Comprehensive Quality Review Report Alfred D. Noyes Children's Center (MD 2010)

7/31/2019 Comprehensive Quality Review Report Alfred D. Noyes Children's Center (MD 2010)

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OFFICE OF QUALITY IMPROVEMENT

Comprehensive Quality Review Report

Alfred D. Noyes Childrens Center

May 10, 2010


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Quality Review Report


Evaluation Dates: April 13-18, 2010

TABLE OF CONTENTS

EXECUTIVE SUMMARY .............................................................................................. 3QI Rating Scale............................................................................................................... 3QI Rating Percentage ...................................................................................................... 4

Executive Summary of Results....................................................................................... 6

Methodology................................................................................................................... 7SUMMARY OF FINDINGS & RECOMMENDATIONS............................................ 9

SAFETY AND SECURITY ............................................................................................. 9Incident Reporting .......................................................................................................... 9

Senior Management Review......................................................................................... 11De-Escalation & Restraint ............................................................................................ 13

Contraband & Room Searches...................................................................................... 15

Seclusion....................................................................................................................... 17Room Checks During Sleep Period .............................................................................. 19

Perimeter Checks .......................................................................................................... 20

Staffing.......................................................................................................................... 22

Control of Keys, Tools & Environmental Weapons..................................................... 24Youth Movement & Counts.......................................................................................... 26

Fire Safety..................................................................................................................... 28

Post Orders.................................................................................................................... 31Staff Training................................................................................................................ 32

Admissions, Intake & Student Handbook..................................................................... 34

Classification................................................................................................................. 36Pending Placement........................................................................................................ 38

Behavior Management .................................................................................................. 39

Structured Rehabilitative Programming ....................................................................... 41Self Assessment ............................................................................................................ 43

BEHAVIORAL HEALTH............................................................................................. 44Intake, Screening & Assessment................................................................................... 44

Informed Consent.......................................................................................................... 46Psychotropic Medication Management......................................................................... 48

Behavioral Health Treatment & Service Delivery........................................................ 49

Treatment Planning....................................................................................................... 51Transition Planning....................................................................................................... 53


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Quality Review Report


Evaluation Dates: April 13-18, 2010

TABLE OF CONTENTS(Continued)

SUICIDE PREVENTION.............................................................................................. 55Documentation of Youth on Suicide Watch................................................................. 55

Environmental Hazards................................................................................................. 57

Clinical Care for Suicidal Youth................................................................................... 59EDUCATION.................................................................................................................. 61

School Entry.................................................................................................................. 61

Curriculum & Instruction.............................................................................................. 62

School Staffing & Professional Development .............................................................. 64Screening & Identification............................................................................................ 65

Parent, Guardian & Surrogate Involvement.................................................................. 66

Individualized Education Programs.............................................................................. 67Career Technology & Exploration Programs ............................................................... 69

Student Supervision ...................................................................................................... 70

School Environment & Climate.................................................................................... 71

Student Transition......................................................................................................... 72MEDICAL CARE........................................................................................................... 73Health Care Inquiry Regarding Injury .......................................................................... 73

Health Assessment........................................................................................................ 75Medication Administration........................................................................................... 78

Dental Care ................................................................................................................... 79

Medical Records Retrieval............................................................................................ 80Special Needs Youth..................................................................................................... 81

Availability of Medical Services .................................................................................. 82


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Facility: Alfred D. Noyes Childrens CenterEvaluation Dates: April 13-18, 2010

EXECUTIVE SUMMARY

A quality improvement assessment and evaluation of the Alfred D. Noyes ChildrensCenterwas conducted April 13-18, 2010 by DJS personnel who are subject-matter

experts in the areas reviewed. The areas that were evaluated have been identified as

those having the most impact on the overall safety and security of youth and staff. Theevaluation was based on information gathered from multiple data sources such as staff

interviews, youth interviews, document review and observations of facility operations,

activities and conditions.

The following Rating Scale was used:

Quality Improvement Rating Scale

Superior Performance Strong evidence that all areas of practice consistently exceed the

standard across the facility/programs; innovative facility-wide approach

is incorporated sufficiently so that it has become routine, accepted

practice.

Satisfactory Performance Performance measure is consistently met across the facility/program;

any gaps are temporary and/or isolated and minor; documentation is

organized and readily available.

Partial Performance Expected level of performance is observed but not facility-wide or on a

consistent basis; implementation is approaching routine levels butfrequently gaps remain; facility had difficulty producing documentation

in some areas.

Non Performance Little or no evidence of adequate implementation of performance

measure; the required activity or standard is not performed at all or

there are frequent and significant exceptions to adequate practice;

documentation could not be produced to substantiate practice.


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At the last QI Review of Noyes in November 2008, 44 standards were evaluated. Following is abrief synopsis of the results from that review:*

Rating # within rating % of total in rating

For this review, a total of43 standards were evaluated with the following results:*

Rating # within rating % of total in rating

NOTE: The DJS Quality Improvement Performance Ratings are aligned with best practices and optimal standards

of care. Therefore, while the facility practice may be in full compliance with minimum constitutional standards, the

facility may still receive partial or non performance ratings as a result of QI reviews.

Superior Performance 0 0%

Satisfactory Performance 9 20 %

Partial Performance 29 66 %

Non Performance 6 14 %

Superior Performance 0 0 %

Satisfactory Performance 15 35 %

Partial Performance 16 37 %

Non Performance 12 28 %


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Noyes Center Performance Comparison

0%

10%

20%

30%

40%

50%

60%

70%

11/12/08 5/10/10

Dates of Review

Percentage

Superior Performance Satisfactory Performance Partial Performance Non Performance


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Executive Summary of Results

Superior

Performance

Satisfactory

Performance

Partial Performance Non Performance

Room Checks DuringSleep Period

Perimeter Checks

PsychotropicMedication

Management

School Entry

Curriculum andInstruction

School Staffing andProfessionalDevelopment

Screening andIdentification

Parent Guardian and

Surrogate Involvement

Student Transition

Health Care InquiryRegarding Injury

Medication

Administration

Dental Care

Medical RecordsRetrieval

Special Needs Youth

Availability of Medical

Services

Incident Reporting

De-escalation and Restraint

Contraband and Room Searches

Control of Keys, Tools and

Environmental Weapons

Fire Safety

Post Orders

Staff Training

Admission, Intake and StudentHandbook

Behavior Management

Intake, Screening and Assessment

Behavioral Health Treatment andService Delivery

Environmental Hazards

Clinical Care for Suicidal Youth

IEPs

School Environment and Climate

Health Assessment

Senior Management Review

Seclusion

Staffing

Youth Movement and Counts

Classification

Structured Rehabilitative

Programming

Informed Consent

Treatment Planning

Transition Planning

Documentation of Youth onSuicide Watch

Career Technology andExploration Programs

Student Supervision


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METHODOLOGY

I. Pre-EvaluationPrior to the evaluation, the facility received a document request list from the

DJS Office of Quality Improvement. This list detailed various documents inthe areas of safety and security, medical care, mental health care and

education that would be reviewed by the QI Team,

II. Entrance Interview with SuperintendentA formal entrance interview was not conducted with the Superintendent on

the first day of the review, but discussions and interviews were conductedthroughout the review. Members of the QI Team asked and discussed with the

Superintendent targeted questions related to safety and security, behavioral

health, behavior management, education, medical and many other areas of

facility operation.

