Comprehensive Quality Review Report Charles H. Hickey Jr. School (MD 2010)

OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report
Charles H. Hickey Jr. School June 21, 2010
DJS QI Report Charles H. Hickey Jr. School June 2010
OFFICE OF QUALITY IMPROVEMENT Quality Review Report Charles H. Hickey Jr. School Evaluation Dates: May 11-14, 2010
TABLE OF CONTENTS
EXECUTIVE SUMMARY .............................................................................................. 3 QI Rating Scale ............................................................................................................... 3 QI Rating Percentage ...................................................................................................... 4 Executive Summary of Results....................................................................................... 6 Methodology ................................................................................................................... 7 SUMMARY OF FINDINGS & RECOMMENDATIONS............................................ 9 SAFETY AND SECURITY ............................................................................................. 9 Incident Reporting .......................................................................................................... 9 Senior Management Review ......................................................................................... 12 De-Escalation & Restraint ............................................................................................ 14 Contraband & Room Searches...................................................................................... 16 Seclusion ....................................................................................................................... 18 Room Checks During Sleep Period .............................................................................. 21 Perimeter Checks .......................................................................................................... 23 Staffing.......................................................................................................................... 26 Control of Keys, Tools & Environmental Weapons..................................................... 28 Youth Movement & Counts.......................................................................................... 30 Fire Safety..................................................................................................................... 32 Post Orders.................................................................................................................... 34 Staff Training ................................................................................................................ 35 Admissions, Intake & Student Handbook..................................................................... 37 Classification................................................................................................................. 39 Pending Placement........................................................................................................ 40 Behavior Management .................................................................................................. 41 Structured Rehabilitative Programming ....................................................................... 43 Self Assessment ............................................................................................................ 44 BEHAVIORAL HEALTH ............................................................................................. 45 Intake, Screening & Assessment................................................................................... 45 Informed Consent.......................................................................................................... 46 Psychotropic Medication Management......................................................................... 47 Behavioral Health Services & Treatment Delivery ...................................................... 48 Treatment Planning....................................................................................................... 49 Transition Planning....................................................................................................... 50 DJS QI Report Charles H. Hickey Jr. School June 2010 i
TABLE OF CONTENTS (Continued)
SUICIDE PREVENTION .............................................................................................. 51 Documentation of Youth on Suicide Watch ................................................................. 51 Environmental Hazards................................................................................................. 54 Clinical Care for Suicidal Youth................................................................................... 56 EDUCATION .................................................................................................................. 57 School Entry.................................................................................................................. 57 Curriculum & Instruction.............................................................................................. 58 School Staffing & Professional Development .............................................................. 60 Screening & Identification............................................................................................ 62 Parent, Guardian & Surrogate Involvement.................................................................. 64 Individualized Education Programs.............................................................................. 65 Career Technology & Exploration Programs ............................................................... 67 Student Supervision ...................................................................................................... 68 School Environment & Climate.................................................................................... 70 Student Transition......................................................................................................... 71 MEDICAL CARE........................................................................................................... 72 Health Care Inquiry Regarding Injury .......................................................................... 72 Health Assessment ........................................................................................................ 74 Medication Administration ........................................................................................... 77 Dental Care ................................................................................................................... 79 Medical Records Retrieval............................................................................................ 81 Special Needs Youth..................................................................................................... 82 Availability of Medical Services .................................................................................. 83
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EXECUTIVE SUMMARY A quality improvement assessment and evaluation of the Charles H. Hickey Jr. School was conducted May 11-14, 2010 by DJS personnel who are subject-matter experts in the areas reviewed. The areas that were evaluated have been identified as those 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.
The following Rating Scale was used:

Quality Improvement Rating 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. Performance measure is consistently met across the facility/program; any gaps are temporary and/or isolated and minor; documentation is organized and readily available. 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. Little or no evidence of adequate implementation of performance measure; the required activity or standard is not performed at all or
Satisfactory Performance
Partial Performance
Non Performance
there are frequent and significant exceptions to adequate practice; documentation could not be produced to substantiate practice.
At the last QI Review of Hickey in June 2009, 38 standards were evaluated. Following is a brief synopsis of the results from that review:*
Rating Superior Performance Satisfactory Performance Partial Performance Non Performance
# within rating 4 27 4 3
% of total in rating 10.5 % 71 % 10.5 % 8%
For this review, a total of 36 standards were evaluated with the following results:*
Rating Superior Performance Satisfactory Performance Partial Performance Non Performance
# within rating 0 15 17 4
% of total in rating 0% 42 % 47 % 11 %
NOTE: 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 partial or non performance ratings as a result of QI reviews.
Hickey Performance Comparison

