comprehensive quality review report cheltenham youth facility (md 2011)

7/31/2019 Comprehensive Quality Review Report Cheltenham Youth Facility (MD 2011)

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OFFICE OF QUALITY IMPROVEMENT

Comprehensive Quality Review Report

Cheltenham Youth Facility

December 22, 2010


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DJS QI Report Page i of 78

CYF

November 2010


Quality Review Report


Evaluation Dates: November 1-5 & 17-19, 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........................................................................................... 9

De-Escalation & Restraint ............................................................................................ 11

Contraband & Room Searches...................................................................................... 13Seclusion....................................................................................................................... 15

Room Checks During Sleep Period .............................................................................. 18

Perimeter Checks .......................................................................................................... 19

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

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

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

Staff Training................................................................................................................ 30

Admissions, Intake & Student Handbook..................................................................... 31Classification................................................................................................................. 33

Pending Placement........................................................................................................ 34

Behavior Management .................................................................................................. 35Structured Rehabilitative Programming ....................................................................... 37

Self Assessment ............................................................................................................ 39BEHAVIORAL HEALTH ............................................................................................. 40

Intake, Screening & Assessment................................................................................... 40Informed Consent.......................................................................................................... 41

Psychotropic Medication Management......................................................................... 42

Behavioral Health Services & Treatment Delivery ...................................................... 43Treatment Planning....................................................................................................... 44

Transition Planning....................................................................................................... 45


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November 2010




Evaluation Dates: November 1-5 & 17-19, 2010

TABLE OF CONTENTS

(Continued)

SUICIDE PREVENTION .............................................................................................. 46

Documentation of Youth on Suicide Watch................................................................. 46Environmental Hazards................................................................................................. 48Clinical Care for Suicidal Youth................................................................................... 49

EDUCATION .................................................................................................................. 50

School Entry.................................................................................................................. 50Curriculum & Instruction.............................................................................................. 51

School Staffing & Professional Development .............................................................. 53

Screening & Identification............................................................................................ 55Parent, Guardian & Surrogate Involvement.................................................................. 56

Individualized Education Programs.............................................................................. 57

Career Technology & Exploration Programs ............................................................... 59

Student Supervision ...................................................................................................... 60School Environment & Climate.................................................................................... 61

Student Transition......................................................................................................... 62

MEDICAL CARE........................................................................................................... 63Health Care Inquiry Regarding Injury .......................................................................... 63

Health Assessment........................................................................................................ 65

Medication Administration........................................................................................... 68Dental Care ................................................................................................................... 71

Medical Records Retrieval............................................................................................ 72

Special Needs Youth..................................................................................................... 74Availability of Medical Services .................................................................................. 76


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November 2010




EXECUTIVE SUMMARY

A quality improvement assessment and evaluation of the Cheltenham Youth Facility wasconducted November 1-5 & 17-19, 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

Cheltenhams strengths include a large open campus design. This design allows for morephysical activity, fresh air and the ability to walk and talk with a youth when he needs to

vent. The staff are seasoned, with many having decades of experience working with at-riskyouth. The front gate security is excellent and staff work diligently to maintain a safe entry

point. Medical care is provided by nurses who care about the youth and who strive to

provide caring and high quality services. Vocational options are offered by the school. TheSuperintendent is new but extremely dedicated and youth-centered in his approach.

Orientation staff are new but already show great promise and initiative in their positions.

The kitchen staff do a great service to both youth and staff by creating meals that arehealthy and delicious. Mental health staff provide one-on-one counseling and are also well-

staffed to ensure services to any youth in crisis.


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November 2010

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 CYF in April 2009, 38 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 16 42 %

Partial Performance 21 55 %

Non Performance 1 3 %

Superior Performance 2 6 %

Satisfactory Performance 14 39 %

Partial Performance 16 44 %

Non Performance 4 11 %


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CYF PERFORMANCE COMPARISON

0%

10%

20%

30%

40%

50%

60%

5/1/09 12/1/10

Date of Repor t

Percentage

Superior Performance Satisfactory Performance Partial Performance Non Performance


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Executive Summary of Results

SuperiorPerformance

Satisfactory Performance Partial Performance Non Performance

Medical Records

Retrieval

Availability ofMedicalServices

Room Checks During Sleep

Period

Admissions, Intake & StudentHandbook

Classification

School Entry

School Staffing & Professional

Development

Screening & Identification

Parent, Guardian & SurrogateInvolvement

Career Technology &

Exploration Programs

School Environment & Climate

Student Transition

Health Care Inquiry Regarding

Injury

Medication Administration

Dental Care

Special Needs Youth

De-Escalation & Restraint

Contraband & Room Searches

Perimeter Checks

Control of Keys, Tools &

Environmental Weapons

Youth Movement & Counts

Fire Safety

Post Orders

Staff Training

Behavior Management

Structured RehabilitativeProgramming

Documentation of Youth on

Suicide Watch

Environmental Hazards

Curriculum & Instruction

Individualized Education

Programs

Student Supervision

Health Assessment

Incident Reporting

Senior Management

Review

Seclusion

Staffing


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OFFICE OF QUALITY IMPROVEMENTCheltenham Youth Facility

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. 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 of

facility operation.III. Primary Interviews

A total of 15 youth were interviewed individually and several more in groups

about a range of areas across the QI review spectrum. This represented 12% ofthe total population at CYF that week. Interviews were also conducted with

facility staff, administration, medical, case management and education staff.

In addition, 11 staff were interviewed specifically about the target areas of thereview 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, programschedules, 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 Medication Pass 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 of

attention.

