Comprehensive Quality Review Report Thomas J.S. Waxter Center (MD 2011)

OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report
Thomas J.S. Waxter Center March 4, 2011
OFFICE OF QUALITY IMPROVEMENT Quality Review Report Thomas J.S. Waxter Center Evaluation Dates: February 2-4, 2011
TABLE OF CONTENTS EXECUTIVE SUMMARY .............................................................................................. 1 Facility Strengths ............................................................................................................ 1 QI Review Ratings Scale ................................................................................................ 2 QI Rating Percentage ...................................................................................................... 2 Executive Summary of Results ....................................................................................... 4 Methodology ................................................................................................................... 5 SUMMARY OF FINDINGS & RECOMMENDATIONS ............................................ 6 SAFETY AND SECURITY ............................................................................................. 6 Incident Reporting .......................................................................................................... 6 Senior Management Review ........................................................................................... 9 De-Escalation & Restraint ............................................................................................ 11 Contraband & Room Searches ...................................................................................... 13 Seclusion ....................................................................................................................... 15 Room Checks During Sleep Period .............................................................................. 17 Perimeter Checks .......................................................................................................... 19 Staffing .......................................................................................................................... 21 Control of Keys, Tools & Environmental Weapons ..................................................... 23 Youth Movement & Counts .......................................................................................... 27 Fire Safety ..................................................................................................................... 29 Post Orders .................................................................................................................... 32 Staff Training ................................................................................................................ 33 Admissions, Intake & Student Handbook..................................................................... 34 Classification................................................................................................................. 36 Pending Placement ........................................................................................................ 38 Behavior Management .................................................................................................. 39 Structured Rehabilitative Programming ....................................................................... 42 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 Waxter March 2011 Page i of 83
OFFICE OF QUALITY IMPROVEMENT Quality Review Report Thomas J.S. Waxter Center Evaluation Dates: February 2-4, 2011
TABLE OF CONTENTS (Continued)
SUICIDE PREVENTION .............................................................................................. 51 Documentation of Youth on Suicide Watch ................................................................. 51 Environmental Hazards ................................................................................................. 53 Clinical Care for Suicidal Youth................................................................................... 54 EDUCATION .................................................................................................................. 55 School Entry.................................................................................................................. 55 Curriculum & Instruction .............................................................................................. 57 School Staffing & Professional Development .............................................................. 59 Screening & Identification ............................................................................................ 61 Parent, Guardian & Surrogate Involvement.................................................................. 62 Individualized Education Programs .............................................................................. 63 Career Technology & Exploration Programs ............................................................... 64 Student Supervision ...................................................................................................... 65 School Environment & Climate .................................................................................... 66 Student Transition ......................................................................................................... 68 MEDICAL CARE ........................................................................................................... 69 Health Care Inquiry Regarding Injury .......................................................................... 69 Health Assessment ........................................................................................................ 71 Medication Administration ........................................................................................... 74 Dental Care ................................................................................................................... 77 Medical Records Retrieval ............................................................................................ 78 Special Needs Youth ..................................................................................................... 80 Availability of Medical Services .................................................................................. 82
DJS QI Report Waxter March 2011
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OFFICE OF QUALITY IMPROVEMENT Quality Review Report Thomas J.S. Waxter Center
EXECUTIVE SUMMARY A quality improvement assessment and evaluation of the Thomas J.S. Waxter Center was conducted February 2-4, 2011 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.
FACILITY STRENGTHS Many Waxter staff indicated, and it was evident from observation, that they are there for the girls and are dedicated to their work there. Girls complimented staff and relayed positive relationships with many of them. Handbooks with rules and information are routinely distributed to all girls. Waxters staff and leadership have made an effort to make the older facility brighter through paint and artwork. The units have a Jewel Room where youth can play activity games on the electronic gaming system or read or draw. Seclusion and suicide watch practices have improved with better documentation and more accountable supervision of at-risk girls. The mental health staffing is robust and counselors take seriously their work with the girls.
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QUALITY IMPROVEMENT REVIEW RATINGS SCALE