80%
70%
60%
50% Percentage
40%
30%
20%
10%
0% 6/12/09 Date of Review Superior Performance Satisfactory Performance Partial Performance Non Performance 6/21/10
OFFICE OF QUALITY IMPROVEMENT Charles H. Hickey Jr. School Executive Summary of Results
Superior Performance Satisfactory Performance
Contraband and Room Searches Fire Safety Admission, Intake and Student Handbook Classification Room Checks During Sleep Behavior Management Perimeter Checks Structured Rehabilitative Programming Curriculum and Instruction School Staffing and Professional Development Screening and Identification Parent, Guardian and Surrogate Involvement IEPs Student Supervision School Environment and Climate Student Transition Health Care Inquiries Regarding Injury Medical Records Retrieval Availability of Medical Services Health Assessments Medication Administration Dental Care Staffing Youth Movement and Counts Staff Training Documentation of Youth on Suicide Watch Environmental Hazards School Entry Special Needs Youth
Partial Performance
Incident Reporting Senior Management Review
Non Performance
Control of Keys, Tools and Environmental Weapons Post Orders
De-escalation and Restraints Seclusion Career Technology and Education
OFFICE OF QUALITY IMPROVEMENT Charles H. Hickey Jr. School METHODOLOGY
I.
Pre-Evaluation Prior to the evaluation, the facility received a document request list from the DJS 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, Entrance Interview with Superintendent A formal entrance interview was not conducted with the Superintendent on the first day of the review, but discussions and interviews were conducted throughout 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. Primary Interviews A total of 9 youth were interviewed individually and 29 in groups (for a total of 38 youth) about a range of areas across the QI review spectrum. This represented about 44 % of the total population at Hickey that week. Interviews were also conducted with facility direct care, administration, medical, behavioral health, case management and education staff. In addition, 10 staff were interviewed specifically about the target areas of the review as well as their general feelings about the operation of the facility. Document Review Documents 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.
II.
III.
IV.
OFFICE OF QUALITY IMPROVEMENT Charles H. Hickey Jr. School METHODOLOGY (Continued)
V.
Observations of Facility Operations Youth movement Structured programming Recreation Unit activities Leisure Time Dining Hall Classroom Activities Review of Quality Improvement Report The 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. Exit Conference An exit conference was not conducted at the facility. Discussions about some portions of the QI findings were conducted on the last days of the review.
VI.
VII.
SUMMARY OF FINDINGS & RECOMMENDATIONS
SAFETY AND SECURITY
INCIDENT REPORTING
RATING: Partial Performance
STANDARD Written 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 52 Facility Incident Reports September 2009-May 2010 Interview with IR Specialist 61 youth grievances April 2009-April 2010 Staff Training Histories Report OIG investigations Interviews with youth Interviews with staff REFERENCES DJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management (CPM) Techniques Policy (RF-02-07); DJS Video Taping of Incidents Policy (RF-0507); DJS Youth Grievance Policy (MGMT-01-07) SUMMARY OF FINDINGS Incident Report (IR) files did contain both written and electronic copies. IRs are generally filled in entirely with few blank areas. Narrative portion includes all four parts and all four are completed. There were no instances found where a youth alleged child abuse and his case was not referred to CPS as required. IR type selected is appropriate. There were a few instances where staff did not check Physical Restraint but the facts as written indicate there likely was some use of force. The IR Specialist typically finds these errors and corrects them. Descriptions of uses of force (when applicable) are sometimes not detailed but at other times are excellent, especially in individual staffs witness statements. This is staff-dependent; overall, descriptions are not as strong as they were in prior reviews. 9
The narratives can best be described as fair. They are not as detailed as they were in prior reviews. All of the IRs contained shift commander comments. About half of the shift commander comments were critiques (as is required); the other half missed supervision issues, missing witness statements and did not help staff to improve their performance. Notifications sections are complete. About 1/3 of the IRs reviewed had missing youth witness statements. Most staff witness statements were present. In 89% of cases, youth in incidents or restraints saw a nurse as required and had a body sheet present in the file. Photos were attached when required. After a review of the Nurses Injury Log and incidents that were discovered through logbook review, the OIG and in-person observation, as well as a review of body sheets that had no incident report attached to them, there is a concern that Hickey staff are not reporting all incidents as required. The reasons for this concern are documented below: a. One incident (a youth in mechanical restraints in the school) was observed by a QI reviewer and was not reported. b. Two others were discovered in gatehouse logs and other documents and had not been reported (a youth climbing on a fence and a staff missing keys.) c. In a random sample of two months (out of six months) worth of Nurses Injury Log logged youth, eleven (11) youth were found to have seen a nurse for an injury, but no IR could be located to correspond to that visit. d. In a review of fourteen body sheets that were not attached to incident reports, seven (7) had no corresponding incident report either in the IR log or in the IR files. e. An incident of staff misconduct (OIG tracking number 10-80948) gave indications that two staff did not want to write up an assaultive incident that occurred on their unit; they instead indicated it was horseplay and only noted it in a logbook entry. No written discipline resulted for either staff as it related to the lack of incident reporting. f. These incidents total 22 unreported incidents found in a sample. g. Medical and other staff feel there are staff who do not report all incidents. Youth are taken to Medical with injuries that occurred days or weeks ago. Youth also come with injuries that do not match up to what the youth is reporting occurred.
Though the quality of the IRs themselves has declined, generally they are acceptable and with work and oversight could be improved quickly. The number of unreported incidents is the greatest concern for QI.
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GRIEVANCES There were 61 youth grievances in the past 12 months at Hickey. The top complaints were as follows, in order: 1) clothing, shoes and other supplies, 2) points and 3) temperature (water and air) and lights. There were still shoe issues on Clinton Hall during the review (youth with only slides; youth with small, illfitting shoes, etc.) and it is unclear why this continues. The Youth Advocate seems to pick up grievances timely (the average time was 2.1 days) and nearly every youth all said they knew where to find and file grievance forms. On a walk through, there were no grievance forms on Roosevelt Hall but they were present in Mandela and Clinton.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Report all incidents. Staff report that they are required to fill out an IR after any incident, but they may not always be doing so. Hickey may need to investigate why this is the case (lack of time/staff support to complete IRs; IR is too long/new staff dont understand it; staff inaction/poor decision may preclude them from reporting something; didnt think something was a big deal; etc.) Even if a staff does not report something as required, the other staff around them must follow through and ensure it is reported in order to protect the integrity of the reporting process. The Administration may wish to address this issue at an all-staff meeting and with unit managers individually. Descriptions in narratives and of uses of force is an area that once was an overall strong point for almost all Hickey staff and may need some refresher training by a qualified person. Require shift commanders to critique staff when they fill out the shift commander comments. Ensure they are sharing these coaching tips with their staff. Check grievance forms on the wall with each walk-through. Require they be restocked continuously.
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SENIOR MANAGEMENT REVIEW
STANDARD Written 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. SOURCES OF INFORMATION 52 Facility Incident Reports September 2009-May 2010 Interviews with staff Review of 26 OIG Investigations Review of seclusion documentation Review of suicide watch documentation Interview with IR Specialist REFERENCES DJS Policy MGMT-03-07 Incident Reporting Policy (MGMT-3-01); ACA 3-JDF-3B-10 and 3-JTS-3B-11 SUMMARY OF FINDINGS All of the IRs had shift commander comments, however only about half of the shift commander comments were critiques (as is required); the other half did not critique staff performance and missed various supervision issues. Some missed issues that seemed very easy to remark on and necessitated follow up that then did not occur. Policy requires senior administrative review of all incident reports within 72 hours. IRs that were reviewed from September and October 2009 were audited by a senior manager and within 72 hours in almost every case. Those audits were also of high quality. However, recent audits in 2010 were not thorough and were not done timely. A review of 15 more recent IRs found audits completed an average of well over two weeks later and 5 more reviewed went well over 55 days. Many IRs were audited the week of the QI review which resulted in rushed, poor quality audits that did not result in any actual oversight. The former system of auditing within 72 hours with a critical eye toward improving staff performance has declined significantly. Corrections are not always made by staff timely; due dates are sometimes disregarded. Seclusion sheet auditing does not seem to be occurring as a part of the IR audit process. Audits were evident on suicide watch documentation, and though they did not catch all errors, they did catch many. The auditing staff is new to this task and 12
may need additional training and time to perfect catching all errors, but they are off to a solid start. When issues are found in suicide watch documentation, there is evidence of employee memos/corrective actions/discipline to show follow-up with staff. Some of the discipline for the more serious infractions of line staff may need to be more stringent than a simple corrective action form. It is up to the facility to decide what safety implications a lack of supervision leaves and to respond accordingly. There is administrative support in the form of the IR Specialist. The IR Specialist provides a layer of oversight in that she ensures incident categories are correct and that all paperwork is collected and organized. Her utility in this position allows the GLM II and shift commanders to concentrate on their own workload. The Office of the Inspector General (OIG) completed 24 investigations in the year, 13 of which related to child abuse allegations. All but one of the child abuse allegations were not sustained; four of the other investigations resulted in sustained findings on staff. Hickey has an excellent investigations team who provide solid external oversight.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure senior management staff at Hickey are skilled in auditing IRs, suicide watch and seclusion sheets. Prevention of a like incident is a goal that can only be accomplished with staff coaching and regular and timely oversight. Ensure auditing occurs within 72 hours as required by policy. Require all shift commanders to critique staff and to share their comments with staff 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 this information to prevent another such occurrence. Ensure shift commanders understand the mechanics of a critique and know what supervision points to catch when they review an incident.
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DE-ESCALATION & RESTRAINT
STANDARD Written 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. SOURCES OF INFORMATION 52 Facility Incident Reports September 2009-May 2010 Facility training records on CPM and Verbal De-escalation Interview with Superintendent Interviews with youth Interviews with staff REFERENCES DJS 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 (when applicable) are sometimes not detailed but at other times are excellent, especially in individual staffs witness statements. This is staff-dependent; overall, descriptions are not as strong as they were in prior reviews. Mechanical restraint documentation in IRs did not always include who applied them, how, or if the youth complied or not. One narrative left its use out altogether; a staff witness statement explained that they were used. Also missing was the length of time in handcuffs and shackles and which staff was constantly supervising the youth until he was released. Most IRs indicated no video was taken as required by DJS Video Taping of Incidents policy. One noted that the staff does not know if Douglass has a camcorder. No follow up to check or obtain one was documented. There were no videos to review as no incidents were videotaped as required. 44/61 (72%) of mandated staff were missing one or more Crisis Prevention and Management (CPM) trainings which is required twice annually. Mechanical restraints appear not to be taught in CPM training.
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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. Ensure all staff document all aspects of mechanical restraint use in IRs. Ensure staff are trained twice yearly in CPM and that mechanical restraints are included in that training. Videotape incidents, restraints and youth behavior as required by policy. Use these videos as training aids for staff.
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CONTRABAND & ROOM SEARCHES
RATING: Satisfactory Performance
STANDARD Written 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 INFORMATION Unit Logbooks Shakedown forms Interview with staff Observation at facility REFERENCES DJS Searches Policy (RF-06-07); Incident Reporting policy (MGMT-03-07); ACA 1SJD-3A-16 SUMMARY OF FINDINGS The facility maintains a Search and Contraband Procedure FOP (CHP-004) dated 12/14/09 which addresses the frequency and video taping of various searches (i.e. rooms, general areas, perimeter, and etc.) throughout the facility. There were no videos of staff conducting searches available for review. Review of documents revealed that room and general area searches are usually conducted at least once per day and documented in the appropriate units logbook. A review of Shakedown forms revealed that the facility is utilizing more than one version of the Shakedown form to document searches. To maintain consistency with recording pertinent information, the facility should use the version of the Shakedown form that identifies the name of the youth assigned to the room being searched. Shakedowns conducted by staff have resulted in the recovery of various contraband items (i.e. a metal rod and coil, a razor, handcuff key, R rated movies, an inappropriate magazine, food, plastic glove, pens, towel, matches and candy wrappers.) Frisk searches and observations made by staff have resulted in the recovery of various contraband items (i.e. a letter containing possible gang content, a cell phone, lighter, cigarette(s), needle, possible live ammunition, a bungee cord with metal hooks, and a DVD for adult/mature audiences.) On several occasions members of the QI team observed staff frisking youth for contraband upon movement (i.e. school, dining area, and gym.) Thirteen incident reports were on file for contraband for the period of October 1, 2009 to May 11, 2010. An interview with staff along with a review of incidents 16
reports suggest that staff know how to handle contraband when it is found. The facility has a secure location for storing contraband. During a tour of the facility, a member of the QI team observed books containing inappropriate language in several rooms in Mandela and Roosevelt Halls.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Review FOP to ensure actual practice comports with FOP policies and procedures. Ensure reading materials for youth contain appropriate language for a juvenile detention setting. Ensure the MSDE school keeps in mind the kind of youth in the facility and is careful about the kind of reading material it orders. Staff should use the version of the facilitys shakedown form that identifies the youth assigned to the room being searched to maintain consistency with documenting pertinent information.
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SECLUSION