VII. Exit ConferenceAn exit conference was conducted via phone on November 22.


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SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY

INCIDENT REPORTING RATING: Non 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

46 Facility Incident Reports June-Nov 2010 7 videotaped incidents 29 Youth Grievances Staff Training Histories Report 19 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 Incident Reports (IRs) at Cheltenham (CYF) were difficult to assess as theycould not all be confidently found. A review of the IR Log, written IRs that could

be found and the IR numbers in the DJS database revealed that the facility is notable to accurately know what their numbers are because IRs are not being tracked,

entered and filed as required. For example:

Month # in IR Log # of written IRs found # in IR database

September 84 57 26

October 96 62 55

* November 58 46 8

* Up to November 17th

The IR files in most cases did not contain both written and electronic copies,mostly because most were not in the IR database. Almost none were in files but

were in various locations throughout the Administration Building.


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IRs that were reviewed were generally filled in entirely. Notifications were themost likely area to be incomplete.

25% of IRs were either checked as the wrong category or missed a category beingchecked (such as physical restraint.)

Four unreported incidents were discovered: (a) fire extinguisher cabinet doorsglass was broken and the fire extinguisher discharged at some point; (b) one

unreported incident was discovered via OIG investigation #10-80201; (c) one

unreported incident was discovered via OIG investigation #10-87208; and (d) areview of one units logbook revealed a contraband incident on November 5

ththat

was not documented in an incident report as required. The incident involved a

staff observing a youth using a sharp metal object to prevent his room door

from closing after being forced into his room. No IRs could be located or werecompleted in these cases. Due to not being able to count IRs and compare that

number with the Nurses Injury Log, no such comparison for unreported incidents

was done to assess for any more unreported incidents.

The narrative portion of the IR included all four parts and all four werecompleted. However detail in them was generally only fair with some staff doing

a very complete job and some giving very little information. It was not possible in

about half the cases to recreate the event from the information given. Two-thirdsdescribed the restraint if one was used.

Child abuse allegations made to nurses were reported to CPS as required. Most of the IRs contained shift commander comments. The quality of those

comments was poor and is indicated in more detail in the next section entitled

Senior Management Review.

Nearly all of the IRs reviewed had all or most youth and staff witness statementspresent.

In 20% of incidents the youth(s) were late (over two hours) being evaluated by thenurse for injury. In 20% of cases, no body sheet was included with the IR.

GRIEVANCES

There were 19 youth grievances from Jan 1-November 17, 2010. The topcomplaint was about not getting phone calls. Consistently problematic were

supplies as well; shoes, clothing and supplies were oftentimes noted by youth as

needs to the Advocate.

The Youth Advocate picks up grievances in less than 2 days on average which isexcellent; every youth said they knew where to find and file grievance forms and

would do so if they had a complaint.


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RECOMMENDATIONS

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

Return to an organized system of IR receipt, review, database entry, file creation,IR audit and filing. Ensure all DJS database numbers are correct by ensuring IRsare all accounted for. Create labeled files by IR # and date and file together in a

cabinet. Ensure both written and electronic copies are filed together. Recommend

filing seclusion sheets inside a folder with the IR for ease of review.

Discontinue or revise the IR Log process. Ensure all youth see the nurse within two hours of any incident or explain on the

IR why that was not possible.

Ensure all body sheets are attached to the IR packet. Ensure in every case, all relevant parties are notified and that the notification is

documented.

Ensure shift commanders review IRs to be sure the incident type/categoryselected is correct.

Encourage staff to give full and complete details about all incidents, includinghow it began, the restraint they did if applicable, youth compliance, what wasbeing said by all parties, whether the youth was calm, and whether the restraint

was successful and if not, why not. This kind of information (including video

review follow-up) can be used to assess whether further or different training isneeded or to confirm that staff did all they could in a difficult situation.

Require shift commanders to critique staff when they fill out the shift commandercomments. Ensure they are sharing these coaching tips with their staff (more on

this in the Senior Management Review section of this report.)


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November 2010

SENIOR MANAGEMENT REVIEW RATING: Non 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.


46 Facility Incident Reports June-Nov 2010 Review of 7 videotaped incidents Interviews with staff Review of 19 OIG Investigations Review of seclusion documentation Review of suicide watch documentation

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

SUMMARY OF FINDINGS

IRs contained shift commander comments that overall did not contain a critique.Of a sample from July and August 2010, 0 of 20 (0%) critiqued staffs handling of

the incident. Some critiques were present in November (after a training by QI) but

only by two shift commanders. The areas missed by shift commanders weresupervision issues, posting issues, witness statement information that contradicted

the IR, vague information, youth concerns about staff treatment of them and poorrestraint detail; overall, the comments did not help give staff any coaching on howto improve or to prevent the next incident which is a clear requirement on the IR

itself.

Policy requires senior administrative review of all incident reports within 72hours. At CYF, this process is led by one GLM and she is responsible for allaudits of all IRs in the entire facility. No other senior managers handle any

auditing of the IRs. As a result, the process is a difficult one for one person to

keep up with. Dates on audits varied.

The questions raised by the auditor were often good but were not timelyaddressed by shift commanders. Some questions were never answered.

There is still not regular video review of incidents by shift commanders.Consequently, any problematic incidents that are not reported fully by staff wouldnot be caught and addressed.

Seclusion sheets showed no evidence of auditing. None were filed with IRs inorder to ensure the seclusion entry and exit times matched those reported.

Suicide watch documentation showed no evidence of auditing.


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The Office of the Inspector General (OIG) completed 19 investigations sinceJanuary 1, 2010, about half (9) of which were sustained. A full 8 of 9 were

sustained for inappropriate restraint technique or excessive force (more on this inthe De-Escalation and Restraint section of this report.) All OIG reports seemed to

be thorough and gave a good accounting of the facts.

RECOMMENDATIONS

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

facility:

Ensure the auditors questions are raised with shift commanders, given out andreturned timely and all concerns are addressed. Consider using group meetings to

address some of these and to improve the speed of the process.

