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On the Implementation of the Settlement Agreement between The United States Department of Justice and The State of Maryland Department of Juvenile Services First Semi-Annual Report Final Draft _____________ March 24, 2006 Monitoring Team Michael Cohen, M.D. Eric Trupin, Ph.D. William Wamsley, Peter Leone, Ph.D. , Acting Team Leader TABLE OF CONTENTS 1. INTRODUCTION.………………….………………………….……….1 2. DEFINITIONS and METHODS……………………………….………….…2
3. SUBSTANTIVE REMEDIAL MEASURES…………………………….…….3
a. SUICIDE PREVENTION .3 b. MENTAL HEALTH.6 c. MEDICAL CARE.11 d. SPECIAL EDUCATION.23 e. FIRE SAFETY……………………….…….…….…………….….32
4. COMPLIANCE and QUALITY ASSURANCE………………….………….36 APPENDIX A: Visits by Consultants .39 APPENDIX B: Summary of Monitors’ Findings.39
On June 29, 2005, the State of Maryland entered into a Settlement Agreement with the United States concerning the conditions at the Cheltenham Youth Center and the Charles H. Hickey School, two juvenile correctional facilities operated by the Maryland Department of Juvenile Services. During the summer of 2005, the Parties jointly agreed upon and appointed a Monitoring Team (Team) to assess, review and report independently on the State’s implementation of and compliance with the provisions of the Settlement Agreement. The Monitoring Team appointed by the Parties included professionals with expertise in the fields of juvenile justice/youth confinement practices/protection from harm, mental health care, medical care, education, and fire safety. One of the members appointed to the Team, Don DeVore, a juvenile justice expert from Connecticut, was selected as Monitoring Team Leader by the Parties. During this first reporting period because of other professional responsibilities, Mr. DeVore resigned from the Monitoring Team. This first semi-annual report of the Monitoring Team report covers the period from July 1, 2005 through January 31, 2006 and reviews compliance with most of the substantive remedial measures of the Settlement Agreement in the areas of mental health, medical care, education, and fire safety. Due to the departure of Mr. DeVore, some provisions of the Agreement involving juvenile justice, youth confinement, and protection from harm were not reviewed by the Team and are not included in this first report. Some sections of the report provide a brief overview of the substantive issues in that area. Each substantive area reviewed include a verbatim statement of each provision of the Settlement Agreement reviewed, followed by an assessment of the status of compliance, discussion, recommendations, and documentation used by the Monitors to arrive at the compliance rating. In this report, the Recommendations should not be interpreted to be requirements necessary to achieve compliance with the provisions of the Settlement Agreement. In the area of Compliance and Quality Assurance, only Medical Care has been reviewed in this report. The numbering system used within the text boxes to identify each provision is identical to the system in the Settlement Agreement. The Monitoring Team received good cooperation of the staff of the Maryland Department of Juvenile Services (DJS). Secretary Kenneth Montague and his staff provided to the Committee complete access to all facilities, youth, staff, files and data. At the conclusion of site visits and during this first reporting period, informal de-briefings were held with superintendents and supervisory staff at Cheltenham and Hickey. The DJS staff was receptive to recommendations made by the Monitoring Team during these exit interviews. Many of the changes discussed in this first report began after the agency received the findings letter issued by DOJ on April 9, 2004. This initial report indicates that the Department of Juvenile Services has made significant strides in remedying deficiencies identified in the CRIPA (Civil Rights of Institutionalized Persons Act) investigation that began in 2003. It also acknowledges that a six month period is not sufficient time to thoroughly review all areas of the Agreement and that the departure of the Team Leader selected by the Parties delayed the release of this first report.
The Monitoring Team collaborated in developing this report; individual monitors were primarily responsible for sections of the report as follows: Michael Cohen
2. DEFINITIONS & METHODS Compliance with the Agreement requires that DJS demonstrate substantial compliance for each of the provisions at Cheltenham and Hickey. In this report, the Monitoring Team describes the steps taken by DJS to implement the provisions of the Settlement and the extent to which DJS has complied with the requirements of the Agreement at both facilities in general. Subsequent reports will evaluate implementation of the Settlement by each facility individually. In assessing compliance, the Committee utilized the following terms which, for the purposes of this first report, have been agreed upon by the Parties: Substantial Compliance: Substantial compliance with all components of the rated provision. Non-Compliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained non-compliance shall not constitute substantial compliance. A rating of substantial compliance shall not be made unless such rating is applicable to both facilities. Partial Compliance: Compliance has been achieved on most of the key components of the Agreement provision at both facilities, but substantial work remains. A rating of partial compliance shall also be made where one of the facilities is in substantial compliance with a provision, but the other is not in substantial compliance. Non Compliance: Non-compliance with most or all of the components of the Agreement requirements at both facilities. Not Reviewed: The Monitoring Team does not have adequate information to rate the provision at this time. A rating of not-reviewed does not suggest either compliance or non-compliance but may reflect the inability of the Monitoring Team to assess a provision. The Monitoring Team reviewed compliance with the Settlement Agreement in several ways. Monitors toured the facilities, interviewed staff, and reviewed records on site. Documents describing procedures and policies were examined and a number of youth were interviewed. The Team also observed and informally talked to youth in classrooms, the living areas, during recreation, and in the dining halls. Team members attempted to verify initial findings through multiple sources of information.
3. SUBSTANTIVE REMEDIAL MEASURES a. Suicide Prevention
III.C. Suicide Prevention III.C. i. Implementation of Policy The State shall take all reasonable measures to assure that all aspects of its Suicide Prevention Policy are implemented. Status: Partial Compliance Discussion: Major concerns were identified in staff implementation and knowledge of Suicide Policies. In response to these concerns a letter was sent to DJS identifying concerns related to unsafe placement of youth in cells with significant hazards for self harm, lack of knowledge related to placement of suicide “cut down” tools and a general confusion over procedures for supervision for youth placed on suicide levels. Recommendation: A letter was sent on 12/7/05 by DOJ documenting these concerns and a corrective action plan was rapidly put in place by DJS and documented in a communication on 12/23/05 which addressed cell modifications, policy reviews, staff training and ongoing audits. Evidentiary Basis: Facility tour, staff and youth interviews. III.C. ii. Suicide Risk Assessments Timely suicide risk assessments, using reliable assessment instruments, shall be conducted at the facilities:
a. for all youth exhibiting behavior which may indicate suicidal ideation, and b. when determining whether to place a youth on suicide precautions or change the level
of suicide precautions. Suicide risks assessment shall be conducted by a qualified mental health professional. If no such professional is available to conduct the assessment due to exceptional circumstances, it shall be conducted by another staff member who has received specific training in conducting such assessments. Youth shall not be removed from suicide precautions by anyone other than a qualified mental health professional.
Status: Partial Compliance Discussion: Youth are assessed on the MAYSI 2 and SASSI. If a youth scores in the Warning Range on the MAYSI an ISO-30 is administered. If continued concerns are evidenced a Bio- Psychosocial interview is conducted. Despite this improved assessment process there is a continued need to enhance staff skill in managing youth who exhibit suicidal and self harming behaviors. Documentation of staff following policies related to mental health removing or lowering level decisions was observed. Recommendation: Increased training of staff on using data from assessments for developing
intervention plans for self harming youth. Evidentiary Basis: Record review, staff and youth interviews. III.C. iii. Mental Health Response to Suicidal Youth Youth at the facilities who demonstrate suicidal ideation or attempt self-harm shall receive timely and appropriate mental health care by qualified mental health professionals. This care shall include helping youth develop skills to reduce their suicidal ideations or behaviors, and providing youth discharged from suicide precautions with adequate follow-up treatment. Status: Partial Compliance Discussion: Continued concerns exist for mental health staff providing adequate treatment interventions and required contacts. Recommendation: Increase skills of mental staff in the management of suicidal youth utilizing cognitive behavioral treatment strategies. Increase training of custody staff in supporting implementation of self regulating behaviors of suicidal youth. Evidentiary Basis: Staff and youth interviews, file and document review III.C. iv. Supervision of Youth at Risk of Self-harm The State shall sufficiently supervise newly-arrived youth, youth in seclusion and other youth at heightened risk of self-harm to maintain their safety. Status: Not reviewed Discussion: Immediate access to mental health staff are incorporated into current SOP and all youth are screened on the MAYSI within 2 hours of arrival to facility Recommendation: Review documentation on next visit Evidentiary Basis: Standard Operating Procedure (SOP) document III.C. v. Housing for Youth at Risk of Self-Harm The State shall take all reasonable measures to assure that all housing for youth at heightened risk of self-harm, including holding rooms, seclusion rooms and housing for youth on suicide precautions, is free of identifiable hazards that would allow youth to hang themselves or commit other acts of self-harm. Status: Not reviewed Discussion: Recommendation: Review/monitor on next visit. Evidentiary Basis:
III.C. vi. Restrictions for Suicidal Youth Youth in the facilities on suicide precautions shall not be restricted in their access to programs and services more than safety and security needs dictate. Status: Partial Compliance Discussion: Policies for managing suicidal youth in the least restrictive settings are in place however the inconsistent implementation of these policies undermines compliance with this expectation. Custody staff was not provided with clear direction from mental health on strategies to effectively manage suicidal youth or help support treatment interventions designed to lower acuity. Input and consultation from Psychiatrists was minimal to both other mental health staff and custody staff. Recommendation: see III. C.i. Evidentiary Basis: Policy review, staff and youth interviews, chart review III.C. vii. Documentation of Suicide Precautions The following information shall be thoroughly and correctly documented, and provided to all staff at the facilities who need to know such information:
a. the times youth are place on and removed from precautions; b. the levels of precautions on which youth are maintained; c. the housing location of youth on precautions; d. the conditions of the precautions; and e. the times and circumstances of all observations by staff monitoring the youth.
