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

7/31/2019 Comprehensive Quality Review Report Charles H. Hickey Jr. School (MD 2010)

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DJS QI Report

Charles H. Hickey Jr. School

June 2010

OFFICE OF QUALITY IMPROVEMENT

Comprehensive Quality Review Report


June 21, 2010


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Quality Review Report


Evaluation Dates: May 11-14, 2010

TABLE OF CONTENTS

EXECUTIVE SUMMARY .............................................................................................. 3QI Rating Scale............................................................................................................... 3

QI Rating Percentage ...................................................................................................... 4

Executive Summary of Results....................................................................................... 6Methodology................................................................................................................... 7

SUMMARY OF FINDINGS & RECOMMENDATIONS............................................ 9

SAFETY AND SECURITY ............................................................................................. 9Incident Reporting .......................................................................................................... 9Senior Management Review......................................................................................... 12

De-Escalation & Restraint ............................................................................................ 14

Contraband & Room Searches...................................................................................... 16Seclusion....................................................................................................................... 18

Room Checks During Sleep Period .............................................................................. 21

Perimeter Checks .......................................................................................................... 23

Staffing.......................................................................................................................... 26Control of Keys, Tools & Environmental Weapons..................................................... 28

Youth Movement & Counts.......................................................................................... 30

Fire Safety..................................................................................................................... 32Post Orders.................................................................................................................... 34

Staff Training................................................................................................................ 35

Admissions, Intake & Student Handbook..................................................................... 37Classification................................................................................................................. 39

Pending Placement........................................................................................................ 40

Behavior Management .................................................................................................. 41Structured Rehabilitative Programming ....................................................................... 43

Self Assessment ............................................................................................................ 44BEHAVIORAL HEALTH............................................................................................. 45Intake, Screening & Assessment................................................................................... 45Informed Consent.......................................................................................................... 46

Psychotropic Medication Management......................................................................... 47

Behavioral Health Services & Treatment Delivery ...................................................... 48Treatment Planning....................................................................................................... 49

Transition Planning....................................................................................................... 50


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Evaluation Dates: May 11-14, 2010

TABLE OF CONTENTS(Continued)

SUICIDE PREVENTION.............................................................................................. 51Documentation of Youth on Suicide Watch................................................................. 51

Environmental Hazards................................................................................................. 54Clinical Care for Suicidal Youth................................................................................... 56

EDUCATION.................................................................................................................. 57School Entry.................................................................................................................. 57

Curriculum & Instruction.............................................................................................. 58School Staffing & Professional Development .............................................................. 60

Screening & Identification............................................................................................ 62

Parent, Guardian & Surrogate Involvement.................................................................. 64Individualized Education Programs.............................................................................. 65

Career Technology & Exploration Programs ............................................................... 67

Student Supervision ...................................................................................................... 68

School Environment & Climate.................................................................................... 70Student Transition......................................................................................................... 71

MEDICAL CARE........................................................................................................... 72Health Care Inquiry Regarding Injury .......................................................................... 72Health Assessment........................................................................................................ 74

Medication Administration........................................................................................... 77

Dental Care ................................................................................................................... 79Medical Records Retrieval............................................................................................ 81

Special Needs Youth..................................................................................................... 82

Availability of Medical Services .................................................................................. 83


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Charles H. Hickey Jr. SchoolEvaluation Dates: May 11-14, 2010

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 theareas 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, youthinterviews, 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.

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

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

organized and readily available.

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

consistent basis; implementation is approaching routine levels but

frequently gaps remain; facility had difficulty producing documentation

in some areas.

Non Performance Little or no evidence of adequate implementation of performance

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


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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 briefsynopsis of the results from that review:*

Rating # within rating % of total in rating

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

Rating # within rating % of total in rating

NOTE: The DJS Quality Improvement Performance Ratings are aligned with best practices and optimal standardsof 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.

