Comprehensive Quality Review Report J.deweese Carter Center (MD 2010)

OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report
J. DeWeese Carter Center July 9, 2010
OFFICE OF QUALITY IMPROVEMENT Quality Review Report J. DeWeese Carter Center Evaluation Dates: June 22-23, 2010
TABLE OF CONTENTS EXECUTIVE SUMMARY .............................................................................................. 1 QI Rating Scale ............................................................................................................... 1 QI Rating Percentage ...................................................................................................... 2 Executive Summary of Results....................................................................................... 4 Methodology ................................................................................................................... 5 SUMMARY OF FINDINGS & RECOMMENDATIONS............................................ 7 SAFETY AND SECURITY ............................................................................................. 7 Incident Reporting .......................................................................................................... 7 Senior Management Review ......................................................................................... 10 De-Escalation & Restraint ............................................................................................ 12 Contraband & Room Searches...................................................................................... 14 Seclusion ....................................................................................................................... 16 Room Checks During Sleep Period .............................................................................. 18 Perimeter Checks .......................................................................................................... 20 Staffing.......................................................................................................................... 22 Control of Keys, Tools & Environmental Weapons..................................................... 24 Youth Movement & Counts.......................................................................................... 27 Fire Safety..................................................................................................................... 29 Post Orders.................................................................................................................... 31 Staff Training ................................................................................................................ 33 Admissions, Intake & Student Handbook..................................................................... 35 Classification................................................................................................................. 37 Pending Placement........................................................................................................ 38 Behavior Management .................................................................................................. 39 Structured Rehabilitative Programming ....................................................................... 41 Self Assessment ............................................................................................................ 43 BEHAVIORAL HEALTH ............................................................................................. 44 Intake, Screening & Assessment................................................................................... 44 Informed Consent.......................................................................................................... 45 Psychotropic Medication Management......................................................................... 46 Behavioral Health Services & Treatment Delivery ...................................................... 47 Treatment Planning....................................................................................................... 48 Transition Planning....................................................................................................... 49 DJS QI Report J. DeWeese Carter Center July 2010 Page i of 80
TABLE OF CONTENTS (Continued) SUICIDE PREVENTION .............................................................................................. 50 Documentation of Youth on Suicide Watch ................................................................. 50 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.................................................................. 63 Individualized Education Programs.............................................................................. 64 Career Technology & Exploration Programs ............................................................... 66 Student Supervision ...................................................................................................... 67 School Environment & Climate.................................................................................... 68 Student Transition......................................................................................................... 69 MEDICAL CARE........................................................................................................... 70 Health Care Inquiry Regarding Injury .......................................................................... 70 Health Assessment ........................................................................................................ 72 Medication Administration ........................................................................................... 75 Dental Care ................................................................................................................... 76 Medical Records Retrieval............................................................................................ 77 Special Needs Youth..................................................................................................... 78 Availability of Medical Services .................................................................................. 79
DJS QI Report J. DeWeese Carter Center July 2010
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EXECUTIVE SUMMARY A quality improvement assessment and evaluation of the 15 bed J. DeWeese Carter Center was conducted June 22-23, 2010 by DJS personnel who are subject-matter experts in the areas reviewed. The areas that were evaluated have been identified as those having the most impact on the overall safety and security of youth and staff. The evaluation was based on information gathered from multiple data sources such as staff interviews, youth interviews, document review and observations of facility operations, activities and conditions.
The following Rating Scale was used:

Quality Improvement Rating Scale
Superior Performance
Strong evidence that all areas of practice consistently exceed the standard across the facility/programs; innovative facility-wide approach is incorporated sufficiently so that it has become routine, accepted practice. Performance measure is consistently met across the facility/program; any gaps are temporary and/or isolated and minor; documentation is organized and readily available. Expected level of performance is observed but not facility-wide or on a consistent basis; implementation is approaching routine levels but frequently gaps remain; facility had difficulty producing documentation in some areas. Little or no evidence of adequate implementation of performance measure; the required activity or standard is not performed at all or there are frequent and significant exceptions to adequate practice; documentation could not be produced to substantiate practice.
Satisfactory Performance
Partial Performance
Non Performance
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J. DeWeese Carter Center July 2010
At the last QI Review of Carter in October 2008, 44 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 7 21 13 3
% of total in rating 16 % 48 % 29 % 7%
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 2 23 10 1
% of total in rating 6% 63 % 28 % 3%
NOTE: The DJS Quality Improvement Performance Ratings are aligned with best practices and optimal standards of care. Therefore, while the facility practice may be in full compliance with minimum constitutional standards, the facility may still receive partial or non performance ratings as a result of QI reviews.
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QUALITY IMPROVEMENT UNIT J. DEWEESE CARTER CENTER JULY 9, 2010
70% 60% 50% Percentage 40% 30% 20% 10% 0% 1/14/2008 Date of Report Superior Performance Satisfactory Performance Partial Performance Non Performance 7/9/2010
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OFFICE OF QUALITY IMPROVEMENT J. DeWeese Carter Center Executive Summary of Results