III. Primary InterviewsA total of 7 youth were interviewed individually and more than 18 in groupsby unit (for a total of 25 youth) about a range of areas across the QI review

spectrum. This represented about 45% of the total population at Noyes thatweek. Interviews were also conducted with facility direct care, administration,

medical, behavioral health, case management and education staff. In addition,

9 staff were interviewed specifically about the target areas of the review aswell as their general feelings about the operation of the facility.

IV. Document ReviewDocuments were reviewed that were requested by the QI Team and provided

by the facility staff in support of facility operations and program services.

The documents included medical records, incident reports, logbooks, program

schedules, seclusion and suicide watch documentation, staffing reports,training records and statistical data, as well as other documents from areas in

fire safety and youth supervision.


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METHODOLOGY

(Continued)

V. Observations of Facility Operations Youth movement Structured programming Recreation Unit activities Shower time

Leisure Time Classroom Activities

VI. Review of Quality Improvement ReportThe facilitys previous QI Report was also reviewed to determine what areas

needing improvement at the last review were improved or were still in need of

attention.

VII. Exit ConferenceAn exit conference was not conducted at the facility due to scheduling

conflicts. A conference call of some key areas was conducted with the

Superintendent and Assistant Secretary of Residential Services that next week.


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SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY

INCIDENT REPORTING RATING: Partial Performance

STANDARDWritten policy, procedure and practice document that all incidents that involve youth

under the supervision of DJS employees, programs, or facilities, including those owned,

operated or contracted with DJS, are reported in detail and in accordance with

departmental guidelines.

SOURCES OF INFORMATION

84 Facility Incident Reports from October 2009-March 2010 Interview with Superintendent 98 youth grievances April 2009-March 2010 Staff Training Histories Report Interviews with youth Interviews with staff

REFERENCESDJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management(CPM) Techniques Policy (RF-02-07); DJS Video Taping of Incidents Policy (RF-05-

07); DJS Youth Grievance Policy (MGMT-01-07)

SUMMARY OF FINDINGS

Incident Report (IR) files did contain both written and electronic copies in mostcases however many electronic copies seem to have been added just before the QI

review indicating this filing system is not routine.

IRs are filled in entirely with few blank areas. Narrative portion includes all four parts and all four are completed. There were no instances found where a youth alleged child abuse and his case was

not referred to CPS as required.

IR type selected is not always appropriate (for example: a group disturbance isinstead listed as a youth-on-youth assault; an attempted escape is listed as only a

youth-on-staff assault; an assault is listed as inappropriate conduct; etc.)Consequently, the statistics in the IR database may not be accurate.

Description of use of force (when applicable) is not detailed and understandableand in many cases. Physical Restraint is not checked on the IR in many cases,even when clearly utilized.

Some narratives are complete and detailed (one could recreate event by readingthe narrative) but still many others give few details. This seems staff-dependent.


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Shift commander comments are present in most IRs; some are added late. Mostare not critiques.

Notifications sections are complete. Most youth witness statements are present. All staff witness statements are present. Nursing Report of Youth Injury forms (body sheets) are present for all youth inassaults or restraints. A photo is not attached of all youth involved in an assault or restraint. One sheet

indicated no film was available, others indicated that the nurse did not photograph

when a youth complained of injury as is required by policy.

GRIEVANCES

There were 98 youth grievances in the past 12 months at Noyes. The topcomplaints were as follows, in order: staff, points, clothing, phone calls, suppliesand programming not occurring as scheduled.

The Youth Advocate seems to pick up grievances timely and youth all said theyknew where to find and file grievance forms. Pencil availability seems to vary by

unit.

The high number of complaints about staff in grievances corresponds to youthindicating in QI interviews that staff do not speak to them very respectfully.

RECOMMENDATIONS

In order to reach Satisfactory Performance status in this area it is recommended that the

facility:

Retain administrative assistant support and train that person to be an IR Specialist.Other facilities have this staff and they are imperative for record-keeping and for

ensuring correct statistics are reported. Create a system whereby that staff entersIRs, has the authority to correct IR types, prints an electronic copy and files all

paperwork. This staff can also ensure audits are carried out and collect

documentation from staff.

Work with staff to improve detail and restraint information in IRs. Require seniorstaff to provide coverage for staff temporarily so that they have the time to write a

complete and thoughtful IR.

Require shift commanders to critique staff and fill in the shift commandercomment by the end of their shift.

Require shift commanders to ensure all incident type boxes on the front of the IRare checked properly before turning in the IR.


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SENIOR MANAGEMENT REVIEW RATING: Non Performance

STANDARDWritten policy, procedure and practice document that incident reports are reviewed and

critiqued by shift commanders and critical documentation, such as incident reports,suicide watch and seclusion paperwork, are routinely audited by senior managers within

DJS timelines and corrections are made by staff timely.


Review of 84 Incident Reports October 2009-March 2010 Interviews with staff Review of six OIG Investigations Review of seclusion documentation Review of suicide watch documentation Interview with the Superintendent and GLM I

REFERENCESDJS Policy MGMT-03-07 Incident Reporting Policy (MGMT-3-01); ACA 3-JDF-3B-10

and 3-JTS-3B-11

SUMMARY OF FINDINGS

Shift commander comments in incident reports (IRs) do not provide a critique tostaff nor specify any follow-up/corrective action to prevent another like incidentor address the current one. Shift commanders do not share their

comments/critiques with staff.

IRs are audited by senior manager within 72 hours in most cases. IR audit is thorough and catches most of the main areas needing correction except

for in the area of incident type (see Incident Reporting section for more on this

topic.)

Corrections are not always made by staff timely; due dates are often disregarded.When corrections do come back from staff, however, staff answer most of the

questions asked of them, though not all satisfactorily.

Seclusion Audit does not seem to be occurring at all. Two seclusions that didoccur were not listed in the seclusion log at all. Auditing of this process did notresult in the Administration being aware that youth are locked in early for

showers and after fights without seclusion documentation (see Seclusion section) Suicide Watch Audit is poor and sporadic; does not catch the main areas needing

correction and did not result in the Administration being aware that staff wereroutinely falsifying sheets on youth (see Documentation of Youth on Suicide

Watch section.)

Employee memos/corrective actions/discipline evidences little follow-up withstaff in suicide watch documentation.


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There is little administrative assistant support and the GLMs are responsible forpaperwork, database input and file organization that is better handled by a

Management Associate. GLMs consequently may not have the time they need to

provide solid middle manager oversight.

The Office of the Inspector General (OIG) completed six investigations, five ofwhich related to child abuse allegations. All were not sustained. One of the fivedid not sustain on what appeared to be a CPM technique not sanctioned by DJS.Though the restraint was not unsafe, it was not appropriate either. One of the

five missed a clear suicide watch violation when a staff left a youths side.

Neither OIG nor the facility administration caught this violation.

Overall, the senior management review should ensure that the facilitys practice isknown to be at high standards, that the management knows what staff are doing

and how they are performing and that preventive strategies are routinely shared.

RECOMMENDATIONS

In order to reach Satisfactory Performance status in this area it is recommended that thefacility:

Ensure staff at Noyes are skilled in auditing suicide and seclusion sheets. Ensureauditing occurs and results in change.

Implement solid and daily reviews of all important facility paperwork. Ensurethere is consistent (and daily if necessary) follow-up of practice.