Superior Performance Strong evidence that all areas of practice consistently exceed the standard across the facility/programs; innovative facility-wide approach is incorporated sufficiently so that it has become routine, accepted practice. 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.
Satisfactory Performance
Partial Performance
Little or no evidence of adequate implementation of performance measure; the required activity or standard is not performed at all or there are frequent and significant exceptions to adequate practice; documentation could not be produced to substantiate practice. _______________________________________________________________________________________________
Non Performance
At the last QI Review of BCJJC in January 2009, 45 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 0 14 25 6 % of total in rating 0% 31 % 56 % 13 %
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 12 18 6
% of total in rating 0% 33 % 50 % 17 %
* 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.
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WAXTER PERFORMANCE COMPARISON
60% 50% 40% Percentage 30% 20% 10% 0% 1/8/09 Date of Report Superior Performance Satisfactory Performance Partial Performance Non Performance 3/4/11
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OFFICE OF QUALITY IMPROVEMENT Thomas J.S. Waxter Center Executive Summary of Results
Superior Performance Satisfactory Performance
Seclusion Youth Movement & Counts Fire Safety Admissions, Intake & Student Handbook Documentation of Youth on Suicide Watch Environmental Hazards Parent, Guardian, & Surrogate Involvement Individualized Education Programs Student Supervision School Entry Dental Care Medical Records Retrieval Special Needs Youth School Staffing & Professional Development Screening & Identification Career Technology & Exploration Programs School Environment & Climate Student Transition Health Care Inquiry Regarding Injury Medication Administration Availability of Medical Services Control of Keys, Tools & Environmental Weapons Staff Training Structured Rehabilitative Programming
Partial Performance
Incident Reporting De-Escalation & Restraint
Non Performance
Senior Management Review Post Orders
Contraband & Room Searches Classification Room Checks During Sleep Period Perimeter Checks Staffing Behavior Management Curriculum & Instruction Health Assessment
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OFFICE OF QUALITY IMPROVEMENT Thomas J.S. Waxter Center 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, suicide prevention 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 with the Superintendent, GLM IIs and key leadership personnel. Members of the QI Team asked and discussed with the Superintendent targeted questions related to safety and security, behavioral health, behavior management, education, medical and many other areas of facility operation. Primary Interviews A total of nine youth were interviewed individually and many more in groups about a range of areas across the QI review spectrum. This represented 26% of the total non-committed population at Waxter that week. Interviews were also conducted with facility staff, administration, medical, case management and education staff. In addition, ten 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. Observations of Facility Operations Youth movement Structured programming Recreation and Medical Leisure Time and Unit activities 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 conducted by phone on February 7, 2011.
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II.
III.
IV.
V.
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 26 Facility Incident Reports from August 2010-February 2011 Youth grievances Review of 10 videotaped incidents Staff Training Histories Report 16 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 The IR files in every case did not contain both written and electronic copies. Not all IRs had been entered into the database or entered on Waxters IR log. IRs are filled in entirely with few blank areas. The most common blank areas were in the notifications sections. There were some unreported/underreported incidents discovered: two were unreported restraints uncovered in OIG reports. 6 of 26 incidents (23%) were labeled incorrectly leading to underreported incidents. For example: IRs labeled inappropriate conduct were sometimes actually youth-on-youth assaults. A youth-on-youth assault was actually a group disturbance (involved four youth). And a suicide related IR left out also contraband. Any misreporting, even if unintentional, skews statistics in the IR database and leaves the facility unaware of the severity of what is actually occurring. The narrative portion of the IR included all four parts and all four were completed. Child abuse allegations were reported to CPS as required, however nurses sometimes checked the incorrect boxes in this section.
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Descriptions of uses of force were fair to poor. More on this is reported in the DeEscalation and Restraint section of this report. Narratives were generally noted as fair to poor. It was difficult to get a sense for exactly how an incident started, occurred, and ended from the IR narrative. In some, the descriptions of why a restraint or seclusion were justified or the extent of a youths aggression were important details left out by staff. Staff should be encouraged to fully document all important aspects of each incident as if they are telling a story. Most of the IRs contained shift commander (SC) comments but most were not critiques. More on the quality of those comments is indicated in the next section entitled Senior Management Review. Detail on exactly where staff were posted was present in only 53% of the IRs reviewed. 7 of 15 (47%) of IRs reviewed had all youth witness statements present. 13 of 15 (87%) of the IRs had all staff witness statements present. Youth(s) were evaluated by the nurse for injury after incidents; however the body sheets were not always attached to the incident reports.
GRIEVANCES There were only 4 written youth grievances in the past 8 months at Waxter. One was about points being taken and 3 were child abuse allegations. The resolution of these grievances was prompt and Advocates picked up grievances on average within 1.5 days. The 3 allegations were properly reported to CPS and OIG. An interview with one of the two Youth Advocates revealed that she and the second Advocate work hard to address youth concerns timely. There was some concern youth who are disruptive receive few consequences for their behavior and sometimes receive extra positive attention, leading to more disruptions. This mirrors the QI findings in the Behavior Management Program section of this report. 7 of 9 youth said they knew where to find and file grievance forms and would do so if they had a complaint. All indicated they knew who the Advocate was. On a walk through to check for stocked grievance forms, forms were stocked and accessible.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Especially encourage staff to give full and complete details about the incident, including all actors, what each did or did not do. Ensure no vague words are used. Encourage them that when describing a restraint they did, to include youth compliance, what was being said by all parties, whether the youth was calm, and whether the restraint was successful and if not, why not. This kind of information can be used to assess whether further or different training is needed or to confirm that staff did all they could in a difficult situation. Through the senior management review process and through vigilance from SCs, ensure all incidents are reported properly and incident categories correct. Retain witness statements from all youth present during the event. Require that staff indicate exactly where they and all youth were posted as the incident commenced. Require all notifications are made and to all relevant parties. Ensure body sheets are attached to all IRs including photos when applicable.
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SENIOR MANAGEMENT REVIEW
RATING: Non Performance
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 26 Facility Incident Reports from August 2010-February 2011 Review of 10 videotaped incidents Interviews with staff Review of 16 OIG Investigations Review of seclusion documentation Review of suicide watch documentation Staff Training Histories Report 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 Almost all of the IRs contained Shift Commander (SC) comments. Almost all SC comments were not critiques of staff performance nor were they preventive in nature (as is required). Also in one from January 19th, a SC added comments later but dated the comments the day the incident occurred. SCs frequently commented on incidents in which they were involved. In order to promote objective critiques, this should move to another supervisor. Policy requires senior administrative review of incident reports within 72 hours (3 days); this is almost never accomplished timely. Only 20% of the incidents are audited and many that were not were critical incidents requiring administrative review within 72 hours. Significant problems in many IRs therefore never saw facility follow-up. Though Inappropriate Conduct incidents on their own are not required to be audited currently per policy, the number reviewed by QI with sometimes substantial issues in terms of either incorrect incident type (should have been youth-on-youth assaults) or with numerous questions about staff supervision should encourage the facility to audit these as well. Video review of an incident is only accomplished occasionally and is not thus far a regular managerial review to assess staff performance. Seclusion sheets showed no evidence of auditing in most cases. Suicide watch documentation is not audited. The Office of the Inspector General (OIG) completed 16 investigations in the past year, 6 of which were sustained. Nearly all seemed to be thorough and gave a
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good accounting of the facts and came to reasonable conclusions. One concern is that OIG is remarking on valid supervision and other concerns and the facility managers seemed to have missed or never commented on/followed up on. For example: in OIG #10-85496, a youth became upset because her room was changed from the dorm to a separate room with no explanation to her; it seemed somewhat retaliatory in nature. This led to her becoming angry, an eventual restraint and injuries. The Investigator rightly commented by way of a preventive critique: there was no documentation to justify moving youth H out of the dorm. Upon reading the IR, this was something that should have been commented on, and corrected by, the facility. RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Require all shift commanders to critique staff and to share their comments with staff so that staff can learn from the management review. Ensure all shift commanders understand the mechanics of a critique and know what supervision points to catch when they review an incident. Ensure regular audits of suicide watch sheets. Ensure seclusion forms are audited along with the IR. See that Shift Commanders document on a video review tracking log when they have reviewed a video and that a Video Reviewed Yes or No line is added to audit sheets to document when senior managers review video. Work with IT at DJS Headquarters to install software on a computer in Intake or another convenient location for SCs so that they can easily review and playback incidents with staff after they occur and coach staff on supervision techniques. Begin auditing all IRs to ensure issues are spotted, preventive coaching is accomplished and if necessary, discipline is accomplished. Assign all Administrators equally so that the task is manageable. The goal of senior management review is to prevent a similar occurrence and improve staff skills. QI is available for technical assistance upon request.
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DE-ESCALATION & RESTRAINT
RATING: Partial Performance
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 26 Facility Incident Reports from August 2010-February 2011 Review of 10 videotaped incidents Staff Training Histories Report Interview with Superintendent Review of 16 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 Videotaping of Incidents Policy (RF-05-07); ACA 1-SJD-3A-14-15 SUMMARY OF FINDINGS Descriptions of uses of force in written IRs were fair to poor. Vague statements like youth was placed on bed or placed on floor give no indication of how the youth was responding, what she said, how the staff placed the youth, in what position, or what the staff were saying or physically doing. Safety cannot be assessed from the descriptions given. Of the ten videos reviewed, one could not be viewed by the angle. Two showed no incident occurred (indicating that staff may not have correctly reported the time of the incident.) One was reviewed and did not match the IR at all. Two did not involve restraints. Four were viewed to assess the fidelity to the incident report version and to assess CPM technique. One of the four showing restraints showed a solid and safe restraint. One was fair, with one staff properly holding the youth and another holding her wrist only. One was good up until the youth was placed in her room: she fell down and the staff pulled her into her room by her arm. And the final restraint involved a staff simply grabbing and pulling a youth by her shirt. Concerning was that in 30% of videos reviewed, there was no match of the incident report to the video. Not only were times possibly incorrect (views were checked for two hours surrounding two reported incident but could still not be found) but in a third, staff reports of no assault were blatantly untrue when viewed on video. Whole parts of the incident as written were missed when viewed
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on video. Since videos are not routinely reviewed as a part of the senior management review process, the facility is unaware of these issues. Videos and IRs indicated that restraints are used in order to move youth for noncompliance which is not permitted by DJS policy or by COMAR. All staff should know this is not permitted and have other options at their disposal. Youth indicated that most staff are nice to them. However, there were a few incidents where staffs language and statements seemed to escalate youth. Youth witness statements and IRs showed clearly the staff statements escalating to a youths eventual incident. Just 9 of 30 staff (30%) were compliant with Crisis Prevention and Management semi-annual training (when reviewing CPM compliance overall, 73% had had CPM at least once in the prior year.) Just 3 of 10 staff knew CPM training was required twice yearly. 2 of 10 stated once yearly and 5 of 10 did not know. Mechanical restraints are not covered in training.
RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Ensure all staff are trained twice yearly in CPM, including mechanical restraints. Ensure all staff are aware that moving a youth for non-compliance is not permitted by DJS policy or by COMAR. Ensure they have other methods they can apply in these situations and that this use of restraint is not tolerated by management. Require SCs only turn in IRs that have full and complete restraint detail from line staff and that they review video to ensure it is accurate. Ensure regular video review of all seclusions, restraints, assaults of any kind and inappropriate conduct to ensure staff response is appropriate and to catch issues as they arise. Ensure staff understand the basics of de-escalating speech. Certain girls may be triggered by certain statements. If staff are coached on de-escalation, they may be able to prevent the youth from becoming upset in the first place. Management should ensure youth witness statements are included in IR reviews and address staff when they seem to have chosen poorly when dealing with the youth.
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CONTRABAND & ROOM SEARCHES
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 and Master Control Logbooks Facility documents Interview with staff Observation at the 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 FOP titled Searches (dated: 2/28/2005) that outlines various search procedures to be carried out at the facility. Further, the FOP indicates that shakedowns are to be completed daily and documented in the appropriate unit and/or Tour Offices logbook. An interview with a Group Life Manager revealed that room and general area searches were not consistently carried out or documented during the period being reviewed. However, the practice has been re-implemented within the past month. An interview with a Shift Commander revealed a new form was developed about a month ago to document the room and general area searches. The facility provided a small number of room search documentation (i.e. January 2011) for the period that is being reviewed. The available documentation revealed that staff recovered various contraband items, such as a 6 pack of soap, 12 magic markers, and pencils during the room searches. Room searches were not consistently documented in unit log books. 4 of 9 staff indicated that room searches occur on every shift. 3 of 9 staff indicated that room searches are conducted daily. 2 of 9 staff indicated that room searches occur once or twice a week. 6 of 9 staff believe they are not given enough time and an adequate number of staff to properly conduct room searches. A QI team member conducted a shakedown of two randomly selected rooms in B Unit. Snacks were found in one room. Both rooms have graffiti written on the walls. A review of maintenance records revealed that a work order has been submitted to have the walls painted. An observation made in C Units dorm revealed paint peeled from a large area of the wall located next to a youths bed. Further, some walls contain blotches of a white substance.
