Comprehensive Quality Review Report Cheltenham Youth Facility (MD 2011)

OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report
Cheltenham Youth Facility December 22, 2010
OFFICE OF QUALITY IMPROVEMENT Quality Review Report Cheltenham Youth Facility Evaluation Dates: November 1-5 & 17-19, 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 ........................................................................................... 9 De-Escalation & Restraint ............................................................................................ 11 Contraband & Room Searches...................................................................................... 13 Seclusion ....................................................................................................................... 15 Room Checks During Sleep Period .............................................................................. 18 Perimeter Checks .......................................................................................................... 19 Staffing.......................................................................................................................... 20 Control of Keys, Tools & Environmental Weapons..................................................... 22 Youth Movement & Counts.......................................................................................... 25 Fire Safety..................................................................................................................... 27 Post Orders.................................................................................................................... 29 Staff Training ................................................................................................................ 30 Admissions, Intake & Student Handbook..................................................................... 31 Classification................................................................................................................. 33 Pending Placement........................................................................................................ 34 Behavior Management .................................................................................................. 35 Structured Rehabilitative Programming ....................................................................... 37 Self Assessment ............................................................................................................ 39 BEHAVIORAL HEALTH ............................................................................................. 40 Intake, Screening & Assessment................................................................................... 40 Informed Consent.......................................................................................................... 41 Psychotropic Medication Management......................................................................... 42 Behavioral Health Services & Treatment Delivery ...................................................... 43 Treatment Planning....................................................................................................... 44 Transition Planning....................................................................................................... 45
DJS QI Report CYF November 2010 Page i of 78
OFFICE OF QUALITY IMPROVEMENT Quality Review Report Cheltenham Youth Facility Evaluation Dates: November 1-5 & 17-19, 2010
TABLE OF CONTENTS (Continued)
SUICIDE PREVENTION .............................................................................................. 46 Documentation of Youth on Suicide Watch ................................................................. 46 Environmental Hazards................................................................................................. 48 Clinical Care for Suicidal Youth................................................................................... 49 EDUCATION .................................................................................................................. 50 School Entry.................................................................................................................. 50 Curriculum & Instruction.............................................................................................. 51 School Staffing & Professional Development .............................................................. 53 Screening & Identification............................................................................................ 55 Parent, Guardian & Surrogate Involvement.................................................................. 56 Individualized Education Programs.............................................................................. 57 Career Technology & Exploration Programs ............................................................... 59 Student Supervision ...................................................................................................... 60 School Environment & Climate.................................................................................... 61 Student Transition......................................................................................................... 62 MEDICAL CARE........................................................................................................... 63 Health Care Inquiry Regarding Injury .......................................................................... 63 Health Assessment ........................................................................................................ 65 Medication Administration ........................................................................................... 68 Dental Care ................................................................................................................... 71 Medical Records Retrieval............................................................................................ 72 Special Needs Youth..................................................................................................... 74 Availability of Medical Services .................................................................................. 76
DJS QI Report CYF November 2010
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OFFICE OF QUALITY IMPROVEMENT Quality Review Report Cheltenham Youth Facility
EXECUTIVE SUMMARY A quality improvement assessment and evaluation of the Cheltenham Youth Facility was conducted November 1-5 & 17-19, 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 Cheltenhams strengths include a large open campus design. This design allows for more physical activity, fresh air and the ability to walk and talk with a youth when he needs to vent. The staff are seasoned, with many having decades of experience working with at-risk youth. The front gate security is excellent and staff work diligently to maintain a safe entry point. Medical care is provided by nurses who care about the youth and who strive to provide caring and high quality services. Vocational options are offered by the school. The Superintendent is new but extremely dedicated and youth-centered in his approach. Orientation staff are new but already show great promise and initiative in their positions. The kitchen staff do a great service to both youth and staff by creating meals that are healthy and delicious. Mental health staff provide one-on-one counseling and are also wellstaffed to ensure services to any youth in crisis.
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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 CYF in April 2009, 38 standards were evaluated. Following is a brief synopsis of the results from that review:* Rating Superior Performance Satisfactory Performance Partial Performance Non Performance # within rating 0 16 21 1 % of total in rating 0% 42 % 55 % 3%
For this review, a total of 36 standards were evaluated with the following results:*
Rating Superior Performance Satisfactory Performance Partial Performance Non Performance
# within rating 2 14 16 4
% of total in rating 6% 39 % 44 % 11 %
* The DJS Quality Improvement Performance Ratings are aligned with best practices and optimal standards of care. Therefore, while the facility practice may be in full compliance with minimum constitutional standards, the facility may still receive partial or non performance ratings as a result of QI reviews.
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CYF PERFORMANCE COMPARISON
60%
50%
40% Percentage
30%
20%
10%
0% 5/1/09 Date of Report Superior Performance Satisfactory Performance Partial Performance Non Performance 12/1/10
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OFFICE OF QUALITY IMPROVEMENT Cheltenham Youth Facility Executive Summary of Results

