Comprehensive Quality Review Report Baltimore City Juvenile Justice Center (Jan 2011)

OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report
Baltimore City Juvenile Justice Center January 20, 2011
OFFICE OF QUALITY IMPROVEMENT Quality Review Report Baltimore City Juvenile Justice Center Evaluation Dates: December 1 - 10, 2010
TABLE OF CONTENTS EXECUTIVE SUMMARY .............................................................................................. 1 Facility Strengths ............................................................................................................ 1 QI Review Ratings Scale ................................................................................................ 2 QI Rating Percentage ...................................................................................................... 2 Executive Summary of Results ....................................................................................... 4 Methodology ................................................................................................................... 5 SUMMARY OF FINDINGS & RECOMMENDATIONS ............................................ 6 SAFETY AND SECURITY ............................................................................................. 6 Incident Reporting .......................................................................................................... 6 Senior Management Review ........................................................................................... 8 De-Escalation & Restraint ............................................................................................ 10 Contraband & Room Searches ...................................................................................... 12 Seclusion ....................................................................................................................... 14 Room Checks During Sleep Period .............................................................................. 16 Perimeter Checks .......................................................................................................... 18 Staffing .......................................................................................................................... 20 Control of Keys, Tools & Environmental Weapons ..................................................... 22 Youth Movement & Counts .......................................................................................... 25 Fire Safety ..................................................................................................................... 27 Post Orders .................................................................................................................... 29 Staff Training ................................................................................................................ 31 Admissions, Intake & Student Handbook..................................................................... 32 Classification................................................................................................................. 34 Pending Placement ........................................................................................................ 36 Behavior Management .................................................................................................. 37 Structured Rehabilitative Programming ....................................................................... 40 Self Assessment ............................................................................................................ 41 BEHAVIORAL HEALTH ............................................................................................. 42 Intake, Screening & Assessment................................................................................... 42 Informed Consent.......................................................................................................... 43 Psychotropic Medication Management......................................................................... 44 Behavioral Health Services & Treatment Delivery ...................................................... 45 Treatment Planning ....................................................................................................... 46 Transition Planning ....................................................................................................... 47
DJS QI Report BCJJC Page i of 81
OFFICE OF QUALITY IMPROVEMENT Quality Review Report Baltimore City Juvenile Justice Center Evaluation Dates: December 1 - 10, 2010
TABLE OF CONTENTS (Continued) SUICIDE PREVENTION .............................................................................................. 48 Documentation of Youth on Suicide Watch ................................................................. 48 Environmental Hazards ................................................................................................. 50 Clinical Care for Suicidal Youth................................................................................... 51 EDUCATION .................................................................................................................. 52 School Entry.................................................................................................................. 52 Curriculum & Instruction .............................................................................................. 54 School Staffing & Professional Development .............................................................. 56 Screening & Identification ............................................................................................ 57 Parent, Guardian & Surrogate Involvement.................................................................. 59 Individualized Education Programs .............................................................................. 60 Career Technology & Exploration Programs ............................................................... 62 Student Supervision ...................................................................................................... 63 School Environment & Climate .................................................................................... 64 Student Transition ......................................................................................................... 65 MEDICAL CARE ........................................................................................................... 66 Health Care Inquiry Regarding Injury .......................................................................... 66 Health Assessment ........................................................................................................ 68 Medication Administration ........................................................................................... 71 Dental Care ................................................................................................................... 73 Medical Records Retrieval ............................................................................................ 75 Special Needs Youth ..................................................................................................... 76 Availability of Medical Services .................................................................................. 79
DJS QI Report BCJJC
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OFFICE OF QUALITY IMPROVEMENT Quality Review Report Baltimore City Juvenile Justice Center
EXECUTIVE SUMMARY A quality improvement assessment and evaluation of the Baltimore City Juvenile Justice Center was conducted December 1-10, 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.
FACILITY STRENGTHS BCJJCs strengths lay in the foundation laid through the federal oversight process. Staff and managers learned and practiced youth supervision and recognition of violence triggers and continue to practice those skills today. BCJJC youth are busy, with a myriad of activities and programming that fills idle time. The Boys Club, begun by the Boys and Girls Clubs of America, is housed inside BCJJC and brings relevant, strengths-based programming to the predominantly African American male population. Youth are connected from BCJJC into their communities when they leave through the community Boys Club. Mental Health staff provide counseling services, send youth out for referrals when needed and are a strong part of the team at BCJJC. The Intensive Services Unit (ISU) provides structure to youth who cannot manage themselves on their unit; it also provides a respite for staff from the most difficult youth. The friendly kitchen staff serve delicious and nutritious meals and create meals for special occasions. The Case Managers prepare detailed court reports. Incident reports are organized and seclusion use must be authorized and is within short timeframes. The unit and shift managers have detailed knowledge of and concern for the youth who they supervise and a good working knowledge of the policies DJS has established; they take pride in having established a more professional, youth-centered environment in what can be a difficult setting.
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QUALITY IMPROVEMENT REVIEW RATINGS SCALE

Superior Performance Strong evidence that all areas of practice consistently exceed the standard across the facility/programs; innovative facility-wide approach is incorporated sufficiently so that it has become routine, accepted practice. Performance measure is consistently met across the facility/program; any gaps are temporary and/or isolated and minor; documentation is organized and readily available. Expected level of performance is observed but not facility-wide or on a consistent basis; implementation is approaching routine levels but frequently gaps remain; facility had difficulty producing documentation in some areas.
Satisfactory Performance
Partial Performance
Little or no evidence of adequate implementation of performance measure; the required activity or standard is not performed at all or there are frequent and significant exceptions to adequate practice; documentation could not be produced to substantiate practice. _______________________________________________________________________________________________
Non Performance
At the last QI Review of BCJJC in March 2009, 45 standards were evaluated. Following is a brief synopsis of the results from that review:* Rating Superior Performance Satisfactory Performance Partial Performance Non Performance # within rating 0 18 25 2 % of total in rating 0% 40 % 55 % 5%
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 1 18 15 2
% of total in rating 3% 50 % 42 % 5%
* 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.
DJS QI Report BCJJC January 2011
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BCJJC Performance Comparison

