Comprehensive Quality Review Report J.deweese Carter Center (MD 2010)

7/31/2019 Comprehensive Quality Review Report J.deweese Carter Center (MD 2010)

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OFFICE OF QUALITY IMPROVEMENT

Comprehensive Quality Review Report

J. DeWeese Carter Center

July 9, 2010


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DJS QI Report Page i of 80


July 2010


Quality Review Report


Evaluation Dates: June 22-23, 2010

TABLE OF CONTENTS

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

QI Rating Scale............................................................................................................... 1QI Rating Percentage ...................................................................................................... 2

Executive Summary of Results....................................................................................... 4

Methodology................................................................................................................... 5SUMMARY OF FINDINGS & RECOMMENDATIONS ............................................ 7

SAFETY AND SECURITY ............................................................................................. 7

Incident Reporting .......................................................................................................... 7

Senior Management Review......................................................................................... 10De-Escalation & Restraint ............................................................................................ 12

Contraband & Room Searches...................................................................................... 14

Seclusion....................................................................................................................... 16Room Checks During Sleep Period .............................................................................. 18

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

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

Control of Keys, Tools & Environmental Weapons..................................................... 24Youth Movement & Counts.......................................................................................... 27

Fire Safety..................................................................................................................... 29

Post Orders.................................................................................................................... 31Staff Training................................................................................................................ 33

Admissions, Intake & Student Handbook..................................................................... 35

Classification................................................................................................................. 37Pending Placement........................................................................................................ 38

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

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

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

Informed Consent.......................................................................................................... 45Psychotropic Medication Management......................................................................... 46

Behavioral Health Services & Treatment Delivery ...................................................... 47

Treatment Planning....................................................................................................... 48Transition Planning....................................................................................................... 49


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DJS QI Report Page ii of 80


July 2010




Evaluation Dates: June 22-23, 2010

TABLE OF CONTENTS(Continued)

SUICIDE PREVENTION .............................................................................................. 50Documentation of Youth on Suicide Watch................................................................. 50

Environmental Hazards................................................................................................. 53

Clinical Care for Suicidal Youth................................................................................... 54EDUCATION .................................................................................................................. 55

School Entry.................................................................................................................. 55

Curriculum & Instruction.............................................................................................. 57

School Staffing & Professional Development .............................................................. 59Screening & Identification............................................................................................ 61

Parent, Guardian & Surrogate Involvement.................................................................. 63

Individualized Education Programs.............................................................................. 64Career Technology & Exploration Programs ............................................................... 66

Student Supervision ...................................................................................................... 67

School Environment & Climate.................................................................................... 68

Student Transition......................................................................................................... 69MEDICAL CARE........................................................................................................... 70

Health Care Inquiry Regarding Injury .......................................................................... 70

Health Assessment........................................................................................................ 72Medication Administration........................................................................................... 75

Dental Care ................................................................................................................... 76

Medical Records Retrieval............................................................................................ 77Special Needs Youth..................................................................................................... 78

Availability of Medical Services .................................................................................. 79


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DJS QI Report Page 1 of 80


July 2010



J. DeWeese Carter CenterEvaluation Dates: June 22-23, 2010

EXECUTIVE SUMMARY

A quality improvement assessment and evaluation of the 15 bed J. DeWeese CarterCenter was conducted June 22-23, 2010 by DJS personnel who are subject-matter experts

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

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

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

conditions.

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 Carter in October 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 of36 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 7 16 %

Satisfactory Performance 21 48 %

Partial Performance 13 29 %

Non Performance 3 7 %

Superior Performance 2 6 %

Satisfactory Performance 23 63 %

Partial Performance 10 28 %

Non Performance 1 3 %


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July 2010

QUALITY IMPROVEMENT UNIT

J. DEWEESE CARTER CENTER

JULY 9, 2010

0%

10%

20%

30%

40%

50%

60%

70%

1/14/2008 7/9/2010

Date of Report

Perce

ntage

Superior Performance Satisfactory Performance Partial Performance Non Performance


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July 2010



Executive Summary of Results

SuperiorPerformance

Satisfactory Performance Partial Performance Non Performance

Student

Supervision

SchoolEnvironment &Climate

Incident Report

Seclusion

Room Checks During SleepPeriod

Perimeter Checks

Staffing

Youth Movement & Counts

Fire Safety

Staff Training

Admissions, Intake & StudentHandbook

Behavior Management

Environmental Hazards

Curriculum & Instruction

School Staffing & ProfessionalDevelopment

Screening & Identification

Parent, Guardian & SurrogateInvolvement

Individualized EducationPrograms

Student Transition

Health Care Inquiry RegardingInjury

Medication Administration

Dental Care

Medical Records Retrieval

Availability of Medical Services

Senior Management Review

De-Escalation & Restraint

Contraband & Room Searches

Control of Keys, Tools &

Environmental Weapons

Post Orders

Classification

Structured RehabilitativeProgramming

Documentation of Youth onSuicide Watch

School Entry

Career Technology & ExplorationPrograms

Health Assessment

Special Needs Youth


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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 conducted

throughout the review. Members of the QI Team asked and discussed with theSuperintendent and Assistant 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 9 youth were interviewed individually and all 15 in groups (for atotal of 15 youth) about a range of areas across the QI review spectrum. This

represented 100% of the total population at Carter that week. Interviews werealso conducted with facility direct care, administration, medical, case

management and education staff. In addition, 7 staff were interviewed

specifically about the target areas of the review as well as their generalfeelings about the operation of the facility.

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

Leisure Time

Classroom Activities

VI. Review of Quality Improvement ReportThe facilitys previous QI Report was also reviewed to determine what areasneeding 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. Discussions about some

portions of the QI findings were conducted on the last day of the review.


