facility keys

are inventoried frequently, a daily inventory of one key ring as prescribed by DJSpolicy is not conducted.

An Interview with the Assistant Facility Administrator (Key Control Officer)revealed that several keys have been replaced with new keys.

The facility maintains a back up key board and 24 Hour Key AuthorizationForms.

TOOLS

A walk through of the Maintenance Section showed it to be clean, wellmaintained and organized. The Maintenance Section is located outside thesecured detention area.

Maintenance maintains a master inventory of the tools assigned to the sectionand the tools are color coded for identification.

The Maintenance staff conduct frequent inventories to account for tools. Power generators are tested weekly.

CULINARY UTENSILS

A walk-through of the Food Service area showed it to be clean, wellmaintained and organized.

Knives and other dangerous utensils are kept secured in a locked cabinet. An inventory of the knives and utensils revealed that they all were accounted

for.

The knives and utensils are inventoried and documented 3 times a day,however, a sign out sheet is not maintained.

The kitchen maintains Material Safety Data Sheets (MSDSs) for hazardouschemicals (cleaning fluids, etc.) used or stored.

ENVIRONMENTAL WEAPONS

During a tour of the facility, it was noted that several pencils were accessible.


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RECOMMENDATIONS


Ensure each key ring is assigned to a hook in a key box. Ensure administrative chits are readily available for staff who do not have an

assigned chit to exchange for a key.

Shift Commanders should verify that staff are signing-in the returned keys at theend of their shift.

Mark emergency and security keys in a manner that identifies them by touch. Replace all keys or locks that do not operate properly. Ensure that key inventories comport with DJS policy.


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YOUTH MOVEMENT & COUNTS RATING: Partial Performance

STANDARDWritten policy, procedure and practice document a system for physically counting youth.

Youth movement is orderly and provides for identifying each youth movement and the

specific location of each youth at all times. Formal and informal headcounts are

conducted and documented in accordance with departmental guidelines. Emergencycounts are conducted and documented when necessary.


Logbooks Interviews with staff Interviews with youth Facility tour Observation of youth movement

REFERENCESDJS Youth Movement and Counts policy RF-02-06; ACA 3-JDF-3A-13 & 14 and 3-JTS-

3A-13 & 14

SUMMARY OF FINDINGS

Written DJS policy requires that each facility conduct and record a physicalcount, at minimum, every 30 minutes or more often based on the need, size of

facility or other circumstances as articulated in their FOP. BCJJC maintains aYouth Movement and Counts FOP that identifies the facilitys counts procedures.

A review of several unit and Master Control logbooks revealed that BCJJC doesnot conduct or record physical counts, at a minimum, every 30 minutes aspursuant to DJS policy. Counts at the facility are conducted and recorded everyfour hours to include the required 2am count. It was noted that several units

sometimes record other counts throughout the day. It appears that the 3rd shift

frequently record 30 minute counts throughout the shift while conducting roomchecks.

Observations revealed that staff do not consistently frisk youth upon movement.Observations also revealed several youth trying to avoid being frisked by moving

about as they lined up for movement. For the most part, youth movement wasorderly.

A review of logbooks revealed very few instances of the actual count beingincluded in the logbook.

The staff do record in the unit logbook whenever a youth is taken from andreturned to a location.

7 of 8 staff interviewed indicated that the maximum number of youth 1 staff cansupervise alone is 6 youth. The facility officially recognizes the youth to staffratio as 6:1.


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RECOMMENDATIONS


Ensure supervisors/shift commanders require staff to conduct counts every 30minutes and call the count into Master Control within fifteen minutes of the count

being taken.

Shift commanders should confirm that the required counts are logged in theappropriate logbooks.

Ensure staff consistently and thoroughly frisk youth upon any movement.


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FIRE SAFETY RATING: Satisfactory Performance

STANDARDWritten policy, procedure and practice document the facilitys fire prevention and safety

precautions in accordance with departmental guidelines. Provisions for adequate fire

protection service provide for the availability of fire protection equipment at appropriate

locations throughout the facility and the control of all use and storage of flammable,toxic, and caustic materials.


