Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 1 of 10 PAGEID #: 2

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

2008 MAY I b P ): 2 I

THE UNITED STATES OF AMERICA,
Plaintiff,
v.
1. THE STATE OF OHIO; 2. THE HONORABLE TED STRICKLAND,
Governor of the State of Ohio, 3. THE OHIO DEPARTMENT OF YOUTH SERVICES; 4. THOMAS STICKRATH, Director
of Ohio Youth Services; 5. THOMAS TEAGUE, Superintendent
of the Circleville Juvenile Correctional Facility; 6. KATIE NEEDHAM, Superintendent of the cuyahoga Hills Juvenile Correctional Facility; 7. MARCI SUTHERLAND, Superintendent of the Freedom Center; 8. BETH OPRISCH, Acting Superintendent of the Indian River Juvenile Correctional Facility; 9. DION NORMAN, Interim Superintendent of the Marion Juvenile Correctional Facility; 10. LARRY GONGWER, Acting Superintendent of the Mohican Juvenile Correctional Facility; 11. FRED NELSON, Superintendent of the Ohio River Valley Juvenile Correctional Facility; and 12. CHRIS MONEY, Superintendent of the scioto Juvenile Correctional Facility,
Defendants.

) ) ) )
) CIVIL
) )

CTION NO:

; C2
) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )

08 047&
.~

COMPI.AINT

Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 2 of 10 PAGEID #: 3

PLAINTIFF, THE UNITED STATES OF AMERICA ("Plain iff") , by

its undersigned attorneys, hereby alleges upon info ation and belief:

1. The Attorney General files this Complaint n behalf of

the United States, pursuant to the pattern or practi e provision

of the Violent Crime Control and Law Enforcement Act of 1994,

42 U.S.C. § 14141, to enjoin the named Defendants fr m depriving

youth confined in Circleville Juvenile Correctional acility,

Cuyahoga Hills Juvenile Correctional Facility, the F eedom

Center, Indian River Juvenile Correctional Facility, Marion

Juvenile Correctional Facility, Mohican Juvenile Co ectional

Facility, Ohio River Valley Juvenile Correctional F ility, and

scioto Juvenile Correctional Facility (collectively, the

"Facilities") of rights, privileges, or immunities

or

protected by the Constitution and laws of the Unite States.

Jurisdiction, Standing, and Venue

2. This Court has jurisdiction over this act'on pursuant

to 28 u.s.c. §§ 1331 and 1345.

3. The United States is authorized to initia e this action

pursuant to 42 U.S.C. § 14141.

4. Venue in the United States District Court for the

Southern District of Ohio is proper pursuant to 28 .S.C. § 1391.

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Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 3 of 10 PAGEID #: 4 Defendants
5. Defendant State of Ohio ("State") is resp sible for the administration of juvenile justice in the State nd operates, or contracts for the operation of, all juvenile jus ce facilities in the State. This action concerns the ministration of the Facilities, which house youth in State custo who are confined for periods of time established by juvenile county courts.
6 . Defendant Ted Strickland is the Governor Ohio, and in this capacity heads the executive branch of Ohio' government. The Governor of Ohio, as chief of the executive bra h, has the duty to ensure that the departments that compose the executive branch of Ohio government guarantee the federal cons itutional and statutory rights of all of the citizens of Ohio, including the youth confined in the Facilities.
7. Defendant the Ohio Department of Youth Ser ices ( "DYS") establishes the general policy to be followed by its juvenile institutions and contractors; provides leadership in developing programs to rehabilitate youth committed to State tody; and is responsible for the promulgation of all rules and ulations necessary and appropriate to the administration and peration of the Facilities.
8. Defendant Thomas Stickrath is Director of he DYS and, in this capacity, exercises administrative control o , and responsibility for, the Facilities.
-3-

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9. Defendant Thomas Teague is the Superinten nt of the

Circleville Juvenile Correctional Facility and is r sponsible for

the administration and day-to-day operations of Cir

10. Defendant Katie Needham is the Superinten nt of the

Cuyahoga Hills Juvenile Correctional Facility and i responsible

for the administration and day-to-day operations of the Cuyahoga

Hills Juvenile Correctional Facility.

11. Defendant Marci Sutherland is the Superin endent of the

Freedom Center and is responsible for the administr tion and day-

to-day operations of the Freedom Center.

12. Defendant Beth Oprisch is the Acting Supe intendent

of the Indian River Juvenile Correctional Facility

responsible for the administration and day-to-day o

of

the Indian River Juvenile Correctional Facility.

13. Defendant Dian Norman is the Interim Supe intendent of

Marion Juvenile Correctional Facility and is respon ible for the

administration and day-to-day operations of the Mar·on Juvenile

Correctional Facility.

14. Defendant Larry Gangwer is the Acting Sup rintendent of

the Mohican Juvenile Correctional Facility and is r sponsible for

the administration and day-to-day operations of the Mohican

Juvenile Correctional Facility.

15. Defendant Fred Nelson is the Superintende t of the Ohio

River Valley Juvenile Correctional Facility and is esponsible

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for the administration and day-to-day operations of the Ohio

River Valley Juvenile Correctional Facility.

16. Defendant Chris Money is the Superintende of the

Scioto Juvenile Correctional Facility and is respon

for the

administration and day-to-day operations of the Sci to Juvenile

Correctional Facility.

17. The individual Defendants named in Paragr hs 6 and 8

through 16 above are officers of the State of Ohio d are sued

in their official capacity only.

Factual Allegations

18. Defendants are legally responsible, in

part, for the operation of the Facilities and for t

and

safety of the youth confined at the Facilities.

19. Defendants are governmental authorities w·th

responsibility for the administration of juvenile j

or

the incarceration of juveniles within the meaning o 42 U.S.C.

§ 14141.

20. Defendants are obligated to operate the F ilities in a

manner that does not infringe upon the federal righ

protected by the Fourteenth Amendment to the Consti tion of the

United States and by other federal law, of individu ls confined

at the Facilities.

21. At all relevant times, Defendants have ac d or failed

to act, as alleged herein, under color of state law.

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22. Defendants have engaged, and continue toe gage, in a

pattern or practice of failing to ensure that youth t the

Facilities are adequately protected from harm and m undue risk

of harm in the following specific respects, among ers:

a. protection from unwarranted uses of rce;

b. protection from the unwarranted use o seclusion;

and

c. access to a functional grievance syst m and

adequate investigation and processing of

grievances.

23. Defendants have engaged, and continue toe gage, in a

pattern or practice of failing to ensure that youth t the

Facilities have their medical needs met in the foll ing

respects, among others:

a. the identification of health problems and initial

health assessments;

b. the evaluation and treatment of sick esidents;

c. the provision of dental care;

d. the provision services for those wit chronic

illnesses and disabilities;

e. disease prevention and health promot'on; and

f. abuse reporting by medical professio

24. Defendants have engaged, and continue to

in a

pattern or practice of failing to provide adequate ental health

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care and rehabilitative treatment to youth at the

in

the following specific respects, among others:

a. the provision of adequate screening d

assessments;

b. the provision of adequate treatment lanning; and

c. the provision of adequate psychologi

25. Defendants have engaged, and continue to gage, in a

pattern or practice of failing to ensure that eligi le youth with

disabilities at the Facilities receive adequate spe ial education

services.

26. Defendants receive federal financial assi tance and, as

such, are subject to Section 504 of the Rehabilitat'on Act of
1973, 29 u.s.c. § 794, and the regulations promulga ed

thereunder.

27. The youth residing at the Facilities incl de youth with

mental illnesses and other disabilities who fall wi hin the

meaning of "children with disabilities" as defined 'n the
Individuals with Disabilities Education Act ("IDEA"), 20 u.s.c.

§ 1401(3) (a) (1), and "individual[s] with a disabili y" as defined
in Section 504 of the Rehabilitation Act of 1973, 2 u.s.c. §

705 (20).

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Violations Alleged

28. The United States incorporates by referenc the

allegations set forth in Paragraphs 17 through 27 as if fully set

forth herein.

29. The acts and omissions alleged in Paragrap s 22, 23,

and 24 constitute a pattern or practice of conduct at violates

the federal rights, as protected by the Fourteenth endment to

the Constitution of the united States, of youth confined at the

Facilities.

30. Through the acts, practices, and omission alleged in

Paragraphs 25, 26, and 27, Defendants have engaged,

continue

to engage in a pattern or practice of failing to co ly with the

IDEA, 20 u.s.c. §§ 1400-1482, and the regulations p omulgated

pursuant thereto, thereby depriving qualified youth of their

rights under that Act and violating 42 U.S.C. § 141

31. Through the acts and omissions alleged in

25, 26, and 27, Defendants have engaged, and contin e to engage,

in a pattern or practice of failing to comply with

the Rehabilitation Act of 1973, 29 U.S.C. § 794 et

the

regulations promulgated pursuant thereto, thereby d priving

qualified youth of their rights under that Act and egulations

and violating 42 u.s.c. § 1414l(a).

32. Unless restrained by this Court, Defendan s will

continue to engage in the acts and omissions set fo th in

Paragraphs 22 through 25 that deprive youth confine at the

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Facilities of rights, privileges, or immunities secu ed or

protected by the Constitution of the United States a d federal law, and will cause irreparable harm to these youth.
PRAYER FOR RELIEF

33. The Attorney General is authorized,

t to

42 U.S.C. § 14141, to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Co rt enter an
order: a. Declaring that the acts, omissions, and pra tices of

Defendants set forth in Paragraphs 22 through 25 ab e constitute

a pattern or practice of conduct that deprives the cilities'

youth of rights, privileges, or immunities secured protected

by the Constitution or laws of the United States, a that those

acts, omissions, and practices violate the Constitu ·on and laws

of the United States;

b. Permanently enjoining Defendants, their off·cers,

agents, employees, subordinates, successors in offi , and all

those acting in concert or participation with

om

continuing the acts, omissions, and practices set f th in Paragraphs 22 through 25 above, and requiring Defen nts to take such actions as will ensure that lawful conditions f confinement are afforded to youth at the Facilities; and

c. Granting such other and further equitable elief as the Court may deem just and proper.

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Case: 2:08-cv-00475-ALM-MRA Doc #: 2 Filed: 05/16/08 Page: 10 of 10 PAGEID #: 11 •
Respectfully subm tted,

GREGORY G. LOCKHART

United States Attorney

southern District of Ohio

303 Marconi Boulevard

Suite 200

Columbus, OH 43215

(614) 469-5715

.

