Comprehensive Quality Review Report Thomas J.S. Waxter Center (MD 2011)

7/31/2019 Comprehensive Quality Review Report Thomas J.S. Waxter Center (MD 2011)

1/86

OFFICE OF QUALITY IMPROVEMENT

Comprehensive Quality Review Report

Thomas J.S. Waxter Center

March 4, 2011


2/86

DJS QI Report Page i of 83

Waxter

March 2011


Quality Review Report


Evaluation Dates: February 2-4, 2011

TABLE OF CONTENTS

EXECUTIVE SUMMARY .............................................................................................. 1

Facility Strengths ............................................................................................................ 1QI Review Ratings Scale ................................................................................................ 2

QI Rating Percentage ...................................................................................................... 2

Executive Summary of Results ....................................................................................... 4Methodology ................................................................................................................... 5

SUMMARY OF FINDINGS & RECOMMENDATIONS............................................ 6

SAFETY AND SECURITY ............................................................................................. 6

Incident Reporting .......................................................................................................... 6Senior Management Review ........................................................................................... 9

De-Escalation & Restraint ............................................................................................ 11

Contraband & Room Searches ...................................................................................... 13Seclusion ....................................................................................................................... 15

Room Checks During Sleep Period .............................................................................. 17

Perimeter Checks .......................................................................................................... 19

Staffing .......................................................................................................................... 21Control of Keys, Tools & Environmental Weapons ..................................................... 23

Youth Movement & Counts .......................................................................................... 27

Fire Safety ..................................................................................................................... 29Post Orders .................................................................................................................... 32

Staff Training ................................................................................................................ 33

Admissions, Intake & Student Handbook ..................................................................... 34Classification................................................................................................................. 36

Pending Placement ........................................................................................................ 38

Behavior Management .................................................................................................. 39Structured Rehabilitative Programming ....................................................................... 42

Self Assessment ............................................................................................................ 44BEHAVIORAL HEALTH ............................................................................................. 45

Intake, Screening & Assessment ................................................................................... 45Informed Consent.......................................................................................................... 46

Psychotropic Medication Management......................................................................... 47

Behavioral Health Services & Treatment Delivery ...................................................... 48Treatment Planning ....................................................................................................... 49

Transition Planning ....................................................................................................... 50


3/86

DJS QI Report Page ii of 83

Waxter

March 2011




Evaluation Dates: February 2-4, 2011

TABLE OF CONTENTS(Continued)

SUICIDE PREVENTION .............................................................................................. 51

Documentation of Youth on Suicide Watch ................................................................. 51Environmental Hazards ................................................................................................. 53Clinical Care for Suicidal Youth................................................................................... 54

EDUCATION .................................................................................................................. 55

School Entry.................................................................................................................. 55Curriculum & Instruction .............................................................................................. 57

School Staffing & Professional Development .............................................................. 59

Screening & Identification ............................................................................................ 61Parent, Guardian & Surrogate Involvement .................................................................. 62

Individualized Education Programs .............................................................................. 63

Career Technology & Exploration Programs ............................................................... 64

Student Supervision ...................................................................................................... 65School Environment & Climate .................................................................................... 66

Student Transition ......................................................................................................... 68

MEDICAL CARE........................................................................................................... 69Health Care Inquiry Regarding Injury .......................................................................... 69

Health Assessment ........................................................................................................ 71

Medication Administration ........................................................................................... 74Dental Care ................................................................................................................... 77

Medical Records Retrieval ............................................................................................ 78

Special Needs Youth ..................................................................................................... 80Availability of Medical Services .................................................................................. 82


4/86

DJS QI Report Page 1 of 83

Waxter

March 2011




EXECUTIVE SUMMARY

A quality improvement assessment and evaluation of the Thomas J.S. Waxter Center wasconducted February 2-4, 2011 by DJS personnel who are subject-matter experts in the

areas reviewed. The areas that were evaluated have been identified as those having themost impact on the overall safety and security of youth and staff. The evaluation was

based on information gathered from multiple data sources such as staff interviews, youth

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

conditions.

FACILITY STRENGTHS

Many Waxter staff indicated, and it was evident from observation, that they are there forthe girls and are dedicated to their work there. Girls complimented staff and relayed

positive relationships with many of them. Handbooks with rules and information areroutinely distributed to all girls. Waxters staff and leadership have made an effort to make

the older facility brighter through paint and artwork. The units have a Jewel Room where

youth can play activity games on the electronic gaming system or read or draw. Seclusionand suicide watch practices have improved with better documentation and more

accountable supervision of at-risk girls. The mental health staffing is robust and counselors

take seriously their work with the girls.


5/86


Waxter

March 2011

QUALITY IMPROVEMENT REVIEW RATINGS SCALE

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

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

is incorporated sufficiently so that it has become routine, accepted

practice.

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 but

frequently 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._______________________________________________________________________________________________

At the last QI Review of BCJJC in January 2009, 45 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 of36 standards were evaluated with the following results:*

Rating # within rating % of total in rating

* 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 partialor non performance ratings as a result of QI reviews.

Superior Performance 0 0 %

Satisfactory Performance 14 31 %

Partial Performance 25 56 %

Non Performance 6 13 %

Superior Performance 0 0 %

Satisfactory Performance 12 33 %

Partial Performance 18 50 %

Non Performance 6 17 %


6/86


Waxter

March 2011

WAXTER PERFORMANCE COMPARISON

0%

10%

20%

30%

40%

50%

60%

1/8/09 3/4/11

Date of Report

Percentage

Superior Performance Satisfactory Performance Partial Performance Non Performance


7/86


Waxter

March 2011



Executive Summary of Results

SuperiorPerformance

Satisfactory Performance Partial Performance Non Performance

Seclusion

Youth Movement & Counts

Fire Safety

Admissions, Intake & Student

Handbook

Documentation of Youth onSuicide Watch

Environmental Hazards

Parent, Guardian, & Surrogate

Involvement

Individualized EducationPrograms

Student Supervision

Dental Care

Medical Records Retrieval

Special Needs Youth

Incident Reporting

De-Escalation & Restraint

Contraband & Room Searches

Room Checks During Sleep

Period

Perimeter Checks

Staffing

Control of Keys, Tools &Environmental Weapons

Staff Training

Structured Rehabilitative

Programming

School Entry

School Staffing & ProfessionalDevelopment

Screening & Identification

Career Technology & ExplorationPrograms

School Environment & Climate

Student Transition

Health Care Inquiry RegardingInjury

Medication Administration

Availability of Medical Services

Senior Management

Review

Post Orders

Classification

Behavior Management

Curriculum & Instruction

Health Assessment


8/86


Waxter

March 2011

OFFICE OF QUALITY IMPROVEMENTThomas J.S. Waxter Center

METHODOLOGY

I. Pre-EvaluationPrior to the evaluation, the facility received a document request list from theDJS Office of Quality Improvement. This list detailed various documents inthe areas of safety and security, medical care, suicide prevention 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 conducted

throughout the review with the Superintendent, GLM IIs and key leadershippersonnel. 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 Interviews

A total of nine youth were interviewed individually and many more in groups

about a range of areas across the QI review spectrum. This represented 26% ofthe total non-committed population at Waxter that week.Interviews were also

conducted with facility staff, administration, medical, case management and

education staff.In addition, ten staff were interviewed specifically about thetarget areas of the review as well 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.