Superior Performance 4 10.5 %

Satisfactory Performance 27 71 %

Partial Performance 4 10.5 %

Non Performance 3 8 %

Superior Performance 0 0 %

Satisfactory Performance 15 42 %

Partial Performance 17 47 %

Non Performance 4 11 %


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Hickey Performance Comparison

0%

10%

20%

30%

40%

50%

60%

70%

80%

6/12/09 6/21/10

Date of Review

Percentage

Superior Performance Satisfactory Performance Partial Performance Non Performance


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Executive Summary of Results

Superior

Performance

Satisfactory Performance Partial Performance Non Performance

Contraband and Room Searches

Fire Safety

Admission, Intake and StudentHandbook

Classification

Behavior Management

Structured Rehabilitative

Programming

Curriculum and Instruction

School Staffing and ProfessionalDevelopment

Screening and Identification

Parent, Guardian and SurrogateInvolvement

IEPs

School Environment and Climate

Health Care Inquiries RegardingInjury

Medical Records Retrieval

Availability of Medical Services

Incident Reporting

Senior Management Review

De-escalation and Restraints

Seclusion

Room Checks During Sleep

Perimeter Checks

Staffing

Youth Movement and Counts

Staff Training

Documentation of Youth onSuicide Watch

Environmental Hazards

School Entry

Student Supervision

Student Transition

Health Assessments

Medication Administration

Dental Care

Control of Keys, Tools andEnvironmental Weapons

Post Orders

Career Technology and

Education

Special Needs Youth


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METHODOLOGY

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

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

education that would be reviewed by the QI Team,

II. Entrance Interview with SuperintendentA formal entrance interview was not conducted with the Superintendent onthe 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 offacility operation.

III. Primary InterviewsA 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. Thisrepresented 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 staffwere interviewed specifically about the target areas of the review as well as

their general feelings about the operation of the facility.IV. 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, programschedules, seclusion and suicide watch documentation, staffing reports,

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

fire safety and youth supervision.


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METHODOLOGY

(Continued)

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

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

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

VII. Exit ConferenceAn exit conference was not conducted at the facility. Discussions about some

portions of the QI findings were conducted on the last days of the review.


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SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY

INCIDENT REPORTING RATING: Partial Performance

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

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

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

departmental guidelines.

SOURCES OF INFORMATION

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

REFERENCESDJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management(CPM) Techniques Policy (RF-02-07); DJS Video Taping of Incidents Policy (RF-05-

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

SUMMARY OF FINDINGS

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 notcheck 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 atother 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.


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The narratives can best be described as fair. They are not as detailed as they werein prior reviews.

All of the IRs contained shift commander comments. About half of the shiftcommander comments were critiques (as is required); the other half missedsupervision 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 discoveredthrough 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 thisconcern are documented below:

a. One incident (a youth in mechanical restraints in the school) was observedby a QI reviewer and was not reported.

b. Two others were discovered in gatehouse logs and other documents andhad not been reported (a youth climbing on a fence and a staff missingkeys.)

c. In a random sample of two months (out of six months) worth of NursesInjury 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) gaveindications that two staff did not want to write up an assaultive incident

that occurred on their unit; they instead indicated it was horseplay andonly 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 areacceptable 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 topcomplaints 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, ill-fitting shoes, etc.) and it is unclear why this continues.

The Youth Advocate seems to pick up grievances timely (the average time was2.1 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 RooseveltHall 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 anyincident, 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 fromreporting 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 reportingprocess. 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 overallstrong point for almost all Hickey staff and may need some refresher training by aqualified person.

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

Check grievance forms on the wall with each walk-through. Require they be re-stocked continuously.


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SENIOR MANAGEMENT REVIEW RATING: Partial Performance

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

critiqued by shift commanders and critical documentation, such as incident reports,suicide watch and seclusion paperwork, are routinely audited by senior managers within

DJS timelines and corrections are made by staff timely.


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

REFERENCESDJS 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 theshift commander comments were critiques (as is required); the other half did notcritique 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 72hours. 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. Areview 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 auditedthe week of the QI review which resulted in rushed, poor quality audits that didnot 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 auditprocess.

Audits were evident on suicide watch documentation, and though they did notcatch all errors, they did catch many. The auditing staff is new to this task and


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may need additional training and time to perfect catching all errors, but they areoff to a solid start.

When issues are found in suicide watch documentation, there is evidence ofemployee 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 decidewhat safety implications a lack of supervision leaves and to respond accordingly.

There is administrative support in the form of the IR Specialist. The IR Specialistprovides a layer of oversight in that she ensures incident categories are correct

and that all paperwork is collected and organized. Her utility in this positionallows the GLM II and shift commanders to concentrate on their own workload.