Status: Partial Compliance Discussion: Documentation needs improvement—although records and logs are considerably more organized than during the initial investigation. Knowledge by staff related to conditions of precautions and specific duties of custody staff in addressing suicidal behaviors, gestures, self harming behaviors and suicidal verbalizations was inadequate. Recommendation: Develop training for custody staff and improve treatment planning and treatment strategies for suicidal and self harming youth. Evidentiary Basis: File, chart and log review, staff interviews III. C. Suicide Prevention. viii. Access to Emergency Equipment. Direct care staff will have equipment to intervene in attempted hanging. Status: Partial compliance Discussion: DJS Standard #51: Suicide Prevention, and Secretary’s Directive E2270-01-01 (revised 11/6/02): Suicide Prevention Policy, do not specifically require appropriate cut-down tools. I was informed during the site visit that all staff is expected to carry cut down tools. During this visit I did not specifically investigate whether staff is carrying the required tool or if such tools are available on all units. Recommendation: (1)
Revise the suicide prevention policies to include the required cut-down tools.
Evidentiary Basis: Site visits October 10-12, interviews with the nursing supervisors, health record review and review of agency health policies or "standards". III.C. ix Suicide and Suicide Attempt Review Appropriate staff shall review all completed suicides and serious suicide attempts at the facilities for policy and training implications. Status: Partial Compliance Discussion: An Interdisciplinary Treatment Team (ITT) has been established to address issues related to the management of suicidal youth and review adherence to effective practices. Minutes and actions taken by this team were not reviewed. The intent is positive and the functioning of this team will be one of the priorities for the next monitoring period Recommendation: Establish procedures and policies for ITT as it relates to Suicide Policy and management procedure activities. Maintain minutes for the ITT meetings and indicate actions taken and subsequent outcomes from these actions. Evidentiary Basis: Staff Interviews, SOP document describing ITT
b. Mental Health III.D. Mental Health III.D. i. Adequate Treatment The State shall provide adequate mental health and substance abuse care and treatment services (including timely emergency services) and an adequate number of qualified mental health professionals. Psychiatric care shall be appropriate to the adolescent population of the facilities and shall be integrated with other mental health services. Status: Non Compliance Discussion: Proposed staffing to address unmet need has been submitted as a budget request. New contractor (Glass & Associates) has been hired to provide mental health services at Hickey. Treatment of both mental health and substance use disorders in both individual and group sessions remains inadequate. Recommendation: Develop protocols for individual and group treatment interventions
emphasizing cognitive behavioral interventions. Evidentiary Basis: Staff and youth interviews, chart review. III.D. ii. Establishment of Director of Mental Health The State shall designate a director of mental health. The director shall meet minimum, standards, as specified by the State to oversee the mental health care and rehabilitative treatment of youth at the facilities by performing the tasks required by this Agreement, including:
a. oversight of mental health care in the facilities, including monitoring the
performance of psychologist, counselors and psychiatrists, and developing and implementing policies and training programs;
b. monitoring of whether staffing and resources are sufficient to provide
adequate mental health care and rehabilitative treatment services to the facilities’ youth and to comply with this Agreement; and
c. development and implementation of a quality assurance program for mental
Status: Substantial Compliance Discussion: Dr. Andrea Weisman appointed Director 1/1/05 Recommendation: Evidentiary Basis:
III.D. iii. Admissions Consultation and Referral If a youth presents at admission to a facility with mental health needs which cannot be met safely at the facility, the State shall transfer the youth promptly to appropriate settings that meet the youth’s needs. Qualified mental health professionals shall be readily available for timely consultations regarding admissions decisions. Status: Partial Compliance Discussion: Discussions are on-going with mental health facilities in order develop MOUs which would allow seamless admission of youth in acute need of hospitalization when identified in intake or during their pending placement stay. At Hickey involvement of Glass & Associates as the Mental Health provider should facilitate this process due to Dr. Glass having admitting privileges to psychiatric inpatient facilities Recommendation: Policy needs development and MOUs with community providers need to be completed. Evidentiary Basis: Staff interviews and file and document review. III.D. iv. Mental Health Screening The State shall develop and implement policies, procedures and practices for all youth
admitted to the facilities to be screened comprehensively by qualified mental health professionals in a timely manner utilizing reliable and valid measures. If, due to exceptional circumstances, no such professional is on-site to conduct the screening, it shall be conducted by another staff member who has received specific training in conducting such assessments and reviewed by a qualified mental health professional. Status: Partial Compliance Discussion: An adequate screening procedure has been established and there is documentation that youth are being screened within 2 hours of admission by a qualified mental health professional. Recommendation: Next visit will focus on assessing compliance with screening procedures and evaluating whether data derived are being utilized in mental health and substance abuse treatment plans and case management strategies, Evidentiary Basis: Staff interviews, document review, chart review III.D. v. Mental Health Assessment Youth in the facilities whose mental health screens indicate the possible need for mental health services shall receive comprehensive, appropriate and up-to-date assessments by qualified mental health professionals. Status: Partial Compliance Discussion: Comprehensive Assessments were not currently being implemented although the mental health Standard Operating Procedure (SOP) outlines a well defined assessment process Recommendation: Include V-DISC in the assessment process in order to increase diagnostic accuracy and improve specificity related to implementing evidence based practice. Evidentiary Basis: File and document review III.D. vi. Treatment Plans Youth in the facilities in need of mental health and/or substance abuse treatment shall have an adequate treatment plan, including a behavior management plan, as appropriate, which shall be implemented in the facilities. Status: Non Compliance Discussion: Treatment plans remain inadequate for all mental health staff Recommendation: Implement treatment plans that identify treatment targets and skills being addressed and how they are being monitored with an emphasis on utilizing
evidence based practices. Evidentiary Basis: chart review, staff and youth interviews III.D. vii. Mental Health Involvement in Housing Decisions The State shall adequately consider mental health issues in providing safe housing for youth in the facilities. Status: Partial Compliance Discussion: Mental Health staff input in housing decisions has improved however there continues to be program and housing limitations for youth with serious behavioral health disorders. Recommendation: Review the option of specialized units for youth with serious behavioral health needs. Evidentiary Basis: Staff and youth interviews III.D. viii. Informed Consent Consistent with State law, the State shall, prior to obtaining consent for the administration of psychotropic medications, provide youth and, as appropriate, their parents or guardians with information regarding the goals, risks, benefits and potential side effects of such medications offered for their treatment, as well as an explanation of what the consequences of not treating with the medication might be, and whether a recommendation is made in a dosage or manner not recognized by the United States Food and Drug Administration. Status: Partial compliance Discussion: Evidence of improved documentation was identified; however, a continued emphasis on both informed consent and youth and parent/guardian knowledge of positive and potential negative effects of medication is required. Glass & Associates indicated they have a procedure to insure consent and risk/benefit are communicated. Recommendation: Develop quality assurance program to insure consent and information is provided to youth and parent/guardian. Evidentiary Basis: Chart reviews. Staff and youth interviews III.D. ix. Mental Health Medications The State shall take all reasonable measures to assure that psychotropic medications are prescribed, distributed, and monitored properly and safely. The State shall provide regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy. Status: Non Compliance Discussion: Continued need to improve and bring psychiatric practice in line with professional standards. SOP identifies medication practices as a target of the Corrective Action Plan. Hiring of Glass & Associates to provide care at Hickey has the potential to significantly improve care at that facility. Cheltenham remains a significant concern. Recommendation: Monitor performance of new provider at Hickey. Seek additional or new providers for CYF. Evidentiary Basis: Chart Review, interviews with current and newly contracted psychiatrists and mental health providers. III.D. x. Mental Health and Developmental Disability Training for Direct Care Staff The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents and supervise them appropriately. Status: Partial Compliance Discussion: Planning for training of staff has been initiated. Current training continues to be inadequate. Recommendation: Develop and implement on going staff training curriculum with skill and performance based assessment of staff competence as an outcome measure of training. Evidentiary Basis: Staff interviews. III.D. xi. Transition Planning The State shall take all reasonable measures to assure that staff create appropriate transition plans for youth leaving the facilities. Such plans shall appropriately consider each youth’s length of stay and subsequent placement. Plans shall include providing the youth and his or her parents or guardian with information regarding with information regarding mental health resources available in the youth’s home community’ making referrals to such services when appropriate; providing appropriate orders for the continuation of prescribed medications; and providing assistance in making initial appointments with service providers. Status: Non Compliance Discussion: Plans to enhance transition planning are being developed. A new Community and Family Resource Center (CFRC) has been located at the Baltimore Juvenile Justice Center designed to provide support for families with youth involved in
the juvenile justice system. It is unclear how families with youth at CYF or CHHS will utilize this center and what impact it will have on transition planning. Recommendation: Review transition procedures and policies during next monitoring tour. Evidentiary Basis: Chart reviews, staff and youth interviews c. Medical Care Overview of Health Services in Juvenile Justice
In general, current professional standards require juvenile justice facilities to provide a health program which is adequate to address the serious health needs of youth in eight broad categories which encompass personnel, administration and services:
(1) Sufficient professional staff, space, and equipment to provide all necessary services; (2) An initial health assessment to identify needs and plan for their care; (3) Evaluation and treatment for sick and injured residents; (4) Dental care to maintain, restore and prevent deterioration of the teeth and gums; (5) Special services for youth with chronic or disabling medical conditions; (6) Services to promote health and prevent disease; (7) A systematic program to continuously improve the quality of health services; and (8) Environmental conditions consistent with current standards for hygiene, sanitation and safety.