QI has discussed the OIG investigation concerns with the Director of the OIG. Hire an Administrative Assistant to assist with filing and organizing paperwork

and following up with staff who miss due dates. This staff can also assist with

counseling memos, tracking of IRs, and inputting of IRs into the database (contact

with Human Resources indicates this position can now be provided to Noyes.) Require shift commanders to critique staff and to share their comments with staff

so that staff can learn from the management review. Ensure this is done the day of

the event so that memories are fresh and staff are encouraged to use this

information to prevent another such occurrence.

Ensure shift commanders understand the mechanics of a critique and know whatsupervision points to catch when they review an incident.


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DE-ESCALATION & RESTRAINT RATING: Partial Performance

STANDARDWritten policy, procedure and practice document the use of verbal crisis intervention

techniques to de-escalate a situation prior to the use of physical restraints. Physicalrestraints are used only when necessary and the least restrictive physical restraint is used

first. Incidents involving physical restraints are video taped.


84 Incident Reports from October 2009-March 2010 Facility training records on CPM and Verbal De-escalation Interview with Superintendent Interviews with youth Interviews with staff

REFERENCESDJS Incident Reporting Policy (MGMT-03-07); DJS Crisis Prevention Management

(CPM), Techniques Policy (RF-02-07); DJS Videotaping of Incidents Policy (RF-05-07);

ACA 1-SJD-3A-14-15

SUMMARY OF FINDINGS

Restraints are not documented clearly and in detail on IRs. The IRs did nottypically document a continuum of verbal and non-verbal interventions prior to

physical restraint; staff tended to react to a fight or incident already in progress.On a positive note, staff intervened via restraint preventing a fight in several

cases. Staff do not always use DJS-approved CPM techniques but they seem to attempt a

safe alternative when they cannot (such as when youth are fighting on theground.) Discussions were held with DJS Training Director around adding more

restraint techniques that can be used by staff in these scenarios.

When staff use something other than a CPM hold, they tended to call it a directtouch. A directive touch is not a restraint per DJS policy and even if used, must

be described so that it can be deduced what was actually done and if it wasappropriate (arm around youths waist, guide by shoulder, etc.)

Of the 28 staff who did not meet training class expectations, 15 of 28 (54%) weremissing Crisis Prevention and Management (CPM) training which is required

twice annually. Youth indicated several times in interviews that the way staff spoke to them was

the one area needing improvement. Some staff also agreed with this assessment

and indicated that relationships with youth are the foundation of de-escalation.

Two times staff were observed threatening youth with room time if they did notcomply with directives, even though room time is not allowable as a sanction per

DJS policy.


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Videos were not able to be reviewed on this visit due to time constraints. Whenthe video cameras were checked, there was one video camera found in Intake that

was not able to be turned on, possibly due to needing recharging. Currently, there

are two new video cameras; one in a GLMs office and the other in the

Superintendents office. These should be made more immediately accessible to

the four living units and their staff, especially when the managers doors arelocked. Of incident reports reviewed, only one indicated a video was taken.

Mechanical restraint documentation did not include who applied them, how, or ifthe youth complied or not. Also missing was the length of time in handcuffs and

shackles and which staff was constantly supervising the youth until he wasreleased. Therefore, compliance could not be established.

There was one IR that described a prone restraint on a bed. Though we understandprone positions sometimes occur as a result of a struggle, the length of time and

reason why this restraint occurred was not documented or justified. Seniormanagers did not detect/follow up on this case.

RECOMMENDATIONS

In order to reach Satisfactory Performance status, it is recommended that the facility:

Re-train and follow up with staff on descriptions of restraints in IRs. Ensure all staff document all aspects of mechanical restraint use in IRs. Some staff may require further training on how to de-escalate and relate to youth. Mounted video recording is strongly recommended in order for Noyes to better

comply with the DJS Videotaping of Incidents policy. If fixed cameras are not

planned in the near future, more handheld cameras should be ordered and used.


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CONTRABAND & ROOM SEARCHES RATING: Partial Performance

STANDARDWritten policy, procedure and practice document searches of rooms, youth and any

contraband found. Incident Reports are written for contraband found in accordance withDJS policy.


Unit Logbooks Facility Daily Room Condition Check Sheets Interview with staff and youth Observation at facility

REFERENCESDJS Searches Policy (RF-06-07); Incident Reporting policy (MGMT-03-07); ACA 1-

SJD-3A-16

SUMMARY OF FINDINGS

The facility maintains a Searches and Inspections FOP (#10) that addresses thefrequency of various searches throughout the facility. A review of the FOP

indicates that it is to be reviewed annually and it is due for re-review.

Rooms are documented as being searched at least once per day. Staff clearlyindicated to the QI team that they check for contraband when they do daily roomchecks using the Daily Room Condition sheet, even though the Administration

sees these as cleanliness/conditions checks. The FOP may need clarification so

that staff are on the same page as Administration.

Two staff indicated they are not given enough time to realistically search eachroom because doing so would leave youth unsupervised. There may be instances

where staff write appears free of contraband or graffiti due to not having time to

check the room thoroughly.

Room searches are not routinely documented in the appropriate units logbook asrequired. A staff member stated that room searches are only documented in the

logbook if contraband is found. All searches are required to be recorded.

Youth are not allowed pencils/pens in their rooms however they are present there. General areas are usually searched a minimum of once per day.

Youth are not routinely frisked upon movement from areas. The boys are friskedsearched less often than the girls.

Four incident reports were on file for contraband for the period of October 1,2009 to April 12, 2010. The recovered contraband consisted of a metal paint can

top that a youth was purportedly going to use as a weapon to facilitate an escape,

a small pin attached to a plastic pen cap, two metal forks, matches and currency.


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The sofas and chairs on Delta Unit have been ripped open exposing its foampadding and frame. The condition of the sofas and chairs is unsafe and provides a

potential hiding place for contraband.

During a tour of the facility, a member of the QI team found two inappropriatemovies (unrated versions of R movies) and two inappropriate books (gang-

related and sexually explicit). Youth on the Kappa Unit were observed playingMortal Kombat which is a violent (i.e. dismemberment, bloody, etc.) videogame.

RECOMMENDATIONS

In order to reach Satisfactory Performance status in this area, it is recommended that thefacility:

Review FOP to ensure procedures are current and appropriate. Require all room searches be accurately recorded in the appropriate logbook.

Ensure staff actually search carefully each room they record. Ensure staff conduct frisk searches upon all youth movements. Review IRs completed in the past several months to discover where contraband is

most typically found. Use this information to alert staff to spend extra time in

these areas when conducting searches.

Ensure that only G, PG, or PG-13 movies/DVDs and T for Teen video gamesare allowed. Disallow staff to bring in movies and games or require facility

approval and cataloguing if they do. Ensure case managers review carefully the

content of any materials brought in for youth.


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SECLUSION RATING: Non Performance

STANDARDWritten policy, practice and procedure provide that youth confined to a locked room, not

during sleeping hours, shall be observed often and have those observations documented,shall only be placed in seclusion if they present an imminent threat to others, a

substantial destruction to property or an imminent threat of escape, and shall be treated

humanely and with concern and care so as to safely maintain the youth until he can be

released in the least amount of time.