The Office of the Inspector General (OIG) completed 24 investigations in theyear, 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 insustained findings on staff. Hickey has an excellent investigations team who

provide solid external oversight.

RECOMMENDATIONS


facility:

Ensure senior management staff at Hickey are skilled in auditing IRs, suicidewatch 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 theday 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 whatsupervision points to catch when they review an incident.


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DE-ESCALATION & RESTRAINT RATING: Partial Performance

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

techniques to de-escalate a situation prior to the use of physical restraints. Physicalrestraints are used only when necessary and the least restrictive physical restraint is used

first. Incidents involving physical restraints are video taped.


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

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

(CPM), Techniques Policy (RF-02-07); DJS Videotaping of Incidents Policy (RF-05-07);

ACA 1-SJD-3A-14-15

SUMMARY OF FINDINGS

Descriptions of uses of force (when applicable) are sometimes not detailed but atother times are excellent, especially in individual staffs witness statements. This

is staff-dependent; overall, descriptions are not as strong as they were in priorreviews.

Mechanical restraint documentation in IRs did not always include who appliedthem, 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 missingwas 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 ofIncidents 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. Usethese videos as training aids for staff.


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reports suggest that staff know how to handle contraband when it is found. Thefacility has a secure location for storing contraband.

During a tour of the facility, a member of the QI team observed books containinginappropriate language in several rooms in Mandela and Roosevelt Halls.

RECOMMENDATIONS

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

Review FOP to ensure actual practice comports with FOP policies andprocedures.

Ensure reading materials for youth contain appropriate language for a juveniledetention setting. Ensure the MSDE school keeps in mind the kind of youth in thefacility and is careful about the kind of reading material it orders.

Staff should use the version of the facilitys shakedown form that identifies theyouth assigned to the room being searched to maintain consistency withdocumenting pertinent information.


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SECLUSION RATING: Partial Performance

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

during sleeping hours, shall be observed often and have those observations documented,shall only be placed in seclusion if they present an imminent threat to others, 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.


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

REFERENCESDJS Seclusion Policy RF-01-07; COMAR 16.18.02

SUMMARY OF FINDINGS

There were 45 total documented seclusions between October 2009 and April2010. 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 noareas 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 forseveral youth while the QI team was present. These are not permitted to be donevertically 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 pickup 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 notreviewing seclusion sheets as a part of their audit.

The shift commander comments (reasons for youth not being released fromseclusion) were of very high quality and clearly indicated why the youth was a

threat and not able to be released.


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Most of the staff in interviews indicated that when a youth is locked inside hisroom 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 inthe 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 theAdministration 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 processesemployed. 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 staffinterviewed noted that group punishment was not a part of the behaviormanagement at the facility and that early bed was not used as punishment.

However, youth interviews consistently said the group accountability was usedfrequently. 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 introuble 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 employedand 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 bedaccording 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 wentto bed.

b. In Clintons logbook, 0 of 16 days indicated that youth went to bedaccording to their level. In 4 of 16 days, the staff wrote that youth went tobed, 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 enoughinformation to tell and nothing was written.

The concern about poor logbook documentation is that staff accountability isnearly 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 grouppunishment credence.


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An IR on 5/25/10 involved a youth being restrained because he was told to go tobed 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


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 (andwhy) rather than fill in several at one time.

Ensure shift commanders know that checking the quality of the sheet (especiallyfor patterns, gaps, etc.) is a part of their responsibility to ensure solid supervisionof youth in seclusion.

Though hard conclusions could not be drawn about logging of youth seclusionsbased 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 checkyouth in their rooms per the seclusion process and for their safety. Begin this

process immediately.

Discontinue any group accountability/punishment processes that individual staffmay 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 documentationof 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 RATING: Partial Performance

SLEEP PERIOD

STANDARD

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


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 facilitymaintains 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 theyouths behavior at the time of the observation.

A review of randomly selected Guard Tour data from January 2010 to May 2010revealed:

- 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 thatindividual 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 timebetween some checks to be between 28 and 150 minutes.

The facility did not provide documentation of any corrective action taken toaddress 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 therequired room checks and documenting their observations of youth throughouttheir shift.