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July 2010

SUMMARY OF FINDINGS & RECOMMENDATIONS

SAFETY AND SECURITY

INCIDENT REPORTING RATING: Satisfactory 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

37 Facility Incident Reports Jan-June 2010

Interview with IR Specialist

Youth grievances June 2009-June 2010 Staff Training Histories Report

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

Incident Report (IR) files did contain both written and electronic copies. Onoccasion the electronic IR was not a word-for-word copy of the written IR. Theyshould be identical.

IRs are generally filled in entirely with few blank areas. White-out was found onsome IRs. White-out should not be in use in the facility at all.

Narrative portion includes all four parts and all four are completed.

There was one instance found where a youth alleged abuse at the hands oftransporting police. An IR was generated but and his case was not referred to

Child Protective Services (CPS) as required. An MSDE school staff was alsoalleged to have engaged in inappropriate touching. An IR was not electronically

entered and that case as well was not reported to CPS as required.

In the case of the youth who alleged abuse against transporting police, theincident was only labeled On-Grounds Medical. It should have been classifiedas an Alleged Child Abuse Not in DJS Custody.


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July 2010

Descriptions of uses of force (when applicable) are not detailed. Most staff tend towrite that they put a youth in a restraint but give no description about how or if

the youth complied.

Descriptions of the events are good but lack all relevant details. Staff should beencouraged to write IRs as if they are telling a story, leaving out no detail andgiving a blow-by-blow account of the event from start to finish. Without details, it

is difficult to critique staff performance.

All of the IRs contained shift commander comments. The quality of thosecomments is indicated in the next section entitled Senior Management Review.

Notifications sections are complete.

Detail on who was present and exactly where they were posted needs someimprovement. One staff wrote in an IR that a staff was posted by a table but in her

witness statement, she indicated she was in the kitchen getting snacks. Her

absence may have contributed to the youth fighting when they did, but no onecaught the discrepancy in either the shift commander comments or audit as a

possible contributing factor.

The number of all youth present was often missing from the IRs. QI believes thisis likely due to the low population of youth (15) and essentially the one unit

concept that small population presents. For clarity, staff should still indicate thenumber of youth present during the incident as sometimes, a youth may be in the

bathroom, at visitation, with a case manager or otherwise not present.

Most of the IRs reviewed had all youth and staff witness statements present.

In 100% of cases, youth in incidents or restraints saw a nurse as required and hada body sheet present in the file. Photos were attached when required.

After a review of the Nurses Injury Log, two sports-related injuries were foundthat did not have corresponding IRs. In every case, a youth with a sports injury

must have a corresponding incident report completed.

GRIEVANCES

There were 19 youth grievances in the past 12 months at Carter. The topcomplaints were as follows, in order: 1) staff, 2) missed recreation time and 3)

temperature (air) and points.

The Youth Advocate seems to pick up grievances timely (the average time was2.5 days) and nearly every youth all said they knew where to find and file

grievance forms. On a walk through, there were stocked grievance formsaccessible to youth and youth indicated they knew how to find and use them.

Only one issue presented: when a youth chooses to discontinue a grievance aftercommencing one, DJS Advocates are to continue to follow up in order to ensure

problems are resolved and youth are not being intimidated. One grievance of thenineteen seemed to allow a youth to drop the issue he originally brought up. All

in all however, the grievances were handled timely and well by the Youth

Advocate and youth indicated that if they had any problem, they would use the

grievance process.


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July 2010

RECOMMENDATIONS

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

Encourage staff to use as much paper as necessary when writing IRs and to leave

out no detail. Descriptions in narratives and of uses of force are an area that mayneed refresher training by a qualified person.

Require shift commanders to critique staff when they fill out the shift commandercomments. Ensure they are sharing these coaching tips with their staff.

Ensure the staff and Administration are aware that any and all youth allegations ofany kind should be reported to CPS and entered into DJS electronic IR database

immediately. Incident type should be listed as Alleged Child Abuse in these

cases.


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July 2010

SENIOR MANAGEMENT REVIEW RATING: Partial 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.




Video reviews

Review of OIG Investigations

Review of seclusion documentation

Review of suicide watch documentation

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

SUMMARY OF FINDINGS

All of the IRs contained shift commander comments. Almost none of the shiftcommander comments were critiques (as is required); the most common areas

missed were supervision issues, missing witness statements, and poor restraint

detail; overall, the comments praised staff performance but did not help give staffany coaching on how to improve.

Policy requires senior administrative review of all incident reports within 72hours. There were audits of all IRs reviewed. There were no dates on the audits

performed at Carter so verification of compliance to policy could not be assessed.This was the same problem found in the last review.

The audits themselves were fair but still missed various areas. Examples included:an IR with only one of two body sheets, lack of restraint detail, lack of rapid

response to verbal argument by youth before fight began, how a youth broke outof a restraint, lack of knowledge of an injured youth being admitted against DJS

policy, etc.

There is evidence of employee memos/corrective actions/discipline to showadministrative follow up when problems are found relating to an incident.

Staff and the Assistant Superintendent indicated incidents were reviewed on videoafterwards but there is no documentation to verify compliance. Only a select staff

knows how to use the video system so more training is recommended.

Seclusion sheet auditing: no seclusions since November 2009. The last sheetsreviewed from mid-2009 showed no evidence of auditing.


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Suicide watch documentation auditing: no evidence of auditing. All sheets werepresent but some patterns were discovered that had not been caught previously by

the facility.

There is administrative support in the form of a Management Associate. Herutility in this position allows the GLM Is and Assistant Superintendent toconcentrate on their own workload.

The Office of the Inspector General (OIG) completed three investigations in the

year, none of which related to child abuse allegations. However one investigationdid indicate that an MSDE counselor was accused by some youth of inappropriatetouching. This incident was reported very late by the facility and CPS was also

not originally called as required. Though OIGs follow up was good and ensured

all reporting was done as required, the facilitys lack of reporting and call to CPSwas a second example of a youth alleging abuse without proper follow up by the

facility.