;

~~~

/;}

:I

/ / ·~~ /J

I

Assistant United states Attorney
Southern District of Ohio 303 Marconi Boulevard Suite 200 Columbus, OH 43215 (614) 469-5715
(614) 469-5240
Mark.Dalessandro®usdoj.gov

GRACE CHUNG BECKE Acting Assistant ttorney General Civil Rights Divi ion
SHANETTA Y. CUT Chief Special Litigati
BENJAMIN O. TAYL Special Counsel Special Litigati n Section GREGORY GONZALEZ STACEY K. GRIGSB Trial Attorneys u.s. Department f Justice Civil Rights Div sion Special Litigati n Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 514-6255

- 10 -

 IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

THE UNITED STATES OF AMERICA, Plaintit1:
v.
THE STATE OF OHIO, et aL
Defendants.

) ) CIVIL ACTION NO: ) 2:08-cv-475 ) ) JUDGE ALGENON L MARBLEY ) ) ) )

JOINT MOTION AND IPROPOSEDI ORDER FOR ENTRY OF STIPULATION AND FOR CONDITIONAL DISMISSAL OF COMPLAINT
The Parties jointly move this Court to enter as its Order the attached Stipulation resolving the United States' claims in this matter as to Scioto Juvenile Correctional Facility (,'Scioto") and Marion Juvcnile Correctional Facility ("Marion") and, separately, to conditionally dismiss the United States' complaint in this matter (Docket ("Dk!.") # 2) as to the remaining 'IX state-operated juvenile correctional facHities that are subject to this litigation (collectively, "State-Operated Juvenile Correctional Facilities").' In support of this motion, the Panics state as follows: I. On May 16. 2008, the United States filed a complaint alleging the existence of ongoing
violations offedcral law regarding conditi(lns of contlnemcnt in all eight Stale-Operated Juvenilc Correctional Fa..:ilities.

The six remaining lilcililies arc: Circkville Juveniic Correctional Facility; Indian River Juvenile Correctional Facility; Cuyaboga Hilb Juvenile Correctional Facility; Mohican Juvenile Corrcclional Facility; Ohio River Valley Jllvenile CillTcctional Facility; and the Freedom Center.

-2· 2. Also on May 16,2008, in the related case ofS.H. v. Taft, No. 2:04-cv-1206, also pending
before this Court, the United States tiled a Motion to Intervene and Request for Continuance of the May 21, 2008 Fairness Hearing ("Intervention Motion"). On May 18, 2008, plaintills in~.JI. tiled Plaintiffs' Response to Department of Justice Motion to Intervene ("Plaintiffs' Response"), (SJ:l Dkt II 102) stating that plaintiffs did not oppose
the United States' intervention in SJi. but did oppose a continuance of the fairness
hearing. Plaintiffs' Response at I. On May 20, 2008, plaintiffs in amended their position and filed a Supplemental Memorandum, in which plaintiffs opposed the United States' Intervention Motion (S.H. Dkt II \o7). Also on May 20, 2008, the defendant in S.H. filed its Memorandum in Opposition to the United States of America's Motion to Intervene & Motion to Continue Fairness Hearing (S.H. Dkt # 106). 3. Before the filing of the complaint herein, the United States and Detendants had engaged in negotiations to resolve the United States' claims. After the tiling oflhe complaint in this matter and the Intervention Motion in S.tt. the Parties, assisted by class counsel in S.H., engaged in Court-facilitated negotiations that led to the Parties' agreement resolving thc complaint herein and the Intervention Motion in!i.l:i Pursuant to that agreement, thc United States withdrew its Intervention Motion on May 2 I, 2008, during the fairness hearing m S.H., subject to the following terms, which were confirmed at the fairness hearing by the Defendants: A. The Court approve and enter as ils Order the attached Stipulation, resolving the
United States' claims herein as to Scioto and Marion; and

-3B. The Court conditionally dismiss the United States' complaint as to the remaining

State-Operated Juvenile Correctional Facilities, subject to the following tenus:

I.

The Defendants shall provide the United States, for review and comment,

all DYS policies associated with conditions of confinement at the State-

Operated Juvenile Correctional Facilities;

II. The United States shall have unfettered access to the Monitor and to the

DYS Compliance Coordinator in S.H.;

Ill. Thc Defendants shall provide the United States with copies of all

performance data gathered by the Monitor in . and

IV. The Defendants shall provide the United States with copies of any reports

prepared by the Monitor in S.H.

ACCORDINGLY, the Parties request that the Court enter the attached Stipulation as its

Order and, subject to the foregoing terms, conditionally dismiss the United States' complaint as

to CirclevIlle Juvenile Correctional Faeihty, Indian River Juvenile Correctional Facility,

Cuyahoga Hills Juvenile Correctional Facility, Mohican Juvenile Correctional Facility, Ohio

River VaHey Juvenile Correctional Facility, and the Freedom Center.

FOR THE UNITED STATES:
GREGORY G. LOCKHART United States Attorney Southern District of Ohio
MARK T. D'ALESSANDRO Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard Suite 200 Columbus,OH 43215
FOR THE DEFENDANTS Sf J Eric Holloway J. ERIC HOLLOWAY Assistant Attorney General Corrections Litigation Section 150 East Gay Street, 16th Floor Columbus.OH 43215 Telephone: (614) 644-7233 Facsimile: (614) 728-9327

-4DATE:

June 5, 2008

GRACE CHUNG BECKER Acting Assistant Attorney General Civil Rights Division
SIlANETTA Y. CUTLAR Chier Special Litigation Section
Sf Gre~ory Gonzalez BENJAMIN O. TAYLOE, JR. Special Counsel Special Litigation Section GREGORY GONZALEZ STACEY K. GRIGSBY Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, KW. Washington. D.C. 20530 Telephone: (202) 514-6255 Facsimile: (202) 514-0212 Email: Gregory.Gonzalcze':/lllsdoj.gov

-5WHEREFORE, for good cause shown, it is SO ORDERED.

 Case 2:08-cv-0047S-ALM-MRA Document 23 Filed 11/23/09 Page 1 of 6

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, Plaintiff, v.
THE STATE OF OHIO, et ai., Defendants.

) ) ) ) ) CIVILACTIONNO: ) 2:08-cv-475 ) ) JUDGE ALGENON L. MARBLEY )

S.H., and all other similarly situated,

)

et ai.,

)

)

Plaintiffs,

)

)

v.

) CIVIL ACTION NO:

) 2:04-cv-1206

TOM STICKRATH,

) ) JUDGE ALGENON L. MARBLEY

Defendant.

)

-----------------------------)

PrQposed Modifications to the Stipulation for Injunctive Relief in U.S.A. v. Ohio

In response to the resignation by Fred Cohen as Monitor in the USA v. Ohio case, (See Doc.

143-1), the United States, through the Department of Justice ("DoJ''), the State of Ohio, through

the Department of Youth Services (''DYS'' or "the State"), and the Plaintiffs in the S.H. v. Stickrath

litigation (collectively, "The Parties'') agree to the following changes to the Stipulation for Injunctive

Relief in the instant case, (Doc. 8). That Stipulation now addresses conditions of confinement at

only one juvenile facility in Ohio, namely the Scioto Juvenile Correctional Facility because the

Marion Juvenile Correctional Facility has been closed by the State of Ohio.

Case 2:08-cv-0047S-ALM-MRA Document 23 Filed 11/23/09 Page 2 of 6
V. Monitoring
The following language replaces the original Sections V.A. and V.B. of the instant Stipulation.
A. Monitor and Consultant Selection) Reporting and Removal
1. By their original terms, the instant Stipulation for Injunctive Relief ("Stipulation") and the agreement in the S.H. v. Stickrath class action ("S.H. litigation") (See Docs. 92-4 and 108 therein) fashioned a unitary monitoring system. Specifically, Fred Cohen has been the sole monitor in both this case and in the S.H. litigation. However, on September 24, 2009, Fred Cohen submitted his resignation as the Monitor in U.SA. v. Ohio. In response, the United States, through the Department of]ustice ("Dor), the State of Ohio through the Department of Youth Services ("DYS" or "the State"), and the Plaintiffs in the S.H. v. Stickrath litigation intend to establish a separate monitoring system in USA. v. Ohio which neither interferes nor conflicts with the monitoring system in the S.H. litigation.
2. Effective immediately, the United States shall serve as the Monitor in USA v. Ohio, using Dr. Kelly Dedel as its lead expert consultant. A copy of Dr. Dedel's curriculum vitae is attached as Exhibit A hereto.
2.1 The Monitor and any consultants selected to assist in monitoring remediation efforts shall coordinate their monitoring activities in this matter with the State to minimize conflicting schedules or other undue burdens on the State. As such, absent exigent circumstances, no site visits by the two sets of Monitors or their respective consultants or subject matter experts should be scheduled so as to occur on the same day or near in time to one another, unless the State consents to such scheduling.
2.2 Dr. Dedel will conduct monitoring activities pertaining to Sections III. A and IILD-G of this Stipulation (protection from Harm, Grievance Process, Special Education, Programming, and Documentation, respectively). Dr. Dedel will coordinate preparation of all reports required under Section VI of this Stipulation.
2.3 A mental health consultant, agreed to by Do] and DYS, will assist the Monitor as a consultant to oversee monitoring activities pertaining to Section III.B (Mental Health) of this Stipulation. The agreed mental health consultant will provide substantive information to the Monitor to complete the reports required under Section VI of this Stipulation as to mental health terms set forth in the instant Stipulation (Doc. 8).
2.4 Do] and DYS agree that the need for a consultant for general medical care under Section IILC (general medical care) of the Stipulation will be assessed as follows.
2.4.1 All available files, documents, and data that the State has conveyed to date to or for Dr. Ronald Shansky, M.D., Dr. Donald T. Sauter, or
2

Case 2:08-cv-0047S-ALM-MRA Document 23 Filed 11/23/09 Page 3 of 6
Dr. Nick Makrides, shall be conveyed to the lead expert consultant by the State, along with any reports that Dr. Shansky, Dr. Donald T. Sauter, or Dr. Nick Makrides, has prepared.
2.4.2 Such files, documents and data shall be conveyed within thirty (30) days of the Court's acceptance of these modifications to this Stipulation.
2.4.3 The lead expert consultant may select a qualified medical consultant, who is familiar with the delivery of medical care in a correctional setting, to conduct this review.
2.4.4 Within two (2) months of receiving the documents and data referenced above, the lead expert consultant shall prepare a report that concludes whether any additional monitoring activity for the area of general medical care is required at all, given the work to date by Dr. Shansky, and the ongoing monitoring efforts in the S.H. litigation. If the Monitor also concludes that additional monitoring is needed as to general medical at Scioto Juvenile Correctional Facility, the Monitor must prepare a report to that effect.
2.4.5 In the Monitor's report regarding additional monitoring efforts needed as to general medical care, the Monitor must specifically identify the discrete areas under the Stipulation in this case that require additional monitoring. The report also must state why such additional monitoring is required. The Monitor's report as to such additional monitoring efforts must be supported by the findings of the lead expert consultant and any other consultant relied upon by the lead expert consultant to conclude additional monitoring activities are needed.
2.4.6 As to any discrete area of general medical so identified by the Monitor in paragraph 2.4.5, Do] and DYS will confer to identify a consultant to work with the Monitor on all of the discretely identified areas of general medical care that need additional monitoring.
3. All Monitor and Consultant Reports shall be provided to Do], DYS and counsel for the Plaintiff class in the S.H. litigation in draft form for comment at least two weeks prior to their issuance. These reports shall be written with due regard for the privacy interests of individual youth and staff and the interest of the State in protecting against disclosure of non-public information.
4. Upon one of three grounds, the Monitor or any consultant assisting the Monitor may be removed from their respective positions on the monitoring team.
4.1 The Monitor or any consultant may be terminated from their duties as Monitor or consultant for good cause, either by prior notice to such Monitor or consultant and the stipulation of Do] and DYS or by order of the Court pursuant to a motion filed by Do] and DYS.
3

Case 2:08-cv-00475-ALM-MRA Document 23 Filed 11/23/09 Page 4 of 6

4.2. If DYS detennines in good faith that the monitoring process has become unduly burdensome, then DYS may give written notice to Do] and to Plaintiffs in the S.H. v. Stickrath litigation of such undue burden being imposed by either the Monitor or consultant.

4.2.1 Such Monitor or consultant shall have thirty (30) days to correct any such undue burdens. If, after such time, DYS concludes that undue burden on the monitoring process has not been alleviated, then it may notify Do], and the Plaintiffs in the S.H. v. Stickrath litigation and the pertinent Monitor or consultant that their services in this matter have ended.

4.2.2. After the removal of a consultant pursuant to the preceding paragraph, Do] and DYS shall agree upon a replacement for the consultant. They shall agree within thirty (30) days, or more if agreed to by both Do] and DYS. If no replacement can be agreed upon, then the procedures in paragraph 5 below will apply, except that only Do] and DYS will select the replacement for the consultant.

4.3. If either DYS or the class Plaintiffs in the S.H. litigation detenrune in good faith that the monitoring process in this case has resulted in conflicting standards for DYS to attain constitutional conditions of conftnement, then either such party may seek a court order in this case to remove the Monitor or any consultant selected by the Monitor. The reasonably supported results of any monitoring report may not constitute good faith grounds to seek the removal of a Monitor or a consultant to the Monitor.

4.4. If any consultant resigns, then Do] and DYS must confer to name a replacement. They shall name a replacement within thirty (30) days, or more if both Do] and DYS agree. If no replacement can be agreed upon, then Do] and DYS each will submit two names, along with resumes and cost proposals, to the Court.

5. Should the position of Monitor become vacant after the implementation of these modiftcations to the Stipulation in this case, Do], DYS, and the Plaintiffs in the S.H. Litigation shall confer regarding the selection of a new Monitor. If they are all unable to agree within thirty (30) days of the vacancy occurring, they each will submit two names, along with resumes and cost proposals, to the Court. A vacancy occurs upon the removal by notice of the Monitor, as set forth above, by Court order, or upon the Court's acceptance of a written letter of resignation from the Monitor.

6.

Subject to the terms in paragraphs 2.4 (to include paragraphs 2.4.1 to 2.4.6.) and 4,

Do], DYS, and the Plaintiffs in the S.H. v. Stickrath litigation agree that no other

Monitors or consultants will be used to conduct monitoring activities. This does not

bar either the Monitor or any approved consultant from retaining a sub-expert for

additional input. However, the State has no obligation to permit such sub-experts to

tour any facilities subject to this Stipulation. Further, the State has no obligation to

respond to any request for documents, files, or data of any kind from such sub-

expert.

4

Case 2:0a·cv·00475-ALM-MRA Document 23 Filed 11/23/09 Page 5 of 6

B. Cost of monitoring. Only for as long as it functions as the Monitor, DoJ will bear the costs of the Monitor and any consultants or sub-experts retained to assist with monitoring activities.

VII. Implementation. Enforcement. and Termination

D. Enforcement and Dispute Resolution. Any dispute regarding the terms or
implementation of this Agreement, or the Monitor's compliance determinations, shall be resolved pursuant to VILD of the Stipulation in U.SA. v. Ohio (Doc 8), specifying that DoJ and DYS shall use the dispute resolution mechanism in the S.H. litigation, (para 256 of Docs. 92-4 and 108 in that case) to resolve the dispute. The Plaintiff class in the S.H. litigation may be a party to any such dispute solely for the purpose of protecting the interests involving the S.H. class.

VIII. Miscellaneous

A. Non-waiver oflegal rights. Notwithstanding the modifications set forth above to the instant Stipulation, (Doc. 8), none of the Parties has waived any right to assert at a later time any remedy for relief or modification to the instant Stipulation, (Doc. 8), that could have been otherwise asserted, absent the ability to reach the agreement reflected within this set of modifications to that Stipulation.

B. No further modifications. DoJ, DYS, and the Plaintiffs in the S.H. v. Stickrath litigation agree that no other terms in the instant Stipulation for Injunctive Relief, (Doc. 8), are being altered by this modification.

IT IS SO STIPULATED AND AGREED.

FOR THE UNITED STATES:

Date: November 23, 2009

Carter M. Stewart United States Attorney Southern District of Ohio 303 Marconi Boulevard Suite 200 Columbus,OH 43215 Telephone: (614) 469-5715
Mark T. D'Alessandro Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard Suite 200 Columbus,OH 43215 Telephone: (614) 469-5715 Facsimile: (614) 469-5240 Email: Mark.Dalessandro@usdoj.gov

Thomas E. Perez Assistant Attorney General Civil Rights Division
Shanetta Y. Cutlar Chief
sl Benjamin O. Thyloe,Jr. BENJAMIN O. TAYLOE,JR. Special Counsel Silvia J. Dominguez Vincent P. Herman Trial Attorneys Special litigation Section Civil Rights Division U.S. Department ofJustice 950 Pennsylvania Avenue, NW Washington, DC 20530

5

Case 2:08-cv-0047S-ALM-MRA Document 23 Filed 11/23/09 Page 6 of 6

Telephone: (202) 514-8103 Facsimile: (202) 514-4883 Email: Benjamin.Tayloe@usdoj.gov Attorneys for Plaintiff

FOR THE STATE:
RlCHARD CORDRAY Ohio Attorney General
sI J. Eric Holloway J. ERlC HOLLOWAY (0063857)
Assistant Attorney General Criminal Justice Section Ohio Attorney General Richard Cordray 150 East Gay Street, Suite 1600 Columbus, OH 43215 (614)-644-7233; Fax: (866) 459-6675 Email: Eric.Holloway@OhioAttomeyGeneral.gov
FOR THE PLAlNTIFFS IN S.H v: STICKRA1H
sl Alphonse A. Gerhardstein ALPHONSE ADAM GERHARDSTEIN Gerhardstein & Branch Co. LPA 617 Vine Street #1409 Cincinnati, OH 45202 (513)-621-9100 Fax: (513)-345-5543 Email: agerhardstein@GBfinn.com

Date: November 23,2009 Date: November 23, 2009

WHEREFORE, for good cause shown, it is SO ORDERED.

6

 Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 1 of 27 PAGEID #: 60

IN THE CNITED STATES DISTRlCT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

CNITED STATES OF AMERICA, Plaintiff,
V,
THE STATE OF OHIO, ct aL, Defendants.

) ) ) ) ) ) CIVIL ACTION NO: ) 2:08-cv-475 ) ) JUDGE ALGENON L. MARBLEY
)
) STIPULATION FOR ) INJUNCTIVE RELIEF

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TABLE OF CONTE1'.1S

L

INTRODUCTION .....................................................................................................!

IL DEFlNIT!ONS ............................................................................................................. 2

III. SUBSTANTIVE REMEDIAL MEASURES ...............................................................5

A. PROTECTION FROM HARM ........................................................................ 5

B. MENTAL HEALTH CARE ......... . ............................................................6 C. GENERAL MEDICAL CARE ........................................................................ !! D. GRIEVANCE PROCESS .............. . .......................................................... 12 E. SPECIAL EDUCATION ............................................................................... 13

F. PROGR.A.MMING ......................................................................................... 15
G. DOCUME:\TATIO:\ ...................................................................................... 16
IV. COMPLIANCE COORDINATION, POLICIES, TRAINING. AND QUALITY ASSURANCE/ QUALITY IMPROVEMENT ........................................................... !?

V. MO:\JTORING......................................................................................................... 18

VI. REPORTING REQU!REMENTS AND RIGHT OF ACCESS ..................................20 Vll. IMPLEMENTATION, ENFORCEMENT, AND TERMINATION ..........................20

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I. INTRODUCTION

A. This Stipulated Judgment is entered into by the parties to resolve all the claims in this action against all Defendants as to the Scioto Juvenile Correctional Facility and the Marion Juvenile Correctional Facility. The United States' claims concerning the remaining six facilities are resolved pursuant to the Court's Order conditionally dismissing the Complaint. [Dkt. ].

B. On March 16, 2005, the United States Department of Justice ("DOJ") notified the State of Ohio (the "State") of its intent to investigate conditions of confinement at the Scioto Juvenile Correctional Facility ("Scioto") in Delaware, Ohio, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, and the Violent Crime Control and Law Enforcement Act of 1994,42 U.S.C. § 14141. Thereafter, on Aprill5, 2005, DOJ notified the State of its intent to conduct a similar investigation at the Marion Juvenile Correctional Facility ("Marion") in Marion, Ohio.

C. In response, the Stale of Ohio, through the Department of Youth Services ("DYS"), indicated that it intended to cooperate with the DO.l investigation, that it had determined that significant ehanges needed to be and would he made, and that it was embarking on a master plan to change the culture and conditions at Scioto and Marion.

D. In this regard, before the DOJ opened its formal investigations of Scioto and Marion (collectively, the "Facilities"), the State hired Fred Cohen, a juvenile justice expert, to assess conditions at the Scioto facility. In August 2004, Mr. Cohen and his team of experts issued findings (the ''Cohen Report"), a copy of which was provided to DOJ. Among other things, the Cohen Report addressed issues regarding protection from harm, medical care, mental health care, and special education at Scioto.

E. From June 27 to JLJly I, 2005, DOJ toured Scioto and Marion with consultants in the fields of medical care and mental health care. A tour of Marion's special education program took place trom July 19 to July 20, 2005.

F.

Throughout the course of the investigation, the State has cooperated with DOJ,

providing access to stafC youth, and docmncnts at both Facilities.

G. On May 9, 2007, DOJ issued fmdings letters, pmsuam to 42 U.S.C. § 1997(a)(l), that concluded that certain conditions at Scioto and Marion violated the constitutional and federal statutory rights of youth confined in the Facilities.

H. The State has indicated that it is finnly committed to providing legally adequate conditinns by lnstituting the remedial ml:asurcs required by tbl~ Stipulation and
that. in many \\"'-l}'S. this Stipulation rormnlizes what had lleen C1grccd tn in
principal in the past and what the DYS rep011edly already has under ''"Y·

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I.

The State represents that it is participating in a collaborative manner with

plaintiffs' counsel in S.H, eta/. v. Stickrath, Case No. 2:04CV1206, which is

currently pending in the United States District Court for tbe Southern District of

Ohio, and that, in the S.H case, the State has elected to implement additional

remedial measures beyond those required to resolve issues raised by the DOJ

findings.

J.

No person or entity is intended to be a third-party beneficiary of the provisions of

this Stipulation for purposes of any civil, criminal, or administrative action, and

accordingly, no person or entity may assert any claim or right as a beneficiary or

protected class under this Stipulation. Notwithstanding the foregoing, DOJ and

the State agree that tbe terms of this Stipulation may be incorporated into tbe

Stipulation for Injunctive Relief resolving the S.II. case.

K. The court finds that this Stipulation satisfies the requirements of 18 U.S.C. § 3626 (a)(l)(A) and shall retain jurisdiction to enforce its terms. The court shall have the power to enforce the Stipulation through specific performance and all other remedies permitted by law.

JL DEFINITIONS

In this Stipulation, tbe following definitions apply:

A. '"Abuse and neglect" shall mean any act or failure to act as caretaker that results in death or physical or emotional injury that harms or threatens to harm a youth's health or welfare.

B. '"DOJ" means the United States Department of Justice, which represents the United States in this matter.

C. '"DYS'' means the Ohio Department of Youth Services.

D. "Effective Date" means the date by which this Stipulation has been signed by representatives for each of the pm1ics to this Stipulation

E. "'lEP" means an Individual Education Plan as defined by the Individuals with Disabilities Education Act (IDE/\), 20 U.S.C.A. ~~ 1400-1482 (West2000 & Supp. 2006), and the regulations promulgated thereunder.

F.

'·Facilities" means Scioto and Marion, col icc lively.

G. ''Implement" means to give practical effect and ensure actual fulfillment by cnnL:rctc measures. including appropriate training of relevant staff

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H. "Include" or "including" means "include, but not be limited to" or "including, but not limited to."

I.

"JCOs" mean the Juvenile Correctional Officers who work at Scioto and Marion.

J.

"Marion" means the Marion Juvenile Correctioml Facility located at 332 Marion

Williamsport Road, Marion, Ohio, and any facility that is built to replace or

supplement Marion.

K. "Over-familiarity" means any inappropriate or unduly intimate or informal conduct between juveniles and staff or employees including conduct that may lead to a romantic or sexual relationship, such as exchanging letters, providing special f~tvors, or inappropriate touching.

L. "Qualified mental health professional" means a mental health care provider sufficiently trained and currently licensed lo provide the services he or she undertakes lo provide.

M. "Quality Assurance/Improvement Program" means a system of selt~auditing and improvement to assess the implementation and effectiveness of all remedies instituted pursuant to this Stipulation, to identify deficits that may exist, and to effectuate new measures to cure deficits identified.

N. "Rehabilitative Services'' means programming and treatment provided to all youth in lhe Facilities. For each youth, programming and treatment shall be suitable to the youth's particular needs, shall address the underlying causes for the youth's confinement, and shall be designed to restore the youth's socially acceptable behaviors and values.

0. '"'Rcslraints" n1eans any chemical or mechanical device used to control the behavior of a youth.

P. "Scioto" means the Scioto Juvenile Correctional Facility located at5993 Home Road. Delaware. Ohio, and any fi1cility that is built to replace or supplement Scioto.

Q. "Seclusion" "seclude'· and ..secluding" mean isolating a youth in a room !'rom
which the youth's ability to egress is blocked. The term seclusion docs not apply
or lO locking a youth in a room during normal hours sleep.

R.

"Serious Incidents" means: usc of f~n-cc; injuries requiring more than Jirst-:.1id

treatment and <:lllegalions or child tlbuse. or ovcr-t8miliarity or other,

inappropriate staff rclatl(\nships with youth, of staff-on-youth violence. or

yout!H,)n-youth violence'. ofsignillcant, actual or attempted self harm, of

youth-on-staff violence. dlld of any sexual contaeL

·'

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S. "Serious mental illness" means the following disorders: psychoses, schizophrenia, bipolar with psychotic features, depression with psychotic features, severe post-traumatic stress disorder, and sehizoaffective disorders.
T. "State" means the State of Ohio, Thomas J. Stiekrath, Director of the Ohio Department of Youth Services, the Ohio Department of Youth Services, and their successors, contractors and agents.
U. "Suicide Precautions" means any level of watch, observation, or measures to prevent sell~harm.
V. "Superintendent" means an individual who is appointed to oversee all aspects of facility operations and is responsible {()r all facility >taff and youth.
W. "Train" means to instruct in the skills addressed to a level that the trainee has the demonstrated proficiency to implement those skills as and when called for in the training. '"I'rained" means to have achieved such protleiency,
X. "Unilicd Case Plan" means the primary DYS document used to establish and describe youth and staff short term responsibilities in high risk/need domains, identify and address release authority and court expectations, document special concerns and summarize youth progress and completion of programs in these areas.
Y. "Use of Force" means any physical contact with a youth by a staff person that has the likely effect of restricting the youth's freedom of movement, that applies physical pressure to the youth's body, or that causes or is likely to cause physical discomfort to the youth, including hand or ann holding lo escort a youth over his or her resistam>e to being escorted. Use of Force does not mean brief and isolated use ofphyskal guidance or positioning that is unlikely to cause physical discomJ[,rt and that is for the purpose of redirecting a youth or providing medical or related treatment
Z. "Yourh" means any juvenile or juveniles committed by a court to, and residing at the Facilities during the operation of this Stipulation.

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III. SUBSTA.-.TIVE REMEDIAL MEASURES

The Department of Youth Services shall provide youth in its charge with a safe and humane environment. Each youth entrusted to the Ohio Department of Youth Services shall receive individual care, treatment, and rehabilitative services in the least restrictive setting consistent with the youth's needs, documented security concerns, and generally accepted professional standards of care. In no event will the level of care in such areas such as safe environment, mental health, special education. programming or any other requirement encompassed in this Stipulation fall below the level described or required in this Stipulation.

A. PROTECTION FROM HARM

I,

The State shall, at all times, provide youth in the Facilities

with safe living conditions. As part of this requirement, the State shall

take appropriate measures to ensure that youth are protected from abuse

and neglect, usc of excessive f(xce, undue seclusion, undue- restraint, and

over familiarization.

2.

The State shall develop and implement comprehensive

policies, procedures, and practices limiting use oftorce on youth to

situations where it is objectively reasonable and necessary. Staff shall be

required to adequately and promptly document and report all uses of force.

3.

The State shall develop and implement policies, procedures

and practices so that staff use seclusion (as defined in this Stipulation)

only in accordance with policy and in an appropriate manner and so that

staff document fully the use and administrative review of any imposition

of seclusion, including the placing of youth in their rooms outside

nonnal sleeping hours.

4. R\'!'Jri!i.nt The State shall develop and implement policies, procedures and practices so that only safe methods of restraint arc used at the facility and only in those circumstances necessary for safety and security and, to the extent possible. when less restrictive means have been properly, but unsuccessfully, attempted, or with respect to therapeutic restraints pursuant to a medical order to protect the health of the youth.

5. Investigation of Serious Incidents: The State shall develop and implement pclicics, procedures. and practices so that appropriate investigations are conduch:d of all incidents of: usc of force: staff-onyouth violence; serious youth-on-youth ,·iolence: inappropriate stair relationships wlth youtk sexual misconduct between yourh; and abusive insfitutional practicc;i. Investigations shall be conducted by per~ams who ~.lo notlmvc direct nr immcdiatr: indirect responsibility I~Jr the cmplnyee(s.) being invcst.igate(L

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6. Staff Training in Behavior Management, P.Q:.Escalation. and Crisis Intervention: The Facilities shall train all staff in behavior management, de-escalation techniques, appropriate communication with youth, and crisis intervention before staff may work in direct contact with youth.
7. Employment Practices: The State shall use reasonable measures, including background check and criminal records check, to determine applicants' fitness to work in a juvenile justice facility prior to hiring employees for positions at the Facilities.
B. MENTAL HEALTH CARE
I. Mental Health Screening: The State shall develop and implement policies, procedures, and practices to ensure that all youth admitted to the Facilities are comprehensively screened tor mental disorders, including substance abuse, depression, and serious mental illness, within twenty-tour hours of admission. This screening shall be performed by qualified personnel, as part of the intake process, consistent with generally accepted professional standards of care.
2. Immediate Referral to a Qualified MelltaL!!el!lthProfessional: If the mental health screen identifies an issue that places the youth's safety at immediate risk, the youth shall be immediately referred to a qualilled mental health professional for assessment, treatment, and any other appropriate action, such as transfer to another, more appropriate setting. The State shall ensure that, absent extraonltnary circumstances, qualified mental health professionals are available t(w consultation within 12 hours of such referrals.
3. Identi lication or PreviouslyJ)ll!<:lentificd Youth with Mental Disorders: The Facilities shall implement policies, procedures, and practices consistent with generally accepted professional standards or cnre to identify and address potential manifestations of mental or behaviof'JI disorder in youth who have not been previously identified as presenting mental health or behavioral needs requiring treatmenr.

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4. Mental Health Assessment: The State shall implement policies, procedures, and practices to ensure that, as part of an overall assessment of the youth's health, risks, strengths and needs, youth who are identified in screening as having possible mental health needs receive timely, comprehensive, and accurate assessments by qualified mental health professionals, consistent with generally accepted professional standards of care. Assessments shall be designed and implemented so as to identity youth with mental disorders in need of specific treatment and contribute to a full plan for managing the youth's risk. Assessments shall be updated as additional diagnostic and treatment information becomes available.

5. Adeguate Mental Health Care and Treatment: The State shall implement policies, procedures, and practices to ensure that adequate mental health and substance abuse care and treatment services (including timely emergency services), and adequate rehabilitative services arc provided to youth in the Facilities by qualified mental health professionals consistent with generally accepted professional standards of care.

6. Treatment Planning: The State shall develop and implement policies, procedures and practices so that treatment service determinations, including ongoing treatment and discharge planning, are consistently made by an interdisciplinary team through integrated treatment planning and embodied in a single, integrated treatment plan.

7. Treatment Teams: At a minimum, the interdisciplinary treatment team lor each youth in need of mental/behavioral health and/or substance abuse treatment should:

a.

Be guided by a trained treatment professional who shall provide

clinical oversight and ensure the proper functioning of treatment

team meetings;

b.

Consist of a stable core of members. including at least the youth,

the social worker. a JCO. one of the youth's teachers. the Unit

Manager, and as warranted by the needs of the youth. the treating

psychiatrist, the treating psychologist registered nurse, and, as

appropriate, other stall

c.

Ensure that needed psychiatric evaluations are conducted on a

youth before administering psychotropic medications to the youth:

d.

Monitor as appropriate but at leaS! monthly, the cftlcacy and

the side effects of psyclwtropic medications. including

consultation with the f[lcility medical, counseling, and other

sLafTwho are 13miliar \\·ith the youth:

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e.

For youth under a psychiatrist's care: ensure the provision of

individual counseling and psychotherapy when needed, in

coordination with facility psychologists; ensure that all youth

referred as possibly in need of psychiatric services are evaluated

and treated in a timely manner; and provide adequate

documentation of treatment in the facility medical records;

f

Include, to the fullest extent practicable, proactive efforts to obtain

the participation of parents or guardians, unless their participation

would be inappropriate for some reason (e.g., the child has been

removed from the parent's custody), in order to obtain relevant

information, understand family goals and concerns, and foster

ongoing engagement;

g.

Meet to assess the treatment plan's efficacy at least every 30

days, and more often as necessary; and

h.

Document treatment team meetings and planning in the youth's

mental health records.

8. Integrated Treatment Plans: The State shall ensure that each youth in need of mental/behavioral health and/or substance abuse treatment shall have an appropriate, integrated, treatment plan, including an appropriate behavior management plan, that addresses such needs. The integrated treatment plan shall be driven by individualized risks and needs. be strengths-based (i.e.. builds on an individual's current strengths), account for the youth's motivation for engaging in activities contributing to hisilJcr wellncss. and be reasonably calculated to lead to improvement in the individual's mentailbehavioral health and well being, consistent with generally accepted professional standards of care.

9. Access to a Qualified Mental Health Professional: TI1e State shall develop and implement policies, procedures, and practices to ensure that Y'>uth who seek access to a qualilicd mental health professional arc provided appropriate access in a timely manner.

I 0. Mental Health lnvolvementjn Housing and Placement Decisions: The Stat~ shall develop and implement a system for m1suring that significantly mentally ill youth who do nol han' the adaptive functioning to manage the
activities of daily living\\ ithin the general population are provided
appropriate housing nnd supporls to assist them in managing within the institutional setting,

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11. Staffing: The State shall staff, by contract or otherwise, the Facilities with adequate numbers of psychiatrists, psychologists, social workers, and other mental health professionals qualitied through training and practical experience to meet the mental health needs of youth residents, as determined by the acuity of those needs. Mental health care shall be integrated with other medical and mental health services and shall comport with generally accepted practices. The State shall ensure that there are sufficient numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming.

12. Medication Notice: Before renewing a psychoactive medication prescription from a community provider or commencing the administration of a psychoactive medication to a youth, the State shall ensure that the youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, are provided with infonnation regarding the goals, risks, benefits, and potential side effects of the medication and given an explanation of the potential consequences of not treating with the medication, and that the youth has an opportunity to consent to such medication.

a.

Involuntary administration of psychotropic medication(s) to

juveniles shall comply with applicable federal and slate laws and

regulations. The DYS clinical director, m consultation with the

DYS medical dirc.;tor, shall review any request with DYS Legal

Services prior to the approval tor involuntary administration.

13. Mental Health McdicatiQt)~~ The State shall develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices. The State shall provide regular training to all health and mental health stair on current issues in psychopharmacological treatment, including intbmration necessary to monitor tor side effects and ctllcaey. The State ,;hall issue and implement policies and procedures for the administration of appropriate tests (including, l(Jr example, blood tests. EKGs, and Abnorrnallnvoluntary
Movement Scale tests) to monitor the efficacy ami any side etTects or
psychoactive mcd.ications in acconlance with generally accepted professional standards. The State shall nlso:

a. Share medication compliance data with the psychiatrist and
document the sharing or Lhis information: and

b, Not withhold the provision of psychostimulants to youth when such treatment is clinicnlly warranted.

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14. Mental Health and Developmental Disability Training for Direct Care Staff: The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents in order to supervise them appropriately.
15. Staff Mental Health Training: The Factlities shall train:
a. All staff who directly interact with youth (e.g., JCOs, social workers, teachers, etc.) on: (i) basic mental health infomJation (e.g., diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern) and rccogmlion of signs and symptoms e-videncing a response to traun1a; and
(ii) teenage development, strength-based treatment strategies, suicide, and, tbr staff who work with female youth, female development.
b. Clinical staff on the prevalence, signs, and symptoms of Post Traumatic Stress Disorder and other disorders associated with trauma.
16. Suicide Prevention: The State shall review and, as appropriate, revise t:urrent suicide prevention practices to ensure that suicide preventions and interventions are implemented eonsisk't!tly and appropriately, consistent with generally accepted professional standards of care,
17. Tr~nsition Pla1ming: The State shall ensure that statTcreate transition plans for youth leaving the Facilities consistent with generally accepted professional standards of care.