Superior Performance
Student Supervision School Environment & Climate
Satisfactory Performance
Incident Report Seclusion Room Checks During Sleep Period Perimeter Checks Staffing Youth Movement & Counts Fire Safety Staff Training Admissions, Intake & Student Handbook Behavior Management Environmental Hazards Curriculum & Instruction School Staffing & Professional Development Screening & Identification Parent, Guardian & Surrogate Involvement Individualized Education Programs Student Transition Health Care Inquiry Regarding Injury Medication Administration Dental Care Medical Records Retrieval Availability of Medical Services
Partial Performance
Senior Management Review De-Escalation & Restraint Contraband & Room Searches Control of Keys, Tools & Environmental Weapons Post Orders Classification Structured Rehabilitative Programming Documentation of Youth on Suicide Watch School Entry Career Technology & Exploration Programs Health Assessment
Non Performance
Special Needs Youth
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OFFICE OF QUALITY IMPROVEMENT J. DeWeese Carter 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, mental health care and education that would be reviewed by the QI Team, Entrance Interview with Superintendent A formal entrance interview was not conducted with the Superintendent on the first day of the review, but discussions and interviews were conducted throughout the review. Members of the QI Team asked and discussed with the Superintendent and Assistant Superintendent targeted questions related to safety and security, behavioral health, behavior management, education, medical and many other areas of facility operation. Primary Interviews A total of 9 youth were interviewed individually and all 15 in groups (for a total of 15 youth) about a range of areas across the QI review spectrum. This represented 100% of the total population at Carter that week. Interviews were also conducted with facility direct care, administration, medical, case management and education staff. In addition, 7 staff were interviewed specifically about the target areas of the review as well as their general feelings about the operation of the facility. Document Review Documents were reviewed that were requested by the QI Team and provided by the facility staff in support of facility operations and program services. The documents included medical records, incident reports, logbooks, program schedules, seclusion and suicide watch documentation, staffing reports, training records and statistical data, as well as other documents from areas in fire safety and youth supervision.
II.
III.
IV.
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OFFICE OF QUALITY IMPROVEMENT J. DeWeese Carter Center METHODOLOGY (Continued)
V.
Observations of Facility Operations Youth movement Structured programming Recreation Unit activities Leisure Time Classroom Activities Review of Quality Improvement Report The facilitys previous QI Report was also reviewed to determine what areas needing improvement at the last review were improved or were still in need of attention. Exit Conference An exit conference was not conducted at the facility. Discussions about some portions of the QI findings were conducted on the last day of the review.
VI.
VII.
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SUMMARY OF FINDINGS & RECOMMENDATIONS
SAFETY AND SECURITY
INCIDENT REPORTING
RATING: Satisfactory 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 37 Facility Incident Reports Jan-June 2010 Interview with IR Specialist Youth grievances June 2009-June 2010 Staff Training Histories Report OIG investigations Interviews with youth Interviews with staff REFERENCES DJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management (CPM) Techniques Policy (RF-02-07); DJS Video Taping of Incidents Policy (RF-0507); DJS Youth Grievance Policy (MGMT-01-07) SUMMARY OF FINDINGS Incident Report (IR) files did contain both written and electronic copies. On occasion the electronic IR was not a word-for-word copy of the written IR. They should be identical. IRs are generally filled in entirely with few blank areas. White-out was found on some IRs. White-out should not be in use in the facility at all. Narrative portion includes all four parts and all four are completed. There was one instance found where a youth alleged abuse at the hands of transporting police. An IR was generated but and his case was not referred to Child Protective Services (CPS) as required. An MSDE school staff was also alleged to have engaged in inappropriate touching. An IR was not electronically entered and that case as well was not reported to CPS as required. In the case of the youth who alleged abuse against transporting police, the incident was only labeled On-Grounds Medical. It should have been classified as an Alleged Child Abuse Not in DJS Custody.
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DJS QI Report
Descriptions of uses of force (when applicable) are not detailed. Most staff tend to write that they put a youth in a restraint but give no description about how or if the youth complied. Descriptions of the events are good but lack all relevant details. Staff should be encouraged to write IRs as if they are telling a story, leaving out no detail and giving a blow-by-blow account of the event from start to finish. Without details, it is difficult to critique staff performance. All of the IRs contained shift commander comments. The quality of those comments is indicated in the next section entitled Senior Management Review. Notifications sections are complete. Detail on who was present and exactly where they were posted needs some improvement. One staff wrote in an IR that a staff was posted by a table but in her witness statement, she indicated she was in the kitchen getting snacks. Her absence may have contributed to the youth fighting when they did, but no one caught the discrepancy in either the shift commander comments or audit as a possible contributing factor. The number of all youth present was often missing from the IRs. QI believes this is likely due to the low population of youth (15) and essentially the one unit concept that small population presents. For clarity, staff should still indicate the number of youth present during the incident as sometimes, a youth may be in the bathroom, at visitation, with a case manager or otherwise not present. Most of the IRs reviewed had all youth and staff witness statements present. In 100% of cases, youth in incidents or restraints saw a nurse as required and had a body sheet present in the file. Photos were attached when required. After a review of the Nurses Injury Log, two sports-related injuries were found that did not have corresponding IRs. In every case, a youth with a sports injury must have a corresponding incident report completed.
GRIEVANCES There were 19 youth grievances in the past 12 months at Carter. The top complaints were as follows, in order: 1) staff, 2) missed recreation time and 3) temperature (air) and points. The Youth Advocate seems to pick up grievances timely (the average time was 2.5 days) and nearly every youth all said they knew where to find and file grievance forms. On a walk through, there were stocked grievance forms accessible to youth and youth indicated they knew how to find and use them. Only one issue presented: when a youth chooses to discontinue a grievance after commencing one, DJS Advocates are to continue to follow up in order to ensure problems are resolved and youth are not being intimidated. One grievance of the nineteen seemed to allow a youth to drop the issue he originally brought up. All in all however, the grievances were handled timely and well by the Youth Advocate and youth indicated that if they had any problem, they would use the grievance process.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Encourage staff to use as much paper as necessary when writing IRs and to leave out no detail. Descriptions in narratives and of uses of force are an area that may need refresher training by a qualified person. Require shift commanders to critique staff when they fill out the shift commander comments. Ensure they are sharing these coaching tips with their staff. Ensure the staff and Administration are aware that any and all youth allegations of any kind should be reported to CPS and entered into DJS electronic IR database immediately. Incident type should be listed as Alleged Child Abuse in these cases.
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SENIOR MANAGEMENT REVIEW
RATING: Partial 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 37 Facility Incident Reports Jan-June 2010 Interviews with staff Video reviews Review of OIG Investigations Review of seclusion documentation Review of suicide watch documentation REFERENCES DJS Policy MGMT-03-07 Incident Reporting Policy (MGMT-3-01); ACA 3-JDF-3B-10 and 3-JTS-3B-11 SUMMARY OF FINDINGS All of the IRs contained shift commander comments. Almost none of the shift commander comments were critiques (as is required); the most common areas missed were supervision issues, missing witness statements, and poor restraint detail; overall, the comments praised staff performance but did not help give staff any coaching on how to improve. Policy requires senior administrative review of all incident reports within 72 hours. There were audits of all IRs reviewed. There were no dates on the audits performed at Carter so verification of compliance to policy could not be assessed. This was the same problem found in the last review. The audits themselves were fair but still missed various areas. Examples included: an IR with only one of two body sheets, lack of restraint detail, lack of rapid response to verbal argument by youth before fight began, how a youth broke out of a restraint, lack of knowledge of an injured youth being admitted against DJS policy, etc. There is evidence of employee memos/corrective actions/discipline to show administrative follow up when problems are found relating to an incident. Staff and the Assistant Superintendent indicated incidents were reviewed on video afterwards but there is no documentation to verify compliance. Only a select staff knows how to use the video system so more training is recommended. Seclusion sheet auditing: no seclusions since November 2009. The last sheets reviewed from mid-2009 showed no evidence of auditing.
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Suicide watch documentation auditing: no evidence of auditing. All sheets were present but some patterns were discovered that had not been caught previously by the facility. There is administrative support in the form of a Management Associate. Her utility in this position allows the GLM Is and Assistant Superintendent to concentrate on their own workload. The Office of the Inspector General (OIG) completed three investigations in the year, none of which related to child abuse allegations. However one investigation did indicate that an MSDE counselor was accused by some youth of inappropriate touching. This incident was reported very late by the facility and CPS was also not originally called as required. Though OIGs follow up was good and ensured all reporting was done as required, the facilitys lack of reporting and call to CPS was a second example of a youth alleging abuse without proper follow up by the facility.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure senior management staff at Carter are skilled in auditing IRs, suicide watch and seclusion sheets and that timely systems are in place to do so. Prevention of a like incident is a goal that can only be accomplished with staff coaching and regular and timely oversight. Further training on IR audits from QI or the Director of Detention are available upon request. Ensure auditing occurs within 72 hours as required by policy. Add a Date of Audit line to the audit form. Add a Video Reviewed-Yes or No line to the audit form as well. Ensure IT trains all GLM Is and the Assistant Superintendent on how to run the video system so that there is always someone on duty to do so when needed. Practice using it weekly. Require all shift commanders to critique staff and to share their comments with staff so that staff can learn from the management review. Ensure this is done the day of the event so that memories are fresh and staff are encouraged to use this information to prevent another such occurrence. Ensure shift commanders understand the mechanics of a critique and know what supervision points to catch when they review an incident. Ensure the staff and Administration are aware that any and all youth allegations of any kind should be reported to CPS and entered into DJS electronic IR database immediately. Err on the side of reporting and allow CPS to perform their role.
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DE-ESCALATION & RESTRAINT
STANDARD Written policy, procedure and practice document the use of verbal crisis intervention techniques to de-escalate a situation prior to the use of physical restraints. Physical restraints are used only when necessary and the least restrictive physical restraint is used first. Incidents involving physical restraints are video taped. SOURCES OF INFORMATION 37 Facility Incident Reports Jan-June 2010 Facility training records on CPM and Verbal De-escalation Interview with Assistant Superintendent Review of videos 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 are not detailed in IRs by all staff. Staff simply write that they placed or put a youth in a restraint, but not how or if he complied. On occasion, incident reports that described a fight indicated there was no restraint used; due to the lack of detail, it was impossible to tell how staff broke the youth up without having to use any force at all. There were some videos to review but these ran slowly and were only able to run through without pausing or rewinding; assessment of physical restraint use was not possible upon review due to this and technical difficulties logging onto the system. No other videos were available to review. 9 of 19 (47%) staff were compliant with Crisis Prevention and Management (CPM) semi-annual training, while 19 of 19 (100%) had CPM training at least once in the last year. All staff are on target to reach the 100% semi-annual goal for 2010. Mechanical restraints are taught in CPM refresher training. The CPM debriefing form has been modified from the form that is attached to the DJS CPM policy. Only the form attached to the policy should be in use.
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RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Re-train and follow up with staff on descriptions of restraints in IRs. Staff should give detailed accounts, including which hand(s) they used, if the youth moved, ran, struggled or complied, and if the staff stood or walked with the youth, etc. Ensure when staff are able to use other means besides force to break up fights, that they describe those interventions in detail. Ensure staff are trained twice yearly in CPM. Discard the modified CPM de-briefing form and use the one attached to the DJS CPM policy. Review videotape of incidents, restraints and youth behavior and ensure all supervisory staff know how to use the video system. Keep and use these videos as training aids for staff and as proof of compliance with proper CPM technique.
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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 Logbooks Facility Room and Common Area Searches FOP Room Inspection Sheets Interview with AFA and 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 Facility Room and Common Area Searches FOP (#009-004) dated 01/22/09, which addresses the frequency of searching youth rooms and common areas. The FOP cites that youth rooms and common areas are to be inspected daily for contraband and each search documented on the appropriate form (i.e. Room Inspection sheet or Common Areas Inspection Sheet) and in the unit logbook. The 1st and 2nd shifts are to alternate the searching/inspecting of rooms for contraband. The facility also maintains a FOP entitled Daily Duties (6a 2p shift) dated 07/15/08, which indicates that the morning staff are to ensure all rooms are clean and contraband removed. Both FOPs indicate they are to be reviewed annually. Based on interviews with eight staff, room searches are usually conducted one to four times a week. The facility did not provide a sufficient number of Room Inspection Sheets to verify that room searches are conducted daily pursuant to their FOP. The reviewed sheets averaged about one room search a week, which would be pursuant to DJS policy. Both DJS policy and the FOP require that staff document room searches in the unit logbook. However, a review of 4 randomly selected weeks from the unit logbook(s) did not reveal any entries pertaining to room searches. This information was provided to the Assistant Facility Administrator for any follow up action deemed appropriate. Two recovered contraband incident reports (room searches) were crossedreference with the Room Inspection Sheets for the same date. Only one recovered contraband incident was listed on a Room Inspection sheet and logged in the unit logbook. The FOP and written DJS policy indicate that common areas (i.e. general areas) are to be searched daily for contraband and the search documented on the
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DJS QI Report