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Interviews with Master Control staff revealed that the metal detectors are not routinely used to search visitors/employees entering the facility. Staff believes that the walkthrough metal detector is unplugged. Staff were not sure if the facility has any handheld metal detectors (wands). Two handheld wands were located in a closet, both were inoperative. Regularly conducted searches of visitors/employees entering a facility are essential to assuring the safety of youth and employees. During a tour of the facility, several pencils were observed on tables and chairs in the two units. A staff was observed accounting for the number of pencils that were given to a youth to sharpen. Pencils should be secured to prevent an unpredictable youth from using a pencil as a sharp (pointed) weapon. Observations made of several youth movements from the school revealed they were frisked upon movement. However, two of three observations made of youth moving from the cafenasium revealed that they were not frisked. A review of the DJS database for the period of January 1, 2010 to February 3, 2011, revealed that staff reported 21 incidents involving the recovering of contraband. The incident reports indicated that staff recovered an array of contraband (i.e. cell phone and charger, scissors, pills, a vial of blood, lighter, markers, currency, I Pod, pregnancy test kits, and etc.) from within the facility.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area, it is recommended that the facility: Have Shift Commanders regularly verify that room and general area searches are documented on the facilitys Shakedown Sheets and in the appropriate logbooks. Ensure that supporting documentation (i.e. Shakedown forms) regarding facility practices are maintained. Ensure staff are familiar with the facilitys room search policy and procedures. Staff should ensure pencils are secured and regularly inventoried to prevent misuse by youth. Ensure staff frisk search youth upon every movement from areas that may contain contraband items. Ensure the appropriate staff are familiar with the operation of the walkthrough and handheld metal detectors. Ensure staff and visitors are wanded. Remove/paint over the graffiti on walls in the sleeping areas.
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SECLUSION
RATING: Satisfactory Performance
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 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 Interview with Superintendent Incident Reports from August 2010-Feb 2011 Seclusion sheets Interviews with youth and staff Observation at facility Videotaped incidents resulting in seclusion REFERENCES DJS Seclusion Policy RF-01-07; COMAR 16.18.02 SUMMARY OF FINDINGS Documented seclusions at Waxter are as follows: # of seclusions 1 0 1 10 3 9 Average Daily Pop* 33 34 35 34 28 29 Rate 0.10 0.00 0.09 0.98 0.35 1.00
Month August September October November December January
* Only includes Waxters detained population
The average length of stay in seclusion is short. For the month of August 2010, the stay averaged 1.65 hours. Eleven (11) documented episodes of seclusion were reviewed. Checks on the sheets by line staff showed few concerns, but often the youth was in her room for very short periods of time (22 minutes, 50 minutes) resulting in only 2-6 checks to review. In 1 of 11 there was a discernable pattern (ending in 9s); in 1 of 11 there was one 15 minute gap; in 1 of 11 staff noted blocked window but did not document what they did about this; in 1 of 11, all codes by staff were incorrect or confusing.
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Codes for standing in hall, attempting to attack peer, showering, and being escorted to room were all codes listed by the line staff but all appear to show a youth not secluded at all. This may have been one staffs error and it was the only sheet of 11 that displayed this issue. In 1 of 11, the youth was still agitated and could not be released at bedtime, but staff ceased seclusion procedures. There was no documented auditing of the seclusion log or observation sheets so the issue in the few sheets noted above were not caught by the facility. The shift commander (SC) comments (reasons for youth not being released from seclusion) were fair. Imminent threat to others is not a justification without more and was seen in use by some SCs. In 1 off 11 the SC noted eating now calm at 6:30 but the youth was not released until 7:30. In 1 of 11, the SC wrote the time (4:30) of her check but nothing further. The facility requires senior administrative approval of seclusion use. In nearly every documented case, medical staff appropriately documented observations. In every documented case, shift commanders visited the youth and made checks timely. The Seclusion Log sometimes had start and end times of seclusion and other pertinent information missing. Youth seemed to be individually processed and not all released at one time, an indicator that seclusion is not being used as punishment. In two videos, the youth belongings were tossed out of the room prior to her escort in. In one, her blanket and pillow were a part of those belongings and these have to remain inside the room unless justified in writing. Seclusion use for lack of staff (staff shortages) was not documented in the seclusion log. It could not be determined if youth are secluded when there are not enough staff to meet ratios. The use of early bed violates DJS seclusion policy. There were no indications from youth or staff that early bedtime was given to the detained population.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that the auditing process includes seclusion sheets and the seclusion log if a seclusion episode occurs. Institute random video review of any seclusions monthly to ensure staff checks are happening as expected and that staff are not putting youth mattresses, pillows or blankets outside of the youths room. Do not remove youths blankets, pillow or mattress when a youth is secluded unless there is written justification for doing so. Track seclusion lengths of stay by rate and ensure all Administrators are aware of seclusion patterns and any burgeoning overuse.
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ROOM CHECKS DURING 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 Sleep Observation Sheets Video recordings REFERENCES ACA 3-JDF-3A-04 and 3-JTS-3A-04 SUMMARY OF FINDINGS The facility maintains a FOP titled Movement and Supervision of Youth that outlines the procedure for documenting visual checks on the Sleep Observation Sheets. The FOP indicates that a visual check is to be made of each youth every 30 minutes during the sleep period. The facility produced a sufficient number of Sleep Observation Sheets to suggest that room checks are routinely practiced. However, the Sleep Observation Sheets contain pre-printed time checks (i.e. 30 minutes intervals) for recording each visual check. The use of pre-printed times on sheets does not accurately reflect the exact time a youth was observed. Randomly selected video recordings from the facilitys video surveillance system (B Unit), from December 30, 2010 to February 2, 2011, were reviewed to assess the level of performance by staff conducting room checks. The following observations were noted: o 12/30/2010 - A staff was observed conducting room checks and documenting the checks. The observation sheets appeared to be posted on the wall at each room. o 1/8/2011 - A staff was observed conducting room checks and documenting the checks. The observation sheets appeared to be posted on the wall at each room. o 1/16/2011 - A staff was observed conducting room checks and documenting the checks. The observation sheets appeared to be posted on the wall at each room. o 1/30/2011 - Observation Sheets were not posted throughout the sleep period.
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o 2/1/2011 - No staff were observed conducting room checks for at least a two hour period. Observation Sheets were not posted throughout the sleep period. Many of the facilitys Sleep Observation sheets contain a supervisors check that is written in the margin of the sheets.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area, it is recommended that the facility: Stop using the Sleep Observations Sheets that contain pre-printed time checks. Write in the exact time of the check. Staff should attempt to randomize checks so as not to fall into a recognizable pattern. Supervisors should randomly review video recordings of the sleep period to ensure staff are conducting checks as required by policy.
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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 documents 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 facility maintains a FOP titled Security Devices and Perimeter/Interior Security Checks (dated: 5/2005) that outlines the procedures for daily checks of the facilitys locks, doors, fences, electronic audio/visual systems, gates and detectors by the Shift Commanders. Interview with a Shift Commander revealed that perimeter checks are to occur at least once during every shift. Perimeter Checks are to be documented onto a newly developed facility form, and in the Master Control and/or Shift Commanders log books. The facility provided some documents (i.e., January 2011) that pertained to the expected frequency (i.e. every shift) for conducting perimeter checks. A review of randomly selected dates recorded in the Master Control and Shift Commanders logbooks revealed that perimeter checks were not consistently documented during the three shifts. During a tour of the facility, it was noted that the facilitys walkthrough metal detector was not used to search visitors and employees entering the facility. Interview with staff revealed that the walkthrough metal detector has not been used for about a month or longer and is probably unplugged. Interviews with two staff (Master Control/main entrance) revealed that they were not sure if the facility has a handheld metal detector (wand). On three occasions, members of the QI team found a security door (i.e., unit and unit hallway) open and unattended. Some doors appeared to have been left unsecured for staffs convenience (i.e., one of two sally port doors). A review of the facilitys Visitors Sign-in/out Log (i.e. loose leaf binder) listed a few entries covering several days in January and February 2011. The arrival and departure times for the vast majority of the visitors were recorded.
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The facilitys front entrance consists of electronically locking doors (i.e., sally port) to control pedestrian traffic entering/exiting the facility. The doors and locking mechanisms appear to be in good working order.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that supporting documentation (i.e. perimeter check forms) regarding facility practices are readily available and maintained. Ensure perimeter checks are consistently documented in the appropriate logbook(s) and on facility forms. Shift Commanders should regularly check the condition of all metal detectors to ensure they are operational, and repair/replace any defective metal detector. Ensure the appropriate staff are trained in the use of the facilitys metal detectors and wands. Staff should frequently check security doors, unoccupied areas and storage rooms to ensure they are kept locked at all times.
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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 Review of Facility Staffing Plan Review of Facility Logbooks Interview with staff and youth Review of Seclusion Logs Observation of facility REFERENCES ACA 1-SJD-1C-03 SUMMARY OF FINDINGS Currently, the facility has five Residential Advisor vacancies, one Group Life Manager I vacancy, one medical staff vacancy and one addictions counselor vacancy. The staffing for all three shifts from five random days in from October 2010 to January 2011 were reviewed (15 shifts). On 4 of those shifts (26%) at least one unit was out of the appropriate staff to youth ratio. Eight of these shifts (53%) had at least one staff member working overtime. The facility reported that there were only two staff members who were out on medical leave. Eight of eleven staff interviewed indicated that they are required to work three or more double shifts per week. Two additional staff members indicated that they have to do at least two double shifts per week. Six of the eleven feel that it is too much. Youth report that activities are missed because there are times when there are not enough staff to supervise youth. At no time during the review were the units observed to be out of the appropriate ratio, however on one occasion a line staff moved nine youth alone.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Review the current staffing pattern to determine the additional staff that are needed. Continue to recruit to fill all available vacant residential staff PINS. Ensure staff ask for assistance if they find themselves with more than 8 youth alone.
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CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS
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 Logbooks and other documents 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 KEYS The facility maintains a FOP titled Key Control (#10-008) that outlines the facilitys key control procedures. The key control policy, in part, requires that incoming employees receive facility keys in exchange for a chit. Interviews with staff and observations made of the key control process revealed that facility keys are not exchanged for a chit as pursuant to DJS policy and the FOP. Facility employees exchange their personal keys for facility keys. Interviews with staff revealed that if an employee does not have a personal key to exchange for a facility key(s), an administrative chit is to be issued to the employee and exchanged for a facility key. Interviews with staff revealed that there is not a designated Key Control Officer and post order for the position. Master Control staff and a maintenance worker are performing several of the tasks associated with managing the key control system (i.e. maintaining keyboards, issuing and inventorying keys, etc.) On two occasions, staff working in Master Control gave facility keys to two visitors from DJS before obtaining their identification, personal keys and the nature of their business at the facility. On two other occasions, visitors were asked for personal keys but not for identification. DJS policy requires that a roster of the names of employees and their assigned chit be maintained at the location where the keys are issued. The facility does not maintain a roster of employees and their assigned chit. Currently, the name of an employee is written on a piece of tape that is placed over a key sets hook number. The aforementioned procedure is use to identify the staff that is to be
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issued that particular key set/ring. The name of a previous employee is still taped over a key set hook/number. Observations made of Master Control logbooks revealed that the name of each staff retrieving and returning keys is recorded. Also, the name of employees retrieving and returning keys is documented on the Staff Daily Sign-in/out Sheet. The posted key inventory list does not match the keys in the keyboard. At minimum, DJS policy requires that the number of keys on one key ring be counted each working day and the count documented in the facility logbook. The inventorying of keys is not documented but visually carried out during each shift. Emergency key rings are not readily identifiable and grouped separately from the regularly issued keys (this procedure would permit ready identification of the emergency keys and allow access to any part of the facility in the event of an emergency.) However, staff indicated that the Shift Commanders have a key(s) that would facilitate the evacuation from all parts of the facility. Interview with the maintenance worker revealed that a set of emergency keys are not maintained at a secure location away from but near the facility as pursuant to DJS policy. Pursuant to DJS policy, every hook in the Working Keyboard is to be filled at all times with either a chit or a set of facility keys so that at a glance a missing key set can be readily detected. An observation of the Working Keyboard revealed that key hooks #10, #16 and #47 were vacant. Staff indicated that the personal keys of the staff issued keysets #10, #16 and #47 were placed in another box. Facility keys were observed maintained on a metallic key ring soldered/crimped at the joint to prevent tampering, loss or removal as pursuant to DJS policy. Eight staff are issued facility keys on a 24 hour basis. Once the facility has been re-keyed, only three staff will be allowed to possess keys on a 24 hour basis. A review of the DJS incident reporting database revealed two incidents involving keys not securely carried by staff. During a restraint incident (#88124, 1/11/11), the keys fell out of staffs pockets and a youth retrieved them. The keys were later found during a search of the youth. In another incident a Shift Commander found a set of facility keys in a courtyard. The staff who lost the key did not officially report the keys missing for about 2 hours. A review of the DJS incident reporting database further revealed that the facility reported a few incidents, such as three broken keys, a blood draw drawer key missing and paint chips jammed in a lock. Interview with a maintenance worker, along with observations made of facility keys, revealed that some keys are notched so that they can be identified by touch. These keys facilitate the prompt release of youth from locked areas in an emergency situation. The facility maintains a Back-up Key Board in a secured location as pursuant to policy. A review of Master Controls logbook, along with observations made, revealed that staff routinely turn-in their facility keys when going on break outside of the perimeter/grounds of the facility. Interview with a maintenance worker revealed that the facility will be re-keyed and a new key control process implemented in the near future.
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TOOLS Interview with a maintenance worker revealed that the facility is in the process of developing a master inventory list for the tools located at the facility. The facility has not identified a Tool Control Officer or implemented a post order for the position. Currently, the maintenance section does not maintain a sign-in/sign-out log for tools. Interviews with staff revealed that some employees bring personal tools (i.e. drills, screwdrivers, and etc.) in the secured area of the facility for the purpose of assembling furniture (i.e. book shelves). Interviews with staff and observations of the maintenance area revealed that certain tools have been engraved with the letter W for identification purposes. Tools are stored at a location outside of the housing/secured area of the facility. Tools are secured in containers (i.e. drawers and cabinets) within the maintenance section. The facility maintains only the smallest amount of any materials (i.e. paint, gasoline and etc.) for use. Such items are stored in areas outside of the secured area of the facility.
KNIVES and UTENSILS Observations made of the food service area revealed that potentially dangerous utensils (i.e. knives, etc.) are kept in a locked cabinet in the Food Service area. Utensils are inventoried three times a day to ensure they are accounted for. However, utensils are not signed for by staff when retrieved or returned to the cabinet. Culinary utensils (i.e. knives, etc.) are not marked for identification purposes. The Food Services area maintains MSDSs for chemicals used in the kitchen area. All chemicals are secured in a closet.