STANDARD Written 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, a substantial destruction to property or an imminent threat of escape, and shall be treated humanely and with concern and care so as to safely maintain the youth until he can be released in the least amount of time. SOURCES OF INFORMATION Facility Seclusion Log Interviews with Superintendent Incident Reports from September 2009-April 2010 Seclusion sheets Unit logbooks Interviews with youth Interviews with staff Observation at facility REFERENCES DJS Seclusion Policy RF-01-07; COMAR 16.18.02 SUMMARY OF FINDINGS There were 45 total documented seclusions between October 2009 and April 2010. The seclusions that were documented were relatively short and averaged just 3 hours in length. Fourteen youth seclusion episodes were reviewed. Of these, 50% of sheets had no areas of concern. The other 50% had issues such as: 15-10 minutes checks rather than 10, checks made after a youth went to court, patterns of all times ending in 5, patterns of all times ending in 8 and one time of release not matching up with the seclusion log release time. A staff on one unit caught up on 45 minutes worth of seclusion checks for several youth while the QI team was present. These are not permitted to be done vertically but must be done one by one horizontally about every ten minutes. The shift commanders who came to check on youth every two hours did not pick up the issues listed above. The auditors who review as part of the senior management oversight are either not catching these errors or more likely, are not reviewing seclusion sheets as a part of their audit. The shift commander comments (reasons for youth not being released from seclusion) were of very high quality and clearly indicated why the youth was a threat and not able to be released. DJS QI Report 18 Charles H. Hickey Jr. School June 2010
Most of the staff in interviews indicated that when a youth is locked inside his room and it is not bedtime yet, that is always seclusion. This is an ideal answer, as DJS wants staff to take seriously seclusion and its use. However three staff did not believe this would always be seclusion. These may be newer staff, and they may need further education in this area. Two of three youth who said they had been in seclusion could not be located in the Hickey seclusion log. Hickey does not log into the Seclusion Log, nor do they check youth per seclusion policy, if there are lock-ins for a lack of staff. One episode of such a type occurred on 3/27/10. If youth are locked into their rooms during waking hours for any reason, seclusion processes must be employed. A conversation with the Administration indicated they had not been logging these, but now would begin doing so. After the review, on the morning of 6/4/10, youth were locked in rooms at 8:30 in the morning due to lack of staff again with no seclusion processes employed. Other examples of youth in rooms due to lack of staff were found on 5/30/10, 6/1/10, and 6/2/10. The use of early bed violates DJS seclusion policy. All Hickey staff interviewed noted that group punishment was not a part of the behavior management at the facility and that early bed was not used as punishment. However, youth interviews consistently said the group accountability was used frequently. Examples of verbatim comments were: if some act up, we all have to go to bed and they take our rec for group accountability and if you get in trouble in group, the whole group goes down early and everybody gets in trouble and the suggestion get people to do what you should do so you dont get locked down suggests that group accountability/punishment is being employed and that youth are being put in bed before their scheduled bedtimes and as punishment. If this is the case, these would be regarded as undocumented seclusions. Logbooks were reviewed for confirmation, with just over the past two weeks being reviewed for bed time information. a. In Roosevelts logbook, 11 of 16 days indicated that youth went to bed according to their level. Times were very close to or at the correct bed time for each level. In 5 of 16 days, the staff did not say when youth went to bed. b. In Clintons logbook, 0 of 16 days indicated that youth went to bed according to their level. In 4 of 16 days, the staff wrote that youth went to bed, but times were around 8pm for all youth, and not by level. In 12 of 16 days, the staff did not say when youth went to bed; from entries, it may have been between 6pm and 8:45pm, but there was not enough information to tell and nothing was written. The concern about poor logbook documentation is that staff accountability is nearly impossible. Without documentation that is clear, it appears all youth in Clinton Hall specifically are put to bed before or around 8pm which does not comport with their BMP level. It also gives the youths concerns about group punishment credence. DJS QI Report 19 Charles H. Hickey Jr. School June 2010
An IR on 5/25/10 involved a youth being restrained because he was told to go to bed and he argued that it wasnt time yet. Beyond the poor restraint description and lack of oversight in that IR, this gives concern as well that youth may be put to bed before they are scheduled. This builds resentment, undermines the BMP and leads to locked room time before bedtime.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that the auditing process includes seclusion sheets. Ensure staff know they must only document one check at a time and about every ten minutes. If they miss a check, they should simply write missed check (and why) rather than fill in several at one time. Ensure shift commanders know that checking the quality of the sheet (especially for patterns, gaps, etc.) is a part of their responsibility to ensure solid supervision of youth in seclusion. Though hard conclusions could not be drawn about logging of youth seclusions based on the two youth who self-reported, ensure that a process s firmly in place to call in and log every seclusion episode every time. Log into the Seclusion Log any youth lock-ins, even for lack of staff, and check youth in their rooms per the seclusion process and for their safety. Begin this process immediately. Discontinue any group accountability/punishment processes that individual staff may have employed; address early bed and why it is disallowed; randomly spot check units for bedtime adherence; interview youth regularly to see if they are in bed according to their level; and require clear and concise logbook documentation of each level bedtime to be sure staff are not giving vague written accounts in order to put youth to bed early. Interview staff as well to see if early bedtimes are being used to manage youth in times of high populations and explore other ways that can be accomplished.
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ROOM CHECKS DURING SLEEP PERIOD
STANDARD Written 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 period, document the youths name and the time the check was conducted SOURCES OF INFORMATION Interviews with staff Logbooks Guard Tour data REFERENCES ACA 3-JDF-3A-04 and 3-JTS-3A-04 SUMMARY OF FINDINGS Based on a review of the facilitys written policies and procedures, the facility maintains a Required Use of Tour Facility Monitoring System FOP (#004); dated 10/15/07, which delineates requirements and procedures for conducting visual checks of each youth during the sleep period. Visual checks are to be conducted at least every 30 minutes and staff are to electronically document the youths behavior at the time of the observation. A review of randomly selected Guard Tour data from January 2010 to May 2010 revealed: - 52% of (151) 2nd shifts never initiate a room check. - 7% of (151) 3rd shifts never initiate a room check. - 35% of the 3rd shifts ended room checks 1 to 5 hours prior to the conclusion of the sleep period. The facility did not provide any documentation (i.e. door sheets) to show that individual room checks were conducted and documented when the Guard Tours pipe was inoperative (i.e. Clinton Hall, 2/8, Guard Tour pipe full) or not available. The review of the Guard Tour data also revealed several instances of the time between some checks to be between 28 and 150 minutes. The facility did not provide documentation of any corrective action taken to address staffs failure to utilize the Guard Tour system or door sheets during the sleep period.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area, it is recommended that the facility: Require the shift commanders to verify that both shifts are conducting the required room checks and documenting their observations of youth throughout their shift. Randomly review Guard Tour data for verification. Any discrepancies or failures by staff to properly perform visual room checks should be reported to the Facility Administrator or designee for corrective action. Require the staff to utilize door sheets if the Guard Tours pipe is inoperative or not available.
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PERIMETER CHECKS
STANDARD Written policy, procedure and practice provide 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 INFORMATION Facility Tour Observation Logbooks and other documentation Interviews with staff REFERENCES DJS Perimeter Security Policy (RF-09-07), and Searches Policy (RF-06-07); ACA 3JDF-3A-12, 2G-02, 3-JTS-3A-12 and 2G-02 SUMMARY OF FINDINGS The facilitys maintains a Perimeter Check (Tour Guard) FOP (#009) that delineates the requirements and procedures for checking the perimeter fences and structures on a daily basis. A review of documents revealed that the facility frequently inspects its inner perimeter (fence) and occupied living units on a daily basis. However, interviews with staff revealed that not all buildings and structures (i.e. King Hall, Jackson Hall, etc.) located within the perimeter are searched (or have their doors checked) on a daily basis. The facilitys front entrance is a controlled access point. The entrance consists of electronically locking gates (sally ports) to prevent unauthorized pedestrian and vehicular traffic from entering or exiting the facility. Visitors entering the facility are checked-in/out at this location. Visitors are not permitted to bring certain personal items (i.e. car keys, etc.) into the secured area. All visitors are identified by photo identification and gatehouse staff fill-out the visitors log indicating name and arrival times of visitors. A review of the facilitys Visitors sign in/out log from January 2010 to May 11, 2010, revealed instances of visitors not signing out of the facility. Employees and visitors entering the facility are scanned by the use of a hand held wand. The walk through metal detector at the front entrance is inoperative and needs to be repaired or replaced. Observations revealed that vehicles exiting the facility are not routinely searched (i.e. visual search of the interior, trunk and underneath) in accordance with DJS policy. 23
A tour of the facilitys fence line revealed several gaps and breaks in the razor wire of the perimeter fence(s). It was noted that the top section of the perimeter fences contains what appears to be no climb fencing; however, the links are large enough to allow small fingers to be inserted to facilitate climbing over the fence. All gates were observed to be locked. A review of the DJS Incident Reporting database revealed an Incident Report (#81033), dated: 3/16/10, in which razor wire was found dangling low on the perimeter fences and broken pieces on the ground. A review of 628 Zone Inspection sheets from January to April 2010, did not mention the condition of the razor wire (i.e. gaps or broken pieces) on the perimeter fences. In April 2010, the minutes from the facilitys Safety Committee cited the condition of the fallen razor wire. On May 2, 2010, two youth were able to escape from the facility, in part, by climbing over several perimeter fences containing razor wire. The review of 628 Zone Inspection sheets also revealed instances of visual checks of the entire inner perimeter being completed within 1 to 4 minutes. Interviews with staff revealed that it is impossible to visually check the entire perimeter in one minute. It should take staff 15 to 25 minutes to visually check the entire inner perimeter fence line. In April 2010, minutes from the facilitys Safety Committee also mentioned that staff were not walking the fence line (perimeter), but only going to the touch buttons located at various points throughout the perimeter. There is a large hole and an uncovered electrical box on the ground in an area of the perimeter that poses a potential safety hazard for staff checking the inner perimeter fence line. The hole was filled partially with stones when re-checked and the electrical cover added, but the cover was not permanently affixed. Several rooms were found unlocked on two units. There are a pile of leaves behind Clinton hall and behind a gate that is tied to a fence near the school. These should be removed.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Repair or replace the walk through metal detector at the front entrance to the facility. Ensure visitors are signed-out when leaving the facility so that their whereabouts can be accounted for in the event of an emergency. Ensure vehicles leaving the facility are searched. Install actual no climb fencing and secure the razor wire to the perimeter fences. Secure the cover plate on the electrical box behind King/Jackson Hall with screws. Also, fill-in the large hole in the ground completely. Ensure all buildings and structures within the perimeter are searched on a daily basis, pursuant to DJS written policy and procedures. 24
Ensure all unoccupied areas and storage rooms are locked at all times, pursuant to DJS policy. Remove the pile of leave behind Clinton Hall and the fence near school; these are potential hiding places for contraband.
25
STAFFING
STANDARD The 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 INFORMATION Facility listing of vacancies Review of Facility Logbooks Interview with superintendent Observation of facility REFERENCES ACA 1-SJD-1C-03 SUMMARY OF FINDINGS The Administration indicated that there are the following vacancies: 2 RAs 1 RA Supervisor 1 Transportation Officer 1 Case Manager Specialist 1 Assistant Superintendent The Superintendent indicated that the lack of the Assistant Superintendent position strains the overall operation of the facility. The facility only has one Group Life Manager II. With only one Assistant Superintendent, this is not adequate for a facility of this population. During the review the facilitys Case Management Supervisor was on long term leave. While this person is out, the position cannot be filled and those duties cannot be accomplished. During the review, there were seven staff members who were on medical leave, three staff members out injured, eight staff members on eight hour restrictions and three others who had received options letters indicating that they cannot perform their job duties. Two weeks prior to the review, there were 23 staff members in one of these categories. This strains the remaining staff and affects their ability to effectively run the facility. To alleviate some staffing needs. Ford Hall was closed and the Orientation unit was moved to Clinton Hall (Clinton B). However, during an observation of the Orientation group on May 12, 2010, Clinton B was found to be out of ratio at 2:19. On the nights of June 2 & 3, 2010, there were 30 youth on Clinton Hall and 2 staff. Twenty-three youth were in rooms and seven youth were sleeping in stack-a-bunks in the gym area of Clinton Hall. The youth who were sleeping in the gym area reported that at least for some period of time, they were all locked 26
inside the cage area with the staff member supervising them from the outside of the caged area. While the staff to youth ratio was maintained for the shift, having the seven youth sleep in the locked gym area together poses a greater safety risk to them than if they were sleeping in rooms. If staffing were increased, Ford Hall could have been opened and the youth could have been in rooms, but with only two staff, this could not have been accomplished. During the school day staff would bring youth over to the school in a group in the correct ratio. However, when classes were split into two groups they were frequently found to be out of ratio. The self contained special education class started late everyday of the review because staff had to be found to supervisor the youth in the school. The school principal indicated that this was a consistent problem.
RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Ensure the staffing plan is adequate for the increased population at Hickey. What was adequate when the facility maintained a 72 bed maximum does not suffice when populations fluctuate between 85 and 100 youth. Fill the Assistant Superintendent position and/or add a GLM II to provide for the administrative and supervisory needs of the facility. The facility should be provided a temporary replacement for the CMS Supervisor position until that person is able to return from long term medical leave. Address the high incidence of staff on leave. The facility should identify those staff who are no longer able to perform their duties and release them so that capable staff can be hired in their place.
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CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS
RATING: Non Performance
STANDARD Written policy, procedure and practice provide for the control of tools, keys 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 all toxic and caustic materials. SOURCES OF INFORMATION Facility Tour Interview with staff REFEERENCES DJS Key Control Policy (RF-06-05), DJS Command Control Centers Policy (RF-09-05); ACA 3-JDF-3A-22 and 3-JTS-3A-22 SUMMARY OF FINDINGS The facility recently implemented a new key control procedure and FOP (#008), dated 4/30/10. However, for the period being reviewed, the facility did not routinely control and account for keys pursuant to written DJS policy. Primarily, unit keys were exchanged among staff at the beginning of each shift at their assigned post and the exchange documented in the unit log book. During the period of 11/09 to 5/10, there were 3 incidents involving lost/stolen facility keys. One incident involved a youth obtaining a facility key(s). The key was recovered after the youth had escaped from the facility. Interviews with staff revealed that back-up and emergency keys are maintained by the facilitys locksmith which is located outside of the confines of the facilitys secured perimeter.