Begin required video viewing (by shift commanders before leaving their shift) ofall alleged group disturbances, youth on staff and staff on youth assaults,inappropriate conduct, restraints, property destruction and child abuse allegations.

Add a Video Reviewed: Yes or No line on the auditing form to clearly showthat this was done and include notes from the video review.

Require all shift commanders to critique staff and to share their comments withstaff so that staff can learn from the management review. Ensure this is done the

day of the event so that memories are fresh and staff are encouraged to use thisinformation to prevent another such occurrence.

Ensure shift commanders understand the mechanics of a critique and know whatsupervision points to catch when they review an incident. See that they do not

critique incidents they themselves are involved in.

Require shift commanders to understand the requirements of suicide watch andseclusion observation sheets and to review for quality while on the floor.

Ensure all sustained OIG findings are followed up by the facility. Ensure an audit system for seclusion documents is instituted. File them with the

IRs in order to make for an easier review. (See the Seclusion section of this report

for more specifics.)

Ensure an audit system for suicide watch documentation. (See the SuicidePrevention section of this report for more specifics.)


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November 2010

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.


46 Facility Incident Reports June-Nov 2010 7 videotaped incidents 19 OIG Investigations Staff Training Histories Report Interview with Superintendent 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 not detailed and were rated atbest Fair overall. Staff statements individually sometimes did a better job ofexplaining the restraint, but again only some staff were able to give the kind of

detail needed to figure out exactly what happened. Shift commanders are notrequiring more detail when IRs are turned in to them.

There were multiple instances of staff using inappropriate restraint techniques inOIG investigations, including pushing youth down, punching youth and putting

youth in choke holds (hands or arms around necks of youth.) Seven of eight

OIG investigations indicated staff used these non-CPM techniques.

Videos revealed instances of staff trying to safely pull multiple youth apart whoare fighting and walking youth safely using a passive restraint technique. They

also showed staff attempting to pull up a youth who was non-compliant (violating

DJS policy), choking a youth and closing a youths arm in a door. There seems tobe a clear distinction between staff who attempt a safe CPM technique and those

who do not. Just 28 of 112 mandated staff (25 %) were compliant with Crisis Prevention and

Management semi-annual training.


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November 2010

RECOMMENDATIONS

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

Re-train and follow up with staff on descriptions of restraints in IRs. Staff shouldgive detailed accounts, including which hand(s) they used, if the youth moved,

ran, struggled or complied, and if the staff stood or walked with the youth, etc. Continue to focus on poor CPM techniques in video reviews and OIG

investigations. Allow staff to review their own incidents on video whenever

possible in order to see exactly where they could have improved or how earlier

intervention of a different kind might have prevented the incident.

Ensure that staff are knowledgeable about other means (besides seated verbaldirectives, hands-on, or use of force) to handle youth who are disruptive in class

or on the unit. Calling mental health, case managers, the Superintendent, etc. are

options as is simply asking the youth to take a brief time-out to calm down in hisunlocked room. Staff should document on the youths point sheet and the unit log

book and describe the behaviors and interventions in detail.

Ensure all staff are trained twice yearly in CPM, including mechanical restraints.


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November 2010

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 requires that sleeping rooms be searched aminimum of once per week for contraband and that the search be recorded in theunits log book. A review of randomly selected unit log books indicated that

room searches are not consistently documented as required.

Interview with 11 staff indicated that the facilitys FOP requires more frequentroom searches than Department policy. Not all of the staff, however, agreed onthe frequency for conducting a room search. Some staff indicated once a week

and others stated every shift.

Interview with staff revealed that the facilitys policy requires staff to record allroom searches on Shakedown forms. Shakedown forms for two of three cottages

were not readily accessible for review.

Four of nine staff indicated that they are not given enough time or assistance torealistically search sleeping youth rooms.

A review of the DJS Incident Reporting Database revealed 9 incidents involvingcontraband from January 1, 2010 to November 15, 2010. A review of one unitslogbook, however, revealed a contraband incident (11/5) that was not documented

in an incident report as required. The incident involved a staff observing a youth

using a sharp metal object to prevent his room door from closing after being

forced into his room. The youth refused to surrender the sharp metal object tostaff and hid it in his room. The staff reportedly left the unit to retrieve a

flashlight so he could search the room for the sharp metal object. No further

information regarding the matter was readily available.

The facility reported two incidents (IR) involving the recovery of dangerousobjects which were described as a metal weapon that was observed in a youths

locker (#80578) and a homemade shank found in a heating vent during a room

search (#82417).


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A search of sleeping rooms revealed several beds that were not properly securedto the floor by metal brackets. Some of the beds have loose or missing metal

brackets that are supposed to secure the beds to the floor.

The facility has conducted searches that resulted in the recovery of pens (used tomake a tattoo device), unidentified pills, an illegal drug and suspectedmarijuana.

QI team observations revealed that youth are not consistently searched forcontraband upon movement.

During a tour of the facility, a QI team member observed youth watching a DVDmovie titled Wanted. The movie is R rated and contains acts of violence. The

movie is about a frustrated office worker [who] learns that he is the son of a

profession assassin, and that he shares his fathers killing abilities. These movies

are inappropriate for showing to youth in the care and custody of the Departmentand should not be inside detention facilities.

The facilitys walk through metal detector/scanner is inoperative. However thefacility is currently using a handheld wand to scan visitors and employees

entering the facility.

RECOMMENDATIONS


facility:

Ensure staff consistently document room searches in the unit logbook. In theevent that facilitys records or sources of information (i.e. shakedown form, etc.)

are lost or destroyed, the unit log book will serve as a source document for theinformation as required by DJS policy.

Ensure Group Life Managers/Shift Commanders verify that all required incidentsare entered into the DJS Incident Reporting Database, as required by DJS policy.