18. Oversight of Mental Health Services: The Facilities shall ensure that youth receive the care they need by developing and implementing an adequate mental health Quality i\ssurancc/Jmprovcment Program; annually assessing the ovcraB efficacy of the staffing) treatments, and interventions used at the Facilities~ and. as appropriate) revising such staffing, treatments and inten cntions.

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C. GEI\ERAL MEDICAL CARE
I, Generallv: The Facilities shall ensure that the individuals they serve receive routine, preventive, and emergency medical and dental care consistent with current, generally accepte<:l professional standards, The Facilities shall ensure that individuals with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards ofcare,
2. Health Records: The State shall develop and implement policies, procedures, and practices to ensure that, consistent with State and Fedeml law, at a minimum, the Juvenile courts in the State, all juvenile detention facilities, and all placement settings from which youth are committed shall timely forward to Scioto, or to the f.1cility of placement (if the records arrive after the youth has been placed), all pertinent youth records regarding medical and mental health care. The Facilities shall develop and implement policies, procedures, and practices to ensure that health care stall', including mental health care stall'. have access to documents that arc relevant to the care and treatment of the youth.
3. Confidential Health Care: The Facilities shall provide health care and assessments in a setting that maintains health care contidentiality, by placing non-medical staff out of line of sight and hearing of the health care assessment or treatment, except in circumstances where documented safety considerations posed by a particular youth require enhanced, non-medical supervision.
4. Lui!i_<il Health Assessment: The f-acilities shall ensure that initial health
assessments nre complete and include: use of growth and weight charts; laboratory test results placed in the youth's health records beli1re the youth is transferred out of reception; results of alllabomtory tesLs. to be provided for each test within 20 days of its pcrtbrmancc; tcstmg of all youth for sexually transmitted diseases; and a problem list and a plan of care tbr each problem identified at reception.
5, Access to Health Services: The Facilities shall ensure that youth can request to be seen by medical staff confidentially and independent from
JCOs and .:ustmlial sta 1r
6. Medication Management: The Facilities shall not discontinue a chronicnlly ill youth· s usual medication ll.x non-medical reasons. including rhat the medicatil)n is not on the Facilities' I(Jrmtdary.
II

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7. Dental Care: The Facilities shall ensure that:

a.

Dental restorative needs are listed on a dental treatment plan for

the youth, tracked by the dental program, and treated on a timely

basis consistent with generally accepted professional standards of

care;

b. Prosthetic dental services are provided based on need, as
determined by the treating dentist, with appropriate consideration for the replacement or repair of missing front teeth, according to generally accepted professional standards of care;

c.

Youth experiencing dcnta,Lpffin are not denied adequate pain

d.

medication· '
Health r

"

" -

. / /;-:'-

contain adequate documentation ofall outside

--

de eonsults, including the clinical examination, treatment plan,

~ ..procedures performed, orders lor management after the

procedures, and any follow-up appointment or plan; and

e. Dental staffing is adequate to meet the restorative dental needs of the Facilities' populations.

8. Managemgm ofC!tronic Illnesses: The Facilities shall ensure that:

a.

Chronic disease policies, protocols, and practices are appropriate

tor chronically ill adolescents;

h. Youth with chronic asthma are continued on their established
medicines on admission unless the youth's condition warrants a
change in trcanncnt; and

c. Youth who frequently usc rescue inhalers arc appropriately monitored and treated by physicians to minimize preventable asthma hospitalization resulting from acute respiratory crisis that lhllows an inadequately treated exacerbation of chronic asthma.

9. Access to Specialtv Care: Absent clinically justified rationale. the Facilities shall not withhold access ln specialist servict:s r<:commended by a treating physician and shall ensure that: prior approval of specialty medical consultations is made by a physician trained and qualitled in pediatrics and adolescent medicine; and assessment criteria Cor the necessity of specialty consultations are based on pediatric and adolescent medicine.

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10. Immunizations: The State shall make reasonable efforts to obtain immunization records for all youth who are detained at the facilities for more than one (I) month. The State shall ensure that medical staff update immunizations for such youth in accordance with nationally recognized guidelines and state school admission requirements. The physicians who determine that the vaccination of a youth is medically inappropriate shall properly record such determination in the youth's medical record.

D. GRIEVANCE PROCESS
I. The State shall develop and implement policies, procedures. and practices to ensure that the Facilities have an adequate j,'lievance system including: no formal or infomml preconditions to the completion and submission of a grievance; review of grievances by the chief inspector; timely initiation aud resolutions of grievances; appropriate corrective action; and written notification provided to the youth of the final resolution of the grievance.
2. A clear explanation of the grievance process shall be provided to each youth upon admission to the Facilities during orientation, and to their parent(s) or guardian(s), and the youth's understanding of the process shall be at least verbally veri lied.
3. Without any staff involvement, youth shall easily be able to obtain grievance forms and submit grievances.

E. SPECIAL EDUCATION

I. Provision of Special Education: The State shall. at all times, provide all youth confined at the Facilities with adequate special education in compliance with the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006), and regulations promulgated thereunder, and this Stipulation.

2. Oversight: The State shall provide adequate oversight of special education at the Facilities.

3. Special Education upon Intake: The State shall ensure that all stlldcnts who qualil)r lOr special education services receive such services within a reasonable time following intake at the Facilities.

4.

Pnrent or Guardian Involvement The State shall develop and

implement policies. procedures, and pmcticcs to appropriately

noti (y und in\'Olve parents c•r gunrdians in the provision nf :=.pccial

education services. whene1·er possible.

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5.

Staffi!lg~ The State shall develop and implement an education

staffing plan to ensure adequate staff to comply with the terms of

this Stipulation.

6. Screening for Special Education Needs:
a. The State shall provide prompt and adequate screening of youth for special education needs and shall identify youth who, upon admission to the Ohio Department of Youth Services, were receiving special education in their home school districts or who may be eligible to receive special education services but have not been so identified in the past.
b. The State shall ensure that those staff conducting the screening, assessment and evaluation processes arc qualitied to do so.
7. Individual Education Plans:
a. The State shall develop an lEP as dell ned in 34 CF .R. § 300.320 for each youth who qualifies tor an lEP. Following development of the IEP, the State shall implement the IEP as soon as possible, As part of satisfying this requirement, the State shall conduct required annual reviews or IEPs, adequately document the provision of special education services, and comply with requirements regarding participation by the professional staff, parents, and student in the lEP process. The State shall, if necessary, develop, review or revise IEPs tor qualified special education smdcnK

b. In developing or modifying the IEP, the State shall ensure that: the IEP ret1ects the individualized educational needs of the youth and that services are provtdcd accordingly; each IEP includes
or documentation the team's consideration of the youth's need for
related servrces and transition planning, and identifies the party responsible for providing such transition services; the student's educational progress is monitored~ teachers are trained on how to momtor progress toward IEP goals and objectives: and teachers understand and use funclinnal bch"viornl assessment and behavior intervention program~ in IEP pl<:mning and implementation.
8. Vocational Education: The Sl<lte shall provide appropriate vocationnl scrvicDs that are required transltlon services for
disabled youth under the IDE;\,

I~

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 17 of 27 PAGEID #: 76
9. F01warding Screening and Assessment Information upon Transfer: The
State shall ensure that, when a youth is discharged from the Facilities
before the interventions or educational evaluations required in Section lli.E. 6 above are complete, the Facilities shall forward to the superintendent of the youth's receiving school district all information regarding screening and evaluations completed to date, noting what evaluations are yet to be performed.
10. Training and Oualirv Assurance: The State shall design and implement adequate annual training requirements tor special education statf.
11. Transition Services: the State sha II comply with any IDEA requirements for providing transition assistance. Tite State shall provide transition assistance to students by providing counseling and concrete intormation regarding appropriate community resources, and how to pursue postsecondary options, re-enroll in school or complete the OED.
F. PROGRAMMING
I. Structured Programming: The State shall provide adequate, structured Rehabilitative Services, including an appropriate mix of physical, recreational, or leisure activities, during non-school hours aod days ("Structured Programming"). The State shall develop and implement Structured Programming at each facility lrom the end ofthe school day until youth go to bed, and on weekends. For youth housed in closed-cell environments, Structured Programming shall be designed to ensure that youth are not contincd in locked cells except: (a) tfom aller Structured Programming to wake-up: (b) as necessary where the youth poses an immediate risk of harm to self or others; or (c) lollowing an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The Structured Programming :-\hall be designl!d to modify behaviors~ provide rehabilitation to the types of youth committed to each lacility, address general health and mental health needs, and be coordinated with youth's individual behavioral and treatment plans. The Stale shall use teachers, school administrators, correctional t)tlicers~ caseworkers, school coun.-.eJor.s. cnuage stafl: and any other qualified assistance to develop and implement the Structured Programming. The Stare shall provide youth \.vith access to progrnmming activitie:s that are required for parole digibiliry.
15

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 18 of 27 PAGEID #: 77

2. Orientation:
a. Admissions Intake and Orientation: The State shall develop and implement policies, procedures, and practices to establish a consistent, orderly admissions intake system, conducive to gathering necessary information about youth, disseminating information to staff providing services and care for youth, and maintaining youth safety. The orientation shall also clearly set torth the rules youth must follow at the Facility, explain how to access medical and mental health care and the grievance system, and provide other information pertinent to the youth's participation in the Facility's programs.
b. Notice to Youth of Facility Rules and Incentives/Consequences for Compliance: The State shall explain the Structured Programming to all youth-during an orientation session that shall set forth the tacility rules, the positive incentives lor compliance and good behavior, and the sanctions lor rule violations. The State shall provide the Facility rules in writing
c. Introductory Handbook. Orientation and Reporting Abuse: Each youth entering the Facilities shall be given an orientation that shall include simple directions for reporting abuse and assuring youth of his/her right to be protected from retaliation for reporting allegations of abuse.

G. DOCUMENTATION
The Facilities shall develop and implement policies, procedures, and practices setting torth clear standards regarding the content, integration. and timeliness of progress notes, transfer notes, school progress notes, discharge notes, and other records, including, but not limited to, an expectation that such records include meaningful, accurate. and coherent assessments of the individual's progress relating to treatment plans, goals and objectives, and that clinically relevant information remains readilv accessible.

I. Progress Notes: The Facilities shall promulgate and implement a policy requiring that all health professionals be required to create and usc
progrc:-;s notes to document, on a regular husis, interactions and each
assessment of youth with mental/behavioral health or substance abuse needs. ln particular, progress notes shall:

n.

In the assessment. address the efficucy of interventions, currently

presenting problems, and the available options to addrc:>s those

problems: and

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 19 of 27 PAGEID #: 78
b. Provide thorough documentation of all crisis interventions or, if not thoroughly documented in the progress notes, provide a reference to alert staff to another document in the youth's tile containing the details of the crisis intervention.
2. Accessibility of Relevant Information: The Facilities shall ensure that youth records are organized m a manner providing treatment teams prompt access to relevant, complete, and accurate documentation regarding the youth's status.
IV. COMPLIANCE COORDINATION, POLICIES, TRAINING, AND QUALITY ASSURANCE/QUALITY IMPROVEMENT
A. Compliance Coordinator: The State shall assign the responsibility for coordinating compliance with this Stipulation to a compliance coordinator who shall report directly to the Director of the Department of Youth Services on these issues and shaU coordinate and assess the State's compliance with this Stipulation and with State policies governing the Facilities.
B. Policies: The State shall revise or develop policies, procedures, protocols, and practices to ensure that they are consistent with, incorporate, address, and implement all provisions of this Stipulation. The State shall revise or develop as necessary other written documents such as screening tools, logs, handbooks, manuals, and forms, to eflectuate the provisions of this Stipulation.
C. Document Review: Within 30 dnys atlcr execution of this Stipulation, the State shall submit a mnstcr plan to the Monitor (sec§ V below), DOJ, and the SH plaintiffs' counsel that establishes a time line of up to one year to revise andior develop written policies, procedures~ protocols. training materials, and screening and assessment tools to eflectuate the provisions of this Stipulation. The master plan and the policies, procedures~ protocols, training materials, and screening and assessment tools shall be submitted to the l'v1onitor, DOJ, and the S.H plaintilh' counsel I(,,. review and comment consistent with this paragraph. DOJ shall provide pron1pt guidance to the State. including spccifk explanations as to how the provisions, policies, or pruccdures, if any, arc inconsistent with the terms of this Stipulation. and shall suggest revisions. In the event that DOJ asserts that policies. procedures, and other written documents arc not ln compliance with the terms of this Stipulation, the parties, in collabt>ration with the SH plaintitls· counseL will agree to a schedule f[>r the parties' experts and the Monitor to communicate. If the pm1!cs arc unable to agree on revisions to the policies, proc~durcs. or practices, the panl.:s shall submit the is-sue to lhe Monitor fi)r re:·wlution . cnnsiMcnt wilh the dispute resolution me-chanisn1 (at paragraph 256) of the Stipubtion approved the court in SJ l

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 20 of 27 PAGEID #: 79
D. Training: The State shall ensure that any person acting for the State in implementing any requirement in Section Ill of this Stipulation has been trained on the implementation of that provision and any corresponding State or Facility policies and procedures.
E. Performance Data: On an ongoing basis, each Facility shall collect and analyze objective statistical data measuring the Facility's pertiJrmancc as to uniform performance indicators through which the implementatiOn of each prov1sion of Section Ill of this Stipulation can be reliably assessed ("Performance Data"). At least annually, the Compliance Coordinator shall independently audit each tacility to verify the accuracy of the Facility's data collection and reporting.
V. MONITORING
A. \1onitor Selection:
Fred Cohen shaH serve as the Monitor in this case and in the SH case. Should the position of Monitor become vacant, the parties to this Stipulation and the S. H parties shall confer regarding selection of a new Monitor and, if unable to agree on a replacement Monitor within 30 days of the vacancy occurring, sha II each submit two names, along with resumes and cost proposals. to the court. The Monitor may be terminated only upon good cause and only with prior notice to, and approval ot: the parties to this Stipulation and the S.H. parties, or by order of 1he court. Furthem10re, the parties agree that the Monitor may usc consultants, who may be retained only after consultation with the parties to this Stipulation and the S.H parties.
B. Cost of Monitor: The cost tor the monitor's fees and expenses shall be bomc by the Slate.
C. Monitor Autonomy: Neither party to this Stipulation, nor any employee or agent of either par1y. shall have any supcrvismy authority over the monitor's activities reports, findings~ or recommendations_
D. Monitor Qualifications: The Monitor shall have experience and education or training in the !icld of juvenile justice. The Monitor may also have education, training, or experience in general or special education, adolescent health and mental health needs (particularly the need> of institutionalized adolescents), and institutional abuse and incident invcstig8lions.
E. M9mtor Access: The Monitor shall have full and complete access to the Facilities, all tncility records. stafl: and residents. The State shall direct all cmployces to coopcrtnc Cully with ihc Monitor. Allnon-puhlic infnrmntil•n obtained by the Mnni!or s!Mll he m;;1intaincd In a ~,;onfidentinl rnanncr.
IX

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 21 of 27 PAGEID #: 80
F. Monitor Ex Patte Communications: The Monitor shall be permitted to initiate and receive ex parte communications with all patties in this and the S. H. case.
G. Limitations on Public Disclosures by :\1onitor: Except as required or authorized by the terms of this Stipulation or the parties acting together, the Monitor shall not: make any public statements (at a conference or othenvise) or issue public tindings with regard to any act or omission of the State or its agents, representatives or employees, or disclose non-public information provided to the Monitor pursuant to this Stipulation. Any press statement made by the Monitor regarding his/her employment must tlrst be approved, in writing, by the parties. The Monitor shall not testify in any other litigation or proceeding with regard to any act or omission of the State or any of its agents, representatives, or employees related to this Stipulation, nor testify regarding any matter or subject that he or she may have learned as a result of his or her performance under this Stipulation. Reports issued by the Monitor shall not be admissible against the State in any proceeding other than a proceeding related to the enrorcement of this Stipulation. Unless such eontlict is waived by the parties, the Monitor shall not accept employment or provide consulting services that would present a conflict of interest with the Monitor's responsibilities under this Stipulation, including being retained (on a paid or unpaid basis) by any current or future litigant or claimant, or such litigant's or claimant's attorney, in connection with a claim or suit against the State or its departments, officers, agents or employees. The records maintained by the Monitor shall be kept confidential to the extent permitted by Ohio's Public Records Law and the federal Freedom oflnfonnation Act. Neither the Monitor nor any person or entity hired or othcnvise retained by the Monitor to assist in furthering any provision of this Stipulntion shall be liable for any claim,
lawsuit or demand arising out of the Monitor· s perrormance pursuant to this
Stipulation. This paragraph does not apply to any proceeding before a court related to pcrfommnce of contm.:ts or subcontracts for monitoring this Stipulation.
H. Monitor Report,: The Monitor shall provide the parties to this Stipulation and to the S.H. case witl1 reports describing the steps taken by the State to implement this Stipulation and evaluate the extent to which the State has complied with each substantive provision of the Stipulation. For each of Marion and Scioto, the Monitor shall prepare the report based upon a site visit conducted no more than six weeks belore the report's issuance. For each requirement o I' Section Ill or this Stipu!otion, the report shall specify: (I) the steps (including dncuments reviewed, meetings attended, and persons interviewed) the Monitor took to assess compliance; (2) the self-assessment steps the JlJcility undertook to assesx compliance and the results thercol; (3) the level of compliance, i.e., ''noncompliance" or "'substantial compliance''~ and (4) the \'kmitor's recommendations. trany, to facilitate or:wslain compliance. During the first year of this Stipulation, the Monitor shall issue a rcp<nt lor each of Marion and Scioto every six months and thereafter every nine months. with interim reports as the Monitor dctc11nines appropriate. The Monitor i~ primarily to assess am! repon
19

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upon compliance; if there is an ambiguity in the meaning or intent of a provision, the Monitor shall seek guidance from the parties. The reports shall be provided to the parties in this and the S.H. case in drali form for comment at least two weeks prior to their issuance. These reports shall be written with due regard for the privacy interests of individual youth and staff and the interest of the State in protecting against disclosure of non-public information. One report may suffice for both this and the S.H. case, and shall address the substantive issues in both this Stipulation and the S.H. litigation.

I.

Monitor Budget: The Monitor shall have a budget suflicient to allow the

Monitor to carry out the responsibilities described in this Stipulation, and shall

provide the parties to this and the S.H. case with a copy of each invoice, when

issued by the Monitor, and notice of payment, when received by the Monitor.

VI. REPORTING REQUIREMENTS AND RIGHT OF ACCESS

A. DOJ Access: DOJ shall have tull and complete access to the youth at the Facilities upon reasonable notice to DYS. DOJ shall have full and complete access to the Facilities, youth records, staiT records, and staff of the Facilities regarding the topics addres»cd in this Stipulation upon reasonable notice to DYS. DOJ shall have the right to conduct interviews with staff, and confidential interviews with residents and former residents. State attorneys may be present at interviews of sta IT and tours of Facilities. All non-public information obtained by DOJ shall be maintained in a confidential manner.
B. Response to DOJ Questions: Within 30 days of receipt of written questions from DOJ concerning the State's compliance with this Stipulallon, the Monitor shall provide DOJ with written answers and access to any requestetl documents regarding the State's compliance with the requirements of this Stipulation.
C. State Documentation of Compliance: The State shall maintain suflicicnt records to document its compliance with all of the requirements of this Stipulation. The Stale shall also maintain (so long as this Stipulation remains in efkcl) any and all records required by or developed under this Stipulation.
D. Privileges: This Stipulation shall not be deemed to waive the attorney/client, attorney work product. deliberative process. or executive privileges. The State
shall not assert physician/patient or psycholhcrnpist/paticnt privileges with respect to the monitoring of this Stipulation.
VII. IMPLEMENTATION, ENFORCEMENT, AND TERMlNATION
i\. lni{H11JJ).Iion to Emplovccs: The State shall ensure that all current and future relevant State cmployt:cs understand the tern1s of policies and procedures addressed hy this Stipulation (to the cxtclll ncccssal)· to carry out their JOb duties and responsibilities).

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B. Implementation: The State shall implement all reforms necessary to effectuate this Stipulation. The implementation shall begin on the eftective date of the Stipulation in the S.H. case. Minor, inconsequential, sporadic, unintentional or isolated harmless instances of noncompliance with this Stipulation shall not be a basis for enforcement, provided they do not affect a substantial interest of the youth.

C. Integration: This Stipulation shall constitute the entire integrated Stipulation of the parties. With the exception of DOJ's tindings letters referenced in Section I. G., no prior or contemporaneous communications, oral or written, will be relevant or admissible for purposes of detennining the meanmg of any provisions herein in any proceeding.

D. Entorcement: If DOJ believes that the State has failed to substantially comply with any obligation under this Stipulation, the parties wilt use the dispute resolution mechanisms in the Stipulation in the S.H. case (paragraph 256 ).

E. Termination: This Stipulation shall terminate three years from its Effective Date. The Stipulation may a Iso end earlier if the State has substantially complied with each of the provisions of the Stipulation and has maintained substantial compliance for at least one year. The burden shall be on the State to demonstrate this level of compliance. Any of subsections A through G of Section Ill of the Stipulation may be terminated if the State sustains its burden with respect to that subsection of the Stipulation. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. i\t the same time, temporary compliance during a period of sustained noncompliance shall not constilttte substantial compliance.

F. Defense of Stipulation: The parties agree to de!'end the provisions of this Stipulation. The parties shall notify each other of any court challenge to this Sllpulution. In the event any provision of this Stipulallon is challenged in any local or $tate court, removal to a federal court shall be sought.

G.

This Stipulation shall be binding on all successors, assignees,

employees, agents and all those working for or on behalf of the State.

H. No Waiver t(,r Failure to Ent(,rcc: Failure by either party to enforce this entire Stipulation or any provision thcn.:ofwith respect to any deadline or an:;/ other provision herein shall not he constnu::d ns a waiver of 1ts righl to enforce other deadlines or prm isions of this Stipulation.

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I. Notice: "Notice" under this Stipulation shall be provided by courier or overnight delivery and shall be provided to the State to the Director of the Department of Youth Services of the State of Ohio, to the Ohio Attorney GeneraL and to the United States to the Chief of the Special Litigation Section, Civil Rights Division, United States Department of Justice.
J. !)nforescen Delav: If any unforeseen circumstance occurs which causes a failure to timely carry out any requirements of this Stipulation, the State shall notify DOJ in writing within 20 calendar days of the time that the State becomes aware of the unforeseen circumstance and its impact on the State's ability to perfonn under the Stipulation. The notice shall describe the cause of the tailure to perlonn and the measures taken to prevent or minimize the failure. The State shall implement all reasonable measures to avoid or minimize any such lailure.
K. N()n-Retaliation: The State agrees that it shall not retahate agamst any person because that person has filed or may tile a complaint, provided information or assistance, or participated in any other manner in an investigation or proceeding relating to this Stipulation. The State is not precluded from taking appropriate action where an individual knowingly asserts a tltlse complaint or knowingly makes false statements.
L. Subheadings: All subheadings in this Stipulation are written for convenience of locating individual provisions. If questions arise as to the meanings of individual provisions, the panies shall tollow the text of each provision.
M. Seventbility: In the event any provision of this Stipulation is declnred invalid for any reason by a court of competent jurisdiction, said Jinding shall not affect the remaining provisions of this Stipulation.
N. Attorneys' Fees and Expenses: Each party shall bear the cost of their fees and expenses incurred in connection witb this matter.

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IT IS SO STIPULATED AND AGREED. FOR THE UNITED STATES:

DATE: June 5, 2008

GREGORY G. LOCKHART United States Attorney Southern District of Ohio

S/ Grace Chung Becker ORACE CHUNG BECKER Acting Assistant Attorney General Civil Rights Division

MARK T. D'ALESSANDRO Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard Suite 200 Columbus, OH 43215

S/ Shanetta Y. Cutlar SHANETTA Y. CUTLAR Chief Special Litigation Section
Sl Benjamin 0. Tayloe, Jr. BENJAMIN 0. TAYLOE, JR. Special Counsel Special Litigation Section GREGORY GONZALEZ STACEY K. GRlGSBY Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W, Washington, D.C. 20530 Telephone: U02) 614-8103 Facsimile: (202) 514-0212 Email: benjamin.Taylocr;'l)usdoj.gov

-'"'

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IT IS SO ST!PliLATED AND AGREED.
FOR THE STATE:
Sf Thomas J. Stickrath THOMAS J. STICKRATH Director Ohio Department of Youth Services
S/ Nancy H. Rogers NANCY H. ROGERS Attorney General of Ohio

DATE: June 4, 2008

Case: 2:08-cv-00475-ALM-MRA Doc #: 8 Filed: 06/24/08 Page: 27 of 27 PAGEID #: 86
WHEREFORE, for good cause shown, it is SO ORDERED.

 Case 2:08-cv-00475-ALM-MRA Document 30 Filed 02/26/10 Page 1 of 7

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

__________________________________ _)

CIVIL ACTION NO: 2:08-cv-475
JUDGE ALGENON L. MARBLEY

S.H., and all other similarly situated, )

et al.,

)

)

Plaintiffs,

)

)

v.

)

) CIVIL ACTION NO:

) 2:04-cv-1206

TOM STICKRATH,

)

) JUDGE ALGENON L. MARBLEY

Defendant.

)

___________________________________ )

ORDER On February 24, 2010, this Court held a Status Conference in S.H. v. Stickrath (the S.H. case) and U.S. v. Ohio (the U.S. case). The Department of Justice and the Monitor in the S.H. case, Mr. Fred Cohen (“Monitor Cohen”), particpated by telephone. Amy Ast, Christine Money, Barbara Moore, and Marci Sutherland, all with the Ohio Department of Youth Services (“DYS”) were also present.

Case 2:08-cv-00475-ALM-MRA Document 30 Filed 02/26/10 Page 2 of 7
The Stipulation in the S.H. case has as a guiding principle that “DYS shall provide youth in its charge with a safe and humane environment.” (S.H. Stipulation ¶ 10.) It also provides that DYS policies and procedures “will be reviewed and revised as needed.” (S.H. Stipulation ¶ 35.) These policies and procedures “will be designed to meet or exceed the minimum level of care requried by the relevant statute or constitutional Amendment. Id.
Recently the Court was informed that youths at the Ohio River Valley (“ORV”) and Circleville DYS facilities were being denied meals when they refused to leave their rooms to eat in the facility dining room or cafeteria. This was allegedly occuring as a result of DYS policy, circulated by Christine Money on August 5, 2009. These youths were allegedly required to remain on their unit when the rest of the youth on their unit went to eat; and as a result there were youths that were not receiving food and not eating. It was reported to the Court was that individuals were refusing to leave their rooms out of fear of being either sexually or physically assaulted.
At the Status Conference the Court had the opportunity to engage with the various stakeholders on this issue. The Court had received a copy of the policy in question from Monitor Cohen. The policy from Christine Money, DYS Deputy Director, addressed to Thomas Teague, Superintendent at Circleville and dated August 5, 2009 states:
[Circleville] has been approved to implement this PILOT for thirty days. Effective immediately the following protocols must be followed when a youth refuses to attend a meal in the cafeteria.
• A staff member MUST inform the youth that eating in the cafeteria is their only opportunity to receive a meal.
• Once the youth has been informed of the opportunity and the youth continues to refuse, a staff member is required to document the refusal in the Unit Log Book and notify the on-duty Operations Manager.
• Any youth who refuses to go to the cafeteria will not receive a carry back
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Case 2:08-cv-00475-ALM-MRA Document 30 Filed 02/26/10 Page 3 of 7
meal. • Any youth refusing to go to the cafeteria shall be placed in their rooms or
in a dorm setting must sit in an assigned location until the unit returns. • IF a youth misses two (2) consecutive meals the Unit Manager must
complete a face to face interview with the youth to determine the reason for the refusal. If the Unit Manager is not available then the unit Social orker or the Operations Manager must complete the interview. • If through the interview, the youth continues to refuse to go to the cafeteria, the Unit Staff are required to develop an individual plan to address the needs of the youth.
A weekly report shall be forwarded to Deputy Director Money indicating the number of youth refusing the opportunity to attend a meal in the cafeteria. At the end of the month, the Deputy Director along with the Superintendent will evaluate the PILOT to determine if it will continue.
(August 5, 2009 DYS Memo on Cafeteria Refusals - CJCF Pilot) (“Cafeteria Refusals Policy).
Al Gerhardstein, class counsel, informed the court that he and his co-counsel had been
unaware of this new DYS policy until February 2010 when an email received by class counsel
alluded to problems with the DYS Cafeteria Refusals Policy. Mr. Gerhardstein stated:
[W]hat happened with the August policy was a system change. We didn’t know about it, and we didn’t find out about it until February, class counsel. We found out about it at the same time I got an email from class counsel or from defense counsel saying don’t worry we’re going to feed the kids...If in fact system changes are shared with us, then we could have a better dialogue, becuase we would have been more engaged on this had we seen the policy and asked some questions.
(Tr. of Status Conf. February 24, 2010 p. 33.)
At the Status Conference the Court confirmed that the DYS Cafeteria Refusals Policy
was implemented not only at Circleville, but also at the other DYS facilities including ORV.
Ms. Moore, Deputy Superintendent at ORV, confirmed the Cour’s information that multiple
youth at DYS facilities had been denied meals when declining to eat. She informed the Court
that while she only knows of one youth at ORV that had been refusing to eat, she was “sure
-3-

Case 2:08-cv-00475-ALM-MRA Document 30 Filed 02/26/10 Page 4 of 7
there are more” and that “[s]ince February 11th, we’ve been tracking youth that’s been refusing.” (Tr. of Status Conf. February 24, 2010 p. 9-10.)
In preparation for the Status Conference, DYS provided this Court with summary data and information about the effect of the DYS Cafeteria Refusals Policy at the Circleville facility. This report is incorporated herein and made a part hereof as Attachment 1. Data was compiled by Mr. Teague and given to Ms. Money. (February 23, 2010 DYS Memo on Meal Refusal Data.) This data shows that between August 2009 and February 2010, 429 meals were refused by the youth at Circleville. (February 23, 2010 Circleville Meal Refusal Statistics.) Of those meals, 386 involved breakfast refusals, 30 involved lunch refusals, and 13 involved dinner refusals. Id. DYS submitted that breakfast refusals represent instances where youth wanted to sleep in. (Tr. of Status Conf. February 24, 2010 p. 18.) DYS, however, did not provide data or support that this was necessarily true for all breakfast refusals, or that the same was true for any of the 43 lunch or dinner refusals. Id. at 19. And pursuant to the terms of the DYS Cafeteria Refusals Policy, the youth who refused meals were not otherwise fed – they simply did not eat those meals. The data from the Circleville facility therefore supports Ms. Moore’s statement that since the enactment of the DYS Cafeteria Refusals Policy there have been multiple instances of youth not having eaten.
Ms. Moore clarified that to her knowledge from August 2009 to February 5, 2010, the DYS Cafeteria Refusals Policy was in full force and effect, but during that time the policy was followed inconsistently with “some unites when they had youth that were refusing to go to the cafeteria were providing carry back meals and some units were not.” Id. at 12. After February 8th, Ms. Moore’s understanding was that if a youth refused to go to the cafeteria at ORV he
-4-

Case 2:08-cv-00475-ALM-MRA Document 30 Filed 02/26/10 Page 5 of 7
would not be fed. Id. at 15. Log books at ORV document youth who refused to eat and the reason for the refusal. Id. at 13. Currently, there are separate log books for cafteria refusals. Id. Prior to February 11, 2010 this information was kept in a log book, but not one that was maintained specifically on the issue of cafeteria refusals. Id. Additionally, prior to February 11, 2010, the log books did not record the specific reason for the cafeteria refusal. Id.
Ms. Moore elaborated that in February 2010 youth refusing to go to the cafeteria at ORV have had food brought back from them and that this represented a policy shift from August of 2009, when DYS first promulgaged the Cafeteria Refusals Policy. Id. at 10-11. According to Ms. Moore,
February 5th is when we got direction that we were going to feed youth that were not going to the cafeteria, and I believe it was the following Monday, the 8th, that we went back tot he youth who were refusing to attend that cafeteria that we were not bringing carry backs with the exception of kids that have some medical conditions. Id. at 11. Ms. Money stated to the Court that the DYS Cafeteria Refusals Policy is “still in full force,” but that DYS is “in the process of drafting an update to designate with more specificity of who has to contact who [sic] and it even has a time to alert the superintendent.” Id. at 21. According to Ms. Money, “[a]ny youth that [sic] refuses to go to a meal and says that he is afraid gets fed...Any time a youth says they’re [sic] afraid at that point we provide the meal, we figure out how to provide it. We might send it to the unit. We might send a kid with staff.” Id. Ms. Money agreed that this practice is not reflected in the DYS Cafeteria Refusals Policy as it currently exists. Id. at 22. THE COURT: Now you would agree that’s not reflected in the current policy as set forth, would you?
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Case 2:08-cv-00475-ALM-MRA Document 30 Filed 02/26/10 Page 6 of 7
MS. MONEY: Not specifically, but that’s what we’ve always done, is any that any time a youth says that they’re afraid for their safety, we do a safety plan. THE COURT: Is that written someplace? Is that memorialized anyplace? MS. MONEY: There is a policy. THE COURT: In any of your rules and regulations? MS. AST: There’s not a specific policy on safety plan. We do have a policy, if we have a kid that we need to put in protective custody or something like that, but it’s– to ask if there is a formal policy, Judge, the answer would be no. THE COURT: It would seem to me, it would make the most sense, and then we would avoid the inconsistency of the application of the policy to have it clearly crafted within the policy, in the language of the policy...to reflect that if a child refuses for safety reasons or out of fear...then that kid would be fed at that meal or at some alternate site or whatever. In other words, memorialize what you already have as a common practice. That way, we will assure uniformity and application of the policy throughout. And most importantly, the kids will get to eat.
Id. at 22-23.
The Cafeteria Refusals Policy, as it was written is at odds with the guiding principle in
the S.H. and U.S. cases that the health and safety of the youth is of paramount importance. Thus,
as this Court Ordered at the Status Conference, DYS will alter its Cafeteria Refusals Policy to
reflect that: (1) the youth in DYS’ custody and care must be fed and any youth articulating any
fear for safety must be fed during the particular meal of refusal; and (2) when youth refuse to eat
a meal in a facility cafeteria, DYS will keep records of the reason for that refusal. Additionally,
by March 3, 2010, DYS will provide to the Court summary information and data on meal
refusals from the Scioto, ORV, and Indian River facilities for the period of August 5, 2009,
when the Cafeterial Refusals Policy was enacted, to February 23, 2010. This summary
information and data should be provided in the same format as the information DYS provided to
this Court about the Circleville facility prior to the Status Conference. The Court also directs
-6-

Case 2:08-cv-00475-ALM-MRA Document 30 Filed 02/26/10 Page 7 of 7

that copies of the log books from the Circleville, Indian River, ORV, and Scioto facilities be provided along with the summary information.1
IT IS SO ORDERED.

DATED: February 26, 2010

s/Algenon L. Marbley ALGENON L. MARBLEY UNITED STATES DISTRICT JUDGE

1The summary information should be submitted by the March 3, 2010 deadline set by the Court at the Status Conference. DYS should submit the copies of the log books to the Court by March 10, 2010.
-7-

Case 2:08-cv-00475-ALM-MRA Document 30-1 Filed 02/26/10 Page 1 of 3
OHIO DEPARTMENT OF YOUTH SERVICES
Ted Strickland, Governor • Thomas J. Stickrath, Director

To: From: Subj: Date:

Christine Money, Deputy Director Thomas J. Teague, Jr. Superintendent Meal Refusal Data February 23, 2010