V. Observations of Facility Operations Youth movement Structured programming Recreation and Medical Leisure Time and Unit activities 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 ofattention.

VII. Exit ConferenceAn exit conference was conducted by phone on February 7, 2011.


9/86


Waxter

March 2011

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

26 Facility Incident Reports from August 2010-February 2011 Youth grievances Review of 10 videotaped incidents Staff Training Histories Report 16 OIG investigations 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

The IR files in every case did not contain both written and electronic copies. Notall IRs had been entered into the database or entered on Waxters IR log.

IRs are filled in entirely with few blank areas. The most common blank areaswere in the notifications sections.

There were some unreported/underreported incidents discovered: two wereunreported restraints uncovered in OIG reports. 6 of 26 incidents (23%) were

labeled incorrectly leading to underreported incidents. For example: IRs labeled

inappropriate conduct were sometimes actually youth-on-youth assaults. A

youth-on-youth assault was actually a group disturbance (involved four youth).And a suicide related IR left out also contraband. Any misreporting, even if

unintentional, skews statistics in the IR database and leaves the facility unawareof the severity of what is actually occurring.

The narrative portion of the IR included all four parts and all four werecompleted.

Child abuse allegations were reported to CPS as required, however nursessometimes checked the incorrect boxes in this section.


10/86


Waxter

March 2011

Descriptions of uses of force were fair to poor. More on this is reported in the De-Escalation and Restraint section of this report.

Narratives were generally noted as fair to poor. It was difficult to get a sense forexactly how an incident started, occurred, and ended from the IR narrative. In

some, the descriptions of why a restraint or seclusion were justified or the extentof a youths aggression were important details left out by staff. Staff should be

encouraged to fully document all important aspects of each incident as if they are

telling a story. Most of the IRs contained shift commander (SC) comments but most were not

critiques. More on the quality of those comments is indicated in the next section

entitled Senior Management Review.

Detail on exactly where staff were posted was present in only 53% of the IRsreviewed.

7 of 15 (47%) of IRs reviewed had all youth witness statements present. 13 of 15 (87%) of the IRs had all staff witness statements present. Youth(s) were evaluated by the nurse for injury after incidents; however the body

sheets were not always attached to the incident reports.

GRIEVANCES

There were only 4 written youth grievances in the past 8 months at Waxter. Onewas about points being taken and 3 were child abuse allegations. The resolution of

these grievances was prompt and Advocates picked up grievances on averagewithin 1.5 days. The 3 allegations were properly reported to CPS and OIG.

An interview with one of the two Youth Advocates revealed that she and thesecond Advocate work hard to address youth concerns timely. There was some

concern youth who are disruptive receive few consequences for their behavior and

sometimes receive extra positive attention, leading to more disruptions. This

mirrors the QI findings in the Behavior Management Program section of thisreport.

7 of 9 youth said they knew where to find and file grievance forms and would doso if they had a complaint. All indicated they knew who the Advocate was. On a

walk through to check for stocked grievance forms, forms were stocked andaccessible.


11/86


Waxter

March 2011

RECOMMENDATIONS

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

Especially encourage staff to give full and complete details about the incident,including all actors, what each did or did not do. Ensure no vague words are used.Encourage them that when describing a restraint they did, to include youth

compliance, what was being said by all parties, whether the youth was calm, and

whether the restraint was successful and if not, why not. This kind of informationcan be used to assess whether further or different training is needed or to confirm

that staff did all they could in a difficult situation.

Through the senior management review process and through vigilance from SCs,ensure all incidents are reported properly and incident categories correct.

Retain witness statements from all youth present during the event. Require that staff indicate exactly where they and all youth were posted as the

incident commenced.

Require all notifications are made and to all relevant parties. Ensure body sheets are attached to all IRs including photos when applicable.


12/86


Waxter

March 2011

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.


26 Facility Incident Reports from August 2010-February 2011 Review of 10 videotaped incidents Interviews with staff Review of 16 OIG Investigations Review of seclusion documentation Review of suicide watch documentation Staff Training Histories Report

REFERENCESDJS Policy MGMT-03-07 Incident Reporting Policy (MGMT-3-01); ACA 3-JDF-3B-10and 3-JTS-3B-11

SUMMARY OF FINDINGS

Almost all of the IRs contained Shift Commander (SC) comments. Almost all SCcomments were not critiques of staff performance nor were they preventive in

nature (as is required). Also in one from January 19th, a SC added comments laterbut dated the comments the day the incident occurred.

SCs frequently commented on incidents in which they were involved. In order topromote objective critiques, this should move to another supervisor. Policy requires senior administrative review of incident reports within 72 hours (3

days); this is almost never accomplished timely.

Only 20% of the incidents are audited and many that were not were criticalincidents requiring administrative review within 72 hours. Significant problems inmany IRs therefore never saw facility follow-up.

Though Inappropriate Conduct incidents on their own are not required to beaudited currently per policy, the number reviewed by QI with sometimes

substantial issues in terms of either incorrect incident type (should have been

youth-on-youth assaults) or with numerous questions about staff supervision

should encourage the facility to audit these as well. Video review of an incident is only accomplished occasionally and is not thus far

a regular managerial review to assess staff performance.

Seclusion sheets showed no evidence of auditing in most cases. Suicide watch documentation is not audited. The Office of the Inspector General (OIG) completed 16 investigations in the past

year, 6 of which were sustained. Nearly all seemed to be thorough and gave a


13/86


Waxter

March 2011

good accounting of the facts and came to reasonable conclusions. One concern is

that OIG is remarking on valid supervision and other concerns and the facilitymanagers seemed to have missed or never commented on/followed up on. For

example: in OIG #10-85496, a youth became upset because her room was

changed from the dorm to a separate room with no explanation to her; it seemedsomewhat retaliatory in nature. This led to her becoming angry, an eventual

restraint and injuries. The Investigator rightly commented by way of a preventive

critique: there was no documentation to justify moving youth H out of thedorm. Upon reading the IR, this was something that should have beencommented on, and corrected by, the facility.

RECOMMENDATIONS

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

facility:

Require all shift commanders to critique staff and to share their comments withstaff so that staff can learn from the management review. Ensure all shift

commanders understand the mechanics of a critique and know what supervisionpoints to catch when they review an incident.