Facility Seclusion Log Interviews with Superintendent Incident Reports from October 2009-March 2010 Seclusion sheets Review of unit logbooks Interviews with youth Interviews with staff Observation at facility

REFERENCESDJS Seclusion Policy RF-01-07; COMAR 16.18.02

SUMMARY OF FINDINGS

The seclusion log was missing two seclusions that did occur and weredocumented on sheets.

There were just 24 total documented seclusions between October 2009 and March2010. The seclusions that were documented were relatively short, and averaged1.8 hours in length.

The seclusion sheets reviewed showed no evidence of management oversight orauditing.

Staff on two youths sheets wrote in times they were purportedly watching theyouth (appeared pre-timed) and the shift commander released the youth and wrote

error across the times that were pre-written in. This appears to be falsificationbut it did not elicit corrective action to the staff by the shift commander at the

time or at any later time. Youth are locked in for showers often before 7pm (6:30 is the most common

time). This is undocumented seclusion as it is not yet bedtime per the facility orper the schedule.

Youth are locked into rooms after incidents, sometimes for brief periods butsometimes for an hour or many hours depending on the unit which violates policy.

Youth on the boys units consistently reported that if they fight and it is after


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school, they can be locked in for the rest of the day. Youth on the girls units didnot report this occurring. Staff may be using locked door seclusion in violation of

policy in order to assert control or manage youth.

Two different staff on two occasions at the facility in front of a QI reviewerthreatened all youth with room time if they did not comply with directives.

RECOMMENDATIONS


facility:

Initiate immediate directives requiring zero shower lock-ins before 7pm.Showering should occur behind unlocked doors unless there is a safety threat.

Initiate a plan to educate staff on displaying seclusion sheets on youths doorsimmediately when youth are placed in a locked room. Require a call in to the

Tour Office for documentation in the Tour Office and Seclusion logs and

immediate authorization by an Administrator. Keep copies of seclusion sheets onevery unit.

Regularly tour units in the afternoons and evenings to assess compliance withseclusion policy.

Ask staff what struggles they might be having controlling the boys in their units toassess if they are using seclusion because they have few other options.


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PERIMETER CHECKS RATING: Satisfactory Performance

STANDARDWritten policy, procedure and practice provide daily security checks of the perimeter to

include, at a minimum: a check of all locks, windows, doors, fences, gates, securitylighting, security devices, and a check of outdoor areas, gates and security fences to

ensure they are secure, free from contraband and have not been tampered with.


Facility Tour Observation Logbooks and other documentation Interviews with staff

REFERENCES

DJS Perimeter Security Policy (RF-09-07), and Searches Policy (RF-06-07); ACA 3-JDF-3A-12, 2G-02, 3-JTS-3A-12 and 2G-02

SUMMARY OF FINDINGS

The facilitys practice is to inspect its perimeter three times a day. Anobservation of the perimeter did not reveal any breaches to the fence and gateswere locked.

There was a large amount of goose feces throughout the grounds of the facility.Since this could potentially become a safety and health hazard, the facility should

have a maintenance plan in place which includes the cleaning of paved areas and

investigation of ways to deter geese.

The facilitys front entrance is a controlled access point. The entrance consist aelectronically locking door to prevent unauthorized entry or exit. Visitors entering

the facility are checked-in/out at this location. Visitors are required to surrender

their personal keys and purses are not allowed into the secure area. All visitors areidentified by photo identification and required to fill out the visitors log

indicating name, arrival and departure times.

A review of the facilitys sign in/out log revealed some instances of visitors notsigning out of the facility at the conclusion of their visit.

It was noted that facilitys employees and other department personnel are notroutinely searched for contraband upon checking into the facility. Although

contraband may often enter a facility by many means, there should be assurances

that staff are not intentionally or inadvertently bringing contraband (i.e. R ratedmovies, metal eating utensils, etc.) into the facility via the front entrance.

Members of the QI Team observed one security door ajar as youth movement wasoccurring. Also, a janitors closet door was left open.


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RECOMMENDATIONS

In order to reach Superior Performance status in this area it is recommended that thefacility:

Ensure visitors sign out when leaving the facility so that their whereabouts can beaccounted for in the event of an emergency. Check purses, bags, and lunchboxes of visitors and staff upon entry.


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STAFFING RATING: Non Performance

STANDARDThe facility maintains a current staffing plan that ensures a sufficient number of trained

staff are present to provide an environment that is safe, secure and conducive to meetingthe recreational, educational and programming needs of the youth.


Facility listing of vacancies Review of the Staffing Pattern dated January 1, 2008 Review of Facility Logbooks Interview with Superintendent Observation of facility

REFERENCES

ACA 1-SJD-1C-03

SUMMARY OF FINDINGS

An official DJS Noyes staffing plan should be approved and implemented. Thisplan should allow for a 1:8 ratio for youth, adequate supervisory coverage, a TourOffice staff person, and rover staff (for emergencies, outdoor recreation coverage,

taking youth to Medical, intake processing, placement interviews, case

management/parent/attorney visits and relief coverage.) Currently, this level ofstaffing is not being achieved.

There are currently two staff members who are on medical leave from the facility. The two boys units were consistently out of ratio during the review, operating at

ratios of 1:10 for the duration of the review. A review of unit logbooks indicated

that this has been the case for months.

Logbook and staff interviews indicate that on the third shift staff members alsomaintain the units out of ratio. During the review there was one staff memberassigned with 19-20 youth, 4-5 of which were sleeping outside locked rooms in

the day room. This is unsafe.

Logbook review and staff member review indicated that on Saturday, April 17,2010 one female staff member was responsible for supervising youth on both theDelta and Omega units at the same time on third shift.

All staff indicated in interviews working several double shifts per week. This canlead to tired and unfocused staff.

Students are frequently allowed to work with school staff in the education roomwithout the supervision of direct care staff. Twelve students from all four units

were pulled together to work with a volunteer on April 14, 2010. Students cometo the unit every morning to be assessed without supervision. Students were

repeatedly observed with education staff in the classroom and gymnasium without

RA supervision.


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Nurses in Medical indicate youth are sometimes unsupervised by RA staff whenin Medical.

Staff members report that taking the Alpha and Kappa units outside is difficultbecause there needs to be at least three staff members in the courtyard toappropriately monitor the youth. Therefore, outdoor programming is impeded by

lack of staff. Youth on the Omega and Delta units reported that they are not able to attend

religious services at times because there are not enough staff members to

accommodate the students who do not wish to go.

RECOMMENDATIONS

In order to reach Satisfactory Performance in this area, it is recommended that the

facility:

Hire more staff. Recent indications from Human Resources are that Noyes hasbeen approved to hire more RA staff.

Do not leave youth unattended with Education staff with no RA present. Do not leave youth unattended in Medical with no RA staff present. Ensure staff work a limited number of double shifts and get sufficient rest. Shift commanders should go into unit coverage when there are not enough RAs to

run a unit at a 1:8 ratio. GLM IIs or Assistant Superintendents then should run thefloor if no Shift Commanders can do so in order to ensure adequate coverage.


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CONTROL OF KEYS, TOOLS RATING: Partial Performance

& ENVIRONMENTAL WEAPONS

STANDARD

Written policy, procedure and practice provide for the control of tools, keys andequipment that could be used as weapons or for other dangerous purposes. There is

system that ensures strict accountability of the receipt, usage, storage, inventory, and

removal of all toxic and caustic materials.