60%
50%
40%
Percentage
30%
20%
10%
0%
3/20/09
1/20/11
Dates of Review
Superior Performance Satisfactory Performance Partial Performance Non-Performance
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OFFICE OF QUALITY IMPROVEMENT Baltimore City Juvenile Justice Center Executive Summary of Results
Superior Performance
Student Supervision
Satisfactory Performance
Incident Reporting Seclusion Perimeter Checks Fire Safety Behavior Management
Partial Performance
Senior Management Review De-Escalation & Restraint Contraband & Room Searches Room Checks During Sleep Period Staffing
Non Performance
School Entry Special Needs Youth
Structured Rehabilitative Programming Documentation of Youth on Suicide Watch Environmental Hazards Curriculum & Instruction School Staffing & Professional Development Parent, Guardian & Surrogate Involvement Individualized Education Programs Career Technology & Exploration Programs School Environment & Climate Health Care Inquiry Regarding Injury Medication Administration Dental Care Medical Records Retrieval
Control of Keys, Tools & Environmental Weapons Youth Movement & Counts Post Orders Staff Training Admissions, Intake & Student Handbook Classification Screening & Identification Student Transition Health Assessment Availability of Medical Services
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OFFICE OF QUALITY IMPROVEMENT Baltimore City Juvenile Justice Center METHODOLOGY
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VII.
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 with the Superintendent, Assistants and key leadership personnel. Members of the QI Team asked and discussed with the Superintendent targeted questions related to safety and security, behavioral health, behavior management, education, medical and many other areas of facility operation. Primary Interviews A total of 13 youth were interviewed individually and several more in groups about a range of areas across the QI review spectrum. This represented 10% of the total population at BCJJC that week. Interviews were also conducted with facility staff, administration, medical, case management and education staff. In addition, 12 staff were interviewed specifically about the target areas of the review as well as their general feelings about the operation of the facility. Document Review Documents were reviewed that were requested by the QI Team and provided by the facility staff in support of facility operations and program services. The documents included medical records, incident reports, logbooks, program schedules, seclusion and suicide watch documentation, staffing reports, training records and statistical data, as well as other documents from areas in fire safety and youth supervision. Observations of Facility Operations Youth movement Structured programming Recreation 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 conducted on December 10, 2010.
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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 41 Facility Incident Reports Jun-Nov 2010 Youth grievances from 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 The IR files in every case contained both written and electronic copies. IRs are filled in entirely with few blank areas. There were no unreported incidents discovered (only one that was discovered and reported late) and staff seem very clear that all are to be reported. The narrative portion of the IR included all four parts and all four were completed. Child abuse allegations were reported to CPS as required. Precipitating events were described as required. Descriptions of uses of force (when applicable) were good. Staff gave descriptions of which arms/hands they used in most cases. However some staff put hands on youth to remove them from areas when they are being noncompliant with directives which violates DJS policy. Narratives were generally noted as good. The reader could get a good idea about how an incident occurred from reading the IR. One deficiency: sometimes the video of the same event showed that key information was left out of the IR. In some, the lack of a bathroom break or the extent of a youths aggression in order
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to justify handcuffs, were important details left out by staff. Staff should be encouraged to fully document all important aspects of each incident. Also, staff must use clear words to describe what they did. A couple of examples that were problematic were: Staff wrote that I disregarded his lunch tray when staff actually threw away his lunch tray. Staff wrote that two youth who were separated re-approached each other when they actually ran and went after each other in the gym and fought (this was listed incorrectly as an Inappropriate Conduct rather than a Youth-on-Youth Assault). Issues such as this give the impression that vagueness is used to cover for what actually did occur. If good senior management follow-up is accomplished, this can be resolved. 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 were complete. Detail on exactly where staff were posted was present in 83% of the IRs reviewed which is very good. All IRs reviewed had all or most youth witness statements present. Nearly all of the IRs had all staff witness statements present. The most common missing staff witness statement was the staff who arrived to assist. They often did participate in at least some of the event but few offered witness statements. In 100 % of incidents the youth(s) were evaluated by the nurse for injury.
GRIEVANCES There were 18 youth grievances in the past 6 months at BCJJC. Half of the complaints were about points. The resolution of these grievances appeared to be prompt and fair. The Youth Advocate picks up grievances in 1.5 days on average; every youth said they knew where to find and file grievance forms and would do so if they had a complaint. On a walk through of all three pods, one unit each was checked for stocked grievance forms; there were stocked grievance forms accessible to youth on 2 of the 3 units (none were on Unit 41).
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Especially encourage staff to give full and complete details about the incident, including all actors, what each did or did not do. Ensure no vague words are used. Encourage them that when describing a restraint they did, to include youth compliance, what was being said by all parties, whether the youth was calm, and whether the restraint was successful and if not, why not. This kind of information can be used to assess whether further or different training is needed or to confirm that staff did all they could in a difficult situation. Retain witness statements from all staff present during the event including those who come to assist.
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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 41 Facility Incident Reports Jun-Nov 2010 Review of 15 videotaped incidents Interviews with staff Review of OIG Investigations Review of seclusion documentation Review of suicide watch documentation Staff Training Histories Report REFERENCES DJS Policy MGMT-03-07 Incident Reporting Policy (MGMT-3-01); ACA 3-JDF-3B-10 and 3-JTS-3B-11 SUMMARY OF FINDINGS All of the IRs contained Shift Commander comments. Most of the shift commander comments were critiques (as is required); there is still a portion of the shift commander group who do not offer and coaching or follow-up on IRs. One Pod Manager and several Shift Commanders offered exceptional critique and incident follow-up. Their efforts included identification of the supervision issue, documented critique to staff, documented counseling of staff and documented further follow-up to ensure an action was taken. These middle managers are the most important day-to-day staff in facilities and BCJJC is fortunate to have some with these very high level skills and obvious dedication to accountability. Policy requires senior administrative review of incident reports within 72 hours which, on average, is accomplished. Audits are completed by all three Pod Managers, one of the two Assistant Superintendents, and one RA Supervisor in charge of the ISU. Only a small portion of the incidents are audited however. Restraints, seclusion use, and other critical incident types are not audited but administrative review of these incidents is required by policy. Of the 15 videos reviewed regarding 15 incident reports, only 5 had been audited; and in 13 of them, some issue presented that would have warranted comment by Administration if reviewed on video. Though Inappropriate Conduct incidents on their own are not required to be audited by policy, the number reviewed by QI with sometimes substantial issues in terms of either incorrect incident type or video reviews that showed concerns
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were large enough in number to make QI strongly encourage their audit as well. Two of the fifteen videos showed employee conduct that led QI to refer to OIG but were not previously caught be management. Some were actually fights but were incorrectly listed as Inappropriate Conduct. Video review of an incident is only accomplished for assaults. And even then, the documentation of that video review showed that only about half of the assaults are video reviewed. Though it is likely that the video indeed was reviewed in many of those cases by Shift Commanders in floor control, there was no documentation to support that. Seclusion sheets showed no evidence of auditing in most cases. Suicide watch documentation is not audited. The Office of the Inspector General (OIG) completed 15 investigations in the past year, 5 of which were sustained. All seemed to be thorough and gave a good accounting of the facts. The OIG investigators at BCJJC are extremely diligent.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Require all shift commanders to critique staff and to share their comments with staff so that staff can learn from the management review. Ensure all shift commanders understand the mechanics of a critique and know what supervision points to catch when they review an incident. Ensure regular audits of suicide watch sheets. Ensure seclusion forms are audited along with the IR. See that Shift Commanders document in the Video Review Tracking Log when they have reviewed a video. Consider adding video review of Inappropriate Conduct incidents to ensure they are correctly designated and are not actually assaults. Begin auditing all IRs to ensure issues are spotted and if necessary, discipline is accomplished. Assign all managers equally so that the task is manageable.
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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 41 Facility Incident Reports Jun-Nov 2010 15 videotaped incidents Staff Training Histories Report Interview with Superintendent Interview with Assistant Superintendents Interviews with youth Interviews with staff REFERENCES DJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management (CPM), Techniques Policy (RF-02-07); DJS Videotaping of Incidents Policy (RF-05-07); ACA 1-SJD-3A-14-15 SUMMARY OF FINDINGS Descriptions of uses of force in written IRs were good. Staff explained in good detail what they did. There was no evidence that restraints went to the floor immediately; standing restraints were most common. There were 3 occasions where staff seemed to lose their cool due to the youths behavior (spitting, for example). Other staff were quick to move in to remove the agitated staff from the situation. But more often, BCJJC staff showed professionalism and calmness in what were extremely heightened situations. Uses of force on youth are last resort methods but when they have to be used, evidence showed that the BCJJC staff do a good job maintaining control and a professional demeanor with youth. Handcuff use at BCJJC is prevalent. DJS policy requires that handcuffs be only used to assure secure movement of youth. Though the BCJJC Superintendent indicates that handcuffs are used as often as they are for safety (per the Superintendent, they are safer than an extended physical restraint), there was little evidence on the video tapes to suggest that handcuffing a youth to walk him a very short distance to his room was always necessary. Other facilities do not use handcuffs as often and do not have any higher incidences of youth or staff injury. In one incident of handcuff use, a youth was found to be in handcuffs more than 15 minutes without further authorization and without constant supervision (youth in handcuffs 32 minutes). Most times handcuffs are off within the first 15 minutes but any restraint use must be audited and scrutinized.
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Of the 15 videos reviewed, most showed uses of force that were reasonable, nonaggressive and safe. Staff used CPM techniques and when they did not or could not, used safe alternatives. An RA Supervisor indicated that he uses restraints in order to move youth for non-compliance which is not permitted by DJS policy or by COMAR. All staff should know this is not permitted. This same issue was also brought to the attention of the facility by the Juvenile Protection Division of the Public Defenders Office via a November 3, 2010 email. Just 27 of 108 staff (25%) were compliant with Crisis Prevention and Management semi-annual training (when reviewing CPM compliance overall, 53% had had CPM at least once in the prior year.) Mechanical restraints are not covered in training.
RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Ensure all staff are trained twice yearly in CPM, including mechanical restraints. Ensure all staff are aware that moving a youth for non-compliance is not permitted by DJS policy or by COMAR. Ensure they have other methods they can apply in these situations and that this use of restraint is not tolerated by management. Monitor handcuff use and ensure they are only used when absolutely necessary. Most youth having to be taken from the unit dayroom to a downstairs room should not require handcuffs. Ensure all staff who are agitated by youth are processed about the incident and have strategies to employ next time in order to remain calm.
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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 Logbook Interview with Staff Observation at the facility REFERENCES DJS Searches Policy (RF-06-07); Incident Reporting policy (MGMT-03-07); ACA 1SJD-3A-16 SUMMARY OF FINDINGS DJS written policy and procedures require that sleeping rooms be searched a minimum of once per week for contraband and the search be documented in the respective units log book. A review of randomly selected unit log books indicated inconsistencies with documenting the required searches as pursuant to DJS policy. Staff interviews along with a review of FOPs indicated that staff are required to search sleeping rooms for contraband at least twice a day (i.e. 1st and 2nd shifts). Each room search is to be recorded on a Shakedown Form. A review of randomly selected Shakedown Forms for the period of August 2010 to November 2010, revealed inconsistencies with staff documenting at least two room searches per day. Three of ten staff interviewed indicated that they are not given enough time or assistance to realistically search each sleeping room. A review of the DJS Incident Reporting Database for the period of January 1, 2010 to December 7, 2010, revealed that the facility reported 37 incidents involving contraband. A QI team search of several sleeping rooms revealed several plastic drinking straws, a pen, paper clip and pencils hidden under mattresses. Also, a pen and a pack of pencils were left attended in a unit dayroom. Several of the sleeping rooms had gang graffiti written on the walls and/or floor. One sleeping room had a collection of inappropriate pictures of females posted on the wall. Staff immediately removed the pictures from the room. Observations revealed that youth are not consistently frisked for contraband upon movement from the dining hall and school. Of the three movements observed, youth were frisked only during only one. During one observation, a staff was in the process of escorting a youth from a classroom and was instructed by a supervisor to search the youth before leaving. The staff responded by asking what was he supposed to be looking for.
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A review of the DJS Incident Reporting database revealed that staff searches and observations have resulted in the recovery of various contraband items (i.e. cell phones and chargers, batteries, a sexuality explicit magazine, a mirror, a MP3 player, headset, tobacco substances, [suspected] marijuana, lighters, matches, sharp objects, seeds, Zantac pills, pens, pencils, etc.) It is admirable that these items are found, but the type and number of incidents is concerning, especially when it is unclear how these items entered detention without being discovered. DJS Security staff utilize a walkthrough metal detector and handheld wand to scan visitors and employees for contraband prior to entering the secured area of the facility. Frequent searches of general areas appear to occur as pursuant to DJS policy.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure staff are familiar with their responsibility to conduct and record room searches as required by policy. Ensure staff under the importance of being thorough and consistent when conducting frisk searches upon movements. Have maintenance eradiate all graffiti from the walls and floor of sleeping rooms. Have staff carry or secure pens/pencils and not leave them about day room/unit. If staff lends a pen/pencil to a youth, they should record that in the logbook and get the pencil back. Review contraband incidents reports to discover the source of contraband and prevent its reoccurrence.
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SECLUSION
RATING: Satisfactory Performance