Common Areas Inspection Sheet and in the unit logbook. The facility did not provide any Common Area Inspection Sheets for review. A review of 4 randomly selected weeks from the unit logbook(s) did not reveal any entries pertaining to common area searches. This information was provided to the Assistant Facility Administrator for any follow up action deemed appropriate. Note: The staff responsible for maintaining the Room and Common Areas Inspection Sheets was not available for follow up regarding the inspection sheets. The facilitys room searches have resulted in the recovery of various contraband items (i.e. cell phone, medication, suspected marijuana, drawing of a floor plan of the facility, trash, pencils, extra clothing/bedding, etc.) Routine frisk searches have resulted in the recovery of contraband as well (i.e. medication) concealed in a youths sock. On several occasions, members of the QI team observed staff frisking youth for contraband upon movement (i.e. to/from school and from the dayroom to their rooms.) Five incident reports were on file for contraband for the period of October 1, 2009 to June 21, 2010. The facility maintains a large selection of DVD movies and books. A review of randomly selected DVDs and books revealed that the contents were appropriate for the ages of the youth assigned to the facility. Interview with staff revealed that the facility does not maintain or allow movies to be shown with a rating beyond PG-13.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area, it is recommended that the facility: Review FOPs to ensure current written procedures and practice coincide. Maintain continuity between FOPs and Department policy by ensuring FOP terms (i.e. Common areas) reflect departmental terms/vocabulary (i.e. General areas.) Ensure all searches/inspections are documented on the appropriate forms and in logbooks. The facility in part received a partial performance rating for this area due to not being able to provide additional documentation regarding the room and general area searches.
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SECLUSION
STANDARD Written policy, practice and procedure provide that youth confined to a locked room, not during sleeping hours, shall be observed often and have those observations documented, shall only be placed in seclusion if they present an imminent threat to others, a substantial destruction to property or an imminent threat of escape, and shall be treated humanely and with concern and care so as to safely maintain the youth until he can be released in the least amount of time. SOURCES OF INFORMATION Facility Seclusion Log Interviews with Assistant Superintendent Incident Reports from Jan-June 2010 Seclusion sheets Interviews with youth Interviews with staff Observation at facility REFERENCES DJS Seclusion Policy RF-01-07; COMAR 16.18.02 SUMMARY OF FINDINGS There have been no documented seclusions between since one in November 2009; before that the most recent one was in July 2009. The seclusions that were documented were relatively short, with two youth in for about hour and five youth involved in a group disturbance in for about 10-12 hours. The staff and Administration consistently indicated that they work to talk to a youth and calm him before resorting to seclusion. Seclusion use has to have Superintendent authorization and it is rarely authorized. Seven youth seclusion episodes from 2009 were reviewed. The two half hour episodes had no areas of concern. The other five youth in the group disturbance had the same kinds of issues on all five sheets. The shift commander missed visits for about five hours. Sheets would end at 2:25 then start up on the next page at 2:00pm, and the shift commander would write a youth was agitated, withdrawn when the RA checking the youth indicated hed been asleep for hours. The shift commander comments (reasons for youth not being released from seclusion) were good and indicated why the youth was a threat and not able to be released; but for the reasons noted above, these may not be entirely accurate. Since there appeared to be no auditing of these sheets, these errors were not highlighted or followed up on with staff. Because seclusion use is so rare at Carter, staff are likely out of practice with some basic components.
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All but one staff in interviews indicated that when a youth is locked inside his room and it is not bedtime yet, that is always seclusion. This is an ideal answer, as DJS wants staff to take seriously seclusion and its use. Carter does not often have issues with a staff shortage that would require youth to stay in their rooms a few minutes or hours later in the morning. However they were reminded that should this occur that should log that there are lock-ins for a lack of staff and watch youth per the DJS Seclusion policy until staff come in. The use of early bed violates DJS seclusion policy. Carter staff interviewed noted that group punishment was not a part of behavior management at the facility and that early bed was not used as punishment. Some staff indicated that 8:15pm was a bedtime that was sometimes used as a sanction for youth. Though this comports with the Level I bedtime and is not technically early bed, it should be included in the written BMP if it is used.
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 if a seclusion episode occurs. Ensure staff are reminded at least monthly about seclusion basic processes so that they are prepared when one occurs to supervise according to policy. Sheets and the checks made should comport with policy. Log into the Seclusion Log any youth lock-ins for lack of staff should this occur, and check youth in their rooms per the seclusion process and for their safety.
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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 Observations sheets REFERENCES ACA 3-JDF-3A-04 and 3-JTS-3A-04 SUMMARY OF FINDINGS The facility maintains an Evening Supervision of Youth FOP #008-001 dated 01/14/09 which indicates that staff shall visually check each resident every 30 minutes, or more frequently. during bedtime hours. Staff are required to document their observations of the youth. Interviews with the Facility Administrators and staff, along with a review of documents revealed that staff conduct visual checks of youth appropriately every 15 minutes instead of every 30 minutes and document their observation at the time of the check. The facility utilities Sleep Observation Sheets to document each visual check. A review of randomly selected Sleep Observation Sheets from January 2010 to June 2010 revealed that 100% of 159 shifts completed the required room checks. The vast majority of the checks were completed within 15 minute intervals. The FOP requires that Supervisors or GLMs review all Sleep Observations sheets to ensure room checks are completed as required. A review of 560 Sleep Observation sheets revealed that the majority of the sheets were not initialed or signed by a supervisor/RGLM as part of the facilitys review process. The majority of staff did not print and sign their name on the Sleep Observation sheets, as required by the FOP. There were some instances of staff not initialing the sheet during each check. Also, some sheets had more than one staff listed making it difficult to determine which staff actually conducted the checks. A very small number of Room Observation sheets contained white-out which obliterated the time and observation code. White-out should not be used to obliterate any errors made on the sheets nor at all on any detention center documentation.
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RECOMMENDATIONS In order to reach Superior Performance status in this area, it is recommended that the facility: Review the FOP to ensure written procedures coincide with actual practices. Have Shift commanders/GLMs verify that they have reviewed Sleep Observations to ensure compliance with policy/procedures. Do not use white-out to obliterate errors made on the sheets, if an error occurs, draw a single-line through the information so that it can still be read. Ensure Shift Commander/GLMs ensure staff write their name legibly and sign the Sleep Observation sheets pursuant to the FOP.
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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 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 Based on interviews with the Assistant Facility Administrator and staff, along with a review of logbooks, staff conduct at least one perimeter check during each shift. The facility was not able to produce any kind of perimeter checklist when requested by QI; the use of one is suggested. The facility maintains a Master Control Identification FOP (#008-011) dated 8/27/08, which states that persons entering the facility must show valid photo identification. To prevent contraband from entering the facility, visitors are not permitted to bring certain items (i.e. keys, cell phones, etc.) into the secure area. The facilitys front entrance is a controlled access point. The entrance consists of electronically locking doors (sally port) to prevent unauthorized pedestrians from entering or exiting the facility. Visitors entering the facility are checked-in at this location. Master Control is located at the front entrance, but is not manned on a continuous basis. If staff is not available in Master Control to monitor the front entrance, visitors may use a telephone located at the entrance to contact staff in order to gain access into the facility. A review of the Visitors log revealed that no record is made of visitors leaving the facility. A hand held metal detection wand is maintained at the front entrance. During a tour of the facility, staff were observed using the wand to scan visitors for contraband, however the QI team was not searched in any way upon entrance. During a tour of the facility, the door to the restroom located on Long Hall was observed open and the area unoccupied. Security doors were observed to be secured at all times, however on one occasion the outer gate to the vehicle sally port was observed open and the area unoccupied. There were no escapes from the facility since the last QI Review.
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DJS QI Report
During a tour of the facility, a flaw was observed that compromises the security of the facility. The detention and administrative areas (i.e. front entrance) share a suspended ceiling consisting of removable ceiling tiles. There are several pipes and a catwalk just above the suspended ceiling that run the length of the facility. There is no barrier above the ceiling that separates the detention and administration areas (i.e. front entrance). By removing a ceiling tile in the detention area and climbing into the area above the ceiling, access can be gained to the front entrance area of the facility. During a tour of the perimeter, a push mower was observed in the recreational yard/area and a ladder leaning against a wall on the outside of the perimeter fence. There are several small piles of leaves observed along the perimeter fence line which could conceal contraband.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure visitors are signed out when leaving the facility so that their whereabouts can be accounted for in the event of an emergency. Wand/search all visitors, staff and DJS or other personnel for contraband every time. Ensure all gates, unoccupied areas and storage rooms are locked/secure at all times when not in use. Facility Administrative staff should meet with maintenance to determine how to secure the space above the suspended ceiling between the detention and administrative areas. Develop a perimeter checklist to ensure staff know what gates, locks, and windows to inspect and document the condition of the items checked. If one has already been developed, begin using it and keep these documents for reference. Have maintenance remove the lawn mower and ladder to a secured area. Remove the leaves along the fence line.
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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 Facility Logbooks Shift schedules Facility Population Report Interview with Assistant Superintendent Interview with Staff Observation at facility Facility Organizational Chart including vacancies REFERENCES ACA 1-SJD-1C-03 SUMMARY OF FINDINGS The staffing ratio at Carter is 1:8 which is within professionally accepted standards. Carter attempts to maintain 1:6 whenever possible. At the time of review there were 18 Direct Care positions filled and 2 vacancies. Of the random days chosen for audit, a total of 24 shifts were reviewed for proper ratio using logbook documentation compared to the facility population sheets and Facility Organizational Chart. No shifts were found to be out of ratio. Observation at the facility on two days also showed the staff to youth ratio was being met. The facility does consistently maintain ratios, however the shifts were sometimes found to be without supervisors. Staff did indicate in interviews that more staff are needed in order to allow them to take leave when they request it. Often supervisors sign the logbook for dates and shifts on days they are not in the building.
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RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Create a schedule that will ensure supervisory staff is available on all shifts. The Assistant Superintendent indicated he plans to remedy this issue by putting in place a Resident Advisor Supervisor who has been recently hired. Fill the two vacant positions. Ensure full staffing to allow for a built-in staff relief factor so that staff leave needs are being met. To ensure that there is no confusion about who was on duty and when the logbook was reviewed by a supervisor, the supervisor should only endorse for the days and shifts that he or she was on duty.
DJS QI Report
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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 Review of 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 The facility maintains a Key Control Policy FOP #009-002 dated 1/5/09. The FOP indicates the procedures for inventorying, storing, and distributing keys. Chits are used to facilitate the distribution of keys. Keys are required to be inventoried at the beginning and end of each shift. The facility has a Key Control Officer responsible for the responsible for the storage and inventory of facility keys. The facility maintains a working key board as the prime issuing point and the main repository for facility keys. The facility maintains an inventory of the working key board. An inspection of the working key board revealed that employees chits were not physically being exchanged for facility keys. Staff were recording their chit number in the key log and taking the chit with them. The working key board also contained several empty hooks that didnt have a key set or chit hanging on them. The inspection of the working key board also revealed that there were three set of keys signed out to staff and no employees chit number recorded in the key log. Incoming employees are to receive keys for exchange of their chit. A review of randomly selected months from the key log revealed the following: January March May 21% of 224 instances of keys issued did not indicate a chit exchange. 21% of 160 instances of keys issued did not indicate a chit exchange. 19% of 188 instances of keys issued did not indicate a chit exchange.
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A review of the key log also revealed the following: o No sign in/out times are used to track the times keys are issued or returned. o Staff do not always sign the key log when returning keys. For example: January 2010 19% of staff returning keys did not sign the key log as required. March 2010 21% of staff returning keys did not sign the key log as required. May 2010 29% of staff returning keys did not sign the key log as required. The majority of the key rings consist of one or two keys, the keys are not maintained on a metal key ring soldered/crimped at the joint to prevent tampering, loss, removal or the adding of unauthorized items onto the key ring. The key rings have a plastic tab affixed to indicate the hook number of the key set but not the number of keys on the ring. Pursuant to DJS policy, the facility maintains a list of staff issued keys on a 24 hour basis. The facility recently inventoried all keys issued to staff on a 24 hour basis. All keys were accounted for. Staff interviews and a review of the incident reporting database reveal that an employee reported misplacing/losing a set of facility keys. A search was conducted for the keys, but to no avail. The Facility Administrator responded by inventorying all facility keys and changing several locks within the facility. The keys were later found among the personal belongings of the employee. The facility maintains a set of emergency keys at a secure location away from but near the facility.
Tools Based on interviews with maintenance staff, the maintenance section does not maintain a sign out log for tools. There is only one maintenance worker assigned to the facility. Interview with maintenance staff and a review of documents revealed that the maintenance section maintains an inventory list of the assigned tools. However, tools are not inventoried on a regular basis.
Environmental Weapons A tour of the facility revealed that mops and brooms, which can pose a risk to the safety of staff and youth, were secured in a locked closet. A spray bottle marked bleach water was observed in a restroom. Interview with staff and an inspection of the spray bottle revealed that the bottle actually contained a mild cleaning solution. Bleach is no longer used in the facility.
Toxic and caustic materials