Facility Tour Interview with the Fire Safety Officer Interviews with maintenance staff Review of Logbooks Examination of Fire Safety Equipment Fire Drill Documentation

REFERENCESDJS Policy MGMT-3-01; ACA 3-JDF-3B-05, ACA 3-JDF-3B-10 and 3-JTS-3B-11

SUMMARY OF FINDINGS

The State Fire Marshal last inspected the facility on March 12, 2010. Nodeficiencies were noted by the Fire Marshal, however, it was indicated that staff

are to ensure keys to the fire protection equipment boxes function properly.

Observations revealed some keys had difficultly unlocking fire extinguisherboxes.

A fire safety vendor last inspected and/or serviced the facilitys fire safetyequipment (i.e. sprinkler system, fire extinguishers and etc.) on September 23,2010. No deficiencies were readily apparent.

An inspection of the Fire Alarm Control Panel located in Master Control revealedthat is was operational and no trouble was indicated. However, the door to theFACP was left open.

Interview with the Fire Safety Officer along with a review of fire drill recordsfrom July 2010 to November 2010 revealed the following:

o During the month of July 2010, four fire drills were conducted. No firedrills were conducted by the 3rd shift.

o During the month of August 2010, two fire drills were conducted. Onefire drill was conducted on the 3

rd

shift at 3am that lasted one minute (theyouth and staff did not depart the building). No fire drills were conducted

by the 1st shift.

o During the month of September 2010, three fire drills were conducted. Nofire drills were conducted by the 3

rdshift.

o According to the Fire Safety Officer, there is no record on any fire drillsoccurring during the month of October 2010.


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o During the month of November 2010, two fire drills were conducted. Nofire drills were conducted by the 2

ndshift

Four fire extinguishers were randomly checked and no deficiencies were noted. Observations revealed that entrances and hallways were unobstructed. Staff and youth interviews revealed that they have participated in a fire drill.

RECOMMENDATIONS

In order to reach Superior Performance status in this area it is recommended that thefacility:

Ensure the FACP in Master Control is locked. The Fire Safety Officer should ensure that each shift conducts at least one fire

drill a month. Fire drill evaluations should be as realistic as possible, when it issafe to do so, in order to train staff and youth on how to conduct an emergency

evacuation.


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POST ORDERS RATING: Partial Performance

STANDARD:Written policy, procedure, and practice provide post order for security post and key staff

positions. Staff members are familiar with roles and responsibilities of the post order

prior to assuming the post. Post orders are current. Shift commanders ensure that post

orders are reviewed by the staff member. Post order signature sheet is signed by the staffassuming the post and initial by the immediate supervisor.

SOURCES OF INFORMATION:

Post Orders Facility Tour & Observation

REFERENCES:DJS Post Orders Policy RF-07-07; ACA 3-JDF-05, 3-JDF-3A-06, 3A-JDF-3A-07

SUMMARY OF FINDINGS:

DJS policy requires that each facility maintain a copy of all Post Orders and PostOrder Signature Forms in Master Control. No Post Orders or Post Order

Signature Forms were available for review in Master Control.

A set of Post Orders and FOPs were obtained from a BCJJC administrative staffand were presented to a QI team member:

o Dining Hall Post Order, date: 11/5/10.o Education Post Order, date: 10/06/10.o RGLM 1 Post Order, date: 11/05/10.o Intake Post Order, date: 11/05/10.o

Master Control Post Order, date: 11/05/10.o Outdoor Recreation Post Order, date: 11/05/10.o Medical Post Order, date: 11/05/10.o Unit Post Order, date: 11/05/10.o Visitation Post Order, date: 11/05/10.

Six (6) posts were checked to verify if the respective Post Order was beingmaintained at or near the post, as required by DJS policy. Only one post

(Education) maintained the required post order and signature form.

There were no special duty/assignment positions (i.e. key control, fire safetyofficer, and etc.) post orders available for review.

The facility did not provide a post order for the Maintenance Shop and some staffpositions (i.e. RA, RA Lead, RA Supervisor) identified in the DJS Post Orderpolicy.


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RECOMMENDATIONS


facility:

Ensure that there is a post order for at least every staff and special dutyassignment positions delineated in policy. (e.g., Resident Advisor series positions)

This will ensure staff are aware in writing of the responsibilities and duties

associated with their positions/post.

Ensure all staff assigned to a specify post or working the post for the first time,read the post order and acknowledge that they understand the duties and

responsibilities associated with the post.