Health records were selected for review because they represented specific types of health problems such as injury, emergency, chronic illness, or to verify information from an interview or log book.
III. E. Medical Care. i. Appropriate Care. The state shall provide adequate, appropriate and timely medical and dental care to meet the individualized needs of youth including acute and chronic medical conditions. The state shall provide sufficient numbers of qualified medical professionals to meet these needs. Status: Partial compliance. Discussion and Recommendations:
The most important issues at this time are the need for permanent full time nursing staff at both sites, and the need for a new clinic at Hickey. Both of these needs require agency planning and budget initiatives. Health Staffing- Hickey
As of 11/30/05 the population at Hickey should have been reduced to 72 male detention beds with average of 3-6 new intakes per day. Contractual nursing services have been increased to permit 24 hour staffing of the clinic. The clinic is staffed with 3 RNs on days; 3 RNs on PMs and 1 RN on nights. There is a nursing supervisor over the whole clinic operation who works weekday days. Nursing services are provided entirely by contract with a private company. Many nurses are part time, working a second job at Hickey. The contractor does not do a good job of scheduling and providing the needed staff, so state health services managers end up making the calls to get nurses to come in to fill the vacant shifts. There is frequent nursing staff turnover. It is hard to keep these part time nurses trained to follow the DJS policies and procedures. One reason health needs are lost to follow-up is the inability to build an experienced, consistent nursing workforce with a permanent staff, trained to the agency policies. All together it is an unsatisfactory situation. The program would be much better staffed with full time DJS nurses. The acting medical director was optimistic that state positions could be filled with full time RNs based on her experience filling vacancies in other DJS facilities. Physician time is adequate with three half days per week. Dentist services are provided off site by a community dentist, 4 youth per day 4 days per week. This is hardly enough time to do initial assessments for new admissions. This is not enough time to take care of new intakes, acute needs and needs of longer term detainees. Clerical support is needed to make up new charts, request records of prior health care, make off- site appointments, file reports in health records, pull and file charts for sick call and doctor clinics, etc. Discussion and Recommendations: Health Staffing- Cheltenham
The intended staffing pattern at Cheltenham is 3 RN’s on days, 2 RN’s on evenings and 1 RN overnight. There is a nursing supervisor on days. This staffing is achieved with a combination of full time state employed nurses and part time temporary agency nurses. One day RN, one
evening RN and the overnight RN are all temporary agency staff. Physician time is adequate at 3 half days per week. The dentist is at Cheltenham one day per week and sees about 15 patients per visit. He tries to do the exams, some fillings and emergency treatment for pain or trauma. With 3 to 6 admissions per day, this is hardly enough time to do the initial exams. Staffing Recommendations: (1)
Hire full time DJS nurses to staff both facilities.
Obtain more dentist services to meet the ongoing needs of resident youth.
Clerical support is needed for the busy detention health programs.
Clinic Space- Hickey
The infirmary and most medical functions are still located outside the fence on the old campus. No youth are housed permanently in that part of the campus, but it is still used for intake and segregation. The satellite clinic behind the fence is actively staffed now and used for sick call, doctor’s clinic and medication administration. However, the satellite clinic was not designed to be a clinic and is in poor condition. During the site visit there was no access to a toilet in the satellite clinic. Hickey Clinic Space Recommendations: (1)
A new clinic with infirmary and intake functions is needed in the fenced campus where
the resident youth are housed and programmed. Consider using a modular building which could be moved to another site after Hickey closes permanently.
Clinic Space- Cheltenham
Space at Cheltenham appeared to be old but adequate. Medical Equipment
The emergency medical equipment at Hickey was incomplete and not well organized. At the main clinic the wrench to open the oxygen tank was not readily available, the gauge on the tank was broken and there was no suction device. Equipment needed for resuscitation was not included in the emergency bag. The bag did not include oxygen, bag-valve mask oxygen reservoir, oral airways, suction, or connecting tubing. At Cheltenham the emergency medical equipment bag did not include a portable hand-operated suction device. Equipment Recommendations:
Package the resuscitation equipment in a portable bag to carry to the site of an on-campus
Equip each emergency bag with a small oxygen tank, bag-valve-mask, tail or reservoir
bag to deliver 100% oxygen, oral airways, and portable hand-operated suction devices.
Equip each oxygen tank with a wrench to turn it on.
Access to Health Services
DJS Standard #1: Access to Health Services, Standard, #36: Daily Handling of Non-emergency Medical Requests, and Standard #37:Sick Call, together define a system for youth to request health services directly from health staff including a secured box for confidential submission of sick call requests. The procedures for nurses sick call appropriately directs nurses to refer to the doctor when a youth presents more than two times for the same complaint.
At Cheltenham youth place their sick call requests in a locked box on the units. The nurse picks up the requests daily during medication administration rounds. I was told at Cheltenham that some sick call triage occurs on the living units during medication administration. This practice needs further evaluation and review. Any routine health services provided outside the clinic raises numerous issues: confidentiality, quality of assessments, proper documentation, and limited access to needed equipment and medicines. Access was not well reviewed at either facility during this site visit.
Dental Care At Hickey the on site dental operatory is closed and there are no plans to reopen or remodel it at this time. It was located in the intake building with the infirmary, far from the housing units behind the fence. Now youth are taken off site to a local dentist’s office, 2 in the morning and 2 in the afternoon four days a week. Staff indicated that as many as 6 youth per day could be served if needed. The Hickey records did indicate exactly what the dentist did for each youth. The medical services monitor was told each new resident has an examination and dental cleaning and prophylaxis. Chart review at Hickey showed that new detention patients have their dental exam about 2 to 3 weeks after admission. I was told that the exam and treatment plan are fully documented on the dentists office chart. Only a list of needed treatment is sent back to the Hickey chart. The complete dental examination and list of restorative and preventive treatment needs should be documented on the Hickey health record. This important health information should then be communicated to the family upon release or to the next placement program. Chart review showed that the treatment recommended by the dentist was not consistently provided. Many cavities were never filled, except when youth were re-admitted and the dentist did some restorative care instead of duplicating the exam. The initial dental assessment at Cheltenham includes only an examination. There is no initial dental cleaning and prophylaxis. Dental Recommendations: (1) At Hickey, include a complete dental operatory in the new health unit inside the fence. It
is much more efficient to provide services on site than to transport youth off-site.
(2) The Hickey dentist should report the complete examination and treatment needs back to (3) Additional dentist time is needed at both facilities to meet the needs of the rapid turnover (4) A system is needed at both facilities for tracking dental needs to make sure youth are Special Medical Services for Youth with Chronic Illness Care for youth with chronic illness was not reviewed in detail at this site visit. The facility physician reported good access to specialist services currently for both facilities.