STANDARD Written policy, practice and procedure provide that youth confined to a locked room, not during sleeping hours, shall be observed often and have those observations documented, shall only be placed in seclusion if they present an imminent threat to others or an imminent threat of escape, and shall be treated humanely and with concern and care so as to safely maintain the youth until he can be released in the least amount of time. SOURCES OF INFORMATION Facility Seclusion Log Interview with Superintendent Interview with Assistant Superintendents Incident Reports from June-Nov 2010 Seclusion sheets Interviews with youth and staff Observation at facility REFERENCES DJS Seclusion Policy RF-01-07; COMAR 16.18.02 SUMMARY OF FINDINGS Documented seclusions at BCJJC are as follows: # of seclusions 73 99 125 56 Average Daily Population 117 122 124 123 Rate 2.01 2.70 3.25 1.52
Month August September October November
There was a rise in October and a fall in November that could not be explained by the Administration so it is unclear what if anything was responsible for these changes. The average length of stay in seclusion is relatively short. For the month of November 2010, the stay averaged 3.34 hours. Seven (7) documented episodes of seclusion were reviewed. Checks on the sheets by line staff showed few concerns. Most staff made all checks (and listed youth behaviors displayed) as required. In two cases, staff wrote missed check when they missed checks of youth due to other unit duties. This is excellent practice and gives their checks even more credibility. There was no documented auditing of the seclusion log or observation sheets; the Superintendent indicated they had stopped doing so but were going to reinstitute the practice. BCJJC used to also track seclusion use and lengths of stay; this also
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is no longer occurring but the Superintendent indicated he will re-institute this as well. There is no random video review of seclusion episodes. The shift commander comments (reasons for youth not being released from seclusion) were good. The facility requires senior administrative approval of seclusion use. In every documented case, medical staff appropriately documented observations. In every documented case, shift commanders visited the youth and made checks timely. Youth were individually processed and not all released at one time, an indicator that seclusion is not being used as punishment. Seclusion use for lack of staff (staff shortages) was documented in the seclusion log as required which is excellent practice. The use of early bed violates DJS seclusion policy. There was one indication by staff (IR# 86971) that a youth had to go to bed at 6:30 due to his behavior. The youth was angry and an incident resulted. This was not caught by the Administration. These kinds of instances can increase exponentially if not caught and staff not counseled that early bed is not permitted. Staff must follow the BMP when imposing consequences for youth.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that the auditing process includes seclusion sheets and the seclusion log if a seclusion episode occurs. Ensure all staff are aware that early bed is not permitted. Institute random video review of 5-10% of seclusions monthly to ensure staff checks are happening as expected. Track seclusion lengths of stay by rate and ensure all Administrators are aware of seclusion patterns and any burgeoning overuse.
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ROOM CHECKS DURING SLEEP PERIOD
STANDARD Written policy, procedure and practice document that staff visually check the safety and security of each youth at least every 30 minutes during the sleep period, unless instructed to check more often due to the status of the youth. Room checks during sleep period document the youths name and the time the check was conducted SOURCES OF INFORMATION Interviews with staff Logbooks Guard Tour documentation REFERENCES DJS Youth Movement and Counts Policy RF-02-06; ACA 3-JDF-3A-04 and 3-JTS-3A04 SUMMARY OF FINDINGS BCJJCs FOP requires that staff conduct a visual check of each youth at least every 30 minutes during bedtime hours and record the observed behavior of the youth at the time of the check. Interviews and a review of FOPs revealed that the facility utilizes the Guard Tour System to electronically record each check during the bedtime hours. The start of each youths bedtime is between 8pm and 9:30pm and corresponds with the youths BMP level. Wake up time is at 5:30am. A review of Master Control logbook(s) indicates that Master Control usually announces around 10:30pm that units are to begin wanding rooms. The announcement suggests that some units may be starting their room checks after 10pm., which is two hours after the level one youth are required to be in locked in their rooms for bed. A review of the Guard Tour data revealed that some units did not start conducting room checks until after 10pm. A review of 132 randomly selected sleep periods (excluding units 42 and 43) revealed that there were: o Ten (10) incidents in which room checks were not checked/documented during the sleep periods; o Sixty-five (65) incidents in which room checks were not conducted prior to 10pm; o Twenty-eight (28) incidents in which room checks ended two to five hours prior to wake up time; and o Twenty-one (21) incidents in which gaps between checks ranged from 90 minutes to 275 minutes.
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DJS and BCJJC FOPs require that staff members who are conducting room checks record the observed behavior of the youth at the time of the check. Staff did not record the observed behavior of any youth while conducting checks. Units 40 and 41 consistently documented the required checks from the beginning to the end of the sleep period, however, they did not document the behavior of the youth. The facility did not provide documentation regarding any malfunctions with the electronic Guard Tour system. BCJJCs Tour Guard FOP requires Pod Managers to confirm weekly that room checks are being completed as required. The randomly selected room checks from August 10, 2010 to December 12, 2010, revealed that the deficiency by staff to record the observed behavior of youth as well as the gaps in checks has gone on unabated.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Require the shift commanders to verify that staff are conducting the required room checks and documenting their observations of youth throughout their shift. Shift Commanders/Pod Managers should randomly review Guard Tour data for verification. Any discrepancies or failures by staff to properly perform room checks should be reported to the Facility Administrator or designee for corrective action.
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PERIMETER CHECKS
STANDARD Written policy, procedure and practice document daily security checks of the perimeter to include, at a minimum: a check of all locks, windows, doors, fences, gates, security lighting, security devices, and a check of outdoor areas, gates and security fences to ensure they are secure, free from contraband and have not been tampered with. SOURCES OF INFORMATION Facility Tour Observations Logbooks Interviews with staff REFERENCES DJS Perimeter Security Policy RF-09-07, Maryland Standards for Juvenile Detention Facilities; ACA 3-JDF-3A-12, 2G-02, 3-JTS-3A-12 and 2G-02. SUMMARY OF FINDINGS DJS policy requires that at least one perimeter check be conducted daily. Interview with staff along with a review of documents revealed that at least one interior perimeter check is conducted during each shift with only a few exceptions. DJS Security Officers frequently inspect the external perimeter of the facility on a daily basis. The Shift Commanders are required to document the interior perimeter checks on a check-off form; however, the time of the check is not indicated. The form only indicates the shift (i.e. 6a-2p, 2p-10p, etc.) at the time of the perimeter check. A review of Master Controls logbook(s) revealed that interior perimeter checks are not consistently documented in the logbook. One entry in the logbook indicated that the perimeter check was completed via camera. During a tour of the facility, three security doors were discovered unlocked (a hallway door, one of the health suites sally port doors and a school door.) DJS Security utilizes a walkthrough metal detector and handheld wand to scan visitors and employees for contraband prior to entering the detention area of the facility. A review of the Visitors logs (i.e. civilians, Community Case Managers, etc.) revealed that 13 % of the visitors between July 1, 2010 and December 6, 2010 did not sign out upon leaving the facility.
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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. Ensure all doors are kept locked when not in use. Ensure Shift Commanders indicate the time of each perimeter check on the form and actually conduct a physical check of the perimeter.
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STAFFING
STANDARD The facility maintains a current staffing plan that ensures a sufficient number of staff is present to provide an environment that is safe, secure and orderly. SOURCES OF INFORMATION Review of Facility Staff Review of Facility Logbooks Interview with staff and youth Interview with Assistant Superintendent Review of Seclusion Logs Observation of facility REFERENCES ACA 1-SJD-1C-03 SUMMARY OF FINDINGS A review of the seclusion log from October 2010 to December 2010 found seven instances when youth were on seclusion because of a lack of direct care staff. The seclusions ranged from a half hour to five hours in length. A review of the school log book from October 2010 to December 2010 indicated that there were six instances when units were held back from first period due to a lack of direct care staff. The Assistant Superintendent indicated that there is a steady flow of overtime at the facility. He reported that there are staff needed in places that are not built into the schedule. He reported that there are an abundance of medical runs requiring two additional staff members per run. He also reported that there has been an increase in special education students in the self-contained class, requiring an additional staff member for first shift. Also, during the review both of the Orientation units held 17 youth apiece. This also required two additional staff members per shift above the scheduled allotment of staff The Assistant Superintendent reported that there are 9 Resident Advisor vacancies, 2 Resident Advisor Lead vacancies and 3 Resident Advisor Supervisor vacancies at the facility. At no time during the review were the units observed to be out of the appropriate ratio. Seven of the eight staff members interviewed indicated that they are required to do at least one double shift a week, with five indicating that they are required to do several double shifts per week. Most of the staff indicated that they dont mind working the double shifts because of the additional money as long as they are given enough time to prepare for them.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Review the current staffing pattern to determine the additional staff that are needed in light of the needs of the facility. Continue to recruit to fill all available vacant residential staff PINS.
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CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS
STANDARD Written policy, procedure and practice provide for the control of tools and equipment that could be used as weapons or for other dangerous purposes. There is system that ensures strict accountability of the receipt, usage, storage, inventory, and removal of all toxic and caustic materials. SOURCES OF INFORMATION Facility Tour Interview with staff Key Inventory Tool & Sharp Objects Inventory REFEERENCES DJS Key Control Policy RF-06-05; DJS Perimeter Security Policy RF-09-07, ACA 3JDF-3A-22 and 3-JTS-3A-22 SUMMARY OF FINDINGS DJS policy requires that each facility maintain a working keyboard as the prime issuing point for facility keys issued on a regular basis. BCJJC has a key control process and maintains two keyboards (i.e. Restricted and Working Keyboards) in Master Control from which keys are issued on a regular basis. The facility utilizes assigned chits, a Sign-in/out Key Log and frequent inventories to account for facility keys throughout the day. A review of the restricted keyboard revealed key RK#27 lying at the bottom of the key box without an assigned hook. DJS policy requires that every assigned hook in a keyboard contain either a key or chit so that it can be readily apparent if a key is missing. An inspection of the working keyboard revealed 4 vacant hooks. A review of the key log revealed that the keys had been signed out. According to MC staff, an administrative chit is usually placed on a hook if the staffs assigned chit is not available when the key is issued. No administrative chits were available. DJS policy requires that a set of facility emergency keys be maintained at a secure location away from, but near the facility (e.g., another DJS facility, local law enforcement facility, etc.). Interview with the Facility Administrator and Assistant Facility Administrative revealed that the Director of DJS Security and Master Control maintain a set of emergency keys. However, both the Director of DJS Security and Master Control are housed in the same building as the facility. A review of the key logs revealed several irregularities with staff recording the return of facility keys. The key logs and Master Control logbook revealed a few instances involving staff failing to return keys at the end of their shift.
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Not all of the keys to pod doors and sleeping rooms are identifiable by touch. Some keys to the fire extinguisher and unit supply/janitor closets have difficulty unlocking the locks. Observation revealed that keys are maintained on a metal key ring soldered/crimped at the joint to prevent tampering, loss or removal. Observed key rings have a tag affixed that indicate the hook number of the key ring and the number of keys on the ring. The Assistant Facility Administrator maintains Back-up keys in a secure location along with an inventory listing of the keys. Policy requires that at least one randomly selected key ring be inventoried daily to verify and record the number of keys attached to the ring. Although facility keys are inventoried frequently, a daily inventory of one key ring as prescribed by DJS policy is not conducted. An Interview with the Assistant Facility Administrator (Key Control Officer) revealed that several keys have been replaced with new keys. The facility maintains a back up key board and 24 Hour Key Authorization Forms.
TOOLS A walk through of the Maintenance Section showed it to be clean, well maintained and organized. The Maintenance Section is located outside the secured detention area. Maintenance maintains a master inventory of the tools assigned to the section and the tools are color coded for identification. The Maintenance staff conduct frequent inventories to account for tools. Power generators are tested weekly.
CULINARY UTENSILS A walk-through of the Food Service area showed it to be clean, well maintained and organized. Knives and other dangerous utensils are kept secured in a locked cabinet. An inventory of the knives and utensils revealed that they all were accounted for. The knives and utensils are inventoried and documented 3 times a day, however, a sign out sheet is not maintained. The kitchen maintains Material Safety Data Sheets (MSDSs) for hazardous chemicals (cleaning fluids, etc.) used or stored.
ENVIRONMENTAL WEAPONS During a tour of the facility, it was noted that several pencils were accessible.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure each key ring is assigned to a hook in a key box. Ensure administrative chits are readily available for staff who do not have an assigned chit to exchange for a key. Shift Commanders should verify that staff are signing-in the returned keys at the end of their shift. Mark emergency and security keys in a manner that identifies them by touch. Replace all keys or locks that do not operate properly. Ensure that key inventories comport with DJS policy.
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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 Logbooks Interviews with staff Interviews with youth Facility tour Observation of youth movement REFERENCES DJS Youth Movement and Counts policy RF-02-06; ACA 3-JDF-3A-13 & 14 and 3-JTS3A-13 & 14 SUMMARY OF FINDINGS Written DJS policy requires that each facility conduct and record a physical count, at minimum, every 30 minutes or more often based on the need, size of facility or other circumstances as articulated in their FOP. BCJJC maintains a Youth Movement and Counts FOP that identifies the facilitys counts procedures. A review of several unit and Master Control logbooks revealed that BCJJC does not conduct or record physical counts, at a minimum, every 30 minutes as pursuant to DJS policy. Counts at the facility are conducted and recorded every four hours to include the required 2am count. It was noted that several units sometimes record other counts throughout the day. It appears that the 3rd shift frequently record 30 minute counts throughout the shift while conducting room checks. Observations revealed that staff do not consistently frisk youth upon movement. Observations also revealed several youth trying to avoid being frisked by moving about as they lined up for movement. For the most part, youth movement was orderly. A review of logbooks revealed very few instances of the actual count being included in the logbook. The staff do record in the unit logbook whenever a youth is taken from and returned to a location. 7 of 8 staff interviewed indicated that the maximum number of youth 1 staff can supervise alone is 6 youth. The facility officially recognizes the youth to staff ratio as 6:1.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure supervisors/shift commanders require staff to conduct counts every 30 minutes and call the count into Master Control within fifteen minutes of the count being taken. Shift commanders should confirm that the required counts are logged in the appropriate logbooks. Ensure staff consistently and thoroughly frisk youth upon any movement.