Ensure regular audits of suicide watch sheets. Ensure seclusion forms are audited along with the IR. See that Shift Commanders document on a video review tracking log when they

have reviewed a video and that a Video Reviewed Yes or No line is added toaudit sheets to document when senior managers review video.

Work with IT at DJS Headquarters to install software on a computer in Intake oranother convenient location for SCs so that they can easily review and playback

incidents with staff after they occur and coach staff on supervision techniques.

Begin auditing all IRs to ensure issues are spotted, preventive coaching isaccomplished and if necessary, discipline is accomplished. Assign all

Administrators equally so that the task is manageable.

The goal of senior management review is to prevent a similar occurrence andimprove staff skills. QI is available for technical assistance upon request.


14/86


Waxter

March 2011

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. Physical

restraints are used only when necessary and the least restrictive physical restraint is used

first. Incidents involving physical restraints are video taped.


26 Facility Incident Reports from August 2010-February 2011 Review of 10 videotaped incidents Staff Training Histories Report Interview with Superintendent Review of 16 OIG investigations 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

Descriptions of uses of force in written IRs were fair to poor. Vague statementslike youth was placed on bed or placed on floor give no indication of how theyouth was responding, what she said, how the staff placed the youth, in what

position, or what the staff were saying or physically doing. Safety cannot beassessed from the descriptions given.

Of the ten videos reviewed, one could not be viewed by the angle. Two showedno incident occurred (indicating that staff may not have correctly reported the

time of the incident.) One was reviewed and did not match the IR at all. Two did

not involve restraints. Four were viewed to assess the fidelity to the incidentreport version and to assess CPM technique.

One of the four showing restraints showed a solid and safe restraint. One was fair,with one staff properly holding the youth and another holding her wrist only. One

was good up until the youth was placed in her room: she fell down and the staffpulled her into her room by her arm. And the final restraint involved a staff

simply grabbing and pulling a youth by her shirt. Concerning was that in 30% of videos reviewed, there was no match of the

incident report to the video. Not only were times possibly incorrect (views werechecked for two hours surrounding two reported incident but could still not be

found) but in a third, staff reports of no assault were blatantly untrue when

viewed on video. Whole parts of the incident as written were missed when viewed


15/86


Waxter

March 2011

on video. Since videos are not routinely reviewed as a part of the senior

management review process, the facility is unaware of these issues.

Videos and IRs indicated that restraints are used in order to move youth for non-compliance which is not permitted by DJS policy or by COMAR. All staff should

know this is not permitted and have other options at their disposal.

Youth indicated that most staff are nice to them. However, there were a fewincidents where staffs language and statements seemed to escalate youth. Youth

witness statements and IRs showed clearly the staff statements escalating to ayouths eventual incident.

Just 9 of 30 staff (30%) were compliant with Crisis Prevention and Managementsemi-annual training (when reviewing CPM compliance overall, 73% had had

CPM at least once in the prior year.)

Just 3 of 10 staff knew CPM training was required twice yearly. 2 of 10 statedonce yearly and 5 of 10 did not know.

Mechanical restraints are not covered in training.RECOMMENDATIONS

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

Ensure all staff are trained twice yearly in CPM, including mechanical restraints. Ensure all staff are aware that moving a youth for non-compliance is not

permitted by DJS policy or by COMAR. Ensure they have other methods they can

apply in these situations and that this use of restraint is not tolerated bymanagement.

Require SCs only turn in IRs that have full and complete restraint detail from linestaff and that they review video to ensure it is accurate.

Ensure regular video review of all seclusions, restraints, assaults of any kind andinappropriate conduct to ensure staff response is appropriate and to catch issues asthey arise.

Ensure staff understand the basics of de-escalating speech. Certain girls may betriggered by certain statements. If staff are coached on de-escalation, they may be

able to prevent the youth from becoming upset in the first place. Management

should ensure youth witness statements are included in IR reviews and addressstaff when they seem to have chosen poorly when dealing with the youth.


16/86


Waxter

March 2011

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 with

DJS policy.


Unit and Master Control Logbooks Facility documents Interview with staff Observation at the 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 FOP titled Searches (dated: 2/28/2005) that outlinesvarious search procedures to be carried out at the facility. Further, the FOP

indicates that shakedowns are to be completed daily and documented in the

appropriate unit and/or Tour Offices logbook.

An interview with a Group Life Manager revealed that room and general areasearches were not consistently carried out or documented during the period beingreviewed. However, the practice has been re-implemented within the past month.

An interview with a Shift Commander revealed a new form was developed abouta month ago to document the room and general area searches.

The facility provided a small number of room search documentation (i.e. January2011) for the period that is being reviewed. The available documentationrevealed that staff recovered various contraband items, such as a 6 pack of soap,

12 magic markers, and pencils during the room searches.

Room searches were not consistently documented in unit log books. 4 of 9 staff indicated that room searches occur on every shift. 3 of 9 staff indicated that room searches are conducted daily. 2 of 9 staff indicated that room searches occur once or twice a week. 6 of 9 staff believe they are not given enough time and an adequate number of

staff to properly conduct room searches.

A QI team member conducted a shakedown of two randomly selected rooms in BUnit. Snacks were found in one room. Both rooms have graffiti written on the

walls. A review of maintenance records revealed that a work order has been

submitted to have the walls painted.

An observation made in C Units dorm revealed paint peeled from a large area ofthe wall located next to a youths bed. Further, some walls contain blotches of a

white substance.


17/86


Waxter

March 2011

Interviews with Master Control staff revealed that the metal detectors are notroutinely used to search visitors/employees entering the facility. Staff believes

that the walkthrough metal detector is unplugged. Staff were not sure if thefacility has any handheld metal detectors (wands). Two handheld wands were

located in a closet, both were inoperative. Regularly conducted searches of

visitors/employees entering a facility are essential to assuring the safety of youthand employees.

During a tour of the facility, several pencils were observed on tables and chairs inthe two units. A staff was observed accounting for the number of pencils that

were given to a youth to sharpen. Pencils should be secured to prevent anunpredictable youth from using a pencil as a sharp (pointed) weapon.

Observations made of several youth movements from the school revealed theywere frisked upon movement. However, two of three observations made of youth

moving from the cafenasium revealed that they were not frisked.

A review of the DJS database for the period of January 1, 2010 to February 3,2011, revealed that staff reported 21 incidents involving the recovering ofcontraband. The incident reports indicated that staff recovered an array of

contraband (i.e. cell phone and charger, scissors, pills, a vial of blood, lighter,

markers, currency, I Pod, pregnancy test kits, and etc.) from within the facility.

RECOMMENDATIONS

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

Have Shift Commanders regularly verify that room and general area searches aredocumented on the facilitys Shakedown Sheets and in the appropriate logbooks.

Ensure that supporting documentation (i.e. Shakedown forms) regarding facilitypractices are maintained. Ensure staff are familiar with the facilitys room searchpolicy and procedures.