RECOMMENDATIONS

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

facility:

Ensure senior management staff at Carter are skilled in auditing IRs, suicidewatch and seclusion sheets and that timely systems are in place to do so.

Prevention of a like incident is a goal that can only be accomplished with staffcoaching and regular and timely oversight. Further training on IR audits from QI

or the Director of Detention are available upon request.

Ensure auditing occurs within 72 hours as required by policy. Add a Date ofAudit line to the audit form.

Add a Video Reviewed-Yes or No line to the audit form as well. Ensure ITtrains all GLM Is and the Assistant Superintendent on how to run the videosystem so that there is always someone on duty to do so when needed. Practice

using it weekly.

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

Ensure the staff and Administration are aware that any and all youth allegations ofany kind should be reported to CPS and entered into DJS electronic IR database

immediately. Err on the side of reporting and allow CPS to perform their role.


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July 2010

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.



Facility training records on CPM and Verbal De-escalation

Interview with Assistant Superintendent

Review of videos



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 are not detailed in IRs by all staff. Staff simply writethat they placed or put a youth in a restraint, but not how or if he complied.

On occasion, incident reports that described a fight indicated there was no

restraint used; due to the lack of detail, it was impossible to tell how staff brokethe youth up without having to use any force at all.

There were some videos to review but these ran slowly and were only able to runthrough without pausing or rewinding; assessment of physical restraint use was

not possible upon review due to this and technical difficulties logging onto the

system. No other videos were available to review.

9 of 19 (47%) staff were compliant with Crisis Prevention and Management(CPM) semi-annual training, while 19 of 19 (100%) had CPM training at least

once in the last year. All staff are on target to reach the 100% semi-annual goal

for 2010. Mechanical restraints are taught in CPM refresher training.

The CPM debriefing form has been modified from the form that is attached to the

DJS CPM policy. Only the form attached to the policy should be in use.


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July 2010

RECOMMENDATIONS

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

Re-train and follow up with staff on descriptions of restraints in IRs. Staff shouldgive detailed accounts, including which hand(s) they used, if the youth moved,

ran, struggled or complied, and if the staff stood or walked with the youth, etc.Ensure when staff are able to use other means besides force to break up fights,

that they describe those interventions in detail.

Ensure staff are trained twice yearly in CPM.

Discard the modified CPM de-briefing form and use the one attached to the DJSCPM policy.

Review videotape of incidents, restraints and youth behavior and ensure allsupervisory staff know how to use the video system. Keep and use these videos as

training aids for staff and as proof of compliance with proper CPM technique.


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July 2010

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 Logbooks

Facility Room and Common Area Searches FOP

Room Inspection Sheets

Interview with AFA and 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 Facility Room and Common Area Searches FOP(#009-004) dated 01/22/09, which addresses the frequency of searching youthrooms and common areas. The FOP cites that youth rooms and common areas are

to be inspected daily for contraband and each search documented on the

appropriate form (i.e. Room Inspection sheet or Common Areas InspectionSheet) and in the unit logbook. The 1st and 2nd shifts are to alternate the

searching/inspecting of rooms for contraband. The facility also maintains a FOP

entitled Daily Duties (6a 2p shift) dated 07/15/08, which indicates that themorning staff are to ensure all rooms are clean and contraband removed. BothFOPs indicate they are to be reviewed annually.

Based on interviews with eight staff, room searches are usually conducted one tofour times a week. The facility did not provide a sufficient number of RoomInspection Sheets to verify that room searches are conducted daily pursuant to

their FOP. The reviewed sheets averaged about one room search a week, which

would be pursuant to DJS policy. Both DJS policy and the FOP require that staffdocument room searches in the unit logbook. However, a review of 4 randomly

selected weeks from the unit logbook(s) did not reveal any entries pertaining to

room searches. This information was provided to the Assistant Facility

Administrator for any follow up action deemed appropriate. Two recovered contraband incident reports (room searches) were crossed-

reference with the Room Inspection Sheets for the same date. Only one recovered

contraband incident was listed on a Room Inspection sheet and logged in the unit

logbook.

The FOP and written DJS policy indicate that common areas (i.e. general areas)are to be searched daily for contraband and the search documented on the


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Common Areas Inspection Sheet and in the unit logbook. The facility did not

provide any Common Area Inspection Sheets for review. A review of 4 randomlyselected weeks from the unit logbook(s) did not reveal any entries pertaining to

common area searches. This information was provided to the Assistant Facility

Administrator for any follow up action deemed appropriate. Note: The staffresponsible for maintaining the Room and Common Areas Inspection Sheets was

not available for follow up regarding the inspection sheets.

The facilitys room searches have resulted in the recovery of various contrabanditems (i.e. cell phone, medication, suspected marijuana, drawing of a floor plan ofthe facility, trash, pencils, extra clothing/bedding, etc.)

Routine frisk searches have resulted in the recovery of contraband as well (i.e.medication) concealed in a youths sock.

On several occasions, members of the QI team observed staff frisking youth forcontraband upon movement (i.e. to/from school and from the dayroom to their

rooms.)

Five incident reports were on file for contraband for the period of October 1, 2009to June 21, 2010.

The facility maintains a large selection of DVD movies and books. A review ofrandomly selected DVDs and books revealed that the contents were appropriatefor the ages of the youth assigned to the facility. Interview with staff revealedthat the facility does not maintain or allow movies to be shown with a rating

beyond PG-13.

RECOMMENDATIONS

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

facility:

Review FOPs to ensure current written procedures and practice coincide.

Maintain continuity between FOPs and Department policy by ensuring FOP terms(i.e. Common areas) reflect departmental terms/vocabulary (i.e. General

areas.)

Ensure all searches/inspections are documented on the appropriate forms and inlogbooks.

The facility in part received a partial performance rating for this area due to notbeing able to provide additional documentation regarding the room and general

area searches.