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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 Interview with the Fire Safety Officer Interviews with maintenance staff Review of Logbooks Examination of Fire Safety Equipment Fire Drill Documentation REFERENCES DJS Policy MGMT-3-01; ACA 3-JDF-3B-05, ACA 3-JDF-3B-10 and 3-JTS-3B-11 SUMMARY OF FINDINGS The State Fire Marshal last inspected the facility on March 12, 2010. No deficiencies were noted by the Fire Marshal, however, it was indicated that staff are to ensure keys to the fire protection equipment boxes function properly. Observations revealed some keys had difficultly unlocking fire extinguisher boxes. A fire safety vendor last inspected and/or serviced the facilitys fire safety equipment (i.e. sprinkler system, fire extinguishers and etc.) on September 23, 2010. No deficiencies were readily apparent. An inspection of the Fire Alarm Control Panel located in Master Control revealed that is was operational and no trouble was indicated. However, the door to the FACP was left open. Interview with the Fire Safety Officer along with a review of fire drill records from July 2010 to November 2010 revealed the following: o During the month of July 2010, four fire drills were conducted. No fire drills were conducted by the 3rd shift. o During the month of August 2010, two fire drills were conducted. One fire drill was conducted on the 3rd shift at 3am that lasted one minute (the youth and staff did not depart the building). No fire drills were conducted by the 1st shift. o During the month of September 2010, three fire drills were conducted. No fire drills were conducted by the 3rd shift. o According to the Fire Safety Officer, there is no record on any fire drills occurring during the month of October 2010.
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o During the month of November 2010, two fire drills were conducted. No fire drills were conducted by the 2nd shift Four fire extinguishers were randomly checked and no deficiencies were noted. Observations revealed that entrances and hallways were unobstructed. Staff and youth interviews revealed that they have participated in a fire drill.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure the FACP in Master Control is locked. The Fire Safety Officer should ensure that each shift conducts at least one fire drill a month. Fire drill evaluations should be as realistic as possible, when it is safe to do so, in order to train staff and youth on how to conduct an emergency evacuation.
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POST ORDERS
STANDARD: Written policy, procedure, and practice provide post order for security post and key staff positions. Staff members are familiar with roles and responsibilities of the post order prior to assuming the post. Post orders are current. Shift commanders ensure that post orders are reviewed by the staff member. Post order signature sheet is signed by the staff assuming the post and initial by the immediate supervisor. SOURCES OF INFORMATION: Post Orders Facility Tour & Observation REFERENCES: DJS Post Orders Policy RF-07-07; ACA 3-JDF-05, 3-JDF-3A-06, 3A-JDF-3A-07 SUMMARY OF FINDINGS: DJS policy requires that each facility maintain a copy of all Post Orders and Post Order Signature Forms in Master Control. No Post Orders or Post Order Signature Forms were available for review in Master Control. A set of Post Orders and FOPs were obtained from a BCJJC administrative staff and were presented to a QI team member: o Dining Hall Post Order, date: 11/5/10. o Education Post Order, date: 10/06/10. o RGLM 1 Post Order, date: 11/05/10. o Intake Post Order, date: 11/05/10. o Master Control Post Order, date: 11/05/10. o Outdoor Recreation Post Order, date: 11/05/10. o Medical Post Order, date: 11/05/10. o Unit Post Order, date: 11/05/10. o Visitation Post Order, date: 11/05/10. Six (6) posts were checked to verify if the respective Post Order was being maintained at or near the post, as required by DJS policy. Only one post (Education) maintained the required post order and signature form. There were no special duty/assignment positions (i.e. key control, fire safety officer, and etc.) post orders available for review. The facility did not provide a post order for the Maintenance Shop and some staff positions (i.e. RA, RA Lead, RA Supervisor) identified in the DJS Post Order policy.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that there is a post order for at least every staff and special duty assignment positions delineated in policy. (e.g., Resident Advisor series positions) This will ensure staff are aware in writing of the responsibilities and duties associated with their positions/post. Ensure all staff assigned to a specify post or working the post for the first time, read the post order and acknowledge that they understand the duties and responsibilities associated with the post. Ensure Master Control maintains a copy of all post orders and Post Order Signature Forms.
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STAFF TRAINING
STANDARD Written policy, procedure and practice provide that all staff who have regular and daily contact with juveniles receive organized, planned and evaluated trainings in accordance with departmental guidelines. Training is designed for continuous development of skills related to job specific learning objectives. SOURCES OF INFORMATION DJS Training Histories report Interviews with staff REFERENCES Maryland Correctional Training Commission (MCTC); ACA 1-SJD-1D-03, ACA 3-JDF-1D-01, ACA JDF-1D-02 SUMMARY OF FINDINGS: Mechanical restraints are not covered in CPM training as required. Of 130 mandated staff, 108 (83%) were reviewed for training compliance and the results were as follows: -- 59/108 (55 %) met the 40 hour annual training requirement. -- 53/108 (49%) of staff had First Aid/CPR/AED training in the prior 12 months. -- 27/108 (25 %) were compliant with Crisis Prevention and Management semiannual training (when reviewing CPM compliance overall, 53% had had CPM at least once in the prior year.) -- 82/108 (76%) were compliant with Suicide Prevention annual training. -- 80/108 (74%) were compliant with Recognizing and Reporting Child Abuse and Neglect annual training. The facilitys five mandated management staff (two Assistant Superintendents and three GLM IIs) who are responsible for holding staff accountable in all of these necessary areas were not compliant with almost any of the main four required trainings annually. One Assistant Superintendent and one GLM II had not had any of the required trainings in two years. After discussions with the Superintendent about this, all five managers were scheduled for all required trainings in December and January and will all attend DJS trainings annually from now forward as required.
RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Ensure all staff needing required trainings attend at a rate above 90% across all categories.
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 and Assistant Superintendents Interview with staff who perform intake/viewed partial intake process Interview with Case Manager Supervisor Review of youth handbook Review of youth base files REFERENCES Admissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile Detention Facilities; DJS Classification Policy RF-01-08; ACA 3-JDF-5A-02, 3-JTS-5A-01, 5B-01 through 04 and 5B-07 & 08 SUMMARY OF FINDINGS Handbook acknowledgement forms were found in youth files. The handbook at BCJJC is very complete. A small error in the BMP section was discussed with BCJJC Administrators. Youth arent getting a handbook at intake because intake staff have no copies to give them. The case managers go over the handbook in Orientation but since youth are signing an acknowledgement at intake that they have received one, they should then receive one at Intake to keep. In all cases, the SASSI and the MAYSI were found to have been completed within two hours of admission as required. Intake staff interviewed knew how to score the MAYSI and does so. The SASSI is completed and scored online which is ideal. Intake staff knew how to scan the results for issues and refer youth to Mental Health staff if they have any concerns on either screening. The FIRRST is completed upon the youths arrival. Staff knew not to accept custody if the youth has any yes answers, however police in almost every case had already left the facility and were not available to take back custody of youth who were injured or mentally unstable. BCJJC transportation fill that role. A medical assessment is done upon admission and in every case within 72 hours.
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The greater issues came in the Orientation unit and process. There are two full units (out of ten total units) dedicated to Orientation youth. These units are consistently well over the 12 youth that can sleep in the 12 beds each has available. Consequently, youth have to sleep out on other units or in other areas. Youth in Orientation stay far longer than what is proscribed by policy. The average length of stay on BCJJCs Orientation Unit is 6.5 days. A full 55% of youth spent more than 3 days on Orientation and of those, the average length of stay was 11.1 days. Youth in Orientation do not follow the posted schedule and have little to no structured programming afforded them. Time is spent watching TV and doing little else. Many youth on Orientation have been to BCJJC numerous times and consequently do not need to be oriented to the facility. Many have medical, mental health and educational records on file and after a brief assessment period, could be housed on a regular unit. Almost no educational services are afforded youth on Orientation. If they were only on the unit for three days or less, this would not be a concern. However since several youth had stays of almost two weeks, this is a significant problem.
RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended the facility: Re-think the need for two Orientation Units. Youth should have all assessments completed within three days and by then, DJS staff should be aware of his court date and whether he is remaining in detention. Youth should be assigned to a unit expeditiously and begin going to school. Currently, only seven units move to school. There is space for one Orientation Unit to return to normal unit status and for those youth to move to school and eliminate the idle time they currently have. Require the Orientation Case Manager to alert all relevant Administrators when a youth is closing in on his third day of Orientation with no unit assignment/transition plan in place yet. Ensure he is in a permanent unit that next day and moving to school as required. Create and follow an Orientation Unit schedule. Do not put events and activities on the schedule that do not occur. Ensure intake staff have copies of the youth handbooks and give one to each youth (along with their state clothing and shoes) upon admittance. Consider working with the Baltimore Police Department to ensure youth are screened on the FIRRST while in holding and upon arrival and that police are required to take youth to hospitals for emergent care if injured upon arrival. This will alleviate the need for DJS Transportation staff to do so.
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CLASSIFICATION
STANDARD Written policy, procedure and practice document that all youth are classified and assigned housing according to current age, severity of current legal charge, most serious prior charge, number of prior serious incidents while in custody and special needs. FOP and practice also provide for reassessment of all youth no later than 60 days following facility admission and within 24 hours of the third serious incident since admission to the facility, and more frequently in response to needs of youth or security of the facility. SOURCES OF INFORMATION Interviews with Admissions/Intake Staff Interview with Case Management Staff Review of base files Observation at facility REFERENCES Maryland Standards for Juvenile Detention Facilities; DJS Classification Policy in editing stage; ACA 3-JDF-5A-02, 3-JTS-5A-01, 5B-01 through 04 and 5B-07 & 08; SUMMARY OF FINDINGS DJS Classification policy requires that each facility develop a FOP that includes: o Identifying the specific employee(s) responsible for: (a) Conducting and completing Housing Classification Assessments and Re-Assessments; (b) Reviewing ASSIST for prior DJS commitments and placements, and inputting admissions data; (c) Reviewing the DJS Incident Database for serious incident involvement (youth on youth or youth on staff assaults, group disturbances, restraints and escapes or attempted escapes); (d) Observing youth to determine if initial classification level and housing assignment is meeting the needs of the youth; and; establishing protocols for housing and proper supervision of youth to ensure that youth are placed in a unit and room suitable to the youths classification level. The required Classification FOP was not available for review. DJS policy requires that classification assessments be implemented for all youth on their admission to the facility. Interview with Intake staff revealed that one staff is responsible for completing the initial classification assessment upon a youths assignment to the facility. 15 of 24 base files reviewed contained the required initial classification assessment form. The Intake staff has devised a system in which the initial classifications are completed on a roster and then the information is later
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transferred to an individual classification form and placed in the base file. This method of completing the classification process may have accounted for some forms not being in a youths base file. During the QI review period, the Intake staff did provide an initial classification form for each youth assigned to the facility. 6 of 6 base files reviewed did not contain the required reclassification form in response to a youth being assigned to the facility more than 60 days or requiring special needs that may require modification of the youths housing assignment. Interview with the Case Manager Supervisor revealed that the process was not conducted and the matter will be corrected. 4 of 24 classification forms contained an error or were incomplete. None of the forms indicated the youths assigned room number. It was noted that after a youth leaves intake, he is assigned to a single bed room in the Orientation Unit before assignment to the general population. An interview with staff along with a review of documentation revealed that a youth may be placed on a Guarded Care/Behavior Plan based on his conduct or need. However, a reclassification form is not routinely completed in these cases. Interviews revealed that Intake and CMS staff have been trained in the proper scoring and utilization of the Housing Classification instruments. DJS policy requires that each facility develop a Housing Plan for each living area. The Housing Plan is to include: o Physical plant description; o Capacity; o Staffing pattern for each shift; o Safety, security and supervision practices; o Single and double youth sleeping rooms; o Youth classification levels and specific population assigned; o General programming; and o Special services and/ or accommodations. The required Housing Plan was not available for review.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Formulate a written FOP and Housing Plan pursuant to DJS policy. Ensure that all Housing Classification Assessment and Re-Assessment forms are placed the youths base file. Have Case Managers complete Housing Classification Re-Assessments of youth in conjunction with the Interdisciplinary Treatment Team, not more than 60 days from the completion date of the Housing Classification Assessment or previous Re-Assessment and within 24 hours of a youth being involved in a third serious incident since initial housing classification assessment. They should also be completed within 24 hours of receiving new information which may affect the youths housing/supervision classification.
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PENDING PLACEMENT
RATING: Not Rated
STANDARD Written policy, procedure and practice document that the facility has a list of youth pending placement, their days committed, and average length of stay and aggressively prioritizes these youth in order to assist the community case managers in placing them as quickly as possible in order to reduce time in detention.
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BEHAVIOR MANAGEMENT