Randomly review Guard Tour data for verification. Any discrepancies or failures by staff to properly perform visual room checks

shouldbe reported to the Facility Administrator or designee for corrective action.

Require the staff to utilize door sheets if the Guard Tours pipe is inoperative ornot available.


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PERIMETER CHECKS RATING: Partial Performance

STANDARDWritten 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, securitylighting, 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.


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 3-JDF-3A-12, 2G-02, 3-JTS-3A-12 and 2G-02

SUMMARY OF FINDINGS

The facilitys maintains a Perimeter Check (Tour Guard) FOP (#009) thatdelineates the requirements and procedures for checking the perimeter fences andstructures on a daily basis.

A review of documents revealed that the facility frequently inspects its innerperimeter (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 ofelectronically locking gates (sally ports) to prevent unauthorized pedestrian and

vehicular traffic from entering or exiting the facility. Visitors entering the facilityare 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 indicatingname 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 heldwand. The walk through metal detector at the front entrance is inoperative andneeds 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.


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A tour of the facilitys fence line revealed several gaps and breaks in the razorwire 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 theperimeter 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, theminutes 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, inpart, by climbing over several perimeter fences containing razor wire.

The review of 628 Zone Inspection sheets also revealed instances of visual checksof 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 innerperimeter 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 ofthe 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


facility:

Repair or replace the walk through metal detector at the front entrance to thefacility.

Ensure visitors are signed-out when leaving the facility so that their whereaboutscan 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 dailybasis, pursuant to DJS written policy and procedures.


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Ensure all unoccupied areas and storage rooms are locked at all times, pursuant toDJS policy.

Remove the pile of leave behind Clinton Hall and the fence near school; these arepotential hiding places for contraband.


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STAFFING RATING: Partial Performance

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

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

SOURCES OF INFORMATIONFacility listing of vacancies

Review of Facility Logbooks

Interview with superintendentObservation of facility

REFERENCESACA 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 Specialist1 Assistant Superintendent

The Superintendent indicated that the lack of the Assistant Superintendentposition strains the overall operation of the facility.

The facility only has one Group Life Manager II. With only one AssistantSuperintendent, this is not adequate for a facility of this population.

During the review the facilitys Case Management Supervisor was on long termleave. 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 andthree 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 toeffectively run the facility.

To alleviate some staffing needs. Ford Hall was closed and the Orientation unitwas moved to Clinton Hall (Clinton B). However, during an observation of theOrientation group on May 12, 2010, Clinton B was found to be out of ratio at2:19. 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


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inside the cage area with the staff member supervising them from the outside ofthe 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 Hallcould 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 werefrequently found to be out of ratio.

The self contained special education class started late everyday of the reviewbecause staff had to be found to supervisor the youth in the school. The school

principal indicated that this was a consistent problem.

RECOMMENDATIONS


Ensure the staffing plan is adequate for the increased population at Hickey. Whatwas 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 theadministrative and supervisory needs of the facility.

The facility should be provided a temporary replacement for the CMS Supervisorposition until that person is able to return from long term medical leave.

Address the high incidence of staff on leave. The facility should identify thosestaff 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 RATING: Non Performance

& ENVIRONMENTAL WEAPONS

STANDARD

Written policy, procedure and practice provide for the control of tools, keys andequipment 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.


Facility Tour Interview with staff

REFEERENCESDJS 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/stolenfacility 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 ofdeveloping an inventory system to account for tools.

Based on interviews with Maintenance staff, a small number of tools are kept onhand in vehicles which are frequently inventoried; however, the inventory is notdocumented.

KNIVES and UTENSILS


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Interviews with kitchen staff, along with observations, revealed that knives andother 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 hisgroup 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 thefacility:

Establish a key control system in accordance with DJS written policy andprocedures.

Ensure staff are trained and held responsible for adhering to proper procedures forthe care and handling of facility keys.

Establish a master inventory list for the tools maintained by the Maintenancesection. Ensure tools are checked/inventoried and documented on a regular basis.

Establish an inventory list of the knives and dangerous utensils maintained by thekitchen. 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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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 andin an orderly fashion.

Fire drills were not consistently logged in the appropriate unit logbook nor werebedtimes. Staff are responsible for making log book entries of all youthmovements 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 withwritten 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 crossout 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 30minutes and call the count into Master Control within fifteen minutes of the count

being taken.