ENVIRONMENTAL WEAPONS Several pencils were observed openly throughout both units. In an incident, a youth attempted to open the unit door by sticking a broom handle through the cage area to activate the electronic door switch. Broom and mops should be properly secured and controlled to prevent their use in facilitating an assault or as a tool to attempt an escape. Observations made of the Intake area revealed a cup of urine in a trash can. Also, a review of the incident reporting database revealed an incident (#84478) that involved a stolen vial of blood found in a living area. To minimize the transmission of any communicable diseases, staff should ensure bodily fluids are handled in accordance to DJS Handling/Disposing of Contaminated Medical Waste policy.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Assign each employee a chit to be exchange for facility keys, as pursuant to DJS Key Control policy. Ensure that the key inventory list matches the keys is the Working Keyboard and is maintained near the keyboard. The key inventory list for the Working Keyboard should be updated as changes are made. Designate a Key Control Officer to be responsible for the storage and inventory of facility keys, as pursuant to DJS policy. Write a Post Order for the Key Control Officer. Ensure each staff working in Master Control reads and understands the Key Control FOP prior to issuing and retrieving facility keys. Maintain a list of the names of employees and their assigned chit number at the location where keys are issued. Complete the process of re-keying the facility and implementing the new key control process as soon as possible. Ensure keys are at inventoried as pursuant to DJS policy. Ensure staff are train to securely carry keys in their possession and promptly report any missing/lost facility keys. Emergency keys should be grouped separately from the regularly issued keys in the keyboard to permit quick identification to allow access throughout the facility in the event of an emergency. Ensure that a set of emergency keys are maintained at a secure location away, but near the facility. To enhance facility security and maintain accountability for keys, reduce the number of staff possessing facility keys on a 24 hour basis. Designate a Tool Control Officer to be responsible for the storage and inventory of facility tools and equipment. Write a Post order for the Tool Control Officer. Do not allow staff to bring personal tools (i.e. drills, screwdrivers, pliers, and etc.) in the facility without proper authorization. The Maintenance and Food Service sections should maintain a sign-in/sign-out log for tools and culinary utensils, respectively. Culinary utensils should be marked for identification purposes.
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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 facility maintains FOPs titled Physical Count and Movement and Supervision of Youth that outline the facility count and supervision of youth procedures. The FOP indicates that an informal count is to be taken of youth every 30 minutes. Further, an official count is to occur daily at 12am, 3am, 6am, 9am, 12pm, 3pm, 6pm and 9pm. Official counts should total no less than 8 official counts daily. A review of randomly selected dates from Master Control logbooks revealed the following official counts per FOP: o November 3, 2010, at 1:18pm to November 4, 2010, at 8am. No counts or information recorded. No explanation for the lapse of information was cited. o November 4, 2010, no counts recorded during the 1st shift. o December 14, 2010, 2 counts during the 1st shift. o December 14, 2010, 8 counts during the 2nd shift. o December 15, 2010, 7 counts during the 3rd shift. o December 15, 2010, 5 counts during the 1st shift. o December 16, 2010, 6 counts during the 3rd shift. o January 3, 2011, 3 counts during the 1st shift. A review of randomly selected dates in unit logbooks revealed instances of counts occurring about every 45 minutes during the 1st and 2nd shifts. Some 3rd shifts recorded a count and check of youth every 15 to 60 minutes.
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4 staff interviewed indicated that informal counts are taken every 30 minutes and recorded in the unit log book. Further, informal counts are taken every 15 minutes during outside recreation. 2 of 4 staff indicated that the informal count is called into Master Control. DJS policy requires that counts recorded in a logbook reveal the time of the count, the count itself, the name of the staff performing the count, location of the youth group and those outside the location where the count is occurring. A review of a unit logbook revealed that staff not did indicate the name of the staff performing the count. A few entries in the Master Control logbook did not reveal the actual count itself. A review of facility logbooks revealed that an official count was taken of all youth in the facility at about 2am, as pursuant to DJS policy. As part of the counting process, the facility maintains a tally of the youth arriving and departing the facility as pursuant to DJS policy. A review of the facility documents revealed that an emergency count is conducted in the event of a discrepancy in a count, as pursuant to DJS policy. Several observations made at the school revealed that youth were frisked upon each movement from the school. However, two of three observations made of youth in the cafenasium revealed that the youth were not frisked upon movement. A review of unit and Master Control logbooks revealed that the facility generally identifies each youth movement and indicates the specific location of each youth at all times. Youth taken from and returned to a location is recorded in the unit log books. Observed group movements were usually orderly and under staff supervision however youth are counting themselves, which is not optimum practice and is against DJS policy, and often a shift commander has to be the one to provide the orderly movement.
RECOMMENDATIONS In order to reach Superior Performance status in this area, it is recommended that the facility: Ensure Shift Commanders verify that every count and the result is individually recorded in the applicable logbook(s) and accurately reflect the number of youth and staff present as well as the name(s) of staff performing the count; the location of groups of youth (library, class, outside area); and youth outside of the location where the count is occurring. Ensure all staff receive training regarding the counting process to include refresher training. Ensure youth do not count themselves but that staff count them. Youth may not participate in counts according to policy.
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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 Interviews with a Group Life Manager and maintenance worker revealed that the facility has a designated Fire Safety Officer. However, the Fire Safety Officer was not available during the QI review. The facility did not have a Post Order for the position of Fire Safety Officer. A State Deputy Fire Marshal inspected the facility on 1/19/11. The inspection by the State Deputy Fire Marshal cited several violations that needed to be corrected, such as a missing smoke detector in the kitchen, a wall plate needed over an electrical outlet, and a semi-annual testing/maintenance needed for the hood fire extinguisher system in the kitchen. The violations cited by the State Deputy Fire Marshal appear to have been corrected as of 2/2/11. The facilitys fire alarm system and sprinkler system were last inspected/tested on October 19, 2010, and November 4, 2010, respectively. A review of repair documents revealed that noted deficiencies were corrected. A review of the facilitys fire drill reports for B and C Units revealed that fire drills were conducted on the following dates between August 2010 and January 2011: o August 16, 17, 22, and 24, 2010. All three shifts documented a fire drill for the month. o September 27, 2010. One fire drill reportedly occurred during the 1st shift. o October 2010. No fire drills reported. o November 23 and 24, 2010. Two fire drills occurred on the 24th. All three shifts documented a fire drill.
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o December 15 and 17, 2010. No record of the 2nd shift conducting a fire drill. Six youth (B unit) refused to get out of bed and participate in a morning fire drill. o January 14 and 31, 2011. On the morning of the 14th, 6 youth (B unit) remained in bed during the fire drill. Five randomly selected fire drill reports were cross-referenced with the Master Controls logbook(s) to access the level of compliance with documenting events. Two of the five reported fire drills were documented in the Master Control logbook. A tour of the facility revealed that the sprinkler head(s) and pipes in the laundry room are covered with lint/dust. Sprinklers covered with dust can malfunction and should be cleaned. Interviews with the maintenance worker, along with observations made of the Fire Alarm Control Panels (FACP), revealed that the facility still operates two separate fire alarm systems. The auditory alarms for both systems are located in the Intake area (i.e. old Tour Office) that is not longer manned on a 24 hour basis. If a fire emergency occurs in one part of the facility, occupants located in the other part of the facility will not receive the auditory alert signaling a fire emergency and vice versa. According to a maintenance worker, the facility plans to merge the two systems with an additional warning system. Eight (8) fire extinguishers were examined. Each fire extinguisher appeared to be in good condition and had a current annual and monthly inspection. In C Unit, a fire extinguisher was on the floor. All fire extinguishers should be mounted to prevent them from being misplaced. Observations made at the facility revealed that egress plans are posted throughout the facility. 9 of 9 staff have reportedly participated in at least one fire drill each month. 5 of 9 youth have reportedly participated in a least one fire drill since being assigned to the facility. Several emergency lighting fixtures tested satisfactorily. Exit signs were illuminated. The facilitys power generator is tested at least weekly.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Write a Post Order for the position of Fire Safety Officer. Ensure all fire drills are documented in the appropriate logbook(s). Ensure youth participate in fire drills when appropriate and ensure all are familiar with emergency evacuation procedures. Any disruption of an emergency evacuation drill by a youth should be constituted as a rule violation and subject the youth to the provision identified in the Behavior Management Program. Ensure each shift performs at least one fire drill per month. Ensure sprinkler heads in the laundry room are free of dust. A can of compressed air would be useful in removing the dust. Mount the fire extinguisher in C Unit on the wall. Connect the two separate fire alarm systems to audibly alert throughout the entire facility to ensure quick notification and evacuation.
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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 does not maintain a FOP that cites specific and general instructions for the operation of every post within the facility. A supervisor staff was unfamiliar with facility Post Orders and was unable to produce them for B and C Units. The facility was unable to provide any Post Orders Signature Sheets as verification that staff are familiar with the duties and responsibilities of a post. No copies of Post Orders and Post Order Signature forms are maintained in Master Control as pursuant to DJS policy. The facility does maintain a Movement and Supervision of Youth FOP #10-001 that outlines procedures for supervising youth located in a building(s), during recreation, in the dining hall, in school, during transportation and etc.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Create and maintain Post Orders and Post Order Signature Sheets as pursuant to DJS policy. Ensure each staff reads and understands the post order prior to assuming the post for the first time. Develop a post order for special duty assignment positions (i.e. Key Control and Fire Safety Officer).
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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 REFERENCES Maryland Correctional Training Commission (MCTC); ACA 1-SJD-1D-03, ACA 3-JDF-1D-01, ACA JDF-1D-02 SUMMARY OF FINDINGS: Mechanical restraints are not covered in CPM training as required. Of 58 mandated staff, 30 (52 %) were sampled and reviewed for training compliance and the results were as follows: -- 20/30 (67 %) met the 40 hour annual training requirement. -- 24/30 (80 %) of staff had First Aid/CPR/AED training in the prior 12 months. -- 9/30 (30 %) were compliant with Crisis Prevention and Management semiannual training (when reviewing CPM compliance overall, 73% had had CPM at least once in the prior year.) -- 24/30 (80 %) were compliant with Suicide Prevention annual training. -- 25/30 (83 %) were compliant with Recognizing and Reporting Child Abuse and Neglect annual training. There is no Assistant Superintendent, but the facilitys two mandated management staff (both GLM IIs) who are responsible for holding staff accountable in all of these necessary areas were compliant with nearly every training requirement which is excellent.
RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Ensure all staff needing required training attend at a rate above 90% across all categories; focus on CPM training.
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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 staff who perform intake Interview with Case Manager Supervisor Review of youth handbook Review of six youth base files and six corresponding medical files REFERENCES Admissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile Detention Facilities; DJS Classification Policy RF-01-08; ACA 3-JDF-5A-02, 3-JTS-5A-01, 5B-01 through 04 and 5B-07 & 08 SUMMARY OF FINDINGS Handbook acknowledgement forms were found in nearly all youth files. Girls at Waxter indicated they received a handbook at admission and copies were readily available in Intake. The handbook at Waxter is very complete. The only error was in the BMP section; the Waxter written BMP and the BMP in the handbook do not match up exactly. Court orders were in every file. Intake staff interviewed knew how to score the MAYSI and does so. Staff indicate MAYSIs are completed within two hours. Psychological staff also indicated MAYSIs are completed for all youth upon admission. The youths base files and medical files were checked for copies of the MAYSI, and in only 2 of 6 cases were they found. The SASSIs were found in the youths medical file, but in all cases, the SASSIs were not completed within two hours as required by policy. Intake staff knew how to scan the results for issues and refer youth to Mental Health staff if they have any concerns on either screening. The FIRRST is completed upon the youths arrival and copies were in 100% of files. Staff knew not to accept custody if the youth has any yes answers.
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A medical assessment is not done upon admission or within 72 hours. There is no formal Orientation Unit at Waxter so this area was not assessed.
RECOMMENDATIONS In order to reach Superior Performance status, it is recommended the facility: Ensure the youth handbooks version of the BMP matches up to Waxters BMP. Administer and score both the SASSI and MAYSI within two hours of a youths admission. Ensure all screenings are in every youths file. Request the software for computerized SASSI screening and scoring from DJS Headquarters to assist in this area. Ensure Nursing completes a medical assessment within 72 hours.
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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 The facility does not maintain a classification FOP as pursuant to DJS policy. The FOP should identify specific employee(s) responsible for conducting and completing Housing Classification Assessments and Re-Assessments; reviewing ASSIST for prior DJS commitments and placements, and inputting admissions data; reviewing the DJS Incident Database for serious incident involvement (youth on youth or youth on staff assaults, group disturbances, restraints and escapes or attempted escapes); observing youth to determine if initial classification level and housing assignment is meeting the needs of the youth; establishing protocols for housing and proper supervision of youth to ensure that youth are placed in a unit and room suitable to the youths classification level. The facility does not maintain a Housing Plan as pursuant to DJS policy. The Housing Plan is required to identify each living area; provide a description of the physical plant description; capacity; staffing pattern for each shift; safety, security and supervision practices; single and double youth sleeping rooms; youth classification levels and specific population assigned; general programming; and special services and/or accommodations. Interviews with the Case Management Supervisor reveal that the facility has not implemented the written DJS Classification process to assess a youths potential vulnerability and needed level of supervision. No classification forms were in youth base files. Presently, upon admission to the facility, youth can be placed in an individual room or dorm based on the youths known history and/or current charge.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Implement the DJS Classification of Youth in Detention Facilities policy (i.e. classification tool, etc.) to ensure youth are properly assessed to determine the appropriate level of supervision and housing assignment each youth is to receive. Write a Housing Plan for each unit and FOP as pursuant to DJS Classification policy.
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PENDING PLACEMENT
RATING: Not Rated