STANDARD Written policy, procedure and practice document a behavior management system which provides a system of rewards, privileges and consequences to encourage youth to fulfill facility expectations and teach youth alternative pro-social behavior. Youth who are not invested in the facilitys system have alternative and individual plans. SOURCES OF INFORMATION Review of Unit Log Books Review of Daily Point Sheets Review of the Student Handbook Review of Behavior Management Plans Review of 6 Guarded Care Plans Review of Intervention Plans Interviews with youth Interviews with of direct care staff REFERENCES DJS Behavior Management Program Policy RF-10-07; Facility Behavior Management Program (BMP) SUMMARY OF FINDINGS A review of Daily Point Sheets indicated that most were completed and calculated correctly. A comparison with the BMP listed in the student handbook indicated that most of deductions were in line with the written program. A review of the audited point sheets showed a great deal of corrections, indicating that there were very severe problems with calculations. However, upon closer review it was determined that the corrections would be made several days after the sheets were turned in. Therefore, one mistake or miscalculation would require that the sheets for the next three to five days be corrected as well. A more timely review of the sheets would alleviate many of the corrections. The calculation mistakes were repeatedly made by the same staff members. The QI team was told that the facility administration has been apprised of the staff who need re-training but it has not yet been accomplished. During the review, the QI team identified three youth who caused disruptions during the school day in one or more classes that, according to the Behavior Management Plan and the Student Handbook, should have received point deductions. When the point sheets of these youth were reviewed, in every case the youth received the appropriate deductions. Teachers were allowed to give and take away points for the times when youth were in school. Youth consistently indicated that they receive the incentives as outlined in the student handbook. They listed commissary as their favorite incentive in the program. Youth reported that bedtimes are administered according to the BMP.
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The Case Managers create court reports for all youth to inform judges of youth behavior and to encourage youth to behave in detention. For youth who have difficulty maintaining appropriate behavior under the Behavior Management Program, the facility creates Guarded Care Plans (GCPs). These plans were to be created for youth on the mental health caseload; they outline negative behaviors, triggers and action plans to help and direct youth to display positive behaviors. Each plan indicated that there were to be follow-up meetings and updates to the original plans. According to the files, five of the six plans were reviewed and updated as scheduled. The Intensive Services Unit (ISU) is also a method for managing youth who do not respond to the BMP. The ISU was formed during federal oversight and made great strides in assisting BCJJC in lowering youth violence rates and worked as a deterrent for violent behavior. There is a written program description that was developed in 2009 and completed in 2010 and it was reviewed for this QI review. In reviewing the intended operation of the ISU, some issues with its operation were found: - Youth admission criteria are not all checked off to ensure fidelity to the ISU model. It appears that youth meet only one or two of the four or five required criterion and are admitted by committee agreement. - No incident information is included in ISU files. No emails or database or IR information is listed to give foundation for the youths entry into ISU or to inform ISU staff on youths previous behavior. - Similarly, youth with violent behavior or youth indicating youth assaulted staff after a restraint are approved for ISU but without any information on exactly what they did to fuel their entry. - Clear justifications for all overrides are not thoroughly documented on the admission form as required. - The Assistant Secretary or Director of Detention are not notified when a youth is admitted into the ISU. - Education staff do not appear to be as available on the ISU as in previous visits. Logbooks sometimes indicated no education staff and only sometimes were packets provided in those cases. - Bedtime for ISU youth is 7 pm, no exceptions, but a youth was allowed to stay up late to do details in December against the program requirements. - Handcuffs are carried and routinely used by ISU staff but are not carried by other direct care staff. The Administration indicated that handcuffs were part of the ISU program but they are not listed in the program design. Handcuff use in ISU cannot be more prevalent due to the youths special designation; it must still conform to DJS policy. - Of 6 youth files, 2 had previous GCPs and neither had a copy of the GCP in the ISU file as required.
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In one case, a youth who had a psychological evaluation listing borderline IQ, lead poisoning, ADHD and a bipolar diagnosis and who was slated for RTC treatment was referred to the ISU but did not have a previous GCP. The ISU Admission form only indicated not responding to BMP when in his case, failing in a GCP would have been required as well for admission. Tracking of a youths behavior and incidents is to be a part of the transition planning and used for quality assurance and improvement purposes. The tracking form for ISU that was in use previously to determine whether the program is successful and how youth are faring after release was requested but was not made available. It is strongly suggested that ISU statistics be tracked and that the program design be adhered to strictly in order to assess success.
NOTE: Though overall, the behavior management systems put into place at BCJJC are worthy of a Satisfactory rating, the ISU should receive extra attention from the Administration to ensure it is following the program design and that the problems listed above are ameliorated. The ISU concept is a good one, but without constant oversight, it is a program that can run the risk of breaking down in original structure and losing its effectiveness. It also could be duplicated across Maryland if shown to be effective, but without good data and tracking of success, it cannot be proven to be a best practice model. RECOMMENDATIONS In order to reach Superior Performance in this area, it is recommended that the facility: Ensure newer staff members receive training on how to appropriate administer the BMP. In addition, staff members who have been identified as needing re-training should be given the training. Ensure that all GCPs are updated as scheduled. Ensure all youth who need a GCP (mental health youth) have one and are worked with by mental health prior to entering ISU. Ensure the ISU program design is re-read and followed exactly to ensure fidelity to the original model. If adjustments are needed, convene a meeting with the Director of Detention, Assistant Secretary of Residential Services and DJS Director of Professional Services or Behavioral Health to ensure any changes are informed changes. Ensure all documents required are in ISU files as required. Track outcomes of ISU youth weekly for quality assurance and make adjustments to lengths of stay or programming as needed.
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STRUCTURED REHABILITATIVE PROGRAMMING
STANDARD Written policy, procedure and practice document that youth receive planned, structured outdoor and indoor activities and regular rehabilitative programming that teaches social skills. SOURCES OF INFORMATION Review of Unit Log Books Interviews with direct care staff Interviews with youth Observations of Structured Activities Review of the Master Schedule REFERENCES DJS Recreational Activities Policy RF-08-07; ACA 3-JDF-5E-01-02-03-04 SUMMARY OF FINDINGS The units were visited on December 2, 2010 (in the evening) during the time the schedule indicated that youth should be in groups. On the six units reviewed, all received groups as outlined in the master schedule. A review of the unit log books indicated that programming is consistent on most of the units. Youth indicated that they enjoy the activities provided by the Boys and Girls Club. Staff and youth on the Orientation units reported that the units do not receive programming as outlined in the master schedule. They reported that outside of recreation the unit spends much of the day doing nothing constructive. Unit log books and observation confirmed this. Youth and staff interviews and logbooks confirm that the youth receive at least one hour of recreation everyday. Youth report that when weather permits they get outside recreation, but because the review was in December they have not been outside for some time. The youth reported that they are offered religious services. However, there is no alternative activity for youth who do not want to participate. A review of the Youth Advisory Board log indicated that the group was meeting consistently.
RECOMMENDATIONS In order to reach Superior Performance in this area, it is recommended that the facility: Ensure that the youth on the Orientation unit receive programming according to the schedule. Provide an alternative activity when the religious programming occurs.
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SELF ASSESSMENT
RATING: Not Rated
STANDARD Written policy, procedure and practice document that the facility superintendent at least twice monthly meets with his or her management staff to assess the facilitys status involving the use of seclusion, restraints, incident reporting numbers and procedures and other key area of facility operation in order to assess the facilitys compliance with DJS norms and expectations.
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BEHAVIORAL HEALTH
INTAKE, SCREENING & ASSESSMENT
RATING: Not Rated
STANDARD Written policy, procedure, and practice require that all youth admitted to a facility will be screened by qualified mental health professional in a timely manner using valid and reliable measures. All youth who screen positively for behavioral health issues will be referred for a full mental health assessment by a mental health professional. All youth who present at the facility with behavioral health issues that, as determined by professional mental health assessment, are beyond the scope of what the facility can safely treat, will be referred to a setting that can more appropriately meet the youth needs.
DUE TO THE LACK OF A BEHAVIORAL HEALTH QI REVIEWER, THIS STANDARD COULD NOT BE ASSESSED.
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INFORMED CONSENT
RATING: Not Rated
STANDARD Written policy, procedure, and practice require that youth, and when appropriate, their guardian, are informed of the risk, benefits, and side effects of medication and the potential consequences of stopping medication abruptly. Youth are also notified that their conversation with clinician, though confidential, may be shared with DJS and the Court if requested.
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PSYCHOTROPIC MEDICATION MANAGEMENT
RATING: Not Rated
STANDARD Written policy, procedure, and practice require that psychotropic medications are prescribed, distributed, and monitored safely.
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BEHAVIORAL HEALTH SERVICES & TREATMENT DELIVERY
RATING: Not Rated
STANDARD Written policy, procedure and practice require that appropriate mental health substance abuse treatment and emergency services are provided by qualified mental health professionals and substance abuse counselors, that it is integrated with the psychiatric services when applicable, and that it is appropriate for the adolescent population. Crisis intervention services should be available in acute incidents. All admitted youth should receive alcohol and drug abuse prevention/education counseling. Family involvement should be highly encouraged. Behavioral health issues should be considered when providing safe housing for youth at the facility.
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TREATMENT PLANNING
RATING: Not Rated
STANDARD Written policy, procedure and practice require that appropriate mental health substance abuse treatment and emergency services are provided by qualified mental health professionals and substance abuse counselors, that it is integrated with the psychiatric services when applicable, and that it is appropriate for the adolescent population. Crisis intervention services should be available in acute incidents. All admitted youth should receive alcohol and drug abuse prevention/education counseling. Family involvement should be highly encouraged. Behavioral health issues should be considered when providing safe housing for youth at the facility.
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TRANSITION PLANNING
RATING: Not Rated
STANDARD Written policy, procedure, and practice requires staff to facilitate appropriate transition plans for youth leaving the facility. Youth, and their guardian when appropriate, should receive information on behavioral health resources, a prescription for medication continuation, and assistance in contacting behavioral health aftercare services to schedule follow-up appointments.
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SUICIDE PREVENTION
DOCUMENTATION OF YOUTH ON SUICIDE WATCH
STANDARD Written policy, procedure, and practice require that all newly arrived youth, youth in seclusion, and youth on suicide precautions are sufficiently supervised. Suicide precaution documentation must include the times youth are placed on and removed from precautions, the current level of precautions, the youths housing location, the conditions of the precautions, and the time and active circumstances of the youths behavior. SOURCES OF INFORMATION Youth medical files Suicide Watch Observation Forms for 3 youth Suicide logbook kept by mental health staff 7 Incident Reports involving suicide ideations/gestures Guard Tour data Interviews with youth Staff Training Histories report Observation at facility REFERENCES DJS Suicide Policy (HC-1-07), ACA 3-JDF-3E-04, 4C-27 & 28, 4C-35, 5A-02, 3-JTS4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.J SUMMARY OF FINDINGS Suicide Watch Observation forms were located in the medical files as required. Staff checks on Suicide Watch Observation forms could be described as generally good. Pre-loaded times were not evident however on occasion, pre-loaded dates were. Staff generally gave good detail in their documented observations of youth. In one case, a youth left the facility for the hospital and staff followed with him and made checks on his sheet as required until he returned. This is excellent practice. In one of the three youths cases, entire observation sheets were missing for either entire days or entire shifts. No one had caught this problem. Audits of suicide watch sheets are not accomplished. If they were in place, an auditor would have likely discovered the missing sheets described above. The Superintendent indicated he would be re-instituting audits of this important paperwork. The Suicide Watch log kept by mental health conforms to policy in that it includes the date, level and name of the youth and conditions of supervision.
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In a sample of all mandated staff, 82 of the 108 staff sampled (76%) were compliant with annual Suicide Prevention DJS-required training. In reviewing incident reports, both line staff and mental health staff responses were good. They took seriously the youths behaviors and acted without delay. Most staff knew they could put a youth on Level III one-to-one watch. All staff indicated that when a youth was on one-to-one watch, they could not leave that youth for any reason, including to break up a fight. Staff indicated that there are enough staff to supervise youth on suicide watch. The only tangible concern was in room checks. A review of the Guard Tour data revealed that 49% of units did not start conducting room checks until after 10pm; 7.5% of rooms were not checked/documented during the sleep periods at all; 21% of checks ended two to five hours prior to wake up time; and 16% had gaps between checks that ranged from 90 minutes to 275 minutes. Since most suicides committed by juveniles in confinement occur while in rooms alone and when not on suicide watch, these gaps in time are not acceptable to ensure safety for our youth and need immediate correction.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: A trained and skilled BCJJC staff should be assigned the duty of auditing Suicide Watch Observation sheets daily; issues found could be relayed immediately to the Administration for re-training or disciplinary action as warranted. Guard Tour data must be reviewed regularly by Pod Managers and senior Administrators to ensure checks are done as required. Staff should be educated as to why this is so crucial.
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ENVIRONMENTAL HAZARDS
STANDARD Written policy, procedure, and practice require that all housing for youth at heightened risk of self-harm is free of identifiable hazards that would allow the youth to commit suicide or other acts of self harm. In case of emergency, all direct care staff at the facility should have immediate access to appropriate equipment to intervene in an attempted suicide. Chemicals and other hazards are properly stored and locked. SOURCES OF INFORMATION Interviews with youth Interviews with staff Observation at facility REFERENCES DJS Suicide Policy (HC-1-07), DJS Safety and Security Inspections Policy RF-04-07, ACA 3-JDF-3E-04, 4C-27 & 28, 4C-35, 5A-02, 3-JTS-4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.J SUMMARY OF FINDINGS 73% of staff in written interviews indicated they carried a cut-down tool; 27% indicated it is kept in a box in the control panel but supervisors have one on their key ring. Every line staff and supervisor is required to have one on their person. Soaps, lotions and cleaners did not appear to be left out or accessible. The Pod Control Panels were locked. No sharp objects were observed and doors checked were locked. No incident reports showed cases of youth ingesting chemicals or soaps or using accessible sharp objects or tie off points to attempt to harm themselves. The rooms displayed no tie-off points except the very necessary faucets/toilets, as in many DJS facilities. No ceiling fixtures, desks, open metal beds or any other hook type point was observed.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that all direct care staff, including supervisors, carry a cut down tool while in detention.