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The facility does not maintain any toxic/caustic materials within the detention area.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Require the management and Key Control Officer see that every hook on the working key board at all times contains either a key ring, a key chit, or a metal tag stamped with the number assigned to that hook to indicate that the hook is not currently assigned a key ring. The Shift Commander should ensure staff receiving or returning keys complete the key log. Conduct regularly scheduled inventory of tools and document each inventory. The Key Control Officer should ensure that all keys are maintained on a metallic key ring soldered/crimped at the joint to prevent tampering, loss, or removal.
DJS QI Report
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YOUTH MOVEMENT & COUNTS
STANDARD Written policy, procedure and practice document a system for physically counting youth. Youth movement is orderly and provides for identifying each youth movement and the specific location of each youth at all times. Formal and informal headcounts are conducted and documented in accordance with departmental guidelines. Emergency counts are conducted and documented when necessary. SOURCES OF INFORMATION Facility Logbooks Interviews with staff Facility tour Observation of youth movement REFERENCES DJS Youth Movement and Counts policy (RF-02-06); DJS Command Control Centers Policy (RF-09-05); ACA 3-JDF-3A-13 & 14 and 3-JTS-3A-13 & 14, JDF-3A-22 and 3JTS-3A-22 SUMMARY OF FINDINGS The facilitys maintains an Official Head Counts FOP 008-009 dated 7/3/08, which delineates procedures for conducting physical and official head counts. The facility requires staff to conduct physical head counts every 30 minutes and official head counts four times a day: 2am, 8am, 2pm, and 8pm. Interviews with staff and a review of unit and master control logbooks revealed that physical counts are conducted and documented every 30 minutes and official counts are conducted and documented four times, every six hours. The facility conducts a formal (Official) count around 2am and reports the count to the appropriate designee, pursuant to DJS policy. The facility maintains a Youth Movement /School Movement FOP # 009-003 dated 12/30/08, which delineates procedures for youth movement within the facility. Youth were observed during movement. Youth walked in single file and in an orderly fashion. A review of the unit logbook(s) revealed that youth movements are being recorded along with the names of youth when they are off the unit (i.e. court, doctors appointment, etc.) along with their location A review of logbooks revealed that staff who record entries (counts and movements) in the logbooks do not always place their initials after the entries.
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RECOMMENDATIONS In order to reach Superior Performance status in this area, it is recommended that the facility: Shift Commanders should instruct all staff who place entries into logbook to write their initials after each entry. The Shift Commander/Supervisor should review the log book(s) during each shift to ensure entries made are consistent with Department policy and procedure. The Shift Commander should make a notation in the log book of any inconsistency found and inform staff of the matter.
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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 and other documents Examination of fire safety equipment REFERENCES DJS Bomb Threat, Explosion and Suspicious Mail Policy (MGMT-3-01); ACA 3-JDF3B-05, ACA 3-JDF-3B-10 and 3-JTS-3B-11 SUMMARY OF FINDINGS The Maryland State Fire Marshal inspected the facility in June 2010. No violations were noted. A fire safety vendor conducted a quarterly inspection and test of the facility sprinkler system in April 2010. No violations were noted. A fire safety vendor tested the facilitys fire protection (alarm) system on March 2010. No deficiencies were noted. A fire safety vendor recharged, tested and inspected all of the facilitys fire extinguishers in April 2010. The facility has appointed a staff as the fire safety officer. All fire exit signs were properly illuminated. Inspection of the FACP revealed that it was operational. Interviews with staff revealed that the FACP and the power generator are tested every week. Interviews with staff along with a review of fire drills records from January 2010 to May 2010 revealed that the 3rd shift does not conduct any fire drills. During a tour of the laundry room, items were observed properly stored 18 inches below the ceiling sprinklers. A desk was observed blocking a fire exit in a classroom. Interview with the Fire Safety Officer revealed that some front door keys are notched for identification by touch. The facility should consider notching/marking all emergency keys in a manner that would make them identifiable by touch.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Shift commanders should ensure that the 3rd shift participates in a fire drill at least once a month if conditions permit. Ensure that furniture does not block any fire exit in the school. Mark/notch all emergency keys for identification by touch.
DJS QI Report
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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 maintains several FOPs that are, in part, about Post Orders. Pursuant to DJS policy, the facility is required to maintain specific and general instructions for the operation of every staff position and special duty assignment (i.e. Resident Advisors, Resident Advisor Lead, Resident Advisor Supervisor, Shift Commander, Security, and key control and safety officer assignments) in the facility. The facility provided a FOP that delineates the duties/responsibilities for the On Call Administrator. The facility did not provide any post orders for the duty assignment of Key Control Officer or Fire Safety Officer. DJS policy requires facilities maintain specific and general instructions for the operation of specific posts (i.e. indoor and outdoor recreation areas, Health Services Unit, Dining area, Laundry, Supply, Hospital and off-property appointments and Maintenance Shop) applicable to the facility. The facility maintains a FOP entitled: 10p-6a Post Orders. (PO #009-007) dated 5/18/09. This FOP is addressed to all direct care staff working the unit on the 3rd shift. The post order covers responsibilities/requirements/duties of staff such as equipment, count procedures, and key control. The facility also maintains other FOPs (i.e. Instructions for other shifts, Intake procedures and Master Control). The facility did not provide any post orders specifically addressing certain posts (i.e. Maintenance Shop, and indoor and outdoor recreation areas) within the facility. No Post Order Signature sheets were maintained with the reviewed FOP/Post Orders.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Develop specific post orders for applicable assignments and posts within the facility (i.e. Fire Safety Officer, Key Control Officer, Indoor/Outdoor Recreations areas and Maintenance shop). Maintain Post Order Signature forms for post orders distributed to staff.
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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 Interview with Training Coordinator REFERENCES Maryland Correctional Training Commission (MCTC); ACA 1-SJD-1D-03, ACA 3-JDF-1D-01, ACA JDF-1D-02 SUMMARY OF FINDINGS: Staff indicated in interviews that they were trained in CPM twice yearly. Mechanical restraints are covered semi-annually in CPM training. Of 19 mandated staff, 19 (100%) were reviewed for training compliance: -- 18/19 (95 %) met the 40 hour annual training requirement for 2009. -- All had CPR/AED training since Jan 2009. Of the staff who had mandatory training class expectations in the required areas: -- 9/19 (47%) were compliant with Crisis Prevention and Management semiannual training (100% had CPM training at least once in the last year) -- 19/19 (100%) were compliant with Suicide Prevention annual training -- 19/19 (100%) were compliant with Recognizing and Reporting Child Abuse and Neglect annual training The Training Coordinators training calendar ensures all staff will not only have well over the number of required hours, but will also meet all expectations by the end of 2010. The calendar contains a spring and fall CPM block which is an excellent addition to ensure staff make their semi-annual requirement.
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RECOMMENDATIONS In order to reach Superior Performance status, it is recommended that the facility: Ensure annual training schedule is being met/followed and ensure all staff needing required semi-annual CPM trainings attend. The facility was very close to a Superior Performance rating and is to be commended.
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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 intake staff Review of youth screening tools Review of youth base files REFERENCES Admissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile Detention Facilities; DJS Classification Policy in final editing stage; ACA 3-JDF-5A-02, 3-JTS-5A01, 5B-01 through 04 and 5B-07 & 08 SUMMARY OF FINDINGS Intake packet contains all necessary paperwork. Court orders and face sheets were completed for 100% of all files reviewed. Classifications were not in all files. Handbook acknowledgement forms were found in 70% of files reviewed, however youth indicated that the rules are read to them upon admission. This is good practice but handbooks should be routinely provided and youth should have a copy to keep and refer to per the DJS detention standards. Intake staff interviewed indicated she offers to read the youth rules to youth in order to account for youth who might be illiterate. Actual names of mental health staff and others who may leave the facility should be removed from the handbook or be updated regularly. Any incentives not offered (such as facility outings or game nights) should also be removed. The MAYSI is completed within two hours of admission. Intake staff interviewed knew how to score the MAYSI and did so. 100% of files had a completed MAYSI. Intake staff indicated she looked at MAYSIs for all No answers and ensured youth re-took the test or mental health was notified if this was found. SASSI is completed within seventy-two hours of admission. 100% of all files had a SASSI present. Staff are not trained to give or score the SASSI; substance abuse staff do this later but not within two hours of the youths arrival.
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DJS QI Report
The FIRRST is completed upon the youths arrival but often after the Custody sign-off is completed. The FIRRST should be completed before custody is signed for and the youth not accepted until he screens negative on all questions. This was discussed with the facility and can be easily switched and remedied. 100% of files had a FIRRST screening form present. A medical assessment is done upon admission, and in every case within 72 hours. Due to Carters small size, there is no formal Orientation unit.
RECOMMENDATIONS In order to reach Superior Performance status, the following is recommended: Ensure SASSI is taken and scored within two hours per policy. Understanding that it will take time to train staff to do so if there is no substance abuse staff onsite, consider training Intake staff to at a minimum give the test and scan SASSI results for youth who may be susceptible to de-toxing while in custody. Medical staff may be helpful in this regard and should confer with Intake staff if results look suspect. Switch the FIRRST and Custody sign off process so that the FIRRST is done first. Ensure all youth are given a copy of the handbook to keep or at a minimum that a copy of the entire handbook is laminated and available in the main dayroom area for youth to refer to. Ensure before doing so that all aspects of the handbook are up to date.
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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 Case Management staff Review of Intake packet Interviews with staff Observation at the facility Review youth base files 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 maintains a Classification System FOP dated 01/02/09. The facility does not double bunk youth. Interviews with the Case Management staff, along with a review of 8 randomly selected Housing Classification Assessment (initial) forms revealed that 6 of the forms were incomplete. One youth had been in the facility for 29 days and had not been properly classified pursuant to policy. Interviews with staff revealed that not all staff have access to ASSIST and therefore are unable to complete the forms. If ASSIST is not accessible, staff attempt to classify youth based on age, physical size, type of charges and level aggression until a proper classification can be made. The facility does not maintain a Housing Plan that identifies low, medium and high supervision rooms. The physical structure of this facility makes proper classification less crucial than at larger sites as there are only two small hallways in which to assign youth to rooms. Staff assign youth who need higher levels of supervision to rooms located closer to the staffs station. This should simply be memorialized in a Housing Plan. RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Develop a Housing Plan and train staff. Ensure staff responsible for completing the Housing Classification Assessment forms have access to ASSIST or that the forms are completed as soon as possible.
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PENDING PLACEMENT
RATING: No Rating
STANDARD Written policy, procedure and practice document that the facility has a list of youth pending placement, their days committed, and average length of stay and aggressively prioritizes these youth in order to assist the community case managers in placing them as quickly as possible in order to reduce time in detention.
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BEHAVIOR MANAGEMENT