Superior Performance
Medical Records Retrieval Availability of Medical Services
Satisfactory Performance
Room Checks During Sleep Period Admissions, Intake & Student Handbook Classification School Entry
Partial Performance
De-Escalation & Restraint Contraband & Room Searches Perimeter Checks
Non Performance
Incident Reporting Senior Management Review Seclusion
Control of Keys, Tools & Environmental Weapons Youth Movement & Counts
Staffing
School Staffing & Professional Development Screening & Identification Parent, Guardian & Surrogate Involvement Career Technology & Exploration Programs School Environment & Climate Student Transition Health Care Inquiry Regarding Injury Medication Administration Dental Care Special Needs Youth
Fire Safety Post Orders Staff Training Behavior Management Structured Rehabilitative Programming Documentation of Youth on Suicide Watch Environmental Hazards Curriculum & Instruction Individualized Education Programs Student Supervision Health Assessment
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OFFICE OF QUALITY IMPROVEMENT Cheltenham Youth Facility 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. 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 15 youth were interviewed individually and several more in groups about a range of areas across the QI review spectrum. This represented 12% of the total population at CYF that week. Interviews were also conducted with facility staff, administration, medical, case management and education staff. In addition, 11 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 Medication Pass 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 via phone on November 22.
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SUMMARY OF FINDINGS & RECOMMENDATIONS
SAFETY AND SECURITY INCIDENT REPORTING RATING: Non 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 46 Facility Incident Reports June-Nov 2010 7 videotaped incidents 29 Youth Grievances Staff Training Histories Report 19 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 Incident Reports (IRs) at Cheltenham (CYF) were difficult to assess as they could not all be confidently found. A review of the IR Log, written IRs that could be found and the IR numbers in the DJS database revealed that the facility is not able to accurately know what their numbers are because IRs are not being tracked, entered and filed as required. For example: # in IR Log 84 96 58 # of written IRs found 57 62 46 # in IR database 26 55 8
Month September October * November
* Up to November 17th
The IR files in most cases did not contain both written and electronic copies, mostly because most were not in the IR database. Almost none were in files but were in various locations throughout the Administration Building.
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IRs that were reviewed were generally filled in entirely. Notifications were the most likely area to be incomplete. 25% of IRs were either checked as the wrong category or missed a category being checked (such as physical restraint.) Four unreported incidents were discovered: (a) fire extinguisher cabinet doors glass was broken and the fire extinguisher discharged at some point; (b) one unreported incident was discovered via OIG investigation #10-80201; (c) one unreported incident was discovered via OIG investigation #10-87208; and (d) a review of one units logbook revealed a contraband incident on November 5th that was not documented in an incident report as required. The incident involved a staff observing a youth using a sharp metal object to prevent his room door from closing after being forced into his room. No IRs could be located or were completed in these cases. Due to not being able to count IRs and compare that number with the Nurses Injury Log, no such comparison for unreported incidents was done to assess for any more unreported incidents. The narrative portion of the IR included all four parts and all four were completed. However detail in them was generally only fair with some staff doing a very complete job and some giving very little information. It was not possible in about half the cases to recreate the event from the information given. Two-thirds described the restraint if one was used. Child abuse allegations made to nurses were reported to CPS as required. Most of the IRs contained shift commander comments. The quality of those comments was poor and is indicated in more detail in the next section entitled Senior Management Review. Nearly all of the IRs reviewed had all or most youth and staff witness statements present. In 20% of incidents the youth(s) were late (over two hours) being evaluated by the nurse for injury. In 20% of cases, no body sheet was included with the IR.
GRIEVANCES There were 19 youth grievances from Jan 1-November 17, 2010. The top complaint was about not getting phone calls. Consistently problematic were supplies as well; shoes, clothing and supplies were oftentimes noted by youth as needs to the Advocate. The Youth Advocate picks up grievances in less than 2 days on average which is excellent; every youth said they knew where to find and file grievance forms and would do so if they had a complaint.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Return to an organized system of IR receipt, review, database entry, file creation, IR audit and filing. Ensure all DJS database numbers are correct by ensuring IRs are all accounted for. Create labeled files by IR # and date and file together in a cabinet. Ensure both written and electronic copies are filed together. Recommend filing seclusion sheets inside a folder with the IR for ease of review. Discontinue or revise the IR Log process. Ensure all youth see the nurse within two hours of any incident or explain on the IR why that was not possible. Ensure all body sheets are attached to the IR packet. Ensure in every case, all relevant parties are notified and that the notification is documented. Ensure shift commanders review IRs to be sure the incident type/category selected is correct. Encourage staff to give full and complete details about all incidents, including how it began, the restraint they did if applicable, 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 (including video review follow-up) 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. Require shift commanders to critique staff when they fill out the shift commander comments. Ensure they are sharing these coaching tips with their staff (more on this in the Senior Management Review section of this report.)
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SENIOR MANAGEMENT REVIEW
RATING: Non Performance
STANDARD Written policy, procedure and practice document that incident reports are reviewed and critiqued by shift commanders and critical documentation, such as incident reports, suicide watch and seclusion paperwork, are routinely audited by senior managers within DJS timelines and corrections are made by staff timely. SOURCES OF INFORMATION 46 Facility Incident Reports June-Nov 2010 Review of 7 videotaped incidents Interviews with staff Review of 19 OIG Investigations Review of seclusion documentation Review of suicide watch documentation REFERENCES DJS Policy MGMT-03-07 Incident Reporting Policy (MGMT-3-01); ACA 3-JDF-3B-10 and 3-JTS-3B-11 SUMMARY OF FINDINGS IRs contained shift commander comments that overall did not contain a critique. Of a sample from July and August 2010, 0 of 20 (0%) critiqued staffs handling of the incident. Some critiques were present in November (after a training by QI) but only by two shift commanders. The areas missed by shift commanders were supervision issues, posting issues, witness statement information that contradicted the IR, vague information, youth concerns about staff treatment of them and poor restraint detail; overall, the comments did not help give staff any coaching on how to improve or to prevent the next incident which is a clear requirement on the IR itself. Policy requires senior administrative review of all incident reports within 72 hours. At CYF, this process is led by one GLM and she is responsible for all audits of all IRs in the entire facility. No other senior managers handle any auditing of the IRs. As a result, the process is a difficult one for one person to keep up with. Dates on audits varied. The questions raised by the auditor were often good but were not timely addressed by shift commanders. Some questions were never answered. There is still not regular video review of incidents by shift commanders. Consequently, any problematic incidents that are not reported fully by staff would not be caught and addressed. Seclusion sheets showed no evidence of auditing. None were filed with IRs in order to ensure the seclusion entry and exit times matched those reported. Suicide watch documentation showed no evidence of auditing.
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The Office of the Inspector General (OIG) completed 19 investigations since January 1, 2010, about half (9) of which were sustained. A full 8 of 9 were sustained for inappropriate restraint technique or excessive force (more on this in the De-Escalation and Restraint section of this report.) All OIG reports seemed to be thorough and gave a good accounting of the facts.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure the auditors questions are raised with shift commanders, given out and returned timely and all concerns are addressed. Consider using group meetings to address some of these and to improve the speed of the process. Begin required video viewing (by shift commanders before leaving their shift) of all alleged group disturbances, youth on staff and staff on youth assaults, inappropriate conduct, restraints, property destruction and child abuse allegations. Add a Video Reviewed: Yes or No line on the auditing form to clearly show that this was done and include notes from the video review. Require all shift commanders to critique staff and to share their comments with staff so that staff can learn from the management review. Ensure this is done the day of the event so that memories are fresh and staff are encouraged to use this information to prevent another such occurrence. Ensure shift commanders understand the mechanics of a critique and know what supervision points to catch when they review an incident. See that they do not critique incidents they themselves are involved in. Require shift commanders to understand the requirements of suicide watch and seclusion observation sheets and to review for quality while on the floor. Ensure all sustained OIG findings are followed up by the facility. Ensure an audit system for seclusion documents is instituted. File them with the IRs in order to make for an easier review. (See the Seclusion section of this report for more specifics.) Ensure an audit system for suicide watch documentation. (See the Suicide Prevention section of this report for more specifics.)
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DE-ESCALATION & RESTRAINT
RATING: Partial Performance
STANDARD Written policy, procedure and practice document the use of verbal crisis intervention techniques to de-escalate a situation prior to the use of physical restraints. Physical restraints are used only when necessary and the least restrictive physical restraint is used first. Incidents involving physical restraints are video taped. SOURCES OF INFORMATION 46 Facility Incident Reports June-Nov 2010 7 videotaped incidents 19 OIG Investigations Staff Training Histories Report Interview with Superintendent Interviews with youth Interviews with staff REFERENCES DJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management (CPM), Techniques Policy (RF-02-07); DJS Videotaping of Incidents Policy (RF-05-07); ACA 1-SJD-3A-14-15 SUMMARY OF FINDINGS Descriptions of uses of force in written IRs were not detailed and were rated at best Fair overall. Staff statements individually sometimes did a better job of explaining the restraint, but again only some staff were able to give the kind of detail needed to figure out exactly what happened. Shift commanders are not requiring more detail when IRs are turned in to them. There were multiple instances of staff using inappropriate restraint techniques in OIG investigations, including pushing youth down, punching youth and putting youth in choke holds (hands or arms around necks of youth.) Seven of eight OIG investigations indicated staff used these non-CPM techniques. Videos revealed instances of staff trying to safely pull multiple youth apart who are fighting and walking youth safely using a passive restraint technique. They also showed staff attempting to pull up a youth who was non-compliant (violating DJS policy), choking a youth and closing a youths arm in a door. There seems to be a clear distinction between staff who attempt a safe CPM technique and those who do not. Just 28 of 112 mandated staff (25 %) were compliant with Crisis Prevention and Management semi-annual training.
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RECOMMENDATIONS In order to reach Satisfactory Performance status, it is recommended that the facility: Re-train and follow up with staff on descriptions of restraints in IRs. Staff should give detailed accounts, including which hand(s) they used, if the youth moved, ran, struggled or complied, and if the staff stood or walked with the youth, etc. Continue to focus on poor CPM techniques in video reviews and OIG investigations. Allow staff to review their own incidents on video whenever possible in order to see exactly where they could have improved or how earlier intervention of a different kind might have prevented the incident. Ensure that staff are knowledgeable about other means (besides seated verbal directives, hands-on, or use of force) to handle youth who are disruptive in class or on the unit. Calling mental health, case managers, the Superintendent, etc. are options as is simply asking the youth to take a brief time-out to calm down in his unlocked room. Staff should document on the youths point sheet and the unit log book and describe the behaviors and interventions in detail. Ensure all staff are trained twice yearly in CPM, including mechanical restraints.
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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 requires that sleeping rooms be searched a minimum of once per week for contraband and that the search be recorded in the units log book. A review of randomly selected unit log books indicated that room searches are not consistently documented as required. Interview with 11 staff indicated that the facilitys FOP requires more frequent room searches than Department policy. Not all of the staff, however, agreed on the frequency for conducting a room search. Some staff indicated once a week and others stated every shift. Interview with staff revealed that the facilitys policy requires staff to record all room searches on Shakedown forms. Shakedown forms for two of three cottages were not readily accessible for review. Four of nine staff indicated that they are not given enough time or assistance to realistically search sleeping youth rooms. A review of the DJS Incident Reporting Database revealed 9 incidents involving contraband from January 1, 2010 to November 15, 2010. A review of one units logbook, however, revealed a contraband incident (11/5) that was not documented in an incident report as required. The incident involved a staff observing a youth using a sharp metal object to prevent his room door from closing after being forced into his room. The youth refused to surrender the sharp metal object to staff and hid it in his room. The staff reportedly left the unit to retrieve a flashlight so he could search the room for the sharp metal object. No further information regarding the matter was readily available. The facility reported two incidents (IR) involving the recovery of dangerous objects which were described as a metal weapon that was observed in a youths locker (#80578) and a homemade shank found in a heating vent during a room search (#82417).