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CLINICAL CARE FOR SUICIDAL YOUTH
RATING: Not Rated
STANDARD Written policy, procedure, and practice require that timely suicide risk assessments, using reliable assessment instruments, are conducted at the facility for all youth exhibiting behavior that may indicate suicidal ideations to determine whether a youth should be placed on suicide precautions or whether the youths level of suicide precautions should be changed. Youth at a facility who exhibit suicidal ideations or attempts should receive timely, appropriate, and professional mental health services. Youth should not be restricted from programs and services more than safety and security needs dictate. All pertinent staff should review all completed suicides and suicide attempts at the facility for policy and training implications.
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EDUCATION
SCHOOL ENTRY
RATING: Non Performance
STANDARD Written policy, procedure and practice document timely enrollment of all students into the educational program. The school will receive a daily roster of students. The receipt of student records should occur in a timely manner. SOURCES OF INFORMATION Interview with record staff Interview with Special Education Lead Teacher Review of 33 student folders (15 special education, 18 general education) Review of Daily Population Reports REFERENCES COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS Only 7of 33 (21%) of students records were requested within 72 hours or 3 school days of admission. Another seven (21%) files had no request done at all. Only five records were received within five school days of admission into the facility. And, there were only two records that contained secondary requests performed in accordance to COMAR 13A.08.07. In addition, only 12 of 33 (36%) of students were interviewed and assessed within 72 hours of admission to the facility. Because the sample percentage was so low, this reviewer hand counted all of the records in the files. Of the 128 youth who were in the facility there were only records for 81 youth (63%). This included records in the special education files, in the general education files and on the desks of the two records clerks. There are two reasons why the records are not requested. First, the education staff did not begin the process of assessing or interviewing most of the youth until the youth were assigned to the unit following Orientation. This should be happening while the students are on the Orientation unit. This is coupled with the fact that the facility keeps youth on the Orientation unit too long. The Orientation process is supposed to be completed within 72 hours or three days of the students admissions into the detention. However a review of the daily population sheet for December 2, 2010 showed that the facility had 38 youth in orientation. Of those youth, 21 (55.3%) had stays longer than three days. The average length of stay of those youth on orientation was 11.1 days. Education staff reported that they receive a population report daily.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: The facility has to change the Orientation process to ensure that youth are not in Orientation past the time it would take for them to be oriented and assessed by the various departments in the facility. Youth who have had multiple stays in the facility may not need to be placed on the Orientation unit and could go directly to a unit. See more on this recommendation in the Admissions, Intake and Student Handbook section of this report. The education staff should begin the records process while the youth are still in Orientation. This would include an initial interview, assessment and records request.
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CURRICULUM & INSTRUCTION
STANDARD Facility schools will ensure that they provide instruction appropriate to the varied needs and abilities of the students enrolled. They should operate on a standard schedule, provide students with a consistent school day, provide instruction appropriate to individual students strengths and needs, provide pre-GED & GED instruction as appropriate, provide extracurricular and enrichment activities & events, integrate computer assisted instruction in the curriculum and provide library services. Facility schools will also ensure that students in alternate settings (i.e. infirmary, seclusion and orientation) are given access to assignments and instruction comparable to others students in the facility. SOURCES OF INFORMATION Review of School schedules Review of school logbooks Interview of two teaching staff members Interview of 12 students Interview of the school principal Observation of transitions to and from class Two Classroom observations Information from the youth advocate REFERENCES MSDE Guidelines DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS In the past, it had been difficult to move the units to and from school in a timely fashion in the mornings and following the lunch break. Previously, units would frequently come late due to a variety of reasons including the lateness of staff, the lateness of breakfast and the inability to manage the behavior of the units in order to move them. At this review, the facility appears to have remedied this issue. Movement to and from school was orderly and efficient. All of the units were moved to school within five minutes of the start time in all but one instance. Though on one day one unit was not in their first period class because there was no teacher, a review of the education logbook confirmed that missing classes was not a norm. The school runs on a block schedule with four ninety minute class sessions per day for each of the units that come to the school. The block schedule reduces the amount of transition between classes and keeps the youth out of the hallway of the school. In addition, the school runs a full day self-contained special education classroom and offers an Advances Studies/GED program for youth who meet eligibility criteria.
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According to the schedule youth on the infirmary unit are to receive three hours of instruction per day provided by a contractual special educator. However, according to the Youth Advocate and observation in the infirmary, the students on the infirmary are not receiving direct instruction and instead have been receiving packets of work because the teacher is out on leave. The education staff must ensure that coverage is provided to youth in the infirmary just as they would with any student on any other unit in the facility. The teachers had curriculum materials for each subject in the 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 instructional styles were displayed, including direct instruction, co-teaching, grouping of students of varied level and use of computers and calculators. Teachers were in their assigned classes, including special education co-teachers. The school has a library and students are able to borrow and take back to their rooms.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that youth receive school according to the school schedule, including the youth in the infirmary. To do so, the school has to manage coverage of absent teachers. This may include the need to hire additional teachers or assistants to ensure that classes are covered.
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SCHOOL STAFFING & PROFESSIONAL DEVELOPMENT
STANDARD The Facility School will maintain a sufficient number of certified staff to provide appropriate education to all students, including related services providers. The school should provide meaningful staff development opportunities to teachers and support staff to enhance their ability to effectively educate youth in detention settings. SOURCES OF INFORMATION Review of a roster of teaching staff Review of teacher certifications Interview with the school principal Interviews with teaching staff and instructional assistances Review of the Professional Development Calendar REFERENCES No Child Left Behind Act of 2001, (NCLB), P.L. 107-110 DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS The school staff consists of: one principal, one assistant principal, six special education teachers (one serving as the special education lead teacher), two math teachers, two language arts teachers, one Social Studies teacher, one art teacher, one computer teacher, one media specialist, one guidance counselor, one testing and assessment staff member, one transition specialist, one school psychologist, two records clerks, three instructional assistants II (IAs) and one administrative assistant. The principal reported that there were vacancies for one science teacher and an IA. Only one teacher is not certified in the content area in which they teach. Related services in the form of counseling are provided by the schools guidance counselor and the school psychologist. Speech language services are provided by a contractual provider. Professional development is provided regularly by MSDE.
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. Continue to recruit for the science and instructional assistant vacancies.
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SCREENING & IDENTIFICATION
STANDARD Qualified professionals shall provide prompt and adequate screening of facility youth for special education needs, including identifying youth who are receiving special education in their home school districts and those eligible to receive special education services that have not been so identified in the past. SOURCES OF INFORMATION Review of special education roster Review of population report Interview of special education lead teacher Review of 15 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 The school assesses the educational level of each student in the facility upon admission to the school using the BASI assessment. Any student that scores below the third grade level on the assessment is automatically screened to determine if there is a possible need for special education services. As stated previously, the students on the Orientation units are not being assessed in a timely manner. Therefore the school is not identifying youth who are in need of special education services. The special education lead teacher indicated that she reviews the admissions roster to identify youth who have been identified as needing special education services from previous stays. But if she does not know the student, they are not identified until their assessment. Only 36 of the 128 (28%) residents of the facility are identified as students previously identified as needing special education services. This is lower than expected in a detention center of this size in the city. The special education lead teacher indicated that she also suspects that there are many more students that are not identified due to a lack of records. All five of the school staff members interviewed understood the procedures for referring student for screening for special education services.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Work in conjunction with the detention staff to develop a plan for interviewing and assessing youth while they are in Orientation. The facility needs to ensure that the youth move from the Orientation unit in a timelier manner so that they can receive their special education services per their IEPs.
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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 lead teacher Interviews with teaching staff Review of 22 current 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. In cases where 10 days notice was not given, a waiver was received from the parents. Documentation of parent contacts, including telephone logs and certified letter receipts, was consistent in each file. The folders also contained emails documenting the invitation of community case managers and representatives from the Department of Rehabilitative Services (DORS). Home schools were not invited to the meetings. 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 trained parent surrogates.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: The school should invite the youths home schools to participate in meetings. The school should 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 15 special education files Interviews of teachers REFERENCES COMAR 13A.05.01.07: IEP Team COMAR 13A.05.01.08: IEP Team Responsibilities COMAR 13A.05.01.09: IEP Documentation Section 504 of the Rehabilitation Act of 1973 (Section 504), 29 U.S.C. 794 DJS Section 504 Guidelines SUMMARY OF FINDINGS 11of the 15 special education files contained IEP meetings held at BCJJC. In all 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. The school does not hold IEP meetings for all students. If the student comes to the facility with a current IEP, the school in some cases decides to accept the IEP as written. This was the case in three of the IEPs reviewed. The special education lead teacher indicated that this was the case for students who have current IEPs and whose classroom instruction needs indicate that they could be fully included in general education classes. However, there was one youth whose IEP indicated that he needed 15 classroom instruction hours outside of the general education setting who had his IEP accepted without a meeting. IEPs indicated a continuum of services at the school ranging from full inclusion to a full-time special education classroom. The school used the Maryland online IEP format for all of the records reviewed at the facility. There was one Section 504 plan that the school had not reviewed. Teachers were aware of students accommodations from the 504 plans and could identify them. Related Services documentation was current and up to date and appropriate in all but one of the files.
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The timeliness of IEP meetings is a concern. Seven of the eleven (64%) meetings were scheduled well after 30 days of admission into the facility. Considering that the average length of stay of youth at the facility is about 14 days, many of the students would not have meetings scheduled during their stays.
RECOMMENDATIONS In order to reach Satisfactory Performance in this area it is recommended that the facility: Ensure that IEP meetings are held for students in a timely manner.
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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 BCJJC School offers two options for Career Technology and Exploration Programs (CTE). There is an Art class and a Computer class. The Art class replaces the Building Trades class that the school previously offered. According the schedule each unit that travels to school receives each option. Both of the teachers hold current certifications in the areas in which they teach. At the time of the review the computer class was not offering the IC3 certifications that are offered at other detention center schools (i.e., Cheltenham and Hickey). The principal reported that school will offer the certification over the next couple of months.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Move forward with the plans convert the computer class to IC3 so that students can earn certifications.
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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 and guidance counselor Review of Cheltenham School Daily Documentation Forms Review of school logbooks REFERENCES Maryland Standards for Juvenile Detention Facilities SUMMARY OF FINDINGS During the review units were not observed out of ratio at any time during the school day. The facility has four staff members assigned to the school daily to assist in movement, bathroom breaks for students, observing youth who are taken to the counselor and to allow staff members to receive breaks. The staff is consistent and works well with the education staff. The school principal reported a marked increase in the ability to manage student behavior and movement over previous reviews. The facility staff do an exceptional job of supervising school movement and student behavior and take pride in their roles in the school. The staff is posted in areas to be able to view the students throughout the school and quickly responded to crises in the education area. Students often and for different reasons meet with education staff in the principal, vice principal, transition specialist or the counselors offices. Though staff are in hallways, they are not posted near these offices.
RECOMMENDATIONS The facility has reached Superior Performance in this area. The only recommendation would be to post staff closer to offices where youth are meeting with educators and counselors individually.
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SCHOOL ENVIRONMENT & CLIMATE
STANDARD The facility will ensure that the school setting is a safe environment conducive to learning and that staff are supported in their jobs. SOURCES OF INFORMATION School observation Interviews with Direct Care staff members Interviews of Educational staff REFERENCES N/A SUMMARY OF FINDINGS There is a marked improvement in the environment in the school over previous reviews. The hallways are quieter and the classrooms are more orderly than they were previously. For the most part, teachers are keeping youth involved with work. Students indicate that the school is like a regular school. Nine of ten (90%) youth indicated they liked school which is very positive for a detention setting. Education staff members report that there is a good working relationship with the facility staff, especially those who are assigned to the school. However they also report that there is inconsistency in the way that some direct care staff manage students. Education staff report that some direct care staff members yell and curse at students when giving directives. This was also observed by this reviewer.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: The education and direct care staff should work together to come up with acceptable guidelines and expectations for addressing the behavior of youth in the classrooms. Education staff and direct care staff should be trained together on surface management techniques to be employed in the classroom.