STANDARD Written policy, procedure and practice document a behavior management system which provides a system of rewards, privileges and consequences to encourage youth to fulfill facility expectations and teach youth alternative pro-social behavior. Youth who are not invested in the facilitys system have alternative and individual plans. SOURCES OF INFORMATION Review of Log Books Review of Daily Point Sheets Interviews with youth Interviews with of direct care staff Review of the Student Handbook REFERENCES DJS Behavior Management Program Policy RF-10-07; Facility Behavior Management Program (BMP) SUMMARY OF FINDINGS The Behavior Management Program (BMP) at Carter allows youth to progress through four levels (Level 1 - Level 4). A review of the facilitys BMP found that both staff and youth had a good understanding of how the program works; this information was revealed during interviews with 14 youth and 6 staff. The total number of points a youth earns daily is posted on each unit. This allows both staff and youth to know the current number of points/level earned by a youth. The youth generally found staff to be fair and consistent when deducting points and that the grievance (or appeals) process was available to them if they felt their points were taken unfairly. Based on interviews with staff and a review of memorandums and FOPs, staff are provided training in the use of the BMP system. No computation errors were noted to the point sheets reviewed. The point sheet was very easy to understand. Points lost for infractions as well as activities purchased were identified on the youth point sheets. One of the chief behavior management strategies employed at Carter is the criminal charging of any youth who assaults another youth. Youth are told when they arrive that this is Carters policy. Carter follows through as well; charging information forwarded to Maryland State Police was evident in the IR files. This consistency and consequence-driven strategy is excellent and the facility is to be commended. Some activities listed in the written BMP were not all being done and should be removed if not offered. A new activity (Carter After Dark) was added. The youth were very excited about this new activity.
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DJS QI Report
The use of early bed violates DJS seclusion policy. Carter staff interviewed noted that group punishment was not a part of the behavior management at the facility and that early bed was not used as punishment, but some indicated 8:15pm was a bedtime that was used as a sanction for youth. Though this comports with the Level I bedtime, it was unclear if this was a permanent level drop or a temporary sanction just for the night.
RECOMMENDATIONS In order to reach Superior Performance in this area, it is recommended that the facility: Identify in writing the behavior that will cause a youths points to be frozen so that staff cannot freeze points in an arbitrary way. The criteria for frozen points should be detailed in the Behavior Management Program and the Student Handbook. Remove the activities no longer offered by the facility from the Behavior Management Program and the Student Handbook and update both to include all current incentives. If an earlier (Level I) bedtime is used as a temporary sanction, include that in the BMP and Student Handbook; ensure such use is not arbitrary by requiring authorization and having a written criteria in order to ensure fairness for all youth.
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STRUCTURED REHABILITATIVE PROGRAMMING
STANDARD Written policy, procedure and practice document that youth receive planned, structured outdoor and indoor activities and regular rehabilitative programming that teaches social skills. SOURCES OF INFORMATION Review of Unit Log Books Review of the Master Schedule Interviews with direct care staff Interviews with youth REFERENCES DJS Recreational Activities Policy RF-08-07; ACA 3-JDF-5E-01-02-03-04 SUMMARY OF FINDINGS Youth indicated that they participate in World of Books, movie nights and other structured activities at Carter. Interviews with youth and staff and logbook review indicated that some but not all of the scheduled activities at the facility occurred as outlined on the master schedule however. In addition, a QI reviewer arrived to meet the unit at a scheduled ART group that did not ever occur. Upon observing an Empowerment Group, not only did the program not last for the time indicated, but it was evident that the facilitator was not prepared for the session. The youth were not expecting it to occur and had begun to play cards and board games when the facilitator arrived. Interviews with youth and staff, observations and logbooks indicated that the youth get at least one hour of recreation per day and two hours of recreation on weekends. Youth and staff report that recreation frequently occurs outside whenever the weather permits. However, because the Carter Center is so small, the inside space designated for recreation is very limited. The exercise room contains one modular exercise station on which youth are able to do pull ups, dips and other calisthenics. The room also contains hula hoops, a climbing wall and weighted exercise balls. As an alternative to the exercise room the youth may choose to play games in the game room. Students who choose this option do not get the required large muscle movement Youth are offered religious services, but there is not an alternative for youth who choose not to participate.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Revise the schedule to accurately reflect programming at the facility. Explore more exercise equipment options for the youth in the facility to use during times when outdoor recreation is not available. Offer concurrent secular programming, even if just arts and crafts, as an alternative to religious services.
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SELF ASSESSMENT
RATING: No Rating
STANDARD Written policy, procedure and practice document that the facility superintendent at least twice monthly meets with his or her management staff to assess the facilitys status involving the use of seclusion, restraints, incident reporting numbers and procedures and other key area of facility operation in order to assess the facilitys compliance with DJS norms and expectations.
DJS QI Report
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BEHAVIORAL HEALTH
INTAKE, SCREENING & ASSESSMENT
RATING: No Rating
STANDARD Written policy, procedure, and practice require that all youth admitted to a facility will be screened by qualified mental health professional in a timely manner using valid and reliable measures. All youth who screen positively for behavioral health issues will be referred for a full mental health assessment by a mental health professional. All youth who present at the facility with behavioral health issues that, as determined by professional mental health assessment, are beyond the scope of what the facility can safely treat, will be referred to a setting that can more appropriately meet the youth needs.
DUE TO THE LACK OF A BEHAVIORAL HEALTH QI REVIEWER, THIS STANDARD COULD NOT BE ASSESSED.
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INFORMED CONSENT
RATING: No Rating
STANDARD Written policy, procedure, and practice require that youth, and when appropriate, their guardian, are informed of the risk, benefits, and side effects of medication and the potential consequences of stopping medication abruptly. Youth are also notified that their conversation with clinician, though confidential, may be shared with DJS and the Court if requested.
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PSYCHOTROPIC MEDICATION MANAGEMENT
RATING: No Rating
STANDARD Written policy, procedure, and practice require that psychotropic medications are prescribed, distributed, and monitored safely.
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BEHAVIORAL HEALTH SERVICES & TREATMENT DELIVERY
RATING: No Rating
STANDARD Written policy, procedure and practice require that appropriate mental health substance abuse treatment and emergency services are provided by qualified mental health professionals and substance abuse counselors, that it is integrated with the psychiatric services when applicable, and that it is appropriate for the adolescent population. Crisis intervention services should be available in acute incidents. All admitted youth should receive alcohol and drug abuse prevention/education counseling. Family involvement should be highly encouraged. Behavioral health issues should be considered when providing safe housing for youth at the facility.
DJS QI Report
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TREATMENT PLANNING
RATING: No Rating
STANDARD Written policy, procedure and practice require that appropriate mental health substance abuse treatment and emergency services are provided by qualified mental health professionals and substance abuse counselors, that it is integrated with the psychiatric services when applicable, and that it is appropriate for the adolescent population. Crisis intervention services should be available in acute incidents. All admitted youth should receive alcohol and drug abuse prevention/education counseling. Family involvement should be highly encouraged. Behavioral health issues should be considered when providing safe housing for youth at the facility.
DJS QI Report
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TRANSITION PLANNING
RATING: No Rating
STANDARD Written policy, procedure, and practice requires staff to facilitate appropriate transition plans for youth leaving the facility. Youth, and their guardian when appropriate, should receive information on behavioral health resources, a prescription for medication continuation, and assistance in contacting behavioral health aftercare services to schedule follow-up appointments.
DJS QI Report
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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 4 youth Suicide Logs for 2 youth 4 Incident Reports involving suicide ideations/gestures Interviews with youth Interviews with staff Observation at facility REFERENCES DJS Suicide Policy (HC-1-07), ACA 3-JDF-3E-04, 4C-27 & 28, 4C-35, 5A-02, 3-JTS4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.J SUMMARY OF FINDINGS The Suicide Watch Observation sheet is an older version and should be discarded. The newest version should be printed off of the DJS Suicide Prevention policy. Communication about youth on watch is mostly informal. The Suicide Watch Log at Carter is handwritten and contains just some of the information necessary for all staff to be able to assist in safe supervision of the youth. Levels were sometimes missing on the initial watch assignment. Conditions for supervision often only said no restrictions. Since it is not typed, it cannot be emailed to all necessary parties or updated with more than a quick one-line comment. It is kept in a binder in Master Control and there is no indication that staff are required to read it daily. The Suicide Watch Logs purpose is to be a continuous record, an information source and to be sure that all youths safety issue are known to all direct care staff who work with them. It should therefore contain information on the youths mental status (e.g., alert or depressed), watch level, initiated date, presenting problem (e.g., youth denied feeling suicidal today but still cannot verbalize a safety plan.), and conditions of supervision (e.g., no pencils or lead, no cleaning materials within reach, youth can color if he feels anxious or seems agitated,
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DJS QI Report
etc.). It should also be shared; one method is to email it daily to all relevant parties including Medical, Education, Case Management and Administration. Youth on watch and any special conditions they might have should be known to all who work direct care in the facility. All staff knew they could put a youth on Level III watch. All staff knew that only mental health clinicians could remove a youth from watch. All but one 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. Ensure all are aware of this responsibility. Staff indicated that there are typically are enough staff to supervise youth on suicide watch. All sheets were present for all youth. Only one short gap was discovered but it was found by the facility the next day of the youths watch and was noted. Documentation of youth on watch on Suicide Watch Observation sheets was found to need some improvement. Three of four youths sheets had evidence of pre-dating and patterned checks. Checks ending in all 0s, multiples of 9, and a pattern of 0,9,8,7,6,5,4,3,2,1 (repeating) were noticed. Most of this was done by one particular staff person. Even in light of this, many other staff did an excellent job making checks with no evidence of patterns. Audits of suicide watch sheets themselves were not evident. Original sheets were in folders by youth name. The originals should be filed in the medical file and a copy in folders or a binder for auditing and oversight. Incident reports reporting suicide ideations and gestures were evident and gave confidence that youth actions and words are taken seriously by staff. The facility only has a short way to go to meet Satisfactory Performance status.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Mental health should distribute a Suicide Watch Log via email to Master Control, Medical, Education, the Administrators, the shift commanders and Case Management. All staff should be required to view this email (or check a hard copy) at the beginning of their shift and be aware of who is on watch, what his level is and what his conditions of supervision are. This information should be relayed to line staff. The facility should spot check with staff to ensure they have reviewed the Log. File all original sheets in the youths medical file and place copies in the binders. A suggestion is to make a copy of each sheet once it has been accounted for, then place the copy in a binder and use that for auditing purposes and staff follow-up. Send the original to the mental health staff for their review. Once they have reviewed the youths daily activities on the sheet, they can send it over to medical and file it in the youths medical file along with any of his other behavioral health paperwork. This complies with policy and allows both entities to review the youths sheet.
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A trained and skilled staff should be assigned the duty of auditing Suicide Watch Observation sheets for patterns, pre-dating or pre-timing, and relay any issues to the Administration for re-training or disciplinary action. Staff who are found to be documenting using patterns of any kind should be retrained in why using clock time and documenting properly are required. Staff should see the vital importance of being the first line of protection for these youth.
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ENVIRONMENTAL HAZARDS
STANDARD Written policy, procedure, and practice require that all housing for youth at heightened risk of self-harm is free of identifiable hazards that would allow the youth to commit suicide or other acts of self harm. In case of emergency, all direct care staff at the facility should have immediate access to appropriate equipment to intervene in an attempted suicide. Chemicals and other hazards are properly stored and locked. SOURCES OF INFORMATION Interviews with youth Interviews with staff Observation at facility REFERENCES DJS Suicide Policy (HC-1-07), DJS Safety and Security Inspections Policy RF-04-07, ACA 3-JDF-3E-04, 4C-27 & 28, 4C-35, 5A-02, 3-JTS-4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.J SUMMARY OF FINDINGS Interviews with 10 direct care staff revealed that 2 did not have a cut down in their possession. The two staff, however, did retrieve a cut down tool at the time of the interview. A tour of the facility revealed that all chemicals, mops and brooms were kept behind locked doors.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that all direct care staff carry a cut down tool while on duty.
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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.
DJS QI Report
