Microsoft word - cripa report #1 leone final edits 3-6-2006.doc

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
1. INTRODUCTION.………………….………………………….……….1
2. DEFINITIONS and METHODS……………………………….………….…2


e. FIRE SAFETY……………………….…….…….…………….….32


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
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.

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.

Partial Compliance
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.

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
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
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.

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

Continued concerns exist for mental health staff providing adequate treatment
interventions and required contacts.

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

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

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
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

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.
Partial Compliance

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.

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.

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.

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
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

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,
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
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
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
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

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
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
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
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.

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
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:

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:

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
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:

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.
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
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.


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
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
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
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
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.

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.
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.
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
. 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.

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
. 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,
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
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
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
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.

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.

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.

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.
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
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
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


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

BadgerRx Gold Covered Medications This is an abridged list of commonly used brand and generic medications covered for BadgerRx Gold members. This list represents only a portion of the total list of covered medications. You may review the entire medication list at or discuss your questions with a customer service representative toll-free at 866-809-9382 (8:30am to 5:00pm

Copyright ©2018 Sedative Dosing Pdf