TOOLS The maintenance section is located outside the secured area of the facility. Interview with Maintenance staff revealed that they are in the process of developing an inventory system to account for tools. Based on interviews with Maintenance staff, a small number of tools are kept on hand in vehicles which are frequently inventoried; however, the inventory is not documented.
KNIVES and UTENSILS
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Interviews with kitchen staff, along with observations, revealed that knives and other dangerous utensils are maintained in a lockable cabinet located in the west campus dining hall which is located outside of the secured area of the facility. It was noted that the kitchen staff still does not maintain an inventory list of the knives and utensils. Kitchen staff will sign out/in the knives and utensils for use in the west campus dining area. A tour of the east campus dining hall revealed two unsupervised youth (kitchen helpers) going in/out of a room containing several metal utensils. Interview with the kitchen staff revealed that the utensils are not inventoried on a daily basis, however, staff are aware of the number of utensil maintained by the dining hall.
ENVIRONMENTAL WEAPONS A tour of the facility revealed several large rocks along the inner perimeter, several milk crates outside of units and a wire rope looped through a linked fence at the front entrance. These items pose a risk to the safety of staff and youth and should be removed or properly secured. In IR #82077, 4/29/10, a youth left his group and went to the front entrance of the facility. While at the front gate, the youth threatened to assault staff with a large stick he had picked up from the ground. Regular grounds checks are recommended.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Establish a key control system in accordance with DJS written policy and procedures. Ensure staff are trained and held responsible for adhering to proper procedures for the care and handling of facility keys. Establish a master inventory list for the tools maintained by the Maintenance section. Ensure tools are checked/inventoried and documented on a regular basis. Establish an inventory list of the knives and dangerous utensils maintained by the kitchen. Ensure inventories are documented and maintained. Ensure unoccupied areas and storage rooms are kept locked at all times. Perform regular grounds searches and remove large rocks, sticks and other potentially dangerous items.
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YOUTH MOVEMENT & COUNTS
STANDARD Written 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. Emergency counts are conducted and documented when necessary. SOURCES OF INFORMATION Facility Logbooks Interviews with staff Facility tour Observation of youth movement REFERENCES DJS Youth Movement and Counts policy (RF-02-06); DJS Command Control Centers Policy (RF-09-05); ACA 3-JDF-3A-13 & 14 and 3-JTS-3A-13 & 14, JDF-3A-22 and 3JTS-3A-22 SUMMARY OF FINDINGS The facilitys maintains a Youth Movement and Facility Counts FOP (#006) dated 3/25/10 that delineates the requirements and procedures for ensuring the security of the facility by conducting counts of the youth and control of their movements. The facilitys reporting and documenting of their 30 minute counts do not comport with written DJS policy and procedures; the facility primarily reports their counts to Master Control every 2 hours during the 1st and 2nd shifts. Thirty minute counts are not being recorded in Master Controls logbook; they are recorded in the unit logbooks. The facility conducts a formal count around 2am and reports the count to the appropriate designee, pursuant to DJS policy. A review of several Master Control logbooks revealed the use of white-out and entries that had been crossed-out in a manner that made them unreadable. During a tour of the facility, a QI member observed a youth left unattended in the gyms restroom while his unit was outside preparing to move to another location. Also, a youth was observed wandering the schools hallways. The youth stated that since the staff was not posted in the hallway, he decided to walk around the school. The staff monitoring the hallways had stepped away to address another matter.
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A review of the DJS Incident Reporting database (IRs #82077, #82388 & #81537) revealed incidences of youth touching the perimeter fence/gate or climbing onto the roof of a building. Observations however also revealed instances of youth walking in single file and in an orderly fashion. Fire drills were not consistently logged in the appropriate unit logbook nor were bedtimes. Staff are responsible for making log book entries of all youth movements and activities, clearly indicating the time the activity began and ended.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area, it is recommended that the facility: Review the FOP to ensure the facilitys count policy and practices comports with written DJS policies and procedures. Logbooks should be reviewed frequently to ensure white-out is not being used. Instruct staff that when a mistake is made, a single line should be used to cross out the mistake and the staff making the entry initial the mistake. All white-out in the facility should be removed. Supervisors/shift commanders should ensure staff conduct counts every 30 minutes 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 the appropriate logbooks. Ensure staff document all youth movements (such as fire drills) as a component for maintaining the accountability of youth.
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FIRE SAFETY
STANDARD Written 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. SOURCES OF INFORMATION Facility Tour Interviews with staff Interviews with maintenance staff Review of Logbooks Examination of Fire Safety Equipment REFERENCES DJS Bomb Threat, Explosion and Suspicious Mail Policy (MGMT-3-01); ACA 3-JDF3B-05, ACA 3-JDF-3B-10 and 3-JTS-3B-11 SUMMARY OF FINDINGS The Maryland State Fire Marshal Office conducted an annual fire safety inspection of the facility on 1/14/10. The fire marshal cited several violations to be corrected. The fire marshal re-inspected the facility on 02/04/10 and noted that the previous violations had been corrected. A fire safety vendor conducted an annual inspection and test of the facility sprinkler system. No violations were noted to exist. A fire safety vendor tested the facilitys fire protection (alarm) system on 11/09. No deficiencies were reported. In March 2010, Mandela Units fire alarm system (which reports to the Gatehouse) malfunctioned. However, the fire alarm on the unit remained operative. The facility instituted a fire watch until the alarm was repaired. The fire extinguishers yearly service and monthly inspection are current. A member of the QI Team randomly tested several emergency lighting fixtures and found them to function properly. All exit signs were illuminated. The facilitys power generator is tested at least weekly. Clinton Hall did not have an evacuation route plan conspicuously posted in the front area of the unit. The facility has a designated fire safety officer. The fire safety officer was not available for an interview. A review of fire drill records revealed that staff conducted at least one fire drill a month during each shift from January to April 2010. DJS QI Report 32 Charles H. Hickey Jr. School June 2010
Twenty-two randomly selected fire drill reports were crossed-reference with the appropriate units logbook. Only 5 of the reported fire drills were recorded in the appropriate logbook. Tour of the facility revealed that two storage rooms had stacked item(s) within 18 inches below the ceiling sprinklers. The Assistant Facility Administrator corrected the issue.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Review unit logbooks to ensure fire drills are being recorded when begun and completed. Ensure staff do not store/stack items within 18 inches of ceiling sprinklers in order that they may operate efficiently. Ensure evacuation route plans are properly posted on Clinton Hall.
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POST ORDERS
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 staff assuming the post and initial by the immediate supervisor. SOURCES OF INFORMATION Facility Tour & Observation Interviews with staff 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 did not provide any post orders for review pertaining to staff positions, at a minimum, Resident Advisors, Resident Advisor Lead, Resident Advisor Supervisor, Shift Commander, Security; and Special duty/assignment positions (i.e. key control, supply, safety officer or emergency management officer). The facility did not provide any post orders for review, as applicable, for Admissions, Housing Units, Multi-purpose room, Indoor and outdoor recreation areas, Transportation, Health Services Unit, Dining area, Laundry, Supply, Visitation Command Control Center (Master Control), Hospital and off-property appointments; and Maintenance Shop. Interview with staff and a tour of the facility revealed that no copies of any post orders are maintained in Master Control in accordance with written DJS policy.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Implement the Departments Post Order policy to ensure staff are familiar with specific and general instructions for the operation of an assigned post.
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STAFF TRAINING
STANDARD Written 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. SOURCES OF INFORMATION DJS Training Histories report Interviews with staff List of mandated staff (did not include case managers/transportation/RA trainees) REFERENCES Maryland Correctional Training Commission (MCTC); ACA 1-SJD-1D-03, ACA 3-JDF-1D-01, ACA JDF-1D-02 SUMMARY OF FINDINGS: About half of staff indicated they were trained in CPM twice yearly, half indicated once yearly. All staff should be aware that CPM is required twice yearly. Most staff did not have the required CPM class twice annually. Some staff indicated CPM training did not teach them enough about real life scenarios they have to deal with in the facility. Some indicated that it would be helpful to have different options to use to break up fights; others suggested that practicing their skills on someone who is behaving aggressively would be useful. Mechanical restraints should be covered semi-annually in CPM training. Of 92 mandated staff, 61 (66%) were chosen randomly for training compliance: -- 47/61 (77 %) met the 40 hour annual training requirement for 2009. -- Nearly all had CPR/AED training since Jan 2009 Of the staff who did not meet training class expectations in the mandatory training classes: 44/61 (72%) were missing Crisis Prevention and Management 12/61 (20%) were missing Suicide Prevention 15/61 (25%) were missing Recognizing and Reporting Child Abuse and Neglect
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RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Ensure annual training schedule is being met/followed and ensure all staff needing required trainings are signed up immediately. Ensure CPM is on the training calendar twice yearly as policy dictates and that all staff receive refreshers twice yearly. This includes mandated management staff. Add mechanical restraint training to CPM refreshers. The names of staff not in compliance with policy requirements can be furnished to the facility upon request.
36
ADMISSIONS, INTAKE & STUDENT HANDBOOK
STANDARD Written 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 the youth, 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. SOURCES OF INFORMATION Interviews with youth Interview with Superintendent Interview with intake staff Review of youth screening tools Review of youth base files REFERENCES Admissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile Detention Facilities; DJS Classification Policy in final editing stage; ACA 3-JDF-5A-02, 3-JTS-5A01, 5B-01 through 04 and 5B-07 & 08 SUMMARY OF FINDINGS Intake packet contains all necessary paperwork. Court orders, face sheets and classifications were completed for 100% of all files reviewed. Handbook is provided to youth at Intake/Orientation. Handbooks were readily available in Intake. Handbook acknowledgement forms were found in 100% of files reviewed. Intake staff interviewed indicated she offers to read the youth rules to youth in order to account for youth who might be illiterate. MAYSI is completed within two hours of admission. Intake staff interviewed knew how to score the MAYSI. 100% of files had a completed MAYSI. Intake staff indicated they looked at MAYSIs for all No answers and ensured youth retook the test if this was found. However a file review of MAYSIs found 3 of 7 youth wrote all Nos on the form. Mental Health is aware and reviews. SASSI is completed within two hours of admission as required. 100% of all files had a SASSI present. Staff are not trained to score the SASSI; substance abuse staff do this later but not within two hours of youth arrival. Two of seven youth gave all false answers on their SASSIs. Again, Mental Health is aware. 37
FIRRST is completed upon youths arrival and custody is not taken until youth screens negative on all questions. A medical assessment is done upon admission, but in every case within 72 hours. Youth on Orientation stayed longer than the three expected days and though QI was told that youth went to school after the third day, this was found not to be the case. Orientation is split in Clinton Hall and they do not have their own logbook. It is impossible to record daily events without a logbook; this should be remedied. Overall the intake process at Hickey remains solid, however Orientation youth are staying too long on Orientation due to bed space needs and therefore are not getting to school timely.
RECOMMENDATIONS In order to reach Satisfactory Performance status, the following is recommended: Ensure SASSI is scored as soon as possible; consider training Intake staff to at a minimum scan SASSI results for youth who may be susceptible to de-toxing while in custody. Medical staff may be helpful in this regard and should confer with Intake staff if results look suspect when on site. Ensure MAYSIs and SASSIs are completed properly by youth. Immediately refer any screening that indicates all of one particular answer to a clinical staff person. Move youth to school after their third day on Orientation. Ensure a written process is in place to do so and follow up to be sure staff are complying. Purchase a logbook for Orientation staff.
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CLASSIFICATION
STANDARD Written policy, procedure and practice document that youth are classified and assigned housing according to standard criteria of risk, age, size, conduct, offense history, present legal charge and special needs SOURCES OF INFORMATION Interview with Intake Staff Review of Intake Packet Interviews with staff Observation at facility REFERENCES Maryland Standards for Juvenile Detention Facilities: DJS Classification Policy RF-0108; ACA 3-JDF-5A-02, 3-JTS-5A-01, 5B-01 through 04 and 5B-07 & 08 SUMMARY OF FINDINGS Procedures have been established to identify the responsibilities of staff and the criteria for assigning youth to the proper living units/rooms based on the results of the assessment(s). The procedures are not yet in a written FOP and Housing Plan format pursuant to DJS policy. Interviews with the Intake Supervisor and Case Management staff, along with a review of 15 randomly selected Housing Classification Assessment forms revealed that initial assessments are being conducted and the forms retained in the base file as required. The appropriate level of supervision and housing assignment are identified upon of the admission process. Five of fifteen youth are overdue for a reassessment based on being at the facility over 60 days. Case Management staff are in the process of addressing the issue. Youth are not always assigned a room compatible with their classification, in part due to the increased population at the facility.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Require Case Managers to reassess youth pursuant to policy (i.e. 60 days, etc.) to ensure they are properly housed and supervised throughout their stay at the facility. Formulate a written FOP and Housing Plan pursuant to DJS policy. 39
PENDING PLACEMENT
RATING: No Rating
STANDARD Written 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
STANDARD Written 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 INFORMATION Review of Unit Log Books Review of Daily Point Sheets Interviews with youth Interviews with of direct care staff Review of the Student Handbook REFERENCES DJS Behavior Management Program Policy RF-10-07; Facility Behavior Management Program (BMP) SUMMARY OF FINDINGS All youth interviewed were able to identify their levels and points. A review of daily individual point sheets indicated frequent mistakes in addition and subtraction of points and the completion of the point sheets. However, there was clear evidence on the point sheets showing they were reviewed and audited. It should be noted that the mistakes were typically made by the same few staff members and that this was noted by the auditor. Additional training for these staff is a good idea, with discipline to follow if the same mistakes occur regularly. A review of the point sheets in comparison with the behavior management procedures outlined in the student handbook indicated that generally staff adhered to the written behavior management policies. In cases where deductions were not correct, the audit process caught the majority of the mistakes. As with the calculation errors, the mistakes were typically made by the same few staff members. Youths points were accurately transferred when the youth was transferred between units. Youth report that they were offered the incentives outlined in the student handbook. The ability to earn additional telephone calls was frequently mentioned as a consistent incentive given. The majority of the youth indicated that they understood the program and that it was explained to them. They indicated that they received a student handbook outlining the program. During the school day teachers are allowed to award and deduct points. 41