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A search of sleeping rooms revealed several beds that were not properly secured to the floor by metal brackets. Some of the beds have loose or missing metal brackets that are supposed to secure the beds to the floor. The facility has conducted searches that resulted in the recovery of pens (used to make a tattoo device), unidentified pills, an illegal drug and suspected marijuana. QI team observations revealed that youth are not consistently searched for contraband upon movement. During a tour of the facility, a QI team member observed youth watching a DVD movie titled Wanted. The movie is R rated and contains acts of violence. The movie is about a frustrated office worker [who] learns that he is the son of a profession assassin, and that he shares his fathers killing abilities. These movies are inappropriate for showing to youth in the care and custody of the Department and should not be inside detention facilities. The facilitys walk through metal detector/scanner is inoperative. However the facility is currently using a handheld wand to scan visitors and employees entering the facility.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure staff consistently document room searches in the unit logbook. In the event that facilitys records or sources of information (i.e. shakedown form, etc.) are lost or destroyed, the unit log book will serve as a source document for the information as required by DJS policy. Ensure Group Life Managers/Shift Commanders verify that all required incidents are entered into the DJS Incident Reporting Database, as required by DJS policy. Staff should conduct a through search for contraband upon youth movement. Ensure only G, PG or PG-13 movies are shown to the youth. Ensure a working flashlight is readily available for staff on the units. Repair or replace the walk through scanner.
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SECLUSION
STANDARD Written policy, practice and procedure provide that youth confined to a locked room, not during sleeping hours, shall be observed often and have those observations documented, shall only be placed in seclusion if they present an imminent threat to others or an imminent threat of escape, and shall be treated humanely and with concern and care so as to safely maintain the youth until he can be released in the least amount of time. SOURCES OF INFORMATION Facility Seclusion Log Interview with Superintendent Incident Reports from June-Oct 2010 Seclusion sheets Videotapes of seclusion and morning hygiene Interviews with youth and staff Observation at facility REFERENCES DJS Seclusion Policy RF-01-07; COMAR 16.18.02 SUMMARY OF FINDINGS There were twenty (20) documented seclusions between August 8 and November 17, 2010. The seclusions that were documented were lengthy, with an average length of stay in seclusion of 32.5 hours, by far the longest length of stay in the state. The Seclusion Log had blank spaces on nearly every line; blanks included: release times, release dates, reasons for confinement, person requesting confinement, entrance times, and person authorizing confinement. Because of this, it was extremely difficult to know actual seclusion times. They had to be pieced together from the sheets the facility could find. It would be impossible for the Superintendent, upon a quick review, to assess seclusion use or to know if a youth was still in seclusion or not. Many youth in group disturbances were all released at the same time. This gave the appearance that seclusion release was not individualized but was instead being used as punishment. There were multiple instances of undocumented seclusion use at Cheltenham: o Youth were observed locked in rooms during morning hygiene and breakfast well after wake up time on a video from November 2, 2010; o All youth on Henry were observed on video locked in on October 18, 2010 after breakfast while the four staff sat at a front table; o After an OIG investigation, staff were sustained on for an undocumented seclusion on July 26, 2010 (lasting 3 hours);
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o Thirty-three (33) youth were discovered locked in until mid-day on November 5, 2010 (due to lack of staff) with no documentation; and o On November 19, 2010, the QI Team saw a youth locked into the dayroom eating lunch alone; the logbook indicated hed been in there since 8:30am due to having issues with another student. The issue of lack of staff, especially on Henry, was mentioned by staff and a youth; youth have to remain locked in until the ratio can be met. Only once was a staff shortage indicated in the seclusion log (August 8, 2010). At no other time was a staff shortage indicated as a reason for seclusion use, and in no case were seclusion processes followed or documentation completed when there was a mass lock-in for lack of staff. Eleven (11) of the documented episodes of seclusion were reviewed. Sheets were fair in that line staff generally documented checks as required. Five (5) youths sheets from October 31, 2010 had missing or inappropriate shift commander comments, no overnight checks, exact 10 minute checks and a one hour gap. On a random video of one seclusion episode reviewed from November 2, 2010, a line staff did make the checks he was supposed to be making at ten minute intervals as required. The shift commander comments (reasons for youth not being released from seclusion) were poor across all eleven youth. Most noted Per Admin or Group Disturbance or Re-evaluate in AM (when it was mid-day) or Waiting for superiors to contact me and the like. Very few gave justifications, which gives the strong appearance seclusion is being used as punishment. The documentation gaps seem to rest more with supervisory staff than with line staff. There was no documented auditing of the seclusion log or observation sheets; the anomalies listed above could have been found and staff correction made if an auditor checked them daily. The seclusion form being used is not a DJS form and does not meet policy expectations. About half the time, it was noted that seclusion ended at 10pm because that was the end of the second shift and the last bedtime. Though true that DJS seclusion policy indicates that seclusion is locked door time not during sleeping hours, it is unsafe to stop watching a volatile youth at the proscribed intervals because bedtime happens to come about. If the youth is in seclusion, it is due to his being so out-of-control that his door cannot be open and he is dangerous to himself or others. Juvenile suicide in confinement studies show that youth in locked rooms are more likely to commit suicide (due to being agitated, depressed, angry or stressed) which is why DJS requires staggered ten minute checks of youth who are in these mental states post-incident. DJS requires in policy that a youth be released as soon as he is calm. If a youth who is on seclusion cannot be processed out at bedtime, then returned to his room with the confidence that he is safe, then the checks must continue through the night and processing tried again in the morning. 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.
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Generally the Tour Office would call and this was documented by the RN. Review of Seclusion documentation for 10/31/10 in which youth were secluded 4 hours found no medical assessments documented for two youth on the door sheets or in the progress notes. In other seclusion cases, medical assessments were not accomplished when seclusion continued overnight. On some, dates and times of notes were missing and documentation did was not consistently accomplished every 2 hours. RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Seclusion processes are poor. Significant work and training will be needed to rectify it. QI is available for technical assistance if requested. Use the DJS-approved Seclusion Observation Sheet attached to policy. Discard the sheet currently in use. Ensure that the auditing process includes seclusion sheets if a seclusion episode occurs. File seclusion sheets in a separate (red) folder inside the IR manila folder so that the entire incident and seclusion can be reviewed/audited together. Require the Seclusion Log to be filled out properly, accurately and in its entirety. Require shift commanders to make an actual attempt to process youth out of seclusion every two hours as required. Continue to review video and discipline shift commanders who do not attempt to speak to youth. Ensure release decisions are individually made. Lessen the length of stay through proper seclusion use and procedures. Ensure all staff know to continue seclusion checks for youth (who are still unsafe to be let out of rooms at bedtime) all night or until they are safely able to process. Do not stop checks simply because it is bedtime. Ensure a youth in any locked room (including a dayroom) is watched following DJS Seclusion policy guidelines. Ensure Medical is promptly notified of any seclusions and that medical checks occur every two hours until release.
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ROOM CHECKS DURING SLEEP PERIOD
RATING: Satisfactory Performance
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 Room check sheets 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 DJS policy requires that staff conduct a room check of each youth during the bedtime period at least every 30 minutes. The facilitys Required Use of Guard Tour Facility Monitoring System and Supervision and Movement FOP indicate different time intervals for conducting room checks. However, both FOPs requirement indicate room check intervals of less than 30 minutes. The facility utilizes the Guard Tour System to electronically record room checks. A review of 40 shifts indicated that staff conduct room checks within established time intervals with some exceptions that exceed the required time intervals. A random review of surveillance video tapes revealed that staff are conducting rooms checks at the required time periods. A review of a units logbook revealed several entries by a staff requesting that a night light be placed in some rooms so that youth can be properly observed.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure a flashlight is readily accessible to staff conducting room checks. Ensure that all FOPs that reference the times room checks are to be conducted comport with one another.
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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 Guard Tour documentation 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 The facility conducts at least one daily check of the perimeter and grounds as required by policy. There were a few exceptions to the facilitys required perimeter checks due to the utility vehicle(s) being inoperative. Based on information received and a tour of the facility, there were times when the latch to the electronic lock on the exterior door of the Tour Office was taped so that the door would remain unlocked for the convenience of staff. During several observations of the Tour Office, an interior security door, unoccupied areas and a storage room were discovered unlocked but not in use. During a tour of the facility, youth were allowed to enter an office to pray and they partially closed the door without staff being present in the room. An unoccupied and open office was located within the same room where the youth were praying. Both offices contained supplies or items that would be considered contraband for a youth to possess. During a tour of the facility, one of the security doors in the Health Center remained unlocked due a key having difficultly operating in the lock.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure staff lock all doors, unoccupied areas, and storage rooms when not in use. Shift Commanders should conduct frequent checks of the Tour Office to ensure that staff do not disable any door locks for their convenience.
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STAFFING
STANDARD The facility maintains a current staffing plan that ensures a sufficient number of staff is present to provide an environment that is safe, secure and orderly. SOURCES OF INFORMATION Facility listing of vacancies Review of Facility Staff Review of Facility Logbooks (Rennie, Cornish, Henry, Infirmary, Education & Master Control) Review of Cheltenham School Daily Documentation Forms Interview with staff and youth Review of Incident Reports Observation of facility REFERENCES ACA 1-SJD-1C-03 SUMMARY OF FINDINGS The staffing for all three shifts from eight random days in from July 2010 to November 2010 were reviewed (24 shifts). On six of those shifts (25%) at least one unit was out of the appropriate staff to youth ratio. A review of incident reports from June 2010 to November 2010 found 7 of 46 incidents (15%) in which the staff and students were not in the appropriate ratio. On November 5, 2010 the Henry locked 33 residents in there rooms because there were only three staff members to supervise them. The residents were not were not allowed out of their rooms until their lunch time. A review of the Cheltenham School Daily Documentation Forms showed that there were numerous days when students were late to school, or did not come to school because there were not enough staff to maintain appropriate ratios. The Henry unit missed the morning session of school three times during the review because of a lack of staff. During the review an observation of the school showed that while the groups came to the school in ratio, the groups were broken down into smaller units in the classrooms. At those times the staff and student ratios were not met. At the time of the review there were 4 direct care staff members out on extended medical leave. Personnel management staff at Cheltenham reported that there are approximately 8 residential staff position vacancies at Cheltenham that the facility is actively trying to fill.
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Staff reported that there is a great deal of mandatory overtime. This was confirmed with the 24 shifts reviewed from July 2010 to November 2010. There were 61 staff members working over time on those 24 shifts. On 9 of the 24 (37.5%) shifts there were at least four staff members working an overtime shift. Staff report that overtime is not distributed evenly among staff. They report that staff members who do not complain are given an unfair amount of overtime. Youth and staff report that activities and school are missed because the units do not have enough staff to manage breaking the groups into small units. Orientation staff are pulled for unit coverage and therefore cannot orient youth or ensure prompt testing and assessment. 10 of 11 staff interviewed feel that there is not a sufficient number of staff employed or working at the facility on a daily basis. 8 of 11 staff indicated that there are sometimes or often not enough staff to supervise youth on suicide watch.
RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Review the current staffing plan to determine what additional staff are needed considering the population. Continue to recruit to fill all available vacant residential staff PINS. Review how overtime is handled among the staff. The facility should ensure that overtime is distributed evenly among the staff members. Ensure unit ratios are met so that Orientation staff are not pulled from their duties.