In May of 2009, Circleville Juvenile Correctional Facility (CJCF) transitioned from a Juvenile Sex Offender Facility into a Close Security Juvenile Correctional Facility for male adjudicated youth in the state of Ohio. At this time, many of the youth that were housed at Marion Juvenile Correctional Facility were transferred to CJCF. Marion was the maximum security facility for youth in the state of Ohio. This brought a new culture of aggressive youth behavior and STG/ Gang related activity into the facility.
During the months of May, June and July, there were many incidents of youth refusing to go to the cafeteria which, in turn, caused food service staff to prepare hundreds of carry back meals to be taken back to the youth on units. This resulted in the programming schedule being disrupted, youth could not get to school on time, and an increase in food service cost. Upon reviewing the increase of carry back meals taken to youth on the units, CJCF administration polled the youth.
It was determined that a large portion of the youth who refused to go to the cafeteria had been threatened by STG/Gang affiliated youth. The STG/Gang affiliated youth used the following tactics to harass and scare new youth and nonSTG affiliated youth as a means of trying to get them to join their gang.
They would tell the youth the following:
• Youth were told that they were not allowed to eat • Youth were told that they had to give up their meals • Youth were told that they could only eat certain meals • Youth were told that if they go against them, they would be jumped on and
beat up • Youth were told that they could not eat because they lost a bet

Circleville Juvenile Correctional Facility • Thomas J. Teague, Jr., Superintendent 640 Island Road • Circleville, OH 43113 • (740) 477-2500 • www.dys.ohio.gov

Case 2:08-cv-00475-ALM-MRA Document 30-1 Filed 02/26/10 Page 2 of 3
It should be noted that when youth were in seclusion, or on unit restriction for rule violations, staff would bring the youth a meal back from the cafeteria. When the meals were brought back to the youth, STG/ Gang youth that were on the unit would come up on the deck area and take the extra meals off the meal tray. Consequently, causing the cafeteria staff to prepare additional meals for the youth whose meal was taken by a STG/Gang youth.
** Not all youth who refused a meal did so because of STG/Gang affiliated activity. Some youth refused to go to the cafeteria because of the following:
• Youth wanted to sleep in • Youth thought it was too hot to go to the cafeteria • Youth did not like what was being served • Youth though it was the staff members responsibility to provide “room
service”
After reviewing the incidents of meals being taken and youth feeling threatened by STG/ Gang youth, we implemented a pilot program for meal refusals. We wanted to ensure that those youth who felt threatened would have the opportunity to receive a meal. Therefore, in August of 2009 we implemented the Meal Refusal Program. CJCF tracked the number of youth meals that were being refused, and the reason why meals were being refused. If a youth refused to go to the cafeteria for safety reasons, staff ensured that a meal was brought back to the unit to them.
Attached please find statistics regarding Meal Refusals in detail.

Case 2:08-cv-00475-ALM-MRA Document 30-1 Filed 02/26/10 Page 3 of 3

Circleville Juvenile Correctional Facility Meal Refusals

Month/Year August 2009

Breakfast 19

Lunch 8

Dinner Total

4

31

September 2009

51

9

4

64

October 2009

43

3

4

50

November 2009

76

5

0

81

December 2009

134

1

0

135

January 2010

43

4

1

48

February 2010

20

0

0

20

386

30

13

429

Meal Refusal Data – Sept. 2009 – Jan. 2010

Month
Sep-09 Oct-09 Nov-09 Dec-09 Jan-10

Days

Mo.

Avg

Mo.

Meals

Pop

30

90

140

31

93

136

30

90

131

31

93

131

31

93

129

Youth Refusing 2 meals in a row:

Offered
12600 12648 11790 12183 11997

# Refused
64 50 81 135 48

# Served
12536 12598 11709 12048 11949

% Served
99.49% 99.60% 99.31% 98.89% 99.60%

% Refused
0.51% 0.40% 0.69% 1.11% 0.40%

Marks Manley Manley Stewart Thomas

215867 B/L

215613

B/L

215613

B/L

215397

B/L

214843

B/L

8/28/09 8/29/09 8/30/09 8/30/09 8/30/09

August ‘09 = 5 Refusals

Johnson Kennedy Finan Mason

215727

B/L

215346

B/L

214944 B/L

213309 B/L

9/8/09 9/8/09 9/8/09 9/9/09

September ‘09 = 4 Refusals

1 week of data collected for August 2009 February 2010 data through Monday, 2/22/10

 Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 1 of 26 PAGEID #: 1791

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DNISION

UNITED STATES OF AMERICA, Plaintiff,
v.
THE STATE OF OHIO, et aI., Defendants.

)

)

)

)

)

)

CNIL ACTION NO: 2:08-cv-475

)

)

)

nJDGEALGENONL.~LEY

)

)

AMENDED STIPULATION FOR

)

INJUNCTIVE RELIEF

)

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 2 of 26 PAGEID #: 1792
TABLE OF CONTENTS
I. IN1RODUCTION ........................................................................................................ 1 II. DEFINITIONS ..............................................................................................................3 III. SUBSTANTNE REMEDIAL MEASURES ...............................................................5
A. PROTECTION FROM HARM ........................................................................5 B. MENTAL HEALTH CARE .............................................................................6 C. GENERAL MEDICAL CARE ........................................................................ ll D. GRIEVANCE PROCESS ................................................................................ 12 E. SPECIAL EDUCATION ................................................................................ 12 F. PROGRAMMING ..........................................................................................13 G. DOCUMENTATION ...................................................................................... 15 N. COMPLIANCE COORDINATION, POLICIES, TRAINING, AND QUALITY ASSURANCE/ QUALITY IMPROVEMENT .......................................................... 15 V. MONITORING ............................................................................................................ 16 VI. REPORTING REQUIREMENTS AND RIGHT OF ACCESS .................................. 20 VII. IMPLEMENTATION, ENFORCEMENT, AND TERMINATION .......................... 20

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 3 of 26 PAGEID #: 1793
I. INTRODUCTION
A. On June 24, 2008, the Court entered the original Stipulated Judgment. (Doc. 8.) Since that time, the parties have amended their agreement twice. (Docs. 27 and 81.) This Amended Stipulation reflects those respective sets of changes and replaces the original agreement in its entirety. This Stipulated Judgment is entered into by the parties to resolve all the claims in this action against all Defendants as to the Scioto Juvenile Correctional Facility ("Scioto"). The United States' claims concerning the remaining six facilities are resolved pursuant to the Court's Order conditionally dismissing the Complaint. (Doc. 7).
B. On March 16,2005, the United States Department of Justice ("DOl") notified the State of Ohio (the "State") of its intent to investigate conditions of confmement at the Scioto Juvenile Correctional Facility in Delaware, Ohio, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, and the Violent Crime Control and Law Enforcement Act of 1994,42 U.S.C. § 14141. Thereafter, on April 15, 2005, DOJ notified the State of its intent to conduct a similar investigation at the Marion Juvenile Correctional Facility ("Marion") in Marion, Ohio.
C. In response, the State of Ohio, through the Department of Youth Services ("DYS"), indicated that it intended to cooperate with the DOJ investigation, that it had determined that significant changes needed to be and would be made, and that it was embarking on a master plan to change the culture and conditions at Scioto and Marion.
D. In this regard, before DOJ opened its formal investigations of Scioto and Marion (collectively, the "Facilities"), the State hired Fred Cohen, a juvenile justice expert, to assess conditions at the Scioto facility. In August 2004, Mr. Cohen and his team of experts issued findings (the "Cohen Report"), a copy of which was provided to DOJ. Among other things, the Cohen Report addressed issues regarding protection from harm, medical care, mental health care, and special education at Scioto.
E. From June 27 to July 1,2005, DOJ toured Scioto and Marion with consultants in the fields ofmedical care and mental health care. A tour of Marion's special education program took place from July 19 to July 20, 2005.
F. Throughout the course of the investigation, the State has cooperated with DOJ, providing access to staff, youth, and documents at both Facilities.
G. On May 9,2007, DOJ issued findings letters, pursuant to 42 U.S.C. § 1997(a)(1), that concluded that certain conditions at Scioto and Marion violated the constitutional and federal statutory rights of youth confined in the Facilities. On June 1,2009, Marion was closed.

Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20111 Page: 4 of 26 PAGEID #: 1794
H. The State has indicated that it is fmnly committed to providing legally adequate conditions by instituting the remedial measures required by this Stipulation and that, in many ways, this StipUlation fonnalizes what had been agreed to in principal in the past and what the DYS reportedly already has under way.
I. The State represents that it is participating in a collaborative manner with plaintiffs' counsel in S.H., et at v. Stickrath, Case No. 2:04CVI206, which is a matter before the United States District Court for the Southern District of Ohio, and that, in the S.H. case, the State has elected to implement additional remedial measures beyond those required to resolve issues raised by the DOJ findings.
J. No person or entity is intended to be a third-party beneficiary of the provisions of this Stipulation for purposes of any civil, criminal, or administrative action, and accordingly, no person or entity may assert any claim or right as a beneficiary or protected class under this Stipulation. Notwithstanding the foregoing, DOJ and the State agree that the tenns of this Stipulation may be incorporated into the Stipulation for Injunctive Relief resolving the S.H. case.
K. The court finds that this StipUlation satisfies the requirements of IS U.S.C. § 3626 (a)(l)(A) and shall retain jurisdiction to enforce its terms. The court shall have the power to enforce the Stipulation through specific perfonnance and all other remedies pennitted by law.
L. On May 9, 2011, the United States, then Monitor in this matter, submitted to the Court its Third Compliance Report assessing the State's compliance with the provisions of the U.S.A. v. Ohio Stipulation. [Doc. 79].
M. On May 20, 2011, the Parties submitted a joint motion to the Court to: (1) terminate 20 provisions under section III, "Substantive Remedial Provisions"; (2) appoint a new monitor and consultants; and (3) modify the monitoring process. [Doc. SO]. The agreed changes are incorporated within this Amended Stipulation for Injunctive Relief.
N. Within the subject area of "Protection From Harm," the Parties agreed to tenninate the following four provisions: A.2, A.4, A.6, and A.7. Within the subject area of "General Medical Care," the Parties agreed to terminate the following seven provisions: C.3, C.4, C.6, C.7, C.S, C.9, and C.10. Within the subject are of "Grievances," the Parties agreed to tenninate one provision: D.3. Within the subject area of "Special Education," the Parties agreed to tenninate the following eight provisions: E.2, E.3, E.4, E.S, E.6, E.9, E.l 0 and E. 11.
O. On June 6, 2011, the court granted the Parties' joint motion to tenninate 20 provisions under section III, "Substantive Remedial Provisions", appoint a new monitor and consultants and modify the monitoring process. [Doc. SI].
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 5 of 26 PAGEID #: 1795
II. DEFINITIONS
In this Stipulation, the following definitions apply:
A. "Abuse and neglect" shall mean any act or failure to act as caretaker that results in death or physical or emotional injury that harms or threatens to harm a youth's health or welfare.
B. "DOl" means the United States Department of Justice, which represents the United States in this matter.
C. "DYS" means the Ohio Department of Youth Services.
D. "Effective Date" means June 5, 2008.
E. "IEP" means an Individual Education Plan as defined by the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006), and the regulations promulgated thereunder.
F. "Facilities" is replaced with the term "Facility," which means the Scioto Juvenile Correctional Facility or "Scioto."
G. "Implement" means to give practical effect and ensure actual fulfillment by concrete measures, including appropriate training of relevant staff.
H. "Include" or "including" means "include, but not be limited to" or "including, but not limited to."
I. "JCOs" mean the Juvenile Correctional Officers who work at Scioto. Such positions now are called Youth Specialists ("YS"). Any use ofJCO in this document is meant to refer to the new title of Youth Specialist.
J. "Over-familiarity" means any inappropriate or unduly intimate or informal conduct between juveniles and staffor employees including conduct that may lead to a romantic or sexual relationship, such as exchanging letters, providing special favors, or inappropriate touching.
K. "Qualified mental health professional" means a mental health care provider sufficiently trained and currently licensed to provide the services he or she undertakes to provide.
L. "Quality AssurancelImprovement Program" means a system of self-auditing and improvement to assess the implementation and effectiveness of all remedies instituted pursuant to this Stipulation, to identify deficits that may exist, and to effectuate new measures to cure deficits identified.
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 6 of 26 PAGEID #: 1796
M. "Rehabilitative Services" means programming and treatment provided to all youth in the Facilities. For each youth, programming and treatment shall be suitable to the youth's particular needs, shall address the underlying causes for the youth's confmement, and shall be designed to restore the youth's socially acceptable behaviors and values.
N "Restraints" means any chemical or mechanical device used to control the behavior of a youth.
O. "Scioto" means the Scioto Juvenile Correctional Facility located at 5993 Home Road, Delaware, Ohio, and any facility that is built to replace or supplement Scioto.
P. "Seclusion" "seclude" and "secluding" mean isolating a youth in a room from which the youth's ability to egress is blocked. The term seclusion does not apply to locking a youth in a room during nonnal hours of sleep.
Q. "Serious Incidents" means: use of force; injuries requiring more than first-aid treatment; and allegations of child abuse, ofover-familiarity or other, inappropriate staffrelationships with youth, of staff-on-youth violence, of youthon-youth violence, of significant, actual or attempted self harm, of youth-on-staff violence, and of any sexual contact.
R. "Serious mental illness" means the following disorders: psychoses, schizophrenia, bipolar with psychotic features, depression with psychotic features, severe post-traumatic stress disorder, and schizoaffective disorders.
S. "State" means the State of Ohio, Harvey J. Reed, Director of the Ohio Department of Youth Services, the Ohio Department ofYouth Services, and their successors, contractors and agents.
T. "Suicide Precautions" means any level of watch, observation, or measures to prevent self-harm.
U. "Superintendent" means an individual who is appointed to oversee all aspects of facility operations and is responsible for all facility staff and youth.
V. "Train" means to instruct in the skills addressed to a level that the trainee has the demonstrated proficiency to implement those skills as and when called for in the training. "Trained" means to have achieved such proficiency.
W. "Unified Case Plan" means the primary DYS document used to establish and describe youth and staff short term responsibilities in high risk/need domains, identify and address release authority and court expectations, document special concerns and summarize youth progress and completion ofprograms in these areas.
4

Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 7 of 26 PAGEID #: 1797
X. "Use ofForce" means any physical contact with a youth by a staffperson that has the likely effect of restricting the youth's freedom ofmovement, that applies physical pressure to the youth's body, or that causes or is likely to cause physical discomfort to the youth, including hand or arm holding to escort a youth over his or her resistance to being escorted. Use of Force does not mean brief and isolated use of physical guidance or positioning that is unlikely to cause physical discomfort and that is for the purpose of redirecting a youth or providing medical or related treatment.
y. "Youili" means any juvenile or juveniles committed by a court to, and residing at, the Facilities during the operation of this Stipulation.
III. SUBSTANTIVE REMEDIAL MEASURES
The Department of Youth Services shall provide youth in its charge with a safe and humane environment. Each youth entrusted to the Ohio Department ofYouth Services shall receive individual care, treatment, and rehabilitative services in the least restrictive setting consistent with the youth's needs, documented security concerns, and generally accepted professional standards of care. In no event will the level of care in such areas such as safe environment, mental health, special education, programming or any other requirement encompassed in this Stipulation fall below the level described or required in this Stipulation. The provisions under Section III reflect the fact that 20 provisions were terminated on June 6,2011 and therefore are not numbered sequentially.
A. PROTECTION FROM HARM
1. Generally: The State shall, at all times, provide youth in the Facilities with safe living conditions. As part of this requirement, the State shall take appropriate measures to ensure that youth are protected from abuse and neglect, use of excessive force, undue seclusion, undue restraint, and over-familiarization.
2. Use of Force: [Removed per Court Order on June 6,2011, Doc. 81.]
3. Seclusion: The State shall develop and implement policies, procedures and practices so that staffuse seclusion (as defined in this Stipulation) only in accordance with policy and in an appropriate manner and so that staff document fully the use and administrative review of any imposition of seclusion, including the placing of youth in their rooms outside normal sleeping hours.
4. Restraint: [Removed per Court Order on June 6,2011, Doc. 81.]
5

Case: 2:08-cv-0047S-ALM-MRA Doc#: 84-1 Filed: 06/20/11 Page: 8 of 26 PAGEID #: 1798
5. Investigation of Serious Incidents: The State shall develop and implement policies, procedures, and practices so that appropriate investigations are conducted of all incidents of: use of force; staff-onyouth violence; serious youth-on-youth violence; inappropriate staff relationships with youth; sexual misconduct between youth; and abusive institutional practices. Investigations shall be conducted by persons who do not have direct or immediate indirect responsibility for the employee(s) being investigated.
6. Staff Training in Behavior Management, De-Escalation, and Crisis Intervention: [Removed per Court Order on June 6, 2011, Doc. 81.]
7. Employment Practices: [Removed per Court Order on June 6, 2011, Doc. 81.]
B. MENTAL HEALTH CARE
1. Mental Health Screening: The State shall develop and implement policies, procedures, and practices to ensure that all youth admitted to the Facilities are comprehensively screened for mental disorders, including substance abuse, depression, and serious mental illness, within twenty-four hours of admission. This screening shall be perfonned by qualified personnel, as part of the intake process, consistent with generally accepted professional standards of care.
2. Immediate Referral to a Oualified Mental Health Professional: If the mental health screen identifies an issue that places the youth's safety at immediate risk, the youth shall be immediately referred to a qualified mental health professional for assessment, treatment, and any other appropriate action, such as transfer to another, more appropriate setting. The State shall ensure that, absent extraordinary circumstances, qualified mental health professionals are available for consultation within 12 hours of such referrals.
3. Identification of Previously Unidentified Youth with Mental Disorders: The Facilities shall implement policies, procedures, and practices consistent with generally accepted professional standards of care to identify and address potential manifestations of mental or behavioral disorder in youth who have not been previously identified as presenting mental health or behavioral needs requiring treatment.
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 9 of 26 PAGEID #: 1799

4. Mental Health Assessment: The State shall implement policies, procedures, and practices to ensure that, as part of an overall assessment of the youth's health, risks, strengths and needs, youth who are identified in screening as having possible mental health needs receive timely, comprehensive, and accurate assessments by qualified mental health professionals, consistent with generally accepted professional standards of care. Assessments shall be designed and implemented so as to identify youth with mental disorders in need of specific treatment and contribute to a full plan for managing the youth's risk. Assessments shall be updated as additional diagnostic and treatment information becomes available.

5. Adeguate Mental Health Care and Treatment: The State shall implement policies, procedures, and practices to ensure that adequate mental health and substance abuse care and treatment services (including timely emergency services), and adequate rehabilitative services are provided to youth in the Facilities by qualified mental health professionals consistent with generally accepted professional standards of care.

6. Treatment Planning: The State shall develop and implement policies, procedures and practices so that treatment service determinations, including ongoing treatment and discharge planning, are consistently made by an interdisciplinary team through integrated treatment planning and embodied in a single, integrated treatment plan.

7. Treatment Teams: At a minimum, the interdisciplinary treatment team for each youth in need of mentallbehavioral health and/or substance abuse treatment should:

a.

Be guided by a trained treatment professional who shall provide

clinical oversight and ensure the proper functioning of treatment

team meetings;

b.

Consist of a stable core of members, including at least the youth,

the social worker, a JCO, one of the youth's teachers, the Unit

Manager, and as warranted by the needs of the youth, the treating

psychiatrist, the treating psychologist, registered nurse, and, as

appropriate, other staff;

c.

Ensure that needed psychiatric evaluations are conducted on a

youth before administering psychotropic medications to the youth;

d.

Monitor as appropriate but at least monthly, the efficacy and

the side effects ofpsychotropic medications, including

consultation with the facility medical, counseling, and other

staff who are familiar with the youth;

7

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 10 of 26 PAGEID #: 1800

e.

For youth under a psychiatrist's care: ensure the provision of

individual counseling and psychotherapy when needed, in

coordination with facility psychologists; ensure that all youth

referred as possibly in need ofpsychiatric services are evaluated

and treated in a timely manner; and provide adequate

documentation of treatment in the facility medical records;

f.

Include, to the fullest extent practicable, proactive efforts to obtain

the participation of parents or guardians, unless their participation

would be inappropriate for some reason (e.g., the child has been

removed from the parent's custody), in order to obtain relevant

infonnation, understand family goals and concerns, and foster

ongoing engagement;

g.

Meet to assess the treatment plan's efficacy at least every 30

days, and more often as necessary; and

h.

Document treatment team meetings and planning in the youth's

mental health records.

8. Integrated Treatment Plans: The State shall ensure that each youth in need ofmentallbehavioral health and/or substance abuse treatment shall have an appropriate, integrated, treatment plan, including an appropriate behavior management plan, that addresses such needs. The integrated treatment plan shall be driven by individualized risks and needs, be strengths-based (i.e., builds on an individual's current strengths), account for the youth's motivation for engaging in activities contributing to hislher wellness, and be reasonably calculated to lead to improvement in the individual's mentallbehavioral health and well being, consistent with generally accepted professional standards of care.

9. Access to a Oualified Mental Health Professional: The State shall develop and implement policies, procedures, and practices to ensure that youth who seek access to a qualified mental health professional are provided appropriate access in a timely manner.

10. Mental Health Involvement in Housing and Placement Decisions: The State shall develop and implement a system for ensuring that significantly mentally ill youth who do not have the adaptive functioning to manage the activities of daily living within the general population are provided appropriate housing and supports to assist them in managing within the institutional setting.

8

Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 11 of 26 PAGEID #: 1801

11. Staffing: The State shall staff, by contract or otherwise, the Facilities with adequate numbers ofpsychiatrists, psychologists, social workers, and other mental health professionals qualified through training and practical experience to meet the mental health needs of youth residents, as determined by the acuity of those needs. Mental health care shall be integrated with other medical and mental health services and shall comport with generally accepted practices. The State shall ensure that there are sufficient numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming.

12. Medication Notice: Before renewing a psychoactive medication prescription from a community provider or commencing the administration of a psychoactive medication to a youth, the State shall ensure that the youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, are provided with information regarding the goals, risks, benefits, and potential side effects of the medication and given an explanation of the potential consequences ofnot treating with the medication, and that the youth has an opportunity to consent to such medication.

a.

Involuntary administration ofpsychotropic medication(s) to

juveniles shall comply with applicable federal and state laws and

regulations. The DYS clinical director, in consultation with the

DYS medical director, shall review any request with DYS Legal

Services prior to the approval for involuntary administration.

13. Mental Health Medications: The State shall develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices. The State shall provide regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy. The State shall issue and implement policies and procedures for the administration of appropriate tests (including, for example, blood tests, EKGs, and Abnormal Involuntary Movement Scale tests) to monitor the efficacy and any side effects of psychoactive medications in accordance with generally accepted professional standards. The State shall also:

a. Share medication compliance data with the psychiatrist and document the sharing of this information; and

b. Not withhold the provision ofpsychostimulants to youth when such treatment is clinically warranted.

9

Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 12 of 26 PAGEID #: 1802
14. Mental Health and Developmental Disability Training for Direct Care Staff: The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents in order to supervise them appropriately.
15. Staff Mental Health Training: The Facilities shall train:
a. All staff who directly interact with youth (e.g., JCOs, social workers, teachers, etc.) on: (i) basic mental health information (e.g., diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern) and recognition of signs and symptoms evidencing a response to trauma; and
(ii) teenage development, strength-based treatment strategies, suicide, and, for staff who work with female youth, female development.
b. Clinical staff on the prevalence, signs, and symptoms of Post Traumatic Stress Disorder and other disorders associated with trauma.
16. Suicide Prevention: The State shall review and, as appropriate, revise current suicide prevention practices to ensure that suicide preventions and interventions are implemented consistently and appropriately, consistent with generally accepted professional standards of care.
17. Transition Planning: The State shall ensure that staff create transition plans for youth leaving the Facilities consistent with generally accepted professional standards of care.
18. Oversi2ht of Mental Health Services: The Facilities shall ensure that youth receive the care they need by developing and implementing an adequate mental health Quality Assurance/Improvement Program; annually assessing the overall efficacy of the staffing, treatments, and interventions used at the Facilities; and, as appropriate, revising such staff'mg, treatments and interventions.
10

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 13 of 26 PAGEID #: 1803
C. GENERAL MEDICAL CARE
1. Generally: The Facilities shall ensure that the individuals they serve receive routine, preventive, and emergency medical and dental care consistent with current, generally accepted professional standards. The Facilities shall ensure that individuals with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care.
2. Health Records: The State shall develop and implement policies, procedures, and practices to ensure that, consistent with State and Federal law, at a minimum, the juvenile courts in the State, all juvenile detention facilities, and all placement settings from which youth are committed shall timely forward to Scioto, or to the facility ofplacement (ifthe records arrive after the youth has been placed), all pertinent youth records regarding medical and mental health care. The Facilities shall develop and implement policies, procedures, and practices to ensure that health care staff, including mental health care staff, have access to documents that are relevant to the care and treatment of the youth.
3. Confidential Health Care: [Removed per Court Order on June 6, 2011, Doc. 81.]
4. Initial Health Assessment: [Removed per Court Order on June 6, 2011, Doc. 81.]
5. Access to Health Services: The Facilities shall ensure that youth can request to be seen by medical staffconfidentially and independent from JCOs and custodial staff.
6. Medication Management: [Removed per Court Order on June 6, 2011, Doc. 81.]
7. Dental Care: [Removed per Court Order on June 6, 2011, Doc. 81.]
8. Management of Chronic illnesses: [Removed per Court Order on June 6, 2011, Doc. 81.]
9. Access to Specialty Care: [Removed per Court Order on June 6,2011, Doc. 81.]
10. Immunizations: [Removed per Court Order on June 6,2011, Doc. 81.]
11

Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 14 of 26 PAGEID #: 1804
D. GRIEVANCE PROCESS 1. The State shall develop and implement policies, procedures, and practices to ensure that the Facilities have an adequate grievance system including: no formal or informal preconditions to the completion and submission of a grievance; review of grievances by the Incident Review Team; timely initiation and resolutions of grievances; appropriate corrective action; and written notification provided to the youth of the final resolution of the grievance. 2. A clear explanation of the grievance process shall be provided to each youth upon admission to the Facilities during orientation, and to their parent(s) or guardian(s), and the youth's understanding of the process shall be at least verbally verified. 3. [Removed per Court Order on June 6,2011, Doc. 81.]
E. SPECIAL EDUCATION 1. Provision of Special Education: The State shall, at all times, provide all youth confmed at the Facilities with adequate special education in compliance with the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006), and regulations promulgated thereunder, and this Stipulation. 2. Oversight: [Removed per Court Order on June 6,2011, Doc. 81.] 3. Special Education upon Intake: [Removed per Court Order on June 6, 2011, Doc. 81.] 4. Parent or Guardian Involvement: [Removed per Court Order on June 6, 2011, Doc. 81.] 5. Staffing: [Removed per Court Order on June 6, 2011, Doc. 81.]
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Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 15 of 26 PAGEID #: 1805
6. Screening for Special Education Needs: [Removed per Court Order on June 6,2011, Doc. 81.]
7. Individual Education Plans:
a. The State shall develop an IEP as defmed in 34 C.F.R. § 300.320 for each youth who qualifies for an IEP. Following development of the IEP, the State shall implement the IEP as soon as possible. As part of satisfying this requirement, the State shall conduct required annual reviews of IEPs, adequately document the provision of special education services, and comply with requirements regarding participation by the professional staff, parents, and student in the IEP process. The State shall, if necessary, develop, review or revise [EPs for qualified special education students.
b. In developing or modifying the IEP, the State shall ensure that: the IEP reflects the individualized educational needs ofthe youth and that services are provided accordingly; each IEP includes documentation of the team's consideration of the youth's need for related services and transition planning, and identifies the party responsible for providing such transition services; the student's educational progress is monitored; teachers are trained on how to monitor progress toward IEP goals and objectives; and teachers understand and use functional behavioral assessment and behavior intervention programs in IEP planning and implementation.
8. Vocational Education: The State shall provide appropriate vocational services that are required transition services for disabled youth under the IDEA.
9. Forwarding Screening and Assessment Information upon Transfer: [Removed per Court Order on June 6, 2011, Doc. 81.]
10. Training and Ouality Assurance: [Removed per Court Order on June 6, 2011, Doc. 81.]
11. Transition Services: [Removed per Court Order on June 6, 2011, Doc. 81.]
F. PROGRAMMING
1. Structured Programming: The State shall provide adequate, structured Rehabilitative Services, including an appropriate mix ofphysical, recreational, or leisure activities, during non-school hours and days
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Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 16 of 26 PAGEID #: 1806
("Structured Programming"). The State shall develop and implement Structured Programming at each facility from the end of the school day until youth go to bed, and on weekends. For youth housed in closed-cell environments, Structured Programming shall be designed to ensure that youth are not confined in locked cells except: (a) from after Structured Programming to wake-up; (b) as necessary where the youth poses an immediate risk of hann to self or others; or (c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The Structured Programming shall be designed to modify behaviors, provide rehabilitation to the types of youth committed to each facility, address general health and mental health needs, and be coordinated with youth's individual behavioral and treatment plans. The State shall use teachers, school administrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualified assistance to develop and implement the Structured Programming. The State shall provide youth with access to programming activities that are required for parole eligibility.
2. Orientation:
a. Admissions Intake and Orientation: The State shall develop and implement policies, procedures, and practices to establish a consistent, orderly admissions intake system, conducive to gathering necessary information about youth, disseminating information to staff providing services and care for youth, and maintaining youth safety. The orientation shall also clearly set forth the rules youth must follow at the Facility, explain how to access medical and mental health care and the grievance system, and provide other information pertinent to the youth's participation in the Facility's programs.
b. Notice to Youth of Facilitv Rules and Incentives/Consequences for Compliance: The State shall explain the Structured Programming to all youth-during an orientation session that shall set forth the facility rules, the positive incentives for compliance and good behavior, and the sanctions for rule violations. The State shall provide the Facility rules in writing
c. Introductory Handbook. Orientation and Reporting Abuse: Each youth entering the Facilities shall be given an orientation that shall include simple directions for reporting abuse and assuring youth of his/her right to be protected from retaliation for reporting allegations of abuse.
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Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 17 of 26 PAGEID #: 1807
G. DOCUMENTATION
The Facilities shall develop and implement policies, procedures, and practices setting forth clear standards regarding the content, integration, and timeliness ofprogress notes, transfer notes, school progress notes, discharge notes, and other records, including, but not limited to, an expectation that such records include meaningful, accurate, and coherent assessments ofthe individual's progress relating to treatment plans, goals and objectives, and that clinically relevant information remains readily accessible.
1. Progress Notes: The Facilities shall promulgate and implement a policy requiring that all health professionals be required to create and use progress notes to document, on a regular basis, interactions and each assessment of youth with mentallbehavioral health or substance abuse needs. In particular, progress notes shall:
a. In the assessment, address the efficacy of interventions, currently presenting problems, and the available options to address those problems; and
b. Provide thorough documentation of all crisis interventions or, if not thoroughly documented in the progress notes, provide a reference to alert staff to another document in the youth's file containing the details of the crisis intervention.
2. Accessibility of Relevant Information: The Facilities shall ensure that youth records are organized in a manner providing treatment teams prompt access to relevant, complete, and accurate documentation regarding the youth's status.
IV. COMPLIANCE COORDINATION, POLICIES, TRAINING, AND QUALITY ASSURANCE/QUALITY IMPROVEMENT
A. Compliance Coordinator: The State shall assign the responsibility for coordinating compliance with this Stipulation to a compliance coordinator who shall report directly to the Director of the Department of Youth Services on these issues and shall coordinate and assess the State's compliance with this StipUlation and with State policies governing the Facilities.
B. Policies: The State shall revise or develop policies, procedures, protocols, and practices to ensure that they are consistent with, incorporate, address, and implement all provisions of this Stipulation. The State shall revise or develop as necessary other written documents such as screening tools, logs, handbooks, manuals, and forms, to effectuate the provisions of this Stipulation.
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Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 18 of 26 PAGEID #: 1808
C. Document Review: Within 30 days after execution of this Stipulation, the State shall submit a master plan to the Monitor (see § V below), DOJ, and the S.H. plaintiffs' counsel that establishes a time line of up to one year to revise and/or develop written policies, procedures, protocols, training materials, and screening and assessment tools to effectuate the provisions of this Stipulation. The master plan and the policies, procedures, protocols, training materials, and screening and assessment tools shall be submitted to the Monitor, DOJ, and the S.H. plaintiffs' counsel for review and comment consistent with this paragraph. DOJ shall provide prompt guidance to the State, including specific explanations as to how the provisions, policies, or procedures, if any, are inconsistent with the terms of this Stipulation, and shall suggest revisions. In the event that DOJ asserts that policies, procedures, and other written documents are not in compliance with the terms of this Stipulation, the parties, in collaboration with the S.H. plaintiffs' counsel, will agree to a schedule for the parties' experts and the Monitor to communicate. If the parties are unable to agree on revisions to the policies, procedures, or practices, the parties shall submit the issue to the Monitor for resolution, consistent with the dispute resolution mechanism (at paragraph 256) of the Stipulation approved the court in S.H.
D. Training: The State shall ensure that any person acting for the State in implementing any requirement in Section III of this Stipulation has been trained on the implementation of that provision and any corresponding State or Facility policies and procedures.
E. Performance Data: On an ongoing basis, each Facility shall collect and analyze objective statistical data measuring the Facility's performance as to uniform performance indicators through which the implementation of each provision of Section III of this Stipulation can be reliably assessed ("Performance Data"). At least annually, the Compliance Coordinator shall independently audit each facility to verify the accuracy of the Facility's data collection and reporting.
v. MONITORING
A. Monitor and Consultant Selection, Reporting, and Removal
1. This Stipulation, as originally written, and the agreement in the S.H. v. Stickrath class action ("S.H. litigation") (See Docs. 92-4 and 108 therein) fashioned a unitary monitoring system. Specifically, Fred Cohen started serving as the only Monitor for both this case and in the S.H. litigation. However, on September 24, 2009, Fred Cohen submitted his resignation as the Monitor in U.S.A. v. Ohio. In response, the DOJ, the State, and the Plaintiffs in the S.H. litigation intended to establish a separate monitoring system in U.S.A. v. Ohio. which neither interferes nor conflicts with the monitoring system in the S.H. litigation.