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

Ensure staff document all youth movements (such as fire drills) as a componentfor maintaining the accountability of youth.


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FIRE SAFETY RATING: Satisfactory Performance

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

precautions in accordance with departmental guidelines. Provisions for adequate fireprotection service provide for the availability of fire protection equipment at appropriate

locations throughout the facility and the control of all use and storage of flammable,

toxic, and caustic materials.


Facility Tour Interviews with staff Interviews with maintenance staff Review of Logbooks Examination of Fire Safety Equipment

REFERENCESDJS Bomb Threat, Explosion and Suspicious Mail Policy (MGMT-3-01); ACA 3-JDF-3B-05, ACA 3-JDF-3B-10 and 3-JTS-3B-11

SUMMARY OF FINDINGS

The Maryland State Fire Marshal Office conducted an annual fire safetyinspection of the facility on 1/14/10. The fire marshal cited several violations tobe 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 facilitysprinkler 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 theGatehouse) 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 notavailable for an interview.

A review of fire drill records revealed that staff conducted at least one fire drill amonth during each shift from January to April 2010.


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Twenty-two randomly selected fire drill reports were crossed-reference with theappropriate 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 18inches 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 andcompleted.

Ensure staff do not store/stack items within 18 inches of ceiling sprinklers inorder that they may operate efficiently.

Ensure evacuation route plans are properly posted on Clinton Hall.


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POST ORDERS RATING: Non Performance

STANDARDWritten 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 orderprior 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.


Facility Tour & Observation Interviews with staff

REFERENCESDJS 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 staffpositions, at a minimum, Resident Advisors, Resident Advisor Lead, ResidentAdvisor 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, forAdmissions, 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-propertyappointments; and Maintenance Shop.

Interview with staff and a tour of the facility revealed that no copies of any postorders are maintained in Master Control in accordance with written DJS policy.

RECOMMENDATIONS


facility:

Implement the Departments Post Order policy to ensure staff are familiar withspecific and general instructions for the operation of an assigned post.


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STAFF TRAINING RATING: Partial Performance

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

contact with juveniles receive organized, planned and evaluated trainings in accordancewith departmental guidelines. Training is designed for continuous development of skills

related to job specific learning objectives.


DJS Training Histories report Interviews with staff List of mandated staff (did not include case managers/transportation/RA trainees)

REFERENCESMaryland 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, halfindicated 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 lifescenarios 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


Ensure annual training schedule is being met/followed and ensure all staffneeding required trainings are signed up immediately.

Ensure CPM is on the training calendar twice yearly as policy dictates and that allstaff 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.


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ADMISSIONS, INTAKE & RATING: Satisfactory Performance

STUDENT HANDBOOK

STANDARD

Written policy, procedure, and practice provide that the admissions process in eachdetention 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.


Interviews with youth Interview with Superintendent Interview with intake staff Review of youth screening tools Review of youth base files

REFERENCESAdmissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile DetentionFacilities; DJS Classification Policy in final editing stage; ACA 3-JDF-5A-02, 3-JTS-5A-

01, 5B-01 through 04 and 5B-07 & 08

SUMMARY OF FINDINGS

Intake packet contains all necessary paperwork. Court orders, face sheets andclassifications were completed for 100% of all files reviewed.

Handbook is provided to youth at Intake/Orientation. Handbooks were readilyavailable 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 inorder to account for youth who might be illiterate.

MAYSI is completed within two hours of admission. Intake staff interviewedknew how to score the MAYSI. 100% of files had a completed MAYSI. Intakestaff indicated they looked at MAYSIs for all No answers and ensured youth re-

took 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 fileshad 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 youthgave all false answers on their SASSIs. Again, Mental Health is aware.


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FIRRST is completed upon youths arrival and custody is not taken until youthscreens 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 arestaying too long on Orientation due to bed space needs and therefore are notgetting 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 aminimum scan SASSI results for youth who may be susceptible to de-toxingwhile 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 referany 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 writtenprocess 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 RATING: Satisfactory Performance

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

housing according to standard criteria of risk, age, size, conduct, offense history, presentlegal charge and special needs


Interview with Intake Staff Review of Intake Packet Interviews with staff Observation at facility

REFERENCESMaryland Standards for Juvenile Detention Facilities: DJS Classification Policy RF-01-

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

SUMMARY OF FINDINGS

Procedures have been established to identify the responsibilities of staff and thecriteria 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 Planformat pursuant to DJS policy.