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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 key board from which facility keys are issued on a regular basis. The facility maintains several key boards in the area of the Tour Office and another key board in the Health Suite. The facility plans to also install a key board in the Administration Building for staff. The facility utilizes a chit and Key Log (sign in/out) to account for the issuance and return of facility keys. A random review of one key log revealed two set of keys exchanged for chits but not signed out by the staff. A random review of the schools key log for the period of 9/27 to 11/15 revealed that 47% of the keys were not recorded in the key log as having been returned. An interview with the Key Control Officer revealed that the facility does not maintain a set of emergency keys at a secure location away from but near the facility. In the future, the facility plans to maintain a set of emergency keys at a nearby State Police Barrack. Currently, there is a set of facility keys maintained in a lockbox in the Gatehouse which is only accessible to a limited number of staff. During a tour of the facility, an entrance door key to Henry Cottage and a key to a security door in the Health Center had difficultly opening the locks. Based on interviews, not all facility keys had been placed on a metal key ring as required by DJS policy. The Key Control Officer is in the process of addressing this matter.
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Policy requires that at least one randomly selected key ring be inventoried daily. Although the facility often inventories the keys, a daily inventory is not conducted in the manner prescribed by policy. Based on an interview with the Key Control Officer, a key audit was conducted in April 2010. Not all security keys (i.e. cage doors and etc.) are identifiable by touch. The facility maintains a back up key board and 24 Hour Key Authorization Forms. Housing Unit keys are exchanged among staff at their assigned duty station and logged in the units logbook.
TOOLS A walk-through of the Maintenance Section showed it to be clean, well maintained and organized. Maintenance maintains a master inventory of the tools assigned to the section. Tools are currently in the process of being inventoried. Staff are responsible for the tools kept in individual toolboxes assigned to each vehicle. Currently, an interim supervisor is managing the Maintenance Section. The interim supervisor plans to inventory tools monthly and utilize a tool sign out sheet. 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 3 times daily, 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 youth were allowed to in a room of a cottage that contained office supplies. Staff were not in the room with the youth at the time.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Mark all security keys in a manner that identifies them by touch. Finish setting up the facilitys key control process. Ensure all keys work properly. Ensure youth do not have access to open offices.
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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 Staff interviews, along with a review of unit and Tour Office logbooks, revealed that the facility does not conduct 30 minute counts as required by DJS policy. The facility has a set number of official/unofficial counts to be conducted daily. The counts are recorded in the appropriate logbooks. Interviews with four staff revealed different versions of the facilitys counting process. A relatively new staff was not familiar with the counting process, two staff indicated that a count is to be conducted every hour and another staff indicated every two hours and upon every youth movement. A review of randomly selected unit logbooks revealed some instances in which staff wrote the counts in the margins and not chronologically according to DJS policy. Also, there were instances when a count was not recorded in the unit logbook during the 3rd shift. The staff do record in the unit logbook whenever a youth has been taken from and returned to a location. Staff do not consistently frisk youth upon movement. 7 of 11 staff interviewed indicated that the maximum number of youth 1 staff can supervise alone is 8 youth. One staff said 6, one said 9 and two did not answer. The facilitys recognized youth to staff ratio is 8:1.
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RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure staff count their youth every 30 minutes and log it into the unit logbook and call it into the Tour Office. Ensure the actual count itself is properly recorded in the unit logbooks. Ensure staff consistently 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 inspected the facility on September 28, 2010. The Fire Marshal indicated deficiencies with some emergency lighting throughout the facility. Observation and interview with the Fire Safety Officer indicated that the deficiencies cited by the Fire Marshall have been corrected. An inspection of the fire safety system (i.e. sprinkler, etc.) by ARK on October 6, 2010, revealed some missing control valve signs, a leaking valve needing to be repaired and recommended certain gauges be inspected. According to the Fire Safety Officer, all of the signs have not been replaced and the leaking valve still needs to be repaired. Observation revealed that an electrical circuit box in the hallway of Cornish Cottage was open. The electrical circuit box was not able to be locked or closed. A youth was later observed playing with the electrical circuit box. The Fire Alarm Control Panel in Cornish and the Gate House shows trouble status. The FACP in Cornish Cottage indicates an internal voltage problem and the FACP in the Gate House indicates a problem with the system at another location. During a routine inspection of the fire extinguishers on October 28, 2010, the Fire Safety Officer discovered that a fire extinguisher box in Henry Cottage had been broken open and the fire extinguisher discharged. The Fire Safety Officer was never informed of the incident or discovered the reason for the fire extinguisher ever being discharged. Six fire extinguishers were randomly checked and found to have a current monthly inspection.
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An observation revealed a mattress at the entrance to Henry Cottage. A youth was seen tripping over the mattress upon exiting the building. Hallways should always remain clear for a fire emergency. Based on an interview with the Fire Safety Officer and available fire drills records, it appears the facility is not conducting fire drills as pursuant to policy (i.e. one each shift per month). Fire drill records indicate that the last fire drills were conducted in August 2010. However, interviews with some youth revealed they have participated in a fire drill in September and October. The Fire Safety Officer indicated that corrective/disciplinary action was supposed to have been taken in the matter.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Replace missing signs and the leaking valve as soon as possible. Have the FACPs in Cornish and the Gate House serviced by a qualified fire safety technician to determine the problem. Ensure exits are not blocked. Ensure fire drills are conducted and documented as pursuant to DJS policy.
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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: Logbooks 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: The facility is required to maintain a copy of each Post Order at the Tour Office, to include a Post Order Signature Sheet. The facility maintained the following Post Orders in the Tour Office. 1. Tour Office Coordinator 2. Housing Unit Staff 3. Unit Manager 4. Shift Commander Still missing from the Tour Office were several post orders that were issued in March 2009; School Monitor, Gatehouse, Health Center, and Security. Not all of the Post Order Signatures Forms had been signed-off by a supervisor as required. Two units were checked for their respective post order and the post orders were found. The Gate House was unable to locate a post order for that post. The facility did not provide a post order for RA staff positions and special duty/assignment position of Fire Safety Officer or Tool Control Officer.
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 positions delineated by policy. (e.g., Resident Advisor series positions) to ensure staff are aware in writing of the responsibilities of their positions/post. Maintain a copy of all post orders and Post Order Signature Forms on file in the Tour Office.
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: Half of the staff interviewed indicated that they were to be trained in CPM yearly even though it is a semi-annual requirement. Mechanical restraints are covered in CPM training. Of 138 mandated staff, 112 (approximately 80% of the mandated staff) were reviewed for training compliance and the results were as follows: -- 64/112 (57 %) met the 40 hour annual training requirement. -- 34/112 (30%) of staff had First Aid/CPR/AED training in the prior 12 months. -- 28/112 (25 %) were compliant with Crisis Prevention and Management semiannual training (when reviewing CPM compliance overall, 58% had had CPM at least once in the prior year.) -- 83/112 (74%) were compliant with Suicide Prevention annual training. -- 83/112 (74%) were compliant with Recognizing and Reporting Child Abuse and Neglect annual training. The facilitys two mandated management staff (both Assistant Superintendents), who are responsible for holding staff accountable in all of these necessary areas, were reviewed for compliance. One was not listed as mandated staff and one was missing both Suicide Prevention and Child Abuse and Neglect reporting classes.
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.
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ADMISSIONS, INTAKE & STUDENT HANDBOOK
STANDARD Written policy, procedure, and practice provide that the admissions process in each detention is operated on a 24 hour basis. The admissions process documents all required elements of the admissions. Such required elements include the initial search of the youth, verification of legal status, verification of basic identifying information, search of ASSIST database to obtain all legal history, photograph of youth upon admission, telephone call, student handbook, clothing and state issued items, and movement to the unit. SOURCES OF INFORMATION Interviews with 3 orientation youth Interview with orientation staff Interview with staff who perform intake 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 and facility rules acknowledgement forms were found in 5 of 5 (100%) of files reviewed. However, youth sign two types of these: one at intake and one at Orientation. The intake handbook and rules sheet should be discarded as the information and handbook are given at Orientation. At times, there is a reported shortage of staff who do intakes. Some case managers have to leave their regular work to do so. There is also a shortage of Orientation staff due to being pulled to cover units. The handbook at CYF is generally complete. A few small errors were corrected and PREA language added that was missing. Youth are offered a handbook at Orientation but do not always take it with them to the unit. They should be encouraged to keep one in their room. The biggest concern is that the SASSI and the MAYSI were sometimes not completed per Mental Health staff. Mental Health staff reported that they have received screenings that are incomplete, un-scored, and without names on them. Of 25 records reviewed, 3 were missing SASSIs and 5 were missing MAYSIs. Two MAYSIs were un-scored and one was not completed. Medical staff confirmed they receive screenings without youths names on them. Intake staff interviewed knew how to score the MAYSI.
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The FIRRST is completed upon the youths arrival. 100% of base files had completed FIRRST screening forms. A medical assessment is done upon admission and in every case within 72 hours. The Orientation process seems generally complete but in need of efficiencies. The two new RA staff assigned plan on updates to the process that make sense. The QI Team offered to assist with a written Orientation curriculum and did so. The new process is beginning in late December 2010. Classification forms were found in 100% of files reviewed.
RECOMMENDATIONS In order to reach Superior Performance status, the following is recommended: Use a written Orientation curriculum. Introduce more efficient Orientation processes: lunch on the Orientation unit, one day maximum stay, planned groups, and a structured day. Remove the intake handbook and rules acknowledgement form from the intake packet. Use only the one used by Orientation. Consider training other administrative staff on how to do intakes so that more staff are able to assist when necessary. Ensure MAYSIs and SASSIs are completed in full, scored and names attached. Ensure these are carefully monitored to see that all youth are receiving them as required.
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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 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 The facility maintains a Classification FOP to include a housing matrix for each cottage. A review of twenty base files revealed that Housing Classification Assessment and Re-Assessments forms (after 60 days) were included. One re-assessment did not include the date of the assessment. Several of the forms did not indicate the youths assigned room number or unit assignment. An interview with the CMS did not reveal if the Case Managers conduct or track the need for a Re-assessments at other times (i.e. youth involved in 3 or more incidents and implement a Guarded Care/Behavior plans as a result, etc.) as pursuant to DJS Policy. Interviews revealed that Intake staff have been trained in the proper scoring and utilization the Housing Classification tool.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure the actual date of classification, room number and assigned unit is recorded on the Classification form completed.
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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 Crisis Management Interview Forms 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. In most cases the points were all filled out completely, give all of the youth all of their points during the day. Deductions would be made in the case where there was an incident, but most students ended the day with all of their one hundred points. During the review, this reviewer identified four 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. The point sheets of these youth were reviewed. In all of the cases the youth received all of their points for education despite their behavior. Teachers were not allowed to give and take away points for the times when youth were in school. Students consistently indicated that they did not receive the incentives as outlined in the student handbook. Students listed commissary as their favorite incentive in the program and the one incentive that is consistently provided. Students reported that bedtimes are not administered according to the BMP. Youth report that all youth are placed in their rooms during showers and that they do not come out after showers. This was supported by the information about bedtimes in the unit log books. While the youth were aware of the behavior management program they did not have it in writing. The youth said that they were told about it in Orientation but it
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is not included in the Student Handbook. It indeed is in the handbook, so there may be a need to laminate the handbook and post it for reference. For students who have difficulty maintaining appropriate behavior under the Behavior Management Program the facility creates Behavioral Management Plans and Intervention Plans. These plans outline negative behaviors, triggers, soothing strategies and action plans to direct youth to display positive behaviors. The information is valuable, but the direct care staff interviewed indicated that they were not made aware of this information. The Crisis Management Interview Form is a form that the mental health staff used to process with you and allow them to discuss behavior triggers and strategies that have worked well for them in the past. While this information could be useful the staff indicated that they were not given the information. Without sharing it with those who work with youth, the plans are not useful.
RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Daily Point sheets should be updated by the staff throughout the day. At the end of an activity the points should be awarded or taken away. During the school day the teachers should award the points for classroom participation and behavior. Incentives should be provided to the youth as outlined in the BMP. Information from Behavioral Management Plans, Intervention Plans and Crisis Management Plans should be shared with the direct care staff who will be the main people interacting with the youth. The Student Handbook should be laminated and posted on all units, in the school, the Health Center , the gym and the dining hall for reference for youth and staff.
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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 Master Schedule indicated that the youth received Behavioral Health and Educational groups from 3:35-4:40 PM and then extra groups between 6:357:35 PM. A review of the unit logbooks did not indicate that there was any consistent programming during these times. The most consistent activity was the mental health groups. The units were visited on November 17, 2010 in the evening during the time the schedule indicated that youth should be in groups. During that time none of the units were in structured activities. Youth were watching movies, playing cards and playing video games. Similarly on November 18, 2010 there was no school at the facility because of teacher training. During that day the youth participated in no structured activities beside recreation. Youth, staff and logbooks confirm that the youth receive at least one hour of recreation everyday. Youth indicated that, weather permitting, they can choose to have recreation outside or inside. The facilitys Assistant Superintendent reported that the facility has not had an Youth Advisory Board Meeting since February 2010. He indicated that they would began again in December 2010. The youth reported that they are not offered any religious services. Staff reported that the church that had previously provided services no longer comes to the facility.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area, it is recommended that the facility: Develop programming to meet the needs of the youth. Facility staff can organize activities to engage the youth. Keeping the youth busy would help to prevent fights and other negative behavior. An activity schedule should be developed and posted monthly so that youth will be aware of upcoming activities. Ensure all schedules are accurate. If groups are not occurring, remove them from the schedules. Continue with the plan to re-establish the Youth Advisory Board Meetings Contact local religious organizations to see if they would offer some programming. When religious services are offered an alternative program should be offered for youth who choose not to participate.
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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 Suicide Tracking Log kept by mental health staff Incident Reports involving suicide ideations/gestures Interview with youth on watch 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 Staff checks on Suicide Observation forms were very difficult to review. Forms had not been copied into a binder; they were in one large stack with various dates, youth, and shifts intermingled; none had been audited; none were in the medical files as required; and it was impossible for the facility or QI to tell whether all dates or times were covered with good staff supervision. From a general overview, checks were sometimes found to be pre-dated, staff sometimes gave location and not behavior of youth, and sometimes supervisors signed on pre-timed lines made by line staff. One supervisor (who works in the school generally) caught several key errors on suicide watch sheets. Upon a visit to one youth on suicide watch on 11/18/10 on Cornish, the sheet was found to have been last filled out at 1:29pm and the current time was 1:54pm; this went beyond the ten minute checks required by policy. The youth, who was a Level III youth, was also not within 5 feet of the staff, but was close by and in the same room.
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The Suicide Watch Log kept by mental health is in the form of a Crisis Management Plan. It is kept daily, emailed out to all facility managers daily, and contains the youths Watch Level, date initiated and re-assessed, strategies for safe supervision, and on-call and assigned therapist. Though this contains generally all policy-required information, it does contain language that is complex and maybe too much so for line staff and middle managers who are unfamiliar with clinical terminology. It is recommended the language be as clear and simple as possible so that all caring for the youth can review it and understand it. There was no method for determining whether CYF staff open the Suicide Watch email daily. Clinical staff do say they relay the information verbally as well as by email in order to ensure all are aware. The facility keeps a Suicide Watch Log Book in the Tour Office that is inaccurate, contains many blank areas and is not useful for determining whether a youth is on watch or not. It should be discontinued; mental healths daily email already contains this information. In a sample of over 80% of all mandated staff, 83 of the 112 staff sampled (74%) were compliant with annual Suicide Prevention DJS-required training. Staff knew they could put a youth on Level III one-to-one watch. Staff indicated that when a youth was on one-to-one watch, they could not leave that youth for any reason, including breaking up a fight. Concerning was that of 11 staff randomly asked, 8 staff indicated that there are sometimes or often not enough staff to supervise youth on suicide watch.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Return to a Suicide Watch Observation Sheet system of daily review, audit, filing and retention by name and date. The sheets should be: copied at Admin and placed in a binder by youth name; the originals daily taken to mental healths offices and placed in a designated folder for their review; reviewed briefly by a clinician and filed in the youths medical file. Ensure auditing of the copies of the Suicide Watch Observation sheets daily by trained staff. Spot check sheets daily for youth on watch. Ensure the Suicide Watch Log mental health keeps is written in clear, readable language. Cease the use of the facilitys Suicide Watch Log Book in the Tour Office. The daily email from mental health already contains this information and mental healths information is far more accurate. Ensure 100% of staff are compliant with Suicide Prevention annual training. Ensure sufficient staff are available to watch youth on suicide watch.
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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), 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 Not all staff carry a cut down pursuant to policy. The facility has several beds that are not suicide resistant beds. In one cottage, an electrical extension cord is laid across a hallway into one sleeping room.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Provide all direct care staff with cut down tools as policy requires, train staff on their use, and monitor that they carry them on their person when working with youth. Bed frames should be replaced with suicide resistant molded plastic beds.
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CLINICAL CARE FOR SUICIDAL YOUTH
RATING: Not Rated
STANDARD Written policy, procedure, and practice require that timely suicide risk assessments, using reliable assessment instruments, are conducted at the facility for all youth exhibiting behavior that may indicate suicidal ideations to determine whether a youth should be placed on suicide precautions or whether the youths level of suicide precautions should be changed. Youth at a facility who exhibit suicidal ideations or attempts should receive timely, appropriate, and professional mental health services. Youth should not be restricted from programs and services more than safety and security needs dictate. All pertinent staff should review all completed suicides and suicide attempts at the facility for policy and training implications.
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EDUCATION
SCHOOL ENTRY
STANDARD Written policy, procedure and practice document timely enrollment of all students into the educational program. The school will receive a daily roster of students. The receipt of student records should occur in a timely manner. SOURCES OF INFORMATION Interview with record staff Interview with Special Education Coordinator Review of 34 student folders (22 special education, 11 general education, 1 Section 504) 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 30 of 34 (88%) of students records were requested within 72 hours or 3 school days of admission. 27 of 34 (79%) of records were received within five school days of admission into the facility. Secondary requests were the only area of concern. 14 of 22 files (66%) that needed a second request were not performed according to COMAR 13A.08.07 30 of 34 (88%) of students were interviewed and assessed within 72 hours of admission to the school. Education staff reported that they receive a population report daily.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that second requests are performed according to COMAR 13A.08.07. This should also increase the amount of records received within five days of admission.
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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 Cheltenham School Daily Documentation Forms Review of school logbooks Interview of two teaching staff members Interview of 8 students Observation of transitions to and from class Two Classroom observations REFERENCES MSDE Guidelines DJS SOP for Special Education Service Delivery in Secure Detention Facilities SUMMARY OF FINDINGS Lateness to school is a chronic issue for CYF. A review of the Cheltenham School Daily Documentation Forms and the School Logbook indicated that units are late almost every day. The documents indicated that units frequently missed the first period of school. There were eleven instances where units did not come to school at all. The reasons included: lack of direct care staff, lack of teaching staff and fights on the unit. During the first day of this review, the Henry unit did not come to school for the entire AM session. This concern has continued even after the implementation of the schools new schedule. At the beginning of the review, the school was using a schedule that had been in place for the entire school year. In an interview with the Principal, a new schedule was presented. The previous schedule included a five hour instructional day. The new schedule provided a six hour instructional day. The schedule attempts to stagger the lunch break for units, which allows for less transition time in the day. While the school is unable to group students totally by ability, the school does an A/B grouping which places youth with special education instructional needs and lower functioning non-special education students in the A group. Special education teachers are assigned to that group. The schedule also addresses some
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equity concerns that teachers had by evening out the number of classes each teacher teaches. The school offers the Science, Technology, Engineering, Mathematics (STEM) program. The school was awarded a grant by the After School Institute to run the program and to train other sites to use STEM. STEM teaches students science, technology and mathematics by using hands on activities. The program rotates so that each of the units can participate. The Principal indicated that CYF is the first detention school to run the program. 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. The school provides pre-GED instruction to youth who qualify. The school has a library and students are able to borrow books and take them back to their rooms.
RECOMMENDATIONS In order to reach Satisfactory Performance status in this area it is recommended that the facility: Ensure that youth receive school according to the school schedule is critical. To do so the facility has to manage staffing of direct care staff and teacher attendance better.
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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, two teacher supervisors, (one of which is the Media Specialist and the other is a Social Studies teacher), 4.5 special education teachers (one serving as the special education coordinator), 2 math teachers, 2 language arts teachers, 1 Social Studies teacher in addition to the teacher supervisor, 1 Careers/Life Skills teacher, 1 guidance counselor, 1.5 Career Tech Education (CTE) teachers, 3.5 Instructional Assistants II (IAs), 2 records clerks (one is actually an IA), 1 guidance assistant (also an IA) and 1 secretary. The Principal reported that there are two special education vacancies. There are also two direct care staff members working in CTE classes. Unlike other larger detention centers schools, the CYF school does not have an Assistant Principal position. A list of certified teachers indicated that all of the classroom teachers but one hold current MSDE certification. In addition, the Woodshop and Graphic Arts classes are run by two non-teachers. With the exception of the math teachers, all of the content area teachers hold certification in their content areas. All of the special educators hold special education certification. The Principal reported the school is in need of good professional development (PD). The education staff get PD in areas of dealing with adjudicated youth, but get little in the teachers content areas. Related services in the form of counseling are provided by the 2.5 mental health staff personnel assigned to the school. Speech language services are provided by a contractual provider.
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RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Provide additional certifications for teachers in all of the content areas that they teach. Continue to recruit for the special education vacancies. Education services should offer professional development in the teachers content areas.
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SCREENING & IDENTIFICATION
STANDARD Qualified professionals shall provide prompt and adequate screening of facility youth for special education needs, including identifying youth who are receiving special education in their home school districts and those eligible to receive special education services who have not been so identified in the past. SOURCES OF INFORMATION Review of child find forms Review of special education roster Review of population report Interview of special education coordinator Review of 22 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 STAR 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. For the most part testing was performed within the appropriate time. 30 of 34 (88%) of students were interviewed and assessed within 72 hours of admission to the school. 44 of the 136 (32%) residents of the facility are identified as students previously identified as needing special education services. Only 3 of the 8 (37.5%) school staff members interviewed understood the procedures for referring student for screening for special education services.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that all of the education staff members know how to recommend that students are screened to determine the need of special education services.