Staff should conduct a through search for contraband upon youth movement. Ensure only G, PG or PG-13 movies are shown to the youth. Ensure a working flashlight is readily available for staff on the units. Repair or replace the walk through scanner.


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SECLUSION RATING: Non 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 Incident Reports from June-Oct 2010 Seclusion sheets Videotapes of seclusion and morning hygiene Interviews with youth and staff

Observation at facility

REFERENCESDJS Seclusion Policy RF-01-07; COMAR 16.18.02

SUMMARY OF FINDINGS

There were twenty (20) documented seclusions between August 8 and November17, 2010. The seclusions that were documented were lengthy, with an average

length of stay in seclusion of 32.5 hours, by far the longest length of stay in thestate.

The Seclusion Log had blank spaces on nearly every line; blanks included:release times, release dates, reasons for confinement, person requestingconfinement, entrance times, and person authorizing confinement. Because ofthis, it was extremely difficult to know actual seclusion times. They had to be

pieced together from the sheets the facility could find. It would be impossible for

the Superintendent, upon a quick review, to assess seclusion use or to know if ayouth was still in seclusion or not.

Many youth in group disturbances were all released at the same time. This gavethe appearance that seclusion release was not individualized but was instead being

used as punishment.

There were multiple instances of undocumented seclusion use at Cheltenham:o Youth were observed locked in rooms during morning hygiene and

breakfast well after wake up time on a video from November 2, 2010;

o All youth on Henry were observed on video locked in on October 18, 2010after breakfast while the four staff sat at a front table;

o After an OIG investigation, staff were sustained on for an undocumentedseclusion on July 26, 2010 (lasting 3 hours);


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o Thirty-three (33) youth were discovered locked in until mid-day onNovember 5, 2010 (due to lack of staff) with no documentation; and

o On November 19, 2010, the QI Team saw a youth locked into thedayroom eating lunch alone; the logbook indicated hed been in there

since 8:30am due to having issues with another student.

The issue of lack of staff, especially on Henry, was mentioned by staff and ayouth; youth have to remain locked in until the ratio can be met. Only once was astaff shortage indicated in the seclusion log (August 8, 2010). At no other timewas a staff shortage indicated as a reason for seclusion use, and in no case were

seclusion processes followed or documentation completed when there was a mass

lock-in for lack of staff.

Eleven (11) of the documented episodes of seclusion were reviewed. Sheets werefair in that line staff generally documented checks as required. Five (5) youths

sheets from October 31, 2010 had missing or inappropriate shift commander

comments, no overnight checks, exact 10 minute checks and a one hour gap.

On a random video of one seclusion episode reviewed from November 2, 2010, aline staff did make the checks he was supposed to be making at ten minute

intervals as required. The shift commander comments (reasons for youth not being released from

seclusion) were poor across all eleven youth. Most noted Per Admin or Group

Disturbance or Re-evaluate in AM (when it was mid-day) or Waiting for

superiors to contact me and the like. Very few gave justifications, which givesthe strong appearance seclusion is being used as punishment.

The documentation gaps seem to rest more with supervisory staff than with linestaff.

There was no documented auditing of the seclusion log or observation sheets; theanomalies listed above could have been found and staff correction made if an

auditor checked them daily.

The seclusion form being used is not a DJS form and does not meet policyexpectations.

About half the time, it was noted that seclusion ended at 10pm because that wasthe end of the second shift and the last bedtime. Though true that DJS seclusionpolicy indicates that seclusion is locked door time not during sleeping hours, it

is unsafe to stop watching a volatile youth at the proscribed intervals because

bedtime happens to come about. If the youth is in seclusion, it is due to his beingso out-of-control that his door cannot be open and he is dangerous to himself or

others. Juvenile suicide in confinement studies show that youth in locked rooms

are more likely to commit suicide (due to being agitated, depressed, angry or

stressed) which is why DJS requires staggered ten minute checks of youth whoare in these mental states post-incident. DJS requires in policy that a youth be

released as soon as he is calm. If a youth who is on seclusion cannot be processed

out at bedtime, then returned to his room with the confidence that he is safe, thenthe checks must continue through the night and processing tried again in the

morning.

Seclusion requires medical evaluation at the time initiated and every 2 hours. Themedical staff was not always informed when youth were placed in seclusion.


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Generally the Tour Office would call and this was documented by the RN.

Review of Seclusion documentation for 10/31/10 in which youth were secluded 4hours found no medical assessments documented for two youth on the door sheets

or in the progress notes. In other seclusion cases, medical assessments were not

accomplished when seclusion continued overnight. On some, dates and times ofnotes were missing and documentation did was not consistently accomplished

every 2 hours.

RECOMMENDATIONS


facility:

Seclusion processes are poor. Significant work and training will be needed torectify it. QI is available for technical assistance if requested.

Use the DJS-approved Seclusion Observation Sheet attached to policy. Discardthe sheet currently in use.

Ensure that the auditing process includes seclusion sheets if a seclusion episodeoccurs. File seclusion sheets in a separate (red) folder inside the IR manila folderso that the entire incident and seclusion can be reviewed/audited together.

Require the Seclusion Log to be filled out properly, accurately and in its entirety. Require shift commanders to make an actual attempt to process youth out of

seclusion every two hours as required. Continue to review video and discipline

shift commanders who do not attempt to speak to youth.

Ensure release decisions are individually made. Lessen the length of stay through proper seclusion use and procedures. Ensure all staff know to continue seclusion checks for youth (who are still unsafe

to be let out of rooms at bedtime) all night or until they are safely able to process.

Do not stop checks simply because it is bedtime. Ensure a youth in any locked room (including a dayroom) is watched following

DJS Seclusion policy guidelines.

Ensure Medical is promptly notified of any seclusions and that medical checksoccur every two hours until release.