Facility Tour Interview with staff

REFEERENCESDJS Key Control Policy (RF-06-05), DJS Command Control Centers Policy (RF-09-05);

ACA 3-JDF-3A-22 and 3-JTS-3A-22

SUMMARY OF FINDINGS

Keys

A Key Control Post Order was not available for review. The facility has a designated Key Control Officer. The facility maintains a Working Key Board from which keys are issued on a

regular basis for the operation of the facility. For the most part, staff are issued

facility keys in exchange for a key chit. The key chit is substituted for the issuedkey set and a key sign in/out log is maintained for certain keys. The issuance and

return of certain keys is also documented in the Tour Offices logbook. It wasnoted that direct care staff exchange unit keys among themselves at their assignedpost. The exchanged is usually documented in the appropriate units log book.

Back up keys are maintained for each unit in the working keyboard.

There is a key inventory list located at the place where the keys are issued toensure staff members issuing/inventorying the keys have a current and accuratekey inventory list.

Keys are inventoried at least once a day and documented in the Tour Officelogbook. It was noted that the inventory does not account for the number of keys

that may be attached to a key ring. Though keys may be inventoried daily, a count

of the number of keys on one randomly selected key ring/set pursuant to policy.

The Key Control Officer is in the process of identifying all facility keys. Security keys are maintained on a metal key ring; however its not readily

apparent if the key sets joint is soldered/crimped because the joint is covered

with a piece of plastic. On one key set the plastic covering the joint is taped onto

the key ring.

Security/exit doors keys are not marked in a manner that would readily identifythe key by touch.


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The facility maintains a set of emergency keys in the Tour Office. A set of emergency keys are located at Headquarters in Baltimore City. It is

recommended that a set of keys be maintained at a location closer to the facility if

at all possible.

Highly Restricted keys should be issued only to authorized employees.Certainemployees have been identified to receive restricted keys.

A Back-up keyboard is maintained in a secured office. There is no master keyinventory list for the keys stored in the back-up key.

Interviews with staff and a tour of the facility revealed that some keys haddifficulty unlocking doors (i.e. bathrooms, closets, security doors, etc.). Themaintenance staff had repaired/exchanged some of the locks but the problem still

exists.

Tools, Environmental Weapons and Toxic and Caustic Materials

A maintenance staff was identified as the designated Tool Control Officer. Thefacility does not maintain a Tool Control FOP.

Tools are maintained in the Maintenance Room which is located outside of thehousing area. The Tool Control Officer maintains a master inventory list of thetools assigned to the facility. Certain tools are inscribed for identification

purposes and they are inventoried quarterly. There is a master inventory list for

the tools maintained at in the maintenance section. However, there is no sign-in/sign-out system to track the use of tools.

A tour of the facility revealed that environmental weapons such as brooms, mops,etc. are located in locked closets. On one occasion a closet containing brooms,

mops, buckets and cleaning liquids was observed open.

Hazardous substances (i.e. gasoline, paint, etc.) are stored at a location outside ofthe main building, and only the smallest amount of substances necessary for

operations is kept on hand.

RECOMMENDATIONS


facility:

Write a FOP for key control and one for Tool Control. The backup key board should be inventoried and a master inventory list

maintained.

Repair/replace locks and keys that do not function properly. Maintain a set of emergency keys at a location closer to the facility, if possible. Mark security doors keys in a manner that they can be readily identified by touch. Inventory all tools on a more regular basis (at least monthly) and document the

results of each inventory.


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YOUTH MOVEMENT & COUNTS RATING: Non Performance

STANDARDWritten policy, procedure and practice document a system for physically counting youth.

Youth movement is orderly and provides for identifying each youth movement and thespecific location of each youth at all times. Formal and informal headcounts are

conducted and documented in accordance with departmental guidelines. Emergency

counts are conducted and documented when necessary.


Facility Logbooks Interviews with staff Facility tour Observation of youth movement

REFERENCESDJS Youth Movement and Counts policy (RF-02-06); DJS Command Control CentersPolicy (RF-09-05); ACA 3-JDF-3A-13 & 14 and 3-JTS-3A-13 & 14, JDF-3A-22 and 3-

JTS-3A-22

SUMMARY OF FINDINGS

The facility maintains a Supervision and Movement of Youth FOP (#02). TheFOP should be reviewed annually to ensure it is current and appropriate.

The facility does not record counts in accordance with policy. The countsconducted by the facility are documented at various times by the Tour Office and

Intake.

The facility does not conduct counts, at a minimum, every 30 minutes orconsistently log counts in the appropriate units logbook and call them in to the

Tour Office. The facility appears to conduct counts every one to two hours and is

logged in a number of places. The Intake Unit routinely acquires counts from theunits at different intervals. Primarily, counts are conducted by Intake during the

1st and 2nd shifts on weekdays and the Tour Office takes over after 10pm and on

weekends.

An official count of all youth is required daily at 2:00 AM. The facility conductsan official count usually typically closer to 3am daily.

A tour of the facility revealed several instances where the male youth were slowto respond to the staff instructions to line up for movement. The male youth were

horse playing and not counting-off properly as directed by staff. One youth wasleft behind by staff due to staff not counting the youth themselves and allowing

youth to do so.


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Youth are left without an RA and unsupervised at Medical with the nurse. Youthare left unsupervised without an RA in education. Youth cannot be counted by the

posted RA if (s)he is not present to count the youth.

RECOMMENDATIONS

In order to reach Satisfactory Performance status in this area, it is recommended that the

facility:

Review the Youth Movement and Counts policy. Conduct counts at least every 30minutes and call them into the Tour Office and log each one there and in unit

logbooks.

Ensure strict accountability for youth at all times. Do not leave youthunsupervised in any area without a custody staff present.

Require staff to count youth as they leave an area rather than having youth countthemselves.


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FIRE SAFETY RATING: Partial Performance

STANDARDWritten policy, procedure and practice document the facilitys fire prevention and safety

precautions in accordance with departmental guidelines. Provisions for adequate fireprotection service provide for the availability of fire protection equipment at appropriate

locations throughout the facility and the control of all use and storage of flammable,

toxic, and caustic materials.


Facility Tour Interviews with staff Phone interview MD Deputy Fire Marshal Inspector Interview with the Assistant Facility Administrator Interviews with maintenance staff Review of Logbooks Examination of fire safety equipment

REFERENCESDJS Bomb Threat, Explosion and Suspicious Mail Policy (MGMT-3-01); ACA 3-JDF-

3B-05, ACA 3-JDF-3B-10 and 3-JTS-3B-11

SUMMARY OF FINDINGS

The facility maintenance staff was identified as the fire safety officer, responsiblefor coordinating fire prevention procedures and facilitating the inspection and

repairs to the facilitys fire safety systems.

A Maryland State Fire Marshals Office inspection was conducted on July 14,2009. The Fire Marshals report stated:

The facilitys fire alarm was tested by a private contractor on April30, 2009.

A new emergency generator is being installed throughout thebuilding and trailers.

In a supplement report, dated July 14, 2009, the fire marshal indicated that

sprinkler heads are to be installed in two offices in the education area and

extension cords removed in the game room. The facility had within 30

days of the inspection date to comply with the Fire Marshalsrequirements. No further violations were noted by the fire marshal and all

previous fire codes from 2007 had been abated.