Staff should ensure pencils are secured and regularly inventoried to preventmisuse by youth.

Ensure staff frisk search youth upon every movement from areas that may containcontraband items.

Ensure the appropriate staff are familiar with the operation of the walkthroughand handheld metal detectors. Ensure staff and visitors are wanded.

Remove/paint over the graffiti on walls in the sleeping areas.


18/86


Waxter

March 2011

SECLUSION RATING: Satisfactory 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 or an

imminent threat of escape, and shall be treated humanely and with concern and care soas to safely maintain the youth until he can be released in the least amount of time.


Facility Seclusion Log Interview with Superintendent Incident Reports from August 2010-Feb 2011 Seclusion sheets Interviews with youth and staff Observation at facility

Videotaped incidents resulting in seclusion

REFERENCESDJS Seclusion Policy RF-01-07; COMAR 16.18.02

SUMMARY OF FINDINGS

Documented seclusions at Waxter are as follows:Month # of seclusions Average Daily Pop* Rate

August 1 33 0.10September 0 34 0.00October 1 35 0.09

November 10 34 0.98

December 3 28 0.35

January 9 29 1.00

* Only includes Waxters detained population

The average length of stay in seclusion is short. For the month of August 2010,the stay averaged 1.65 hours.

Eleven (11) documented episodes of seclusion were reviewed. Checks on thesheets by line staff showed few concerns, but often the youth was in her room forvery short periods of time (22 minutes, 50 minutes) resulting in only 2-6 checks to

review.

In 1 of 11 there was a discernable pattern (ending in 9s); in 1 of 11 there was one15 minute gap; in 1 of 11 staff noted blocked window but did not documentwhat they did about this; in 1 of 11, all codes by staff were incorrect or confusing.


19/86


Waxter

March 2011

Codes for standing in hall, attempting to attack peer, showering, and being

escorted to room were all codes listed by the line staff but all appear to show ayouth not secluded at all. This may have been one staffs error and it was the only

sheet of 11 that displayed this issue. In 1 of 11, the youth was still agitated and

could not be released at bedtime, but staff ceased seclusion procedures.

There was no documented auditing of the seclusion log or observation sheets sothe issue in the few sheets noted above were not caught by the facility.

The shift commander (SC) comments (reasons for youth not being released fromseclusion) were fair. Imminent threat to others is not a justification without

more and was seen in use by some SCs. In 1 off 11 the SC noted eating nowcalm at 6:30 but the youth was not released until 7:30. In 1 of 11, the SC wrote

the time (4:30) of her check but nothing further.

The facility requires senior administrative approval of seclusion use. In nearly every documented case, medical staff appropriately documented

observations.

In every documented case, shift commanders visited the youth and made checkstimely.

The Seclusion Log sometimes had start and end times of seclusion and otherpertinent information missing.

Youth seemed to be individually processed and not all released at one time, anindicator that seclusion is not being used as punishment.

In two videos, the youth belongings were tossed out of the room prior to herescort in. In one, her blanket and pillow were a part of those belongings and thesehave to remain inside the room unless justified in writing.

Seclusion use for lack of staff (staff shortages) was not documented in theseclusion log. It could not be determined if youth are secluded when there are not

enough staff to meet ratios.

The use of early bed violates DJS seclusion policy. There were no indicationsfrom youth or staff that early bedtime was given to the detained population.

RECOMMENDATIONS

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

Ensure that the auditing process includes seclusion sheets and the seclusion log ifa seclusion episode occurs.

Institute random video review of any seclusions monthly to ensure staff checksare happening as expected and that staff are not putting youth mattresses, pillows

or blankets outside of the youths room. Do not remove youths blankets, pillow or mattress when a youth is secluded

unless there is written justification for doing so.

Track seclusion lengths of stay by rate and ensure all Administrators are aware ofseclusion patterns and any burgeoning overuse.


20/86


Waxter

March 2011

ROOM CHECKS DURING RATING: Partial Performance

SLEEP PERIOD

STANDARDWritten policy, procedure and practice document that staff visually check the safety and

security of each youth at least every 30 minutes during the sleep period, unless instructed

to check more often due to the status of the youth. Room checks during sleep period,document the youths name and the time the check was conducted


Interviews with staff Logbooks Sleep Observation Sheets Video recordings

REFERENCESACA 3-JDF-3A-04 and 3-JTS-3A-04

SUMMARY OF FINDINGS

The facility maintains a FOP titled Movement and Supervision of Youth thatoutlines the procedure for documenting visual checks on the Sleep Observation

Sheets. The FOP indicates that a visual check is to be made of each youth every30 minutes during the sleep period.

The facility produced a sufficient number of Sleep Observation Sheets to suggestthat room checks are routinely practiced. However, the Sleep Observation Sheets

contain pre-printed time checks (i.e. 30 minutes intervals) for recording each

visual check. The use of pre-printed times on sheets does not accurately reflectthe exact time a youth was observed.

Randomly selected video recordings from the facilitys video surveillance system(B Unit), from December 30, 2010 to February 2, 2011, were reviewed to assess

the level of performance by staff conducting room checks. The followingobservations were noted:

o 12/30/2010 - A staff was observed conducting room checks anddocumenting the checks. The observation sheets appeared to be posted onthe wall at each room.

o 1/8/2011 - A staff was observed conducting room checks and documentingthe checks. The observation sheets appeared to be posted on the wall at

each room.o 1/16/2011 - A staff was observed conducting room checks and

documenting the checks. The observation sheets appeared to be posted on

the wall at each room.

o 1/30/2011 - Observation Sheets were not posted throughout the sleepperiod.


21/86


Waxter

March 2011

o 2/1/2011 - No staff were observed conducting room checks for at least atwo hour period. Observation Sheets were not posted throughout the sleepperiod.

Many of the facilitys Sleep Observation sheets contain a supervisors check thatis written in the margin of the sheets.

RECOMMENDATIONS

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

facility:

Stop using the Sleep Observations Sheets that contain pre-printed time checks.Write in the exact time of the check. Staff should attempt to randomize checks so

as not to fall into a recognizable pattern.

Supervisors should randomly review video recordings of the sleep period toensure staff are conducting checks as required by policy.


22/86


23/86


24/86


25/86


Waxter

March 2011

RECOMMENDATIONS

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

facility:

Review the current staffing pattern to determine the additional staff that areneeded.

Continue to recruit to fill all available vacant residential staff PINS. Ensure staff ask for assistance if they find themselves with more than 8 youth

alone.


26/86


Waxter

March 2011

CONTROL OF KEYS, TOOLS RATING: Partial Performance

& ENVIRONMENTAL WEAPONS

STANDARDWritten policy, procedure and practice provide for the control of tools, keys and

equipment that could be used as weapons or for other dangerous purposes. There is

system that ensures strict accountability of the receipt, usage, storage, inventory, andremoval of all toxic and caustic materials.