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 Review of the Student Handbook Review of Behavior Management Plan (BMP) Review of Intervention Plans Interviews with youth Interviews with of direct care staff REFERENCES DJS Behavior Management Program Policy RF-10-07; Facility Behavior Management Program (BMP) SUMMARY OF FINDINGS There were many discrepancies between the written BMP and the explanation given in the youth handbook. The list of behaviors resulting in a loss of points was different. Also, there was no explanation of incentives, rebates and commissary in the handbook. The BMP also indicates that there should be warnings given prior to points being taken, but this information is not included in the handbook. A review of Daily Point Sheets indicated that most were not completed. The individual areas (i.e. education, programming, meals) were empty on most of the sheets. The students would then be awarded all of their points. While the areas were not filled in, there were deductions listed for infractions. Most of the calculations on the sheets seemed correct, but a comparison of the deductions on the sheets to the youth handbook showed that the deductions were administered inconsistently. There appeared to be no audits/oversight of the sheets to correct inappropriate deductions miscalculations. All but one of the eleven staff members interviewed indicated that they received training on the BMP and three of eleven indicated that they needed additional training. Six of the eleven staff members interviewed said that they did not feel that the BMP was working. Four of the staff commented that the program was not administered consistently. They state that the program does not provide enough incentives and that all students are not held to the same standards.
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Five of nine youth interviewed indicated that they did not know how many points that they had because they did not care about the points. The same number of students indicated that the system was not explained to them and that they learned the system from other youth in the facility. During the review this reviewer identified a youth who caused disruptions during the school day in one or more classes that, according to the Behavior Management Plan and the Student Handbook, should have resulted in point deductions. Then the point sheets of this youth were reviewed. In all of the cases, the youth did not receive the appropriate deductions. In addition, two videos of incidents showed that one student that ransacked the unit received no loss of points, while another student lost all of her points for having to be restrained. Neither was consistent with the student handbook or the written Behavior Management Plan. Teachers indicated that they were allowed to give and take away points for the times when youth were in school. However after being asked, two teachers reported that they only sign the sheets when they have to take points away, and do not award points for every student. Youth consistently indicated that they did not know much about incentives. This makes sense given the fact that they are not listed in the youth handbook. Students indicated that they do receive commissary, but that the commissary often does not have the things that they want. A review of the point sheets showed that one youth amassed 28,368 points during her time at the facility and during a three month period, spent none of them on any incentives. Youth reported that bedtimes are not administered per the BMP. This was supported by the logbooks that showed that youth were sent to showers and beds at the same time. Incident reports from the facility also indicated that youth were up well after the time when all youth in the facility should have been in their rooms. The facility did not create Guarded Care Plans for youth in the facility who were not able to be successful using the facilities BMP. Clinical staff were aware of individual youth needs and were addressing them, however staff did not have written guidance through individual plans to support the clinicians recommendations.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Retrain staff on how to administer the BMP to ensure appropriate implementation and record keeping. Update/correct the youth handbook to match the BMP. Ensure that staff are filling out the youths point sheets throughout the day. This would ensure that the points reflect the youths behaviors. Teachers should also award points for each of the students at each class period. Audit point sheets. Ensure the BMP is explained to all youth by their case manager. Provided a varied option of incentives to youth. The facility should interview the youth for suggestions on incentives that they would value. Ensure that GCPs are created for youth who cannot benefit from the BMP.
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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 Interviews with direct care staff Interviews with youth Observations of Structured Activities Review of the Master Schedule REFERENCES DJS Recreational Activities Policy RF-08-07; ACA 3-JDF-5E-01-02-03-04 SUMMARY OF FINDINGS A review of the master schedule indicated that programming was offered on Saturdays and Sundays. This programming was offered through Class Acts Arts. The detention youth received programming from 9am to 11am on Saturdays. Class Acts returns on Sundays from 9am to 11am. There was no other programming scheduled for detention during the week. Youth report that they enjoy the Class Acts programming. Youth report that they do activities such as poetry and drumming with Class Acts. Youth report, and observations and logbooks confirmed, that the youth spend much of their time during the week doing very little constructive activity. There was arts and crafts occurring one unit which youth seems to be enjoying and youth indicated staff regularly do provide this for them. Youth also reported that they receive mental health groups and Narcotics Anonymous groups that were not included in the master schedule. Youth, staff and logbooks confirm that the youth receive at least one hour of recreation everyday. Youth report that recreation has not been outdoors in recent months however this has been during winter months. The youth reported that they are offered religious services. However, there is no alternative activity for youth who do not want to participate. Youth reported that they will have to go to their rooms if they do not participate. During the first three days of the review the school was not in session because of professional development for education staff. This would have been an ideal time for the facility to provide additional programming for youth. While some youth on the detention unit were provided arts and crafts activities, youth on the honors unit simply watched television during what would have been the school hours.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Provide more programming during the week. The youth should have less leisure time so that they are engaged and might then get into fewer altercations. The master schedule should include the groups that are provided by the mental health staff. Consider additional recreation on the weekends to prevent idle time. Provide an alternative activity during the time when the religious programming occurs. Provide recreation outdoors whenever possible. Ensure when the calendar is published and school has professional development days that these days are planned for in advance and youth given a variety of programming options to keep them busy (chess tournaments, track and field days, rap and musical competitions, etc.)
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SELF ASSESSMENT
RATING: Not Rated
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: Not Rated
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: Not Rated
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.
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PSYCHOTROPIC MEDICATION MANAGEMENT
RATING: Not Rated
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: Not Rated
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: Not Rated
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: Not Rated
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 Suicide Watch Observation Forms for 5 youth Suicide logbook kept by mental health staff Incident Reports involving suicide ideations/gestures Guard Tour data Interviews with youth Interview with facility Psychologist Staff Training Histories report 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 Suicide Watch Observation forms were located in the medical files as required. Staff generally gave good detail in their documented behavioral observations of youth. Staff made checks vertically as required and staggered their times. Mental Health staff indicated they believed the facility was improving in suicide watch supervision. Staff checks on Suicide Watch Observation forms could be described as generally good with some occasional anomalies involving individual staff. Gaps in times were found in 3 of the 6 youths sheets however the gap was only on one day. Those gaps were 33 minutes, 2 hours and 16 hours. In one of the six youths cases, one youth had sheets with multiple patterns (e.g., all checks ending in 0, all checks in multiples of 9). In another of the six youth cases, there were two sheets for the same youth on the same day. Times on one were indicating the youth was talking with peers and in the dining hall. Times on the second indicated the youth was talking with a clinician and the clinician made the checks indicating she was assessing the youth. Since the youth could not have
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been in two places at one time, it appeared the first sheet was not an accurate accounting of where the youth was. Audits of suicide watch sheets are not accomplished. If they were in place, an auditor would have likely discovered the issues listed above. A review of an observation sheet on February 3rd at 2pm of a youth on Level III watch was up to date and the staff positioned properly within 5 feet of the youth. The Suicide Watch log kept by mental health conforms to policy in that it includes the date, level and name of the youth and conditions of supervision. Communication about youth on watch includes a note in the logbook, verbal notification to line staff from mental health, verbal notification to the Tour Office, a suicide log emailed out daily to all managers, and a paper copy of this log on each unit in a binder. Logbooks revealed staff did write in bold print when a youth was on watch. Binders were current with log information. Weekends were not always updated as mental health staff typically do not work regular weekend shifts. In a sample of all mandated staff, 24 of the 30 staff sampled (80%) were compliant with annual Suicide Prevention DJS-required training. In reviewing incident reports, both line staff and mental health staff responses were good. They took seriously the youths behaviors and acted without delay. All staff knew they could put a youth on Level III one-to-one watch. 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. Almost all staff indicated that there are enough staff to supervise youth on suicide watch. One concern was in overnight room checks. A review of the room check observation sheets revealed that they had pre-printed times and could not be relied upon to ensure overnight checks were occurring as required by policy. Since most suicides committed by juveniles in confinement occur while in rooms alone and when not on suicide watch, these sheets and the processes surrounding them should be improved.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: A trained and skilled Waxter staff should be assigned the duty of auditing Suicide Watch Observation sheets daily; issues found could be relayed immediately to the Administration for re-training or disciplinary action as warranted. To ensure youth safety at night, discontinue using pre-printed overnight room check sheets and require staff to write in the actual time they do each check. Require senior managers and the overnight SC to do random video review of staff to ensure checks occur as listed on their door sheets.
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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 73% of staff in written interviews indicated they carried a cut-down tool; 27% indicated it is kept in a box in the control panel but supervisors have one on their key ring. Every line staff and supervisor is required to have one on their person. Soaps, lotions and cleaners did not appear to be left out or accessible. The Pod Control Panels were locked. No sharp objects were observed and doors checked were locked. No incident reports showed cases of youth ingesting chemicals or soaps or using accessible sharp objects or tie off points to attempt to harm themselves. The rooms displayed no tie-off points except the very necessary faucets/toilets, as in many DJS facilities. No ceiling fixtures, desks, open metal beds or any other hook type point was observed.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that all direct care staff, including supervisors, carry a cut down tool while in detention.
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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 records staff Interview with Special Education Lead Teacher Review of 30 student folders (4 special education, 26 general 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 Only 18 of 30 (60%) students records were requested within 72 hours or 3 school days of admission. At the date of the review, eight of these files contained no records. There were only two records that contained secondary requests performed in accordance to COMAR 13A.08.07. Four records were from previous stays at the facility. All of the previous stays were within a month of the current admissions. Two of these files contained notes that indicated that the records clerk confirmed that there were no new records. But there was no information about how this was confirmed. The students were not being assessed. Some students with previous admissions had older assessments in their files, but none of the newly admitted students had assessments. The most recent assessment found in any of the files was dated June 8, 2010. Education staff reported that they receive a population report daily.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that records are requested according to COMAR 13A.08.07: EducationStudent in State Supervised Care-Transfer of Educational Records. The school administrator should periodically review the process to ensure that the timelines are met. The school needs to ensure that the students are given an educational assessment upon admission to the facility.
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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 Review of Detention and Honors Unit logbook Review of teachers attendance books Interview of two teaching staff members Interview of 9 students Interview of the Teacher Supervisor Observation of transitions to and from class Two classroom observations REFERENCES MSDE Guidelines DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS The school day was very sporadic for the youth on the detention unit on the day of the review. The detention students did not arrive to their 9:00 am first period class until 9:29 am. Of the 21 youth listed on the population sheet, only five came to the first period class. By the second period only seven of the youth were in class. The staff member assigned to the youth in school indicated to this reviewer that the other youth refused school. A review of teacher attendance books indicated that the day described above was not an isolated occurrence. There were students that refused school daily. In addition, there were numerous student absences which indicated that the youth were on unit restriction. It should be noted the prior to the review the students were receiving education on the units while the classrooms were being remodeled. The teaching staff reported and attendance books showed that even while they were on the units the students would still refuse school by leaving the areas or returning to their rooms. Direct care staff confirmed this and indicated in interviews that some youth often refuse school.
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The schools schedule indicated that the youth are to receive 5 hours of instruction per day. On the final day of the review, the school was to begin implementing a new schedule that was to increase the hours of instruction from 5 hours to 6 hours. However, the schedule was not implemented. School staff indicated that the schedule could not be implemented because the first period conflicted with the administering of medication. The facility administration indicated that that this was not the case, but gave no reason why the new schedule did not start. The teachers had curriculum materials for each subject in the classrooms. Classroom areas are well appointed and students had materials to complete their work. The classrooms had be recently remodeled adding whiteboards and Smartboards in some classrooms. During classroom observations objectives and agendas are on the board. A variety of instructional styles were displayed, including direct instruction, grouping of students of varied level and use of computers and calculators. One teacher showed a video for the classes. It should be noted that this is the third time that this reviewer has observed this teacher showing a video; there may be a need for more supervisory oversight to ensure teachers are using a variety of teaching methods. The school currently has no separate pre-GED/GED class. The students are still provided pre-GED instruction in the subject area classes. At the time of the review there was one student scheduled to sit for the GED exam.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: The facility has to ensure that you are attending school on a daily basis. Students should not be allowed to refuse school. Teachers cannot teach youth who are not present. There simply is not enough consistent school provided across the population to give a Satisfactory rating. Proceed with the new schedule to increase the daily hours of instruction to six.
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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 Review of a roster of teaching staff Review of teacher certifications Interview with the teacher supervisor Interviews with teaching staff and instructional assistances Review of the 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 school staff consists of: one teacher supervisor, one special education teacher, one health teacher, one math teacher, one English teacher, one Social Studies teacher, one Life Skills teacher and one instructional assistance II (IA) who serves as the records clerk. Only one teacher is not certified in the content area in which they teach. There is one vacancy for the Computer/GED instructor position. The English, Social Studies, Life Skills and Special Education teachers hold Advance Professional Certifications (APC) to teach in their assigned subject area. The math teacher does have a Standard Professional Certification (SPC), but not in that subject area. Health teacher holds a Provisional Teacher Certification. The facility provided the DJS Educational Services Unit Professional Development Calendar. The calendar outlined days, but did not indicate what type professional development was offered. The teacher supervisor reported that teachers had trainings with mental health professionals and child abuse trainings. When asked if there was content area information provided the teacher supervisor indicated there was none. Given the fact that the school has a teacher teaching out of her content area and a teacher on provisional certification, it is important that they get training on how to teach the class to which they are assigned. The special education teacher reported that she received one in-service on special education procedures in the last year. The school could not provide sign-in sheets from the professional development sessions. These were requested form DJS OPS; only three sign-in sheets (from July 2010 and February 2011) were provided and in each case not all teachers attended.