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STUDENT TRANSITION
STANDARD Written documentation shows that the facility school creates progress reports and Maryland Student Transfer Reports (MSTR) for students in the facility within five days of the release of the student and that the school notifies DJS' Office of Pupil Personnel Services (OPS)of the creation of that documentation so that the Office can disseminate those reports to the youth's home school. SOURCES OF INFORMATION Record staff interview Review of 17 folders of released youth August 2010 from November 2010. Interview with DJS Office of Pupil Services (OPS) staff REFERENCES COMAR Transition COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records SUMMARY OF FINDINGS Only 10 of the 17 (59%) student files contained Maryland Student Transfer Forms (MSTRs). OPS staff indicated that the school does not provided MSTRs for students upon the students release from the facility. She reported that forms are only received when they are requested by their office. Though this practice by MSDE is in compliance with COMAR (and MSDE is in fact in compliance with COMAR in this area), DJS QI Standard requires these to be sent regardless of home school request.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that a MSTR or a progress report is generated for each student released from the facility and sent to the youths home school for any earned classroom credit.
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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: Facility Incident Reports (88) Nursing Report of Youth Injury (139) Youth Health Records (YHR) review Nurses Injury logbook Interviews with staff Interviews with youth REFERENCES: DJS Incident Reporting policy (MGMT-03-07); Photographing of Injuries policy (RF-1105); Reporting & Investigating Child Abuse Policy (MGMT-1-00) SUMMARY OF FINDINGS 88 incident reports and 139 accompanying Nursing Report of Youth Injuries forms from August November 2010 were reviewed. In 85 of the 88 incidents, youth were assessed by medical staff when required, which is excellent. The exceptions were three incidences involving physical restraint. In one incident the staff stated in the incident report medical not required. The other two did not indicate why youth were not taken to medical. For youth that refused medical treatment, in all but 2 cases a Treatment Refusal Form was attached to the incident report. During interviews Direct Care Staff and youth acknowledged that they knew medical evaluations were required when youth were involved in altercations. A Nursing Report of Youth Injury (Body Sheet) was accomplished for 139 of the 144 youth that were evaluated by medical. o Two lapses were for the same youth who was seen in medical and transported off-grounds for emergency mental health admission. The youths progress notes discussed the transport but did not provide information regarding his health status at the time of transport. o Two youth were involved in either an alleged youth on youth physical assault or physical restraint, and the Injury log book stated youth were assessed but a body sheet was not attached to the incident reports or found in the YHR.
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o A youth was transported off-grounds for an eye injury; the assessment was documented in the YHR. Assessments were accomplished within two hours of the incident unless youth were placed in seclusion or several youth were involved. Youth were visually assessed in their rooms and later taken to medical for evaluation. Body sheets were correctly completed for youth statement, Injury Severity Rating (ISR), pain level, assessment and treatment, and signatures. Injury locations were not documented on the body silhouette as required by policy. ISRs were consistent with injuries depicted in the photographs, assessment and interventions. Photographs were routinely taken for all youth with a completed Body Sheet whether there was an injury or not. Photographs were not labeled correctly, with most missing either date of birth or date photo was taken. Photos were attached to the incident report and in the YHR. Several photos were printed on paper with poor visibility of injury site. Photographs were not taken for a youth with a head laceration which required transport to the emergency room. Another youth had a photo of his face but no photo of his injured hand was taken. All youth that required further care were referred off-grounds or placed on the appropriate clinic schedule. Follow-up was documented in the YHR. The Injury Report logbook was not consistently maintained. No body sheets were entered into the logbook on 11/16/2010 including 4 of the body sheets contained in this review. In 6 other instances body sheets were not logged.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Complete body sheets for all youth that received medical evaluation. If youth required emergency interventions, body sheets should still be accomplished at a time when doing so will not disrupt care provided. Document location and description of injury on body silhouette on sheet per policy. Accurately maintain Injury logbook ensuring all body sheets are logged. Conduct periodic internal quality review to make sure log is accurate. Obtain good quality photos of all injuries (where injuries are visible) and ensure they are clearly marked.
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HEALTH ASSESSMENT
STANDARD Written policy, procedure and practice document that adequate health assessments are completed on all youth within 72 hours of admission. SOURCES OF INFORMATION Interviews with medical staff Nursing logbooks Youth Health Records review (25) REFERENCES ACA 1-SJD-4C-18-19-20; NCCHC Y-E-04; COMAR 18-4A-03, 10.09.23; DJS Standard #33 Health Assessment SUMMARY OF FINDINGS 25 records were reviewed representing 20% of the population during this review. 24 databases were completed at this facility and one was obtained from the transferring facility. Nursing assessments were completed on all youth within 24 hours of admission with documentation on the nursing assessment database. Additionally, admission nursing progress notes were completed for youth who had been re-admitted within 6 months of release. Progress notes did not always specify the previous admission or include pertinent information from the last admission. On 16 (68%) of the databases all sections were correctly completed. Consistently missed was description of body tattoos; other areas missed were current medication and allergies. Only (8) 25% of the databases contained Nursing Diagnosis. All but 4 databases were signed as reviewed by the physician although the History and Physical Examination form indicated the physician did review the RN assessment. Admission Nursing progress notes were completed for all but 3 admissions. Notes contained pertinent information (i.e., significant medical history, orientation to medical services, and disposition to unit.) History and Physical (H&P) examinations were completed within 7 days for all youth. Only 24 % (6) forms were completed for BMI, vision screening, vital signs, date, and initials. Although heights and weights were consistently obtained, growth charts were only completed for 2 youth that had 30 day reviews completed. Master Problem Lists were not consistently completed. Behavioral Health diagnoses were consistently missed on these Lists; acute conditions were not closed; and no resolution or interventions were given for youth with chronic illnesses.
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Admissions and admission labs were correctly entered in the admission and lab log books. MMRV titers were not included in admission lab work therefore if a youths immunization records were not available, immunization status for MMR or Varicella was not known. Although 3 youth were missing placement of current or status of last PPD on the admission database, PPDs for the youth were documented in the PPD log book. Entries in the logbook were correctly annotated for dates, results, and initials. 68% of the charts contained immunization records. Of those 17 records only 11 where reviewed by the physician. In 6, immunizations were ordered and of those, 4 youth received immunizations. The medical staff expressed difficulty obtaining immunization records for youth. This reviewer witnessed an RN phoning the parents to obtain consent for a youth during intake. Both parents refused to provide the requested information and were adamant in their refusal to allow their son to receive immunizations. Health Status Alerts (HSAs) were not consistently completed. For 12 youth with allergies and dietary restrictions 10 (83%) HSAs were completed and distributed. Of 20 youth identified with special needs (illnesses, activity restrictions, treatments) only 9 (45%) had a HSA related to their condition. Distribution of HSAs would ensure appropriate communication between direct care staff and medical personnel. 30 day reviews were not accomplished for 16 of the 17 youth that required it. Three youth were given a 60 day review only. The Nursing Supervisor stated that they usually completed less than ten 30 day reviews per month and that the inability to get youth to the health center was a primary factor. They used the population sheet to determine youth requiring 30 day review. Of the 9 youth that required a discharge summary, none were done for a 0% completion rate. The Nursing Supervisor stated that the staff forwarded information to the family, case manager, placement facility, and primary care physician upon discharge but did not complete the discharge summary nor was the communication of such information evident in the progress notes. Seclusion requires medical evaluation at the time initiated and every 2 hours. The medical staff was not always informed when youth were placed in seclusion. Generally the RN was notified when the youth was brought to the health center for completion of the Report of Injury. At that time the initial medical assessment was documented. The review of 15 occurrences of Seclusion revealed that in all but 1 case was the youth(s) involved not evaluated by medical staff. Not all youth(s) were evaluated within 2 hours of initiation of Seclusion but each youth was evaluated at least once during seclusion as per documentation. Medical staff used the Tour Guard to electronically record their assessment and time and therefore staff did not always document assessment on the door sheet or the progress notes. Medical Staff did maintain a Seclusion logbook. In interviews, youth stated that when in seclusion they were assessed by medical. RN staff did not consistently use or review the communication book to report between shifts, which resulted in omissions and delay in implementation of treatment orders, administering medications, and obtaining labs.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the health care unit at the facility: Implement a comprehensive internal quality assurance program to ensure adequate documentation and adherence to assessment standards. Implement DJS Shift report and communication guidelines to prevent lapses in care. Complete all areas of the Nursing Admission Assessment. Progress notes for youth readmitted should contain all pertinent information as well as the date of last admission and database from which information is obtained. Ensure H&P has screening results, and vital signs are completed with appropriate dates and initials. Improve immunization completion rates. Improve tracking of records requests; ensure records received are reviewed by the physician; consents obtained or refusals documented; and ordered/consented immunizations given. Complete Master Problem Lists. Ensure chronic illnesses and significant acute illness/injuries, and behavioral heath diagnoses are included. Document resolution dates for acute conditions and ongoing for episodic or chronic conditions. Complete HSAs for all youth with special needs. Include pertinent data on population sheets and distribute HSAs to facility staff. Improve communication re: special health needs of youth throughout the facility. Adhere to DJS standards for continuity of care. Complete a 30 day review on youth particularly those receiving treatment to evaluate effectiveness of treatment and current health status. Discharge summaries are an essential element. They must be completed to include any significant health issues and treatment occurring during detention. They may be completed after discharge and should be distributed to appropriate persons and/or agencies. Adhere to documentation procedures for youth in Seclusion. Medical staff should assess youth and document on the door sheet and in the progress notes every two hours of seclusion.
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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 Medication Administration Records (MAR) Youth Health Records review (25) Observation REFERENCES DJS Pharmaceutical Services policy (HC-02-07); ACA 1-SJD-4C-16-17 SUMMARY OF FINDINGS The Medication Administration Records (MAR) and medical records of 25 youth were reviewed. The current months MAR for each youth as well as those from previous months was evaluated. During this review there were 22 youth on psychotropic medications. The records of 5 current youth and 2 former youth were evaluated. Medication orders were written and appropriately transcribed onto the MAR. Verbal and telephone orders were signed by ordering clinician on the next clinic day. Nurses appropriately signed and initialed all MARs. In 14 of the 15 MARs (93%) missed medications were appropriately documented on the front of the MAR. But on only 73 % (11) were missed medications documented on the back of the MAR with an explanation of why medication was not given. This included whether youth refused medications. When youth did refuse, appropriate Treatment Refusals were documented. Only in one instance was a staff signature not obtained when a youth refused to sign. In another instance the refusal form was not dated. According to both the RNs and the psychiatrist, if a youth refused a psychotropic medication 3 times they were referred to the physician for evaluation and change in treatment plan. PRN medications were not consistently documented on the back of the MAR and effectiveness was not indicated. Completed Consents for psychotropic medications were found in the medical records for 5 of the youth. Medications were correctly secured, stored, and disposed of. Expired medications were found in the emergency supply kit but there were no expired stock medications. A count of controlled medications was conducted by this reviewer and was correct; however, there was not sufficient documentation to indicate counts were conducted daily at shift change.
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During this review medication was observed being administered to one youth in the health center. The RN verified youth by name and picture, the MAR was used to prepare medication, and visual inspection for ingestion was done. Although this reviewer did not observe the routine scheduled medication administration, two RNs were interviewed regarding administration procedures. The RNs stated that the medication cart was taken to each pod, a supervisor or designated staff directed youth movement, youth were identified by photo and name, and swallowing was confirmed. Interviews with youth and direct care staff confirmed the verification of youth identity and medication ingestion. According to the Nursing Supervisor, medications for youth released are returned to the pharmacy for credit to the account, or placed in stock. Controlled medications are destroyed. Parents/guardians were contacted to pick up medications, but this did not always happen. No efforts were made to contact the youths Case Manager.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Ensure each youth on psychotherapeutic medications has a signed consent in the YHR. Improve documentation on the MAR to include signatures, initials, missed meds, effectiveness, and refusals. Complete Treatment Refusal forms with appropriate signatures when youth refuses medications. Decrease the amount of medications destroyed by contacting case managers when youth are released through court. Document daily CDS counts between shifts.
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DENTAL CARE
STANDARD Written policy, procedure and practice document all youth receive timely and adequate dental care. SOURCES OF INFORMATION Interviews with medical staff Nursing logs (Appointment Log and Clinic Lists) Youth Health Records review (25) REFERENCES ACA 1-SJD-4C-22; DJS Health Care Services Standard 35, Oral Screening and Oral Health Care SUMMARY OF FINDINGS Dental clinic was conducted twice a week on site, Tuesday and Thursday. Youth were scheduled for initial dental examination at the time of admission. Due to the number of youth requiring dental examinations, prophylactic cleanings, and restorations, the average waiting time for an initial examination was 2 weeks. In all but two (2) of the 25 records reviewed youth had received at least one annual dental examination. Dental appointments were documented on the Immunization and Referral Tracking form with completion indicated in all but one record. One youth was scheduled but there was no indication in the medical record why the appointment was not completed. In general, documentation existed that youth refused an appointment or if an appointment was rescheduled. All youth requiring more extensive dental treatment or orthodontic services were referred off-ground. Referrals and post-referral treatment plans were documented in the records. In most instances youth that complained of oral pain via sick call or outside of dental clinic hours were triaged and treated according to nursing protocol for management of oral pain. In one case a youth completed two sick call slips regarding dental pain, and another youth completed a sick call slip for a chipped tooth sustained while playing basketball; neither youth was assessed by the RN as evidenced by documentation. According to the sick call slip and nursing report of injury, the youth were placed on the dental clinic lists. One of the youths completed his dental appointment while the other youth was released prior to his appointment and this information was not forwarded to parents or case manager.