Facility Tour Interview with staff Logbooks and other documents

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

The facility maintains a FOP titled Key Control (#10-008) that outlines thefacilitys key control procedures. The key control policy, in part, requires that

incoming employees receive facility keys in exchange for a chit.

Interviews with staff and observations made of the key control process revealedthat facility keys are not exchanged for a chit as pursuant to DJS policy and the

FOP. Facility employees exchange their personal keys for facility keys.Interviews with staff revealed that if an employee does not have a personal key toexchange for a facility key(s), an administrative chit is to be issued to the

employee and exchanged for a facility key.

Interviews with staff revealed that there is not a designated Key Control Officerand post order for the position. Master Control staff and a maintenance workerare performing several of the tasks associated with managing the key control

system (i.e. maintaining keyboards, issuing and inventorying keys, etc.)

On two occasions, staff working in Master Control gave facility keys to twovisitors from DJS before obtaining their identification, personal keys and the

nature of their business at the facility. On two other occasions, visitors were

asked for personal keys but not for identification. DJS policy requires that a roster of the names of employees and their assigned

chit be maintained at the location where the keys are issued. The facility does not

maintain a roster of employees and their assigned chit. Currently, the name of an

employee is written on a piece of tape that is placed over a key sets hooknumber. The aforementioned procedure is use to identify the staff that is to be


27/86


Waxter

March 2011

issued that particular key set/ring. The name of a previous employee is still taped

over a key set hook/number.

Observations made of Master Control logbooks revealed that the name of eachstaff retrieving and returning keys is recorded. Also, the name of employees

retrieving and returning keys is documented on the Staff Daily Sign-in/out Sheet.

The posted key inventory list does not match the keys in the keyboard. At minimum, DJS policy requires that the number of keys on one key ring be

counted each working day and the count documented in the facility logbook. Theinventorying of keys is not documented but visually carried out during each shift.

Emergency key rings are not readily identifiable and grouped separately from theregularly issued keys (this procedure would permit ready identification of the

emergency keys and allow access to any part of the facility in the event of an

emergency.) However, staff indicated that the Shift Commanders have a key(s)that would facilitate the evacuation from all parts of the facility.

Interview with the maintenance worker revealed that a set of emergency keys arenot maintained at a secure location away from but near the facility as pursuant to

DJS policy.

Pursuant to DJS policy, every hook in the Working Keyboard is to be filled at alltimes with either a chit or a set of facility keys so that at a glance a missing keyset can be readily detected. An observation of the Working Keyboard revealed

that key hooks #10, #16 and #47 were vacant. Staff indicated that the personal

keys of the staff issued keysets #10, #16 and #47 were placed in another box.

Facility keys were observed maintained on a metallic key ring soldered/crimpedat the joint to prevent tampering, loss or removal as pursuant to DJS policy.

Eight staff are issued facility keys on a 24 hour basis. Once the facility has beenre-keyed, only three staff will be allowed to possess keys on a 24 hour basis.

A review of the DJS incident reporting database revealed two incidents involvingkeys not securely carried by staff. During a restraint incident (#88124, 1/11/11),

the keys fell out of staffs pockets and a youth retrieved them. The keys werelater found during a search of the youth. In another incident a Shift Commander

found a set of facility keys in a courtyard. The staff who lost the key did not

officially report the keys missing for about 2 hours.

A review of the DJS incident reporting database further revealed that the facilityreported a few incidents, such as three broken keys, a blood draw drawer key

missing and paint chips jammed in a lock.

Interview with a maintenance worker, along with observations made of facilitykeys, revealed that some keys are notched so that they can be identified by touch.

These keys facilitate the prompt release of youth from locked areas in an

emergency situation.

The facility maintains a Back-up Key Board in a secured location as pursuant topolicy.

A review of Master Controls logbook, along with observations made, revealedthat staff routinely turn-in their facility keys when going on break outside of the

perimeter/grounds of the facility.

Interview with a maintenance worker revealed that the facility will be re-keyedand a new key control process implemented in the near future.


28/86


Waxter

March 2011

TOOLS

Interview with a maintenance worker revealed that the facility is in the process ofdeveloping a master inventory list for the tools located at the facility.

The facility has not identified a Tool Control Officer or implemented a post orderfor the position.

Currently, the maintenance section does not maintain a sign-in/sign-out log fortools.

Interviews with staff revealed that some employees bring personal tools (i.e.drills, screwdrivers, and etc.) in the secured area of the facility for the purpose of

assembling furniture (i.e. book shelves).

Interviews with staff and observations of the maintenance area revealed thatcertain tools have been engraved with the letter W for identification purposes.

Tools are stored at a location outside of the housing/secured area of the facility.Tools are secured in containers (i.e. drawers and cabinets) within the maintenance

section.

The facility maintains only the smallest amount of any materials (i.e. paint,gasoline and etc.) for use. Such items are stored in areas outside of the securedarea of the facility.

KNIVES and UTENSILS

Observations made of the food service area revealed that potentially dangerousutensils (i.e. knives, etc.) are kept in a locked cabinet in the Food Service area.

Utensils are inventoried three times a day to ensure they are accounted for.However, utensils are not signed for by staff when retrieved or returned to the

cabinet. Culinary utensils (i.e. knives, etc.) are not marked for identification

purposes.

The Food Services area maintains MSDSs for chemicals used in the kitchen area.All chemicals are secured in a closet.

ENVIRONMENTAL WEAPONS

Several pencils were observed openly throughout both units. In an incident, a youth attempted to open the unit door by sticking a broom handle

through the cage area to activate the electronic door switch. Broom and mops

should be properly secured and controlled to prevent their use in facilitating an

assault or as a tool to attempt an escape.

Observations made of the Intake area revealed a cup of urine in a trash can. Also,a review of the incident reporting database revealed an incident (#84478) that

involved a stolen vial of blood found in a living area. To minimize thetransmission of any communicable diseases, staff should ensure bodily fluids are

handled in accordance to DJS Handling/Disposing of Contaminated Medical

Waste policy.


29/86


Waxter

March 2011

RECOMMENDATIONS


facility:

Assign each employee a chit to be exchange for facility keys, as pursuant to DJSKey Control policy.

Ensure that the key inventory list matches the keys is the Working Keyboard andis maintained near the keyboard. The key inventory list for the Working Keyboard

should be updated as changes are made.

Designate a Key Control Officer to be responsible for the storage and inventory offacility keys, as pursuant to DJS policy.

Write a Post Order for the Key Control Officer. Ensure each staff working in Master Control reads and understands the Key

Control FOP prior to issuing and retrieving facility keys.

Maintain a list of the names of employees and their assigned chit number at thelocation where keys are issued.

Complete the process of re-keying the facility and implementing the new keycontrol process as soon as possible.

Ensure keys are at inventoried as pursuant to DJS policy. Ensure staff are train to securely carry keys in their possession and promptly

report any missing/lost facility keys.