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Related services in the form of counseling are provided by DJS mental health providers. Speech language services are provided by a contractual provider.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Provide additional certifications for teachers in all of the content areas that they teach. DJS should provide content area professional development for teachers. Teachers need trainings on how to deliver the curriculum in the subjects that they teach. Ensure all teachers attend all required hours of professional development as scheduled. Continue to recruit for teacher vacancy.
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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 that have not been so identified in the past. SOURCES OF INFORMATION Review of special education roster Review of population report Interview of special education lead teacher Review of 2 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 Only 4 of 34 students (12%) of the students were identified as previously receiving special education services. Given the fact that there were eight (22%) files with no records, and that none of the students are being assessed to determine possible areas of need, this reviewer is not confident in that number. The schools special education teacher indicated that this is the lowest number of youth that she has had on her caseload since she has worked at the facility. Both school staff members interviewed understood the procedures for referring student for screening for special education services.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that records are requested according to COMAR 13A.08.07: EducationStudent in State Supervised Care-Transfer of Educational Records. The school administrator should periodically review the process to ensure that the timelines are met. The school needs to ensure that the students are given an educational assessment upon admission to the facility.
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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 teacher Review of 4 current special education files Review of 4 former special education files REFERENCES COMAR 13A.05.01.07: IEP Team. COMAR Transition SUMMARY OF FINDINGS Two of the four current students had meetings scheduled prior to the review. In both cases parents are given 10 days prior notice before an IEP meeting. Three of the four former students were given 10 days prior notice before the meeting. Documentation of parent contact, including telephone logs and copies of letters, was consistent in each file. The folders also contained emails documenting the invitation of community case managers and representatives from the Department of Rehabilitative Services (DORS). Home schools were invited to the meetings. All notices accurately indicated the purpose of the meetings and the meeting attendees. The notices offered the option for parents to participate via the telephone. The school has a trained parent surrogate. One of the four students who had been at the facility two times before did not have a meeting scheduled even though the facility was in possession of her IEP and knew received special education services.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Ensure the meetings are scheduled as soon as possible. Because of the dynamic nature of the population it is important that the facility holds meetings as soon as possible and for all youth.
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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 4 current special education files Review of 4 former special education files Interviews of teachers REFERENCES COMAR 13A.05.01.07: IEP Team COMAR 13A.05.01.08: IEP Team Responsibilities COMAR 13A.05.01.09: IEP Documentation Section 504 of the Rehabilitation Act of 1973 (Section 504), 29 U.S.C. 794 DJS Section 504 Guidelines SUMMARY OF FINDINGS Only one of the four current special education files contained IEPs developed at Waxter. The IEP team was consistently well constituted. The four IEPs of released students had teams that were properly constituted. IEPs indicated a continuum of services at the school ranging from full inclusion to a full-time special education classroom The school used the Maryland online IEP format for the current IEP and three of the four IEPs of released youth. Related Services documentation was current and up to date and appropriate in all but one of the files. This section is reviewing how currently identified special education youths services are provided. Since youth are not assessed timely not records received, there may be more youth who are in need of these services.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Ensure that related services documentation is consistent with IEPs. The teacher supervisor should review files to determine that services are provided as needed. Ensure youth records are requested and received timely and that youth are assessed timely in order to ensure disabilities are identified.
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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 offers students the SafeServe program. This program allows students to receive certification in food handling. Students receive the training during the Life Skills class.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Offer multiple options for CTE to the youth.
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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 Review of logbooks REFERENCES Maryland Standards for Juvenile Detention Facilities SUMMARY OF FINDINGS During the review units were not observed out of ratio at anytime during the school day. However, it should be noted that the majority of the students were not in school during the observations. Unlike other detention schools, there are no staff members assigned specifically to the school area. If an additional staff member is needed to assist in the school or is needed to provide relief or a break for staff members, that person has to come outside to the trailer classrooms from inside the facility.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Provide a staff member that is assigned to work with the school. This person would be able to provide coverage for staff, escort students who need to be moved and assist in crisis situations at the school.
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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 REFERENCES N/A SUMMARY OF FINDINGS There is a marked improvement in the physical environment in the school over previous reviews. All of the trailer classrooms were renovated. The walls were reinforced so that the adjacent classrooms cannot be heard through the walls. The doors were fixed and the old chalk boards were replaced with white boards. Some of the classrooms were updated with Smart boards to be used in conjunction with computers. Education staff members are mixed in how they report being supported by staff. Some teachers, who have good relationships with direct care staff report that they are supported well, while other teachers report that they do not receive the same support. This reviewer observed a staff member telling a student that she didnt have to listen to a teacher because she is crazy and then telling a youth not say anything to a teacher because she knows how he is. This undermines the teachers authority with the students. At the same time, some of the teachers did not display that they had the skills to manage the students behaviors. Those teachers were observed in verbal power struggles and other behaviors (such as threatening restrictions or point deductions) that had the resulting consequence of escalating the behaviors of the youth. This observer also reviewed a lack of consistency when dealing with some youth. One student refused to sit, walked around the classroom and repeatedly touched the hair of a direct care staff person who was assigned to supervise her. Aside from repeatedly telling the youth to stop playing the staff member did nothing to redirect the youths behavior.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area it is recommended that the facility: The education and direct care staff need to work together to agree on acceptable guidelines and expectations for addressing the behavior of youth in the classrooms. Education staff and direct care staff should be trained together on surface management techniques to be employed in the classroom. The direct care staff and the education staff should all also be trained in the proper use of the BMP.
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STUDENT TRANSITION
STANDARD Written documentation shows that the facility school creates progress reports and Maryland Student Transfer Reports (MSTR) 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 17 folders of released youth from September 2010 to January 2011. Interview with DJS Office of Pupil Services (OPS) staff REFERENCES COMAR Transition COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records SUMMARY OF FINDINGS Only 9 of the 17 (59%) student files contained MSTRs. OPS staff indicated that the school does not provided MSTRs for students upon the students release of the facility. She reported that forms are only received when they are requested by their office.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that a MSTR or a progress report is generated for each student released from the facility.
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MEDICAL CARE HEALTH CARE INQUIRY REGARDING INJURY RATING: Partial Performance
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: Facility Incident Reports (72) Nursing Report of Youth Injury (83) Youth Health Records (YHR) review Nurses Injury logbook Interviews with staff Interviews with youth 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 72 incident reports and 88 accompanying Nursing report of Youth Injuries forms from August 2010 January 2011 were reviewed. In all incident reports, staff stated the youth(s) were taken to medical for evaluation although body sheets were not attached to the incident reports in 6 incidents for a total of 11 missing body sheets. In one incident involving 6 youth, the incident report stated 2 were seen by medical, yet no body sheets were attached to the report nor any documentation to say why the others were not evaluated. In the medical injury log book, the names of the 6 youth were entered as having been evaluated. In 5 incidents youth were transported off-grounds for emergency care, all youth were evaluated by the RN either at the time of transport or the next duty day as evidenced by documentation in the progress notes. In addition, each youth had a body sheet completed and filed in the youth health record but not attached to the incident report. In the last incident, both youth involved in a youth on youth altercation were photographed, but only one had a body sheet attached to the report. One body sheet was found in the wrong IR file. Overall, when there were missing documents or incomplete areas in an incident report, those same incident reports were missing body sheets as well. Medical staff stated that this has been a consistent problem; copies of the body sheet are either given directly to the shift commander or placed in their mailbox only to be requested by another person at a later date because it was not attached to the incident report. It was recommended that body sheets be given directly to the shift commander
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or their designee and that a signature is obtained in the injury logbook to verify chain of custody. Youth were evaluated within 2 hours of incident on most occasions; however when youth were late to the nurse, no documentation was provided to explain the delay. Youth involved in incidents that occurred after clinic hours were evaluated the next duty day. During interviews direct care staff and youth acknowledged that medical evaluations were required when youth were involved in altercations. Body sheets were correctly completed for: youth statement, Injury Severity Rating (ISR), pain level, assessment and treatment, and signatures most of the time. Injury locations were not documented on the body silhouette as required by policy. On three body sheets reviewed, the RN documented inappropriate statements in the area intended for physical findings. Instead of describing the injury or stating no injury the RNs described the incident or the actions of the youth (i.e., youth pulled away from staff and was disrespectful, unnecessary force was used or physical abuse. Nurses were advised to include those comments only if they were directly stated by the youth and then should be documented as the youths statement. Also, if staff were witness to the incident their remarks should be included in a witness statement, not on the body sheet. ISRs were routinely documented and were consistent with injuries depicted in the photographs, assessment and interventions. Photographs were routinely taken for all youth with a completed Body Sheet and filed in the YHR; however, in several cases they were not included with copies of the body sheet in the incident report. Photographs were correctly labeled. All youth that required further care were referred off-grounds or placed on the appropriate clinic schedule. Follow-up was documented in the YHR. The Injury Report logbook had large gaps in which no entries were made. Until recently (Oct 2010) only 1 RN was appointed the task of entering data into the logbook, if she was unavailable entries were not made. More recently, the RN that completed the evaluation had that responsibility.
RECOMMENDATIONS In order to reach Satisfactory Performance status, the facility and its health unit should do the following: Ensure body sheet is completed for each youth involved in an incident. Attach body sheets with photographs of all participants to the Incident Report. Require Shift Commanders or designees to sign for body sheets/photographs received from the health clinic. Re-enforce appropriate documentation on all areas of the body sheet. Maintain an accurate Injury Logbook. Each RN completing a body sheet should make a correct and timely entry into the logbook. Conduct periodic quality review activities to ensure compliance with standards.
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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 Nursing logbooks Youth Health Records review (14) Interview with youth (12) Interview with staff (4) REFERENCES ACA 1-SJD-4C-18-19-20; NCCHC Y-E-04; COMAR 18-4A-03, 10.09.23; DJS Standard #33 Health Assessment SUMMARY OF FINDINGS 14 youth health records (YHR) were reviewed representing 41% of the detention population during this review. Thirteen (13) youth were admitted at this facility and one (1) of the fourteen was transferred from another DJS facility. Nursing assessments were accomplished for only 23% (3) of the 13 youth within 72 hours. (For the purpose of this review, either a completed 7 page assessment or a comprehensive progress noteif the youth was a transfer from another facility or if the youth refused, was accepted.) The average length of time from arrival to completed nursing assessment was 8 days, with the length of time ranging from 416 days. There was no documentation in the YHR to indicate why an assessment was not accomplished within 72 hours. The admission logbook was not maintained, with documentation beginning in October 2010. Five (5) of the youth during this review were not entered into the logbook and no entries had been made since Jan 27, 2011. Based on handwriting evidence, only 1 RN was making entries. Admission labs were obtained on all youth even if an assessment was not completed. Results were haphazardly entered into the logbook and only documented on the nursing assessment in two records with the exception of urine pregnancy tests which were documented on a specific form in all records. History & Physical (H&P) examinations were completed within 7 days on 62% (8) of the youth.The average length of time for the 5 youth that did not meet the standard was 8 days, with times ranging from 920 days. Although in some cases the youth had been scheduled for clinic, there was no documentation in the YHR to indicate why the appointment was not completed (i.e. court, youth movement issues, youth refusal, etc.)