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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 provided Documentation of parent contacts was consistent in each file. All notices accurately indicated the purposes of the meetings and the meeting attendees. The notices offered the option for parents to participate via the telephone. The school does not have a trained parent surrogate. The folders contained fax receipts documenting the invitation of community case managers and representatives from the Department of Rehabilitative Services (DORS). Home schools were not invited to the meetings. Meetings were consistently held within 30 days of admission to the facility.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: The school should invite the youths home schools to participate in meetings. The school should 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 22 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 18 of the 22 special education files contained IEP meeting notes of IEP meetings held at CYF 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. Most of the IEPs were providing the same services in the area of classroom instruction. 17 of 22 (77%) of IEPs indicated the same hours of classroom instruction and received services in the same setting. There was very little continuum of services. IEPs should reflect the needs of the student, not the program. The school used the Maryland online IEP format for 9 of 22 (41%) of the records. It should be noted that the majority of the online IEPs were done recently under the new special education lead teacher. 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.
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RECOMMENDATIONS In order to reach Satisfactory Performance in this area it is recommended that the facility: Ensure that IEPs are individualized for the individual students. A continuum of services should be provided to meet the students needs. Ensure that all related service hours and contacts are documented in the student folders. Continue to increase the use of the online IEP process.
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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 CYF offers several options for Career and Technology Education (CTE) classes. The school offers Horticulture, Graphic Arts, Computer and Woodshop. In addition the school offers a Career Education class. The schedule indicates that each unit will have access to the options. The only concern keeping this area from being rated as Superior is the consistency of the staffing for the programs. Two of the instructors do not hold education degrees or certification. These staff members are currently in direct care staff positions. At the time of the review, the Principal and the Facility Administrator were attempting to ensure that those staff would be consistently assigned to the school and that education staff could be present and participate so that the class could be held and counted for credit.
RECOMMENDATIONS In order to reach Superior Performance in this area it is recommended that the facility: Ensure that educational staff will be assigned to all of the CTE classes so that the classes can occur consistently according to the schedule and for credit.
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STUDENT SUPERVISION
STANDARD The facility will ensure that staffing is appropriate to supervise students in the educational setting, as well as during transitions to and from the school setting. SOURCES OF INFORMATION Classroom observations Observation of transitions Interview of school administrators and guidance counselor Review of Cheltenham School Daily Documentation Forms Review of school logbooks REFERENCES Maryland Standards for Juvenile Detention Facilities SUMMARY OF FINDINGS Staffing in the school is a concern. As previously reported in the Curriculum and Instruction and the Staffing sections of this report, students are frequently out of school, in many cases due to a lack of direct care staff. During the review, units were frequently out of ratio, particularly when units were split into class groupings. The facility has two staff members assigned to the school to assist in movement, observe youth who are taken to the counselor and to allow staff members to receive breaks. But with the high population, two school staff are not sufficient. The Principal reported that the facility is currently hiring additional staff members, some of which would be assigned to the school.
RECOMMENDATIONS In order to reach Satisfactory Performance in this area it is recommended that the facility: Review the staffing of the entire facility to ensure that there are enough staff members to supervise the youth on a daily basis. The facility should continue with plans to increase the number of staff assigned to the school.
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SCHOOL ENVIRONMENT & CLIMATE
STANDARD The facility will ensure that the school setting is a safe environment conducive to learning and that staff are supported in their jobs. SOURCES OF INFORMATION School observation Interviews with Direct Care staff members Interviews of Educational staff REFERENCES N/A SUMMARY OF FINDINGS Previously the staff had concerns over the cleanliness of the building and the fact that they were required to clean bathrooms that were used by the youth. Recently, CYF has contracted a cleaning company to clean these areas of the school. Education staff members report an increase in communication with the new Facility Administrator and reported that they feel that he is making positive changes in the school. The education staff now has a daily meeting with direct care staff members to plan for the day. Education staff still report that there is inconsistency in the way that staff manage students. Staff report that negative student behaviors are not addressed consistently.
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 Records staff interview Review of 30 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 26 of the 30 (86%) student files contained MSTRs or progress reports. The MSTRs were dated indicating that they were created within five (5) days of the students release from the facility. The OPS staff who prepare admission packets to potential placements indicated that the reports are in the students files that are sent to them.
RECOMMENDATIONS In order to reach Superior Performance status in this area it is recommended that the facility: Ensure that a MSTR or a progress report is created for each student released from the facility.
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MEDICAL CARE
HEALTH CARE INQUIRY REGARDING INJURY
STANDARD: Written policy, procedure, and practice ensures that all youth are seen by medical staff after any incident in which they are involved, regardless of whether there is an injury, shortly after the incident occurs. SOURCES OF INFORMATION: Facility Incident Reports (32) Youth Health Records (YHR) review Nursing Report of Youth Injury (43) Nurses Injury logbook Interviews with staff (11) Interviews with youth (15) REFERENCES: DJS Incident Reporting policy (MGMT-03-07); Photographing of Injuries policy (RF-1105); Reporting & Investigating Child Abuse Policy (MGMT-1-00) SUMMARY OF FINDINGS In 31 of the 32 incidents reviewed, youth were assessed by medical staff as required. The exception was an incident which involved physical restraint and a suicidal gesture. There was no explanation provided of why youth was not assessed. A Nursing Report of Injury (body sheet) was accomplished for 41 of 43 youth that were evaluated by medical staff. In some cases, Body Sheets were in medical files but were not with the incident report. For one youth a nursing progress note and photo was done but no body sheet. In the other instance, the logbook indicated the youth was evaluated by the RN but no body sheet was attached to the incident report or located in the youths health record (YHR). Interviews of Direct Care staff and youth indicated knowledge of the requirement for medical assessment after each incident. Most staff indicated youth was to be evaluated immediately after an incident. Five incidences were found where the youth was late to the nurse. There was no documentation to explain the delays for these youth. Each body sheet contained a verbatim youth statement or a detailed explanation when youth refused to respond.
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Each youth was photographed at least once even when there was no visual or complaint of injury. Photographs were accurately labeled although the printed dates on a few photographs were inconsistent with the day of the assessment. This appeared to be a problem with the digital camera. Photographs were placed with the body sheet in the YHR. Injuries as evident in photographs were consistent with Injury Severity Rating (ISR). Injuries were not described or marked on any of the body sheets. Instead, photos were attached. According to policy, markings should be documented as well. There was excellent documentation of treatment administered on the body sheet and further explanation in the nursing progress notes. All youth that required further care were referred to off-grounds care and/or evaluated by the Physician in clinic. The Injury Report logbook was consistently maintained, with each body sheet logged.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Ensure all youth involved in an incident are assessed by medical staff timely. Document location and description of injury on body sheet per policy.
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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 logs 24 Youth Health Records review 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 24 records were reviewed representing 20% of the population during this review. Nursing assessments were completed on all youth on the day of admission with documentation on the nursing assessment database or in the nursing progress notes with the youth had been re-admitted within 3 months of release. Only 48 % of the databases were completely documented. Consistently missed was description of body tattoos. Other missing items included vision screening, PPD placement and labs obtained and in two, the last page was completely blank. Only (4) 22% of the databases contained Nursing Diagnosis. These were for youth with chronic illnesses or special needs. 13 (65%) were reviewed by the physician. A nursing progress note was completed in 13 (65%) of the records. Discrepancies were found in admission notes that were accomplished for readmissions instead of the database. These notes lacked labs, status of PPD, current medications, current status of any chronic illness and allergies; the notes did not refer to the date of the database from which the information was being obtained. In one case the database used was at least 8 months old, the youth had been readmitted twice before this current admission and only one database was accomplished. History and Physical (H&P) examinations were completed within 7 days for all youth. Only 35% (5) forms were completed for BMI, vision screening, vital signs, date, and initials. Only 1 record contained a growth chart. Master Problem Lists were not consistently completed. 4 missed either a chronic illness or an acute injury sustained during detention; behavioral health notes/diagnoses were not noted on Master Problem Lists.
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Admissions and admission labs were correctly entered in the log book. In 3 records admission labs where either not recorded, not filed or not reviewed by the physician. For one youth there was notification from the lab that the RPR was not run and there was no documentation in the record to suggest another sample was sent for testing. Health Status Alerts (HSAs) were completed for most youth; those with allergies or dietary restrictions were more likely to have had HSAs completed and distributed. Of 15 youth identified with special needs (illnesses, activity restrictions, treatments) only 9 (60%) had a HSA. Distribution of HSA would ensure appropriate communication between direct care staff and medical personnel. PPD status, whether accomplished within the year or placed at admission was noted in all but one record. Placement was noted in the PPD logbook with results documented and initialed. As prevalent throughout DJS detention facilities, updating youth immunization status for required immunizations is substandard. In only 9 records were immunization records present. Only 4 indicated they were reviewed by the physician. Of those 4 reviewed, 2 required immunizations which were ordered. None of those immunizations were given. HIV counseling and testing is conducted by the Prince Georges County Health Department once a week. Results are forwarded to the facility health center. 30 day reviews were accomplished for 11(100%) of the youth. 73% were correctly completed. The remainder did not reflect current health status, treatment or injuries sustained since admission or previous 30 day review. All 30 day reviews were reviewed by the physician. Allergies were noted on the Master Problem List and the front of the chart. 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 tour office would call and this was documented by the RN. Review of Seclusion documentation for 10/31/10 in which 7 youth were secluded 4 hours found no medical assessments documented for 2 youth on the door sheets or in the progress notes. In other seclusion cases, medical assessments were not accomplished when seclusion continued overnight. A preprinted Seclusion progress note was being utilized. On some, dates and times of notes were missing and documentation did was not consistently accomplished every 2 hours. Discharge summaries were appropriately completed and distributed for 8 (100%) of the records as indicated.
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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: Continue the current efforts to improve documentation through internal quality assurance activities. 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. Complete Master Problem Lists. Ensure chronic illnesses and significant acute illness/injuries, and behavioral health diagnoses are included. Document resolution dates for acute conditions and ongoing for episodic or chronic conditions. Distribute HSA for all youth with chronic illnesses. Adhere to documentation procedures for youth in Seclusion. Facility Staff should notify medical when youth are placed in seclusion. Medical staff should assess youth and document at the beginning of and after 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 (9) Medication Administration Records (MAR) Youth Health Records review Observation REFERENCES DJS Pharmaceutical Services policy (HC-02-07); ACA 1-SJD-4C-16-17 SUMMARY OF FINDINGS During this QI review 37 youth were receiving psychotherapeutic medications. 45 Medication Administration Records (MARs) and 21 Health Records for both current and former youth were reviewed. Medication orders were written and appropriately transcribed on MARs. Verbal and telephone orders were signed by the ordering clinician on the next clinic day. Nurses appropriately signed and initialed all MARs with the exception of one Contracted Agency RN on the night shift who consistently failed to sign and initial the MARs. Missed medications were correctly noted and explained on the back of the MARs. PRN medications were noted on the MARs but effectiveness was not consistently noted. Youth refusal of medications was indicated on the MARs as well as on the Treatment refusal form. In some instances when youth refused to sign, a staff signature was not obtained. Youth with multiple refusals were referred to the physician for follow-up. Consents for psychotherapeutic medications were present for all but one youth. In this instance, the youth was age 18 and staff was unsure if consent was needed. Consent forms used were specific to Glass Health Services and included all pertinent information except medication dosage; thus, additional consents were not obtained with changes in dosages. Medications were correctly secured, stored, and disposed of. There with no expired medications found. Medication inventories were conducted per protocol. Medication administration was observed on two occasions. In both instances the RN traveled to the units to administer medications. The midday administration involved only 1 youth on 1 unit, while the evening administration involved a total of 42 youths on all three units.