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November 2010

ROOM CHECKS DURING RATING: Satisfactory 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 Room check sheets 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

DJS policy requires that staff conduct a room check of each youth during thebedtime period at least every 30 minutes. The facilitys Required Use of GuardTour Facility Monitoring System and Supervision and Movement FOP indicate

different time intervals for conducting room checks. However, both FOPs

requirement indicate room check intervals of less than 30 minutes.

The facility utilizes the Guard Tour System to electronically record room checks. A review of 40 shifts indicated that staff conduct room checks within establishedtime intervals with some exceptions that exceed the required time intervals. A random review of surveillance video tapes revealed that staff are conducting

rooms checks at the required time periods.

A review of a units logbook revealed several entries by a staff requesting that anight light be placed in some rooms so that youth can be properly observed.

RECOMMENDATIONS

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

Ensure a flashlight is readily accessible to staff conducting room checks. Ensure that all FOPs that reference the times room checks are to be conducted

comport with one another.


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PERIMETER CHECKS RATING: Partial 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

Guard Tour documentation

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

The facility conducts at least one daily check of the perimeter and grounds asrequired by policy. There were a few exceptions to the facilitys requiredperimeter checks due to the utility vehicle(s) being inoperative.

Based on information received and a tour of the facility, there were times whenthe latch to the electronic lock on the exterior door of the Tour Office was taped

so that the door would remain unlocked for the convenience of staff.

During several observations of the Tour Office, an interior security door,unoccupied areas and a storage room were discovered unlocked but not in use.

During a tour of the facility, youth were allowed to enter an office to pray andthey partially closed the door without staff being present in the room. Anunoccupied and open office was located within the same room where the youth

were praying. Both offices contained supplies or items that would be considered

contraband for a youth to possess.

During a tour of the facility, one of the security doors in the Health Centerremained unlocked due a key having difficultly operating in the lock.

RECOMMENDATIONS


Ensure staff lock all doors, unoccupied areas, and storage rooms when not in use. Shift Commanders should conduct frequent checks of the Tour Office to ensure

that staff do not disable any door locks for their convenience.


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November 2010

STAFFING RATING: Non 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 INFORMATIONFacility listing of vacanciesReview of Facility Staff

Review of Facility Logbooks (Rennie, Cornish, Henry, Infirmary, Education & Master

Control)Review of Cheltenham School Daily Documentation Forms

Interview with staff and youth

Review of Incident Reports

Observation of facility

REFERENCES

ACA 1-SJD-1C-03

SUMMARY OF FINDINGS

The staffing for all three shifts from eight random days in from July 2010 toNovember 2010 were reviewed (24 shifts). On six of those shifts (25%) at leastone unit was out of the appropriate staff to youth ratio.

A review of incident reports from June 2010 to November 2010 found 7 of 46incidents (15%) in which the staff and students were not in the appropriate ratio.

On November 5, 2010 the Henry locked 33 residents in there rooms because therewere only three staff members to supervise them. The residents were not were not

allowed out of their rooms until their lunch time.

A review of the Cheltenham School Daily Documentation Forms showed thatthere were numerous days when students were late to school, or did not come toschool because there were not enough staff to maintain appropriate ratios. The

Henry unit missed the morning session of school three times during the review

because of a lack of staff. During the review an observation of the school showed

that while the groups came to the school in ratio, the groups were broken downinto smaller units in the classrooms. At those times the staff and student ratios

were not met.

At the time of the review there were 4 direct care staff members out on extendedmedical leave.

Personnel management staff at Cheltenham reported that there are approximately8 residential staff position vacancies at Cheltenham that the facility is activelytrying to fill.


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Staff reported that there is a great deal of mandatory overtime. This wasconfirmed with the 24 shifts reviewed from July 2010 to November 2010. There

were 61 staff members working over time on those 24 shifts. On 9 of the 24(37.5%) shifts there were at least four staff members working an overtime shift.

Staff report that overtime is not distributed evenly among staff. They report that

staff members who do not complain are given an unfair amount of overtime.

Youth and staff report that activities and school are missed because the units donot have enough staff to manage breaking the groups into small units.

Orientation staff are pulled for unit coverage and therefore cannot orient youth orensure prompt testing and assessment.

10 of 11 staff interviewed feel that there is not a sufficient number of staffemployed or working at the facility on a daily basis.

8 of 11 staff indicated that there are sometimes or often not enough staff tosupervise youth on suicide watch.

RECOMMENDATIONS

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

facility:

Review the current staffing plan to determine what additional staff are neededconsidering the population.

Continue to recruit to fill all available vacant residential staff PINS. Review how overtime is handled among the staff. The facility should ensure that

overtime is distributed evenly among the staff members.

Ensure unit ratios are met so that Orientation staff are not pulled from their duties.


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November 2010

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 key board from whichfacility keys are issued on a regular basis. The facility maintains several keyboards in the area of the Tour Office and another key board in the Health Suite.

The facility plans to also install a key board in the Administration Building for

staff.

The facility utilizes a chit and Key Log (sign in/out) to account for the issuanceand return of facility keys.

A random review of one key log revealed two set of keys exchanged for chits butnot signed out by the staff.

A random review of the schools key log for the period of 9/27 to 11/15 revealedthat 47% of the keys were not recorded in the key log as having been returned.

An interview with the Key Control Officer revealed that the facility does notmaintain a set of emergency keys at a secure location away from but near thefacility. In the future, the facility plans to maintain a set of emergency keys at a

nearby State Police Barrack. Currently, there is a set of facility keys maintained

in a lockbox in the Gatehouse which is only accessible to a limited number ofstaff.

During a tour of the facility, an entrance door key to Henry Cottage and a key to asecurity door in the Health Center had difficultly opening the locks. Based on interviews, not all facility keys had been placed on a metal key ring as

required by DJS policy. The Key Control Officer is in the process of addressing

this matter.