Emergency keys should be grouped separately from the regularly issued keys inthe keyboard to permit quick identification to allow access throughout the facilityin the event of an emergency.

Ensure that a set of emergency keys are maintained at a secure location away, butnear the facility.

To enhance facility security and maintain accountability for keys, reduce thenumber of staff possessing facility keys on a 24 hour basis.

Designate a Tool Control Officer to be responsible for the storage and inventoryof facility tools and equipment.

Write a Post order for the Tool Control Officer. Do not allow staff to bring personal tools (i.e. drills, screwdrivers, pliers, and etc.)

in the facility without proper authorization.

The Maintenance and Food Service sections should maintain a sign-in/sign-outlog for tools and culinary utensils, respectively.

Culinary utensils should be marked for identification purposes.


30/86


Waxter

March 2011

YOUTH MOVEMENT RATING: Satisfactory Performance

& COUNTS

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

Youth movement is orderly and provides for identifying each youth movement and the

specific location of each youth at all times. Formal and informal headcounts areconducted 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 Centers

Policy (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 FOPs titled Physical Count and Movement and Supervisionof Youth that outline the facility count and supervision of youth procedures.

The FOP indicates that an informal count is to be taken of youth every 30minutes. Further, an official count is to occur daily at 12am, 3am, 6am, 9am,

12pm, 3pm, 6pm and 9pm. Official counts should total no less than 8 officialcounts daily.

A review of randomly selected dates from Master Control logbooks revealed thefollowing official counts per FOP:

o November 3, 2010, at 1:18pm to November 4, 2010, at 8am. No counts orinformation recorded. No explanation for the lapse of information wascited.

o November 4, 2010, no counts recorded during the 1st shift.o December 14, 2010, 2 counts during the 1st shift.o December 14, 2010, 8 counts during the 2nd shift.o December 15, 2010, 7 counts during the 3rd shift.o

December 15, 2010, 5 counts during the 1

st

shift.o December 16, 2010, 6 counts during the 3rd shift.o January 3, 2011, 3 counts during the 1st shift.

A review of randomly selected dates in unit logbooks revealed instances of countsoccurring about every 45 minutes during the 1st and 2nd shifts. Some 3rd shifts

recorded a count and check of youth every 15 to 60 minutes.


31/86


Waxter

March 2011

4 staff interviewed indicated that informal counts are taken every 30 minutes andrecorded in the unit log book. Further, informal counts are taken every 15 minutes

during outside recreation. 2 of 4 staff indicated that the informal count is calledinto Master Control.

DJS policy requires that counts recorded in a logbook reveal the time of the count,the count itself, the name of the staff performing the count, location of the youth

group and those outside the location where the count is occurring. A review of a

unit logbook revealed that staff not did indicate the name of the staff performingthe count. A few entries in the Master Control logbook did not reveal the actual

count itself.

A review of facility logbooks revealed that an official count was taken of allyouth in the facility at about 2am, as pursuant to DJS policy.

As part of the counting process, the facility maintains a tally of the youth arrivingand departing the facility as pursuant to DJS policy.

A review of the facility documents revealed that an emergency count is conductedin the event of a discrepancy in a count, as pursuant to DJS policy.

Several observations made at the school revealed that youth were frisked uponeach movement from the school. However, two of three observations made of

youth in the cafenasium revealed that the youth were not frisked upon movement.

A review of unit and Master Control logbooks revealed that the facility generallyidentifies each youth movement and indicates the specific location of each youth

at all times.

Youth taken from and returned to a location is recorded in the unit log books. Observed group movements were usually orderly and under staff supervision

however youth are counting themselves, which is not optimum practice and isagainst DJS policy, and often a shift commander has to be the one to provide the

orderly movement.

RECOMMENDATIONS

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

facility:

Ensure Shift Commanders verify that every count and the result is individuallyrecorded in the applicable logbook(s) and accurately reflect the number of youth

and staff present as well as the name(s) of staff performing the count; the locationof groups of youth (library, class, outside area); and youth outside of the location

where the count is occurring.

Ensure all staff receive training regarding the counting process to includerefresher training.

Ensure youth do not count themselves but that staff count them. Youth may notparticipate in counts according to policy.


32/86


Waxter

March 2011

FIRE SAFETY RATING: Satisfactory Performance

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

precautions in accordance with departmental guidelines. Provisions for adequate fire

protection service provide for the availability of fire protection equipment at appropriate

locations throughout the facility and the control of all use and storage of flammable,toxic, and caustic materials.


Facility Tour Interviews with staff 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

Interviews with a Group Life Manager and maintenance worker revealed that thefacility has a designated Fire Safety Officer. However, the Fire Safety Officer

was not available during the QI review.

The facility did not have a Post Order for the position of Fire Safety Officer. A State Deputy Fire Marshal inspected the facility on 1/19/11. The inspection by

the State Deputy Fire Marshal cited several violations that needed to be corrected,such as a missing smoke detector in the kitchen, a wall plate needed over an

electrical outlet, and a semi-annual testing/maintenance needed for the hood fireextinguisher system in the kitchen. The violations cited by the State Deputy Fire

Marshal appear to have been corrected as of 2/2/11.

The facilitys fire alarm system and sprinkler system were last inspected/tested onOctober 19, 2010, and November 4, 2010, respectively. A review of repairdocuments revealed that noted deficiencies were corrected.

A review of the facilitys fire drill reports for B and C Units revealed that firedrills were conducted on the following dates between August 2010 and January

2011:

o August 16, 17, 22, and 24, 2010. All three shifts documented a fire drillfor the month.o September 27, 2010. One fire drill reportedly occurred during the 1st shift.o October 2010. No fire drills reported.o November 23 and 24, 2010. Two fire drills occurred on the 24th. All three

shifts documented a fire drill.


33/86


Waxter

March 2011

o December 15 and 17, 2010. No record of the 2nd shift conducting a firedrill. Six youth (B unit) refused to get out of bed and participate in amorning fire drill.

o January 14 and 31, 2011. On the morning of the 14th, 6 youth (B unit)remained in bed during the fire drill.

Five randomly selected fire drill reports were cross-referenced with the MasterControls logbook(s) to access the level of compliance with documenting events.

Two of the five reported fire drills were documented in the Master Controllogbook.

A tour of the facility revealed that the sprinkler head(s) and pipes in the laundryroom are covered with lint/dust. Sprinklers covered with dust can malfunction and

should be cleaned.

Interviews with the maintenance worker, along with observations made of the FireAlarm Control Panels (FACP), revealed that the facility still operates two separate

fire alarm systems. The auditory alarms for both systems are located in the Intakearea (i.e. old Tour Office) that is not longer manned on a 24 hour basis. If a fire

emergency occurs in one part of the facility, occupants located in the other part of

the facility will not receive the auditory alert signaling a fire emergency and vice

versa. According to a maintenance worker, the facility plans to merge the twosystems with an additional warning system.