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July 2010

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, a

substantial destruction to property or an imminent threat of escape, and shall be treatedhumanely 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 Assistant Superintendent

Incident Reports from Jan-June 2010

Seclusion sheets


Interviews with staff Observation at facility

REFERENCESDJS Seclusion Policy RF-01-07; COMAR 16.18.02

SUMMARY OF FINDINGS

There have been no documented seclusions between since one in November 2009;before that the most recent one was in July 2009. The seclusions that weredocumented were relatively short, with two youth in for about hour and five

youth involved in a group disturbance in for about 10-12 hours. The staff and Administration consistently indicated that they work to talk to a

youth and calm him before resorting to seclusion. Seclusion use has to haveSuperintendent authorization and it is rarely authorized.

Seven youth seclusion episodes from 2009 were reviewed. The two half hourepisodes had no areas of concern. The other five youth in the group disturbance

had the same kinds of issues on all five sheets. The shift commander missed visitsfor about five hours. Sheets would end at 2:25 then start up on the next page at

2:00pm, and the shift commander would write a youth was agitated, withdrawn

when the RA checking the youth indicated hed been asleep for hours.

The shift commander comments (reasons for youth not being released from

seclusion) were good and indicated why the youth was a threat and not able to bereleased; but for the reasons noted above, these may not be entirely accurate.

Since there appeared to be no auditing of these sheets, these errors were nothighlighted or followed up on with staff. Because seclusion use is so rare at

Carter, staff are likely out of practice with some basic components.


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July 2010

All but one staff in interviews indicated that when a youth is locked inside hisroom and it is not bedtime yet, that is always seclusion. This is an ideal answer,

as DJS wants staff to take seriously seclusion and its use.

Carter does not often have issues with a staff shortage that would require youth tostay in their rooms a few minutes or hours later in the morning. However theywere reminded that should this occur that should log that there are lock-ins for a

lack of staff and watch youth per the DJS Seclusion policy until staff come in.

The use of early bed violates DJS seclusion policy. Carter staff interviewednoted that group punishment was not a part of behavior management at thefacility and that early bed was not used as punishment. Some staff indicated that

8:15pm was a bedtime that was sometimes used as a sanction for youth. Though

this comports with the Level I bedtime and is not technically early bed, itshould be included in the written BMP if it is used.

RECOMMENDATIONS

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

facility:

Ensure that the auditing process includes seclusion sheets if a seclusion episodeoccurs. Ensure staff are reminded at least monthly about seclusion basic processes

so that they are prepared when one occurs to supervise according to policy. Sheets

and the checks made should comport with policy.

Log into the Seclusion Log any youth lock-ins for lack of staff should this occur,and check youth in their rooms per the seclusion process and for their safety.


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July 2010

ROOM CHECKS DURING RATING: Satisfactory 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



Logbooks

Sleep Observations sheets

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

SUMMARY OF FINDINGS

The facility maintains an Evening Supervision of Youth FOP #008-001 dated01/14/09 which indicates that staff shall visually check each resident every 30

minutes, or more frequently. during bedtime hours. Staff are required todocument their observations of the youth.

Interviews with the Facility Administrators and staff, along with a review ofdocuments revealed that staff conduct visual checks of youth appropriately every

15 minutes instead of every 30 minutes and document their observation at thetime of the check.

The facility utilities Sleep Observation Sheets to document each visual check. A review of randomly selected Sleep Observation Sheets from January 2010 to

June 2010 revealed that 100% of 159 shifts completed the required room checks.

The vast majority of the checks were completed within 15 minute intervals.

The FOP requires that Supervisors or GLMs review all Sleep Observations sheetsto ensure room checks are completed as required. A review of 560 SleepObservation sheets revealed that the majority of the sheets were not initialed or

signed by a supervisor/RGLM as part of the facilitys review process.

The majority of staff did not print and sign their name on the Sleep Observationsheets, as required by the FOP. There were some instances of staff not initialingthe sheet during each check. Also, some sheets had more than one staff listed

making it difficult to determine which staff actually conducted the checks. A very small number of Room Observation sheets contained white-out which

obliterated the time and observation code. White-out should not be used to

obliterate any errors made on the sheets nor at all on any detention centerdocumentation.


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July 2010

RECOMMENDATIONS

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

Review the FOP to ensure written procedures coincide with actual practices.

Have Shift commanders/GLMs verify that they have reviewed Sleep Observationsto ensure compliance with policy/procedures.

Do not use white-out to obliterate errors made on the sheets, if an error occurs,draw a single-line through the information so that it can still be read.

Ensure Shift Commander/GLMs ensure staff write their name legibly and sign theSleep Observation sheets pursuant to the FOP.


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July 2010

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, security

lighting, security devices, and a check of outdoor areas, gates and security fences to

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


Facility Tour

Observation

Logbooks


REFERENCESDJS 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

Based on interviews with the Assistant Facility Administrator and staff, alongwith a review of logbooks, staff conduct at least one perimeter check during each

shift. The facility was not able to produce any kind of perimeter checklist whenrequested by QI; the use of one is suggested.

The facility maintains a Master Control Identification FOP (#008-011) dated8/27/08, which states that persons entering the facility must show valid photo

identification. To prevent contraband from entering the facility, visitors are not

permitted to bring certain items (i.e. keys, cell phones, etc.) into the secure area. The facilitys front entrance is a controlled access point. The entrance consists of

electronically locking doors (sally port) to prevent unauthorized pedestrians from

entering or exiting the facility. Visitors entering the facility are checked-in at this

location. Master Control is located at the front entrance, but is not manned on acontinuous basis. If staff is not available in Master Control to monitor the front

entrance, visitors may use a telephone located at the entrance to contact staff in

order to gain access into the facility.

A review of the Visitors log revealed that no record is made of visitors leavingthe facility.