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Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 19 of 26 PAGEID #: 1809
2. Effective July 1, 2011, Dr. Kelly Dedel shall serve as the Monitor in U.S.A. v. Ohio, replacing the DOJ in that role.
2.1 The Monitor and any consultants assisting in monitoring remediation efforts shall coordinate their monitoring activities in this matter with the State to minimize conflicting schedules or other undue burdens on the State. As such, absent exigent circumstances, the Monitor, consultants, or sub-experts, in this case may not visit Scioto within a week of a previously scheduled visit by the Monitor of the S.H. litigation, unless the State consents to such scheduling.
2.2 Dr. Dedel will conduct substantive monitoring activities pertaining to Sections lILA and IILD-G ofthis Stipulation (Protection from Harm, Grievance Process, Special Education, Programming, and Documentation, respectively). Dr. Dedel will coordinate preparation of, and issue, all Monitor reports required by this Stipulation.
2.3 Dr. Daphne Glindmeyer, M.D., a mental health consultant, will assist the
Monitor as a consultant to oversee monitoring activities pertaining to Section m.B
(Mental Health) of this Stipulation. Dr. Glindmeyer will provide substantive information to the Monitor to help the Monitor to prepare and issue the reports required under this Stipulation as to the mental health terms set forth in the Stipulation.
2.4 Dr. Michelle Staples-Home, M.D., a medical care consultant, will assist the Monitor as a consultant to oversee monitoring activities pertaining to Section IILC (General Medical Care) ofthis Stipulation. Dr. Staples-Home will provide substantive information to the Monitor to help the Monitor to prepare and issue the reports required under this StipUlation as to the medical care terms set forth in the Stipulation.
3. All Monitor and Consultant Reports shall be provided to DOJ and DYS at least two weeks prior to their issuance. These reports shall be written with due regard for the privacy interests of individual youth and staff and the interest of the State in protecting against disclosure of non-public information.
4. Upon one of two grounds, the Monitor or any consultant assisting the Monitor may be removed from their respective positions on the monitoring team.
4.1 The Monitor or any consultant may be terminated from their duties as Monitor or consultant for good cause, either by prior notice to such Monitor or consultant and the stipulation ofDOJ and DYS, or by order of the Court pursuant to a motion filed by DOJ or DYS.
4.2. If either DYS or the class Plaintiffs in the S.H. litigation determine in good faith that the monitoring process in this case has resulted in conflicting standards for DYS to attain lawful conditions ofconfmement, then either such party may seek a court order in this case to remove the Monitor or any consultant to the Monitor. The
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Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 20 of 26 PAGEID #: 1810
reasonably supported results of any monitoring report may not constitute good faith grounds to seek the removal of a Monitor or a consultant to the Monitor.
5. If the position of Monitor becomes vacant, the following steps will apply:
5.1 DOl and DYS shall confer regarding the selection of a new Monitor.
5.2 If DOl and DYS are all unable to agree within thirty (30) days of the vacancy occurring, or within a time agreed to by each of those parties, then DOl and DYS shall submit two names, along with resumes and cost proposals, to the Court. The Court shall then select the replacement monitor.
5.3 A vacancy occurs upon the removal by notice of the Monitor or a consultant as set forth in 4.1 or 4.2 above, by Court order, or upon the Court's acceptance of a written letter of resignation from the Monitor or consultant.
6. 001 and DYS agree that no other Monitors or consultants, except those named in Part 2 above, will be used to conduct monitoring activities in this case. This does not bar either the Monitor or any approved consultant from retaining a sub-expert for additional input. However, the State has no obligation to permit such sub-experts to tour any facilities subject to this Stipulation. Further, the State has no obligation to respond to any request for documents, files, or data of any kind from such sub-expert. And, the State has no obligation to fund such sub-experts without its prior approval and agreement.
B. Cost of Monitor and Monitoring Team: The State shall pay the costs ofthe fees and expenses for both the monitor and the other members of the monitoring team.
C. Monitor Autonomy: Neither party to this Stipulation, nor any employee or agent of either party, shall have any supervisory authority over the monitor's activities reports, fmdings, or recommendations.
D. Monitor Qualifications: The Monitor shall have experience and education or training in the field of juvenile justice. The Monitor may also have education, training, or experience in general or special education, adolescent health and mental health needs (particularly the needs of institutionalized adolescents), and institutional abuse and incident investigations.
E. Monitor Access: The Monitor shall have full and complete access to the Facilities, all facility records, staff, and residents. The State shall direct all employees to cooperate fully with the Monitor. All non-public information obtained by the Monitor shall be maintained in a confidential manner.
F. Monitor Ex Parte Communications: The Monitor shall be permitted to initiate and receive ex parte communications with all parties in this and the S.H. case.
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G. Limitations on Public Disclosures by Monitor: Except as required or authorized by the terms of this Stipulation or the parties acting together, the Monitor shall not: make any public statements (at a conference or otherwise) or issue public findings with regard to any act or omission of the State or its agents, representatives or employees, or disclose non-public information provided to the Monitor pursuant to this Stipulation. Any press statement made by the Monitor regarding hislher employment must first be approved, in writing, by the parties. The Monitor shall not testify in any other litigation or proceeding with regard to any act or omission of the State or any of its agents, representatives, or employees related to this Stipulation, nor testify regarding any matter or subject that he or she may have learned as a result of his or her performance under this Stipulation. Reports issued by the Monitor shall not be admissible against the State in any proceeding other than a proceeding related to the enforcement of this Stipulation Unless such conflict is waived by the parties, the Monitor shall not accept employment or provide consulting services that would present a conflict of interest with the Monitor's responsibilities under this Stipulation, including being retained (on a paid or unpaid basis) by any current or future litigant or claimant, or such litigant's or claimant's attorney, in connection with a claim or suit against the State or its departments, officers, agents or employees. The records maintained by the Monitor shall be kept confidential to the extent permitted by Ohio's Public Records Law and the federal Freedom of Information Act. Neither the Monitor nor any person or entity hired or otherwise retained by the Monitor to assist in furthering any provision of this Stipulation shall be liable for any claim, lawsuit or demand arising out of the Monitor's performance pursuant to this Stipulation. This paragraph does not apply to any proceeding before a court related to performance of contracts or subcontracts for monitoring this Stipulation.
H. Monitor Rc:morts: The Monitor shall provide DOJ and DYS with reports describing the steps taken by the State to implement this Stipulation and evaluate the extent to which the State has complied with each substantive provision of the Stipulation. The Monitor shall prepare the report based upon a site visit of Scioto conducted no more than six weeks before the report's issuance. For each requirement of Section III of this Stipulation, the report shall specify: (1) the steps (including documents reviewed, meetings attended, and persons interviewed) the Monitor took to assess compliance; (2) the self-assessment steps the facility undertook to assess compliance and the results thereof; (3) the level of compliance. i.e.,"noncompliance" or "substantial compliance"; and (4) the Monitor's recommendations, ifany, to facilitate or sustain compliance. The Monitor shall issue a report for Scioto every six months, with interim reports as the Monitor determines appropriate. The Monitor is primarily to assess and report upon compliance; if there is an ambiguity in the meaning or intent of a provision, the Monitor shall seek guidance from the parties. The reports shall be provided to DOJ and DYS in draft form for comment at least two weeks prior to their issuance. These reports shall be written with due regard for the privacy interests of individual youth and staff and the interest of the State in protecting against disclosure of non-pUblic information.
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Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 22 of 26 PAGEID #: 1812
I. Monitor Budget: The Monitor shall have a budget sufficient to allow the Monitor and the consultants named in Part A.2 above to carry out the responsibilities described in this StipUlation, and shall provide DOJ and DYS with a copy of each invoice, when issued by the Monitor, and notice of payment, when received by the Monitor. The Monitor will consult with the Defendants to set the monitoring budget for each fiscal year while injunctive relief is in place. Defendants shall pay the fees associated with the monitoring under this Stipulation.
VI. REPORTING REQUIREMENTS AND RIGHT OF ACCESS
A. DOJ Access: DOJ shall have full and complete access to the youth at the Facilities upon reasonable notice to DYS. OOJ shall have full and complete access to the Facilities, youth records, staff records, and staff of the Facilities regarding the topics addressed in this Stipulation upon reasonable notice to DYS. DOJ shall have the right to conduct interviews with staff, and confidential interviews with residents and former residents. State attorneys may be present at interviews of staff and tours of Facilities. All non-pUblic information obtained by DOJ shall be maintained in a confidential manner.
B. Re§ponse to DO] Questions: Within 30 days of receipt of written questions from DOJ concerning the State's compliance with this Stipulation, the Monitor shall provide DOJ with written answers and access to any requested documents regarding the State's compliance with the requirements of this Stipulation.
C. State Documentation of Compliance: The State shall maintain sufficient records to document its compliance with all of the requirements of this Stipulation. The State shall also maintain (so long as this StipUlation remains in effect) any and all records required by or developed under this Stipulation.
D. Privileges: This Stipulation shall not be deemed to waive the attorney/client, attorney work product, deliberative process, or executive privileges. The State shall not assert physician/patient or psychotherapist/patient privileges with respect to the monitoring ofthis Stipulation.
VII. IMPLEMENTATION, ENFORCEMENT, AND TERMINATION
A. Information to Employees: The State shall ensure that all current and future relevant State employees understand the terms of policies and procedures addressed by this Stipulation (to the extent necessary to carry out their job duties and responsibilities).
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Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 23 of 26 PAGEID #: 1813
B. Implementation: The State shall implement all refonns necessary to effectuate this Stipulation. The implementation shall begin on the effective date of the Stipulation in the S.H. case. Minor, inconsequential, sporadic, unintentional or isolated hannless instances of noncompliance with this Stipulation shall not be a basis for enforcement, provided they do not affect a substantial interest of the youth.
C. Integration: This Stipulation shall constitute the entire integrated Stipulation of the parties. With the exception of 001's findings letters referenced in Section L G., no prior or contemporaneous communications, oral or written, will be relevant or admissible for purposes of detennining the meaning of any provisions herein in any proceeding.
D. Enforcement: If DO] believes that the State has failed to substantially comply with any obligation under this Stipulation, the parties will use the dispute resolution mechanisms in the Stipulation in the S.H. case (paragraph 256).
E. Tennination: This Stipulation shall tenninate when the State has substantially complied with each of the provisions of the Stipulation and has maintained substantial compliance for two consecutive reporting periods following the initial fmding of substantial compliance. The burden shall be on the State to demonstrate this level of compliance. Any of subsections A through G of Section III of the StipUlation may be terminated if the State sustains its burden with respect to that subsection of the Stipulation. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained noncompliance shall not constitute substantial compliance. The Defendants shall retain all rights, protections, and remedies under the Prison Litigation Refonn Act of 1995, 18 U.S.C. § 3626 ~.
F. Defense of Stipulation: The parties agree to defend the provisions ofthis Stipulation. The parties shall notify each other of any court challenge to this Stipulation. In the event any provision of this Stipulation is challenged in any local or state court, removal to a federal court shall be sought. The terms of this Stipulation shall apply only to this Stipulation, and may not be used to affect or interpret any other agreement including S.H. v Stickrath regarding the State of Ohio.
G. Successors: This StipUlation shall be binding on all successors, assignees, employees, agents and all those working for or on behalf of the State.
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Case: 2:08-cv-00475~ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 24 of 26 PAGEID #: 1814
H. No Waiver for Failure to Enforce: Failure by either party to enforce this entire Stipulation or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions ofthis Stipulation.
L Notice: "Notice" under this Stipulation shall be provided electronically or by courier or overnight delivery and shall be provided to the State to the Director ofthe Department of Youth Services ofthe State ofOhio, to the Ohio Attorney General, and to the United States to the Chief ofthe Special Litigation Section, Civil Rights Division, United States Department ofJustice.
J. Unforeseen Delay: If any unforeseen circumstance occurs which causes a failure to timely carry out any requirements of this Stipulation, the State shall notifY DOJ in writing within 20 calendar days ofthe time that the State becomes aware of the unforeseen circumstance and its impact on the State's ability to perform under the Stipulation. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. The State shall implement all reasonable measures to avoid or minimize any such failure.
K. Non~Reta1iation: The State agrees that it shall not retaliate against any person because that person has filed or may file a complaint, provided information or assistance, or participated in any other manner in an investigation or proceeding relating to this Stipulation. The State is not precluded from taking appropriate action where an individual knowingly asserts a false complaint or knowingly makes false statements.
L Subheadings: All subheadings in this Stipulation are written for convenience of locating individual provisions. If questions arise as to the meanings of individual provisions, the parties shall follow the text of each provision.
M. Severability: In the event any provision of this Stipulation is declared invalid for any reason by a court of competent jurisdiction, said finding shall not affect the remaining provisions of this Stipulation.
N. Attorneys' Fees and Expenses: Each party shall bear the cost of their fees and expenses incurred in connection with this matter.
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Case: 2:08-cv-00475-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 25 of 26 PAGEID #: 1815

IT IS SO STIPULATED AND AGREED.
FOR THE UNITED STATES:
CARTER M. STEWART United States Attorney Southern District of Ohio
JOHN STARK. Assistant United States Attorney Southern District ofOhio 303 Marconi Boulevard Suite 200 Columbus, OH 4321

DATE: June 20,2011
THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Section Chief Special Litigation Section
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section
sf Silvia J. Dominguez Silvia 1. Dominquez Rashida Ogletree Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 Telephone: (202) 514-6255 Facsimile: (202) 514-0212

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Case: 2:08-cv-0047S-ALM-MRA Doc #: 84-1 Filed: 06/20/11 Page: 26 of 26 PAGEID #: 1816

IT IS SO STIPULATED AND AGREED.
FOR THE STATE:
sf Harvey J. Reed HARVEY J. REED Director Ohio Department of Youth Services

DATE: June 20,2011

sf J. Eric Holloway J. ERIC HOLLOWAY (0063857) Lead Counsel for Defendants Ohio Attorney General's Office
JASON FULLER (0085184) Co-Counsel for Defendants Ohio Attorney General's Office
Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, OH 43215 Telephone: 614-644-7233 Facsimile: 866-459-6675 Email: Eric.Holloway@OhioAttorneyGeneral.gov Email: Jason.Fuller@OhioAttorneyGeneral.gov

WHEREFORE, for good cause shown,

~

fi[ it is SO ORDERED this

day of j ( J..!I\.JL

,2011.

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 Case: 2:08-cv-00475-ALM-MRA Doc #: 81 Filed: 06/06/11 Page: 1 of 6 PAGEID #: 1774

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, )

)

Plaintiff,

)

v.

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

CIVIL ACTION NO: 2:08-CV-475 Judge Algenon L. Marbley

ORDER AMENDING CERTAIN PROVISIONS OF STIPULATION
For good cause shown, and pursuant to the Parties' consent, the Court hereby grants the Parties' Joint Motion to Amend Certain Provisions of Stipulation ("Joint Motion"). (See Dkt. 80.)
Accordingly, the Stipulation for Injunctive Relief, (Dkt. 8), as amended on December 15, 2009, (Dkt. 27), is modified to remove the substantive provisions and the termination provision, and modify the monitoring provisions, as follows:
Stipulation, Section III The following provisions are hereby removed from Section III (Substantive Remedial Measures) of the Stipulation for Injunctive Relief: 1. Provision A.2 (Use of Force) 2. Provision A.4 (Restraint) 3. Provision A.6 (Staff Training in Behavioral Management, De-Escalation, Crisis Intervention) 4. Provision A. 7 (Employment Practices)

Case: 2:08-cv-00475-ALM-MRA Doc #: 81 Filed: 06/06/11 Page: 2 of 6 PAGEID #: 1775
5. Provision C.3 (Confidential Health Care) 6. Provision C.4 (Initial Health Assessment) 7. Provision C.6 (M:edication Management) 8. Provision C.7 (Dental Care) 9. Provision C.8 (M:anagement of Chronic Illness) 10. Provision C.9 (Access to Specialty Care) 11. Provision C.10 (Immunizations) 12. Provision D. 3 (Grievance Process) 13. Provision E.2 (Oversight) 14. Provision E.3 (Special Education Upon Intake) 15. Provision E.4 (Initial Health Assessment) 16. Provision E.5 (Staffing) 17. Provision E.6 (Screening for Special Education needs) 18. Provision E. 9 (Forwarding Screening and Assessment Information Upon
Transfer) 19. Provision E.10 (Training and Quality Assurance) 20. Provision E.11 (Transition Services)
Stipulation, Section VII.E Further, the first sentence of provision E (Termination) in Section VII of the Stipulation for Injunctive Relief is removed to eliminate the automatic termination of the Stipulation. Provision E (Termination) in Section VII of the Stipulation for Injunctive Relief shall also include the following statement: "The Defendants shall retain all rights, protections, and remedies under the Prison Litigation Reform Act of 1995, 18 U.S.C. § 3626 et seg."
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Case: 2:08-cv-00475-ALM-MRA Doc #: 81 Filed: 06/06/11 Page: 3 of 6 PAGEID #: 1776
Stipulation, Section V
Further, effective July 1, 2011, the December 15, 2009, Order Modifying the
Stipulation for Injunctive Relief (Dkt. 27), is vacated, reverting Stipulation Section
V back to its original terms. Also effective July 1, 2011, Stipulation Sections V.A,
V.H, and V.I. are removed and replaced with:
A. Monitor and Consultant Selection, Reporting, and Removal
1. This Stipulation, as originally written, and the agreement in the S.H. v. Stickrath class action ("S.H. litigation") (See Docs. 92-4 and 108 therein) fashioned a unitary monitoring system. Specifically, Fred Cohen started serving as the only Monitor for both this case and in the S.H. litigation. However, on September 24, 2009, Fred Cohen submitted his resignation as the Monitor in U.S.A. v. Ohio. In response, the DOJ, the State, and the Plaintiffs in the S.H. litigation intended to establish a separate monitoring system in U.S.A. v. Ohio. which neither interferes nor conflicts with the monitoring system in the S.H. litigation.
2. Effective July 1, 2011, Dr. Kelly Dedel shall serve as the Monitor in U.S.A. v. Ohio, replacing the DOJ in that role.
2.1 The Monitor and any consultants assisting in monitoring remediation efforts shall coordinate their monitoring activities in this matter with the State to minimize conflicting schedules or other undue burdens on the State. As such, absent exigent circumstances, the Monitor, consultants, or sub-experts, in this case may not visit Scioto within a week of a previously scheduled visit by the Monitor of the S.H. litigation, unless the State consents to such scheduling.
2.2 Dr. Dedel will conduct substantive monitoring activities pertaining to Sections liLA and III.D-G of this Stipulation (Protection from Harm, Grievance Process, Special Education, Programming, and Documentation, respectively). Dr. Dedel will coordinate preparation of, and issue, all Monitor reports required by this Stipulation.
2.3 Dr. Daphne Glindmeyer, M.D., a mental health consultant, will assist the Monitor as a consultant to oversee monitoring activities pertaining to Section III.B (Mental Health) of this Stipulation. Dr. Glindmeyer will provide substantive information to the Monitor to help the Monitor to prepare and issue the reports required under this Stipulation as to the mental health terms set forth in the Stipulation.
3

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2.4 Dr. Michelle Staples-Horne, M.D., a medical care consultant, will assist the Monitor as a consultant to oversee monitoring activities pertaining to Section III.C (General Medical Care) of this Stipulation. Dr. Staples-Horne will provide substantive information to the Monitor to help the Monitor to prepare and issue the reports required under this Stipulation as to the medical care terms set forth in the Stipulation.
3. All Monitor and Consultant Reports shall be provided to DOJ and DYS at least two weeks prior to their issuance. These reports shall be written with due regard for the privacy interests of individual youth and staff and the interest of the State in protecting against disclosure of non-public information.
4. Upon one of two grounds, the Monitor or any consultant assisting the Monitor may be removed from their respective positions on the monitoring team.
4.1 The Monitor or any consultant may be terminated from their duties as Monitor or consultant for good cause, either by prior notice to such Monitor or consultant and the stipulation of DOJ and DYS, or by order of the Court pursuant to a motion filed by DOJ or DYS.
4.2. If either DYS or the class Plaintiffs in the S.H. litigation determine in good faith that the monitoring process in this case has resulted in conflicting standards for DYS to attain lawful conditions of confinement, then either such party may seek a court order in this case to remove the Monitor or any consultant to the Monitor. The reasonably supported results of any monitoring report may not constitute good faith grounds to seek the removal of a Monitor or a consultant to the Monitor.
5. If the position of Monitor becomes vacant, the following steps will apply:
5.1 DOJ and DYS shall confer regarding the selection of a new Monitor.
5.2 If DOJ and DYS are all unable to agree within thirty (30) days of the vacancy occurring, or within a time agreed to by each of those parties, then DOJ and DYS shall submit two names, along with resumes and cost proposals, to the Court. The Court shall then select the replacement monitor.
5.3 A vacancy occurs upon the removal by notice of the Monitor or a consultant as set forth in 4.1 or 4.2 above, by Court order, or upon the Court's acceptance of a written letter of resignation from the Monitor or consultant.
6. DOJ and DYS agree that no other Monitors or consultants, except those named in Part 2 above, will be used to conduct monitoring activities in this case. This does not bar either the Monitor or any approved consultant from retaining a
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 81 Filed: 06/06/11 Page: 5 of 6 PAGEID #: 1778
sub-expert for additional input. However, the State has no obligation to permit such sub-experts to tour any facilities subject to this Stipulation. Further, the State has no obligation to respond to any request for documents, files, or data of any kind from such sub-expert. And, the State has no obligation to fund such sub-experts without its prior approval and agreement.
H. Monitor Reports: The Monitor shall provide DOJ and DYS with reports describing the steps taken by the State to implement this Stipulation and evaluate the extent to which the State has complied with each substantive provision of the Stipulation. The Monitor shall prepare the report based upon a site visit of Scioto conducted no more than six weeks before the report's issuance. For each requirement of Section III of this Stipulation, the report shall specify: (1) the steps (including documents reviewed, meetings attended, and persons interviewed) the Monitor took to assess compliance; (2) the self-assessment steps the facility undertook to assess compliance and the results thereof; (3) the level of compliance. i.e.,"noncompliance" or "substantial compliance"; and (4) the Monitor's recommendations, if any, to facilitate or sustain compliance. The Monitor shall issue a report for Scioto every six months, with interim reports as the Monitor determines appropriate. The Monitor is primarily to assess and report upon compliance; if there is an ambiguity in the meaning or intent of a provision, the Monitor shall seek guidance from the parties. The reports shall be provided to DOJ and DYS in draft form for comment at least two weeks prior to their issuance. These reports shall be written with due regard for the privacy interests of individual youth and staff and the interest of the State in protecting against disclosure of non-public information.
I. Monitor Budget: The Monitor shall have a budget sufficient to allow the Monitor and the consultants named in Part A.2 above to carry out the responsibilities described in this Stipulation, and shall provide DOJ and DYS with a copy of each invoice, when issued by the Monitor, and notice of payment, when received by the Monitor. The Monitor will consult with the Defendants to set the monitoring budget for each fiscal year while injunctive relief is in place. Defendants shall pay the fees associated with the monitoring under this Stipulation.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 81 Filed: 06/06/11 Page: 6 of 6 PAGEID #: 1779 The Parties are ordered to submit to this Court for approval a complete
amended Stipulation, reflecting all the above ordered modifications, by June 17, 2011.
Nothing in this Order shall be construed as affecting the rights or obligations of the Parties to S.H. v. Reed, 2:04-cv-1206. ORDERED this _ ____,.G:,=--_day of J(...w4t::.- , 2011.
6

 Case: 2:08-cv-00475-ALM -MRA Doc #: 42 Filed: 06/04/10 Page: 1 of 7 PAGEID #: 380

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

__________________________________ _)

CIVIL ACTION NO: 2:08-cv-475
JUDGE ALGENON L. MARBLEY

S.H., and all other similarly situated, )

et al.,

)

)

Plaintiffs,

)

)

v.

)

) CIVIL ACTION NO:

) 2:04-cv-1206

TOM STICKRATH,

)

) JUDGE ALGENON L. MARBLEY

Defendant.

)

___________________________________ )

ORDER It is hereby ORDERED that Defendants show cause as to why they should not be held in contempt for submitting false and or inaccurate data pursuant to an Order of this Court. This matter is scheduled for a contempt hearing on July 1, 2010, at 9:00 a.m., in Courtroom 331.
I. BACKGROUND On February 24, 2010, this Court held a Status Conference in S.H. v. Stickrath (the S.H. case) and U.S. v. Ohio (the U.S. case) to discuss the Ohio Department of Youth Services’ (“DYS”) policy of denying meals to youth when they refused to leave their rooms to eat in the

Case: 2:08-cv-00475-ALM -MRA Doc #: 42 Filed: 06/04/10 Page: 2 of 7 PAGEID #: 381
facility dining room or cafeteria (“Meal Refusal Policy”).1 The Department of Justice and the
Monitor in the S.H. case, Mr. Fred Cohen (“Monitor Cohen”), participated by telephone. Amy
Ast, Christine Money, Barbara Moore, and Marci Sutherland, all with DYS, were also present.2
In preparation for the Status Conference DYS provided to this Court summary data and
information about the effect of the DYS Meal Refusal Policy at the Circleville Juvenile
1The policy from Christine Money, DYS Deputy Director, addressed to Thomas Teague, Superintendent at Circleville and dated August 5, 2009 states:
[Circleville] has been approved to implement this PILOT for thirty days. Effective immediately the following protocols must be followed when a youth refuses to attend a meal in the cafeteria.
 A staff member MUST inform the youth that eating in the cafeteria is their only opportunity to receive a meal.
 Once the youth has been informed of the opportunity and the youth continues to refuse, a staff member is required to document the refusal in the Unit Log Book and notify the on-duty Operations Manager.
 Any youth who refuses to go to the cafeteria will not receive a carry back meal.
 Any youth refusing to go to the cafeteria shall be placed in their rooms or in a dorm setting must sit in an assigned location until the unit returns.
 IF a youth misses two (2) consecutive meals the Unit Manager must complete a face to face interview with the youth to determine the reason for the refusal. If the Unit Manager is not available then the unit Social orker or the Operations Manager must complete the interview.
 If through the interview, the youth continues to refuse to go to the cafeteria, the Unit Staff are required to develop an individual plan to address the needs of the youth.
A weekly report shall be forwarded to Deputy Director Money indicating the number of youth refusing the opportunity to attend a meal in the cafeteria. At the end of the month, the Deputy Director along with the Superintendent will evaluate the PILOT to determine if it will continue.
(August 5, 2009 DYS Memo on Cafeteria Refusals - CJCF Pilot).
2At the time of the Status Conference, Christine Money was serving as DYS Deputy Director of Facility Programs and Operations. Ms. Money has since been appointed to serve as the Interim Director for DYS.
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Correction Facility (“Circleville”). (See Doc. 160 Order Attachment 1.)3 At the Status Conference, the Court confirmed that the DYS Meal Refusal Policy was implemented not only at Circleville, but also at the other DYS facilities, including the Ohio River Valley Juvenile Correctional Facility (“ORV”), the Scioto Juvenile Correctional Facility (“Scioto”), and the Indian River Juvenile Correctional Facility (“Indian River”). The Court also found that the Meal Refusal Policy, as it was written, to be at odds with the guiding principle in the S.H. and U.S. cases that the health and safety of the youth is of paramount importance. (See Doc. 160.) On February 26, 2010, this Court ordered DYS to alter its Meal Refusal Policy to reflect that: (1) the youth in DYS’ custody and care must be fed and any youth articulating any fear for safety must be fed during the particular meal of refusal; and (2) when youth refuse to eat a meal in a facility cafeteria, DYS will keep records of the reason for that refusal. Id. at 6. Further, this Court ordered DYS to provide summary information and data on meal refusals from the Scioto, ORV, and Indian River facilities for the period of August 5, 2009, when the Meal Refusal Policy was enacted, to February 23, 2010. Id. And DYS was directed to provide copies of the log books from the Circleville, Indian River, ORV, and Scioto facilities along with the summary information.4 Id. at 7.
On March 3, 2010, DYS submitted to this Court summary data on meal refusals at the Scioto, ORV, and Indian River facilities. (Doc 162 Notice of Compliance Ex. A.) On March 9,
3All citations to the record in this Order refer to the Docket in the S.H. Case, 2:04-CV1206.
4Currently, DYS maintains separate log books for meal refusals. (Tr. of Status Conf. February 24, 2010 p.13.) Prior to February 11, 2010 this information was kept in a log book, but not one that was maintained specifically on the issue of meal refusals. Id. Additionally, prior to February 11, 2010, the log books did not record the specific reason for the meal refusal. Id.
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Case: 2:08-cv-00475-ALM -MRA Doc #: 42 Filed: 06/04/10 Page: 4 of 7 PAGEID #: 383
2010, DYS filed a Motion for relief from the Court’s February 26, 2010 Order requiring the
submission of log book data, or in the alternative for an extension of time to submit the log book
data. On March 17, 2010, this Court entered an Order granting DYS an extension of time, until
April 9, 2010, to supply the log book data. (Doc. 165.) On April 13, 2010, DYS filed manually with the Clerk’s Office the log book data on the Meal Refusal Policy.5 (Doc. 175.) On June 1,
2010, DYS filed with this Court a Notice of Supplemental Notice of Compliance with Court
Order, which provided summary data for meal refusals at the DYS facilities from March 2010
through May 2010. (Doc. 178 Ex. A p. 2.)
II. ANALYSIS
This Court has now had an opportunity to review the summaries and log book data
provided by DYS. For none of the DYS juvenile correctional facilities does the summary data
accurately reflect or match the data provided in the log books maintained by DYS.
Scioto provided this Court with the most accurate data regarding the number of meal
refusals by the youth confined within this facility. Both the summary data for Scioto (See Doc. 162 Ex. A p. 1.) and the log book data from Scioto6 (See Ex. 1) accounted for a total of 83 meal
5On April 9, 2010, DYS filed an Unopposed Motion for Order to Permit Defendant to Manually File the required log book data. (Doc. 173.) On April 12, 2010, this Court granted the Unopposed Motion. (Doc. 174.)
6DYS provided the summary data on the Meal Refusals Policy for Circleville, Scioto, Indian River, and ORV demonstrating the number of breakfasts, lunches, and dinners refused each month. (See Doc. 160 Attachment 1; Doc. 162 Ex. A.) DYS provided the log book data on the Meal Refusals Policy for Circleville, Scioto, Indian River, and ORV demonstrating the number of meal refusals per unit. (See Doc. 172 Attachment 1; Doc. 175.) Therefore, the Court compiled the log book data to document the number of meal refusals by month to enable a sideby-side comparison with the summary data provided by DYS. Attached as Exhibit 1 to this Order is a chart reflecting the meal refusals documented in the log book data from Scioto. (See Doc. 172 Attachment 1 Exs. B00435-36, B00437-449, B00450-459, B00460-501.) Attached as
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Case: 2:08-cv-00475-ALM -MRA Doc #: 42 Filed: 06/04/10 Page: 5 of 7 PAGEID #: 384
refusals from November 2009 through February 2010. Although the summary data and log book data accounted for the same number of total meal refusals within the four month period, the two data sources did not accurately reflect the same number of breakfast, lunch, and dinner refusals for the months of November 2009 and December 2009. (See Doc. 162 Ex. A p. 1.; Ex. 1.)
The summary data provided by DYS for ORV showed that 110 meals were refused during the applicable time period. (See Doc. 162 Ex. A p. 2.) The log book data from ORV accounted for 134 meal refusals during the same time period. (See Ex. 2.)
The summary data provided for Circleville, did not accurately reflect the data recorded in the logs for the total number of meals refused by youth from August 2009 through February 2010. The summary data for Circleville reported that a total of 429 meals were refused during this time period. (See Doc. 160 Attachment 1.) The summary indicated that 386 breakfasts, 30 lunches, and 13 dinners were refused within the seven month period. Id. The log data documented 435 meal refusals from August 2009 through February 2010. (See Ex. 3.) The log data shows that 355 breakfasts, 36 lunches, and 44 dinners were refused. Id.
Indian River egregiously reported the number of meal refusals by youth in its summary
Exhibit 2 to this Order is a chart reflecting the meal refusals documented in the log book data from ORV. (See Doc. 172 Attachment 1 Exs. 000383-391, B00392-399, B00400, B00401-403, B00404-406, B00407-419, 000420-424, B00425-434.) Attached as Exhibit 3 to this Order is a chart reflecting the meal refusals documented in the log book data from Circleville. (See Doc. 172 Attachment 1 Exs. B00001-18, B00019-57, B00058-89, B0090-120, B00121-144, B00145178, B00179-192.) Attached as Exhibit 4 to this Order is a chart reflecting the meal refusals documented in the log book data from Indian River. (See Doc. 172 Attachment 1 Exs. B0193211, B00212-267, B00268-332, B00333-339, B00340-353, B00354-358, B00359-368, B00369382.) Attached as Exhibit 5 to this Order is a chart reflecting the meal refusals documented in the charts submitted from Indian River. (See Doc. 172 Attachment 1 Exs. B000502-706, B000707-1513, B001514-2291, B002292-3094, B003095-3913, B003914-4631, B0046324813.)
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Case: 2:08-cv-00475-ALM -MRA Doc #: 42 Filed: 06/04/10 Page: 6 of 7 PAGEID #: 385
data, log data, and charts submitted to this Court. Unlike the other facilities, Indian River also submitted charts as a third source of data to report the number of breakfast, lunch and dinner refusals occurring during the seven months the Meal Refusals Policy was in place. None of these same three sources of information lead to the same conclusions regarding the numbers of meals refused at the facility. The summary data reported that 1,622 meals were refused by youth at Indian River from August 2009 through February 2010. (See Doc. 162 Ex. A p. 3.) The log book data from Indian River accounts for only 581 meal refusals during the same time period.7 (See Ex. 4.) The charts from Indian River show that a shocking 2,160 meals were refused by youth in this facility from August 2009 through February 2010. (See Ex. 5.)
It is of particular concern to this Court that DYS appears to have misrepresented the effects of its Meal Refusal Policy in the summary data it was ordered to provide. (See Doc. 160 Attachment 1; Doc. 162 Ex. A.) It is also unclear why discrepancies exist between the log book data and the summary data documenting meal refusals at DYS facilities, which both document data compiled by DYS. At the Show Cause hearing, DYS should be prepared to explain these discrepancies and to provide evidentiary support that: (1) DYS policy on meal refusals is in compliance with the requirements of the Stipulations in S.H. and U.S.; and (2) DYS accurately
7 The information compiled from Indian River’s log book data reflects this Court’s best efforts at deciphering the recorded entries. The entries were often illegible, did not include dates for recorded meal refusals, and the time for many refusals had been cut off when the log books were copied, making it impossible to know which meal the youth had refused.
-6-

Case: 2:08-cv-00475-ALM -MRA Doc #: 42 Filed: 06/04/10 Page: 7 of 7 PAGEID #: 386 documents all meal refusals in the appropriate log books at each of the DYS juvenile correctional facilities.
IT IS SO ORDERED. s/Algenon L. Marbley
ALGENON L. MARBLEY UNITED STATES DISTRICT JUDGE DATED: June 4, 2010
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 IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

__________________________________ _)

CIVIL ACTION NO: 2:08-cv-475
JUDGE ALGENON L. MARBLEY

S.H., and all other similarly situated, )

et al.,

)

)

Plaintiffs,

)

)

v.

)

) CIVIL ACTION NO:

) 2:04-cv-1206

TOM STICKRATH,

)

) JUDGE ALGENON L. MARBLEY

Defendant.

)

___________________________________ )

ORDER On July 14, 2010 and July 15, 2010, a hearing on the Order to Show Cause was held in the above referenced matters as to why Defendants, the Ohio Department of Youth Services (“DYS”), should not be held in contempt for submitting false and or inaccurate data pursuant to an Order of this Court. After the presentation of testimony and other evidence by DYS, the Court finds the following:

1. DYS will not be held in contempt on the issue of whether the summaries submitted to this Court , which documented the number of meal refusals, were intentionally falsified or contained inaccurate data.
2. The current protocol on meal refusals is not in compliance with the requirement in the Stipulations in the S.H. v. Stickrath and U.S. v. Ohio cases that DYS shall provide youth in its custody with a safe and humane environment. Thus, that protocol is invalid and shall be replaced by a new policy that the parties are to develop jointly by July 30, 2010. Counsel in S.H. v. Ohio and U.S. v. Ohio, the respective monitoring teams, and DYS are to be involved in this policy development.
3. The new policy shall be implemented with a training component, memorialized in writing, that is to be uniform and conducted consistently with DYS procedures for implementing policies.
4. The existing protocol will terminate upon Court approval of the policy submitted on or before July 30, 2010.
IT IS SO ORDERED.

DATED: July 16, 2010

s/Algenon L. Marbley ALGENON L. MARBLEY UNITED STATES DISTRICT JUDGE

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U.S. Department of Justice v. The State of Ohio Civil Action No: 2:08‐cv‐475
Protection from Harm Compliance Report
Final Version submitted June 10, 2010