Five out of nine staff members interviewed indicated that they needed more training on the facilitys behavior management system. A review of the logbook on Clinton Hall indicated times where there was only one bedtime for the entire unit. Eight oclock, which is the time Level One youth are to go to bed, was the only time listed, if a time was listed at all. This suggests that youth were not put to bed according to the levels that they have earned During interviews, the youth indicated that there is a practice called group accountability. When asked to define it, youth indicated that there are times when the entire unit receives consequences when one or a few members of the group are exercising negative behavior. Youth indicated that they are responsible for helping to manage the behaviors of the group. The youth indicated that consequences include loss of activities, loss of recreation or going to bed early. A practice of group accountability would not only be unfair to youth and go directly against the policies of the behavior management program, but it would cause an unsafe culture of students attempting to manage the behaviors and actions of other youth without receiving training and instruction.
RECOMMENDATIONS In order to reach Superior Performance in this area, it is recommended that the facility: Offer additional training to those staff members identified as not being proficient in the operation of the behavior management system. Ensure that all youth on all units are provided with the incentives that they have earned including later bedtimes. Ensure staff write in the logbooks what time each level goes to bed each night to ensure this incentive is provided. Ensure that there is no group accountability. The Administration should ensure that youth are never informally responsible for managing the behavior of other youth in a detention setting.
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STRUCTURED REHABILITATIVE PROGRAMMING
STANDARD Written policy, procedure and practice document that youth receive planned, structured outdoor and indoor activities and regular rehabilitative programming that teaches social skills. SOURCES OF INFORMATION Review of Unit Log Books Review of the Master Schedule Review of Calendar of Events Interviews with direct care staff Interviews with youth REFERENCES DJS Recreational Activities Policy RF-08-07; ACA 3-JDF-5E-01-02-03-04 SUMMARY OF FINDINGS Pride Youth Services began providing services to the facility in April 2010. They provide chess club twice a week to each of the units. They also provide the AMEN mentoring program that offers manhood programs and counseling programs to each unit twice a week. Facility staff provide a weekly bingo night for the youth as well as a book club. Interviews with youth and staff, observations and logbooks indicated that the scheduled activities at the facility generally occur as outlined on the master schedule. Youth participate in at least one hour of recreation per day and two hours of recreation on weekends. Youth report that recreation frequently occurs outside and that the units are often allowed to determine if recreation will occur inside or outside. Youth are offered religious services, but there is no alternative for youth who choose not to participate.
RECOMMENDATIONS In order to reach Superior Performance in this area, it is recommended that the facility: Offer concurrent secular programming, even if just arts and crafts, as an alternative to religious services.
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SELF ASSESSMENT
RATING: No Rating
STANDARD Written 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 DJS norms and expectations.
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BEHAVIORAL HEALTH
INTAKE, SCREENING & ASSESSMENT
RATING: No Rating
STANDARD Written policy, procedure, and practice require that all youth admitted to a facility will be 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, THIS STANDARD COULD NOT BE ASSESSED.
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INFORMED CONSENT
RATING: No Rating
STANDARD Written 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 the Court if requested.
46
PSYCHOTROPIC MEDICATION MANAGEMENT
RATING: No Rating
STANDARD Written policy, procedure, and practice require that psychotropic medications are prescribed, distributed, and monitored safely.
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BEHAVIORAL HEALTH SERVICES & TREATMENT DELIVERY
RATING: No Rating
STANDARD Written 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. 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.
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TREATMENT PLANNING
RATING: No Rating
STANDARD Written 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. 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.
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TRANSITION PLANNING
RATING: No Rating
STANDARD Written 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 to schedule follow-up appointments.
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SUICIDE PREVENTION
DOCUMENTATION OF YOUTH ON SUICIDE WATCH
STANDARD Written policy, procedure, and practice require that all newly arrived youth, youth in seclusion, and youth on suicide precautions are sufficiently supervised. Suicide precaution documentation must include the times youth are placed on and removed from precautions, the current level of precautions, the youths housing location, the conditions of the precautions, and the time and active circumstances of the youths behavior. SOURCES OF INFORMATION Youth medical files Interview with two Glass Psychologists Suicide Watch Observation Forms for 6 youth Suicide Watch logs Incident Reports involving suicide ideations/gestures Interviews with youth Interviews with staff Observation at facility REFERENCES DJS Suicide Policy (HC-1-07), ACA 3-JDF-3E-04, 4C-27 & 28, 4C-35, 5A-02, 3-JTS4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.J SUMMARY OF FINDINGS Communication about youth on watch is mostly informal. The Suicide Watch Log (a more formal method of notification which is completed daily) began to be emailed to all relevant parties on June 1, 2010. It is updated daily regardless and a copy is left in the gatehouse. The mental health staff bring youth to Medical and also phone and write in that a youth is on watch/has moved in level. If the log were emailed and required to be viewed by staff daily, the Medical visit would not be necessary. The quality of the Suicide Watch Log is exceptional. Information on the youths mental status, level, initiated date, presenting problem and conditions of supervision is detailed and of very high quality and is a statewide model on how a suicide watch log should be completed. All staff knew they could put a youth on Level III watch. All staff knew that only mental health clinicians could remove a youth from watch. 51
All staff indicated that when a youth was on one-to-one watch, they could not leave that youth for any reason, including to break up a fight. Staff indicated that there are never times when there are not enough staff to supervise youth on suicide watch. However the Youth Advocate reported that on June 6, 2010 during a late night unannounced visit to Douglas Hall, there were eight (8) youth and two (2) staff. Two of the eight youth were on Level III suicide watch and were being monitored by only one staff. Staff were viewed supervising youth on Level III watch during a day shift on one day of the review; both staff were on double shifts and both appeared very tired. A Hickey staff has been disciplined for falling asleep while watching a youth previously. One clinician indicated he has had to awaken a staff. This issue relates to the findings in the Staffing section of this report. There are documented incidents of youth on watch being able to cut themselves or engage in other self-harming behavior without explanation. Documentation of youth on watch on Suicide Watch Observation sheets was very staff dependent. Many staff made excellent notes and comments. Descriptions were clear and detailed, such as: youth refused meds or is sitting sadly or using random profanity. One staff watching a youth who is a cutter indicated scratching arm/asked him to stop/he said ok. They gave descriptions of behavior and not location. They followed the youth to court or a hospital visit and continued checks without fail. These staff do an excellent job and their supervision is without question. Other staff are not giving the QI team the same confidence: they are noting location instead of behavior. Their checks were found to go backwards (e.g., 5:18, 5:26, 5:05, 5:14, 5:22, etc.) or were blatantly patterned (e.g., such as all numbers ending in 9,8,7,6,5,4,3,2,1 backwards) or more creatively patterned (e.g., on one sheet, three distinct patterns by one staff were noted: multiples of 9, backwards checks, then a pattern of subtracting exactly 1 from each time and duplicating that over the hours.) A psychologist noted that when he checks on youth, sometimes staff say they need to catch up on their checks (fortunately, he does not allow this.) The differences between the solid Hickey staff and the staff who are simply trying to shortcut their way through their checks was stark. The larger issue was that many of the patterns and issues found by the shortcut staff were not caught by Hickeys auditors. Therefore the staff are not being corrected timely or at all. Audits were evident however, and though they did not catch all errors, they did catch some and proof of staff corrective actions was also evident. Some of the discipline for the more serious infractions may need to be more stringent than a simple corrective action form. The facility should decide what safety implications a lack of supervision leaves and respond accordingly. The auditing staff may need more training and QI can provide that upon request. There were gaps in checks of between 5 hours and 8 hours. These tended to be on the first shift, where likely the checks may have been done, but no sheets were present to verify this.
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There were days when entire sheets were not accounted for. Half of the youth were missing sheets from several days. Some sheets were in the medical file and some in separate binders. As system to ensure all originals are in the medical file and all copies are in the binders has not quite been established. It seems that if a system were re-established to account for all sheets and systematically file them, the unaccounted for sheets would not be the problem they currently are. Incident reports reporting suicide ideations and gestures were evident and gave confidence that youth actions and words are taken seriously by mental health staff.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Mental health should continue the recent practice of distributing the suicide log via email. Hard copies if needed as well should then be distributed to: Master Control, the gatehouse, Medical, Education, the Administrators, the shift commanders and Case Management. All staff should be required to view this email (or check the hard copy) at the beginning of their shift and be aware of who is on watch and what his/her level is. Spot check staff to ensure compliance. File all original sheets in the youths medical file and place copies in the binders. A suggestion is to make a copy of each sheet once it has been accounted for, then place the copy in the binder in the TMA and use that for auditing purposes and staff follow-up. Send the original to Glass (mental health) for their review. Once they have reviewed the youths daily activities on the sheet, they can send it over to medical and file it in the youths medical file along with any of his other behavioral health paperwork. This complies with policy and allows both entities to review the youths sheet. More audit training may be necessary. Staff who are found to be documenting poorly should be re-trained in exactly why the watch is so important, that checks must be made contemporaneously with the actual time, that catching up is not possible and that we have DJS youth who will, if given one opportunity, harm themselves. Staff should see the vital importance of being the first line of protection for this youth. Staff corrective actions for egregious patterns, falling asleep or failure to turn in sheets to prove supervision of the youth should match the seriousness of the safety issue this kind of problem presents. Ensure staff on double shifts are capable of providing sharp supervision. See recommendations in the Staffing section of this report.
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ENVIRONMENTAL HAZARDS
STANDARD Written policy, procedure, and practice require that all housing for youth at heightened risk of self-harm is free of identifiable hazards that would allow the youth to commit suicide or other acts of self harm. In case of emergency, all direct care staff at the facility should have immediate access to appropriate equipment to intervene in an attempted suicide. Chemicals and other hazards are properly stored and locked. SOURCES OF INFORMATION Interviews with youth Interviews with staff Observation at facility REFERENCES DJS Suicide Policy (HC-1-07), DJS Safety and Security Inspections Policy RF-04-07, ACA 3-JDF-3E-04, 4C-27 & 28, 4C-35, 5A-02, 3-JTS-4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.J SUMMARY OF FINDINGS Interviews with 14 direct care staff revealed that 9 did not carry a cut down tool, 3 staff stated they sometimes carry the tool and 1 stated that he does carry a cut down tool. Two of four staff were unable to locate a cut down tool when asked to retrieve the tool. Some of the restrooms located in the Peabody school, TMA building (incentive area), and living unit(s) contain horizontal pipes just above the rear of the toilet (potential tie-off points) that pose a suicide risk for youth. An unlocked cabinet in the school contains several one gallon containers of carpet and disinfectant cleaner which pose a suicide risk for youth. A tour of facility revealed a one gallon container of Lever fluid soap in an unlocked bathroom and a bottle of Pine Fresh (green colored cleaning fluid) located in an unlocked office. On a Nursing Report of Youth Injury form, a youth alleged he drank a green colored fluid. Tours of the facility revealed several instances of open doors of closets, laundry rooms, restrooms and youth doors.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Provide all direct care staff with cut down tools as policy requires, train staff on their use, and monitor that they carry them on their person when working with youth. These should be checked in and out with keys and radios. Ensure staff are mindful of potential tie-off locations and secure all substances that pose a suicide risk for youth. Check with the facilitys maintenance section to determine if the horizontal pipes in the restrooms can be covered or re-routed in a manner as not to pose a suicide risk. Secure all doors when not in use.
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CLINICAL CARE FOR SUICIDAL YOUTH
RATING: Not Rated
STANDARD Written policy, procedure, and practice require that timely suicide risk assessments, using reliable assessment instruments, are conducted at the facility for all youth exhibiting behavior that may indicate suicidal ideations to determine whether a youth should be placed on suicide precautions or whether the youths level of suicide precautions should be changed. Youth at a facility who exhibit suicidal ideations or attempts should receive timely, appropriate, and professional mental health services. Youth should not be restricted from programs and services more than safety and security needs dictate. All pertinent staff should review all completed suicides and suicide attempts at the facility for policy and training implications.
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EDUCATION
SCHOOL ENTRY
STANDARD Written policy, procedure and practice document timely enrollment of all students into the educational program. The school will receive a daily roster of students. The receipt of student records should occur in a timely manner. SOURCES OF INFORMATION Interview with record staff Review of 26 student folders (12 general education, 14 special education) Review of Daily Population Reports REFERENCES COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS 24 of 26 (92%) students records were requested within 72 hours or 3 school days of admission. 23 of 26 (88%) records were received within five school days of admission into the facility. Only 15 of 26 (58%) students were interviewed and assessed within 72 hours of admission to the school. This was due to the facility holding youth on the Orientation unit longer than 72 hours. During the last day of the review, 14 youth from Orientation were newly admitted to the school. These youth had stays in the facility ranging up to 13 days. Records indicated that secondary requests for records were made, when needed.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure youth on Orientation are moved to a unit and to school within 72 hours.
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CURRICULUM & INSTRUCTION