A hand held metal detection wand is maintained at the front entrance. During a

tour of the facility, staff were observed using the wand to scan visitors forcontraband, however the QI team was not searched in any way upon entrance.

During a tour of the facility, the door to the restroom located on Long Hall wasobserved open and the area unoccupied. Security doors were observed to besecured at all times, however on one occasion the outer gate to the vehicle sally

port was observed open and the area unoccupied.

There were no escapes from the facility since the last QI Review.


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July 2010

During a tour of the facility, a flaw was observed that compromises the security ofthe facility. The detention and administrative areas (i.e. front entrance) share a

suspended ceiling consisting of removable ceiling tiles. There are several pipesand a catwalk just above the suspended ceiling that run the length of the facility.

There is no barrier above the ceiling that separates the detention and

administration areas (i.e. front entrance). By removing a ceiling tile in thedetention area and climbing into the area above the ceiling, access can be gained

to the front entrance area of the facility. During a tour of the perimeter, a push mower was observed in the recreational

yard/area and a ladder leaning against a wall on the outside of the perimeter fence.

There are several small piles of leaves observed along the perimeter fence linewhich could conceal contraband.

RECOMMENDATIONS


Ensure visitors are signed out when leaving the facility so that their whereaboutscan be accounted for in the event of an emergency.

Wand/search all visitors, staff and DJS or other personnel for contraband everytime.

Ensure all gates, unoccupied areas and storage rooms are locked/secure at alltimes when not in use.

Facility Administrative staff should meet with maintenance to determine how tosecure the space above the suspended ceiling between the detention and

administrative areas.

Develop a perimeter checklist to ensure staff know what gates, locks, andwindows to inspect and document the condition of the items checked. If one has

already been developed, begin using it and keep these documents for reference.

Have maintenance remove the lawn mower and ladder to a secured area.

Remove the leaves along the fence line.


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July 2010

STAFFING RATING: Satisfactory Performance

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

present to provide an environment that is safe, secure and orderly.

SOURCES OF INFORMATION Facility Logbooks

Shift schedules

Facility Population Report

Interview with Assistant Superintendent

Interview with Staff

Observation at facility

Facility Organizational Chart including vacancies

REFERENCESACA 1-SJD-1C-03

SUMMARY OF FINDINGS

The staffing ratio at Carter is 1:8 which is within professionally acceptedstandards. Carter attempts to maintain 1:6 whenever possible.

At the time of review there were 18 Direct Care positions filled and 2 vacancies.

Of the random days chosen for audit, a total of 24 shifts were reviewed for properratio using logbook documentation compared to the facility population sheets and

Facility Organizational Chart. No shifts were found to be out of ratio. Observationat the facility on two days also showed the staff to youth ratio was being met.

The facility does consistently maintain ratios, however the shifts were sometimesfound to be without supervisors.

Staff did indicate in interviews that more staff are needed in order to allow themto take leave when they request it.

Often supervisors sign the logbook for dates and shifts on days they are not in thebuilding.


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July 2010

RECOMMENDATIONS

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

Create a schedule that will ensure supervisory staff is available on all shifts. TheAssistant Superintendent indicated he plans to remedy this issue by putting in

place a Resident Advisor Supervisor who has been recently hired.

Fill the two vacant positions. Ensure full staffing to allow for a built-in staff relieffactor so that staff leave needs are being met.

To ensure that there is no confusion about who was on duty and when the logbookwas reviewed by a supervisor, the supervisor should only endorse for the days andshifts that he or she was on duty.


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July 2010

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

Review of 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

The facility maintains a Key Control Policy FOP #009-002 dated 1/5/09. TheFOP indicates the procedures for inventorying, storing, and distributing keys.Chits are used to facilitate the distribution of keys. Keys are required to be

inventoried at the beginning and end of each shift.

The facility has a Key Control Officer responsible for the responsible for thestorage and inventory of facility keys.

The facility maintains a working key board as the prime issuing point and the

main repository for facility keys. The facility maintains an inventory of the working key board.

An inspection of the working key board revealed that employees chits were notphysically being exchanged for facility keys. Staff were recording their chit

number in the key log and taking the chit with them. The working key board also

contained several empty hooks that didnt have a key set or chit hanging on them.

The inspection of the working key board also revealed that there were three set ofkeys signed out to staff and no employees chit number recorded in the key log.

Incoming employees are to receive keys for exchange of their chit. A review ofrandomly selected months from the key log revealed the following:

January 21% of 224 instances of keys issued did not indicate a chitexchange.

March 21% of 160 instances of keys issued did not indicate a chit

exchange.May 19% of 188 instances of keys issued did not indicate a chit

exchange.


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July 2010

A review of the key log also revealed the following:o No sign in/out times are used to track the times keys are issued or

returned.

o Staff do not always sign the key log when returning keys. For example: January 2010 19% of staff returning keys did not sign the key log

as required. March 2010 21% of staff returning keys did not sign the key log

as required. May 2010 29% of staff returning keys did not sign the key log

as required.

The majority of the key rings consist of one or two keys, the keys are notmaintained on a metal key ring soldered/crimped at the joint to prevent tampering,

loss, removal or the adding of unauthorized items onto the key ring.

The key rings have a plastic tab affixed to indicate the hook number of the key setbut not the number of keys on the ring.

Pursuant to DJS policy, the facility maintains a list of staff issued keys on a 24hour basis. The facility recently inventoried all keys issued to staff on a 24 hour

basis. All keys were accounted for.

Staff interviews and a review of the incident reporting database reveal that anemployee reported misplacing/losing a set of facility keys. A search wasconducted for the keys, but to no avail. The Facility Administrator responded by

inventorying all facility keys and changing several locks within the facility. The

keys were later found among the personal belongings of the employee.

The facility maintains a set of emergency keys at a secure location away from butnear the facility.