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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 Guidance Counselor Interview with the Assistant Superintendent Review of 15 student folders (10 general education, 5 special education) Review of Daily Population Reports REFERENCES COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS 10 of 15 (66%) students records were requested within 72 hours or 3 school days of admission. 7 of 15 (47%) of records were received within five school days of admission into the facility. Only 3 of 15 (20%) of students were interviewed and assessed within 72 hours of admission to the school. The average time from admission to assessment and interviewing was just over 11 days. The school was not performing secondary requests for records. On the first day of the review, three students (20%) with stays ranging from 12 to 27 days did not have records in their folders. A review of the folders indicated that there were no follow up request for records when they were not received in a timely manner. The records for two of the youth were received on the second day of the review June 23, 2010.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: The school should request records according to COMAR 13A.08.07. Records should be requested upon the youths admission to the school; progress should be tracked; and when necessary, additional requests for records should be made.
DJS QI Report
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CURRICULUM & INSTRUCTION
STANDARD Facility schools will ensure that they provide instruction appropriate to the varied needs and abilities of the students enrolled. They should operate on a standard schedule, provide students with a consistent school day, provide instruction appropriate to individual students strengths and needs, provide pre-GED & GED instruction as appropriate, provide extracurricular and enrichment activities & events, integrate computer assisted instruction in the curriculum and provide library services. Facility schools will also ensure that students in alternate settings (i.e. infirmary, seclusion and orientation) are given access to assignments and instruction comparable to others students in the facility. SOURCES OF INFORMATION Review of School schedules Observation of transitions to and from class Two Classroom observations Interview of two teaching staff members Interview of nine youth Review of logbooks REFERENCES MSDE Guidelines DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS School started on time in the morning and afternoon on the first day of the review. School also started on time in the morning of the second day of the review. However, school started about an hour late on the second day of the review. The school staff were in a meeting that lasted into the school time. During that time the youth remained on the unit playing cards and games. Transitions and class changes occurred according to the schedule. The teachers had curriculum materials for each subject in their classrooms. Classroom areas are well appointed and students had materials to complete their work. During classroom observations objectives and agendas are on the board. A variety of teaching styles were displayed, including direct instruction, co-teaching, use of computers and calculators. The school provides pre-GED instruction to youth who qualify. The school has a library for the use of the students. Students are able to check out books and take them back to their rooms.
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Students earn student service learning hours by maintaining the landscaping around the school building. Students also have earned student service learning hours by developing anti-bullying literature.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that youth attend classes according to the school schedule. At times when youth have to miss instructional time, the school should have a plan and supply work for the youth to do during that time.
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SCHOOL STAFFING & PROFESSIONAL DEVELOPMENT
STANDARD The Facility School will maintain a sufficient number of certified staff to provide appropriate education to all students, including related services providers. The school should provide meaningful staff development opportunities to teachers and support staff to enhance their ability to effectively educate youth in detention settings. SOURCES OF INFORMATION Roster of teaching staff List of teacher certifications Principal interview Teacher and IA interviews 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 principal (who splits duties between Carter and the Lower Eastern Shore Childrens Center); two general education teachers; one special education teacher; one instructional assistant; one school counselor; and one secretary. A list of certified teachers indicated that all three of the teachers in the classroom held valid teacher certifications from MSDE. The special education teacher holds a current special education certification. The teacher who teaches math and science does not hold certification in either of those areas. The teacher who teaches Social Studies and English only holds certification in Social Studies. Teachers received staff development to better their teaching skills. The staff development was provided monthly to all MSDE education staff. The areas of staff development included: differentiated instruction, instructional use of data, transition and career scope assessment training, High School Assessment (HSA) and Middle School Assessment (MSA) training, Special Education law and policy and Library/Media curriculum, Read 180. A new staff development schedule for the new the new fiscal year outlined similar sessions. Related services in the form of counseling are provided by the schools social worker. Speech language services are provided by a contractual provider.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Provide additional certifications for teachers in all of the content areas that they teach.
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SCREENING & IDENTIFICATION
STANDARD Qualified professionals shall provide prompt and adequate screening of facility youth for special education needs, including identifying youth who are receiving special education in their home school districts and those eligible to receive special education services who have not been so identified in the past. SOURCES OF INFORMATION Review of child find forms Review of special education roster Review of population report Interview of school secretary Review of 5 special education student folders REFERENCES Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400-1490 COMAR 13A.13.01.05: Program and Service Components-Comprehensive Child Find System. COMAR 13A.08.07.01: Education-Student in State Supervised Care-Transfer of Educational Records DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS School staff members understand the procedures for referring students for screening for special education services. The school assesses the educational level of each student in the facility upon admission to the school using the Basic Achievement Skills Inventory (BASI). Any student who scores below the third grade level on the assessment is automatically screened to determine if there is a possible need for special education services. The concern with the testing is that it did not occur within a reasonable time of admission. The average time from admission to assessment was just over 11 days. The school loses valuable time by this delay that could be used to identify youth. 5 of the 15 (33%) residents of the facility are identified as students previously identified as needing special education services.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that youth are assessed in a timely manner to ensure the identification of special education students.
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PARENT, GUARDIAN & SURROGATE INVOLVEMENT
STANDARD Written documents show that parents, guardians or surrogate parents are notified of and invited to participate in evaluations, eligibility determination, Individualized Education Programs (IEPs) development and team meetings, and decisions regarding provisions of special education services. SOURCES OF INFORMATION Review of IEP documentation Interview with special education teachers Interviews with teaching staff Review of 5 current special education files Review of 4 former special education files REFERENCES COMAR 13A.05.01.07: IEP Team. COMAR Transition SUMMARY OF FINDINGS In all cases parents are given 10 days prior notice before an IEP meeting. Documentation of parent contacts was consistent in each file. All notices accurately indicated the purposes of the meetings and the meeting attendees. The notices offered the option for parents to participate via the telephone. The school does not have a trained parent surrogate. The folders contained certified mail receipts and fax receipts documenting the invitation of community case managers and representatives from the Department of Rehabilitative Services (DORS). Home schools were not invited to the meetings.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Invite the youths home schools to participate in meetings. Identify and train parent surrogates.
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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 5 special education files of current student files Review of 4 special education files of released students. 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 IEP meetings were consistently scheduled well beyond thirty days of youth admission into the facility. Because of the dynamic nature of the population of detention facilities, holding meetings this far into the youths stays runs the risk of students not having their IEPs updated while they are in the facility. Both screening and identification and meeting set up, especially with a population of only 15 youth, should be accomplished more quickly. None of the current special education students in the facility had IEP meetings conducted at the Carter Center. Four files of released special education students were reviewed to determine if IEPs were being completed at the facility. In all 4 of the files, the IEP teams were consistently well constituted. School counselors and social workers were frequently participants in IEP meetings of students in need of their services. Two of the four IEPs of former students indicated that the youth required a related service of either counseling or speech/language services. In those files, both service logs indicated that the students were receiving related services as outlined in their IEPs. Two of the five current files indicated that the youth required a related service of counseling. The service log for one youth indicated that youth was receiving services as outlined in the IEP. The other did not. All 4 files of released students contained IEP team notes that were well written and contained solid information on why changes were being made. IEPs were individualized and did not seem like carbon copies of each other. IEPs
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demonstrated that the school provided a continuum of services from full inclusion to pullout of special education students for math and English classes. The school used the Maryland online IEP format. There were no 504 plans for current or released students available to be reviewed. Teachers were aware of students accommodations from the 504 plans and could identify them.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Ensure that all related service hours and contacts are documented in the student folders. Ensure meetings are scheduled as soon as possible so that youth can have their IEPs updated; do not wait to schedule meetings after the youth has been in residence for over 30 days.
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CAREER TECHNOLOGY & EXPLORATION PROGRAMS
STANDARD The facility will provide students opportunities to explore career interests and to develop skills useful in obtaining employment. SOURCES OF INFORMATION Review of school schedule Interview with school principal REFERENCES COMAR 13A.04.02: Secondary School Career and Technology Education SUMMARY OF FINDINGS The school current has no vocational options. The school principal indicated that the school is preparing to offer the Serve Safe program. This is a 20 hour program that would provide youth with certification in food handling. In addition, the school is developing a plan to offer the C-Tech course, which trains youth in copper cabling. One of the schools current teachers has become certified to teach the classes. The school currently offers a career class that teaches students job seeking skills such as filling out applications, interviewing skills and resume writing.
RECOMMENDATIONS In order to reach Satisfactory Performance in this area it is recommended that the facility: Move forward with the Serve Safe and C-Tech courses for students.
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STUDENT SUPERVISION
RATING: Superior Performance
STANDARD The facility will ensure that staffing is appropriate to supervise students in the educational setting, as well as during transitions to and from the school setting. SOURCES OF INFORMATION Classroom observations Observation of transitions Interview of school administrators REFERENCES Maryland Standards for Juvenile Detention Facilities SUMMARY OF FINDINGS When the unit comes to school it is split into two classes. One staff member is assigned to each classroom. An additional staff member is assigned to the hallway of the school. This staff member is responsible for managing movement in the hallways, providing coverage for staff breaks and responding to crisis in the school building. This staff member also performs searches of the youth as they enter and exit the facility and the school building. Observations of student movement to and from the school demonstrated that youth were escorted to and from the building in the correct ratio and safely.
RECOMMENDATIONS The facility has reached Superior Performance status.
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SCHOOL ENVIRONMENT & CLIMATE
RATING: Superior Performance
STANDARD The facility will ensure that the school setting is a safe environment conducive to learning and that staff are supported in their jobs. SOURCES OF INFORMATION School observation Interviews with Direct Care staff members Interviews of Educational staff Interview with the facility assistant superintendent Interview of nine youth REFERENCES N/A SUMMARY OF FINDINGS The Carter Center School is well appointed and orderly. The classrooms are large enough to more than meet the needs of the population. The school principal indicated that the facility administrators do a good job of supporting the education program. The principal indicated that the facilitys Assistant Superintendent is present in the school daily and interacts with the education staff. The Assistant Superintendent also indicated that there is a positive working relationship between the school and facility leadership. Education staff indicated that they feel supported by the direct care staff. Most youth spoke positively about school, indicating that it was like regular school.