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Policy requires that at least one randomly selected key ring be inventoried daily.Although the facility often inventories the keys, a daily inventory is not conducted

in the manner prescribed by policy.

Based on an interview with the Key Control Officer, a key audit was conducted inApril 2010.

Not all security keys (i.e. cage doors and etc.) are identifiable by touch. The facility maintains a back up key board and 24 Hour Key Authorization

Forms.

Housing Unit keys are exchanged among staff at their assigned duty station andlogged in the units logbook.

TOOLS

A walk-through of the Maintenance Section showed it to be clean, wellmaintained and organized.

Maintenance maintains a master inventory of the tools assigned to the section. Tools are currently in the process of being inventoried.

Staff are responsible for the tools kept in individual toolboxes assigned toeach vehicle.

Currently, an interim supervisor is managing the Maintenance Section. Theinterim supervisor plans to inventory tools monthly and utilize a tool sign out

sheet.

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 accountedfor.

The knives and utensils are inventoried 3 times daily, however, a sign outsheet 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 youth were allowed to ina room of a cottage that contained office supplies. Staff were not in the roomwith the youth at the time.


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November 2010

RECOMMENDATIONS


Mark all security keys in a manner that identifies them by touch. Finish setting up the facilitys key control process. Ensure all keys work properly. Ensure youth do not have access to open offices.


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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

Staff interviews, along with a review of unit and Tour Office logbooks, revealedthat the facility does not conduct 30 minute counts as required by DJS policy.

The facility has a set number of official/unofficial counts to be conducted daily.The counts are recorded in the appropriate logbooks.

Interviews with four staff revealed different versions of the facilitys countingprocess. A relatively new staff was not familiar with the counting process, twostaff indicated that a count is to be conducted every hour and another staff

indicated every two hours and upon every youth movement.

A review of randomly selected unit logbooks revealed some instances in whichstaff wrote the counts in the margins and not chronologically according to DJSpolicy. Also, there were instances when a count was not recorded in the unit

logbook during the 3rd shift.

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

Staff do not consistently frisk youth upon movement. 7 of 11 staff interviewed indicated that the maximum number of youth 1 staff can

supervise alone is 8 youth. One staff said 6, one said 9 and two did not answer.The facilitys recognized youth to staff ratio is 8:1.


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November 2010

RECOMMENDATIONS


facility:

Ensure staff count their youth every 30 minutes and log it into the unit logbookand call it into the Tour Office.

Ensure the actual count itself is properly recorded in the unit logbooks. Ensure staff consistently frisk youth upon any movement.


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November 2010

FIRE SAFETY RATING: Partial 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 inspected the facility on September 28, 2010. The FireMarshal indicated deficiencies with some emergency lighting throughout the

facility. Observation and interview with the Fire Safety Officer indicated that the

deficiencies cited by the Fire Marshall have been corrected.

An inspection of the fire safety system (i.e. sprinkler, etc.) by ARK on October 6,2010, revealed some missing control valve signs, a leaking valve needing to berepaired and recommended certain gauges be inspected. According to the Fire

Safety Officer, all of the signs have not been replaced and the leaking valve stillneeds to be repaired.

Observation revealed that an electrical circuit box in the hallway of CornishCottage was open. The electrical circuit box was not able to be locked or closed.

A youth was later observed playing with the electrical circuit box.

The Fire Alarm Control Panel in Cornish and the Gate House shows troublestatus. The FACP in Cornish Cottage indicates an internal voltage problem andthe FACP in the Gate House indicates a problem with the system at another

location.

During a routine inspection of the fire extinguishers on October 28, 2010, the FireSafety Officer discovered that a fire extinguisher box in Henry Cottage had beenbroken open and the fire extinguisher discharged. The Fire Safety Officer was

never informed of the incident or discovered the reason for the fire extinguisher

ever being discharged.

Six fire extinguishers were randomly checked and found to have a currentmonthly inspection.


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An observation revealed a mattress at the entrance to Henry Cottage. A youthwas seen tripping over the mattress upon exiting the building. Hallways should

always remain clear for a fire emergency.

Based on an interview with the Fire Safety Officer and available fire drillsrecords, it appears the facility is not conducting fire drills as pursuant to policy(i.e. one each shift per month). Fire drill records indicate that the last fire drills

were conducted in August 2010. However, interviews with some youth revealed

they have participated in a fire drill in September and October. The Fire SafetyOfficer indicated that corrective/disciplinary action was supposed to have been

taken in the matter.

RECOMMENDATIONS


Replace missing signs and the leaking valve as soon as possible. Have the FACPs in Cornish and the Gate House serviced by a qualified fire safety

technician to determine the problem.

Ensure exits are not blocked. Ensure fire drills are conducted and documented as pursuant to DJS policy.


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November 2010

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:

Logbooks 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:

The facility is required to maintain a copy of each Post Order at the Tour Office,to include a Post Order Signature Sheet. The facility maintained the following

Post Orders in the Tour Office.

1. Tour Office Coordinator2. Housing Unit Staff3. Unit Manager4. Shift Commander

Still missing from the Tour Office were several post orders that were issued in

March 2009; School Monitor, Gatehouse, Health Center, and Security.

Not all of the Post Order Signatures Forms had been signed-off by a supervisor asrequired.

Two units were checked for their respective post order and the post orders werefound.

The Gate House was unable to locate a post order for that post. The facility did not provide a post order for RA staff positions and special

duty/assignment position of Fire Safety Officer or Tool Control Officer.

RECOMMENDATIONS


facility: Ensure that there is a post order for at least every staff positions delineated by

policy. (e.g., Resident Advisor series positions) to ensure staff are aware in

writing of the responsibilities of their positions/post.

Maintain a copy of all post orders and Post Order Signature Forms on file in theTour Office.