Tools

Based on interviews with maintenance staff, the maintenance section does notmaintain a sign out log for tools. There is only one maintenance worker assigned

to the facility.

Interview with maintenance staff and a review of documents revealed that themaintenance section maintains an inventory list of the assigned tools. However,tools are not inventoried on a regular basis.

Environmental Weapons

A tour of the facility revealed that mops and brooms, which can pose a risk to thesafety of staff and youth, were secured in a locked closet.

A spray bottle marked bleach water was observed in a restroom. Interview withstaff and an inspection of the spray bottle revealed that the bottle actually

contained a mild cleaning solution. Bleach is no longer used in the facility.

Toxic and caustic materials


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July 2010

The facility does not maintain any toxic/caustic materials within the detentionarea.

RECOMMENDATIONS

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

facility:

Require the management and Key Control Officer see that every hook on theworking key board at all times contains either a key ring, a key chit, or a metal tag

stamped with the number assigned to that hook to indicate that the hook is notcurrently assigned a key ring.

The Shift Commander should ensure staff receiving or returning keys completethe key log.

Conduct regularly scheduled inventory of tools and document each inventory.

The Key Control Officer should ensure that all keys are maintained on a metallickey ring soldered/crimped at the joint to prevent tampering, loss, or removal.


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July 2010

YOUTH MOVEMENT & COUNTS RATING: Satisfactory 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 the

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

conducted and documented in accordance with departmental guidelines. Emergencycounts are conducted and documented when necessary.


Facility Logbooks


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 facilitys maintains an Official Head Counts FOP 008-009 dated 7/3/08,which delineates procedures for conducting physical and official head counts.

The facility requires staff to conduct physical head counts every 30 minutes and

official head counts four times a day: 2am, 8am, 2pm, and 8pm.

Interviews with staff and a review of unit and master control logbooks revealed

that physical counts are conducted and documented every 30 minutes and officialcounts are conducted and documented four times, every six hours.

The facility conducts a formal (Official) count around 2am and reports the countto the appropriate designee, pursuant to DJS policy.

The facility maintains a Youth Movement /School Movement FOP # 009-003dated 12/30/08, which delineates procedures for youth movement within thefacility.

Youth were observed during movement. Youth walked in single file and in anorderly fashion.

A review of the unit logbook(s) revealed that youth movements are beingrecorded along with the names of youth when they are off the unit (i.e. court,

doctors appointment, etc.) along with their location A review of logbooks revealed that staff who record entries (counts and

movements) in the logbooks do not always place their initials after the entries.


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July 2010

RECOMMENDATIONS

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

Shift Commanders should instruct all staff who place entries into logbook to writetheir initials after each entry.

The Shift Commander/Supervisor should review the log book(s) during each shiftto ensure entries made are consistent with Department policy and procedure. TheShift Commander should make a notation in the log book of any inconsistencyfound and inform staff of the matter.


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July 2010

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 maintenance staff

Review of logbooks and other documents

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 Maryland State Fire Marshal inspected the facility in June 2010. Noviolations were noted.

A fire safety vendor conducted a quarterly inspection and test of the facilitysprinkler system in April 2010. No violations were noted.

A fire safety vendor tested the facilitys fire protection (alarm) system on March

2010. No deficiencies were noted. A fire safety vendor recharged, tested and inspected all of the facilitys fire

extinguishers in April 2010.

The facility has appointed a staff as the fire safety officer.

All fire exit signs were properly illuminated.

Inspection of the FACP revealed that it was operational. Interviews with staffrevealed that the FACP and the power generator are tested every week.

Interviews with staff along with a review of fire drills records from January 2010to May 2010 revealed that the 3

rdshift does not conduct any fire drills.

During a tour of the laundry room, items were observed properly stored 18 inchesbelow the ceiling sprinklers.

A desk was observed blocking a fire exit in a classroom. Interview with the Fire Safety Officer revealed that some front door keys are

notched for identification by touch. The facility should consider

notching/marking all emergency keys in a manner that would make themidentifiable by touch.


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July 2010

RECOMMENDATIONS


Shift commanders should ensure that the 3rd shift participates in a fire drill at leastonce a month if conditions permit.

Ensure that furniture does not block any fire exit in the school.

Mark/notch all emergency keys for identification by touch.


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July 2010

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 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


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 several FOPs that are, in part, about Post Orders.

Pursuant to DJS policy, the facility is required to maintain specific and generalinstructions for the operation of every staff position and special duty assignment

(i.e. Resident Advisors, Resident Advisor Lead, Resident Advisor Supervisor,Shift Commander, Security, and key control and safety officer assignments) in the

facility. The facility provided a FOP that delineates the duties/responsibilities for

the On Call Administrator. The facility did not provide any post orders for the

duty assignment of Key Control Officer or Fire Safety Officer.

DJS policy requires facilities maintain specific and general instructions for the

operation of specific posts (i.e. indoor and outdoor recreation areas, HealthServices Unit, Dining area, Laundry, Supply, Hospital and off-propertyappointments and Maintenance Shop) applicable to the facility. The facility

maintains a FOP entitled: 10p-6a Post Orders. (PO #009-007) dated 5/18/09. This

FOP is addressed to all direct care staff working the unit on the 3 rd shift. The post

order covers responsibilities/requirements/duties of staff such as equipment, countprocedures, and key control. The facility also maintains other FOPs (i.e.

Instructions for other shifts, Intake procedures and Master Control). The facility

did not provide any post orders specifically addressing certain posts (i.e.Maintenance Shop, and indoor and outdoor recreation areas) within the facility.

No Post Order Signature sheets were maintained with the reviewed FOP/Post

Orders.


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July 2010

RECOMMENDATIONS

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

Develop specific post orders for applicable assignments and posts within the

facility (i.e. Fire Safety Officer, Key Control Officer, Indoor/Outdoor Recreationsareas and Maintenance shop).