Kelly Dedel, Ph.D. One in 37 Research, Inc. 1608 NW Riverscape Street Portland, OR 97209 (503) 799‐0915 www.onein37.com

USDOJ v The State of Ohio

Protection From Harm Compliance Report 1.

Case: 2:08-cv-00475-ALM-MRA Doc #: 62 Filed: 09/21/10 Page: 2 of 41 PAGEID #: 792

On June 4, 2008, The United States Department of Justice (DOJ) and the State of Ohio (the State) signed a stipulation for injunctive relief (the Stipulation) concerning conditions at the Scioto Juvenile Correctional Facility (Scioto) and the Marion Juvenile Correctional Facility (Marion). The Stipulation adopted the same monitoring team used in a concurrent suit, S.H. et al., v. Tom Stickrath (S.H.), led by Fred Cohen, Esq. This team was charged with monitoring the extent to which the State had effectively implemented the reforms required by the Stipulation and providing detailed reports to the Parties. Since the Stipulation was signed, the State closed the Marion facility.
In late 2009, Mr. Cohen announced his intention to resign his position as the Monitor for the Stipulation, while continuing his duties as the lead monitor in S.H. On November 23, 2009, the Parties amended the Stipulation to assigning monitoring duties for Scioto to the DOJ. Both Parties agreed that I, Dr. Kelly Dedel, would serve as the DOJ’s expert for protection from harm and special education issues. This report discusses conditions at Scioto pertaining to the 12 provisions related to protecting youth from harm.
Section V.H of the Stipulation requires the Monitor/expert to provide the Parties with reports “describing the steps taken by the State to implement [the] Stipulation and to evaluate the extent to which the State has complied with each substantive provision of the Stipulation.” A report from my initial site visit was submitted on March 5, 2010. Due to the limited time on site, a follow‐up visit was conducted during the week of April 5, 2010. This report amends the findings from the initial tour to deliver a more complete assessment of the level of compliance currently observed at Scioto.

In preparation for and just following my April 2010 visit, I reviewed the following documents:  AMS Incident Report Log, January 1 through December 31, 2010 (Bates 003597‐003939)  AMS Seclusion Summary, January 1 through December 31, 2010 (Bates 003940‐003987)  AMS Grievance Log, January 1 through March 27, 2010 (Bates 005429‐005460)  Use of Force Data, January 2009‐December 2009 (not Bates stamped, produced on site)  11 incident reports involving physical restraint, randomly selected from those occurring January‐
December, 2009 (not Bates stamped, produced on site)  Seclusion Data for 2009 (Bates 004735‐004737)  Facility Consequence Logs for 5 youth (Bates 004738‐004758)  Managing Youth Resistance (MYR) training materials (Bates 005214‐005428)  Training Logs for 2009 and 2010 (Bates 004759‐004846)  2009 and 2010 Training Plans (Bates 004847‐004872)  Suspected Child Abuse and Neglect Reporting forms for 2009‐2010 (Bates 004887‐004920)  Chief Inspector’s reports, 2009‐2010 (Bates 003998‐004077)  Facility‐Based investigations, 2009‐2010 (Bates 005096‐005208)  Investigations Training Manual (Bates 004921‐5095)  Facility Based Investigations (Bates 005096‐005208)  Documentation of Criminal Background Checks for new employees 2009‐2010 (Bates 005209‐
005213)  Grievance Trends (Bates 005461‐005475)  Grievance Handbook, to be implemented May 1, 2010 (Bates 005476‐005477)  Volunteer Programming, Monthly Schedule and Number of Attendees (Bates 005478‐005500)  A collection of ODYS policies and Standard Operating Procedures, referenced by number and
title throughout this report

USDOJ v The State of Ohio

Protection From Harm Compliance Report 2.

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This amended report expands on my findings from my initial tour of the facility to create a final product that comprehensively describes the status of the facility with regard to the reforms required by the Stipulation. For each provision, the full text is provided, along with a detailed discussion of the State’s compliance as required by the Stipulation. The specific language from the Stipulation is presented in italics below, along with my interpretation of it.
 “The self‐assessment steps the facility undertook to assess compliance and the results thereof.” Although the State was fully responsive to all of my requests, they had taken very few steps to assess their own level of compliance. In my experience, this is typical during initial facility tours. As a result, the content of this report is driven by my own efforts to assess compliance, rather than on the facility’s self‐assessment. In the future, the State should analyze data, identify patterns and trends, develop explanatory conclusions, and develop targeted interventions designed to further their reform efforts. The agenda for my subsequent visits to the facility should be led by the presentation of this information.
 “[My own] steps taken to assess compliance.” Over the past few months, I requested a large volume of information from the State (listed on the previous page of this report, and in the Introduction of my original report). This information was delivered generally in a timely manner and allowed me to form conclusions about the policy, procedure and practice in each of the key areas. The State’s cooperation toward this end is much appreciated. To the extent that the State can begin to replicate these, or similar, analyses during the normal course of business, their efforts to demonstrate compliance with the Stipulation will be enhanced.
 “Recommendations for facilitating or sustaining compliance.” These recommendations are generally outcome‐focused so as to reinforce the spirit of the provision itself, but also to permit the State sufficient flexibility to satisfy both this Stipulation and the requirements of S.H. If more detailed technical assistance is desired, or discussions of how to reach the intended outcome is needed, I will defer to the DOJ, as Monitor, as to the level of technical assistance to be provided to the State.
 “Sources of information that form the basis of [my] opinion.” These will include documents, interviews and observations from my previous visit to the facility, along with information gathered during this most recent visit.

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III.A.1 General Protection From Harm. The State shall, at all times, provide youth in the facilities with safe living conditions. As part of this requirement, the State shall take appropriate measures to ensure that youth are protected from abuse and neglect, use of excessive force, undue seclusion, undue restraint, and over‐familiarization.

Self Assessment

The State did not present any specific information to show improvements in protecting youth from abuse, neglect, use of excessive force, undue seclusion, undue restraint or over‐familiarization.

Moving forward, the State should track and present data and any analysis it has
conducted on the following performance measures:  Number of abuse allegations received and sustained;  Number of inappropriate relationship allegations received and
sustained;  Number of unnecessary and excessive use of force allegations received
and sustained;  Rate of youth on youth violence;  Rates of physical and mechanical restraint across various incident types;  Frequency of the use of seclusion across various types of rule violations;
and  Duration of the various types of seclusion (e.g., time out; prehearing
confinement; disciplinary confinement).

Steps Taken to Assess Compliance

This information could be prepared to show a trend across time, e.g., from the date on which the Stipulation was signed through the present day. Rather than using raw numbers, rates per youth (e.g., # incidents in a month / average daily population for the month) should be used to neutralize the impact of fluctuations in the facility population over time.
Data on the rates of certain types of incidents along with the average daily population for each month July 2008 through January 2010 were requested to identify trends in each area. Please see the graphs located in the Appendix.

Physical Restraint Chart 1 shows the rate of physical and mechanical restraint usage for the period July 2008 through January 2010. In general, the rate of both types of restraint decreased significantly during that time period. Major decreases in these areas were contemporaneous with the ODYS training in Managing Youth Resistance (MYR) that occurred in June 2009. The MYR curriculum emphasizes non‐physical techniques for responding to youth non‐compliance. The average rate of physical restraint in the 8 months following this training was .26, compared to an average rate of .48 in the 11 months preceding it. This represents a decrease of 46%. A comparison of average rates of mechanical restraint use (.1075 in the 8 months following versus .1854 in the 11 months preceding the training) reveals a 42% decrease.

Chart 3 shows the rate of youth on youth violence (e.g., fights and assaults) from July 2008 through December 2009. Clearly, the rates of assaults have decreased

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precipitously. Using the date of the MYR training as a somewhat arbitrary timeline for changes in the facility’s culture, a comparison of the rate of youth on youth violence before the training (.1982) and after the training (.0943) reveals a 48% decrease.
Although further analysis is needed, these data suggest that reductions in the use of physical restraint can be accounted for entirely by the contemporaneous reduction in the rate of youth violence. In other words, staff appear to intervene physically at the same rate as in the past, relative to the number of assaults occurring. More qualitatively however, anecdotal information suggests that the specific intervention techniques used may have evolved over time, with fewer youth being taken to the floor and more youth being restrained and escorted in upright positions. In preparation for the next tour, the ODYS should examine the type of physical intervention used in addition to looking at overall rates when it does its self‐assessment.
Because staff appear to be well‐versed in the continuum of physical restraint options and have learned to temper their responses to apply the least amount of force necessary to gain control of the situation, further reductions in the rate of physical restraint will likely depend on the facility’s success in developing interventions that address the conditions underlying youth violence, non‐ compliance, and aggression toward staff. The role of a well‐executed, well‐timed physical restraint in preventing the harm associated with youth‐on‐youth violence, youth aggression toward staff, or significant property destruction should not be disregarded. However, the overall goal is to reduce the number of situations that require physical intervention in order to maintain a safe and secure facility.
Use of Seclusion Data provided by the State permitted an analysis of the frequency of the use of seclusion. Chart 4 shows changes in the frequency of seclusion since January 2009, compared to the average daily population for each month. While there are significant variations in the use of seclusion over time, the trendlines on the chart show that the overall use of seclusion is declining at a pace that is commensurate with reductions in the overall facility population. In other words, the rate of the use of seclusion has not changed significantly over time.
Not only is the frequency of the use of seclusion at issue, but also the duration. Chart 2 shows the average time youth spent in seclusion from July 2008 to December 2009. A spike in the average duration of seclusion is evident at approximately the same time period as the decreases in the other measures (June 2009). Prior to June 2009, the average time in seclusion per youth was 4.345 hours, compared to 17.875 hours since June 2009. This represents an increase in the time spent in seclusion of approximately 400%. In large part, this increase can be explained by the DYS’ implementation of the CRAVE program, which is discussed in III.A.3.

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While the increasing use of seclusion to control youth behavior may have led indirectly to the decrease in institutional youth violence, the apparent overreliance on this form of behavior management is of great concern, as discussed in detail in provision III.A.3.

Allegations of Abuse and Neglect The ODYS Chief Inspector’s Office investigated 11 allegations of abuse or neglect during 2009. (Note: two other investigations by the Chief Inspector’s Office were provided by the State. One investigated a youth‐on‐youth assault with serious injury and the other investigated a youth‐on‐staff assault and thus they are not germane to this provision). Of the 11 allegations, only two were sustained (18%) for either excessive use of force or inappropriate contact between staff and youth. Two others found secondary violations of DYS policy (i.e., failure to engage in a restraint and bringing contraband (CDs, cell phone) into the facility). The investigations are of very high quality and appear to lead to reasonable conclusions. Based on my experience in other jurisdictions, the facility does not have an unusually high rate of substantiated allegations.

Recommendations
Sources of Information

This discussion provides only a broad look at the extent to which the reforms required by the Stipulation have been implemented and have improved the State’s ability to protect youth from harm. A more thorough discussion of the underlying causes and influences on the data is required to fully understand the State’s progress in meeting the requirements of each provision. Each of these issues is discussed in detail in the subsequent sections of this report.
To reach substantial compliance, it is recommended that the State: 1. Produce data on the rates of the major events covered by the Stipulation (e.g., allegations of abuse, excessive force, etc.; youth on youth violence; use of seclusion; use of force; etc.) over time. Investigate the underlying causes of increases or decreases in the key indicators and adjust facility practices as needed to ensure that youth are adequately protected from harm. 2. Reach substantial compliance with the other provisions related to protecting youth from harm.
 “Monthly Data as Collected by ODYS from June 2008 – October 2009,” prepared by ODYS and expanded to include November 2009 through January 2010 at my request
 AMS Seclusion Log, January‐December, 2009  Investigations completed by the DYS Chief Inspector’s Office in 2009,
n=11.

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III.A.2 Use of Force. The State shall develop and implement comprehensive policies, procedures, and practices limiting use of force on youth to situations where it is objectively reasonable and necessary. Staff shall be required to adequately and promptly document and report all uses of force.

Self Assessment

The State produced a series of ODYS policies pertaining to the Use of Force. ODYS policy #301.05 “Managing Youth Resistance” limits the use of force to exceptional circumstances when all other appropriate, pro‐active, non‐physical behavior management techniques have been exhausted or failed. The policy also requires staff to use only the minimum amount of force necessary to stabilize the situation and explicitly prohibits the excessive use of force.

SOP #301.05.01 “Use of Force” describes the continuum of resistance that non‐ compliant youth are likely to display (from verbal threats to physical engagement and beyond) and clearly delineates a hierarchy of appropriate responses to each type of behavior. This SOP also details staff responsibilities for documenting incidents that involve any type of physical or mechanical restraint. SOP #101.14.01 “Institutional Incident Review” delineates the procedures for referring incidents with questionable practices or serious negative outcomes for review and investigation.

SOP #301.05.02 “Planned Interventions” discusses the application of physical restraint in situations where immediate restraint is unnecessary but where a youth’s behavior threatens to escalate to the point that restraint would ultimately become necessary. The overall objective in a planned use of force is to prevent harm to other youth, staff, or the youth himself/herself. The planned intervention requires immediate activation of a handheld video camera and exhaustion of all non‐physical alternatives (e.g., verbal de‐escalation strategies, time and distance, and counseling by staff with whom the youth has a strong rapport). If non‐physical measures are not sufficient to bring about compliance, the Incident Commander instructs staff to engage in a physical restraint using the least amount of force necessary. Once the youth begins to comply, the restraint is tempered or ceased altogether. These actions are to be undertaken in consultation with medical and mental health staff.

The ODYS’ policies and standard operating procedures adequately address the requirements of this provision.

Aside from these policies, the State did not produce any specific information to
demonstrate the level of compliance with this provision. Moving forward, the
State should track and present data on the following issues:  Rates of physical and mechanical restraint across broad categories of
incident types (e.g., fights/assaults, non‐compliant behavior, attempted
self harm);  Rates of physical restraint across housing units, staff, youth or other
factors that may contribute to the likelihood of the use of restraint;  Proportion of Planned Interventions that are resolved without the
application of physical or mechanical restraint;  Rates at which incidents are resolved using standing physical

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Steps Taken to Assess Compliance

intervention techniques versus those that require taking the youth to the ground;  For a given time period (e.g., 6 months), results of the Incident Report Institutional Reviews that assess the extent to which force was used appropriately;  Proportion of direct care staff who have received MYR training in the preceding 12 months;  Updates to MYR training curriculum that respond to areas in need of skill development among staff.
As discussed in provision III.A.1, the rates of physical restraint were down approximately 46% in late 2009, compared to the preceding year. These decreases mirror the reductions in youth violence witnessed over the same period, suggesting that physical restraint may be used no less often than in the past as a response to youth‐on‐youth violence.

However, physical restraint is also used in response to youth’s non‐compliant behavior or to prevent youth from harming themselves. As discussed above, in order to fully and accurately understand where reductions in the use of force have occurred, the State should review the use of physical restraint across a variety of incident types.

During the current tour, facility administrators indicated their belief that the rate of restraints was tied to the size of the facility population, which in the Reception Units is driven by the length of stay. To investigate this issue more closely, I requested data on the number of restraints per month and the average daily population for each month. These data, along with a calculated rate of restraint are presented in the table below.

Restraints , ADP, and Rate, Jan 2009‐Feb 2010

Month

# Restraints ADP

Rate

Jan 09

65

165

.39

Feb 09

59

182

.32

Mar 09

97

200

.49

Apr 09

88

223

.39

May 09

86

212

.41

Jun 09

69

206

.33

Jul 09

46

185

.25

Aug 09

27

163

.17

Sep 09

14

139

.10

Oct 09

30

134

.22

Nov 09

37

122

.30

Dec 09

20

108

.19

Jan 10

21

102

.21

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Feb 10 Average

33

120

.29

49

161

.29

Facility administrators indicated their belief that physical restraint was used less often than in the past, primarily due to decreases in the average daily population and average length of stay for youth at Scioto. In general, this is true. When the facility population is higher, the rate of restraint is generally higher as well. However, this pattern does not always hold. In July and August 2009, the ADP was above the average for the time period (185 and 163, versus 161 youth), yet the rate of restraints was below average (.25 and .17, versus .29). Further, in November 2009 and February 2010, the opposite occurred: the ADP was well‐ below average (122 and 120, versus 161 youth) and yet the rate of restraints was approximately average (.30 and .29, versus .29).

These data suggest that while the rate of restraints is generally decreasing along with the size of the facility population, the relationship is not always direct or proportional. Additional analysis by the facility is needed to identify patterns that may exist across housing units, staff, times of day etc. to discover the situations that appear to make the use of physical restraint more likely. Such an analysis would lead to targeted interventions designed to reduce the need for physical restraint across those specific situations.

More qualitatively, interviews with facility administrators revealed beliefs about the use of force that were in sharp contrast to the practices described in the DOJ’s Findings Letter of 2007. Policy, training and attitudes of facility administrators all emphasize the benefits of verbal de‐escalation and limitations on the use of physical interventions to only those situations in which lesser methods have failed. Interviews with Youth Specialists and Operations Managers echoed these sentiments. All staff were aware of the mandate to temper their use of restraint, limiting it only to that necessary to obtain compliance from the youth. In addition, all staff clearly understood the need to give youth verbal commands, time and distance prior to intervening physically if an immediate risk of harm to youth safety was not present (e.g., in cases of non‐compliance, youth threatening staff, or potential property destruction).

However, several staff voiced their confusion about whether it was permitted to ever intervene physically in these situations, believing that actual harm must first occur before physical restraint could be justified. While the State’s focus on avoiding the “rush to restrain” that characterized the DOJ’s findings in 2007 is laudable, the overall goal of preventing harm from occurring, whether this is to youth, staff, or property, may need to be reiterated.

To further evaluate this issue, a sample of 29 incident reports from throughout 2009 was reviewed. In general, the written reports reflected the DYS mandate to limit the use of restraint . All of the IRs described staff’s efforts to resolve the situation without physical intervention (e.g., relying on verbal skills; patience; evaluating the level of risk posed by the youth) prior to the use of force.

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However, particularly early in 2009, some of the staff’s witness statements (the Youth Intervention Report or Responder Report) contained vague language (e.g., “grabbed the youth” or “separated the youth”) so that the actual level of physical intervention could not be ascertained. Although each use of force was reviewed by the Institutional Incident Review process, the reviewer rarely made comments or requested corrections toward this end.
Interviews with 11 youth suggested that staff provide ample opportunities for the youth to calm down or to cease fighting before using physical intervention. Youth reported that staff appeared to do only what was necessary to gain control of the situation and youth did not perceive staff to be heavy‐handed in their use of force. These findings mirror those of John Platt from his November 2009 tour where youth reported that staff were quick to respond to defuse situations but did not “overreact” when using force.

Recommendations
Sources of Information

1. Clarify for the staff that the overall goal of the use of physical restraint is to prevent harm and when there is an imminent likelihood of harm to staff, youth or property, staff are authorized to utilize safe methods of restraint as necessary to reduce the risk of harm. For example, this directive could be communicated at Shift Briefing or during training.
2. Analyze data on physical restraints to identify the situations and conditions that make restraints more likely to occur. In part, this may be driven by the effect of crowding or the frustration experienced by some youth who languish at the Reception Center, but it is likely that other dynamics influence the use of restraints. My review of the incident report summaries in 2009 suggest that the girls units have much higher rates of restraints than the boys, and are likely for different reasons. These patterns need to be identified so that specific interventions to can be designed to address the root causes.
3. During the routine Institutional Incident Reviews, request clarification or additional information when staff do not fully describe their involvement in a restraint. In general, encourage staff to describe, rather than label, their actions.
 Policy #301.05 “Managing Youth Resistance,” SOP #301.05.01 “Use of Force,” Policy #101.14 “Incident Reporting,” SOP #101.14.01 “Institutional Incident Review”, and SOP #301.05.02 “Planned Interventions”
 “Monthly Data as Collected by ODYS from June 2008 – October 2009,” prepared by ODYS and expanded to include November 2009 through January 2010 at my request
 “Scioto Juvenile Correctional Facility: Protection From Harm Data, January 2009‐March 2010” provided at my request.
 Interviews with Facility Administrators, ODYS Administrators, and staff from the Ohio Attorney General’s Office
 Demonstration of MYR tactics by staff trainers  29 Incident Reports, selected randomly from those generated in January‐

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December, 2009  Interviews with 11 youth, assigned to various housing units at Scioto  Interviews with 7 staff (Youth Specialists and Operations Managers) from
1st and 2nd Shifts

III.A.3 Seclusion. The State shall develop and implement policies, procedures and practices so that staff use seclusion only in accordance with policy and in an appropriate manner and so that staff document fully the use and administrative review of any imposition of seclusion, including the placing of youth in their rooms outside normal sleeping hours.

Self Assessment

The State did not produce any specific information to demonstrate compliance in this area.

The primary policy pertaining to seclusion is SOP #301.05.03 “Seclusion— Reporting, Monitoring and Documentation Requirements.” This SOP indicates that seclusion should be used as a last resort when other less restrictive interventions have failed to manage youth behavior effectively. Youth in seclusion are to be visited by administrative, mental health, medical, social work and medical staff on a daily basis and must be afforded the same general living conditions as youth in the general population. Supervisors must re‐ evaluate the need for seclusion every three hours, and seclusions stretching beyond 24 hours must be approved by the facility Superintendent. The policy specifies that youth should be removed from seclusion when they demonstrate they no longer pose a threat to self or others.

Other policies provided additional useful information about the circumstances in which seclusion is considered to be an appropriate response. These include Policy #303.01 “Youth Rules, Interventions and Incentives,” SOP #303.01.01 “Rules of Youth Conduct,” SOP #303.01.02 “Youth Intervention Sanctions,” and SOP #303.01.03 “Youth Intervention Hearings.” Most notably, these SOPs emphasize that the primary objective of an intervention is to avoid future rule violations and to enhance rehabilitation while preserving the security and safety of fellow youth and staff.

As read, the policies and SOPs are certainly in line with contemporary thinking in the field, but I am concerned about the extent to which this philosophy has been operationalized, as discussed in more detail below.

Moving forward, the State should track and present the following data:  Rates of the use of seclusion, distinguishing “time‐out,” “pre‐hearing
confinement,” and “disciplinary confinement”;  Rates of the use of “time‐out” across specific types of non‐compliant
behavior;  Rates of the use of “pre‐hearing confinement” and “disciplinary

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confinement” across specific types of rule violations;  Changes in the duration of “time‐out,” “pre‐hearing confinement,” and
“disciplinary confinement” across time;  Rates of the use of alternative sanctions across specific types of non‐
compliant behavior;  Results of internal audits of the completeness and quality of Seclusion
Monitoring Sheets for a given time period (e.g., 5 days selected from
each month).

Steps Taken to Assess Compliance

Overall, I am concerned that the facility relies excessively on seclusion as a behavior management tool and that its duration is excessive and therefore unlikely to create lasting behavior change. These perceptions are based on a review of the AMS Seclusion Log from January through December, 2009; a qualitative review of the circumstances under which seclusion is used via my review of 29 incident reports; and interviews with administrators, staff and youth.

Frequency of Seclusion As discussed in the introduction to this report and as shown in Chart 4 in the Appendix, the frequency of the use of seclusion has decreased over time at a pace that mirrors decreases in the facility’s population. While there are certainly variations from month to month, the average rate of the use of seclusion from the first half of the year (.85) is nearly identical to the latter half of 2009 (.85).

Facility Administrators reported that seclusion is a permissible response to both disruptive and violent misbehavior among youth. Disruptive behavior is broadly interpreted to mean anything that interferes with the orderly operation of the facility. Upon my request, the State provided data on the use of seclusion across specific types of rule violations in 2009. These data are summarized below:

Use of Seclusion, Proportion by Incident Category, 2009

Month % Y/S assault % Y/Y assault % disruptive behavior

Jan

14

22

64

Feb

6

31

63

Mar

4

36

60

Apr

3

24

73

May

4

32

64

Jun

11

25

64

Jul

10

18

73

Aug

2

8

90

Sep

~

9

91

Oct

5

8

89

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Nov

9

14

78

Dec

5

8

86

AVERAGE

6%

22%

72%

Overall, approximately 6% of all seclusions were in response to a youth on staff assault; 22% were in response to a youth on youth assault; and 72% were in response to disruptive behavior (which includes damage to property). Given the reductions in assaultive behavior that occurred in late 2009 as a result of the DYS’ CRAVE policy (discussed in more detail below), the proportion of seclusions related to disruptive behavior has increased. As discussed above, the actual rate of seclusion (controlling for the size of the population) has not changed significantly since CRAVE was implemented. In other words, the facility uses seclusion approximately as often, but now predominantly in response to non‐assaultive behavior.

The 29 incident reports I reviewed suggested that, although the duration is relatively short (i.e., an hour, maybe two) seclusion is potentially overused in response to low‐level misbehavior. Throughout 2009, there were many instances in which youth were placed in seclusion for failing to complete their schoolwork and other types of program refusals. The problems with obtaining compliant behavior in the school setting appeared to be particularly pronounced among the boys’ reception units. In these situations, the use of seclusion likely reinforced the youth’s non‐compliant behavior by giving him what he desired in the first place (e.g., the youth wants to get out of doing his schoolwork; he refuses and is sent back to his unit to spend time in his room). SOP #303.01.02 “Youth Intervention Sanctions” includes a broad array of low‐ and medium‐range sanctions that would be more effective for less serious rule violations than seclusion. The extent to which these sanctions are used as alternatives to seclusion is unknown at this time.

Duration of Seclusion When youth have committed a primary rule violation, they are placed in seclusion pending a disciplinary hearing that must occur within 7 business days of the incident, excluding weekends and holidays. My review of seclusion documents suggested that the hearing is nearly always held on the third day following the incident. For youth whose misbehavior occurs on a Wednesday, Thursday, Friday or Saturday, the 3‐day timeline is nearly always extended to account for the weekend days. If found guilty at the hearing, youth may receive an additional 5 days in disciplinary confinement. The AMS log showed that there are a significant number of youth who spend an extended amount of time—6 to 8 days, often—isolated from their peers, staff, programming and other activities that, research has shown, have a far greater likelihood of changing the youth’s behavior than isolation. While isolation can effectively suppress unwanted behavior, it does nothing to address the underlying causes of the behavior and therefore does little to change it. While seclusion is often

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an appropriate immediate response to youth’s aggressive behavior, it is essential to remember that the overall goal of behavior management is to increase the youth’s engagement with the program, not to separate them from it.
Most of the youth I interviewed had spent time in seclusion during their stay at Scioto and I discussed their experience of this practice to determine whether they received the services to which they are entitled and also to gather their perceptions of the effectiveness of seclusion as a way to create a safer facility. They reported inconsistent access to showers, recreation and education services, although all were visited regularly by direct care, mental health, social work and medical staff and received “Treatment Packets” that asked them to consider the reasons they engaged in the behavior. While they acknowledged that the unpleasantness of seclusion could be a deterrent to future misbehavior, when asked about the circumstances that led them to misbehave, most youth had little confidence of their ability to handle the same situation differently in the future.
Facility Administrators reported their intention to reduce the frequency and duration of seclusion. In June 2009, the DYS implemented a new policy to address acts of violence in its facilities (Consistent Response to Acts of Violence, or CRAVE). Involvement in aggressive of violent behavior resulted in immediate seclusion pending a disciplinary hearing, followed by a period of disciplinary confinement of up to five additional days. As discussed above, the CRAVE policy often results in seclusions of 8 days, sometimes longer. In early 2010, despite witnessing significant reductions in the number of assaults as a result of the CRAVE protocol, the DYS decided to revise the protocol in an effort to make the duration of seclusion more proportional to the seriousness of the assault. The IRAVE (Individualized Response to Acts of Violence) is intended to reduce the use of pre‐hearing confinement and may also encourage the use of other program restrictions in lieu of seclusion. While the IRAVE appears to be more in line with contemporary standards for youth discipline, the quality and success of its implementation is unknown at this time.
As with all initiatives that significantly change the response to youth misbehavior, its credibility among both youth and staff is essential to its effectiveness. While I did not discuss IRAVE during my youth interviews in February, comments from staff during my April visit suggested that many staff believe that IRAVE will result only in youth spending less time in their rooms, that it has simply “discounted the cost” of assaultive behavior. It will be very important for the facility to enhance its use of alternative sanctions as it reduces its reliance on seclusion. The choice should not be “seclusion or nothing,” but rather an array of sanctions designed to address the underlying causes of the youth’s behavior and to deter future aggression.

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Recommendations

Seclusion and the Risk of Self Harm Anytime a youth is placed behind a locked door, the risk of self‐harm (both intentional and accidental) increases. To mitigate these risks, staff must check on the youth frequently to assure his or her safety. Seclusion was used in 11 of the 18 incidents I reviewed during my first visit to the facility, and I audited the Seclusion Monitoring Sheets to ensure that the safety checks met generally accepted practices. In nearly all cases, a complete set of Monitoring Sheets was available and could be assembled into chronological order. Most of the sheets evidenced frequent checks on the youth’s safety at random intervals not exceeding 15 minutes. Staff also routinely indicated the youth’s affect and behavior. A few staff indicated that they checked the youth at exact 15‐minute intervals or other repeating patterns of observations. Not only is this level of precision impossible to accomplish, it does not adequately protect youth from self‐harm. Safety checks should occur at random intervals and staff should use the actual clock time to document this procedure.

Finally, a few of the staff I spoke with were concerned that certain staff on the 3rd shift were not dependable in their efforts to verify the youth’s safety and welfare throughout the night. Because the 15‐minute checks are recorded on paper, rather than tracked through an electronic system, it is possible for staff to misrepresent their actions. Efforts to further investigate this issue could include ensuring that 3rd Shift Operations Managers visit the housing units at random and unpredictable intervals to verify that the seclusion documentation does not misrepresent the time at which checks were done (i.e., staff have not filled in the sheet for the entire shift in advance). Further, a regular review of the videotape footage of staff activities during 3rd Shift could also be used to verify the written documentation. Footage of the overnight hours on a single housing unit for the prior two weeks was reviewed by the DOJ attorney and Assistant Superintendent at my request, and no problems were identified. However, given the potential for serious harm to occur and the fact that a few staff commented on this issue, it is worth additional efforts to ensure that staff are following these safety procedures properly.

1. Limit the use of pre‐hearing confinement to those situations in which the youth presents an immediate risk to the safety of other youth and staff. Once this risk has abated, release the youth from confinement. Hearings could still operate on the 3‐day schedule if necessary, but only those youth whose behavior remains out of control should spend that time confined to their rooms.
2. Increase the use of sanctions other than seclusion to address youth misconduct. Particularly when the youth has not been assaultive, sanctions designed around skill development (e.g., frustration tolerance, impulse control, etc.) are more appropriate and likely more effective in the long‐term.
3. Continue Seclusion Monitoring practices to verify youth’s safety and welfare when they are confined to their rooms. Ensure that staff document their offering the youth a shower, recreation and education materials, as required, and record their observations about the youth’s

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Sources of Information

welfare using actual clock time. 4. Utilize the 3rd Shift Operations Managers and regular videotape review
to verify the accuracy of documentation regarding the safety and
welfare checks of youth on seclusion during the overnight hours.
 AMS Seclusion Log, January through December 2009  Total Number of Seclusion, by Incident Type, 2009 (Bates 004735)  Seclusion Monitoring Sheets for 11 instances in which seclusion was
used to respond to youth misbehavior, selected randomly from
incidents occurring between October and December, 2009  Interviews with Facility Administrators, ODYS Administrators, and Ohio
Attorney General staff  Interviews with 11 youth, assigned to various housing units at Scioto  Interviews with 7 staff (Youth Specialists and Operations Managers)
from 1st and 2nd Shifts

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III.A.4 Restraint. The State shall develop and implement policies, procedures and practices so that only safe methods of restraint are used at the facility and only in those circumstances necessary for safety and security and, to the extent possible, when less restrictive means have been properly, but unsuccessfully, attempted or with respect to therapeutic restraints pursuant to a medical order to protect the health of the youth.

Self Assessment

The State produced a series of ODYS policies and standard operating procedures pertaining to the use of physical restraint. SOP #301.05.01 “Use of Force” refers to the set of techniques approved for use at Scioto, but also gives staff permission to use alternative methods providing: 1) they are more practical at the time; 2) the response is measured and progressive and does not go beyond what is used to neutralize the situation; and 3) does not risk harm or pain to the youth or staff involved. This is an appropriate degree of latitude to afford to staff and properly emphasizes tempering the response and youth and staff safety.

The SOP goes on to describe restraints that are absolutely prohibited (e.g., chokeholds; pressure point holds or pain compliance techniques; etc.) and also discusses ways to limit the risk of positional asphyxia.

These policies and standard operating procedures adequately address the requirements of this provision.

Other than the policies, the State did not produce any specific information to
demonstrate its compliance with this provision. Moving forward, the State
should track and produce information related to the following:  Instances in which staff exhibited improper technique (accompanied by
videotaped footage when available) and the coaching or disciplinary
actions that were taken to improve staff skill;  Proportion of direct care staff who have received MYR training in the
preceding 12 months;  Updates to MYR training curriculum that respond to areas in need of
skill development among staff.

Steps Taken to Assess Compliance