STANDARD Facility schools will ensure that they provide instruction appropriate to the varied needs and abilities of the students enrolled. They should operate on a standard schedule, provide students with a consistent school day, provide instruction appropriate to individual students strengths and needs, provide pre-GED & GED instruction as appropriate, provide extracurricular and enrichment activities & events, integrate computer assisted instruction in the curriculum and provide library services. Facility schools will also ensure that students in alternate settings (i.e. infirmary, seclusion and orientation) are given access to assignments and instruction comparable to others students in the facility. SOURCES OF INFORMATION Review of School schedules Observation of transitions to and from class Three Classroom observations Interview of three teaching staff members Interview of nine youth Review of logbooks REFERENCES MSDE Guidelines DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS School started on time in the morning everyday during the review. Students generally arrived on time after lunch. However, on May 14, 2010 Clinton Hall did not return following the lunch break for the fourth period. Staff indicated that lunch ran late. Transitions and class changes occurred according to the schedule. The school schedule provides equal access to all classes to each unit. Classroom areas are well appointed and students had materials to complete their work. During classroom observations objectives and agendas are on the board. A variety of teaching styles were displayed. The school provides GED instruction. Testing for youth in all DJS facilities is held at Hickey. In fact, youth from four DJS facilities (Hickey, Schaeffer House, Victor Cullen and the Baltimore City Juvenile Justice Center) took the GED test on May 11, 2010. The school schedule indicated that the school provides two hours per day of direct instruction to youth in the infirmary. However, a review of the logbook indicated DJS QI Report 58 Charles H. Hickey Jr. School June 2010
that the two hour time was not consistently adhered to. The schools principal indicated that the students are provided instruction according COMAR guidelines on Home/Hospital teaching, and that according to those guidelines the school only needs to provide six hours of instruction per week to the youth. Even so, it is important to maintain a consistent structure for the youth, including educational services as indicated on the schedule. In addition, any youth with an IEP housed on the infirmary unit should have an IEP indicating that they are receiving services in a Home/ Hospital setting. RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: The school should ensure the services are provided as scheduled to the youth on the infirmary unit. Also, special education students assigned to the unit should have IEPs indicating that services will be provided according to the Home/Hospital guidelines.
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SCHOOL STAFFING & PROFESSIONAL DEVELOPMENT
STANDARD The Facility School will maintain a sufficient number of certified staff to provide appropriate education to all students, including related services providers. The school should provide meaningful staff development opportunities to teachers and support staff to enhance their ability to effectively educate youth in detention settings. SOURCES OF INFORMATION Roster of teaching staff List of teacher certifications Assistant principal interview Teacher and IA interviews Review of the MSDE Professional Development Calendar. REFERENCES No Child Left Behind Act of 2001, (NCLB), P.L. 107-110 DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS The Hickey School is currently fully staffed, with the exception of the Life Skills teacher for which the school was currently interviewing. At the last review in May of 2009, the school was recruiting an Occupational Skills teacher. However, according to the principal, that position is no longer available. A list of certified teachers indicated that all of the teachers in the classroom held current teacher certifications from MSDE. The schools Social Studies, Science and Math teachers are not certified in the content areas in which they teach. Teachers receive staff development to better their teaching skills. The staff development is provided monthly to all MSDE education staff. The areas of staff development include: differentiated instruction, instructional use of data, transition and career scope assessment training, High School Assessment (HSA) and Middle School Assessment (MSA) training, Special Education law and policy and Library/Media curriculum, Read 180. Related services in the forms of counseling and speech language services are provided by a contractual provider.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Revisit the need for the OST teacher. Continue to recruit for the Life Skills teacher position Ensure that all teachers are certified in the content area in which they teach.
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SCREENING & IDENTIFICATION
STANDARD Qualified professionals shall provide prompt and adequate screening of facility youth for special education needs, including identifying youth who are receiving special education in their home school districts and those eligible to receive special education services who have not been so identified in the past. SOURCES OF INFORMATION Review of child find forms Review of special education roster Review of population report Interview of four teaching staff Review of 14 special education student folders REFERENCES Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400-1490 COMAR 13A.13.01.05: Program and Service Components-Comprehensive Child Find System. COMAR 13A.08.07.01: Education-Student in State Supervised Care-Transfer of Educational Records DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS School staff members understand the procedures for referring students for screening for special education services. However, the other staff members in the facility (i.e. direct care staff) are not aware of the procedures. The school assesses the educational level of each student in the facility upon admission to the school using the Basic Achievement Skills Inventory (BASI). Any student who scores below the third grade level on the assessment is automatically screened to determine if there is a possible need for special education services. 34 of the 86 (40%) residents of the facility are identified as students previously identified as needing special education services.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: The facility should train all of the staff in the facility on the basic procedures for referring a student for special education services and the signs for which to look.
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PARENT, GUARDIAN & SURROGATE INVOLVEMENT
STANDARD Written documents show that parents, guardians or surrogate parents are notified of and invited to participate in evaluations, eligibility determination, Individualized Education Programs (IEPs) development and team meetings, and decisions regarding provisions of special education services. SOURCES OF INFORMATION Review of IEP documentation Interview with special education teachers Interviews with teaching staff Review of 14 special education files REFERENCES COMAR 13A.05.01.07: IEP Team. COMAR Transition SUMMARY OF FINDINGS In all cases parents are given ten (10) days prior notice before an IEP meeting. Documentation of parent contacts was consistent in each file. All notices accurately indicated the purposes of the meetings and the meeting attendees. The notices offer the option for parents to participate via the telephone. The school has a trained parent surrogate. All folders contained certified mail receipts and fax receipts documenting the invitation of community case managers and representatives from the Department of Rehabilitative Services (DORS). Home schools were not invited to the meetings. Meetings were consistently scheduled well beyond thirty (30) days of the youths admissions to the facility. Because of the dynamic nature of the population of detention facilities, holding meetings this far into a youths stay runs the risk of students not having their IEPs updated while they are in the facility.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: The school should invite the youths home schools to participate in meetings. The school should ensure that IEPs are scheduled and held within 30 days of the youths admission to ensure that appropriate services are provided to them while in detention. DJS QI Report 64 Charles H. Hickey Jr. School June 2010
INDIVIDUALIZED EDUCATION PROGRAMS
STANDARD Written policy, procedure and practice provide that Individualized Education Programs are completed according to federal, State and departmental guidelines. The facility will also ensure that accommodations and services are provided according to each students Section 504 plan and that students Section 504 plans are reviewed and revised as needed. SOURCES OF INFORMATION Review of 14 special education student files and 1 504 plan Interviews of teachers REFERENCES COMAR 13A.05.01.07, .08, .09 Section 504 of the Rehabilitation Act of 1973 (Section 504), 29 U.S.C. 794 DJS Section 504 Guidelines SUMMARY OF FINDINGS In all 14 of the files, IEP teams were consistently well constituted. School counselors, social workers and speech language providers were frequently participants in the IEP meetings of students in need of their services. Nine of the fourteen IEPs indicated that the youth required a related service of either counseling or speech/language services. In those files, 8 of 9 (88%) service logs indicated that the students were receiving related services of counseling and speech language services as outlined in their IEPs. All 14 files contained IEP team notes were well written and contained good information on why changes were being made. IEPs were individualized and did not seem like carbon copies of each other. IEPs demonstrated that the school provided a continuum of services from full inclusion to self-contained special education classes for all academic areas. The school consistently used the Maryland online IEP format. There were section 504 plans in the files. Teams were appropriately constituted. Teachers were aware of students accommodations from the 504 plans and could identify them.
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RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Ensure that all related service hours and contacts are documented in the student folders.
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CAREER TECHNOLOGY & EXPLORATION PROGRAMS
STANDARD The facility will provide students opportunities to explore career interests and to develop skills useful in obtaining employment. SOURCES OF INFORMATION Review of school schedule Interview with school principal REFERENCES COMAR 13A.04.02: Secondary School Career and Technology Education SUMMARY OF FINDINGS The school current has no vocational options. The school principal indicated that the school is preparing to offer the Internet and Computing Core Certification (IC3) course through its computer class. IC3 is a standards-based training and certification program for basic computing and internet knowledge and skills. Successful completion of IC3 ensures skills required for basic use of computer hardware, software, networks, and the internet. The school no longer offers the Occupational Skills Training class (OST) in which students learned basic carpentry skills. During the review the school was currently interviewing for a Life Skills teacher position. The Life Skills class would teach students job seeking skills such as filling out applications, interviewing skills and resume writing.
RECOMMENDATIONS In order to reach Satisfactory Performance in this area it is recommended that the facility: Move forward with the IC3 course for students. Reconsider the need for the OST class. Continue to recruit and hire a Life Skills teacher.
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STUDENT SUPERVISION
STANDARD The facility will ensure that staffing is appropriate to supervise students in the educational setting, as well as during transitions to and from the school setting. SOURCES OF INFORMATION Classroom observations Observation of transitions Interview of school administrators REFERENCES Maryland Standards for Juvenile Detention Facilities SUMMARY OF FINDINGS The facility has assigned three posts in the school building. These staff are responsible for managing movement in the hallways, providing coverage for staff breaks, supervising youth restroom breaks and responding to crises in the school building. These staff also perform searches of the youth as they enter and exit the facility. While there are three posts, during the review there were only two staff members physically posted in the school. Observations of student movement to and from the school demonstrated that youth were escorted to and from the building in the correct ratio. However, when the units got to school and separated into class groups, they were frequently out of ratio. This was partly do to the fact that two staff members were pulled from their assigned units to staff the self-contained special education class and another staff member is pulled to provide supervision for the schools GED class. Since the staffing for the self-contained class and the GED class was allocated once the students were in the school building, there was a delay in the start of that class on each day of the review. Youth from the different units had to be pulled from their units during the first period after staff had been identified. The school principal indicated that this was a daily occurrence.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: The facility needs more staff to manage the population and to allow the youth to take advantage of the school programs. The facility should determine coverage for the self-contained and GED classrooms prior to the youth entering the building to ensure that class time is not lost.
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SCHOOL ENVIRONMENT & CLIMATE
STANDARD The facility will ensure that the school setting is a safe environment conducive to learning and that staff are supported in their jobs. SOURCES OF INFORMATION School observation Interviews with Direct Care staff members Interviews of Educational staff Interview with the facility superintendent REFERENCES N/A SUMMARY OF FINDINGS The Peabody school at Hickey is well appointed and provides enough space to meet the needs of the staff and students. The school is clean and classrooms are large enough to meet the needs of the population. The school principal indicated that there is a very productive working relationship with the current Administration at the facility. The facility Superintendent indicated the same. Education staff indicated that for the most part, they feel supported by the direct care staff. However, two teachers indicated that there is a lot of socializing of the staff, particularly at the end of the hallway opposite of the main entrance. The education staff indicated that this happens mostly in the morning and during the shift changes in the afternoon. While the staff to student ratios in the class is a safety issue, the teachers indicated that staff members manage behaviors in the classroom setting. Most youth spoke positively about school, indicating that it was like regular school.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Direct care staff members should refrain from congregating in the school building in order to ensure an orderly learning environment. More staffing is needed to manage the education to maintain the safe and orderly environment. DJS QI Report 70 Charles H. Hickey Jr. School June 2010
STUDENT TRANSITION
STANDARD Written documentation shows that the facility school creates progress reports (Maryland Student Transfer Reports) for students in the facility within five days of the release of the student and that the school notifies DJS' Office of Pupil Personnel Services (OPS)of the creation of that documentation so that the Office can disseminate those reports to the youth's home school. SOURCES OF INFORMATION Record staff interview Review of 15 folders of released youth January 2010 from May 2010. Interview with the school principal Interview with OPS staff REFERENCES COMAR Transition COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records SUMMARY OF FINDINGS 12 of the 15 student files contained MSTRs or progress reports. The reports were dated indicating that they were created within five (5) days of the students release from the facility. During the review, MSDE and DJS were attempting to work out an issue in which MSDE was not allowing its schools, of which Hickey is one, to transfer records to the DJS OPS and to the students community case managers. The principal explained that because OPS and the case managers are not school or education programs, they are not able to send the records, per COMAR 13A.08.07. The principal did indicate that the records can and are sent to other detention schools, educational placements and home schools. OPS staff indicated that the process is slowing up DJS ability to place committed youth into placements, as educational records are included in the packets reviewed by potential placements.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Resolve the issue of student records to ensure that youth are not hindered in being placed in their next placement. Ensure that a MSTR or a progress report is created for each student released. DJS QI Report 71 Charles H. Hickey Jr. School June 2010
MEDICAL CARE
HEALTH CARE INQUIRY REGARDING INJURY