Maintain Post Order Signature forms for post orders distributed to staff.


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July 2010

STAFF TRAINING RATING: Satisfactory 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 accordance

with departmental guidelines. Training is designed for continuous development of skills

related to job specific learning objectives.


DJS Training Histories report


Interview with Training Coordinator

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

SUMMARY OF FINDINGS:

Staff indicated in interviews that they were trained in CPM twice yearly.

Mechanical restraints are covered semi-annually in CPM training.

Of 19 mandated staff, 19 (100%) were reviewed for training compliance:

-- 18/19 (95 %) met the 40 hour annual training requirement for 2009.

-- All had CPR/AED training since Jan 2009.

Of the staff who had mandatory training class expectations in the required areas:

-- 9/19 (47%) were compliant with Crisis Prevention and Management semi-

annual training (100% had CPM training at least once in the last year)

-- 19/19 (100%) were compliant with Suicide Prevention annual training-- 19/19 (100%) were compliant with Recognizing and Reporting Child Abuse

and Neglect annual training

The Training Coordinators training calendar ensures all staff will not only havewell over the number of required hours, but will also meet all expectations by the

end of 2010. The calendar contains a spring and fall CPM block which is an

excellent addition to ensure staff make their semi-annual requirement.


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July 2010

RECOMMENDATIONS

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

Ensure annual training schedule is being met/followed and ensure all staffneeding required semi-annual CPM trainings attend. The facility was very close toa Superior Performance rating and is to be commended.


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July 2010

ADMISSIONS, INTAKE & RATING: Satisfactory Performance

STUDENT HANDBOOK

STANDARDWritten policy, procedure, and practice provide that the admissions process in each

detention is operated on a 24 hour basis. The admissions process documents all required

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



Interview with Superintendent

Interview with intake staff

Review of youth screening tools

Review of youth base files

REFERENCESAdmissions and Orientation Policy RF-03-07; Maryland Standards for Juvenile Detention

Facilities; 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. Court orders and face sheets were

completed for 100% of all files reviewed. Classifications were not in all files. Handbook acknowledgement forms were found in 70% of files reviewed,

however youth indicated that the rules are read to them upon admission. This is

good practice but handbooks should be routinely provided and youth should have

a copy to keep and refer to per the DJS detention standards.

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

Actual names of mental health staff and others who may leave the facility shouldbe removed from the handbook or be updated regularly. Any incentives not

offered (such as facility outings or game nights) should also be removed.

The MAYSI is completed within two hours of admission. Intake staff interviewed

knew how to score the MAYSI and did so. 100% of files had a completedMAYSI. Intake staff indicated she looked at MAYSIs for all No answers and

ensured youth re-took the test or mental health was notified if this was found.

SASSI is completed within seventy-two hours of admission. 100% of all files hada SASSI present. Staff are not trained to give or score the SASSI; substance abusestaff do this later but not within two hours of the youths arrival.


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July 2010

The FIRRST is completed upon the youths arrival but often after the Custodysign-off is completed. The FIRRST should be completed before custody is signed

for and the youth not accepted until he screens negative on all questions. This wasdiscussed with the facility and can be easily switched and remedied. 100% of

files had a FIRRST screening form present.

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

Due to Carters small size, there is no formal Orientation unit.

RECOMMENDATIONS

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

Ensure SASSI is taken and scored within two hours per policy. Understandingthat it will take time to train staff to do so if there is no substance abuse staff on-

site, consider training Intake staff to at a minimum give the test and scan SASSI

results for youth who may be susceptible to de-toxing while in custody. Medicalstaff may be helpful in this regard and should confer with Intake staff if results

look suspect.

Switch the FIRRST and Custody sign off process so that the FIRRST is done first.

Ensure all youth are given a copy of the handbook to keep or at a minimum that acopy of the entire handbook is laminated and available in the main dayroom area

for youth to refer to. Ensure before doing so that all aspects of the handbook areup to date.


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July 2010

CLASSIFICATION RATING: Partial 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, present

legal charge and special needs


Interview with Case Management staff

Review of Intake packet


Observation at the facility

Review youth base files

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 facility maintains a Classification System FOP dated 01/02/09.

The facility does not double bunk youth.

Interviews with the Case Management staff, along with a review of 8 randomlyselected Housing Classification Assessment (initial) forms revealed that 6 of the

forms were incomplete. One youth had been in the facility for 29 days and had

not been properly classified pursuant to policy. Interviews with staff revealed thatnot all staff have access to ASSIST and therefore are unable to complete the

forms. If ASSIST is not accessible, staff attempt to classify youth based on age,physical size, type of charges and level aggression until a proper classification can

be made.

The facility does not maintain a Housing Plan that identifies low, medium andhigh supervision rooms. The physical structure of this facility makes properclassification less crucial than at larger sites as there are only two small hallways

in which to assign youth to rooms. Staff assign youth who need higher levels ofsupervision to rooms located closer to the staffs station. This should simply be

memorialized in a Housing Plan.

RECOMMENDATIONS

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

Develop a Housing Plan and train staff.

Ensure staff responsible for completing the Housing Classification Assessmentforms have access to ASSIST or that the forms are completed as soon as possible.


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July 2010

PENDING PLACEMENT RATING: No Rating

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 aggressively

prioritizes these youth in order to assist the community case managers in placing them as

quickly as possible in order to reduce time in detention.


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July 2010

BEHAVIOR MANAGEMENT RATING: Satisfactory 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 Log Books

Review of Daily Point Sheets


Interviews with of direct care staff

Review of the Student Handbook

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

SUMMARY OF FINDINGS

The Behavior Management Program (BMP) at Carter allows youth to progressthrough four levels (Level 1 - Level 4). A review of the facilitys BMP found that

both staff and youth had a good understanding of how the program works; thisinformation was revealed during interviews with 14 youth and 6 staff.