Eight (8) fire extinguishers were examined. Each fire extinguisher appeared to bein good condition and had a current annual and monthly inspection. In C Unit, a

fire extinguisher was on the floor. All fire extinguishers should be mounted toprevent them from being misplaced.

Observations made at the facility revealed that egress plans are posted throughoutthe facility.

9 of 9 staff have reportedly participated in at least one fire drill each month. 5 of 9 youth have reportedly participated in a least one fire drill since being

assigned to the facility.

Several emergency lighting fixtures tested satisfactorily. Exit signs were illuminated. The facilitys power generator is tested at least weekly.


34/86


35/86


Waxter

March 2011

POST ORDERS RATING: Non 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 order

prior to assuming the post. Post orders are current. Shift commanders ensure that post

orders are reviewed by the staff member. Post order signature sheet is signed by the staffassuming 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 does not maintain a FOP that cites specific and general instructionsfor the operation of every post within the facility.

A supervisor staff was unfamiliar with facility Post Orders and was unable toproduce them for B and C Units.

The facility was unable to provide any Post Orders Signature Sheets asverification that staff are familiar with the duties and responsibilities of a post.

No copies of Post Orders and Post Order Signature forms are maintained inMaster Control as pursuant to DJS policy.

The facility does maintain a Movement and Supervision of Youth FOP #10-001that outlines procedures for supervising youth located in a building(s), duringrecreation, in the dining hall, in school, during transportation and etc.

RECOMMENDATIONS


facility:

Create and maintain Post Orders and Post Order Signature Sheets as pursuant toDJS policy.

Ensure each staff reads and understands the post order prior to assuming the postfor the first time.

Develop a post order for special duty assignment positions (i.e. Key Control andFire Safety Officer).


36/86


37/86


38/86


Waxter

March 2011

A medical assessment is not done upon admission or within 72 hours. There is no formal Orientation Unit at Waxter so this area was not assessed.

RECOMMENDATIONS

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

Ensure the youth handbooks version of the BMP matches up to Waxters BMP. Administer and score both the SASSI and MAYSI within two hours of a youths

admission. Ensure all screenings are in every youths file.

Request the software for computerized SASSI screening and scoring from DJSHeadquarters to assist in this area.

Ensure Nursing completes a medical assessment within 72 hours.


39/86


40/86


41/86


42/86


Waxter

March 2011

BEHAVIOR MANAGEMENT RATING: Non Performance

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

provides a system of rewards, privileges and consequences to encourage youth to fulfill

facility expectations and teach youth alternative pro-social behavior. Youth who are not

invested in the facilitys system have alternative and individual plans.


Review of Unit Log Books Review of Daily Point Sheets Review of the Student Handbook Review of Behavior Management Plan (BMP) Review of Intervention Plans Interviews with youth Interviews with of direct care staff

REFERENCESDJS Behavior Management Program Policy RF-10-07; Facility Behavior ManagementProgram (BMP)

SUMMARY OF FINDINGS

There were many discrepancies between the written BMP and the explanationgiven in the youth handbook. The list of behaviors resulting in a loss of points

was different. Also, there was no explanation of incentives, rebates and

commissary in the handbook. The BMP also indicates that there should be

warnings given prior to points being taken, but this information is not included inthe handbook.

A review of Daily Point Sheets indicated that most were not completed. Theindividual areas (i.e. education, programming, meals) were empty on most of thesheets. The students would then be awarded all of their points. While the areas

were not filled in, there were deductions listed for infractions. Most of the

calculations on the sheets seemed correct, but a comparison of the deductions onthe sheets to the youth handbook showed that the deductions were administered

inconsistently. There appeared to be no audits/oversight of the sheets to correct

inappropriate deductions miscalculations.

All but one of the eleven staff members interviewed indicated that they receivedtraining on the BMP and three of eleven indicated that they needed additionaltraining.

Six of the eleven staff members interviewed said that they did not feel that theBMP was working. Four of the staff commented that the program was not

administered consistently. They state that the program does not provide enoughincentives and that all students are not held to the same standards.


43/86


44/86


Waxter

March 2011

RECOMMENDATIONS

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

facility:

Retrain staff on how to administer the BMP to ensure appropriate implementationand record keeping.

Update/correct the youth handbook to match the BMP. Ensure that staff are filling out the youths point sheets throughout the day. This

would ensure that the points reflect the youths behaviors. Teachers should also

award points for each of the students at each class period. Audit point sheets.

Ensure the BMP is explained to all youth by their case manager. Provided a varied option of incentives to youth. The facility should interview the

youth for suggestions on incentives that they would value.

Ensure that GCPs are created for youth who cannot benefit from the BMP.


45/86


46/86


Waxter

March 2011

RECOMMENDATIONS

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

Provide more programming during the week. The youth should have less leisuretime so that they are engaged and might then get into fewer altercations.

The master schedule should include the groups that are provided by the mentalhealth staff.

Consider additional recreation on the weekends to prevent idle time. Provide an alternative activity during the time when the religious programming

occurs.

Provide recreation outdoors whenever possible. Ensure when the calendar is published and school has professional development

days that these days are planned for in advance and youth given a variety of

programming options to keep them busy (chess tournaments, track and field days,rap and musical competitions, etc.)


47/86


48/86


49/86


50/86


Waxter

March 2011

PSYCHOTROPIC MEDICATION RATING: Not RatedMANAGEMENT

STANDARDWritten policy, procedure, and practice require that psychotropic medications are

prescribed, distributed, and monitored safely.

DUE TO THE LACK OF A BEHAVIORAL HEALTH QI REVIEWER, THIS

STANDARD COULD NOT BE ASSESSED.


51/86


Waxter

March 2011

BEHAVIORAL HEALTH SERVICES RATING: Not Rated

& TREATMENT DELIVERY

STANDARDWritten policy, procedure and practice require that appropriate mental health substance

abuse treatment and emergency services are provided by qualified mental health

professionals and substance abuse counselors, that it is integrated with the psychiatricservices 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.




52/86


Waxter

March 2011

TREATMENT PLANNING RATING: Not Rated

STANDARDWritten policy, procedure and practice require that appropriate mental health substance

abuse treatment and emergency services are provided by qualified mental health

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

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




53/86


54/86


55/86


Waxter

March 2011

been in two places at one time, it appeared the first sheet was not an accurate

accounting of where the youth was.

Audits of suicide watch sheets are not accomplished. If they were in place, anauditor would have likely discovered the issues listed above.

A review of an observation sheet on February 3rd at 2pm of a youth on Level IIIwatch was up to date and the staff positioned properly within 5 feet of the youth.

The Suicide Watch log kept by mental health conforms to policy in that itincludes the date, level and name of the youth and conditions of supervision.