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Medications were prepared at the medication cart in the Health Center. Using the MARs, the RNs placed the prescribed tablets/capsules in an envelope labeled with the youths full name, date of birth, medication name and dosage. The envelopes were placed in a tote bag marked for each unit. Topical medications and liquids remained in their original containers and were prepared at the time of administration. Each unit was provided a daily list of youth receiving medications and the RN notified each unit via telephone before leaving the health center. Medication administration on the units took place from 1900 2050. The following observations were noted: o On the units there were no designated locations to administer medications nor a specific staff member designated to assist the RN. On two units the RN was positioned in locations where youth were actively walking around and the RN was left alone at intervals while the RA located youth needed for medications which allowed more than one youth to present for meds at one time. o Youth were identified by name, date of birth, and photo contained in the MAR binder. Visual inspection was done for each youth as indicated. o Med administration occurred during shower times on 2 units which caused delays in getting youth for their meds. On one unit, it took over 10 minutes to medicate 2 of the 14 youth. Youth that were in their beds for the night often refused to come for meds, this accounted for the 5 youth refusals during this observation. Upon release from the facility RN staff attempt to forward remaining medications to the youth via parent or PO pickup or with the youth when transferred to another facility or placement. Because County Sheriffs do not transport medications, youth released from court may not receive their medications resulting in the destruction of large amounts of medication. When youth were transferred, the escorts did not always come to the health center to retrieve medications.
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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 record. Improve documentation on the MAR to include signatures, initials, missed meds, effectiveness, and refusals Provide designated locations and direct care staff for medication administration on the units which would limit youth movement around the administration area; reduce the administration time; and, increase security for the RN and controlled drugs. Utilize the daily medication list that each unit receives to make sure youth are available during medication administration. This would decrease administration time and med refusals. With a more efficient medication administration process the RN would be able to provide PRN meds or treatments to other youth. Currently if a youth needed a PRN medication they were taken to the health center when the direct care staff was available. Improve the medication transportation process for youth going to placement or transferring to another detention facility. Reduce the amount of medications destroyed upon youth release.
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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 A Dental Clinic is conducted at least two days per week, Monday and Thursday. Youth are scheduled for an initial dental examination at the time of admission. Due to the number of youth requiring dental examinations, prophylactic cleanings, and restoration, it may be greater than 10 days before a newly admitted youth will have the initial dental examination. In all but one case reviewed, a youth received at least one annual dental examination. For the one youth, the referral tracking form contained an appointment date but there was no documentation in the health record that an examination was ever completed. All youth requiring orthodontic services were referred off-ground. Referrals and postreferral treatment plans were documented in the records. Youth who complained of dental pain in sick call or outside of dental clinic hours received treatment in accordance with nursing protocols for dental pain and were placed on the dental clinic list for the next clinic day. Clinic lists showed when youth refused dental appointments, were released prior to appointments, or were in court at time of appointment; this was not documented in the medical record specifically on the Referral Tracking form. Two youth were released prior to dental examination and were not rescheduled when they were readmitted. One of the youth was currently detained for greater than 30 days. When staff was notified of this, youth was given an appointment for the next available dental clinic.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Complete documentation of dental appointments on the Referral Tracking form. Indicate whether appointment was completed, refused, rescheduled, or cancelled.
MEDICAL RECORDS RETRIEVAL
RATING: Superior Performance
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 Nursing logs 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 The facility has a medical administrative assistant who does an exceptional job of maintaining the youth health records. In addition, the Nursing Supervisor proactively manages internal quality review activities to ensure receipt of youth medical records, appropriate filing and review of pertinent health information, and completion of documentation. Youth health records were maintained in a secure location, readily accessible as needed by appropriate staff. Archived records were stored in file cabinets and boxes in three different locations due to limited space. Staff was meticulous in obtaining medical records for all youth with previous detentions or confinements, or 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 always obtained. Lab/diagnostic results were consistently filed in the records and initialed by the medical clinicians. Records were very well organized with forms filed in appropriate sections. In addition, staff further labeled section (i.e. consents, immunizations) making it easier to find information. Records for youth with extensive information were divided into volumes, with older volumes filed beside current volumes. Staff developed printed name labels for each youth which were used to ensure each form in the health recorded was properly identified. In most cases progress notes were identified by the service of the writer. Dates and times were noted.
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While nursing progress notes were not always in SOAP format, they were very comprehensive, thorough, and pertinent. Documentation in the progress notes indicated youth disposition and when copies of records were forwarded to transferring facility for placement location.
RECOMMENDATIONS The facility has met Superior Performance
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SPECIAL NEEDS YOUTH
STANDARD Written policy, procedure and practice document that youth with special needs are screened as such upon admission within 72 hours, have a special needs treatment plan put into place, identifying the problem/need, goals, intervention, the youths progress evaluation and review date. SOURCES OF INFORMATION Interviews with medical staff Interview with staff (11) Nursing logs Youth Health Records review REFERENCES DJS Health Care ProcedureSpecial Needs Treatment Plans (2007) SUMMARY OF FINDINGS From May October 2010 the facility had 62 youths with identified special needs. A temporary list of youth with special needs is maintained. Given the number of youth with special needs, the acuity of youth in the infirmary, and facility census, the overall management of youth with special needs meets standards. The records of 15 (24%) current and former youth were reviewed. All youth were appropriately identified during the admission nursing assessment and physical examination. Medical records from community physicians or previous placements were obtained. In only 57 % (8 of 15) of the cases were treatment plans initiated. Treatment plans were placed with MARs; but for youth who were released the treatment plans were not in the health records. In only 2 of the 8 records were the preprinted treatment plans individualized or updated to reflect changes in status. In most instances the care plans were blank. The Master Problem Lists were not complete to indicate resolution or appropriate interventions. In 3 cases (a youth with asthma and two youth with fractures) the conditions were not listed at all. Documentation of off-ground referrals was evident in the progress notes and on the Referral Tracking form. Health Status Alerts were completed for 9(60%) of the youth. Youth with dietary directions, allergies, or activity restrictions were more likely to have had HSA completed and distributed. For youth housed in the infirmary, an HSA was not completed. Though these youth were housed in the health center some did attend class, groups, and recreation. Distribution of HSA would ensure appropriate communication between direct care staff and medical personnel.
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In interviews, Resident Advisors used the HSA and the population sheet to identify youth with allergies and dietary or activity restrictions. They stated that they relied on youth to tell them if they had asthma or if they witnessed a youth receiving inhalers during med passes. 30 day reviews were consistently done. Each RN was assigned a unit and utilized the population sheet to determine the youth that required reviews. 8 of 38 records of youth with Asthma were reviewed. In all records the Asthma Assessment tools, Peak flow monitoring, and orders for rescue inhalers were completed although in one instance a youth was admitted in May and the assessment was not accomplished until July. Records indicated this youth refused his admission nursing assessment; subsequent 30 day review did initiate a nursing assessment or an asthma assessment. Asthma Action Plans were completed for all youth. For one youth, the action plan was accomplished at another facility and there was no indication that it was reviewed by the MD upon transfer to CYF. PRN inhalers were in the stock supply for all youth with a diagnosis of asthma. Those receiving daily maintenance medications had individual labeled PRN inhalers. In a review of MARs, only one youth required PRN inhalers. Pre and Post treatment Peak flows were documented on the MARs. The records of 8 youth housed in the infirmary for medical treatment ranging from isolation to post-operative care were reviewed. 7 records contained infirmary admission orders. 6 of the orders included frequency of nursing observation (5 every shift and PRN, and 1 every day). In 3 cases the RNs only documented every day instead of every shift as ordered. Follow-up by MD was evident. An infirmary discharge order was missing for one youth.
RECOMMENDATIONS In order to reach Superior Performance status, the facility and its health unit should do the following: Initiate treatment plans for each youth. Ensure they are individualized and updated. Complete Health Status Alerts for all youth with special health care needs. Input information into ASSIST to be reflected on the daily population sheets. Update the Master Problem Lists to include all injuries and medical conditions since admission. Indicate on-going for chronic conditions. Complete the 30 day reviews to accurately reflect changes in status since admission or since previous 30 day reviews. Utilize the pre-printed Infirmary Admission Orders to ensure all relevant treatment plans are included in the admission orders. Adhere to orders for frequency of nursing documentation.
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AVAILABILITY OF MEDICAL SERVICES
RATING: Superior Performance
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 (11) Interviews with youth (9) Nursing logs Youth Health Records 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 typically 2 RNs on days, 3 RNs on evenings and 1 RN on nights. This facility averages 11 intakes/day with the majority occurring on the evening shift (3:00-11:00pm). On the Monday of this review, 2 RNs and the Nursing Supervisor were on duty with 4 clinics including the Nurse clinic for sick call being held. The somatic health clinic had 17 youth scheduled, the Dental clinic 14 youth, and Mental Health had 3 youth. In addition there were 7 youth in seclusion on one unit which required medical assessment every 2 hours. Somatic health clinics are held three times a week with a Physician; Mental Health clinic is held twice a week; and Dental clinic is held twice a week. 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 accurately stated the procedures for notifying the health center for urgent and emergency care. Pharmacy services are available weekdays. Orders placed in the morning were delivered in the afternoon. Emergency stock medications were available in the medication room. Mobile radiographic services were available for x-rays and EKGs as needed. Laboratory services were provided by Quest Diagnostics, with daily weekday collection. The state laboratory collected twice a week.
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During the week of this review there were 10 youth that were taken to off-grounds appointments. Youth were referred off grounds for vision and other services as needed. The health center had an active team of personnel responsible for obtaining off-grounds appointments and providing transportation which significantly increased the access to care for youth at this facility as well as reduced the number of appointment cancellations. First-aid kits were located on each unit. Each kit contained a content list and First-aid Administration Report. Monthly checks were conducted. Direct care staff indicated appropriate use of the first-aid kit but admitted that they did not document when they administered care. An AED was located in the Health Center. Weekly checks were accomplished. Direct Care Staff expressed that they were not current in CPR/AED/First Aid training and they were unaware of common side effects of psychotherapeautic 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, staff did not view this as a major concern. Three oxygen tanks were located in the health center. Daily checks were completed and tanks labeled with amount (i.e. full, partial, empty.) Each unit was provided with a green binder containing health care related agency and facility policies and procedures as well as the Health Status Alerts (HSA) for youth housed on that unit. In interviews, the Direct Care Staff were knowledgeable of binders and information contained within. HSA for food allergies/restrictions were available and in use in the dining hall. Sick call slips were available in wall holders on each unit along with a locked collection box. Sick call slips are collected each morning by the RN during medication administration and logged into the sick call log book. 23 sick call slips were reviewed. Youth were triaged to RN clinic or to the appropriate clinic. If youth complained more than once for the same problem, they were referred to the appropriate clinic. Sick call assessments were accurately documented on the sick call slip or reflected in the progress notes. During interviews, youth and staff verified the sick call procedures and stated that at no time were youth denied access to health care when requested via sick call slip. Youth also stated they did not have to disclose the reason for a sick call request to RAs. Staff also stated that the clinic would accommodate youth that required medical care between sick call times. Storage areas were appropriately organized and clean, with access restricted to designated personnel. Refrigerator temperatures and sharps inventories were consistently completed and accurately recorded.
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RECOMMENDATIONS The facility has met Superior Performance status. Only one recommendation: Ensure 100% compliance with CPR/AED/First-Aid Training for Direct Care Staff.
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Comprehensive Quality Review Report Cheltenham Youth Facility (MD 2011)