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With the exception of the 3 completed nursing assessments, vital signs, height/weight, and vision screening were only documented on the H&P. In all but a few records was the documentation missing. Master Problem Lists were complete for acute and chronic conditions as well as Behavioral Health diagnosis. Resolutions and interventions were not documented. PPD placement or status was documented on the nursing assessment for 7 of the 13 youth. Results were not documented in the health records for 10 youth. The PPD logbook was not a reliable source to confirm results because of the inaccuracy in recording dates PPDs were read. There were substantial gaps in data. The Nursing Supervisor stated that it was the normal practice to document the dates PPDs were to be read on the Medication Administration Record (MAR) and that RNs would document the results on the MAR. 3 of 13 records contained immunization records. There was documentation in only 1 chart that indicated records were requested. Of those 3 records only 1 was reviewed by the physician and immunizations were ordered but not given for that youth. Referrals for dental, gynecology, and vision were not documented or tracked on the Referral Tracking form which resulted in delays in scheduling and lack of follow-up if an appointment was cancelled. Health Status Alerts (HSAs) were not consistently completed. For 4 youth with allergies and dietary restrictions 2 (50%) HSAs were completed and distributed. Of 10 youth identified with special needs (illnesses, activity restrictions, treatments) only 3 (30%) had a HSA related to their condition. Distribution of HSAs would ensure appropriate communication between direct care staff and medical personnel. 30 day reviews were not accomplished for any of 4 youth when required. Discharge summaries were not completed for 2 youth where indicated. The review of 6 occurrences of Seclusion lasting two hours or more revealed that in all cases youth were evaluated at least once by the RN; in all but 1 case within the first 30 minutes of seclusion. In the exception, the youth was not evaluated until 45 minutes after seclusion had been discontinued. The medical staff was not always informed when youth were placed in seclusion. RN staff did not consistently use or review the communication book to report between shifts, which resulted in omissions and delay completing nursing assessments, implementing treatment orders, administering medications, and obtaining labs.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the health care unit at the facility: Complete nursing assessments and physical examinations on all youth within acceptable timeframes. Document all exceptions according to DJS standards. Maintain accurate admission, lab, and PPD logbooks. Ensure all RNs are responsible for entering appropriate data. Track all internal clinic appointments as well as off-ground referrals. Utilize Referral Tracking form. Revise current clinic appointment process to ensure all youth are scheduled for clinics and system is in place to track cancellations or incomplete appointments. Improve immunization processes: document records requests, ensure records are reviewed and administer immunizations ordered or document when consent is denied. Complete and appropriately distribute Health Status Alerts on all youth as indicated. Implement and maintain effective communications system between shifts. Institute documented shift reports where possible and require RNs to sign/acknowledge that they read the communication logbook. Complete 30 day reviews and complete and distribute Discharge Summaries to ensure continuity of care upon release or transfer. Institute an active quality review process involving all RNs to ensure compliance with DJS and nursing practice standards.
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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 staff Interviews with youth Medication Administration Records (MAR) Youth Health Records review (14) Observation REFERENCES DJS Pharmaceutical Services policy (HC-02-07); ACA 1-SJD-4C-16-17 SUMMARY OF FINDINGS 14 health records and Medication Administration Records (MARs) including 6 of the 14 youth currently receiving psychotropic medications were reviewed. Medication orders were written appropriately to include start and stop dates; when transcribed to the MAR nurses failed to consistently document the stop date. MARs were not appropriately maintained: o Non-medication or non-treatment (i.e., double mattress, court dates) orders were routinely included on the MARs to the degree that medications to be given were obscured and commonly resulted in two MARs per youth. This could have been a contributing factor to the multitude of medications being missed. o There was no consistency in highlighting or indicating when medications were discontinued. o Missed medications were not correctly documented. Many doses and in some cases whole days of medications were missed with no documented explanations. In the few cases that were appropriately circled, no accompanying explanations were documented on the back of the MAR. PRN medications were noted on the MARs but effectiveness was not consistently noted. Refusals were not consistently documented on Treatment Refusal forms with youth signatures. Medication refusal forms used did not indicate that the youth was explained the consequences of refusing medication nor that they understood these consequences. Refusals to sign were not always witnessed. There was not documentation to indicate youth were referred to the clinician for further evaluation.
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Telephone orders were signed by the ordering clinician on the next clinic day. Consents for psychotropic medications were present for 5 of the 6 youth. At the time of admission, a telephone order was obtained for medications and the youth was scheduled twice for the psych clinic but was never seen prior to transfer. Photographs were with all but one MAR reviewed. A count of controlled medications was conducted by this reviewer and was correct; however, counts were not conducted daily by staff at shift change. Medications were correctly secured; there were many expired medications in the stock meds and one expired medication in the emergency kit. Overall medication storage was appropriate except that one stock cabinet mixed liquids and pills; staff was advised to place liquids on the bottom shelf. Controlled substances were appropriately secured. Medications were appropriately secured and accompanied all youth when transported to court or upon transfer. Unit staff stated they receive a list of youth receiving medications on a shift report. Units A and B move the entire unit after breakfast to the clinic which required youth not receiving meds to have to wait in the hallway, sometimes leading to disruption. There is nothing to keep the youth engaged during these waits. Medication administration was observed on 2 different days. 3 units (approximately 20 youth) received morning medications. Administration on one day took 2 hours and on the other day lasted over 2.5 hours. Length of time was determined by youth cooperation, timeliness of youth transport, and number of youth being treated for other medical complaints when getting medications. Youth receiving medications were seated in the hallway. Youth were called by name to the halfdoor; identified by name and birthday; medications and dosages were verified with youth and MAR; and visual verification of ingestion was done. Photographs were filed with MARs for all but one youth. During interviews, youth stated that not all RNs verified their identity with name or date of birth. RNs stated that they were familiar with youth and also used staff to identify youth during medication administration. Youth confirmed that RNs checked for cheeking of medications. However, an incident report completed in December 2010 indicated a youth was given a prescription medication by another youth and required off-grounds emergency care.
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RECOMMENDATIONS In order to reach Satisfactory Performance status, the facility and its health unit should do the following: Appropriately maintain Medication Administration Records (MAR) to include stop dates for medications; highlight discontinued medications to prevent errors in administration; consider separating non-medication related orders at the bottom of the MAR or on an additional page to prevent obscuring medication orders. Determine why medications are frequently missed or not documented on the MAR if given. Conduct periodic quality reviews to enforce compliance with nursing standards. Re-enforce appropriate documentation of missed medications. Adhere to appropriate procedures for obtaining and documenting youth refusals; refer youth to prescribing clinician for evaluation. Obtain consents for all youth receiving psychotropic medications. Adhere to standards for medication storage, security and inventory. Conduct periodic inventories to remove expired stock medications. Conduct daily counts of CDS per DJS standards. Reduce time required to complete medication administration to increase staff productivity: o Improve youth movements to medical during time of medication administration. Consider transporting only youth to receive medications so as to prevent other youth from being in the hallway unnecessarily. Move small groups of youth to medical at one time to receive medications or if not feasible, arrange for activities (i.e. install television, handheld games, etc.) to occupy the youth while they wait in the hallway.
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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 Nursing logs (Appointment Log and Clinic Lists) Youth Health Records review (13) REFERENCES ACA 1-SJD-4C-22; DJS Health Care Services Standard 35, Oral Screening and Oral Health Care SUMMARY OF FINDINGS Dental services are not available within the facility. Dental history was assessed by the RN during the admission assessment and screening was completed during the physical examination by the physician. Youth requiring dental services were referred to an off-grounds provider Several youth were seen in sick call for tooth pain or gum soreness. They were treated according to Nursing Protocols for pain and then referred for dental care. Although Dental referrals were ordered and documented on the dental clinic log, they were not documented in the YHR on either the Referral Tracking form or in the progress notes. Therefore it was difficult to know if appointments were completed at the time of youth release. Dental problems were not consistently added to the Master Problem List. There was no indication that Dental treatment, accomplished during detention or pending at time of release, was communicated to the youths parent/guardian. Oral hygiene education was not being done.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Document the status of dental appointments (i.e., cancellation, completion, follow-up) to ensure pending care is forwarded to parent/guardian or placement facility. Incorporate oral hygiene education in programming since not all youth are seen by dental services. Include dental treatments in 30 day reviews and discharge summaries.
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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 Observation Youth Health Records review (13) REFERENCES ACA 1-SJD-4C-18-19-20; DJS Health Care Services Standard 58, Health Record Format and Contents; DJS Health Care Services Standard 61, Availability and Use of Health Records. SUMMARY OF FINDINGS Active youth health records were stored in a file cabinet in the front office of the medical clinic accessible to all staff. Inactive files were stored haphazardly in multiple locations within the clinic, storage room and storage shed making it difficult to locate records when needed. For youth with previous detentions, medical records were requested, received and reviewed & placed in the youth health records. Staff did obtain medical records from primary care providers for youth with chronic illnesses or identified health concerns. Summaries of care, diagnostic, and laboratory results for youth referred off-grounds were obtained and appropriately filed. Labs/diagnostic results were appropriately filed with documented evidence of physician review. Individual records overall were organized but several had loose papers inside. The Nursing Supervisor stated that this was a common practice; to collect pages within the folder to reduce manipulation of the clasps to prevent breakage; she stated that they have been recycling folders because they could not get any new 6-part folders. It is unclear whether a request had been made for folders or not, or whether that request was denied or not. One medical record had forms belonging to another youth placed in the lab section. All handwritten and typed forms contained youth name and date of birth.
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RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Organize inactive files: purge outdated records and establish an effective filing system. Obtain new 6-part folders to appropriately secure all forms in records.
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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. SOURCES OF INFORMATION Interviews with medical staff Interview with staff Nursing logs Youth Health Records review (10) REFERENCES DJS Health Care ProcedureSpecial Needs Treatment Plans (2007); DJS Standard #50, Infirmary Care; SUMMARY OF FINDINGS A log of youth with special needs was maintained by the Nursing Supervisor. The records of 10 youth with special needs were reviewed. All special needs were identified during initial nursing assessment or physical examination. All medical conditions were documented on the Master Problem List although interventions and resolution were not included. Follow-up care was routinely documented in the progress notes and referral appointments were indicated on the Referral Tracking form; dates of completion were missing. Summaries of Care for referrals were filed in the health records. Health Status Alerts (HSAs) were only accomplished for 3 of the 10 youth. During interviews direct care staff acknowledged that the RNs were to distribute HSAs, but stated they were more likely to know if a youth had a special need if the youth told them. HSAs were found in folders on both units but they were not up to date. Special Needs treatment plans were not utilized. 30-day reviews were not accomplished for any of the five youth requiring one nor were discharge summaries for the two youth released. Six records of youth with Asthma were reviewed. All youth had completed Asthma Assessment Tools which were reviewed by the clinician and action plans initiated as indicated. All youth had Peak Flow measurements with some monitored daily or weekly. All youth had PRN inhalers ordered and stocked. Overall asthma management was satisfactory with the exception of PRN administration of inhalers. Interventions were documented in the progress notes but RNs did not document pre- or post- treatment peak flows. Each time a youth required PRN treatments they were placed on the next clinic list for evaluation.
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Management of youth with other special needs was documented appropriately, i.e. blood glucose monitoring, special activity restrictions and isolation precautions, dietary requirements, treatments, and follow-up.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Appropriately complete and distribute Health Status Alerts for all youth when indicated. Obtain and documents peak flow status pre- and post- PRN inhaler use. Appropriately utilize referral tracking form to document appointment scheduled and completed. Complete 30 day reviews on all youth to include treatment administered during detention. Complete and distribute Discharge Summaries to ensure continuity of care upon release or transfer. Implement active quality review program to ensure compliance with standards.
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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 Interview with staff Interviews with youth Nursing logs Youth Health Records (YHR) review Observation REFERENCES ACA 1-SJD-4C-01; ACA 1-SJD-4C-05. ACA 3-JDF-4C-28 SUMMARY OF FINDINGS The hours of operation for medical are 7:00 am 9:30 pm on weekdays and 8:00 am to 8:30 pm on weekends. Generally 2 RNs staff each morning and evening shift with one RN providing coverage on the weekend shift. The Nursing Supervisor is available 24/7 by telephone. A pediatrician and nurse practitioner provide somatic health care 2 days per week; psychiatric clinic is provided 2 days a week; and gynecology clinic is held at least 1 day per week and as needed. All somatic health services have practitioners who provide 24 hour coverage by phone. Contact information is available in the health clinic. Direct Care Staff indicated knowledge of the process to contact medical staff and access services in the event of an emergency or if care was needed after clinic hours. Pharmacy services were available daily with requests faxed in the a.m. and delivery accomplished in the p.m. Mobile radiology services were available as needed. Youth were referred off-grounds for dental, vision, and specialty services; the offgrounds log was not accurately maintained. The emergency kit is located beneath the front desk; documentation indicated it was being checked but it contained expired medication. First Aid kits were available on each unit although they were not checked monthly as required. Staff stated medical did replace supplies as needed. AED was located in the Tour Office with weekly checks found for Jul 10 Jan 11 only. Direct care staff correctly indicated the equipments location.
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An oxygen tank was located in the exam room but it was not being checked weekly. Most concerning is that sick call is not conducted in accordance with DJS standards. While each unit had sick call slips and a collection box was present in the cafeteria, youth, medical staff, and direct care staff stated that the slips were not collected daily from the boxes. Youth stated that they gave the slips to the RA who in turn would deliver them to the clinic when convenient. All of this resulted in no sick call being conducted for days; youth submitting multiple requests for the same complaint; increased youth frustration with clinic staff; and violation of youth privacy and confidentiality when seeking medical care. A sick call log was not consistently maintained. The health clinic received numerous phone calls throughout the day for youth requesting to be seen, or youth were brought to the clinic during medication administration times in response to unanswered sick calls. If unable to be seen they often became disruptive, staff frustration increased, and youth would have to be transported back to the clinic which impacted staff on the units or pulled youth out of other activities. Refrigerator checks were conducted with a few missing dates. Food, medication, vaccines, and lab specimens were stored in the same refrigerator which is not acceptable. Syringes and sharps were secured but inventory counts were not consistently accomplished. Youth were witnessed being left alone in the treatment room which provided access to supplies. In an incident report filed in September 2010 a youth removed a vial of blood from the clinic unbeknownst to the staff on duty. (The RN had obtained blood samples on multiple youth and placed the tubes of blood on the front desk.) While providing care to the youth she turned her back and the youth took the blood. Direct care staff accompanying youth to the clinic did not always maintain visual contact with the youth. Often, they sat in the hallway; if they had a group of youth, their attention was divided which allowed the youth sitting in the clinic to move freely.
RECOMMENDATIONS In order to reach Satisfactory Performance status, the facility and its health unit should do the following: Conduct and document appropriate checks of emergency equipment. Adhere to standards for access to medical care: conduct sick call daily as required. Correctly store refrigerated items in separate units. Conduct and document inventories of sharps and syringes in accordance to standards. Ensure youth are carefully supervised by the nurse or a Direct Care Staff when in the treatment area.
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Comprehensive Quality Review Report Thomas J.S. Waxter Center (MD 2011)