Care for youth with asthma seems to have improved at Cheltenham. Peak flow measurements are being used to assess the severity of asthma on admission. Nurses are beginning to document peak flow or response to treatment for youth who request to use their “as needed” inhalers. Peak flow sheets for each asthmatic are placed in the medication notebook, where the nurse can easily find them and document results on them. Staff on the units is not documenting use of inhalers on the unit. Youth with latent tuberculosis infection treated with isoniazid preventive therapy should be tested initially and monitored for liver toxicity. Though rare, this complication of isoniazid treatment can be very serious. A youth with hepatitis C infection at Cheltenham had no clinical or laboratory assessment of the severity or activity of his disease. His chronic infection was not listed on the problem list. Chronic Illness Recommendations: (1)
Establish nursing protocols for assessment of asthma using peak flow meter at baseline,
to assess severity of asthma attacks, and to determine effectiveness of treatment.
Establish more consistent follow through on the needs of chronically ill youth. A good
chronic illness management program begins with the facility physician who actively provides direction to the program through protocols for nurses and patient specific orders to suit each unique situation.
Health Promotion and Disease Prevention The immunization program at both facilities had important gaps. Chart review showed that Hepatitis B vaccine was rarely ordered by the physician or nurse practitioner. Clear guidelines for assessment of immunization status are needed, as I found several youth whose need for the adolescent tetanus-diphtheria booster was missed by the doctor or nurse practitioner. A better system is needed for tracking the hepatitis B series. The current approach is to copy the order from month to month on the medication administration record. This was clearly not working at Hickey as youth were lost to follow-up without finishing the hepatitis B series. I doubt it would work reliably anywhere. Health education was not reviewed at this site visit. Disease Prevention Recommendations: (1)
Provide explicit guidelines for assessment of immunization records and bringing youth
fully up to date for age per current public health guidelines.
Develop an effective tracking system to complete immunization series timely. An
appointment calendar allows due dates to be projected ahead and recorded for the entire year.
III. E. Medical Care. ii. Medical Director. A qualified, licensed physician shall supervise clinical practices and medical policy development, and shall participate in quality assurance and infection control programs at the facilities. Status: Non-compliance Discussion: The Medical Director position is vacant. During this site visit I was informed that the position is approved to be filled and has been advertised. The salary available is up to a maximum of $150,000 per year. This may not be enough to recruit a full time medical director in the greater Baltimore- Washington DC market. Recommendations: (1) Offer a salary that will be competitive in the local physician market. Evidentiary Basis: Site visits October 10-12, interviews with the nursing supervisors. III. E. Medical Care. iii. Health Assessments. The State shall conduct adequate health assessments for youth upon entry or re-entry to the facilities. Status: Partial compliance Discussion: Youth admitted to training schools are a medically neglected population with a greater prevalence of acute and chronic illnesses than the general adolescent population. They require a comprehensive assessment because they often have had little or no medical care prior to placement, and they are more likely to have chronic illnesses, infections, and physical disabilities than average youth. DJS Standard #33: Health Assessment defines the content of the initial health assessment on admission to the facility. This policy defines the component parts of the assessment, but does not define the essential outcome that should result, i.e. an up to date problem list and plan of care. Essentially the same initial health evaluation occurs at both Hickey and Cheltenham. Chart review showed that the initial health assessment includes initial screening interview immediately after admission; standardized nursing history, confirmation of medicines with prescribing physician or parent; physical examination by a physician or nurse practitioner; tuberculosis skin test; tests for sexually transmitted diseases including syphilis, chlamydia, and gonorrhea; complete blood count; and screening visual acuity. Several important components of the initial health assessment are missing, including: formal hearing screening with a standard instrument; urine analysis for blood and protein; blood tests of liver and kidney functions, and plotting height and weight on standard adolescent growth charts. The significant abnormalities identified are not all listed on the Problem List and there is no
written management plan for each problem that was identified. Chart review showed that problems not listed on the problem list are often lost to follow-up. Recommendations:
Revise DJS Standard #33: Health Assessment to include the expected outcomes of the
initial health assessment which are an up to date problem list and plan of care for each active health problem.
Include formal hearing screening with a standard instrument, urine analysis for blood and
protein, blood tests of liver and kidney function, and growth charts in the admission health assessment.
The Problem List should include all significant current and past health problems.
There should be a written plan of care for each active health problem.
Evidentiary Basis: Site visits October 10-12, interviews with the nursing supervisors, health record review and review of agency health policies or "standards". II. E. Medical Care. iv. Medication Administration. The State shall develop and implement standards for medication administration, and shall train all staff responsible for medication administration to
prevent medication discontinuity and errors.
Status: Partial compliance Discussion: DJS Standard #27 provides explicit standards for medication administration. This standard is long and detailed. DJS Standard #39: Direct Orders provides procedures for physicians’ orders to continue needed medicine for new admissions, and medication dose schedules. There is a new pharmacy contract for both facilities which provides for same day or next day delivery of prescriptions, emergency deliveries; starter doses with expiration dates; and monthly pharmacist quality review using a standard checklist. Timely delivery and well maintained stock of starter doses are necessary resources to support timely continuation of medicines on admission. There is no training for nurses at this time on facility medication management. There is a 16 hours training for line staff on how to supervise youth when they take their medicine. Hickey: Most medicines are administered at the Satellite Clinic behind the fence where the youth live, go to school and recreate. Sometimes the nurse goes to the youth in program or on the unit to administer medicine. This might occur during a unit lock down, or when a youth is in segregation. Cheltenham: Most medicines are administered on the units, or wherever the nurse may have to go to find the youth. Review of the medication administration records (MARs) at both facilities showed that most residents were getting their medicines as prescribed most of the time. Missed doses were charted with explanations on the MARs. No show for medication did occur, but this is no longer common. Recommendations: (1)
Nurse training in facility medication management based on the policies and procedures.
All medicines should be administered in the clinic under stable and controlled conditions
to allow consistently safe and accurate nursing practice.
Evidentiary Basis: Site visits October 10-12, interviews with the nursing supervisors, health record review and review of agency health policies or "standards". III. E. Medical Care. v. Records Retrieval. The State shall make all reasonable efforts to assure that the facilities obtain available pertinent youth records regarding medical and mental health care. Status: Partial compliance Discussion: Health records provide useful information about prior health needs and health services received. Youth with chronic disease under active treatment have a doctor who is managing their care. Records of prior care help guide current management. Young people transferred from another institutional placement should come with records of their recent health assessments and services. The more information Hickey puts together during the detention phase, the easier it will be for the next health program to continue needed care. Information about immunizations, chronic illness management, recent trauma or surgery, current medications, and results of screening tests should be obtained and communicated to the family or the next program or placement. None of the DJS standards or policies discuss the need to obtain records of prior care. The Nursing Assessment form completed on admission begins with a list of prior DJS placements and notation whether records have been requested. Hickey charts showed that records from detention were obtained by fax from some sites. Youth coming from facilities not operated by DJS do not come with records at all. DJS must obtain consent for release from parents, then request health records. Health staff is trying to obtain past records of care. Charts showed some detention records. I did not review enough pertinent health records at this site visit to determine that records are being obtained from specialists who were managing youth with chronic illness in the community. Neither facility has access to the agency data system or email. They cannot obtain the reports or health information available on the agency data system. Recommendations: (1)
Develop a policy on obtaining prior health care records consistent with the agreement.
Provide the health program with support staff to obtain health records from prior
Provide the health units access to the agency data system and email.
Evidentiary Basis: Site visits October 10-12, interviews with the nursing supervisors, health record review and review of agency health policies or "standards". III. E. Medical Care. vi. Record System. The State shall develop and implement standards, procedures and practices to create an integrated medical and mental health record system, and shall maintain the system. Status: Partial compliance Discussion: This section calls for an integrated health record to improve communication and coordination among the health professionals working with each youth. The goal is better communication and coordination, not necessarily a specific record format. In some settings a single health record will work well, while in others, separate records with ongoing exchange of information may work better. DJS Standard #58: Health Record Format and Contents defines the layout of the health record. This policy requires mental health records to be kept separately, but crucial health information is to be shared continuously between somatic health and behavioral health. The current layout of the health record includes the following chart sections:
Initial assessment, immunizations, dental
This format is not easy to work with because too many subjects are mixed together in the same section. There is no discrete mental health section. Medical care is documented in several different sections instead of all together in the progress notes in chronological order. Until there is a permanent mental health provider organization for Hickey it will be hard to develop any understanding about exchanging information between somatic health (medical, nursing and dental care) and behavioral health (psychiatry, psychology, social work and counseling). The agency acting medical director and director of behavioral health services can try to work out an acceptable approach to record sharing. Recommendations: (1) DJS medical and behavioral health program managers should develop plan for a record system that fosters communication and coordination among disciplines. Evidentiary Basis: Health record structure; Review of records of youth prescribed psychiatric medicines for mental health information. d. SPECIAL EDUCATION Overview of Special Education in Juvenile Corrections
Special education services in juvenile corrections are delivered in the context of the
general education program. That is, special education services as defined by IDEA, the Individuals with Disability Education Act 20 U.S.C. §§1400-1490 do not constitute a “stand alone” service delivery system. The provisions in this section of the Settlement Agreement are based on the IDEA and implementing regulations, and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794. In a number of other states, juvenile correctional agencies and education programs have achieved compliance with the requirements of IDEA.