The SOP does a commendable job of describing the expected practices pertaining to the use of safe methods of restraint. These expectations are reinforced by administrators and supervisors who review each use of force to determine its appropriateness. Copies of these reviews were attached to each of the 25 incident reports I reviewed in which force was used. Although some of the incident reports lacked sufficient detail to determine the precise restraint technique used (see III.A.2 for more discussion on this issue), most of them were detailed enough to reveal that staff utilized safe methods of restraint. Further, I reviewed videotaped footage of approximately eight incidents that involved physical restraints and did not note any problems in this area.

Several facility‐based investigations also addressed the question of whether physical restraint was used safely and appropriately. Some of the staff involved

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were ultimately disciplined for excessive or inappropriate uses of force in situations in which youth did not pose an immediate danger to youth or staff at the time the restraint was executed or in which staff technique was deemed to be unsafe. This level of internal monitoring and vigilance to ensure that staff utilize only safe methods of restraint bodes well for long‐term compliance in this area.
Several of the youth I interviewed had been involved in a fight during their stay at Scioto. I asked them to describe the way in which staff intervened in the fight and how it was ultimately brought under control. All of the youth indicated that staff tried to break up the youth by first using verbal commands. Failing that, staff intervened physically. I asked each youth to describe in detail the specific way in which staff intervened, sometimes having the youth act out his/her position and that of staff. In every case, the interventions described by youth appeared to be pulled directly from the MYR curriculum (e.g., they described the C‐escort technique) or another method that did not appear to be harmful in any way (e.g. a bear hug and pulling the youth away from the youth). None of the youth reported the use of chokeholds, pressure point holds or pain compliance techniques.
A review of facility training logs indicated that throughout 2009 and early 2010, nearly all staff received training in Managing Youth Resistance (MYR), which included the use of verbal strategies, DYS‐approved techniques, and medical risks involved in physical restraint. I also reviewed the MYR training curriculum and found it to be of high‐quality and in line with contemporary standards.
When interviewed, staff were able to describe the techniques learned during the MYR training. While some staff commented that MYR techniques were not always practical given the location, behavior or positioning of the youth involved, they were able to describe safe alternative methods of restraint. Perhaps most importantly, staff were keenly aware of what not to do (i.e., techniques that carried with them the risk of harming the youth).

Recommendations
Sources of Information

No recommendations in this area.
 SOP #301.05.01 “Use of Force”  Discussions with MYR staff trainers  Review of Managing Youth Resistance (MYR) training curricula  Facility training logs, 2009 and early 2010  Use of Force Reviews connected to 25 incident reports in which force
was used, randomly selected from those generated between January
and December, 2009  Facility‐based investigations examining the question of whether
restraint was used properly and safely, n=26, from 2009 and early 2010  Interviews with 11 youth, assigned to various housing units at Scioto  Interviews with 7 staff (Youth Specialists and Operations Managers)
from 1st and 2nd Shifts

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III.A.5 Investigation of Serious Incidents. The State shall develop and implement policies, procedures and practices so that appropriate investigations are conducted of all incidents of: use of force; staff‐on‐ youth violence; serious youth‐on‐youth violence; inappropriate staff relationships with youth; sexual misconduct between youth; and abusive institutional practices. Investigations shall be conducted by persons who do not have direct or immediate indirect responsibility for the employee being investigated.

Self Assessment

Several policies are relevant to this provision. SOP #305.05.01 “Use of Force” requires all incidents involving physical or mechanical restraint to be reviewed by the Operations Administrator and the Deputy Superintendent for Direct Services within two days of their occurrence. Among other things, the purpose of this review is to assess whether force was necessary, whether the level of force used was appropriate to the risk posed by the youth, and whether the restraint was tempered once control was established. In addition, the Superintendent is required to review 10% of all incident reports involving a use of force each month. [As I reviewed incident reports, I noticed that some were marked “10%” to indicate that they had been part of the superintendent’s monthly review].

SOP #101.14.01 “Institutional Incident Review” requires the Operations Administrator to review all incident reports by the next business day following their occurrence. Facility administrators reported that they meet each morning to review incidents occurring the day before, and often review the accompanying video footage to determine whether an investigation is warranted. Together, these two SOPs adequately address the requirements of this provision pertaining to use of force, serious youth on youth violence and sexual misconduct between youth.

Policy #304.05 “Suspected Child Abuse and Neglect Reporting” adequately addresses the other requirements of this provision pertaining to staff on youth violence; inappropriate staff relationships with youth; and abusive institutional practices. In addition to the facility‐based review required by the SOPs discussed above, incidents of this nature must also be reported to the appropriate Public Children Services Agency (PCSA) and to the Ohio State Highway Patrol (OSHP). All ODYS staff are mandated reporters, although they may delegate the actual reporting duty to the Facility Superintendent after completing a Suspected Child Abuse and Neglect Reporting Form.

Once reported and referred for investigation, Policy #101.05 “Investigations” requires investigations to begin within 24 hours. Investigations pertaining to the use of force must be completed within 14 days of assignment, while 30 days are allocated to other types of investigations. Incidents that are considered critical or serious (both of which are appropriately detailed in the policy) are investigated by the Chief Inspectors’ Office. Non‐critical incidents (e.g., uses of force in violation of policy, consensual sexual contact between youth, youth on youth assaults with injury, etc.) are investigated by facility staff.

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The policies are comprehensive, appropriately detailed and address all of the
issues required by this provision. Aside from these policies, the State did not
produce any specific information to demonstrate its compliance in this area.
Moving forward, the State should track and present data on the following:  Number of Use of Force Reviews, and the number that identified a
violation of policy;  Number of incidents referred for investigation based on the Use of
Force Review or the more routine administrative review of incidents
that occurs each morning, and the outcomes of these investigations;  Number of Suspected Child Abuse and Neglect Reports filed, proportion
that made the appropriate notifications and the proportion that were
reported within the required timelines;  Number of incidents referred for facility‐based investigation, the
findings of the investigations, and the proportion that were completed
within the required timelines;  Number of incidents referred to the Chief Inspectors’ Office, the
findings of the investigations, and the proportion that were completed
within the required timelines.

Steps Taken to Assess Compliance

In order to assess the extent to which the State has made the required reforms in this area, I reviewed all of the Suspected Child Abuse Reports (n=5) for alleged abuses occurring on Scioto grounds 2009 and early 2010; all investigations (n=13) completed by the Chief Inspector’s Office in 2009 and early 2010related to the issues specified in this provision; and all investigations (n=29) completed by facility investigators in 2009 and 2010related to the issues specified in this provision.

The DYS’ Investigations Manual clearly delineates which matters must be investigated by the various bodies (facility, Chief Inspector, Ohio State Patrol) and provides excellent guidance for conducting sound investigations of allegations of abuse and staff misconduct. In particular, the sections on Interview Preparation, Interview Technique and Use of Force reviews were particularly useful. The Manual also mandates a specific template for investigative reports and describes the content required in each section.

Suspected Child Abuse Reports Among the 5 suspected child abuse reports documenting alleged abuses on Scioto grounds, I could locate the investigation for only two of them. The other three reports were from early 2010, and it is entirely possible that the investigation was not yet complete and thus I did not receive a copy of it. [While beyond the scope of this provision, it is worth noting that the majority of suspected child abuse reports did not make all of the notifications required by DYS policy. In three of the five reports, either the Child Services Agency or the Ohio State Patrol was notified, although policy requires staff to notify both agencies.] Across the Chief Inspector’s investigations I reviewed, a suspected child abuse report does not appear to have been filed for an allegation that meets the requirements of the mandated reporting policy (Investigation #1001090109). Reconciling these data is essential to ensure that appropriate

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efforts are made to investigate allegations of abuse and neglect, either by DYS, the Child Services Agency, or the Ohio State Patrol.
Investigations by the Chief Inspector’s Office Although the types of allegations to be reviewed by the Chief Inspector’s Office versus facility based staff are clearly specified in policy, my review of some of the investigations left me confused as to why they were undertaken by the Chief Inspector. For example, several of the investigations addressed allegations of excessive use of force, youth on youth violence, and youth on staff violence. DYS policy suggests that these would be handled by the facility. In the end, this distinction has no real bearing on the State’s compliance with this provision, given that the incidents were investigated by someone. However, it may be worth reviewing the scope of work for each body to ensure compliance with policy.
Universally, the 13 investigations completed in 2009 and early 2010 were of high‐quality:
 All youth and staff involved in or related to the event in question were interviewed, except in extreme circumstances;
 Interviews with the accused, victims and witnesses were both timely and thorough;
 Investigators followed new leads and sought to resolve contradictions that emerged through the course of their interviews;
 Videotape footage, unit logs, and other sources of evidence were routinely accessed and used to form conclusions about what transpired; and
 Investigative reports provided full accounts of what occurred and reconstructed events in detail; and
 With few exceptions, investigations were completed within the timelines prescribed by policy.
 Perhaps most importantly, the investigators conclusions were grounded in facts and appeared to be reasonable.
 Even when the primary allegation was unfounded, staff were routinely cited for violating DYS policy, when appropriate.

Facility‐Based Investigations Among the 29 facility‐based investigations submitted for my review, most were adequate, while some of were of higher quality (e.g., # 550910018, #5501090105, and #5501090144). However, a few investigations suffered from the following problems:
 Investigators failed to interview all of the staff and youth involved;  Accounts of interviews amounted to conclusory statements rather than
descriptions of staff actions (e.g., “staff reported they used the least amount of force necessary” or “staff accurately described the event in question” without actually describing the event or indicating what it was compared to in determining accuracy);

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Recommendations
Sources of Information

 Some investigations included only a statement that staff or youth were interviewed without summarizing the substance of those interviews;
 A couple of investigations were significantly delayed which compromised the ability of witnesses to accurately recall the events in question.
More generally, the large majority of facility‐based investigations were not completed within the 14‐day timeline prescribed by policy. Of the 29 reports, only 31% were completed on time.
Despite these problems, the investigations with complete accounts of witness interviews appeared to result in reasonable conclusions and certainly highlight the facility’s commitment to ensuring that staff utilize physical restraint safely and only when necessary. Fully one‐third of the investigations cited staff for a violation of policy or procedure, most often related to the unnecessary use of force.
It is worth noting that during my own interviews with youth and those of John Platt during his November 2009 tour, none of the youth reported they had been subjected to any form of physical abuse or sexual misconduct. All of the youth we spoke with knew how to report such an event, should it occur. Further, the staff I interviewed knew the procedures for reporting child abuse allegations and also appeared to take the issue of being under investigation very seriously. Their main concern was the length of time they were placed on posts where they do not have contact with youth pending the outcome of the investigation. Completing investigations in a timely manner is particularly important for both staff morale and to alleviate the various staffing shortages that have plagued the facility.
1. Ensure that all incidents of abuse or neglect are properly reported to both the Child Services Agency and the Ohio State Patrol.
2. Ensure that facility‐based investigators interview all witnesses and provide detailed summaries of all interviews.
3. Complete all investigations within the timelines prescribed by DYS policy.
 Policy #304.05 “Suspected Child Abuse and Neglect Reporting,” Policy #101.05 “Investigations,” SOP #305.05.01 “Use of Force,” and SOP #101.14.01 “Institutional Incident Review.”
 DYS Investigations Manual  Suspected Child Abuse Reports, filed in response to alleged events on
Scioto grounds in 2009 and early 2010, n=5  Chief Inspector’s Investigations from 2009 and early 2010, n=15  Facility‐Based Investigations from 2009 and early 2010, n=29  Interviews with 11 youth, assigned to various housing units at Scioto  Interviews with 7 staff (Youth Specialists and Operations Managers)
from 1st and 2nd Shifts

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III.A.6 Staff Training in Behavior Management, De‐Escalation and Crisis Intervention. The facilities shall train all staff in behavior management, de‐escalation techniques, appropriate communication with youth and crisis intervention before staff may work in direct contact with youth.

Self Assessment

The ODYS has several policies relevant to this provision. Policy #104.01 “Staff Development” requires all staff to have access to training and development opportunities needed to maintain safety and security in institutional settings. This includes a 5‐phase training that include New Employee Orientation (40 hours), Basic Academy (120 hours), Site Specific Orientation (40 hours), De‐ Escalation training and Managing Youth Resistance (i.e., Use of Force) training (40 hours), and On‐The‐Job training (80 hours). Once hired, all employees are required to attend 40 hours of in‐service training each year. The policy also requires each facility to have a full‐time Training Coordinator and specifies the coursework required for the individual who holds this position. These ODYS requirements are well in excess of the generally accepted practice.

SOPs #104.01.01, #104.01.02, and #104.01.03 provide additional detail on the topics and issues that must be addressed in the New Employee Orientation, Basic Academy, Site Specific Orientation, and On‐The‐Job training programs. SOP #104.01.05 “Annual In‐Service Training” requires a Site Coordinator to conduct an annual assessment of training needs, and requires employee performance to be assessed in each area, specifying an 80% passage rate on all assessments. As with the policies, these SOPs are comprehensive, detailed, and fully meet the requirements of this provision.

The State did not produce any other specific information designed to
demonstrate compliance with this provision. Moving forward, the State should
track and present data on the following:  List of new employees and the dates on which they completed each of
the 5 phases of training;  Summary statistics on the proportion of new employees who
completed each training before working independently with youth;  List of current employees and the dates on which they completed each
component of the annual in‐service training;  Summary statistics on the proportion of current employees who
completed the full battery of annual training;  Annual training plans completed by the facility’s Site Coordinator.

Steps Taken to Assess Compliance

When interviewed, all staff were conversant in the various techniques for de‐ escalation and physical intervention addressed in training. They also reported that the training in CPR/First Aid and Emergency Response left them prepared to manage situations in which youth may harm themselves. Universally, they reported that the verbal strategies training was the most helpful, but that the true learning occurred during the OJT process.

The Annual Training Plans for 2009 and 2010 include all of the topics specified in this provision: verbal strategies for de‐escalating youth, managing youth

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resistance, physical and mechanical restraint, CPR and First Aid, and Emergency Response Training. I reviewed the curricula for most of these courses (except CPR/First Aid) and found them to be comprehensive and engaging. The State has recently developed a new behavior management program (Strength Based Behavior Management System—SBBMS) with training scheduled for May 2010.
The State also provided Quarterly Training Logs that indicate the date on which staff completed each training course. Data on the proportion of staff who have completed each course are provided in the Annual Training Plans. As of December 31, 2009:
 96% of all staff were certified in CPR/First Aid/AED;  98% of all staff had completed MYR training in both policy, technique
and the use of mechanical restraints;  100% of the Supervisors completed the Planned Intervention training;
Further, 100% of new employees in 2009 received all of the required Phases of training.
The 2009 Annual Training Plan also provides a list of action steps to fortify the already solid training program. These include offering trainings at a higher frequency and throughout the year, increasing instructor availability, ensuring veteran staff are available to provide OJT, and ensuring that staff receive adequate notice when scheduled for training.
In 2010, all staff will receive training in youth interventions, grievances, MYR technique and practice, mechanical restraints, planned interventions, medical risks in restraints, and the new Strength Based Behavior Management System (SBBMS). With the addition of the SBBMS, assuming the similar rates of completion by staff, the 2010 training plan will address all of the requirements of this provision.

Recommendations
Sources of Information

1. Implement the SBBMS training module as planned, ensuring that all
staff develop the competencies necessary to supervise youth safely.
 Policy #104.01 “Staff Development, “ and SOPs #104.01.01 “New
Employee Orientation and Basic Academy Training,” #104.01.02 “Site
Specific Orientation Training,” #104.01.03 “On‐The‐Job Training,” and
104.01.05 “Annual In‐Service Training.”  Annual Training Plans for 2009 and 2010  Quarterly Training Logs, 2009 and Q1 2010  Managing Youth Resistance (MYR) and Emergency Response Training
(EMT) training curricula  Interviews with 7 staff (Youth Specialists and Operations Managers)
from 1st and 2nd Shifts

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III.A.7 Employment Practices. The State shall use reasonable measures, including background checks and criminal records checks, to determine applicants’ fitness to work in a juvenile facility prior to hiring employees for positions at the facility.

Self Assessment

The State did not produce any specific information pertaining to the level of compliance with this provision.

SOP #103.03.04 “Pre‐Employment Background Investigation” went into effect April 1, 2010. Prior to that employee background investigations were governed by SOP #103.03.02 “Applicant Selection Procedures.” The current policy discusses criminal background checks for all new employees. Background checks are required only for candidates who, having passed a variety of other screening and interview procedures, are being recommended for employment with DYS. By checking a variety of sources including the Law Enforcement Automated Data System (LEADS), the Department of Mental Retardation and Developmental Disability Abuser Registry, Sex Offender Registry, and fingerprint databases, applicants with certain offenses on their records are deemed ineligible for employment. Exclusionary offenses include murder, arson, rape, robbery, sexual assault, drug trafficking, weapons violations, among others, and appear to be in line with contemporary standards in this area. For certain less serious offenses, applicants are eligible for employment with DYS if they have been off supervision for five or three years, depending on the severity of the offense.

In the future, the State should provide the following:  List of Scioto applicants recommended for employment, the date on
which the background check was completed, any exclusionary offenses,
and the hiring decision.

Steps Taken to Assess The State submitted the names of the four employees who were recommended

Compliance

for employment at Scioto during 2009. All of these individuals passed the

criminal background check and were eventually hired by the State.

Recommendations
Sources of Information

The State appears to have implemented employment practices that meet the requirements of this provision.
 SOP #103.03.04 “Pre‐Employment Background Investigations” along with relevant appendices and SOP #103.03.02 “Applicant Selection Procedure,” which was replaced by the preceding policy
 Background Checks for Scioto New Hires, 2009 (Bates 003594)

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III.D.1 Grievances. The State shall develop and implement policies, procedures and practices to ensure that the facility has an adequate grievance system including: no formal or informal preconditions to the completion and submission of a grievance; review of grievances by the chief inspector; timely initiation and resolution of grievances; appropriate corrective action; and written notification provided to the youth of the final resolution of the grievance.

Self Assessment

The ODYS grievance policy was revised in January 2010 in order to comply with a concurrent lawsuit over the matter and the Prison Litigation Reform Act (Case No. 2:04‐CV‐692). Policy #304.03 “Youth Grievance Process” allows youth to grieve “any action, incident, living condition, dispute or the application of any policy or practice that the youth believes to be harmful, unjust, or a specific violation of his or her rights.” Youth may not use the grievance process to challenge disciplinary matters (which have their own appeal process), release decisions, or court actions.

The policy addresses all of the components required by this provision:  No preconditions. Youth may file a grievance at any time for any of the reasons specified above.  Review by the Chief Inspector. All grievances must be reviewed by the
Chief Inspectors office, via the AMS system. Each grievance is logged
into AMS, and once resolved, all supporting documentation is scanned
into the system and thus available for off‐site review. The Chief Inspector is also required by policy to provide quarterly cumulative
summaries and to conduct a formal audit at least annually.  Timely initiation and resolution. The policy requires the Grievance
Coordinator to retrieve grievances from the locked boxes daily (M‐F)
and to resolve the grievance within 14 days of receipt.  Appropriate corrective action. Grievance decisions must be based on
the merits of the issues raised. If the facts of the situation are disputed,
the Grievance Coordinator must take the necessary steps to resolve the
dispute, by consulting facility records and interviewing staff, youth or
others who may have knowledge of the issue.  Written notification to the youth of the resolution. The policy requires
the Grievance Coordinator to review the grievance with the youth and
to return the form, with the written resolution, to the youth.

The State produced copies of all grievances submitted in February, April,
August, October, November and December, 2009, along with a log showing the
State’s success in meeting the required timelines. Grievances from February,
April, and August 2009 were requested while on site in April, 2010, but were
not delivered until June, 8, 2010. Moving forward, the State should track and
present data on the following:  Monthly trend data (number, type, etc.) compiled by the Grievance
Coordinator, as required by policy;  Proportion of grievances resolved within the 14 day timeline;  Proportion of grievances requiring a timeline extension and the reasons
for those extensions;  Copies of the quarterly cumulative summaries compiled by the Chief

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Inspector, as required by policy;  Copies of the annual audit conducted by the Chief Inspector, as
required by policy.

Steps Taken to Assess Compliance

At my request, the State submitted data on all grievances submitted between January 1, 2009 and March 25, 2010. Of the 533 grievances submitted, 99% were resolved within the 14‐day timeline. Among the 119 that were appealed to a Manager, 97% were responded to within the required timelines. Among the 54 grievances appealed to the Chief Inspector, 69% were resolved within required timelines.

The new policy changes the appeal process, and thus efforts to address the timeliness of the Chief Inspector’s response are moot at this point. Beginning May 1, 2010, the Grievance Coordinator’s resolution will exhaust the appeals process. If the youth is not satisfied with the response, he or she may submit another grievance contesting the response. All grievances will be reviewed by the Chief Inspector’s office.

The Grievance Coordinator was well‐prepared to transition to the new system and had already trained both staff and youth in the new procedures. From her perspective there were no barriers to the prompt resolution of youth grievances. Most recently, she reports that youth are concerned about laundry issues (e.g., clothes not being returned) and by problems experienced in the school setting (boys only). Over the past year, there have been relatively few allegations of abuse or mistreatment, and these are always referred for investigation (which was verified by my own review of the grievances).

I reviewed all grievances submitted in February, April, August, October, November and December 2009 (n=233). Universally, I found the initiation and resolution of the grievance process to be timely. Very few of the grievances I reviewed exceeded the 14‐day limit. For the sake of clarity, I used the requirements of the most recent policy to assess compliance, even though I know that some of the requirements have been changed. For example, I believe the previous policy required resolution within 10 days of receipt. That said, the vast majority of grievances I reviewed met even this more stringent guideline.

In addition to being timely, the content of the response to the youths’ complaints was high‐quality. The Grievance Coordinator made clear efforts to gather relevant facts and to arrive at seemingly fair and reasoned decisions. This effort to pursue an appropriate resolution was in evidence even when the youth had been released from the facility, which is an excellent practice. Copies of the resolution were routinely forwarded to youth at his or her current location.

When youth alleged verbal or physical abuse, the grievances were immediately referred for investigation, and once assigned, the investigation number was recorded on the grievance form for easy cross‐referencing. Further, the Grievance Coordinator also skillfully used the grievance process to clarify

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elements of policy and procedure that may have been confusing to youth, staff, or to the Grievance Coordinator herself.
Most of the youth I spoke with believed the grievance process “worked” and felt it was a solid option for addressing their complaints. This impression mirrors that of John Platt from his November 2009 tour. However, some of the youth I spoke with stated that while the Grievance Coordinator was conscientious about contacting them to address their issues, they had various misgivings about the process. Several were concerned that the process was not sufficiently private, and were uncomfortable with the idea that the staff would learn their identities if they complained. A couple youth thought the process did not work because “they take the staff’s word” over the youth’s, a sentiment that appeared to be connected to a specific situation that was not ruled in the youth’s favor rather than an assessment of the grievance system as a whole. That said, the youth’s privacy concerns could be addressed by reinforcing with staff their duty not to dissuade, influence or retaliate against youth in any way when youth choose to exercise their right to use the grievance process.

Recommendations
Sources of Information

The State appears to have fully implemented a grievance policy that meets the
requirements of this provision.
 Policy #304.03 “Youth Grievance Process”  AMS Grievance Log, January 1, 2009 through March 27, 2010  Monthly Grievance Reports, January 2009 through February 2010  Reviewed approximately 233 grievances for content and timeliness
submitted in February, April, August, October, November and
December, 2009.  Interviews with Facility Administrators, ODYS Administrators, and Ohio
Attorney General staff  Interview with the Grievance Coordinator

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III.D.2 Grievance Explained to Youth. A clear explanation of the grievance process shall be provided to each youth upon admission to the facilities during orientation and to their parents or guardians, and the youth’s understanding of the process shall be at least verbally verified.

Self Assessment

Policy #304.03 “Youth Grievance Process” requires the facility’s orientation process to include a thorough instruction in the use of the grievance process and for each youth to receive a copy of the Youth Grievance Handbook. Upon receiving the information , each youth is required to sign a letter of understanding, which is placed in the youth’s institutional file. The Youth Grievance Handbook was recently updated to reflect the version of the policy going into effect on May 1, 2010.

The State did not provide any other specific information pertaining to its level of compliance with this provision. Moving forward, the State should provide the following information:
 For a sample of youth admitted to the facility, the proportion for whom a signed letter of understanding was located in their institutional files.
 For a sample of youth admitted to the facility, the proportion of parents received packets containing information on the youth grievance process and procedures for parents to address their concerns with facility administrators.

Steps Taken to Assess Compliance

I interviewed 11 youth, at least one youth from each housing unit, to obtain a cross‐section of facility experiences. Without exception, the youth reported they had received instructions about the grievance process during orientation and had a copy of the Handbook. They could also explain the mechanics of the grievance system: they knew where to obtain a grievance form, where the boxes were located, and that the Grievance Coordinator would come to discuss their complaint with them.

Recommendations
Sources of Information

Staff from the Ohio Attorney General’s office explained that the new policy does not provide for parents to utilize the youth grievance process . While they are informed of the mechanics of the youth grievance process via the information packet sent to all parents upon a youth’s admission to Scioto, they are directed to submit their concerns directly to the Facility Superintendent, either verbally or in writing. This process appears to meet the intent of this provision.
1. Provide an introduction to the revised Youth Grievance Process to all youth at Orientation.
2. Provide parents with an information packet describing how their child may access the Grievance Process along with the procedures for parents to file a complaint with the Facility Superintendant.
 Policy #304.03 “Youth Grievance Process”  Youth Grievance Handbook  Interviews with 11 youth, assigned to various housing units at Scioto  Interview with staff from the Ohio Attorney General’s Office

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III.D.3 Grievance Process. Without any staff involvement, youth shall easily be able to obtain grievance forms and submit grievances.

Self Assessment

Policy #304.03 “Youth Grievance Process” requires grievance forms to be located on each living unit, library, school and other locations where youth congregate. Grievance boxes are to be co‐located and locked at all times.

During my tour of Scioto, facility staff pointed out the location of several grievance boxes and locations where youth can obtain forms. No other additional information is needed from the State to verify compliance.

Steps Taken to Assess I toured the facility and noted the location of grievance boxes in living units and

Compliance

in the school, along with the availability of grievance forms.

Recommendations
Sources of Information

Across the 11 youth I interviewed, all of them knew where to obtain a grievance form and how to submit it. They did not have any concerns in this area. The Grievance Coordinator reported that she has not received any complaints from youth that the materials needed to file a grievance were unavailable.
The State appears to have implemented a grievance process that meets the requirements of this provision.
 Tour of Scioto, February 10, 2010  Interviews with 11 youth, assigned to various housing units at Scioto  Interview with the Grievance Coordinator

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III.F.1 Structured Programming. The State shall provide adequate structured rehabilitative services, including an appropriate mix of physical, recreational or leisure activities during non‐school hours and days. The State shall develop and implement structured programming from the end of the school day until youth go to bed, and on weekends. For youth housed in closed‐cell environments, programming shall be designed to ensure that youth are not confined in locked cells except: a) from after programming to wake up; b) as necessary where youth poses an immediate risk of harm to self or others; c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The programming shall be designed to modify behaviors, provide rehabilitation to the types of youth committed at the facility, address general health and mental health needs, and be coordinated with the youth’s individual behavioral and treatment plans. The State shall use teachers, school administrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualified assistance to develop and implement structured programming. The State shall provide youth with access to programming activities that are required for parole eligibility.

Self Assessment

The State did not produce any specific information to document its compliance with this provision.

Several policies are relevant to this provision:  Policy #107.01 “Volunteer Coordination” emphasizes the commitment
to secure citizen involvement in DYS programs;  Policy #506.01 “Recreation Programming” highlights the commitment
to provide both recreation and structured leisure programs to all
youth, including those in seclusion;  Policy #506.02 “Community Service” directs facilities to develop
activities that benefit public and private community agencies and
organizations;  Policy #506.03 “Youth Idleness Reduction” assigns the responsibility to
monitor youth idleness to a designated facility staff member who
assesses the extent to which the facility master schedule is followed;  Policy #507.01 “Religious Services” commits the DYS to provide
opportunities for youth to practice their faith and discusses the role of
the facility Chaplain.
These various policies ensure that youth idle time is kept to a minimum, and
that daily activities are both structured and meaningful to the youths efforts to
reintegrate into the community.

A draft policy #503.04 “Structured Programming” was also provided. This policy requires a posted schedule of all daily activities designed to keep youth engaged from morning to night. This policy appears to integrate the main ideas of the policies discussed above, along with the new behavior management program discussed below. I am uncertain of its implementation date.

In addition, the soon‐to‐be‐issued SOP #303.01.06 “Strength Based Behavior Management System” outlines the procedures for a multi‐level behavior motivation system that focuses on reinforcing desirable behavior and sanctions negative behavior. The SBBMS includes a phase system, daily point system, and various methods for reinforcing positive behaviors (e.g., verbal applause, earned and purchased incentives). Procedures for implementing the system are

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clearly detailed in the policy and as designed, appear to be in line with contemporary standards for behavior management. Staff training in the SBBMS is scheduled for May 2010, with implementation to occur shortly thereafter.
Moving forward, the State should produce information on the following:  Monthly reports of volunteer activities, recreation programs, community
service projects, youth idleness reduction monitoring, and religious services, all of which are required by the DYS policies required above.  Data describing the implementation and effectiveness of the SBBMS, such as the number of youth attaining each phase, awarding of incentives, imposition of various sanctions, and the effect these have had in reducing youth aggression and non‐compliant behavior.

Steps Taken to Assess The extent to which rehabilitative programming adequately addresses the

Compliance

treatment needs of Scioto youth will be referred to the Mental Health expert,

Dr. Daphne Glindmeyer.

My interviews with Facility Administrators and unit staff indicated a clear commitment to reducing youth’s idle time and to engage youth in structured activities throughout the day. These activities include recreation, structured leisure activities, staff‐led activities, rehabilitative groups, community service projects and volunteer‐led programs. The facility should be applauded for employing such a broad cross‐section of community members and facility staff toward this end.

Interviews with the Volunteer Coordinator and facility Chaplain revealed a high‐ level of enthusiasm for enriching the environment at Scioto with an array of programming led by community volunteers. Two solid training programs were implemented to support this effort: 1) Volunteer Training that addresses safety and security issues and makes volunteers aware of contraband issues, etc.; and 2) Staff Training in Volunteer Services that provides staff with guidance and suggestions about how to make volunteers feel welcome, ensure their safety, and emphasizes the need for youth to arrive on‐time to all scheduled activities.

Scioto is reportedly the leader in total volunteer hours among the DYS programs in the State. The Annual Statistical Report for volunteer services submitted by the State shows that each week, there are approximately 5 to 10 programs available for youth participation. Youth participation is generally well‐ distributed across housing units, although gender‐specific programs for both boys and girls are noted. Most programs serve a relatively small number of youth with only 2 to 5 youth participating in many of them. Certain events— movie nights and holiday parties—have a much greater level of participation.

Two barriers to providing structured programming were noted by the Volunteer Coordinator and Chaplain. The first, which is actually a positive indication of the State’s compliance with this provision, is the competition among volunteer programs for the somewhat limited time available in the youth’s schedule. The

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plethora of programs available can lead to a limited number of participants in any one program. Related, and more serious in terms of the ability to comply with this provision, is the issue of staffing. The fact that the boys’ reception units may house 20‐30 youth who are supervised by only two direct care staff means that transporting youth safely to the variety of programs is often compromised. It is not uncommon for youth to be late or to not report at all to the scheduled volunteer activities. Not only is this demoralizing for the volunteers and youth, but also impacts the facility’s ability to comply with DYS policy in this area and to satisfy the requirements of this provision.
My tour of the facility included three housing units. School was not in session that day, but most youth on each housing unit were engaged in structured activities and staff were moving about the units interacting with youth. Staff on one unit showed me the curriculum for staff‐led activities that included things such as instruction on proper room layout, laundry, clothing, job interviews, setting goals, new vocabulary words, spelling bees, rules of ping pong, balancing a checkbook, etc.