Ensure Master Control maintains a copy of all post orders and Post OrderSignature Forms.


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STAFF TRAINING RATING: Partial Performance

STANDARDWritten policy, procedure and practice provide that all staff who have regular and daily

contact with juveniles receive organized, planned and evaluated trainings in accordance

with departmental guidelines. Training is designed for continuous development of skills

related to job specific learning objectives.


DJS Training Histories report Interviews with staff

REFERENCESMaryland Correctional Training Commission (MCTC); ACA 1-SJD-1D-03, ACA3-JDF-1D-01, ACA JDF-1D-02

SUMMARY OF FINDINGS:

Mechanical restraints are not covered in CPM training as required. Of 130 mandated staff, 108 (83%) were reviewed for training compliance and the

results were as follows:

-- 59/108 (55 %) met the 40 hour annual training requirement.

-- 53/108 (49%) of staff had First Aid/CPR/AED training in the prior 12 months.-- 27/108 (25 %) were compliant with Crisis Prevention and Management semi-

annual training (when reviewing CPM compliance overall, 53% had had

CPM at least once in the prior year.)-- 82/108 (76%) were compliant with Suicide Prevention annual training.

-- 80/108 (74%) were compliant with Recognizing and Reporting Child Abuseand Neglect annual training.

The facilitys five mandated management staff (two Assistant Superintendentsand three GLM IIs) who are responsible for holding staff accountable in all of

these necessary areas were not compliant with almost any of the main fourrequired trainings annually. One Assistant Superintendent and one GLM II had

not had any of the required trainings in two years. After discussions with the

Superintendent about this, all five managers were scheduled for all requiredtrainings in December and January and will all attend DJS trainings annually from

now forward as required.

RECOMMENDATIONS

In order to reach Satisfactory Performance status, it is recommended that the facility:

Ensure all staff needing required trainings attend at a rate above 90% across allcategories.


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ADMISSIONS, INTAKE & RATING: Partial Performance

STUDENT HANDBOOK

STANDARDWritten policy, procedure, and practice provide that the admissions process in each

detention is operated on a 24 hour basis. The admissions process documents all required

elements of the admissions. Such required elements include the initial search of theyouth, verification of legal status, verification of basic identifying information, search of

ASSIST database to obtain all legal history, photograph of youth upon admission,

telephone call, student handbook, clothing and state issued items, and movement to the

unit.


Interviews with youth Interview with Superintendent and Assistant Superintendents Interview with staff who perform intake/viewed partial intake process Interview with Case Manager Supervisor Review of youth handbook Review of youth base files

REFERENCESAdmissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile Detention

Facilities; DJS Classification Policy RF-01-08; ACA 3-JDF-5A-02, 3-JTS-5A-01, 5B-01

through 04 and 5B-07 & 08

SUMMARY OF FINDINGS

Handbook acknowledgement forms were found in youth files. The handbook at BCJJC is very complete. A small error in the BMP section was

discussed with BCJJC Administrators. Youth arent getting a handbook at intakebecause intake staff have no copies to give them. The case managers go over the

handbook in Orientation but since youth are signing an acknowledgement at

intake that they have received one, they should then receive one at Intake to keep.

In all cases, the SASSI and the MAYSI were found to have been completedwithin two hours of admission as required.

Intake staff interviewed knew how to score the MAYSI and does so. The SASSI is completed and scored online which is ideal. Intake staff knew how to scan the results for issues and refer youth to Mental

Health staff if they have any concerns on either screening. The FIRRST is completed upon the youths arrival. Staff knew not to accept

custody if the youth has any yes answers, however police in almost every case

had already left the facility and were not available to take back custody of youthwho were injured or mentally unstable. BCJJC transportation fill that role.

A medical assessment is done upon admission and in every case within 72 hours.


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The greater issues came in the Orientation unit and process. There are two fullunits (out of ten total units) dedicated to Orientation youth. These units are

consistently well over the 12 youth that can sleep in the 12 beds each hasavailable. Consequently, youth have to sleep out on other units or in other areas.

Youth in Orientation stay far longer than what is proscribed by policy. Theaverage length of stay on BCJJCs Orientation Unit is 6.5 days. A full 55% of

youth spent more than 3 days on Orientation and of those, the average length of

stay was 11.1 days. Youth in Orientation do not follow the posted schedule and have little to no

structured programming afforded them. Time is spent watching TV and doing

little else.