The education services at the Hickey School are provided by staff from the Maryland
State Department of Education while education services at Cheltenham are provided by staff of the Department of Juvenile Services. During the first reporting period, the Hickey School closed two units used for committed youth. Like Cheltenham Youth Center, the Hickey School now just serves as a detention facility. However, at both facilities there are a substantial number of youth who have been committed by the Courts and who have “pending placement” status. These children spend weeks and sometimes months in the detention centers waiting for available space at long-term treatment facilities. A review of the “night sheets” indicates lengths of stay for the residents in the DJS facilities. Of the 76 youth at the Hickey School on January 11, 2006, 19 or 25% of the residents had been at the facility more than two months. Seven residents had been at Hickey more than three months. Of the 105 youth at Cheltenham on January 12, 2006, 26 or 25% had been at the facility more than two months. Twelve youth or 11% of the children had been there more than three months. These numbers do not include youth who spent time in detention were returned to the community or placed in treatment and later returned to the detention center during the same year. The time youth spend at Hickey and Cheltenham should affect the design of the education program and the course offerings available to students.
In several respects, neither Hickey nor Cheltenham has the support or expectations
associated with most other school programs. Neither school is accredited by a professional association such as the Middle States Association of Colleges and Secondary Schools. In a number of other states correctional facilities in both long and short-term institutions have been accredited for a number of years as special function schools. At both Hickey and Cheltenham, there is not a system in place that enables the school to hire substitute teachers. It was not uncommon at both facilities during the first reporting period to have instructional aides teaching classes in a number of content areas. Many students stated that they were not allowed to have books in their rooms. At both Hickey and Cheltenham, students are assigned to classes on the basis of their living units and not on the basis of their instructional needs.
From the time of the first visit of the Education Monitor to the Hickey School on October
10 through subsequent visits to both Hickey and Cheltenham, the quality of education services improved. For the most part, students have positive things to say about education services though many volunteered that they are not challenged by the coursework and most indicated that they were not assigned homework. While changes made during the first reporting period were
responsive to the provisions of the Settlement Agreement and resulted in more appropriate services to youth, significant work remains to be done. III. F. Special Education i. Provision of Required Special Education. The State shall provide all eligible youth confined at the facilities special education services as required by the IDEA, 20 U.S.C. 1400-1490, and regulations promulgated thereunder, and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, and regulations promulgated thereunder. Status: Partial compliance Discussion: While significant steps have been made during the first reporting period, challenges remain before all eligible youth confined at Cheltenham Youth Center and the Hickey School receive appropriate services. For example, on November 16 at Cheltenham School, some students eligible for special education were not receiving services mandated on their Individualized Education Programs (IEPs) in part because the special education teacher at Cheltenham was filling in for a teacher who was on long-term leave. Cheltenham and to an extent, the Hickey School have had difficulty attracting and retaining highly qualified teachers and administrators in part because of large discrepancies between compensation received by public school teachers and the State’s pay scale for institutional teachers. The State will experience difficulty complying with IDEA and the settlement requirements because salary discrepancies with the public schools. This issue is discussed in greater detail below under provision III. E. vii. Teachers working for DJS have had no raises except cost of living adjustments for many years. According to DJS staff, the agency actively recruits for and receives many applications for vacant positions but potential candidates often do not pursue employment after they learn about the salary structure. Teachers can earn thousands of dollars more each year working a 10-month contract with the public schools rather than a 12-month contract for DJS. As a result of vacancies, special education staff assumes responsibilities associated with unfilled positions. For example, a teaching assistant at Cheltenham was serving as a records clerk instead of assisting in the classroom because the clerk position was unfilled. The teaching assistant, clearly needed in classrooms with an average of 15 to 20 students, has since been reclassified as a clerk, a position that had not previously been allocated to the school. The special education coordinator at Cheltenham also serves as acting administrator several days each week because the school has only a part-time acting principal. Two administrators from the Youth Centers in western Maryland spend time at Cheltenham each week to assist with administrative responsibilities. With regard to delivery of services, review of IEPs at the Hickey School reveals that in almost every instance, when students arrive at Hickey, IEPs are revised and students are scheduled for less service than they previously received in the public schools and private placements prior to their detention. This issue is reviewed in greater detail below under provision III. F. v. While this has not occurred at Cheltenham, until recently lack of staff has interfered with delivery of services as required on students’ IEPs. During the end of this first reporting period, additional special education teachers were transferred from the Baltimore City Juvenile Justice Center to Cheltenham. A total of four special education teachers now provide instruction at that facility.
During this first reporting period, staff at Cheltenham struggled to get students from their cottages and breakfast to school on time in the morning. For example, records for the first eight school days in January show that students from two cottages, Rennie and Henry arrived at school anywhere from 15 minutes to one hour late. On January 3 and 4, 2006, students from Henry arrived 60 minutes late to school and on January 6 and 9, students from Henry arrived 15 minutes late for school. Students from Rennie arrived 50 minutes late on January 5, 2006, 55 minutes late on January 6, and 40 minutes late on January 9 and 10. A number of special education students are among those arriving late to school. Recommendation: Achieving compliance with the general provision that the State provide adequate special education services requires fully staffing the education programs, developing more adequate provisions for transition and vocational education, and fully implementing students’ IEPs. These issues are reviewed in subsequent sections. Cottage staff and facility administrators need to develop plans to ensure that students arrive at school on time Evidentiary Basis: Site visit to Cheltenham 11/16/05 and 1/12/06, interview with staff, review of files; site visit to Hickey 10/10-11, 2005 and 1/5/06, interview with staff, review of files. III. F. Special Education Provision: ii. Supervision of Education. The State shall designate a director of education within the facilities. The director shall meet minimum standards as specified by the State. The State shall provide the director with sufficient staff and resources to perform the tasks required by this Agreement, including: a. overseeing the special education program in the facilities, including development and implementation of policies and training programs; b. monitoring whether special education staffing and resources are sufficient to provide adequate special education services to qualified youth at the facilities and to comply with this Agreement; c. developing and implementing a quality assurance program for special education services; d. developing and implementing an adequate vocational program for all eligible youth. Status: Substantial Compliance Discussion: In April 2005, DJS hired Dr. Sheri Meisel as Director of Education Services for the Department. She has responsibility for the education program at Cheltenham and all other DJS facilities except the Hickey School, the Baltimore City Juvenile Justice Center, and the Lower Eastern Shore Children’s Center. In the summer of 2004, the Maryland State Department of Education (MSDE) assumed responsibility for education at the Charles H. Hickey School. Dr. Carolyn Buser, is the Director of the Correctional Education Program at MSDE and Dr. James Keeley is the Field Director. Raleigh Turnage, is the principal, and Don Trost is the Assistant Principal for the Hickey School. At the present time Cheltenham operates without a principal or assistant principal and DJS has not been able to fill this position for a number of months. Currently there are large discrepancies between resources available to the education program at