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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:

Half of the staff interviewed indicated that they were to be trained in CPM yearlyeven though it is a semi-annual requirement.

Mechanical restraints are covered in CPM training. Of 138 mandated staff, 112 (approximately 80% of the mandated staff) were

reviewed for training compliance and the results were as follows:

-- 64/112 (57 %) met the 40 hour annual training requirement.-- 34/112 (30%) of staff had First Aid/CPR/AED training in the prior 12 months.

-- 28/112 (25 %) were compliant with Crisis Prevention and Management semi-

annual training (when reviewing CPM compliance overall, 58% had hadCPM at least once in the prior year.)

-- 83/112 (74%) were compliant with Suicide Prevention annual training.

-- 83/112 (74%) were compliant with Recognizing and Reporting Child Abuseand Neglect annual training.

The facilitys two mandated management staff (both Assistant Superintendents),who are responsible for holding staff accountable in all of these necessary areas,were reviewed for compliance. One was not listed as mandated staff and one was

missing both Suicide Prevention and Child Abuse and Neglect reporting classes.

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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November 2010

ADMISSIONS, INTAKE & RATING: Satisfactory 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 3 orientation youth Interview with orientation staff Interview with staff who perform intake 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 and facility rules acknowledgement forms were found in 5 of 5 (100%)of files reviewed. However, youth sign two types of these: one at intake and oneat Orientation. The intake handbook and rules sheet should be discarded as the

information and handbook are given at Orientation.

At times, there is a reported shortage of staff who do intakes. Some case managershave to leave their regular work to do so. There is also a shortage of Orientationstaff due to being pulled to cover units.

The handbook at CYF is generally complete. A few small errors were correctedand PREA language added that was missing. Youth are offered a handbook at

Orientation but do not always take it with them to the unit. They should beencouraged to keep one in their room.

The biggest concern is that the SASSI and the MAYSI were sometimes notcompleted per Mental Health staff. Mental Health staff reported that they havereceived screenings that are incomplete, un-scored, and without names on them.Of 25 records reviewed, 3 were missing SASSIs and 5 were missing MAYSIs.

Two MAYSIs were un-scored and one was not completed. Medical staff

confirmed they receive screenings without youths names on them.

Intake staff interviewed knew how to score the MAYSI.


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The FIRRST is completed upon the youths arrival. 100% of base files hadcompleted FIRRST screening forms.

A medical assessment is done upon admission and in every case within 72 hours. The Orientation process seems generally complete but in need of efficiencies. The

two new RA staff assigned plan on updates to the process that make sense. The QITeam offered to assist with a written Orientation curriculum and did so. The new

process is beginning in late December 2010.

Classification forms were found in 100% of files reviewed.RECOMMENDATIONS

In order to reach Superior Performance status, the following is recommended:

Use a written Orientation curriculum. Introduce more efficient Orientation processes: lunch on the Orientation unit, one

day maximum stay, planned groups, and a structured day.

Remove the intake handbook and rules acknowledgement form from the intakepacket. Use only the one used by Orientation.

Consider training other administrative staff on how to do intakes so that morestaff are able to assist when necessary.

Ensure MAYSIs and SASSIs are completed in full, scored and names attached.Ensure these are carefully monitored to see that all youth are receiving them asrequired.


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November 2010

CLASSIFICATION RATING: Satisfactory 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 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

The facility maintains a Classification FOP to include a housing matrix for eachcottage.

A review of twenty base files revealed that Housing Classification Assessmentand Re-Assessments forms (after 60 days) were included. One re-assessment did

not include the date of the assessment. Several of the forms did not indicate theyouths assigned room number or unit assignment.

An interview with the CMS did not reveal if the Case Managers conduct or trackthe need for a Re-assessments at other times (i.e. youth involved in 3 or more

incidents and implement a Guarded Care/Behavior plans as a result, etc.) as

pursuant to DJS Policy.

Interviews revealed that Intake staff have been trained in the proper scoring andutilization the Housing Classification tool.

RECOMMENDATIONS

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

facility:

Ensure the actual date of classification, room number and assigned unit isrecorded on the Classification form completed.


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November 2010

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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November 2010

BEHAVIOR MANAGEMENT RATING: Partial 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 Crisis Management Interview Forms

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. In most cases the points were all filled out completely, give all of the

youth all of their points during the day. Deductions would be made in the case

where there was an incident, but most students ended the day with all of their one

hundred points. During the review, this reviewer identified four youth who caused disruptions

during the school day in one or more classes that, according to the Behavior

Management Plan and the Student Handbook, should have received point

deductions. The point sheets of these youth were reviewed. In all of the cases theyouth received all of their points for education despite their behavior.

Teachers were not allowed to give and take away points for the times when youthwere in school.

Students consistently indicated that they did not receive the incentives as outlinedin the student handbook. Students listed commissary as their favorite incentive inthe program and the one incentive that is consistently provided. Students reported

that bedtimes are not administered according to the BMP. Youth report that all

youth are placed in their rooms during showers and that they do not come outafter showers. This was supported by the information about bedtimes in the unit

log books.

While the youth were aware of the behavior management program they did nothave it in writing. The youth said that they were told about it in Orientation but it


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is not included in the Student Handbook. It indeed is in the handbook, so there

may be a need to laminate the handbook and post it for reference.

For students who have difficulty maintaining appropriate behavior under theBehavior Management Program the facility creates Behavioral Management Plans

and Intervention Plans. These plans outline negative behaviors, triggers, soothing

strategies and action plans to direct youth to display positive behaviors. Theinformation is valuable, but the direct care staff interviewed indicated that they

were not made aware of this information. The Crisis Management Interview Formis a form that the mental health staff used to process with you and allow them todiscuss behavior triggers and strategies that have worked well for them in the

past. While this information could be useful the staff indicated that they were not

given the information. Without sharing it with those who work with youth, the

plans are not useful.