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RECOMMENDATIONS In order to maintain Superior Performance status, the facility and its health unit should do the following: Comply with nursing protocols for management of oral pain. Ensure youth are notified that their sick call slip was received and informed of the resolution (i.e., that they are on the next clinic list.) Complete documentation of Dental appointments on the Referral Tracking form. Include dental treatments in 30 day reviews and discharge summaries.
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MEDICAL RECORDS RETRIEVAL
STANDARD Written policy, procedure and practice document that efforts are made upon a youths admission to obtain prior medical records. SOURCES OF INFORMATION Interviews with medical staff Observation Youth Health Records review REFERENCES ACA 1-SJD-4C-18-19-20; DJS Health Care Services Standard 58, Health Record Format and Contents; DJS Health Care Services Standard 61, Availability and Use of Health Records. SUMMARY OF FINDINGS Youth health records were filed on shelves in a room located behind the nurses station. Records were accessible as needed by appropriate staff. Archived records were located on floor- to- wall shelves in a locked room as well as in boxes in the Nursing Supervisors office. Staff obtained medical records for all youth with previous detentions or confinements, or from primary care providers for youth with chronic illnesses or identified health concerns. Medical records were requested, received, reviewed and appropriately filed. Summaries of care, diagnostic, and laboratory results for all youth who were referred off-grounds for medical or dental services were obtained. Lab/diagnostic results were consistently filed in the records and reviewed by requesting providers. Records were generally organized with few forms not in the appropriate location. Many records were extremely thick, particularly for those youth who were followed by mental health. Forms were found loose in these records or detached from clasps because of overfilling. Individual forms and pages were identified by youth name and date of birth. In most cases progress notes were identified by the service of the writer. Dates and times were noted.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Discontinue overstuffing of medical records. Create an additional volume to be maintained with the current volume if indicated
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 Interview with staff Nursing logs Youth Health Records review (20) REFERENCES DJS Health Care ProcedureSpecial Needs Treatment Plans (2007); DJS Standard #50, Infirmary Care; SUMMARY OF FINDINGS This health center does not maintain a log of youth with special needs. The Nursing Supervisor provided a list of 24 youth with special needs from memory. 20 YHRs of youth with special needs were reviewed. While the medical staff did a great job of obtaining a comprehensive assessment on each youth and identifying a special need, communicating with the youths primary care provider for evaluation/follow-up, and coordinating referrals; overall implementation of the special needs program fell short of standards. 13 of 15 youth admitted with a history of special needs were identified during the initial nursing assessment. The exceptions were youths readmitted with a history of a heart murmur and asthma which were not documented in the subsequent admissions progress note. The other 5 youth had conditions which occurred or were identified during their detention. In 17 (85%) of the YHR, special needs were documented on the Master Problem List. Resolution was not reflected on any of the problem lists. It was recommended that resolution for chronic illness be identified as ongoing. In the three missing documentation, two were for youth who sustained injuries (eye injury, fractured ankle) and the other youth was being treated for asthma. Only 53% (10 of 19) of the records contained a Treatment Care Plan. Of those with care plans, only 20 % (2 of 10) were individualized for the youth. The remaining were blank with most only having the youths name noted. Health Status Alerts (HSAs) were only completed for 9 youth or 45% of those with special needs. Youth were more likely to have HSA completed if they also had allergies or food restrictions. Medical staff stated they did not routinely complete HSAs for youth with chronic illness unless it impacted daily activities. Direct care
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staff were unaware of youth on their unit with special needs (like asthma) unless they received medications. Although youth were re-evaluated by somatic health or referred off-grounds for periodic follow-up care, 30 day reviews were not accomplished. Of the 14 youth requiring 30 day reviews only 4 (29%) had either a 30 day or 60 day review completed. No discharge summaries were completed or distributed to parents/guardians upon release or forwarded to placement facilities. Asthma Management: o 8 youth were identified with a history of Asthma. Of these 6 (75%) were receiving daily treatment (Singulair, Advair) or requiring bronchodilators for exercise induced asthma. o Asthma Assessment Tools were accomplished for each youth. Even though youth scored less than 19 on the Asthma Control Test indicating poor control, no youth had an Asthma Action Plan implemented. Nor did the youth have peak flow tests completed other than those obtained during completion of the Asthma Assessment Tool. o All youth did have prn inhalers ordered and available in stock. Management of youth with Diabetes Mellitus was documented on the Diabetes flow sheet. One youth with a diagnosis of Hypertension received daily anti-hypertensives yet no blood pressure monitoring was being done per standard nursing practice. Records for 4 youth housed in the infirmary were reviewed. Only 1 had written orders admitting them to the infirmary while 3 had written orders releasing them to the units. There were no orders specifying nursing frequency of nursing observation or documentation. Nurses documented in the progress notes as needed. Youth were evaluated by the physician while in the infirmary. Treatments were implemented and documented as ordered.
RECOMMENDATIONS In order to reach Satisfactory Performance status, the facility and its health unit should do the following: Implement an internal quality review program to ensure standards are met. Ensure admission progress notes which are completed in lieu of admission databases address youths special needs as well as the date when the last nursing admission database completed. Complete Special Needs Treatment Plans for all identified youth. Individualize the preprinted forms as indicated for each youth. Complete Master Problem Lists, include interventions and treatment. For resolution date in chronic illness, this reviewer recommends indicate the date as ongoing with a review date noted. Acute should have a resolution date when no longer present. Ensure Health Status Alerts are communicated to all relevant persons. Maintain binder on each unit; the facility should work hand-in-hand with medical to ensure
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staff can identify youth with special health needs. Methods include the on-unit binder, shift reports/briefings, log books, input in ASSIST, and noted on population sheet. Adhere to Asthma Management Standards. Implement standard nursing practice in regards to monitoring youth with special needs (i.e. monitoring blood pressure with anti-hypertensive medication administration.) Complete 30 day reviews and discharge summaries on all youth to ensure continuity of care in the community or forwarding facilities. Adhere to DJS guidelines for Infirmary Care.
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AVAILABILITY OF MEDICAL SERVICES
STANDARD Written policy, procedure and practice show that services for youth by trained medical staff for routine care and treatment are available 7 days per week; that there is an oncall procedure in place when medical staff are not on duty; that emergency care in case of emergent need is available and properly utilized; and that there are working sick call procedures in place that appropriately and timely address the sick youths needs. SOURCES OF INFORMATION Interviews with medical staff Interview with staff Interviews with youth Nursing logs Youth Health Records (YHR) review Observation REFERENCES ACA 1-SJD-4C-01; ACA 1-SJD-4C-05. ACA 3-JDF-4C-28 SUMMARY OF FINDINGS The health center has 24/7 nursing coverage. There were usually 2 RNs on days, 3 RNs on evenings and 1 RN on nights. During a typical week this facility had from 5 14 intakes on a given day with the majority occurring on the evening shift (3:0011:00pm) after court. Clinics were held as follows: Somatic health clinics four times a week; Mental health clinic four times a week; and Dental clinic twice a week. There were 2 scheduled clinics per day. The Nursing Supervisor or a designated RN and a physician for each service is oncall 24/7. Contact information is posted in the health center. Protocols for obtaining off-grounds emergency care were available. Direct Care Staff were knowledgeable of health center hours and stated they would contact medical staff by telephone in the event of an emergency. Pharmacy services were available weekdays. Orders placed in the morning were delivered in the afternoon. Stock medications were available. STAT calls were made for medications required outside of regular delivery times. Problems occurred when CDS were required: faxed prescriptions were not accepted which sometimes led to a 2 day wait for medications. Mobile radiographic services were available for x-rays and EKGs as needed. Laboratory services were provided by Quest Diagnostics, with daily week day collection. The state laboratory collected three times a week. Youth were transported off grounds for specialty appointments. Staff stated this process has improved, with fewer cancellations due to transportation issues.
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Emergency equipment was not maintained throughout the facility: o First Aid Kits: Of the 3 Pods only 2 had First Aid Kits which were locked in either the Supervisors Office or supply closet. Direct Care Staff did not know where they were located. The First Aid Kits were not checked at all by medical. Medical staff stated they only saw the kits to replace supplies when needed. o The AED was located under the sink in the Health Center. It was not being checked weekly as required. Staff including an RN or orientation did not know where the AED was located. o Oxygen tanks were empty and were not being checked daily as required. o The Emergency Kit was maintained in a cabinet in the health center. Monthly checks were not done; expired meds were found in the Emergency Kit during this review. Just 49% of Direct Care Staff were current in CPR/AED/First Aid training. Staff was unaware of common side effects of psychotropic medications. In addition they did not know the early signs of distress in youth with asthma or other health conditions. Because youth with acute illnesses or unstable chronic illnesses were housed in the infirmary, and the Health Center had 24/7 coverage, medical and direct care staff did not view this as a major concern. 28 Sick Call request slips were reviewed. In most cases assessments and treatment was documented on slips or in the progress notes. But in several cases (5) there was no documentation that an assessment was done by the RN. o Youth stated sick call slips were located in boxes on the unit walls. During this review 2 of 5 units did not have sick call slips available. The boxes on both of these units were waiting to be reattached. o Completed requests were placed in a locked box on each unit and collected by the RN during the morning medication administration. o Youth confirmed that they had unimpeded access to sick call slips; however, 2 youth stated that they did not receive treatment when a request was made. Upon review it was noted that youth were scheduled for clinic as stated on their request but youth were never evaluated by the RN and were not informed that they would be seen in the next available clinic. This lack of communication and failure to triage youth led youth to submit another sick call request and also resulted in one youth filing a Grievance. Youth and Direct Care Staff stated that the health center would accommodate youth that required medical care between sick call times depending on the nurse on duty and the youth. Staff stated that certain RNs would not see youth that may have been disrespectful in the past which caused a problem if the RN was the only one on duty at the time the youth requested to be seen. Environmental checks were not consistently accomplished. Refrigerator temperatures were not recorded on the weekends. Sharp inventories were correct during this review although daily inventories were inconsistent as noted in the Sharps logbook. Movement of youth to the health center impacted access to care. During this review one Direct Care Staff was assigned to medical to escort youth for appointments and to provide security while youth was in the health center. This created significant lags in youth being present in the clinic for scheduled appointments. Somatic, mental and
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dental providers had to wait for youth which often times resulted in youth not being seen during that clinic day or providers having to extend their hours for that clinic day in order to complete all appointments. RECOMMENDATIONS In order to reach Satisfactory Performance status, the facility and its health unit should do the following: Improve the access to and management of emergency and first aid equipment throughout the facility. First Aid Kits: Standardize contents; store in accessible areas on each unit; ensure all staff knows where they are located. Conduct monthly inventories and restock according to content lists. Ensure documentation is done on all youth who receive treatment. AED: Store in an accessible location; ensure all staff know where it is located; conduct weekly inspections to ensure functionality. Oxygen tanks: Conduct daily checks and replace empty tanks appropriately. Ensure 100% of Direct Care Staff receive are current in CPR/AED/First Aid Training. Develop a list of common psychotropic medication side effects so that staff may be alerted to issues youth may have such as increased fluids, altered behavior, frequent snacks, etc Ensure all youth have equal access to medical care. Ensure all youth have access to sick call requests on all units. Replace missing boxes as soon as possible. Conduct sick call according to ACA and DJS standards. All youth that submit a request will be evaluated by an RN with assessment and interventions documented on the sick call request slip or in the progress note. RNs will implement treatments in accordance with DJS Nursing Protocols. Conduct inventories and refrigerator checks daily with appropriate documentation. Improve youth movement to the health center to ensure access to medical care. Assign additional direct care staff during clinic hours to reduce physician wait time and increase the number of youth able to be seen.
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Comprehensive Quality Review Report Baltimore City Juvenile Justice Center (Jan 2011)

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Comprehensive Quality Review Report Baltimore City Juvenile Justice Center (Jan 2011)

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OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report

Baltimore City Juvenile Justice Center January 20, 2011

DJS QI Report BCJJC

QUALITY IMPROVEMENT REVIEW RATINGS SCALE

Rating Superior Performance Satisfactory Performance Partial Performance Non Performance

DJS QI Report BCJJC January 2011

BCJJC Performance Comparison

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

OFFICE OF QUALITY IMPROVEMENT Baltimore City Juvenile Justice Center METHODOLOGY

DJS QI Report BCJJC January 2011

SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY INCIDENT REPORTING RATING: Satisfactory Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

SENIOR MANAGEMENT REVIEW

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

DE-ESCALATION & RESTRAINT

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

CONTRABAND & ROOM SEARCHES

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

RATING: Satisfactory Performance

Month August September October November

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

ROOM CHECKS DURING SLEEP PERIOD

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

RATING: Satisfactory Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

YOUTH MOVEMENT & COUNTS

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

RATING: Satisfactory Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

RATING: Partial Performance

ADMISSIONS, INTAKE & STUDENT HANDBOOK

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011

RATING: Partial Performance

DJS QI Report BCJJC January 2011

DJS QI Report BCJJC January 2011