A tour of the facility revealed that the facility did not comply with the fire

marshals requirement that sprinkler heads be installed in the two offices


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located in the Education area. Notwithstanding the fire marshalsrequirement, the offices continue to be used by school staff. It was noted

that youth do not occupy or utilize the offices cited by the fire marshal.

Interview with the maintenance staff revealed that sprinklers will not be

installed in the offices due to the cost of the installation. The decision notto install the sprinklers has not been communicated to the Fire MarshalsOffice. Therefore, the requirement cited by the Fire Marshal still needs to

be resolved.

Interview with the maintenance staff and observations made at the facilityrevealed that the extension cords cited by the fire marshal had been

removed.

A private vendor conducted an inspection of the facilitys sprinkler system onMay 26, 2009. The inspection cited insufficient clearance between storage and a

sprinkler deflector, a missing wrench, two bent heads in a unit, and head boxesneed to be mounted. Interviews with maintenance staff revealed that thedeficiencies had been corrected. However, there was no documentation available

to show when corrective action was completed.

Monthly internal inspections of the fire alarm and sprinkler system areconducted; however, the inspections are not documented.

The facilitys fire extinguishers yearly and monthly inspections are current. Arandom inspection of 8 fire extinguishers revealed that they are properly charged.A tour of the facility revealed that a fire extinguisher in Delta Units closet was

not mounted.

A sprinkler head in one unit and a ceiling vent in another are covered with dust.The dust should be removed to ensure the sprinkler and vent operates properly.

Egress plans are conspicuously posted and show the locations and directions tothe nearest exit(s). Exit signs were illuminated and emergency lighting

operational. Doorways were observed to be free of obstruction. Fire doors were

observed to be closed or equipped with a self-closing device.

The Fire alarm annunciation panel and the Fire Alarm Control Panel show poweron and no indication of system trouble.

A/S control value was secure. A stock of sprinkler heads and tools is maintainedin the vicinity of the sprinkler controls.

Interview with Maintenance staff revealed that the sprinklers, emergency lightingand other fire safety equipment is inspected monthly, but no documentation is

made of the inspections. Interviews with youth and staff along with a review of documentation revealed

that for the period of January 1, 2010 to March 31, 2010, each shift practiced one

fire drill per month.

The power generator is tested at least once a week and has a fuel supply thatexceeds 24 hours.

No flammable and hazardous chemicals were observed inside the facility.


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RECOMMENDATIONS


facility:

All efforts must be made to correct any deficiencies cited by the Fire Marshal. Ifa deficiency is not going to be corrected, that decision must be communicated to

the Fire Marshal for approval. All of this should be done in writing. If this is

done, the facility will be in Satisfactory Performance status.

Documentation of all corrective action efforts as a result of the Fire Marshaland/or private vendors inspection, as well as documentation of sprinkler andsafety equipment testing, should be kept and reviewed for follow-up.

Mount all fire extinguishers properly.


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POST ORDERS RATING: Partial Performance

STANDARDWritten policy, procedure, and practice provide post order for security post and key staff

positions. Staff members are familiar with roles and responsibilities of the post orderprior to assuming the post. Post orders are current. Shift commanders ensure that post

orders are reviewed by the staff member. Post order signature sheet is signed by the staff

assuming the post and initial by the immediate supervisor.


Facility Tour & Observation Interviews with staff

REFERENCESDJS Post Orders policy (RF-07-07); ACA 3-JDF-05, 3-JDF-3A-06, 3A-JDF-3A-07

SUMMARY OF FINDINGS

The facility maintains a Housing Unit Post Officer which describes the duties ofseveral staff positions/posts within the housing unit(s). The facility also maintainsa post order for the position of Unit Manager and Shift Commander.

The facility does not have a post order for the Key Control or Fire Safety officer. The facility does not have a post order for the Admissions/Intake section, Medical

Unit, Game Room, and Maintenance.

The Tour office maintains a post order book which contains Post Order FOP(#05), Housing Unit Staff Post 1A-4B, Unit Manager, and a Shift Commander

P.O. (#06). A random check of two units revealed the presence of a Housing Unitpost order on one unit.

A post order signature form was maintained with observed post ordersRECOMMENDATIONS


Develop post orders for Admissions/Intake section, Medical Unit, Game Room,Maintenance and special duty/assignment positions such as Key Control and Fire

Safety Officer.


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STAFF TRAINING RATING: Partial Performance

STANDARDWritten policy, procedure and practice provide that all staff who have regular and daily

contact with juveniles receive organized, planned and evaluated trainings in accordancewith departmental guidelines. Training is designed for continuous development of skills

related to job specific learning objectives.


DJS Training Histories report Interviews with staff Interview with Facility Training Coordinator List of mandated staff (did not include case managers or RA trainees)

REFERENCES

Maryland Correctional Training Commission (MCTC); ACA 1-SJD-1D-03, ACA3-JDF-1D-01, ACA JDF-1D-02

SUMMARY OF FINDINGS:

Half of staff indicated they were trained in CPM twice yearly, half indicated onceyearly. All staff should be aware that CPM is required twice yearly.

Most staff indicated CPM training did not teach them enough about real lifescenarios they have to deal with in the facility. Most indicated that they neededdifferent options to use in the kinds of situations they are faced with and that the

physical aspect of CPM needed to be more intense.

Mechanical restraints should be covered semi-annually in CPM training. Results of training are reflecting only training through March 25, 2010. There was

some indication that some staff trainings were conducted recently but were not

entered in the database yet. Since they were not in the Training Histories Reportthey could not be counted as being completed for this report.

Of 42 mandated staff:-- 27/42 (64%) met the 40 hour annual training hour

requirement in DJS policy for 2009

-- 8/42 (19%) had CPR/AED training since Oct 1, 2008

-- 14/42 (33%) had met required annual or semi-annual

training class expectations in DJS policy for 2009 (see below)

Of the 28 staff who did not meet training class expectations, the numbers missing the

trainings is broken down as follows:


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15/28 (54%) were missing Crisis Prevention and Management13/28 (46%) were missing Suicide Prevention

20/28 (71%) were missing Recognizing and Reporting Child Abuse and Neglect

RECOMMENDATIONS


Ensure annual training schedule is being met/followed and ensure all staffneeding required trainings are signed up immediately. CPR training is especially

important for meeting suicide prevention policy expectations as it is an

emergency first aid measure.

Ensure training information is timely entered in the Training Histories Report inorder to assess compliance.

Add mechanical restraints to CPM refreshers. In light of the fact that several staff were seen falsifying suicide watch checks, the

training class in this area may need further review to assess why staff seem to feelit is appropriate to write in a check during a time it is not occurring.

The names of staff not in compliance with policy requirements was furnished tofacility.


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ADMISSIONS, INTAKE & RATING: Partial Performance

STUDENT HANDBOOK

STANDARD

Written policy, procedure, and practice provide that the admissions process in eachdetention is operated on a 24 hour basis. The admissions process documents all required

elements of the admissions. Such required elements include the initial search of the

youth, verification of legal status, verification of basic identifying information, search of

ASSIST database to obtain all legal history, photograph of youth upon admission,

telephone call, student handbook, clothing and state issued items, and movement to the

unit.