RECOMMENDATIONS


facility:

Daily Point sheets should be updated by the staff throughout the day. At the endof an activity the points should be awarded or taken away.

During the school day the teachers should award the points for classroomparticipation and behavior.

Incentives should be provided to the youth as outlined in the BMP. Information from Behavioral Management Plans, Intervention Plans and Crisis

Management Plans should be shared with the direct care staff who will be the

main people interacting with the youth.

The Student Handbook should be laminated and posted on all units, in the school,the Health Center , the gym and the dining hall for reference for youth and staff.


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November 2010

STRUCTURED REHABILITATIVE RATING: Partial 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 Master Schedule indicated that the youth received Behavioral Health andEducational groups from 3:35-4:40 PM and then extra groups between 6:35-

7:35 PM. A review of the unit logbooks did not indicate that there was anyconsistent programming during these times. The most consistent activity was the

mental health groups.

The units were visited on November 17, 2010 in the evening during the time theschedule indicated that youth should be in groups. During that time none of theunits were in structured activities. Youth were watching movies, playing cards

and playing video games. Similarly on November 18, 2010 there was no school atthe facility because of teacher training. During that day the youth participated inno structured activities beside recreation.

Youth, staff and logbooks confirm that the youth receive at least one hour ofrecreation everyday. Youth indicated that, weather permitting, they can choose to

have recreation outside or inside.

The facilitys Assistant Superintendent reported that the facility has not had anYouth Advisory Board Meeting since February 2010. He indicated that they

would began again in December 2010.

The youth reported that they are not offered any religious services. Staff reportedthat the church that had previously provided services no longer comes to the

facility.


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November 2010

RECOMMENDATIONS


facility:

Develop programming to meet the needs of the youth. Facility staff can organizeactivities to engage the youth. Keeping the youth busy would help to prevent

fights and other negative behavior. An activity schedule should be developed and

posted monthly so that youth will be aware of upcoming activities.

Ensure all schedules are accurate. If groups are not occurring, remove them fromthe schedules.

Continue with the plan to re-establish the Youth Advisory Board Meetings Contact local religious organizations to see if they would offer some

programming. When religious services are offered an alternative program should

be offered for youth who choose not to participate.


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November 2010

SELF ASSESSMENT RATING: Not Rated

STANDARDWritten policy, procedure and practice document that the facility superintendent at least

twice monthly meets with his or her management staff to assess the facilitys status

involving the use of seclusion, restraints, incident reporting numbers and procedures and

other key area of facility operation in order to assess the facilitys compliance with DJSnorms and expectations.


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November 2010

BEHAVIORAL HEALTH

INTAKE, SCREENING& ASSESSMENT RATING: Not Rated

STANDARD

Written policy, procedure, and practice require that all youth admitted to a facility willbe screened by qualified mental health professional in a timely manner using valid and

reliable measures. All youth who screen positively for behavioral health issues will be

referred for a full mental health assessment by a mental health professional. All youth

who present at the facility with behavioral health issues that, as determined by

professional mental health assessment, are beyond the scope of what the facility can

safely treat, will be referred to a setting that can more appropriately meet the youth

needs.

DUE TO THE LACK OF A BEHAVIORAL HEALTH QI REVIEWER, THISSTANDARD COULD NOT BE ASSESSED.


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November 2010

INFORMED CONSENT RATING: Not Rated

STANDARDWritten policy, procedure, and practice require that youth, and when appropriate, their

guardian, are informed of the risk, benefits, and side effects of medication and the

potential consequences of stopping medication abruptly. Youth are also notified that

their conversation with clinician, though confidential, may be shared with DJS and theCourt if requested.

DUE TO THE LACK OF A BEHAVIORAL HEALTH QI REVIEWER, THIS

STANDARD COULD NOT BE ASSESSED.


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November 2010

PSYCHOTROPIC MEDICATION RATING: Not RatedMANAGEMENT

STANDARDWritten policy, procedure, and practice require that psychotropic medications are

prescribed, distributed, and monitored safely.




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CYF

November 2010

BEHAVIORAL HEALTH SERVICES RATING: Not Rated

& TREATMENT DELIVERY

STANDARDWritten policy, procedure and practice require that appropriate mental health substance

abuse treatment and emergency services are provided by qualified mental health

professionals and substance abuse counselors, that it is integrated with the psychiatricservices when applicable, and that it is appropriate for the adolescent population. Crisis

intervention services should be available in acute incidents. All admitted youth should

receive alcohol and drug abuse prevention/education counseling. Family involvement

should be highly encouraged. Behavioral health issues should be considered when

providing safe housing for youth at the facility.




47/81


CYF

November 2010

TREATMENT PLANNING RATING: Not Rated

STANDARDWritten policy, procedure and practice require that appropriate mental health substance

abuse treatment and emergency services are provided by qualified mental health

professionals and substance abuse counselors, that it is integrated with the psychiatric

services when applicable, and that it is appropriate for the adolescent population. Crisisintervention services should be available in acute incidents. All admitted youth should

receive alcohol and drug abuse prevention/education counseling. Family involvement

should be highly encouraged. Behavioral health issues should be considered when

providing safe housing for youth at the facility.




48/81


CYF

November 2010

TRANSITION PLANNING RATING: Not Rated

STANDARDWritten policy, procedure, and practice requires staff to facilitate appropriate transition

plans for youth leaving the facility. Youth, and their guardian when appropriate, should

receive information on behavioral health resources, a prescription for medication

continuation, and assistance in contacting behavioral health aftercare services toschedule follow-up appointments.




49/81


CYF

November 2010

SUICIDE PREVENTION

DOCUMENTATION OF YOUTH RATING: Partial Performance

ON SUICIDE WATCH

STANDARDWritten policy, procedure, and practice require that all newly arr