The total number of points a youth earns daily is posted on each unit. This allowsboth staff and youth to know the current number of points/level earned by a

youth. The youth generally found staff to be fair and consistent when deducting points

and that the grievance (or appeals) process was available to them if they felt theirpoints were taken unfairly.

Based on interviews with staff and a review of memorandums and FOPs, staff areprovided training in the use of the BMP system.

No computation errors were noted to the point sheets reviewed. The point sheetwas very easy to understand. Points lost for infractions as well as activities

purchased were identified on the youth point sheets.

One of the chief behavior management strategies employed at Carter is thecriminal charging of any youth who assaults another youth. Youth are told when

they arrive that this is Carters policy. Carter follows through as well; charginginformation forwarded to Maryland State Police was evident in the IR files. Thisconsistency and consequence-driven strategy is excellent and the facility is to be

commended.

Some activities listed in the written BMP were not all being done and should beremoved if not offered. A new activity (Carter After Dark) was added. The youthwere very excited about this new activity.


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July 2010

The use of early bed violates DJS seclusion policy. Carter staff interviewednoted that group punishment was not a part of the behavior management at the

facility and that early bed was not used as punishment, but some indicated8:15pm was a bedtime that was used as a sanction for youth. Though this

comports with the Level I bedtime, it was unclear if this was a permanent level

drop or a temporary sanction just for the night.

RECOMMENDATIONS

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

Identify in writing the behavior that will cause a youths points to be frozen sothat staff cannot freeze points in an arbitrary way. The criteria for frozen points

should be detailed in the Behavior Management Program and the StudentHandbook.

Remove the activities no longer offered by the facility from the BehaviorManagement Program and the Student Handbook and update both to include all

current incentives.

If an earlier (Level I) bedtime is used as a temporary sanction, include that in theBMP and Student Handbook; ensure such use is not arbitrary by requiringauthorization and having a written criteria in order to ensure fairness for all youth.


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July 2010

STRUCTURED REHABILITATIVE RATING: Partial Performance

PROGRAMMING

STANDARDWritten policy, procedure and practice document that youth receive planned, structured

outdoor and indoor activities and regular rehabilitative programming that teaches social

skills.

SOURCES OF INFORMATIONReview of Unit Log Books

Review of the Master ScheduleInterviews with direct care staff


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

SUMMARY OF FINDINGS

Youth indicated that they participate in World of Books, movie nights and otherstructured activities at Carter.

Interviews with youth and staff and logbook review indicated that some but notall of the scheduled activities at the facility occurred as outlined on the master

schedule however.

In addition, a QI reviewer arrived to meet the unit at a scheduled ART group thatdid not ever occur. Upon observing an Empowerment Group, not only did the

program not last for the time indicated, but it was evident that the facilitator wasnot prepared for the session. The youth were not expecting it to occur and had

begun to play cards and board games when the facilitator arrived.

Interviews with youth and staff, observations and logbooks indicated that theyouth get at least one hour of recreation per day and two hours of recreation onweekends. Youth and staff report that recreation frequently occurs outside

whenever the weather permits.

However, because the Carter Center is so small, the inside space designated forrecreation is very limited. The exercise room contains one modular exercise

station on which youth are able to do pull ups, dips and other calisthenics. The

room also contains hula hoops, a climbing wall and weighted exercise balls. As analternative to the exercise room the youth may choose to play games in the game

room. Students who choose this option do not get the required large muscle

movement

Youth are offered religious services, but there is not an alternative for youth whochoose not to participate.


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July 2010

RECOMMENDATIONS

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

Revise the schedule to accurately reflect programming at the facility.

Explore more exercise equipment options for the youth in the facility to useduring times when outdoor recreation is not available.

Offer concurrent secular programming, even if just arts and crafts, as analternative to religious services.


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July 2010

SELF ASSESSMENT RATING: No Rating

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 status

involving the use of seclusion, restraints, incident reporting numbers and procedures and

other key area of facility operation in order to assess the facilitys compliance with DJSnorms and expectations.


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July 2010

BEHAVIORAL HEALTH

INTAKE, SCREENING& ASSESSMENT RATING: No Rating

STANDARD

Written policy, procedure, and practice require that all youth admitted to a facility willbe screened by qualified mental health professional in a timely manner using valid and

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

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

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

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

safely treat, will be referred to a setting that can more appropriately meet the youth

needs.

DUE TO THE LACK OF A BEHAVIORAL HEALTH QI REVIEWER, THISSTANDARD COULD NOT BE ASSESSED.


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July 2010

INFORMED CONSENT RATING: No Rating

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

guardian, are informed of the risk, benefits, and side effects of medication and the

potential consequences of stopping medication abruptly. Youth are also notified that

their conversation with clinician, though confidential, may be shared with DJS and theCourt if requested.

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

STANDARD COULD NOT BE ASSESSED.


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July 2010

PSYCHOTROPIC MEDICATION RATING: No RatingMANAGEMENT

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

prescribed, distributed, and monitored safely.




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July 2010

BEHAVIORAL HEALTH SERVICES RATING: No Rating

& 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.




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July 2010

TREATMENT PLANNING RATING: No Rating

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.




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July 2010

TRANSITION PLANNING RATING: No Rating

STANDARDWritten policy, procedure, and practice requires staff to facilitate appropriate transition

plans for youth leaving the facility. Youth, and their guardian when appropriate, should

receive information on behavioral health resources, a prescription for medication

continuation, and assistance in contacting behavioral health aftercare services toschedule follow-up appointments.




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July 2010

SUICIDE PREVENTION

DOCUMENTATION OF YOUTH RATING: Partial Performance

ON SUICIDE WATCH

STANDARDWritten policy, procedure, and practice require that all newly arrived youth, youth in

seclusion, and youth on suicide precautions are sufficiently supervised. Suicide

precaution documentation must include the times youth are placed on and removed from

precautions, the current level of precautions