RECOMMENDATIONS The facility has reached Superior Performance status.
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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 Records staff interview Review of 8 folders of released youth January 2010 to June 2010 Interview with OPS staff REFERENCES COMAR Transition COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records SUMMARY OF FINDINGS 7 of the 8 (88%) student files contained MSTRs or progress reports. The MSTRs were dated indicating that they were created within five (5) days of the students release from the facility. OPS staff indicated that the reports are in the students files that are sent to them.
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 created for all students released from the facility.
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MEDICAL CARE
HEALTH CARE INQUIRY REGARDING INJURY
STANDARD: Written policy, procedure, and practice ensures that all youth are seen by medical staff after any incident in which they are involved, regardless of whether there is an injury, shortly after the incident occurs. SOURCES OF INFORMATION: 37 Facility Incident Reports Jan-June 2010 Nursing Report of Youth Injury forms Nurses Injury Log Interviews with staff Interviews with youth Observation at facility REFERENCES: DJS Incident Reporting policy (MGMT-03-07); Photographing of Injuries policy (RF-1105); Reporting & Investigating Child Abuse Policy (MGMT-1-00) SUMMARY OF FINDINGS In 100% of cases, youth in incidents or restraints saw a nurse as required and had a body sheet present. All body sheets were filled out in their entirety. One nurse did not write the verbatim response of a youth who reported injuries. This, in addition to facility staff error, led to a child abuse complaint not being reported to the nurse by the youth. A verbatim response to the question What happened? often is the best way to ensure youth report the events exactly as they alleged they occurred. There were no other instances found where a youth alleged child abuse to the nurse and his case was not referred to CPS by the nurse as required. The ISRs seemed to be reasonable based on the injury/complaint of youth. All youth were seen within two hours as required. Youth indicated and staff indicated that after a fight, youth are required to and do see the nurse as soon as possible afterwards. Nursing may not always log every youth visit to the nurse as required in the Nurses Injury Log. In a review of one months worth of logs, 2 youth went to the nurse for injuries and were not listed in the log. Nurses must carefully and reliably log in every youth who appears in medical for any injury. Photographs were attached as required.
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RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Record youths verbatim response to what happened on the body sheet in every case.
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HEALTH ASSESSMENT
STANDARD Written policy, procedure and practice document that adequate health assessments are completed on all youth within 72 hours of admission. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Medical file review (five charts in detail) REFERENCES ACA 1-SJD-4C-18-19-20 DJS Special Needs Treatment Plans Health Care Procedure (2007); ACA 1-SJD-4C-18-19-20 SUMMARY OF FINDINGS There were Admission Progress Notes written in the Progress Notes on all admissions. Nursing Assessments were completed within 72 hours on all Youth Health Record files reviewed. All admission physicals were completed within 72 hours of admission. The Progress Notes lack other pertinent documentation such as notification of parents, follow-up on treatments, HIV pre or post test counseling, and outcomes from inpatient or outpatient referrals. The vital signs and vision screens were not consistently documented on the physical exam on the five Youth Health Record files reviewed. When they are documented, they should be dated in real time with the day they were taken if different from the day of the physical examination. Admission labs and TB skin tests were completed on the seven charts reviewed. The Lab Log documentation was not current. Labs should be entered into the log as they are obtained and when the results are received. Allergies were documented in the Youth Health Record file but not on the Master Problem List and not on the allergy stickers on the front of the Youth Health Record file. Health Status Alerts were completed and distribution to the respective disciplines in the facility was noted. The immunization tracking and referral forms were being utilized, but not completed, on the Youth Health Record files. The form, when utilized, assists health care professionals to track immunization records requested, received, reviewed and immunization ordered. Also, this tracks follow-up referrals, appointments and completion of the appointments especially dental exams and follow-ups. There were youth who had orders for follow-up referrals for dental and vision that did not have the information documented on the form. There was
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no documentation in the Youth Health Record file to note that the physicians orders had been addressed. Documentation was present in four (4) of the five (5) Youth Health Record files reviewed that an Immunization Record had been requested, received and reviewed. The fifth was a new admission so that had not yet been addressed. There were immunization orders written and transcribed onto the Medication Administration Record forms (MARs) but they lacked consistent documentation in the Youth Health Record file that the consents were requested and obtained. One request for consent had been mailed 10 days prior to the audit so explanation was given to the nurses that the youth could be offered the vaccine since the parent/guardian had not responded. The Master Problem Lists were present in the Youth Health Record file. The MD is doing an excellent job of documenting the actual problem but nursing is not completing the Intervention/Treatment and Outcomes. Mental Health continues to lack completion of documentation of mental health issues on the Master Problem Lists. One youth had a history of Asthma. The Asthma Assessment tool and Asthma Treatment Plan were not completed. The first aid kits were not in place. The procedure of securing the first aid kits by staff on the units and accountability for the contents with documented monthly checks should be put in place. The AED Log was up to date; it documents that the equipment is functioning and expiration dates have been checked. The Nursing Report of Youth Injury reports reviewed contained excellent documentation. The youths name should also be noted on the picture that is taken as part of the Nursing Report of Youth Injury process. Documentation in the Youth Health Record file of any follow-up of injuries was lacking. Nurses were able to give verbal accounts of the follow-up and treatment but this should also be documented. The Growth Charts and BMI were not in any of the Youth Health Record files. The 30 Day Assessments were being completed. The PPD Log should have the date the PPD was actually read in addition to the results and the initials of the nurse who read the PPD.
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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: Date vision screens and completed vital signs the day they were taken if different from the day the physical is dated. Ensure the nurse obtains the proper consents and administers the vaccines as prescribed. Documentation of the immunization requests, date received, date reviewed and date administered are completed on the Tracking and Referral form in the Youth Health Record file. All log books must be kept up to date as incidents occur, labs are obtained and results received. Document on the Immunization Tracking and Referral form any initial or followup referrals, appointments and completion of the appointments. Complete Master Problem Lists with any and all medical and mental healthrelated information, and allergies. The Intervention and Treatment section of the Master Problem List must be completed. The Asthma Assessment Tool, Asthma Treatment Plan and the Nursing Progress Note for the Assessment of Need for Rescue Inhaler must be utilized. The MD/NP must complete an Asthma Treatment Plan on all youth who present with a history of asthma. Procedures for securing first aid kits on each unit and their monthly checks must be put back into place. The nurses must document all follow-up care. Growth /BMI Charts must be put into place with completed and dated documentation. . Document that HIV testing is offered and complete consent forms with documentation of pre and post test results placed in the Youth Health Record file. Place the name of the youth on the Nursing Report of Youth Injury picture that is taken. Date the PPD when it was actually read next to the results with the nurses initials.
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MEDICATION ADMINISTRATION
STANDARD Written policy, procedure and practice document that medications are given as prescribed. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs MARs Medical file review (five charts) REFERENCES DJS Pharmaceutical Services policy (HC-02-07); ACA 1-SJD-4C-16-17 SUMMARY OF FINDINGS Medications are being properly administered. The youths picture is included with the MARs and the nurse asks the youth his or her name to confirm that the youth is the proper person before meds are administered. The CDS (controlled drug substance) shift inventory is in place with proper documentation. The sharps count inventory also is in place with proper documentation. Start and stop dates were incomplete on the MARs. This was noted on any verbal orders obtained and on any Nursing Assessment Protocol Orders that were activated. If a medication is administered, an order must be activated. Consistently when Oxy Pads are ordered, there is no activation of the Nursing Assessment Protocols on the Physicians Order sheet. Medications had expired and there was no documentation of the inventory being checked monthly for expiration of medications and supplies.
RECOMMENDATIONS In order to reach Superior Performance, it is recommended that the health care unit at the facility: If incomplete documentation from the MD presents, return to MD to document the reason why a medication was prescribed, and a start and stop date. If a youth is being administered and medication even if it is over the counter an order must be present in the Physicians Order sheet and also documented on the MAR. Initiate monthly checks for expiration of medication and supplies.
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DJS QI Report
DENTAL CARE
STANDARD Written policy, procedure and practice document all youth receive timely and adequate dental care. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Medical file review REFERENCES ACA 1-SJD-4C-22 SUMMARY OF FINDINGS Routine dental examinations by a dentist and treatment are not completed on each youth at Carter. The youth are screened for any dental complaints upon admission and youth with urgent dental problems are referred to a dentist in the community for treatment. Dental pain is managed according to a nursing protocol for dental pain (and collaborating physicians orders) to keep the youth comfortable prior to and after treatment is received as necessary.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the health care unit of the facility: Document on the tracking and referral form all dental appointments made and completed. Ensure this listing remains up-to-date.
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MEDICAL RECORDS RETRIEVAL
STANDARD Written policy, procedure and practice document that efforts are made upon a youths admission to obtain prior medical records. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Medical file review REFERENCES ACA 1-SJD-4C-18-19-20 SUMMARY OF FINDINGS Youth detained at Carter may have a history of having previous health records on file at that facility. The facility keeps past Youth Health Record Files. Upon reviewing the process for the requests of records from other providers, the process was intact and functional.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the health care unit of the facility: Continue to fax requests to DJS facilities and private providers for records and utilize the tracking and referral system to help document these requests. Notify the DJS Director of Nursing if after follow-up the facility is unable to obtain the records from another DJS facility.
DJS QI Report
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SPECIAL NEEDS YOUTH
RATING: Non Performance
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 Interviews with youth Nursing logs Medical file review REFERENCES DJS Health Care ProcedureSpecial Needs Treatment Plans (2007) SUMMARY OF FINDINGS Special Needs plans were not present.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the health care unit of the facility: Ensure that Special Needs Treatment Plans are completed per DJS Health Care Operational and Procedure Standards.
DJS QI Report
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AVAILABILITY OF MEDICAL SERVICES
STANDARD Written policy, procedure and practice show that services for youth by trained medical staff for routine care and treatment are available 7 days per week; that there is an oncall procedure in place when medical staff are not on duty; that emergency care in case of emergent need is available and properly utilized; and that there are working sick call procedures in place that appropriately and timely address the sick youths needs. SOURCES OF INFORMATION Interviews with medical staff Interviews with youth Nursing logs Sick call log Medical file review REFERENCES None SUMMARY OF FINDINGS Youth indicate they see a nurse when they are sick and sick call forms are present and used by youth. Sick calls are completed on a daily basis seven days per week, but there is little documentation in medical. The Sick Call log is not being utilized as directed. There is no documentation in the Progress Notes section of the Youth Health Record file or in the Sick Call log. There were only 4 entries for 3 weeks in June. A doctor is on call 24/7. Nursing coverage is seven days per week: Monday-Thursday 7:30AM - 10:30 PM and 8 hours on Friday, Saturdays and Holidays and 12 hours on Sunday. The Nursing Supervisor is on call to the facility 24/7. There is a doctors clinic once per week. There is community access for all other referrals to include dental referrals. A pharmacy delivers to the facility daily as needed except on Sundays and there also is a back up emergency pharmacy for after hours. There are lab services with pick up as needed.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the health care unit in the facility: The Sick Call log process must be put into place and documentation on all encounters both in the Youth Health Record file and in the Sick Call Log.
DJS QI Report
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Comprehensive Quality Review Report J.deweese Carter Center (MD 2010)