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Comprehensive Quality Review Report Thomas J.S. Waxter Center (MD 2011)

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OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report

Thomas J.S. Waxter Center March 4, 2011

TABLE OF CONTENTS (Continued)

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

QUALITY IMPROVEMENT REVIEW RATINGS SCALE

Rating Superior Performance Satisfactory Performance Partial Performance Non Performance

DJS QI Report Waxter March 2011

WAXTER PERFORMANCE COMPARISON

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY INCIDENT REPORTING RATING: Partial Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

SENIOR MANAGEMENT REVIEW

RATING: Non Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

DE-ESCALATION & RESTRAINT

RATING: Partial Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

CONTRABAND & ROOM SEARCHES

RATING: Partial Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

RATING: Satisfactory Performance

Month August September October November December January

* Only includes Waxters detained population

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

ROOM CHECKS DURING SLEEP PERIOD

RATING: Partial Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

RATING: Partial Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

RATING: Partial Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS

RATING: Partial Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

YOUTH MOVEMENT & COUNTS

RATING: Satisfactory Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

RATING: Satisfactory Performance

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

DJS QI Report Waxter March 2011

RATING: Non Performance

DJS QI Report Waxter March 2011

RATING: Partial Performance

DJS QI Report Waxter March 2011

ADMISSIONS, INTAKE & STUDENT HANDBOOK

RATING: Satisfactory Performance