Hickey and the program at Cheltenham. In November, there were 8 vacancies among the 60 education positions allotted to the Hickey school. [This number included staff at the two schools serving committed youth that are now closed.] At Cheltenham, vacancies in November included the principal, a teaching assistant, and a math teacher. Neither Hickey nor Cheltenham has a science teacher. The math position at Cheltenham was filled in November but the principal’s position has been vacant since May 3, 2005. Several candidates with appropriate experience and credentials have interviewed for the position of principal. Because of the large salary discrepancy between what DJS pays principals under the IEPP (Institutional Educator Pay Plan) and the public schools, none of the candidates were interested in the job. Large discrepancies between the State’s IEPP and the teacher and administrator salaries paid by the Baltimore County Public Schools and the Prince Georges County Public Schools [the jurisdictions in which Hickey and Cheltenham are located] make it extremely difficult to recruit and retain staff. Teachers at Hickey and Cheltenham work a 12-month year and receive salary that is comparable to staff working in the public schools on 10-month contracts. While the school at Hickey, operated by MSDE, has a plethora of computers, related equipment, and furniture, for most of the reporting period students at Cheltenham lacked many of these things. For example, during site visits on October 12 and November 12, there were two classrooms that staff couldn’t use because there were no teachers to staff them. Desks, chairs, computers, and career education materials for several classrooms ordered early in the semester had not arrived by January 12, 2006 at the time of the most recent visit to Cheltenham. At both Hickey and Cheltenham, speech and language specialists, social workers, and some psychological services are provided through contracts with private providers. Students appear to receive related services mandated on their IEPs. The State needs to develop and implement a competitive salary schedule. Lack of a salary structure comparable to those used by the public schools is one of the most serious impediments to hiring qualified staff. Although the state is required to review the IEPP periodically, according to staff this hasn’t happened in a number of years. A competitive salary schedule needs to be more than a one-time fix. A competitive schedule needs mandated, periodic reviews and adjustments to ensure its comparability with local school districts. Education staff needs to be compensated for 12 months of employment. Recommendation: The pay scale used by the State for teachers, teacher aides, administrators and support staff at Hickey and Cheltenham, the Institutional Educator Pay Plan or IEPP, needs to be competitive in order to attract and retain highly qualified staff. It will be difficult for the administrators to implement and sustain the provisions of the Settlement Agreement without adequate staff. Evidentiary Basis: Interviews with Drs. Meisel and Buser. Visits to Cheltenham on October 12, November 16, 2005 and January 12, 2006 and to Hickey on October 10, 11, 2005 and January 6, 2006. III. F. Special Education Provision: iii. Screening and Identification. Qualified professionals shall provide prompt and adequate screening of facility youth for special education needs, including identifying youth who
are receiving special education services in their home school districts and those eligible to receive special education services who have not been identified in the past. Status: Substantial Compliance Discussion: At both Hickey and Cheltenham Youth Center, staff conducts intake interviews with youth within the first two days of arrival. During the intake process, staff learns about youths’ prior school experience and begins the process of requesting records from other schools. At both schools, education staff does a good job of determining prior special education status and obtaining records. Youth who perform poorly on academic screening measures at intake and are suspected of having disabling conditions, are often referred by teachers and other staff for special education services. During the first reporting period, one student from Hickey was referred for an initial evaluation. According to staff, he was transferred from Hickey prior to the completion of his assessment and the development of his IEP. Recommendation: At the present time, the education staff at Cheltenham Youth Center does not have access to the internet and the ASSIST on-line data retrieval system within the school building. The special education coordinator has to go to another building on campus and use another staff member’s computer in order to access this web-based file of special education students. Access to the internet within the school building would increase the efficiency of the Cheltenham special education team. Evidentiary Basis: Interviews with students and staff at Hickey and Cheltenham. III. F. Special Education Provision iv. Parent, Guardian, and Surrogate Involvement. The State shall appropriately notify and involve parents, guardians or surrogate parents in evaluations, eligibility determinations, Individualized Education Programs (“IEPs”), placement and provision of special education services. Status: Substantial compliance Discussion: Staff at both Hickey and Cheltenham did a good job of contacting parents and involving them or surrogates in the IEP development process. At both sites, parents or surrogates participated in IEP meetings in person or by teleconference. Recommendation: Both sites should improve the system they use to document contact with parents. While some files reviewed clearly indicated who contacted parents and when, in other files it was difficult to determine how initial contact was made. Evidentiary Basis: Review of 20 student files at Hickey School and 28 student files at Cheltenham Youth Center. Interviews with staff at both sites. III. F. Special Education Provision v. Individualized Education Programs. The State shall develop and/or implement an adequate IEP, as defined in 34 C.F.R. 300.340, for each youth who qualifies for an IEP. Consistent with the requirements of 34 C.F.R. 300.343 (b) (2), within 30 days of a determination that a youth is eligible for special education and related services, the State shall conduct an IEP meeting to develop an IEP. As part of satisfying this requirement, DJS must conduct required re- evaluations of IEPs, adequately provide and documents all required instructional services, conduct appropriate assessments and comply with requirements regarding student and teacher participation in the IEP process. Mental health staff shall be involved in the development of IEPs of all youth with identified mental illness. Goals and objectives shall be stated in realistic and measurable terms. Status: Partial compliance. Discussion: Twenty IEPs and education files of current students at the Hickey School and twenty-eight IEPs and education files of current students at Cheltenham were reviewed. The special education staff at both facilities did a good job of retrieving records from students’ previous schools and for the most part, files were well organized. At the Hickey School, every student’s file contained an IEP from a previous school. At Cheltenham, 22 of the 28 files contained IEPs developed for youth at previous schools. Hickey School At Hickey, all the IEPs reviewed were changed at intake to reflect the nature of the setting – a correctional environment – rather than students’ needs. In every case, the number of hours of direct special education service was reduced. In half of the cases, the number of hours of related services such as speech and language therapy or counseling, was reduced. Typically, IEPs were revised to indicate that most or all special education instruction was to take place in the regular classroom. Interviews with both students and teachers revealed that services specified on IEPs were not actually being provided. Teachers indicated that they didn’t have sufficient time to provide direct services to all students on their caseload. Students reported that they hadn’t been receiving special education services or that they didn’t see their special education teachers regularly. There also appears to be lack of good communication between direct care staff and education staff. The record indicates that students were in the infirmary without the knowledge of school staff who could bring materials to them. Students also moved from detention to “pending placement” status and often a change in cottage status without notification of school staff; these changes made it difficult for school staff to provide appropriate services and meet procedural timelines. Cheltenham Youth Center At Cheltenham, students’ IEPs from their former schools were reviewed by the staff in a timely manner. For the most part, the Cheltenham staff attempted to implement these IEPs as written. However, lack of special education teachers during the first part of this reporting period resulted in students not receiving special education services as specified on their IEPs. While the situation has improved greatly now that Cheltenham has four special education teachers, the school in general is understaffed as most classrooms have from 15 to 18 pupils, including special education classes designed for students with the most significant learning needs.
A serious problem at both the Hickey School and Cheltenham Youth Center involved the adequacy of transition components of students’ IEPs. While some transition planning occurs at each site, a review of IEPs revealed that most transition plans were not related to their post institutional placements. Adequacy of IEPs and specificity of plans developed for youth is much more than a technical requirement of IEP development as required by federal and state statutes and the Settlement Agreement. For example, during this first reporting period, a student was released from the Hickey School and sent to a group home in a school district other than his home district. For nearly five weeks, the group home staff and a DYS social worker were unable to enroll this student in the public schools. The student remained idle during this time in the group home until he went AWOL and was promptly returned to Hickey. The student was an individual with a history of learning and behavior disorders who previously had been receiving special education services. Similarly, a student left Cheltenham, was returned to the community, and later violated the conditions of his parole. Like the student at Hickey, he was not able to attend school after being released from Cheltenham. Recommendation: Staff at Hickey and Cheltenham needs to review school schedules and means of delivering education services. At Hickey, the common practice of significantly reducing the level and intensity of special education services for students because, as one staff member stated, 'students are in an alternative setting' is not warranted by students' needs. In both settings, class placement is driven by cottage placement. While this appears to be a long standing practice, other juvenile correctional facilities have found ways to meet students' needs without compromising the safety or security of the institution. Evidentiary Basis: Interviews with students and teachers at Hickey School and the Cheltenham Youth Center. Review of 48 student files. III. F. Special Education Provision: vi. Vocational Education. The State shall develop and implement adequate vocational education services for all youth. Status: Partial Compliance Discussion: For many youth in detention, prevocational education consisting of career education or career exploration and life skills meets the requirements for vocational education in a short- term placement. However, while most youth at Hickey and Cheltenham are detainees, many youth spend several months in a “pending placement” status. For these youth as well as detainees who remain at the detention centers for more than 45 days, a more intensive experience is appropriate. During this first reporting period, the vocational program was not thoroughly reviewed. At the Charles H. Hickey School students participate in a life skill/technology course. The vocational program at the Hickey school was enhanced when a vocational education teacher from the Impact School at Hickey transferred to the detention school. In addition to the vocational class, students at Hickey also meet periodically with a transition specialist.