Many youth on Orientation have been to BCJJC numerous times andconsequently do not need to be oriented to the facility. Many have medical,mental health and educational records on file and after a brief assessment period,

could be housed on a regular unit.

Almost no educational services are afforded youth on Orientation. If they wereonly on the unit for three days or less, this would not be a concern. However sinceseveral youth had stays of almost two weeks, this is a significant problem.

RECOMMENDATIONS

In order to reach Satisfactory Performance status, it is recommended the facility:

Re-think the need for two Orientation Units. Youth should have all assessmentscompleted within three days and by then, DJS staff should be aware of his court

date and whether he is remaining in detention. Youth should be assigned to a unitexpeditiously and begin going to school.

Currently, only seven units move to school. There is space for one OrientationUnit to return to normal unit status and for those youth to move to school andeliminate the idle time they currently have.

Require the Orientation Case Manager to alert all relevant Administrators when ayouth is closing in on his third day of Orientation with no unit

assignment/transition plan in place yet. Ensure he is in a permanent unit that nextday and moving to school as required.

Create and follow an Orientation Unit schedule. Do not put events and activitieson the schedule that do not occur.

Ensure intake staff have copies of the youth handbooks and give one to eachyouth (along with their state clothing and shoes) upon admittance.

Consider working with the Baltimore Police Department to ensure youth arescreened on the FIRRST while in holding and upon arrival and that police arerequired to take youth to hospitals for emergent care if injured upon arrival. This

will alleviate the need for DJS Transportation staff to do so.


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CLASSIFICATION RATING: Partial Performance

STANDARDWritten policy, procedure and practice document that all youth are classified and

assigned housing according to current age, severity of current legal charge, most serious

prior charge, number of prior serious incidents while in custody and special needs. FOP

and practice also provide for reassessment of all youth no later than 60 days followingfacility admission and within 24 hours of the third serious incident since admission to the

facility, and more frequently in response to needs of youth or security of the facility.


Interviews with Admissions/Intake Staff Interview with Case Management Staff Review of base files Observation at facility

REFERENCESMaryland Standards for Juvenile Detention Facilities; DJS Classification Policy in editing

stage; ACA 3-JDF-5A-02, 3-JTS-5A-01, 5B-01 through 04 and 5B-07 & 08;

SUMMARY OF FINDINGS

DJS Classification policy requires that each facility develop a FOP that includes:o Identifying the specific employee(s) responsible for:

(a) Conducting and completing Housing Classification

Assessments and Re-Assessments;(b) Reviewing ASSIST for prior DJS commitments and

placements, and inputting admissions data;(c) Reviewing the DJS Incident Database for serious incidentinvolvement (youth on youth or youth on staff assaults,

group disturbances, restraints and escapes or attempted

escapes);

(d) Observing youth to determine if initial classification leveland housing assignment is meeting the needs of the youth;

and; establishing protocols for housing and proper supervision of

youth to ensure that youth are placed in a unit and room suitable tothe youths classification level.

The required Classification FOP was not available for review.

DJS policy requires that classification assessments be implemented for all youthon their admission to the facility. Interview with Intake staff revealed that onestaff is responsible for completing the initial classification assessment upon a

youths assignment to the facility.

15 of 24 base files reviewed contained the required initial classificationassessment form. The Intake staff has devised a system in which the initial

classifications are completed on a roster and then the information is later


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transferred to an individual classification form and placed in the base file. This

method of completing the classification process may have accounted for someforms not being in a youths base file. During the QI review period, the Intake

staff did provide an initial classification form for each youth assigned to the

facility.

6 of 6 base files reviewed did not contain the required reclassification form inresponse to a youth being assigned to the facility more than 60 days or requiring

special needs that may require modification of the youths housing assignment.Interview with the Case Manager Supervisor revealed that the process was notconducted and the matter will be corrected.

4 of 24 classification forms contained an error or were incomplete. None of theforms indicated the youths assigned room number. It was noted that after a

youth leaves intake, he is assigned to a single bed room in the Orientation Unitbefore assignment to the general population.

An interview with staff along with a review of documentation revealed that ayouth may be placed on a Guarded Care/Behavior Plan based on his conduct or

need. However, a reclassification form is not routinely completed in these cases.