Communication about youth on watch includes a note in the logbook, verbalnotification to line staff from mental health, verbal notification to the Tour Office,

a suicide log emailed out daily to all managers, and a paper copy of this log on

each unit in a binder. Logbooks revealed staff did write in bold print when a youth

was on watch. Binders were current with log information. Weekends were notalways updated as mental health staff typically do not work regular weekend

shifts.

In a sample of all mandated staff, 24 of the 30 staff sampled (80%) werecompliant with annual Suicide Prevention DJS-required training.

In reviewing incident reports, both line staff and mental health staff responseswere good. They took seriously the youths behaviors and acted without delay.

All staff knew they could put a youth on Level III one-to-one watch. All staff indicated that when a youth was on one-to-one watch, they could not

leave that youth for any reason, including to break up a fight.

Almost all staff indicated that there are enough staff to supervise youth on suicidewatch.

One concern was in overnight room checks. A review of the room checkobservation sheets revealed that they had pre-printed times and could not be reliedupon to ensure overnight checks were occurring as required by policy. Since most

suicides committed by juveniles in confinement occur while in rooms alone and

when not on suicide watch, these sheets and the processes surrounding themshould be improved.

RECOMMENDATIONS

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

facility:

A trained and skilled Waxter staff should be assigned the duty of auditing SuicideWatch Observation sheets daily; issues found could be relayed immediately to the

Administration for re-training or disciplinary action as warranted.

To ensure youth safety at night, discontinue using pre-printed overnight roomcheck sheets and require staff to write in the actual time they do each check.Require senior managers and the overnight SC to do random video review of staff

to ensure checks occur as listed on their door sheets.


56/86


Waxter

March 2011

ENVIRONMENTAL HAZARDS RATING: Satisfactory Performance

STANDARDWritten policy, procedure, and practice require that all housing for youth at heightened

risk of self-harm is free of identifiable hazards that would allow the youth to commit

suicide or other acts of self harm. In case of emergency, all direct care staff at the

facility should have immediate access to appropriate equipment to intervene in anattempted suicide. Chemicals and other hazards are properly stored and locked.


Interviews with youth Interviews with staff Observation at facility

REFERENCESDJS Suicide Policy (HC-1-07), DJS Safety and Security Inspections Policy RF-04-07,

ACA 3-JDF-3E-04, 4C-27 & 28, 4C-35, 5A-02, 3-JTS-4C-22, 4C-24, DJS Incident

Reporting Policy (MGMT-2-01); COMAR 14.31.06.13.J

SUMMARY OF FINDINGS

73% of staff in written interviews indicated they carried a cut-down tool; 27%indicated it is kept in a box in the control panel but supervisors have one on their

key ring. Every line staff and supervisor is required to have one on their person.

Soaps, lotions and cleaners did not appear to be left out or accessible. The PodControl Panels were locked. No sharp objects were observed and doors checked

were locked.

No incident reports showed cases of youth ingesting chemicals or soaps or usingaccessible sharp objects or tie off points to attempt to harm themselves. The rooms displayed no tie-off points except the very necessary faucets/toilets, as

in many DJS facilities. No ceiling fixtures, desks, open metal beds or any other

hook type point was observed.

RECOMMENDATIONS

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

facility:

Ensure that all direct care staff, including supervisors, carry a cut down toolwhile in detention.


57/86


Waxter

March 2011

CLINICAL CARE FOR RATING: Not Rated

SUICIDAL YOUTH

STANDARDWritten policy, procedure, and practice require that timely suicide risk assessments,

using reliable assessment instruments, are conducted at the facility for all youth

exhibiting behavior that may indicate suicidal ideations to determine whether a youthshould be placed on suicide precautions or whether the youths level of suicide

precautions should be changed. Youth at a facility who exhibit suicidal ideations or

attempts should receive timely, appropriate, and professional mental health services.

Youth should not be restricted from programs and services more than safety and security

needs dictate. All pertinent staff should review all completed suicides and suicide

attempts at the facility for policy and training implications.




58/86


Waxter

March 2011

EDUCATION

SCHOOL ENTRY RATING: Partial Performance

STANDARD

Written policy, procedure and practice document timely enrollment of all students intothe educational program. The school will receive a daily roster of students. The receipt

of student records should occur in a timely manner.


Interview with records staff Interview with Special Education Lead Teacher Review of 30 student folders (4 special education, 26 general education) Review of Daily Population Reports

REFERENCES

COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer ofEducational Records

DJS SOP for Special Education Service Delivery in Secure Detention FacilitiesSUMMARY OF FINDINGS

Only 18 of 30 (60%) students records were requested within 72 hours or 3 schooldays of admission. At the date of the review, eight of these files contained no

records. There were only two records that contained secondary requestsperformed in accordance to COMAR 13A.08.07.

Four records were from previous stays at the facility. All of the previous stayswere within a month of the current admissions. Two of these files contained notesthat indicated that the records clerk confirmed that there were no new records. Butthere was no information about how this was confirmed.

The students were not being assessed. Some students with previous admissionshad older assessments in their files, but none of the newly admitted students had

assessments. The most recent assessment found in any of the files was dated June8, 2010.

Education staff reported that they receive a population report daily.


59/86


Waxter

March 2011

RECOMMENDATIONS

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

Ensure that records are requested according to COMAR 13A.08.07: Education-Student in State Supervised Care-Transfer of Educational Records. The school

administrator should periodically review the process to ensure that the timelines

are met.

The school needs to ensure that the students are given an educational assessmentupon admission to the facility.


60/86


Waxter

March 2011

CURRICULUM & INSTRUCTION RATING: Non Performance

STANDARDFacility schools will ensure that they provide instruction appropriate to the varied needs

and abilities of the students enrolled. They should operate on a standard schedule,

provide students with a consistent school day, provide instruction appropriate to

individual students strengths and needs, provide pre-GED & GED instruction asappropriate, provide extracurricular and enrichment activities & events, integrate

computer assisted instruction in the curriculum and provide library services. Facility

schools will also ensure that students in alternate settings (i.e. infirmary, seclusion and

orientation) are given access to assignments and instruction comparable to others

students in the facility.


Review of School schedules Review of Detention and Honors Unit logbook Review of teachers attendance books Interview of two teaching staff members Interview of 9 students Interview of the Teacher Supervisor Observation of transitions to and from class Two classroom observations

REFERENCES

MSDE Guidelines DJS SOP for Special Education Service Delivery in Secure Detention Facilities

SUMMARY OF FINDINGS

The school day was very sporadic for the youth on the detention unit on the day ofthe review. The detention students did not arrive to their 9:00 am first period class

until 9:29 am. Of the 21 youth listed on the population sheet, only five came to

the first period class. By the second period only seven of the youth were in class.The staff member assigned to the youth in school indicated to this reviewer that

the other youth refused school.

A review of teacher attendance books indicated that the day described above wasnot an isolated occurrence. There were students that refuse