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Comprehensive Quality Review Report Cheltenham Youth Facility (MD 2011)

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OFFICE OF QUALITY IMPROVEMENT Comprehensive Quality Review Report

Cheltenham Youth Facility December 22, 2010

TABLE OF CONTENTS (Continued)

DJS QI Report CYF November 2010

OFFICE OF QUALITY IMPROVEMENT Quality Review Report Cheltenham Youth Facility

DJS QI Report CYF November 2010

QUALITY IMPROVEMENT REVIEW RATINGS SCALE

Rating Superior Performance Satisfactory Performance Partial Performance Non Performance

DJS QI Report CYF November 2010

CYF PERFORMANCE COMPARISON

DJS QI Report CYF November 2010

OFFICE OF QUALITY IMPROVEMENT Cheltenham Youth Facility Executive Summary of Results

DJS QI Report CYF November 2010

OFFICE OF QUALITY IMPROVEMENT Cheltenham Youth Facility METHODOLOGY

DJS QI Report CYF November 2010

SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY INCIDENT REPORTING RATING: Non Performance

Month September October * November

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

SENIOR MANAGEMENT REVIEW

RATING: Non Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

DE-ESCALATION & RESTRAINT

RATING: Partial Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

CONTRABAND & ROOM SEARCHES

RATING: Partial Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

RATING: Non Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

ROOM CHECKS DURING SLEEP PERIOD

RATING: Satisfactory Performance

DJS QI Report CYF November 2010

RATING: Partial Performance

DJS QI Report CYF November 2010

RATING: Non Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

CONTROL OF KEYS, TOOLS & ENVIRONMENTAL WEAPONS

RATING: Partial Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

YOUTH MOVEMENT & COUNTS

RATING: Partial Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

RATING: Partial Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

RATING: Partial Performance

RATING: Partial Performance

DJS QI Report CYF November 2010

ADMISSIONS, INTAKE & STUDENT HANDBOOK

RATING: Satisfactory Performance

DJS QI Report CYF November 2010

DJS QI Report CYF November 2010

RATING: Satisfactory Performance