Interviews revealed that Intake and CMS staff have been trained in the properscoring and utilization of the Housing Classification instruments.

DJS policy requires that each facility develop a Housing Plan for each living area.The Housing Plan is to include:

o Physical plant description;o Capacity;o Staffing pattern for each shift;o Safety, security and supervision practices;o Single and double youth sleeping rooms;o Youth classification levels and specific population assigned;o General programming; ando Special services and/ or accommodations.

The required Housing Plan was not available for review.

RECOMMENDATIONS


facility:

Formulate a written FOP and Housing Plan pursuant to DJS policy. Ensure that all Housing Classification Assessment and Re-Assessment forms are

placed the youths base file.

Have Case Managers complete Housing Classification Re-Assessments of youthin conjunction with the Interdisciplinary Treatment Team, not more than 60 days

from the completion date of the Housing Classification Assessment or previous

Re-Assessment and within 24 hours of a youth being involved in a third seriousincident since initial housing classification assessment. They should also be

completed within 24 hours of receiving new information which may affect the

youths housing/supervision classification.


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PENDING PLACEMENT RATING: Not Rated

STANDARDWritten policy, procedure and practice document that the facility has a list of youth

pending placement, their days committed, and average length of stay and aggressively

prioritizes these youth in order to assist the community case managers in placing them as

quickly as possible in order to reduce time in detention.


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BEHAVIOR MANAGEMENT RATING: Satisfactory Performance

STANDARDWritten policy, procedure and practice document a behavior management system which

provides a system of rewards, privileges and consequences to encourage youth to fulfill

facility expectations and teach youth alternative pro-social behavior. Youth who are not

invested in the facilitys system have alternative and individual plans.

SOURCES OF INFORMATIONReview of Unit Log Books

Review of Daily Point SheetsReview of the Student Handbook

Review of Behavior Management Plans

Review of 6 Guarded Care Plans

Review of Intervention PlansInterviews with youth

Interviews with of direct care staff

REFERENCESDJS Behavior Management Program Policy RF-10-07; Facility Behavior ManagementProgram (BMP)

SUMMARY OF FINDINGS

A review of Daily Point Sheets indicated that most were completed and calculatedcorrectly. A comparison with the BMP listed in the student handbook indicated

that most of deductions were in line with the written program.

A review of the audited point sheets showed a great deal of corrections, indicatingthat there were very severe problems with calculations. However, upon closerreview it was determined that the corrections would be made several days afterthe sheets were turned in. Therefore, one mistake or miscalculation would require

that the sheets for the next three to five days be corrected as well. A more timely

review of the sheets would alleviate many of the corrections.

The calculation mistakes were repeatedly made by the same staff members. TheQI team was told that the facility administration has been apprised of the staff

who need re-training but it has not yet been accomplished.

During the review, the QI team identified three youth who caused disruptionsduring the school day in one or more classes that, according to the BehaviorManagement Plan and the Student Handbook, should have received point

deductions. When the point sheets of these youth were reviewed, in every case the

youth received the appropriate deductions.

Teachers were allowed to give and take away points for the times when youthwere in school.

Youth consistently indicated that they receive the incentives as outlined in thestudent handbook. They listed commissary as their favorite incentive in the

program. Youth reported that bedtimes are administered according to the BMP.


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The Case Managers create court reports for all youth to inform judges of youthbehavior and to encourage youth to behave in detention.

For youth who have difficulty maintaining appropriate behavior under theBehavior Management Program, the facility creates Guarded Care Plans (GCPs).

These plans were to be created for youth on the mental health caseload; theyoutline negative behaviors, triggers and action plans to help and direct youth to

display positive behaviors. Each plan indicated that there were to be follow-up

meetings and updates to the original plans. According to the files, five of the sixplans were reviewed and updated as scheduled.

The Intensive Services Unit (ISU) is also a method for managing youth who donot respond to the BMP. The ISU was formed during federal oversight and made

great strides in assisting BCJJC in lowering youth violence rates and worked as adeterrent for violent behavior. There is a written program description that was

developed in 2009 and completed in 2010 and it was reviewed for this QI review.

In reviewing the intended operation of the ISU, some issues with its operationwere found:

- Youth admission criteria are not all checked off to ensure fidelityto the ISU model. It appears that youth meet only one or two of the

four or five required criterion and are admitted by committeeagreement.