At Cheltenham, the vocational offering for students is a horticulture class; students also have access to a career center. Career education materials ordered during this first reporting period had not been delivered at the time of a second visit by the education monitor in January. The horticulture class at Cheltenham operates in a regular classroom and does not have the space or greenhouse typically needed for horticultural vocational programs. The current efforts are a step in the right direction but lack the intensity and equipment found in other vocational programs. While some of the current programs may be appropriate for some students in a short-term facility, there are students at both facilities who need more intensive experience than a single vocational class, 50 or 60 minutes each day. Recommendation: Students at both Hickey and Cheltenham need access to high quality vocational education programming. In a short-term facility, these programs provide youth a sample of various vocational possibilities and particularly for older students, enable them to spend more than one period each day in vocational class. Students detained at the schools in excess of 60 days including those pending placement, should have access to a more intensive and diversified vocational education program. Evidentiary Basis: Visits to Hickey and Cheltenham. Discussion with students. Review of class schedules. III. F. Special Education Provision: vii. Staffing. The director of education shall provide adequate education staffing. Status: Partial compliance Discussion: As noted above under Provision: ii. b, adequately staffing has been a challenge because of the inadequacy of the system of compensation for teachers, instructional aides, and administrators. Both Hickey and Cheltenham lack an intensive reading remediation program for students. While staff at both schools report that they periodically work with students on a 1 to 1 basis on reading, there is no regularly scheduled class devoted entirely to reading instruction for illiterate students. During interviews, several students reported that they would like to receive additional instruction in reading. Recommendation: Class sizes, particularly at Cheltenham are too large for the population. With 15 to 18 students in the general education classrooms, a disproportionate amount of time is spent on management of the class. Students with special needs in large classes have a difficult time keeping up with other students. The inclusive instruction envisioned for those classrooms isn’t possible in large classes. While there are no professional standards for class size in juvenile corrections, typical class sizes in juvenile corrections are 1 to 10 or 1 to 12. Evidentiary Basis: Discussion of teaching and other education staff vacancies with Drs. Buser & Meisel, Principal Don Trost at Hickey, and special education coordinator Ty Blackwell at Cheltenham. III. F. Special Education Provision: viii. Section 504 Plans. The State shall develop and implement appropriate Section 504 plans for all eligible youth. Status: Not reviewed. Discussion: Hickey School and the Cheltenham Youth Center report that they request from students’ prior schools, copies of 504 plans along with other records. During subsequent monitoring periods, implementation of 504 plans and documentation of accommodations will be carefully reviewed. Recommendation: No recommendations at this time. Evidentiary Basis: Discussion with education staff. e. FIRE SAFETY Overview of Fire Safety in Juvenile Justice Fire safety issues in juvenile facilities include any condition that may result in the ignition of fire or the spread of fire and other associated products of combustion from its point of origin to surrounding areas. Products of combustion are the by-products of fire such as heat, smoke, toxic fumes and other particulate matter. Life safety issues include conditions or lack of conditions that as a result, may jeopardize safety to life due to fire conditions. For the purpose of creating a guide for these determinations, the National Fire Protection Association’s, National Fire Codes which also includes the Life Safety Code, were used for monitoring. The Life Safety Code is a nationally recognized code published by the National Fire Protection Association that sets standards for the protection of life in buildings from the effects of fire or other similar conditions. However, the Life Safety Code was not the only method for the determination of fire and life safety issues but was simply used as a guide based on nationally recognized standards. My experience and application of fire and building codes along with my experience with detention and correctional facilities were used as the basis for this report.
When inspecting for fire and life safety conditions in correctional facilities, there are
several factors that must be considered in order to properly evaluate the conditions in the facility. Most fire safety experts agree that these factors include: (1) suppression and detection (automatic sprinkler systems and smoke detection systems), (2) occupant protection (protection from the effects of fire by way of safe pathways to the outside or to a safe location within the building), (3) ignition control (limiting methods or sources by which a fire can begin such as lighters, matches, electrical wiring, appliances, etc.), (4) fuel control (limiting the amounts of materials that will burn or support combustion within the cell areas and throughout the building), (5) planning and training (developing emergency evacuation procedures, training in the use of fire protection equipment, practicing emergency procedures). The presence or absence of each of these factors determines the overall levels of fire and life safety of the facility. Since the safety and well-being of each child is dependent upon the ability of each of the staff to perform their emergency evacuation procedures properly and upon the operation and reliability of each life safety system installed in the buildings, these factors are critical to ensure the appropriate levels of fire and life safety. Even though the provisions in the Settlement Agreement between the Department of Justice and the State of Maryland do not address all of these factors, indirectly they all apply to the provisions as it relates to life safety of the occupants. III. G.Fire Safety Precautions. The State shall develop and implement adequate fire safety precautions. The precautions shall include appropriate maintenance of fire suppression and detection equipment and maintenance of doors and door locks so that they may be opened in the event of a fire. Status: Partial compliance in the area of maintenance of fire suppression and detection equipment. Partial compliance in the area of maintenance of doors and door locks. Discussion: Partial compliance has been assigned to the issue of maintenance of fire suppression and detection equipment due to the lack of maintaining the equipment and in some instances, the incomplete installation of the equipment. (Note: Since this was my first tour at these facilities, I am unable to determine any progress that has been made).
Fire Suppression and Detection Equipment
A. Automatic sprinkler systems are not installed in all buildings but the ones in which
sprinklers are installed are not being maintained as required by the Settlement Agreement, especially in the buildings at Charles H. Hickey Jr. facility. Many of the tags required to be affixed to the sprinkler riser of each building indicating when it was last inspected and/or tested by the sprinkler contractor, is either missing completely or is out of date. There is no assurance that the sprinkler systems will operate properly when needed if the systems are not tested at least annually by an independent licensed sprinkler contractor.
B. The sprinkler systems that have been installed in many of these buildings are incomplete
due to the omission of sprinklers in the attic space (Hickey and Cheltenham). Since there are combustibles materials exposed in the attic space, sprinklers are required in order to be considered “fully sprinklered” buildings.
C. In several of the buildings at the Cheltenham facility, the main control valve for the
sprinkler system have no safeguards to prevent the system from being shut off without the knowledge of staff.
D. Portable fire extinguishers have been discharged in various locations in both the Hickey
facility and the Cheltenham facility but have not been recharged and retagged. In some locations portable fire extinguishers have been removed and not replaced. These portable fire extinguishers are vital in preventing small fires from becoming large fires and threatening life safety.
E. Required portable fire extinguishers are in some cases, behind locked doors at the Hickey
facility, in which most staff do not have access to keys to the room.
F. Since smoke detection systems are required to be connected to the fire alarm systems, the
proper maintenance and testing of the fire alarm systems directly affect the performance of the smoke detectors.
G. Fire alarm panels in most buildings at both facilities were indicating that the system was
either in the alarm mode or in the trouble mode and in one building, the fire alarm system was completely shut off. This indicates that the systems will not function properly when needed if the conditions are not cleared and repaired.
H. Most of the staff at both facilities were not able to actuate the fire alarm system due to
their lack of possessing a key to the fire alarm pull box.
I. Several of the fire alarm control panels could not be opened to reset the system due to
J. There was no indication that the fire alarm systems are being tested and maintained
properly on at least an annual basis at the Hickey facility. There are reports from a fire alarm contractor on the Cheltenham facility indicating where the systems were tested but, when identifying a problem, there is no follow-up on how the problem was resolved or if it was resolved.
K. Battery operated smoke detectors are being utilized in some areas where smoke detection
systems (smoke detectors connected directly to the fire alarm system) should be installed.
Partial compliance has been assigned to the issue of the maintenance of doors and door locks due to inability to identify the appropriate keys to release the locking devices on some of the doors. A. Keys for doors to rooms containing fire protection equipment such as portable fire
extinguishers could not be located or identified in a timely manner.
B. Keys to doors to individual sleeping rooms could not be identified by touch in a timely
C. The staff in the Thurgood Marshall Academy at the Charles H. Hickey Jr. facility did not
have access to any of the side doors in the corridor system. If the main entrance/exit of the building is blocked due to fire, the staff has no means of opening the doors at each side of the building at the end of these long corridors.
Recommendation: The State of Maryland Department of Juvenile Services should take the following action to address each of the conditions that are identified above:
Fire Suppression and Detection Equipment
A. Ensure that every sprinkler system is being tested at least on an annual basis at both
facilities by an independent licensed sprinkler contractor. Keep a file on all paper work generated by the sprinkler contractor and make sure that the contractor attaches a their company’s tag to the sprinkler riser identifying who performed the work, the date of the inspection and/or testing and any deficiencies identified during the inspection and testing. Keep copies of all paper work identifying all follow-up work performed on the sprinkler systems. This information should be immediately available upon request by the authority having jurisdiction. In addition, all buildings at both facilities where there is any locking of youths in the building should be equipped throughout with a complete automatic sprinkler system.