STANDARD: Written policy, procedure, and practice ensures that all youth are seen by medical staff after any incident in which they are involved, regardless of whether there is an injury, shortly after the incident occurs. SOURCES OF INFORMATION: 52 Facility Incident Reports September 2009-May 2010 Nursing Report of Youth Injury forms Nurses Injury Log Interviews with staff Interviews with youth Observation at facility REFERENCES: DJS Incident Reporting policy (MGMT-03-07); Photographing of Injuries policy (RF-1105); Reporting & Investigating Child Abuse Policy (MGMT-1-00) SUMMARY OF FINDINGS In 89% of cases, youth in incidents or restraints saw a nurse as required and had a body sheet present in the file. Two of eighteen required body sheets were not present in the files nor were they listed in the Nurses Injury Log. In one suicide-related gesture, a youth self-reported that he drank a green liquid. The youth was not taken to medical to check for illness or to call poison control. In general, however, youth seem to be consistently taken to the nurse when needed. Nearly all body sheets were filled out in their entirety. One nurse was not writing the verbatim response of youth but was instead summarizing what he said. The DJS Director of Nursing was informed and will follow up. The ISR seemed to be reasonable based on the injury/complaint of youth. Most youth were seen within two hours as required. 11% were seen late; no explanations were given as to why. Youth indicated and staff indicated that after a fight, youth are required to and do see the nurse as soon as possible afterwards. Nursing may not always log every youth visit to the nurse as required in the Nurses Injury Log. Two months worth of logs were reviewed randomly. In one month, 10 youth went to the nurse for injuries and were not listed in the log. In 72
another month, 2 youth were not listed. Nurses must carefully and reliably log in every youth who appears in medical for any injury. There were no instances found where a youth alleged child abuse to the nurse and his case was not referred to CPS as required. Photographs were attached as required.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Ensure all youth with injuries are brought for examination and that every youth is logged into the Nurses Injury Log as required. Ensure youth who may have ingested something are taken to medical and given proper medical or emergency attention. Record youths verbatim response to what happened on the body sheet. Do not summarize. If youth are late to Medical after an incident, record why on the body sheet or IR.
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HEALTH ASSESSMENT
STANDARD Written policy, procedure and practice document that adequate health assessments are completed on all youth within 72 hours of admission. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Medical file review general and specific REFERENCES ACA 1-SJD-4C-18-19-20 DJS Special Needs Treatment Plans Health Care Procedure (2007); ACA 1-SJD-4C-18-19-20 SUMMARY OF FINDINGS Nursing Assessments completed upon admission are crucial for the identification, quality of care and management of acute and chronic health care issues of our youth. Upon a review of eight (8) Youth Health Record files, all eight had the seven page nursing assessment completed at the time of admission. One was incomplete due to the youth having flagged on the FIRRST form (he was admitted to the hospital for a mental health emergency.) A description of tattoos and scars should be documented in detail. Admission physicals were completed on six of the eight youth within 72 hours of admission. The admission physicals lacked documentation of vital signs on all eight records reviewed. Vital signs should be completed and dated the day they were taken if different from the day the physical is completed. Admission labs were completed on half of the youth at the time of admission and five of the eight eventually completed had lab results filed. A vision screen was available in six of the eight charts reviewed. Two youth needed vision referrals. One had been scheduled and completed and the other had not been scheduled. Five of the eight had documentation of a PPD being administered. The five completed had the results appropriately documented. In a review of the PPD log book from July 2009 thru May 1, 2010 documentation showed there were 483 PPDs administered and of that number, 31 entries had no documentation noted of results, or the reason why the PPD had not been read. Allergies were documented consistently and notification by Health Status Alert was completed to the respective disciplines in the facility. The immunization tracking and referral forms are not being completed in the Youth Health Record files. This form, when utilized, would track immunization 74
records requested, received, reviewed and immunizations ordered, as well as follow-up referrals, appointments and completion of the appointments; especially dental exams and follow-ups. Due to the number of youth who return to Hickey, it is imperative that this be consistently utilized. Documentation was present in eight of the eight Youth Health Record files that Immunization Records had been requested; seven of the eight Immunization Records had been received and reviewed by the MD/NP. The Master Problem Lists were being utilized (as eight of the eight youth had Master Problem Lists) but many problems were missing and they lacked consistent completed interventions with resolution dates. Mental Health continues to lack consistent documentation of mental health issues on the Master Problem Lists. The Asthma Assessment Tool is being completed but not the Asthma Treatment Plan. These must be completed and placed in the Youth Health Record file and behind each youths Medication Administration Record form ( MAR) for immediate reference when a youth is having a respiratory complaint. Documentation on the Progress Notes is not consistently timed by both the nurses and the MDs. The entry on the Progress Note does not reflect the problem number from the Master Problem List. The Sick Call log is being utilized as directed. The Growth/BMI Charts were present in eight of the eight Youth Health Record files. The heights and weights were plotted on eight of the eight but the BMIs were not present. The 30 Day Assessments are being completed.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area, it is recommended that the health care unit at the facility: Continue to ensure the Admission Nursing Assessments are completed within 72 hours. Make sure a description of any tattoos or scars is documented (not just they are present.) Ensure the vision screen is completed. If there is a reason that it was not completed as part of the admission nursing assessment, then document with specific follow-up information. Vital signs must be completed and documented on the admission physical and be dated the day they were taken if different from the day the physical was completed. Ensure a standardized procedure or checklist is followed so that all youth have PPDs administered and read with proper documentation. Time Progress Notes and note problem number from the Master Problem List on Progress Notes. 75
Ensure that Immunization Records are requested from IMMUNET, parents, schools and physicians as required. The MD/NP is required to review, date and sign the record once received and prescribe immunizations as needed. Ensure the nurse obtains the proper consents and administers the vaccines as prescribed. See that documentation of the immunization request, date received, date reviewed and date administered are completed on the Immunization Tracking and Referral form in the Youth Health Record file. Document on the Immunization Tracking and Referral form any initial or followup referrals, appointments and completion of the appointments. Complete Master Problem Lists with any and all medical and mental healthrelated information about the youth so that, at a glance, the youths overall health needs are known to the nurses, physicians and mental health staff. Ensure the BMI is documented for each youth. The Asthma Assessment Tool and the Asthma Treatment Plans must be completed and housed in the designated area of the MAR and the Youth Health Record file.
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MEDICATION ADMINISTRATION
STANDARD Written policy, procedure and practice document that medications are given as prescribed. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs MARs Medical file review general and specific REFERENCES DJS Pharmaceutical Services policy (HC-02-07); ACA 1-SJD-4C-16-17 SUMMARY OF FINDINGS In a review of eight youth health record files, it was found that all youth had been properly prescribed medications by the MD/NP. Upon review of the MARs (Medication Administration Records) medications were being properly administered. Photographs of the youth are not present on all MARs as required. There were numerous Physicians Orders that had been initiated as verbal orders to the nurse and that had not been co-signed by the prescribing MD. The psychotropic medication verbal physicians orders were not co-signed by the psychiatrists. The on-call psychiatrist during non-clinic hours often gives the verbal orders for medication administration for new admissions or PRN medications that may be necessary. The psychiatrist that actually sees the youth at Hickey does not co-sign his orders. The orders must be co-signed after the nurse receives the verbal order; they cannot be left unsigned. Psychotropic Medication Consent forms to permit the administration of psychotropic medication were inconsistently unavailable. Information regarding why this documentation was not available in the Youth Health Record file was that there was a backlog of filing by the mental health staff. The Physicians Orders are also not consistently timed as to when they were written by the prescribing MD. Sometimes, youth who may refuse, be sent to court, or released for other reasons might not receive a dose of their prescribed medication. Documentation is present to support the missed doses of medication. The CDS (controlled drug substance) shift inventory is in place with proper documentation. The sharps count inventory also is in place with proper documentation. 77
RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the health care unit at the facility: Continue to require a residential staff person to accompany and be able to identify the youth to the nurse administering medications. Continue to require the nurse to ask the youth his or her name and once confirmation has been made that the youth is the proper person, only then shall the medication be administered to that youth. Add a photo of each youth with each youths MAR as a second check to confirm that the right youth is being administered medication. All orders must be co-signed by the prescribing psychiatrist when a verbal order is received and written by the RN. MD orders must be timed when written on the Physicians Order sheets. There should be no psychotropic medications administered by the nursing staff unless there is documentation present in the Youth Health Record file of the Psychotropic Medication Consent form being completed and signed appropriately.
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DENTAL CARE
STANDARD Written policy, procedure and practice document all youth receive timely and adequate dental care. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs and Dental logs Medical file review general and specific REFERENCES ACA 1-SJD-4C-22 SUMMARY OF FINDINGS Dental examinations are completed with screenings, prophylaxis, and treatment by a dentist at Hickey. Dental pain is managed according to nursing protocol for dental pain (and collaborating physicians orders) to keep the youth comfortable prior to and after treatment is received as necessary. Five of the eight Youth Health record files reviewed showed youth had been seen by the dentist. Follow-ups were not able to be tracked due to the lack of documentation. In review of the Sick Call log management of dental complaints was appropriate. There was not documentation on the tracking and referral form in the Youth Health Record file of previous, pending, and completed dental appointments. Documentation from the dentist is acceptable but lacks the youths name and date of service consistently on the actual dental treatment/exam form. The documentation is completed on the attached referral form and the two are stapled together. If the papers were to come apart there would be no way of knowing to whom the dental record belonged. In reviewing the dental logs the present scheduling procedure for dental services does not reflect the rescheduling of youth who still need to be scheduled, those who need to be scheduled for follow-up, and those who are scheduled for emergent dental treatment.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Correct the documentation so that the operational procedure for scheduling youth with the dentist for screening, prophylaxis, triage, and treatment is managed so that no youth are inadvertently missed in the process. Document on the tracking and referral form all dental appointments scheduled, completed, and follow-ups. Ensure this listing remains up-to-date. Document youths name, date of birth and date of service on each dental treatment/exam form.
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MEDICAL RECORDS RETRIEVAL
STANDARD Written policy, procedure and practice document that efforts are made upon a youths admission to obtain prior medical records. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Medical file review REFERENCES ACA 1-SJD-4C-18-19-20 SUMMARY OF FINDINGS Youth who have been previously detained at Hickey or another DJS facility should already have a health record file from those admissions. Upon a general review, the process for the request of records from other providers is intact and functional. Six of the eight youth had a copy of their original court orders in their Youth Health Record file. However, when a youth returns to court, the current court order is not given to Medical and so is not available in the Youth Health Record file. New court orders should be placed in the youths base file but a copy also given to Medical to file in the chart.
RECOMMENDATIONS In order to reach Superior Performance status, t is recommended that the facility: Notify DJS Director of Nursing if, after a written and verbal request for records is made to another DJS facility, Hickey is still unable to obtain the records. New court orders should be placed in the youths base file but a copy also given to Medical to file in the chart.
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SPECIAL NEEDS YOUTH
STANDARD Written policy, procedure and practice document that youth with special needs are screened as such upon admission within 72 hours, have a special needs treatment plan put into place, identifying the problem/need, goals, intervention, the youths progress evaluation and review date. To include all youth who are housed in an Infirmary with a physicians order. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Medical file review REFERENCES DJS Health Care ProcedureSpecial Needs Treatment Plans (2007) SUMMARY OF FINDINGS Upon review of MARs, logs and Youth Health Record files, Special Needs Treatment Plans were not being completed for youth requiring them. All youth housed in the Infirmary should have Special Needs Treatment Plans actively in place. Operational procedure for the youth in the Infirmary states that the youth are to be checked by a nurse every two hours with documentation in the Youth Health Record file. This was being completed. In review of one special needs youth in the Infirmary, there was a lack of documentation for a medical procedure and lack of documentation of a medication administration process. Both are unacceptable.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Nurses must review all youth files and complete Special Needs Treatment Plans on any youth with an acute health diagnosis or a special need. In addition, all youth housed in the Infirmary, with a MDs order, must have a Special Needs Treatment Plan completed that is followed by the nursing staff on duty.
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AVAILABILITY OF MEDICAL SERVICES
STANDARD Written policy, procedure and practice show that services for youth by trained medical staff for routine care and treatment are available 7 days per week; that there is an oncall procedure in place when medical staff are not on duty; that emergency care in case of emergent need is available and properly utilized; and that there are working sick call procedures in place that appropriately and timely address the sick youths needs. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Sick call log Medical file review REFERENCES None SUMMARY OF FINDINGS The Sick Call log is being utilized as directed. Documentation is being made on the youths Sick Call slip by the nurse when the youth are seen for Sick Call. The Sick Call slip is then placed in the Progress Notes section of the Youth Health Record file. Youth indicate they see a nurse when they are sick. Sick calls are completed on a daily basis seven days per week. There were no sick call forms on Clinton Hall; they were present on Mandela and Roosevelt. A doctor is on call 24/7. Nursing coverage is seven days per week: MondayFriday 7am - 11:30pm and 12 hours on Saturday, Sunday and holidays. In addition, the Nursing Supervisor is on call to the facility 24/7. The is a doctors clinic twice per week and DJS Medical Director visits one day per week. There is community access for all other referral to include dental referrals. A mobile x-ray comes to the facility for EKG's, x-rays and sonograms. A pharmacy delivers to the facility daily except on Sundays and there also is a back up emergency pharmacy for after hours. There are lab services with daily and twice weekly service depending on need.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the health care unit in the facility: Ensure sick call forms are continuously stocked.
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Comprehensive Quality Review Report Charles H. Hickey Jr. School (MD 2010)