- No incident information is included in ISU files. No emails ordatabase or IR information is listed to give foundation for theyouths entry into ISU or to inform ISU staff on youths previous

behavior.

- Similarly, youth with violent behavior or youth indicatingyouth assaulted staff after a restraint are approved for ISU but

without any information on exactly what they did to fuel their

entry.

- Clear justifications for all overrides are not thoroughly documentedon the admission form as required.

- The Assistant Secretary or Director of Detention are not notifiedwhen a youth is admitted into the ISU.

- Education staff do not appear to be as available on the ISU as inprevious visits. Logbooks sometimes indicated no educationstaff and only sometimes were packets provided in those cases.

- Bedtime for ISU youth is 7 pm, no exceptions, but a youth wasallowed to stay up late to do details in December against theprogram requirements.

- Handcuffs are carried and routinely used by ISU staff but are notcarried by other direct care staff. The Administration indicated that

handcuffs were part of the ISU program but they are not listed inthe program design. Handcuff use in ISU cannot be more prevalent

due to the youths special designation; it must still conform to DJS

policy.- Of 6 youth files, 2 had previous GCPs and neither had a copy of

the GCP in the ISU file as required.


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- In one case, a youth who had a psychological evaluation listingborderline IQ, lead poisoning, ADHD and a bipolar diagnosis andwho was slated for RTC treatment was referred to the ISU but did

not have a previous GCP. The ISU Admission form only indicated

not responding to BMP when in his case, failing in a GCP wouldhave been required as well for admission.

- Tracking of a youths behavior and incidents is to be a part of thetransition planning and used for quality assurance andimprovement purposes. The tracking form for ISU that was in usepreviously to determine whether the program is successful and

how youth are faring after release was requested but was not made

available. It is strongly suggested that ISU statistics be tracked andthat the program design be adhered to strictly in order to assess

success.

NOTE: Though overall, the behavior management systems put into place at BCJJC are

worthy of a Satisfactory rating, the ISU should receive extra attention from the

Administration to ensure it is following the program design and that the problems listed

above are ameliorated. The ISU concept is a good one, but without constant oversight, itis a program that can run the risk of breaking down in original structure and losing its

effectiveness. It also could be duplicated across Maryland if shown to be effective, but

without good data and tracking of success, it cannot be proven to be a best practicemodel.

RECOMMENDATIONS

In order to reach Superior Performance in this area, it is recommended that the facility:

Ensure newer staff members receive training on how to appropriate administer theBMP. In addition, staff members who have been identified as needing re-trainingshould be given the training.

Ensure that all GCPs are updated as scheduled. Ensure all youth who need a GCP (mental health youth) have one and are worked

with by mental health prior to entering ISU.

Ensure the ISU program design is re-read and followed exactly to ensure fidelityto the original model. If adjustments are needed, convene a meeting with theDirector of Detention, Assistant Secretary of Residential Services and DJS

Director of Professional Services or Behavioral Health to ensure any changes are

informed changes.

Ensure all documents required are in ISU files as required. Track outcomes of ISU youth weekly for quality assurance and make adjustments

to lengths of stay or programming as needed.


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BCJJC

January 2011

STRUCTURED REHABILITATIVE RATING: Satisfactory Performance

PROGRAMMING

STANDARDWritten policy, procedure and practice document that youth receive planned, structured

outdoor and indoor activities and regular rehabilitative programming that teaches social

skills.

SOURCES OF INFORMATIONReview of Unit Log Books

Interviews with direct care staffInterviews with youth

Observations of Structured Activities

Review of the Master Schedule

REFERENCESDJS Recreational Activities Policy RF-08-07; ACA 3-JDF-5E-01-02-03-04

SUMMARY OF FINDINGS

The units were visited on December 2, 2010 (in the evening) during the time theschedule indicated that youth should be in groups. On the six units reviewed, all

received groups as outlined in the master schedule. A review of the unit log booksindicated that programming is consistent on most of the units. Youth indicated

that they enjoy the activities provided by the Boys and Girls Club.

Staff and youth on the Orientation units reported that the units do not receiveprogramming as outlined in the master schedule. They reported that outside ofrecreation the unit spends much of the day doing nothing constructive. Unit log

books and observation confirmed this.

Youth and staff inter