B. If the State Fire Marshal’s Office has agreed to the omission of sprinkler heads in the
attic spaces of all the sprinklered buildings, a copy of the agreement or documentation where the it was approved to omit the sprinklers in the attic space and the Section of the adopted code identifying such acceptance needs to be provided for review.
C. At the Cheltenham facility, the OS&Y valve for the sprinkler system is not locked in
place nor is there a tamper switch to indicate that the system has been turned off. The State should either provide a heavy duty chain and lock for the OS&Y valve to ensure it can not be turned off or provide a tamper switch for the system which will sound an alarm at the fire alarm control panel if the valve is being attempted to be turned off.
D. Any portable fire extinguisher at either facility should be immediately removed from
service if it has been discharged for any reason. It should be replaced with another fully charged extinguisher immediately. The discharged extinguisher should be taken to a gathering point for any discharged extinguisher and in turn, be serviced, recharged and tagged before placing it back in service. These portable fire extinguishers should not be
used for any other purpose, including holding doors open, other than to extinguish fires in the infancy stages. They should not be attempted to be used on large fires.
E. Where portable fire extinguishers are placed in rooms or spaces that are secured, provide
keys to all staff that they may be subject to using the fire extinguisher so that the extinguisher is readily available in the event of a fire.
F. Just as sprinkler systems require to be maintained, smoke detection and fire alarm
systems do as well. As stated, all smoke detection systems are required to be connected to the fire alarm system serving any given building. The failure to maintain the fire alarm/smoke detection system in a building provides for a false sense of security to the occupants of the building. Therefore, to ensure the smoke detectors will perform as required, the fire alarm system must also be constantly maintained.
G. Whenever a fire alarm panel is indicating that the system is in the trouble mode or in the
alarm mode and the building has been checked to insure that no fire or smoke is apparent, the staff must immediately notify the fire alarm contractor to begin the process of eliminating the condition causing the trouble. If the condition cannot be corrected within few hours, all building staff must be notified so that they are aware of the condition as well as all staff on future shifts until the condition has been rectified. Written procedures to address this arrangement should be developed.
H. Wherever key locked fire alarm pull stations are located, all staff must be provided with
a key to actuate the fire alarm system if it becomes necessary. The staff should not have to wait for a supervisor to actuate the fire alarm system once a fire or smoke has been identified.
I. Just as the pull stations to actuate the fire alarm system require all personnel to maintain
a key, the same holds true for the ability to gain access to the fire alarm control panel. At the Cheltenham facility, the key to open the fire alarm control panel in each building could not be identified. At least one staff member in each building and on each shift should maintain the key to the fire alarm control panel in the event the system needs to be silenced or reset.
J. Documentation and correspondence needs to be maintained on all information related to
the maintenance and testing of the fire alarm systems. I reviewed no documentation at the Charles H. Hickey Jr. facility indicating where maintenance and testing on the fire alarm system in each building is being performed. Inspections and testing of the various components of the systems must be done periodically as indicated by NFPA 72, National Fire Alarm Code. It is the responsibility of the State to ensure this is being done.
K. All battery operated smoke detectors must be replaced at both facilities with a hard-wired
smoke detection system. Battery-operated smoke detectors are not reliable enough in an institutional environment to provide the level of early warning and safety to the occupants, especially where the occupants are under some level of restraint.
A. Keys to rooms or spaces that are locked and contain fire protection equipment such as
portable fire extinguishers must be made available to all personnel that could ultimately have to use the equipment. This was the case in the gymnasium building at the Charles H. Hickey Jr. facility. Upon the discovery of a small fire, the ability to extinguish the
fire in its infancy stages could eliminate the creation of a large life threatening fire. However, if the fire extinguisher is behind a locked door and there is no key available to unlock the door, the results could be devastating.
B. Keys to unlock doors to sleeping rooms or individual cells must be made to be quickly
identifiable by both sight and touch. In the event of a fire, staff must be able to immediately identify the appropriate key to unlock various doors in the means of egress, especially doors to the individual cells and the doors to the outside. This can be done in various ways including notching the keys, the use of rivets or applying tape or other material to the key. The touch method should be practiced until each staff member is comfortable with this ability.
C. The staff at the Thurgood Marshall Academy at the Charles H. Hickey Jr. facility need to
maintain keys to all doors that may need to be used in the event of a fire. This includes the doors to the adjacent cafeteria and the doors to the exterior on the opposite side of the building. Without the ability to unlock these doors and utilize these doors as egress doors, the corridors become dead end corridors that exceed 70 feet in length.
Evidentiary Basis: The Charles H. Hickey Jr. facility was toured on the 10th and 11th of October 2005. The Cheltenham Youth Facility was toured on the 12th of October 2005. During visits and report preparation, emergency evacuation and fire drill procedures as well as brief descriptions of each building at the Cheltenham Youth Facility were reviewed. Information regarding emergency evacuation procedures, fire alarm testing logs, generator testing logs, Fire Marshal inspection reports, sprinkler test and inspection reports were requested for the Charles H. Hickey Jr. Facility but have not yet been received. Various staff personnel were interviewed regarding various fire safety issues and procedures at both facilities. 4. COMPLIANCE and QUALITY ASSURANCE IV. A. Document Development and Revision. The State shall revise and/or develop policies, procedures, protocols, training curricula, and practices as necessary to make them compliant with the provisions of this Agreement. The State shall revise and/or develop as necessary other written documents such as screening tools, logs, handbooks, manuals, and forms, to effectuate the provisions of this Agreement. Status: Partial compliance Discussion: Policies need to be revised to include all of the provisions of the agreement. This report points out specific health policies or standards that require revision. Manuals, protocols and training are all necessary for implementation of consistent policies and procedures. Recommendations: (1) Develop a comprehensive plan for program development and training to implement the health provisions of the agreement. Evidentiary Basis: Updated policies and procedures, forms, protocols, manuals and training designs. IV. Compliance and Quality Assurance. B. Document Review. Written State policies, procedures, and protocols that address the provisions of this Agreement regarding the following topics shall be submitted to the Monitoring Team for review and approval within ninety (90) calendar days of the execution of this Agreement: use of force/crisis management; use of restraints and seclusion; mental health, medical and dental screening and assessment; treatment planning; and medication administration and monitoring. The State shall supply the DOJ with copies of all such policies, procedures, and protocols when it submits them to the Monitoring Team. The Monitoring Team shall approve and/or suggest revisions to these policies, procedures, and protocols within thirty (30) days of receipt, unless a longer period is agreed upon by the parties. Status: Partial compliance Discussion: Documents received during this monitoring period included the Health Care Services Standards and Operational Procedures which have been discussed throughout this report. Recommendations: (1) Send revised health care standards, policies and procedures for review and comments by the monitoring team. Evidentiary Basis: Timely response to requests for documents. IV. Compliance and Quality Assurance. C. Quality Assurance. The State shall develop and implement quality assurance programs for protection from harm, suicide prevention, mental health care, medical care, special education services, and fire safety. Status: Partial compliance Discussion: Monitoring routine components of the health program assures that they are well implemented. Completeness of initial health evaluation, staff and youth tuberculosis screening, sick call assessments, medication administration, outstanding dental needs, and outstanding requests for specialty consultations reflect the access, evaluation, and treatment functions of the health program.
Sentinel events, on the other hand, are unusual occurrences that signify a possible failure of the health program, such as true emergencies, emergency room visits, hospital admissions, deaths,
and unusual incidents. Monitoring sentinel events can provide information about how well a health program is responding to critical health needs. DJS Standard #6 Comprehensive Quality Assurance Program creates a quality assurance committee and specifies quarterly review of nursing process measures such as orders carried out and legibility as well as outcome measures such as adequacy of treatment plans and medicines prescribed. These audits are carried out by the agency health bureau staff that supervise all facility health programs. Recent audits of the Hickey health program were provided to me. The existing program is a reasonable effort to establish and maintain a standard of practice for the aspects of care that are included in the audit tool. This effort would result in more actual improvement if the services targeted for review were to change with each audit. Also, audit of clinical outcomes will result in clinical quality improvement. For example, audit the completeness of dental care to identify problems with scheduling and follow-up of dental needs; or, audit injuries occurring during restraints to identify problems Recommendation: (1)
DONALD ROBBINS, DMD, FAGD, FIAOMT BIOSAFEDENTISTRY® 1982 – Present 12th & Lombard Streets Philadelphia, PA 19102 President American Endodontic Society Levittown, PA LICENSURE Chester County Hospital West Chester, PA International Academy of Oral Medicine and Toxicology International College of Cranio-Mandibular Orthopedics DONALD ROBBINS, DMD DENTAL LEARNING RESOURCE, LLC F
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