Interviews with youth Interview with Superintendent Interview with intake staff Review of youth screening tools Review of youth medical files

REFERENCESAdmissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile DetentionFacilities; DJS Classification Policy in final editing stage; ACA 3-JDF-5A-02, 3-JTS-5A-

01, 5B-01 through 04 and 5B-07 & 08

SUMMARY OF FINDINGS

Intake packet contains all necessary paperwork including property forms, facesheet and consents.

Handbook is not provided to youth at intake/orientation nor do they have accessto one on the unit or in their rooms.

Intake staff interviewed indicated she offers to read the youth rules to youth inorder to account for youth who might be illiterate.

MAYSI is reported to be completed within two hours of admission. Intake staffinterviewed knew how to score the MAYSI. Intake staff indicated they looked atMAYSIs for all No answers and ensured youth re-took the test if this wasfound. However a file review of MAYSIs found some un-scored and with pages

missing. Proper and consistent completion may be staff-dependent.

SASSI is not completed within two hours of admission as required. Staff are not trained to administer or score the SASSI and substance abuse staff do

not provide this service within two hours of youth arrival.

FIRRST is completed upon youths arrival and custody is not taken until youthscreens negative on all questions.

A medical assessment is done upon admission, but in every case within 72 hours.


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RECOMMENDATIONS

In order to reach Satisfactory Performance status, the following is recommended:

Print handbooks and provide one to all youth at intake. Place a laminated copy of an updated student handbook on all units for easy

reference by youth.

Ensure SASSI is completed at intake and that intake staff are trained in how toscore or at a minimum scan SASSI results for youth who may be susceptible to

de-toxing while in custody. Medical staff may be helpful in this regard and shouldconfer with intake staff if results look suspect when on site.

Ensure substance abuse staff are timely aware of any youth who comes throughintake and screens for substance abuse on the SASSI.

Ensure MAYSIs are scored properly and that all staff are aware of how to scorethe MAYSIs and find warning signs. Ensure all pages of the MAYSI are

completed and filed in the youths medical file.


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CLASSIFICATION RATING: Non Performance

STANDARDWritten policy, procedure and practice document that youth are classified and assigned

housing according to standard criteria of risk, age, size, conduct, offense history, presentlegal charge and special needs


Interview with Intake Staff Review of Intake Packet Interviews with staff Observation at facility

REFERENCESMaryland Standards for Juvenile Detention Facilities: DJS Classification Policy RF-01-

08; ACA 3-JDF-5A-02, 3-JTS-5A-01, 5B-01 through 04 and 5B-07 & 08

SUMMARY OF FINDINGS

The Classification System FOP (#06) does not conform to the requirementsestablished by the Departments Classification policy. Department policy

requires that the FOP includes, but not be limited to identifying the specificemployee(s) responsible for conducting and completing Housing Classification

Assessments and Re-Assessments; reviewing ASSIST for prior DJS commitments

and placements, and inputting admissions data; reviewing the DJS IncidentDatabase for serious incident involvement; observing youth to determine if initial

classification level and housing assignment is meeting the needs of the youth; andestablishing protocols for housing and proper supervision of youth to ensure thatyouth are placed in a unit and room suitable to the youths classification level.

The facility does not utilize the DJS Housing Classification instrument toestablish a youths housing classification and supervision level.

The facilitys current classification practice is to assign youth to a particular unitbased on age, gender, physical stature, and prior/current criminal charges. Due to

the facilitys high population, no single rooms are available to house youth with a

history of sexual offenses. Therefore, youth entering the facility with a history ofsexual offenses are currently assigned to sleep in the dayroom.

Staff are not familiar with or utilize the Departments Classification process. Reclassification must be conducted in response to circumstances or special needs

that may require modification of housing assignments.The facility does not

utilize the DJS reclassification process.

An appropriate Housing Plan has not implemented pursuant to policy. Low,medium and high supervision rooms have not been established.


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RECOMMENDATIONS


facility:

Implement the Departments Classification system to ensure youth are housed andsupervised properly for safety. Rewrite classification FOP to comport with DJS Policy.


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PENDING PLACEMENT RATING: Not Rated

STANDARDWritten policy, procedure and practice document that the facility has a list of youth

pending placement, their days committed, and average length of stay and aggressivelyprioritizes these youth in order to assist the community case managers in placing them as

quickly as possible in order to reduce time in detention.


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BEHAVIOR MANAGEMENT RATING: Partial Performance

STANDARDWritten policy, procedure and practice document a behavior management system which

provides a system of rewards, privileges and consequences to encourage youth to fulfillfacility expectations and teach youth alternative pro-social behavior. Youth who are not

invested in the facilitys system have alternative and individual plans.


Review of Unit Log Books Review of Daily Point Sheets Interviews with youth Interviews with direct care staff Review of the Point and Level boards on the units

REFERENCESDJS Behavior Management Program Policy RF-10-07; Facility Behavior Management

Program (BMP)

SUMMARY OF FINDINGS

All youth interviewed were able to identify their levels and points. A review of daily individual point sheets indicated some mistakes in addition and

subtraction of points.

Each unit was missing numerous point sheets. There were 20 days since January1, 2010 where there were no daily point sheet totals for any unit in the facility. In

addition, the documenting of points in the unit log books was inconsistent.

Youth report that there are very few incentives offered at the facility. The abilityto earn additional telephone calls was frequently mentioned as the consistentincentive given. A later bedtime is also attached to the levels.

Youth indicated that program was not explained well to them. Youth are not givena written handbook with the BMP in it to be able to refer to and no copy of theprogram is posted in the units.

Five out of nine staff members interviewed indicated that they needed moretraining on the facilitys behavior management system


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STRUCTURED RATING: Non Performance

REHABILITATIVE PROGRAMMING

STANDARD

Written policy, procedure and practice document that youth receive planned, structuredoutdoor and indoor activities and regular needs-based rehabilitative programming that

teaches social skills.


Review of Review of Unit Log Books Review of the Master Schedule Review of calendar of Events Observations on the Unit Interviews with direct care staff Interviews with youth Interviews with two mental health Staff

REFERENCESDJS Recreational Activities Policy RF-08-07; ACA 3-JDF-5E-01-02-03-04

SUMMARY OF FINDINGS

Scheduled activities at the facility rarely occur according to the calendar. Staffand youth report that the youth have free time most weekdays from the time

school ends to bedtime and all weekend as well.

Youth receive at least one hour of indoor recreation per day. However, therecreation is almost never outside as required by policy, even on pleasant weather

days.

While the male residents are provided with barbering services, the femaleresidents are not provided with hair care services.

Youth are offered religious services, but there is no alternative for youth whochoose not to participate.

The facility is being providing some programming from Class Acts. It is limitedin its hours and works with one unit at a time. The programming observed seemed

of interest to the youth.

Direct care staff generally do not provide any programming or groups. One RAdoes provide a Book Club for the girls units.

Mental health staff are providing few groups. Around half of the youth surveyedin the mental health files showed youth received group intervention, but thegroups were mostly facilitated by the case manager. Most were not

psychotherapeutic.

Unit observation on four days yielded no observed structured activity beyondClass Acts on one day. Most of the time was spent watching television.


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RECOMMENDATIONS

In order to reach Satisfactory Performance in this area, it is recommended that thefacility:

Remove the schedules indicating programs that do not occur and replace themwith accurate schedules.

Ensure that youth receive recreation outside when weather permits. Encouragetwice daily weekend recreation and add structured games/tournaments.