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Comprehensive Quality Review Report Charles H. Hickey Jr. School (MD 2010)

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OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report

Charles H. Hickey Jr. School June 21, 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

TABLE OF CONTENTS (Continued)

DJS QI Report Charles H. Hickey Jr. School June 2010

The following Rating Scale was used:

DJS QI Report Charles H. Hickey Jr. School June 2010

Rating Superior Performance Satisfactory Performance Partial Performance Non Performance

% of total in rating 10.5 % 71 % 10.5 % 8%

Rating Superior Performance Satisfactory Performance Partial Performance Non Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

Hickey Performance Comparison

DJS QI Report Charles H. Hickey Jr. School June 2010

De-escalation and Restraints Seclusion Career Technology and Education

DJS QI Report Charles H. Hickey Jr. School June 2010

OFFICE OF QUALITY IMPROVEMENT Charles H. Hickey Jr. School METHODOLOGY

DJS QI Report Charles H. Hickey Jr. School June 2010

OFFICE OF QUALITY IMPROVEMENT Charles H. Hickey Jr. School METHODOLOGY (Continued)

DJS QI Report Charles H. Hickey Jr. School June 2010

SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

SENIOR MANAGEMENT REVIEW

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

DE-ESCALATION & RESTRAINT

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

CONTRABAND & ROOM SEARCHES

RATING: Satisfactory Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

ROOM CHECKS DURING SLEEP PERIOD

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS

RATING: Non Performance

KNIVES and UTENSILS

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

YOUTH MOVEMENT & COUNTS

RATING: Partial Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

DJS QI Report Charles H. Hickey Jr. School June 2010

RATING: Satisfactory Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

RATING: Non Performance

DJS QI Report Charles H. Hickey Jr. School June 2010

RATING: Partial Performance