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Comprehensive Quality Review Report J.deweese Carter Center (MD 2010)

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OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report

J. DeWeese Carter Center July 9, 2010

DJS QI Report J. DeWeese Carter Center July 2010

The following Rating Scale was used:

J. DeWeese Carter Center July 2010

Rating Superior Performance Satisfactory Performance Partial Performance Non Performance

Rating Superior Performance Satisfactory Performance Partial Performance Non Performance

J. DeWeese Carter Center July 2010

QUALITY IMPROVEMENT UNIT J. DEWEESE CARTER CENTER JULY 9, 2010

J. DeWeese Carter Center July 2010

OFFICE OF QUALITY IMPROVEMENT J. DeWeese Carter Center Executive Summary of Results

J. DeWeese Carter Center July 2010

OFFICE OF QUALITY IMPROVEMENT J. DeWeese Carter Center METHODOLOGY

J. DeWeese Carter Center July 2010

OFFICE OF QUALITY IMPROVEMENT J. DeWeese Carter Center METHODOLOGY (Continued)

J. DeWeese Carter Center July 2010

SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY

RATING: Satisfactory Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

SENIOR MANAGEMENT REVIEW

RATING: Partial Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

DE-ESCALATION & RESTRAINT

RATING: Partial Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

CONTRABAND & ROOM SEARCHES

RATING: Partial Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

RATING: Satisfactory Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

ROOM CHECKS DURING SLEEP PERIOD

RATING: Satisfactory Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

RATING: Satisfactory Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

RATING: Satisfactory Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS

RATING: Partial Performance

J. DeWeese Carter Center July 2010

Toxic and caustic materials

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

YOUTH MOVEMENT & COUNTS

RATING: Satisfactory Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

RATING: Satisfactory Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

RATING: Partial Performance

J. DeWeese Carter Center July 2010

J. DeWeese Carter Center July 2010

RATING: Satisfactory Performance