Interviews with the Intake Supervisor and Case Management staff, along with areview 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 housingassignment are identified upon of the admission process.

Five of fifteen youth are overdue for a reassessment based on being at the facilityover 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 partdue 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.) toensure they are properly housed and supervised throughout their stay at the

facility.

Formulate a written FOP and Housing Plan pursuant to DJS policy.


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PENDING PLACEMENT RATING: No Rating

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

pending placement, their days committed, and average length of stay and aggressivelyprioritizes these youth in order to assist the community case managers in placing them as

quickly as possible in order to reduce time in detention.


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BEHAVIOR MANAGEMENT RATING: Satisfactory Performance

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

provides a system of rewards, privileges and consequences to encourage youth to fulfillfacility expectations and teach youth alternative pro-social behavior. Youth who are not

invested in the facilitys system have alternative and individual plans.

SOURCES OF INFORMATIONReview of Unit Log BooksReview of Daily Point Sheets

Interviews with youth

Interviews with of direct care staffReview of the Student Handbook

REFERENCESDJS 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. Itshould 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 thesestaff 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 managementprocedures 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 staffmembers.

Youths points were accurately transferred when the youth was transferredbetween units.

Youth report that they were offered the incentives outlined in the studenthandbook. The ability to earn additional telephone calls was frequentlymentioned as a consistent incentive given.

The majority of the youth indicated that they understood the program and that itwas 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.


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Five out of nine staff members interviewed indicated that they needed moretraining on the facilitys behavior management system.

A review of the logbook on Clinton Hall indicated times where there was onlyone bedtime for the entire unit. Eight oclock, which is the time Level One youthare 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 thatconsequences 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 anunsafe 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 proficientin the operation of the behavior management system.

Ensure that all youth on all units are provided with the incentives that they haveearned 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 ensurethat youth are never informally responsible for managing the behavior of otheryouth in a detention setting.


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STRUCTURED REHABILITATIVE RATING: Satisfactory Performance

PROGRAMMING

STANDARD

Written policy, procedure and practice document that youth receive planned, structuredoutdoor and indoor activities and regular rehabilitative programming that teaches social

skills.

SOURCES OF INFORMATIONReview of Unit Log BooksReview of the Master Schedule

Review of Calendar of Events

Interviews with direct care staffInterviews with youth

REFERENCESDJS 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. Theyprovide chess club twice a week to each of the units. They also provide theAMEN 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 masterschedule.

Youth participate in at least one hour of recreation per day and two hours ofrecreation on weekends. Youth report that recreation frequently occurs outsideand 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 whochoose 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 analternative to religious services.


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SELF ASSESSMENT RATING: No Rating

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

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

STANDARDWritten 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

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

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




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PSYCHOTROPIC MEDICATION RATING: No Rating

MANAGEMENT

STANDARD

Written policy, procedure, and practice require that psychotropic medications areprescribed, distributed, and monitored safely.




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BEHAVIORAL HEALTH SERVICES RATING: No Rating

& TREATMENT DELIVERY

STANDARD

Written policy, procedure and practice require that appropriate mental health substanceabuse 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.

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


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TREATMENT PLANNING RATING: No Rating

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

abuse treatment and emergency services are provided by qualified mental healthprofessionals 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

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

plans for youth leaving the facility. Youth, and their guardian when appropriate, shouldreceive 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 RATING: Partial Performance

ON SUICIDE WATCH

STANDARDWritten 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.


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

REFERENCESDJS Suicide Policy (HC-1-07), 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

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 logwere emailed and required to be viewed by staff daily, the Medical visit wouldnot be necessary.

The quality of the Suicide Watch Log is exceptional. Information on the youthsmental 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 onlymental health clinicians could remove a youth from watch.


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All staff indicated that when a youth was on one-to-one watch, they could notleave that youth for any reason, including to break up a fight.

Staff indicated that there are never times when there are not enough staff tosupervise youth on suici