Offer hair care/cutting services to the girls (comparable to the boys.) Offer an alternative activity to religious services, even if simnply arts and crafts. Add mental health groups such as ART or another relevant program. Encourage line staff to do morning groups focusing on a concept or principle.

Contact BCJJC Administration for that facilitys staff group curriculum.


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SELF ASSESSMENT RATING: Not Rated

STANDARDWritten policy, procedure and practice document that the facility superintendent at least

twice monthly meets with his or her management staff to assess the facilitys statusinvolving the use of seclusion, restraints, incident reporting numbers and procedures and

other key area of facility operation in order to assess the facilitys compliance with DJS

norms and expectations.


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BEHAVIORAL HEALTH

INTAKE, SCREENING& ASSESSMENT RATING: Partial Performance

STANDARDWritten policy, procedure, and practice require that all youth admitted to a facility will

be screened by a qualified mental health professional in a timely manner using valid and

reliable measures. All youth who screen positively for behavioral health issues will be

referred for a full mental health assessment by a mental health professional. All youth

who present at the facility with behavioral health issues that, as determined by

professional mental health assessment, are beyond the scope of what the facility can

safely treat, will be transferred to a setting that can more appropriately meet the youths

needs.


12 Youth medical charts Interviews with youth Interview with Intake Officer Interview with Case Manager Interview with RA Interview with Addictions Counselor Interview with Nurse Interview with Social Worker Interview with Psychologist and Psychiatrist Interview with Assistant Superintendent

REFERENCESDJS Suicide Policy (HC-1-07)

SUMMARY OF FINDINGS

Six charts were found to have the FIRRST assessments. Of the six, three werecompliant and were done at intake. Two were done in previous years, and one was

done on the youths previous, but not current, intake date.

Eighty-three percent of the reviewed charts had court orders. Sixty-seven percent of the SASSIs and ninety-two percent of the MAYSIs were in

the charts. However, the MAYSI was frequently not scored or completed. In oneinstance, the MAYSI did not indicate high risk, but the psychosocial laterindicated drug use by the youth. In another instance, the SASSI indicated high

risk for substance abuse, but no service was rendered to the youth. The SASSI

and MAYSI do not have to be redone if they were completed within the last thirtydays and copies are filed in the charts.


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Twenty-five percent of the charts had psychiatric notes completed. There were nofull scale psychiatric evaluations.

Only 16% of the charts had completed psycho-socials.RECOMMENDATIONS


Assure that the FIRRST assessment is completed at intake and before custody isaccepted in every case.

Complete a psycho-social assessment for every youth within two weeks afteradmission to determine treatment needs.

Assure the MAYSI is completed and scored at intake every time the youth isadmitted.

Assure that all Psychiatric notes are filed.


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INFORMED CONSENT RATING: Non Performance

STANDARDWritten policy, procedure, and practice requires that youth, and when appropriate, their

guardian, are informed of the risks, benefits, and side effects of medication and thepotential consequences of stopping medication abruptly. Youth are also notified that their

conversations with clinicians, though confidential, may be shared with DJS and the Court

if requested.


12 Youth medical charts Interview with Case Manager Interview with Nurse Interview with Social Worker Interview with Psychologist and Psychiatrist Interview with Assistant Superintendent

REFERENCESDJS Suicide Prevention Policy (HC-1-07), ACA 3-JDF-3E-04. 4C-27 & 28, 4C-35, 5A-

02, 3-JTS-4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR14.31.06.13.j

SUMMARY OF FINDINGS

Six of twelve charts examined had youth who were taking prescribed medication.Consents were in the charts for five (83%) of the six charts.

Only one of the six charts had consent for medication that adhered to theguidelines of informed consent. (Guidelines include points such as the medicationname, benefits, side effects, etc.)

Just 8% of the charts reviewed had an informed consent for mental healthtreatment.

Sixty-six percent (66%) of the charts had consents for substance abuse treatment. HIPAA disclosure of confidentiality was found in just 50% of the charts.


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RECOMMENDATIONS


Obtain a signed informed consent for each youth as soon as medication isprescribed and before administering the medication.

Consent forms should be fully completed with the medication name, dosages,benefits and the possible side effect before the consent is obtained.

Parent/Guardian/Caregiver must be informed on the benefits and risks associatedwith the medication the youth is prescribed.

Execute behavioral health consent for treatment as per HIPAA and 42 CFR Part IIregulations.


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PSYCHOTROPIC MEDICATION RATING: Satisfactory Performance

MANAGEMENT

STANDARD

Written policy, procedure, and practice require that psychotropic medications areprescribed, distributed, and monitored properly and safely.


12 Youth medical files Interview with youth Interview with Nurse Interview with Case Manager Observation at facility

REFERENCES

DJS Suicide Policy (HC-1-07), ACA 3-JDF-3E-04. 4C-27 & 28, 4C-35, 5A-02, 3-JTS-4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.j

SUMMARY OF FINDINGS

The six charts of the medicated males and females were examined. There wassufficient evidence that 100% of the medications were administered according toproper protocol.

Youth had documented psychiatric follow-up. There was just one mishap wherethe psychiatrist prescribed medication on 1/7/2010, but on 4/16/2010 it was not

transcribed and filled. The youth was, therefore, not medicated as prescribed. This

was the only error found in this area.

RECOMMENDATIONS

In order to reach Superior Performance status in this area it is recommended that the

facility:

Clearly correlate the psychiatric report for each child with the medication sheetsto ensure there are no mistakes in transcribing medications.

Ensure clear evidences of the documented response to the medication and the sideeffects.


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BEHAVIORAL HEALTH TREATMENT RATING: Partial Performance

& SERVICE DELIVERY

STANDARD

Written policy, procedure, and practice require that appropriate mental health andsubstance abuse treatment and emergency services are provided by qualified mental

health professionals and substance abuse counselors, that it is integrated with psychiatric

services when applicable, and that it is appropriate for the adolescent population. Crisis

intervention services should be available in acute incidents. All admitted youth should

receive alcohol and drug abuse prevention /education counseling. Family involvement

should be highly encouraged. Behavioral health issues should be considered when

providing safe housing for youth at the facility.


12 Youth medical files Interviews with youth Interview with Psychologist Interview with Addictions Counselor Interview with RA Interview with Social Worker Interview with Case Manager Observation at facility, including treatment meeting

REFERENCESDJS Suicide Policy (HC-1-07), ACA 3-JDF-3E-04. 4C-27 & 28, 4C-35, 5A-02, 3-JTS-4C-22, 4C-24, DJS Incident Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.j

SUMMARY OF FINDINGS

Fifty-eight percent (58%) of the charts reviewed showed youth received groupintervention. The groups were mostly facilitated by the case manager. Most of

the groups were not psychotherapeutic.

Only 41% of the charts showed evidence of individualized therapeutic contact.The mental health personnel who provided the contact varied (psychiatrist,psychologist, social worker, case manager.)

The documented quality of the contact was poor. No chart reviewed haddocumented substance abuse education. Sixteen percent (16%) of the chartsreviewed had youth who were at high risk for substance abuse.

No chart reviewed had documented family contact. No chart reviewed had documented community case manager contact.


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RECOMMENDATION


Implement biweekly mental health groups that are facilitated by the social worker. Conduct individual therapy with youth who would de

Comprehensive Quality Review Report Alfred D. Noyes Children's Center (MD 2010)

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