I reviewed the Unit Schedules for both weekdays and weekends and found them to be replete with structured activities for youth. During his November 2009 tour, John Platt’s interviews with youth indicated that staff routinely follow the unit schedules and that services are provided as planned. During my own interviews, youth reported that while it was difficult for them to be separated from their families and peer groups at home, they had plenty to do during the day and were rarely bored. This impression is in conflict with John Platt’s from his November 2009 tour, in which the youth he interviewed indicated they would like more to do during the day. These differences are likely due to the small samples of youth interviewed by both of us.
The girls’ units and the Cognitive‐Behavior Therapy (CBT) unit both utilize a behavior management program, PROOF, that is similar in structure and philosophy to the upcoming SBBMS program. Reportedly, the boys’ reception units will implement a modified version of the SBBMS to account for the boys’ shorter lengths of stay. I will assess the implementation of the SBBMS on my next visit to the facility.

Recommendations
Sources of Information

1. Ensure sufficient direct care staff are available to transport youth to the variety of programs available to them. Make efforts to limit tardiness and absenteeism.
2. Fully implement the SBBMS and track its effectiveness in reducing youth aggression and non‐compliance and their consequences (e.g., seclusion).
 Policy #107.01 “Volunteer Coordination”, Policy #506.01 “Recreation Programming”, Policy #506.02 “Community Service”, Policy #506.03 “Youth Idleness Reduction”, Policy #507.01 “Religious Services”, draft policy #503.04 “Structured Programming”, and SOP #303.01.06

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“Strength Based Behavior Management System”  Interviews with Facility Administrators, ODYS Administrators, and Ohio
Attorney General staff  Interview with the Volunteer Coordinator and Chaplain  Annual Statistical Report for Volunteer Services, 2009  Tour of Scioto, February 10, 2010  Interviews with unit staff  Unit Schedules for weekdays and weekends  Interviews with 11 youth, assigned to various housing units at Scioto

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III.F.2 Orientation. (a) Admissions Intake and Orientation. The State shall develop and implement policies, procedures and practices to establish a consistent, orderly admissions intake system, conducive to gathering necessary information about youth, disseminating information to staff providing services and care for youth, and maintaining youth safety. The orientation shall also clearly set forth the rules youth must follow at the facility, explain how to access medical and mental health care and the grievance system, and provide other information pertinent to the youth’s participation in the facility’s programs. (b) Notice to Youth of Facility Rules and Incentives/Consequences for Compliance. The State shall explain the structured programming to all youth during an orientation session that shall set forth the facility rules, the positive incentives for compliance and good behavior and the sanctions for rule violations. The State shall provide the facility rules in writing. (c) Introductory Handbook, Orientation and Reporting Abuse. Each youth entering the facilities shall be given an orientation that shall include simple directions for reporting abuse and assuring youth of his/her right to be protected from retaliation for reporting allegations of abuse.

Self Assessment

Policy #501.01 “Reception and Orientation” requires a thorough screening, assessment and orientation regarding procedures, rules, programs and services for all youth admitted to DYS. It is not specific as to how this is to be accomplished and none of the other SOPs provided appeared to provide greater detail. However, Policy #303.01 “Youth Rules, Interventions, and Incentives” provided a few details relevant to this provision. Within 24 hours of admission, youth are required to receive instruction on facility rules, chargeable offenses, the range of penalties, disciplinary procedures and incentive programs. Most of these issues are at least mentioned in the Youth Orientation Handbook provided by the State.

The State did not provide any other specific information to demonstrate its compliance with this provision. Moving forward, the State should present the following information:
 Orientation materials that address the key requirements of this provision (e.g., facility rules, access to medical and mental health care, the grievance system, incentives and consequences for violating facility rules, reporting allegations of abuse);
 For a sample of youth, the proportion who received a complete orientation program.

Steps Taken to Assess Compliance

Each section of this provision is discussed separately below.
a) While the DYS policies submitted by the State do not specify exactly how the information is to be transmitted, based on the information gathered from Facility Administrators and from the Youth Orientation Handbook, the Orientation process appears to cover each of the topics required by this provision:
 Institutional Rules: the Handbook includes sections on Rules of Conduct, Contraband, Line Movement, Cafeteria Rules, Med Call, and Clothing. The State could consider including the level of detail contained in SOP #303.01.01 “Rules of Youth Conduct,” which is far more comprehensive than what is presented in the Handbook.

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 Accessing Mental Health Care: the Handbook advises youth to complete a “Request for Services” form, available on each housing unit, and to submit it to unit staff;
 Accessing Medical Care: the Handbook directs youth to complete a Health Call Form, available on each housing unit, and to enter his or her name and DYS number on the list, along with the nature of their health concern (DYS may wish to consult with the Medical expert assigned to this case to ascertain whether it is appropriate to require the youth to state the nature of their medical concern);
 Grievance system: the Handbook refers youth to the Grievance Handbook, which gives specific instructions for accessing this system. As noted in provision III.D.2, the Youth Grievance Handbook needs to be updated to reflect current policy; and
 Program participation: the Handbook contains information on the treatment, recreation, religious, and education programs available to youth at Scioto.

All of the youth I interviewed knew how to access medical and mental health services and the grievance system. They indicated they received a structured orientation that was useful to their understanding what was expected of them at Scioto. They also reported they received a copy of the Youth Orientation Handbook and stated it was easily understandable. These impressions mirrored those of John Platt from his November 2009 tour.

b). The Youth Orientation Handbook provides a comprehensive list of facility rules and the consequences for violating them. It briefly describes the Intervention Hearing process and states that youth may receive time in seclusion for violating institutional rules. It does not, however, discuss the imposition of any alternative sanctions. All of these topics are discussed in great detail in SOPs #303.01.01, #303.01.02, and #303.01.03. The State could consider expanding this section of the Handbook to ensure that youth are fully informed, particularly as the new SBBMS is implemented.

All of the youth I interviewed reported they received a copy of the Youth Orientation Handbook. I talked to two girls on the mental health unit and asked them to show me and explain their point cards and the way in which points are calculated. Both could do so very coherently. The boys I talked to while on the CBT unit could also provide details about the operation of the PROOF system. As the SBBMS program is implemented, hopefully this level of attachment and engagement with the program will continue.

c). The Youth Orientation Handbook provides a clear prohibition against all forms of physical and sexual abuse, both at the hands of staff and other youth. It includes strategies for avoiding sexual assault and clear instructions for what to do if assaulted.

All of the youth I interviewed understood the prohibition against verbal,

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physical and sexual abuse and all reported that, if this were to occur, there were several staff to whom they would feel comfortable reporting what happened to them. These impressions mirror those of John Platt from his November 2009 tour.

Recommendations
Sources of Information

1. Explain the full range of consequences for violating facility rules (i.e., sanctions other than seclusion) during the orientation process and
include this information in the Youth Orientation Handbook.
2. Explain the incentive programs (i.e., SBBMS) to youth during the
orientation process and include this information in the Youth
Orientation Handbook.
 Policy #501.01 “Reception and Orientation,” Policy #303.01 “Youth
Rules, Interventions and Incentives” and SOP #303.01.01 “Rules of
Youth Conduct,” Policy #303.01.06 “Strength Based Behavior
Management System”  Youth Orientation Handbook  Youth Grievance Handbook  Strength Based Behavior Management System Staff Manual  Interviews with Facility Administrators, ODYS Administrators and Ohio
Attorney General staff  Interviews with 11 youth, assigned to various housing units at Scioto

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Chart 1. Rate of Physical and Mechanical Restraints, July 2008 ‐ January 2010
0.8 0.72
0.7

0.6 0.52 0.53

0.54

0.52

0.51

0.5

0.45

0.43

0.41

0.41

0.41

0.4 0.34

0.3

0.3 0.25 0.26

0.23

0.24 0.22

0.25

0.25 0.24

0.2

0.18

0.18

0.15

0.2

0.19

0.19

0.16

0.14

0.14

0.1 0.08

0.11

0.1

0.07 0.06

0.11 0.1 0.08

0

Phys Rest Mech Rest

Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10

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Chart 2. Average Time In Seclusion, July 2008‐ December 2009
35

30

29

25

20

15

10 10

66

5

5

5 1.4

2 1.3 1.5

5.6 4

0

22

21

21

15 14
12
9

Secl Hrs

Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10

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Chart 3. Rate of Youth on Youth Violence, July 2008‐ December 2009

0.35

0.33

0.3

0.25

0.21

0.2

0.18

0.22 0.2

0.16

0.16

0.15 0.14

0.13

0.1

0.05

0.27
0.21 0.18
0.12 0.11
0.07 0.06
0.05 0.04

Y on Y Violence

0

Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09

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Chart 4. Changes in Use of Seclusion and ADP, 2009
250

200

150

Axis Title

100

50

0

jan

feb

mar

apr

may

jun

jul

aug

sept

oct

nov

dec

# seclusions 171

125

201

170

211

176

159

173

83

127

97

85

ADP

165

182

200

223

212

206

185

163

139

134

122

108

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Consultantʼs Report: Buckeye United Schools
John Wills Lloyd, Ph.D.
At the behest of the United States Department of Justice Special Litigation Section of the Civil Rights Division, I reviewed the special eduction program and services provided to students with disabilities served by schools operated by the State of Ohio’s Departments of Education (ODE) and Youth Services (DYS) for incarcerated youths.1 Concerns about special education arose from an investigation of the Ohio facilities for adjudicated youths and focused on “protecting residents from harm, medical care, mental health care, grievances, and provision of special education.”23 I undertook this review because special education is one of seven areas of remediation stipulated in the agreement between the U.S. Department of Justice Ohio’s Departments of Education and Youth Services that resulted from United States v. Ohio, No. 2:08CV-00475-ALM-MRA. My report addresses the stipulations related to special education that appear in the agreement.
On 9 November 2009 I toured the William K. Willis and Scioto River High Schools (William K. Willis is the school for girls and Scioto River High School serves boys when they stay at the facility during intake processing at the Scioto facility). I toured and reported about special education at the Marion facility of DYS in 2005. Prior to the 2009 tour, I received documents describing policies and procedures for provision of education, including special education, and other services for the youths incarcerated at Scioto and other facilities in the Buckeye United Schools (BUS).4 Subsequently, I received additional documentation. This report is based the following sources: In addition to my observations and interviews with faculty and staff during the tour and the documentation I received prior to and following the tour, I also drew data from publicly available documents.5
1 Ohioʼs Department of Education has, of course, responsibility for providing both general and special eduction for students in Ohioʼs schools. Ohioʼs Department of Youth Services is the juvenile corrections system for Ohio; DYS is statutorily mandated to incarcerate felony offenders, ages 10 to 21, who have been adjudicated and committed to an Ohio facility by one of Ohioʼs juvenile courts.
2 See http://www.justice.gov/crt/split/documents/scioto_ﬁndlet_5-9-07.pdf
3 Note that the syntax of the phrase “protecting residents from... provision of special education” is inconsistent with the thrust of this report and the agreement. I hope to ensure that students with disabilities are guaranteed their rights to special education.
4 I also reviewed documents related to the Consent Order for the class action suit Doe v. Ohio, Case No. 2:91-cv-464; because that action was not the subject of my tour, I used those materials only as background.
5 There are extensive data available to the public about local education agencies from the Ohio Department of Education Web site. However, reports about Buckeye United Schools are only presented for some indicators. For example, a section providing basic data (e.g., “District Proﬁle Report, also known as the Cupp Report”) and another on reports about disciplinary actions did not include Buckeye United Schools.

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My general impression is that the education services and the policies and procedures I was able to assess during my tour of November 2009 were markedly improved over the services I found when I toured the Marion facility in July of 2005. For example, there is a consistent curriculum in place; it is individualized to meet the wide range of students’ academic achievement (thus, at least partially, addressing the needs of students with disabilities), and Buckeye United Schools maintains data about the performance of the students as they progress through the curriculum (i.e., monitoring of progress). Furthermore, there are recently revised policies and procedures that addressed issues I described in my 2005 report.
Not all is well, however. The main question, in my view, is whether those students with disabilities or who might have disabilities are actually receiving special education.
I present this report in two major parts. First I review the agreements in the Stipulation for Injunctive Relief, and then I provide general comments. The former carries more weight. I offer the latter in hopes of helping ODYS and ODE to help students in their care.
Stipulated Agreements
I took as the foundation for this report whether the state of Ohio was meeting the requirements of the stipulation agreed to by Ohio and the United States Department of Justice’s Civil Rights Division.6 I examined each of the requirements specified in the section on special education in the stipulation. The numbering of the sections corresponds with the requirements in the Stipulation for Injunctive Relief.
1. Provision of Special Education: The State shall, at all times, provide all youth conﬁned at the Facilities with adequate special education in compliance with the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006), and regulations promulgated thereunder, and this Stipulation. IDEA requires that schools provide a free, appropriate public education for students with
disabilities. Schools should conduct child find activities, perform assessments or evaluations, determine eligibility, convene meetings to write individualized education programs (IEPs, including Individualized Transition Plans for eligible youths), monitor students’ performance and report results to parents, review IEPs, and re-evaluate students. To be sure, Ohio policy (504.04, dated 1 May 2002) affirms the state’s responsibility and commitment to providing special education, and Buckeye United Schools is providing a free public education. The issues that arise are about the appropriateness of the educational services provided by Buckeye United Schools. I do not see these issues as resulting from malfeasance on the part of Buckeye United Schools.
Under the provisions of the re-authorized IDEA, which became effective 1 July 2005, the U.S. Department of Education Office of Special Education Programs (OSEP) required states to develop six-year “State Performance Plans” (SPPs). OSEP identified 20 indicators of whether
6 The issues of compliance are also relevant to the United States Department of Education because,according to ﬁnancial data for 2009, Buckeye United Schools served 490 students with disabilities and received $245,560.90 in IDEA Part B funds.

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each state is implementing the requirements and purposes of Part B of IDEA and required states to submit performance reports annually. As a part of the IDEAmandated responsibilities, Ohio must submit a SPP that documents its implementation of IDEA Part B, and Ohio published such a document for 2007-2008. Table 1 shows the performance for Buckeye United Schools (abbreviated “BUS” in the headers of the table).
I put a grey background on indicators that are not relevant to the review of the Buckeye United Schools special education program. I did so for the following reasons. (For more about the criteria, please see the documents provided by the the OSEP-supported Regional Resource Centers Program.7)
1. The Buckeye United Schools do not serve students with disabilities during their preschool years, so there is no need to review criteria related to pre-school services.
2. If Buckeye United Schools suspend a student, the student continues to be the responsibility of DYS; Buckeye United Schools cannot send a child to be in the care of her or his parents.

Indicator

SPP Target

BUS Status

1. Graduation Rates
2. Drop-Out Rates
3.Assessment a. Participation b. Reading competence c. Math competence
4. Suspension/Expulsion

85% 13.2%*

22% 77.70%

98% UN UN

98.63% NR 63%

5. School Age LRE [lower is better—JWL] 12.5%

NR

6. Preschool LRE

7. Preschool Outcomes

8. Parent Involvement

90%

NR

9. Disproportionality - Child with a Disability

10. Disproportionality - Eligibility Category

11. Child Find (percent initial evaluations completed in 60 day)

Not

NR

stated

12. Early Childhood Transition
13. Secondary Transition 14. Post-School Outcomes 15. Identiﬁcation and Correction of Noncompliance

100% 79%

NR NR NDR

16. Complaint Timelines

17. Due Process Timelines 18. Hearing Requests Resolved by Resolution Sessions

NDR NDR

19. Mediation Agreements

NDR

20. State Reported Data

Table 1: State Performance Plan (SPP) Indicators of Compliance with IDEA Part B Requirements

7 For explanation, see the Regional Resource Centers Program support documents at http://spp-aprcalendar.rrfcnetwork.org/byindicator.html

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3. Some indicators are aggregated across the state of Ohio; they do not refer to indicators specific to the Buckeye United Schools.
4. Some indicators address the very foci of this report. For example, the state education agency is required to report what it has done to respond to problems in a timely manner and correct those problems. The Ohio Annual Performance Report8 documents results for each indicator. Following
the documentation on Ohio’s Web site, I have entered “NR” to indicate that the data for a particular rating are not reported due to small group size, in order to ensure student privacy.” Where I could not find data about Buckeye United Schools compliance with IDEA SPP results, I put “NDR” in Table 1.
These data reveal reason for concern about the extent to which Ohio is protecting the rights of students with disabilities to a free and appropriate education. The available reports simply do not provide sufficient data to show whether Buckeye United Schools is meeting the needs of these students. For example, one of the most fundamental requirements is that local education agencies act expeditiously when the agency has cause to evaluate a student for disability and need for special education. As shown in Table 1, ODE does not report data about whether Buckeye United Schools performs initial evaluations within the legally mandated 60 days of referral. By using the regulation-mandated provision that state education agencies do not have to report data when doing so might identify individual students, ODE calls into question its compliance with the regulation. Furthermore, as developed later, there is a referral process, but it is not clear whether it is implemented in a way that protects the rights of students with disabilities.
The “NR” in this report putatively is to protect the privacy of students in the Buckeye United Schools. Whom are they protecting by not revealing these data? How many students’ identities who they are evaluating would be compromised if these data were reported? Is there only one or a few out of all the intakes? How carefully, in fact, is Buckeye United Schools screening students upon intake for those who may have previously unidentified disabilities? In a later section of this report, I raise questions about the screening or child find processes employed by DYS and ODE.
According to the Ohio Department of Education, Buckeye United Schools is not among the LEAs that is scheduled for review in 2009-2010. Given the federal and class actions, I find it surprising that Ohio is not monitoring the Buckeye United Schools. Closely monitoring Buckeye United Schools during the current situation would help establish Ohio’s representation of students with disabilities.
8 http://education.ohio.gov/GD/Templates/Pages/ODE/ODEDetail.aspx? page=3&TopicRelationID=967&ContentID=16567&Content=82621. Note that I used the data from 2007-08; the data from 2008-09 became available February 2010.

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Recommendation 1: Justice should request a copy of the actual raw data for 2008-2009 from the Ohio Department of Education to assess whether Buckeye United Schools is meeting the standards in the Ohio State Performance Plan and the responsibilities stipulated in the agreement between the U.S. and Ohio. These data should include not just the percentages, but also the actual numbers, because percentages might misrepresent compliance (e.g., 100% of initial evaluations completed in 60 days could occur if there is only one initial evaluation and it is completed within the mandated 60 days).

Part B, Section 612(3) CHILDFIND.— ‘‘(A) IN GENERAL.—All children with disabilities residing in the State, including children with disabilities who are homeless children or are wards of the State and children with disabilities attending private schools, regardless of the severity of their disabilities, and who are in need of special education and related services, are identified, located, and evaluated and a practical method is developed and implemented to determine which children with disabilities are currently receiving needed special education and related services. Source: 20 U.S.C. § 1412 State Eligibility
Box 1: Responsibility for child find.

2. Oversight: The State shall provide adequate oversight of special education at the Facilities.
The Ohio State Department of Education has worked with the Department of Youth Services to provide coordination and oversight for the special education program. During the tour, I met with Hyacinth (“Cynthie”) Macintosh, the individual in the Buckeye United Schools
who serves as Administrator for Exceptional Youth at Ohio Department of Youth Services.

Ohio Department of Education has appropriate plans and procedures in place to provide services consistent with IDEA to students with disabilities. The documents are published on the EdResources Web site.9 Even though these procedures and guidance make clear that ODE knows what should be happening, the data provided in Table 1 beg the question of whether Ohio is, in fact, exercising reasonable oversight for the Buckeye United Schools programs. The problem is not that there is clear evidence of failure, but that there is not evidence of success.

The Ohio Department of Youth Services Policies and Standard Operating Procedures are dated 7 July 2009. Some of these documents are relevant for some of the issues identified in the stipulation. For example, policy 504.04 addresses how Buckeye United Schools will handle serious behavior problems and includes forms and documents 504.04.08.A and 504.04.08.B for Functional Behavioral Assessments and Behavior Intervention Plans, respectively; those documents would be important in meeting the IEP goals for students in the facilities. The existence of these procedures provides evidence of state oversight and during interviews, staff members mentioned the procedures. However, I was not reassured by their discussion of the procedures that they were implementing standard practices to fulfill those procedures. (See, for example, my observations later in this report about child find and monitoring social-behavioral progress.)

9 http://www.edresourcesohio.org/ogdse/

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Recommendation 2: Ohio should periodically review its policies and standard operating procedures and continue to update and refine them to promote the provision of free and appropriate education for students with disabilities in the Buckeye United Schools.
3. Special Education upon Intake: The State shall ensure that all students who qualify for special education services receive such services within a reasonable time following intake at the Facilities. Given the population of youths who are served by the DYS, it is likely that many have
disabilities requiring special education. Some students enrolled in Buckeye United Schools already have been identified as having disabilities and have IEPs at intake. Those who have IEPs should begin receiving service immediately upon receipt of the in-force IEP from the youth’s previous school.
According to procedures and forms employed by Buckeye United Schools, during intake youths are asked whether they have received special education services previously. There are also checklists for staff to note whether special education records (e.g., an IEP) have been requested from a youth’s previous school and to maintain records about such matters (e.g., SOP 504.07.03).
To be sure, many of the youths in the Buckeye United Schools were identified as needing special eduction prior to their entry into the juvenile justice system. Youths who already have IEPs should routinely receive special education services from the Buckeye United Schools. The only evidence I have about how promptly students with extant IEPs began receiving services was assurances by staff members that once official documents are in hand, the Buckeye United Schools record system shows the presence of the IEPs; note, however, that staff members include questions about special education in their initials interviews with youths during intake.
During my 2005 tour, I learned that youths lost nearly a month of schooling during the intake process. It appears to me that the pace of intake represents an improvement in the provision of educational services over what was occurring in 2005. Still, it is not clear for how long students are denied free, appropriate public education from the time of their admission to the time special education services begin. If students are missing 20 days of a school year, they are losing something greater than 10% of educational time for that year.
Recommendation 3: Ohio should report to Justice the average number of days (and the briefest and longest durations, too) from intake to the onset of special education services for students with in-force IEPs. A reasonable standard to apply in evaluating these data would be the same as employed in determining whether suspension or expulsion constitutes a change in placement: 10 days; if a student is denied services for 10 school days, her rights under IDEA are being denied.
4. Parent or Guardian Involvement: The State shall develop and implement policies, procedures, and practices to appropriately notify and involve parents or guardians in the provision of special education services, whenever possible.

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When I toured (now closed) Hickory Grove High School at the Marion facility in 2005, I was able to observe an IEP meeting in which a parent participated by long-distance telephone. I do not know whether such participation occurs regularly or infrequently. Ohio documents (e.g., CI 206) show that staff members are directed to employ such procedures. The limited sample of IEPs I was able to review included documents showing that Buckeye United Schools personnel were contacting parents and guardians.
Recommendation 4: Buckeye United Schools should continue to employ methods such as having parents participate by telephone in special education meetings. Buckeye United Schools should also continue to document its efforts to contact parents or guardians of students with disabilities.
5. Stafﬁng: The State shall develop and implement an education stafﬁng plan to ensure adequate staff to comply with the terms of this Stipulation. The faculty and staff of Scioto’s schools are led by Principal Joseph Becker. DYS data
show that there are 24 faculty members (17 for William K. Wills School and 7 for Scioto River High School) as well as other members of the administrative staff. A count of the number of teachers on the faculty shows 30, however. Although I did not receive data about how many of the teachers were certified to teach special education, I met several who said they were certified. Members of the staff with whom I met at Scioto told me that there is a secretarial position at each of the Buckeye United Schools whose job is to handle special education materials.
The classes that I observed during the November 2009 tour were quite small. The largest had six students. There is no problem with overcrowding or excessive case loads.
Recommendation 5.1: Ohio should continue to employ professionals who have appropriate credentials.
Recommendation 5.2: Document the development and implementation of a staffing plan for Buckeye United Schools.
6. Screening for Special Education Needs: 6.a. The State shall provide prompt and adequate screening of youth for special education needs and shall identify youth who, upon admission to the Ohio Department of Youth Services, were receiving special education in their home school districts or who may be eligible to receive special education services but have not been so identiﬁed in the past. One of the hallmarks of providing special education for students with disabilities is
making certain that students who should receive services are, in fact, identified and found eligible for special education. Schools should routinely screen for students at risk for disabilities and, as appropriate, conduct follow-up evaluations to ascertain whether each individual student who is found during screening is assessed to determine whether she is eligible, in fact.
Because intake is the first opportunity that DYS would have to evaluate whether a student was eligible for special education because of a disability, it seems like a good time to check for

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the possibility. During the tour, I asked a group of administrators—including a school psychologist, guidance counselor, school assessor, a representative from the Buckeye United Schools central office, and others—to recount the intake process. They described a multi-day sequence of activities that included (a) an interview with the individual in-coming youth about her or his previous schools, grade level, participation in special education, and career plans; (b) formal requests for educational records from the most recent school; and (c) systematic assessment, including achievement testing as well as testing to determine where in the curriculum the student should be placed. They told me that on the fourth day of a youth’s incarceration, classwork begins.
Given that the average age of youths in the Buckeye United Schools is 16.8 years and the average reading level is lower than the normative level for 13-year-olds (i.e. 6.7 grade10), it seems likely that some youths with disabilities probably are not recognized, although DYS and Buckeye United Schools are required to do so by law. Youths with substantial reading problems generally are identified as having learning disabilities under IDEA. Rough calculations indicate that about 800 youths in Buckeye United Schools are reading below 7th grade levels. Surely some of the 800 youths in this group have IEPs. How many in that group do not have IEPs and what is Buckeye United Schools doing about evaluating those who have not previously been found eligible and are reading at such low levels?
ODE has clear statements about the importance of child-find efforts. State policies (504.04.01) guide screening procedures. The standard operating procedures direct educators to schedule meetings, conduct assessments, and etc. The EdResources Web site directs local education agencies such as Buckeye United Schools with statements such as this one: “The school district should prepare and adopt clearly written screening and referral procedures for children suspected of having a disability and make those procedures accessible to community agencies and individuals.”
The absence of a systematic set of procedures for screening students upon intake to the DYS schools was a substantial concern in 2005. During the 2009 tour, I repeatedly asked the educators and youth services officials11 attending the meetings with me about how the intake procedures were structured to respond when youths who manifested problems with reading (a hallmark of the IDEA category of learning disabilities) came into the system. What would the ODYS do when a 15-year-old who had no IEP but was reading at 2nd- or 3rd-grade level was taken into the Buckeye United Schools? I learned that the “Intervention Assistance Teams” handled pretty much everything atypical during intake. Their answers focused on psychosocial problems; I was unsure whether anyone understood that a youth might manifest an academic
10 Data from 2008 DYS statistics at http://www.dys.ohio.gov/dnn/AgencyInformation/Statistics/tabid/117/ Default.aspx.
11 Group interview 9 November 2009 with Stacy Caldwell, Brenda Cronin, Al Cicone, Jane Anne BentzMiller, and others at the Scioto facility.

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problem. They told me that the IAT might refer a youth for further evaluation, but this was not specific. When I pressed them about what data came from the intake process, they consistently referred to subjective reports, not standardized assessments.
Because the population of students served by Buckeye United Schools is at risk for emotional and behavior disorders, I was glad to learn that there is a routine screening for mental health problems during intake. According to report “Standards Compliance Reaccreditation Audit” the Commission on Accreditation for Corrections, 100% of 1774 youths were screened for mental health problems and 111 were receiving mental health treatment plans. It is not clear whether, as it should, screening for mental health issues routinely triggers evaluation for special education.
During the tour, interviewees referred to the Intervention Assistance Team (IAT) as being responsible for referrals. Apparently, the IATs depend mostly on anecdotal data to determine whether youths have problems and whether interventions used have been effective.
Ohio policies (504.04.01; 504.07.03) guide identification procedures. They are silent about important matters such as the trustworthiness of measures employed in screening and assessment for eligibility. I got no clear evidence that Buckeye United Schools has created and implemented a process for assessing the learning and behavioral characteristics of youths who come into the DYS system. To be sure, possible special education needs are one of only many concerns that are considered during the intake process, but they should not receive short shrift.
Given that the population of youths who are likely to pass through its intake processes, the OYDS and the Buckeye United Schools should create a standardized system for screening the learning and behavioral characteristics of each youth who comes into the juvenile justice system. Youths who may have disabilities should be evaluated right away using reliable and valid measures, and appropriate individualized education programs should be developed for those who have disabilities and special education needs.
Recommendation 6a.1: Ohio should continue routine screening for mental health issues and make sure that the process feeds resulting data into the provision of special education services, as appropriate.
Recommendation 6a.2: Given the unique circumstances for Buckeye United Schools, Justice should request that Buckeye United Schools show or develop explicit policies and procedures for screening youth at intake for learning disabilities, intellectual disabilities, or emotional and behavior disorders (“emotional disturbance”).
Recommendation 6a.3: Justice should require that Buckeye United Schools routinely refer for eligibility determination any youth who, at the time of intake, does not have an IEP and reads, writes, or computes below the 40th percentile on a reliable and valid standardized inventory of reading, arithmetic, or written expression achievement; Buckeye United Schools should document the level of screening conducted on a per-child basis, showing age,

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achievement in core academic areas (reading, arithmetic, and written expression), and disposition (waived, further evaluation, eligibility review) and special education status for each youth.
6.b. The State shall ensure that those staff conducting the screening, assessment and evaluation processes are qualiﬁed to do so.
Based on their answers to my questions during interviews, I have reservations about whether staff understand basic psychometric concerns (e.g., reliability and validity). For example, staff members talked about assessment in ways that reflected little precision and professional judgement. When asked how they established baseline levels of performance in reading and social-behavioral problems, they reported that teachers “chipped in” with subjective observations. They did not refer to systematic assessment procedures that have empirically established reliability and validity, the two hallmarks of trustworthy assessments.
I have no formal data to indicate whether the staff are or are not qualified. I presume that they are; a school psychologist was among those participating in my group interview. Buckeye United Schools did not provide résumés or other evidence of staff members’ qualifications and training.
Recommendation 6b.1: Justice should request that Buckeye United Schools provide documentation of the qualifications and training of the staff conducting screening.
Recommendation 6b.2: Justice should require that Buckeye United Schools document that staff members responsible for screening youth for disabilities have professional qualifications and training necessary for their duties.
7. Individual Education Plans: 7.a. The State shall develop an IEP as deﬁned in 34 C.F.R. §300.320 for each youth who qualiﬁes for an IEP. Following development of the IEP, the State shall implement the IEP as soon as possible. As part of satisfying this requirement, the State shall conduct required annual reviews of IEPs, adequately document the provision of special education services, and comply with requirements regarding participation by the professional staff, parents, and student in the IEP process. The State shall, if necessary, develop, review or revise IEPs for qualiﬁed special education students. Ohio reported that nearly 50% of the youths in William K. Wills School have IEPs. The
state has guidance for developing IEPs and forms for preparing them (IEP PR-07 Form, which was revised 6 May 2009). There is also policy (504.04) about how Buckeye United Schools is to address serious behavior problems (with forms and documents for Functional Behavioral Assessments and Behavior Intervention Plans; 504.04.08.A and 504.04.08.B). These forms are appropriate.
I reviewed IEPs for four students served by Buckeye United Schools. During the tour I requested 15 IEPs. The four IEPs, which used Ohio’s standardized form, had students’ and parents’ names redacted. Two were for girls. Three of the four had been written after the November 2009 tour. I cannot say to what extent the four I reviewed are representative of the IEPs in force for William K. Willis School, let alone Buckeye United Schools.

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On the whole, the four IEPs seemed acceptable. They included the relevant contents (driven by the form): dates, transition plans, goals, objectives, measurement statements, etc. Across the

Student Objectives Drawn Directly from IEPs

D. R.

D. will be able to successfully redirect/ refocus negative behaviors through verbal and non-verbal cues successfully 4 out of 5 times.

four IEPs there were nine goals. Each included one goal focused on behavior, and three included academic foci.
The foremost concern I had with

D. R.

D. will apply reading comprehension strategies, including contrasting, recalling, summarizing, making inferences, and drawing correct conclusions 8 our of 10 times.

the IEPs was that the quality of the goals and objectives was often poor. For example, instead of specifying a measurable outcome, some objectives

L. W.

L. will be able to successfully redirect/ refocus negative behaviors through verbal and non-verbal cues successfully 4 out of 5 times.

stated the methods, procedures, or

L. W.

techniques that would be employed in

efforts to help students. Table 2 includes

examples (as typed from the documents)

D. J.

of this problem, selected from the IEPs I

reviewed.

Note the duplicate objectives for D. R. and L. W., a feature which does not

L. will use de-escalation techniques (ie, deep-breathing, counting, journaling, etc.) when frustrated 8 out of 10 times.
She will ask for help needed to pass her classes, and utilize accomodations allowed to her, evidenced by passing grades (at least 60%) in each of her classes for 4 consecutive quarters.
Table 2: Selected objectives from students’ IEPs.

argue for the individualization of the

documents. However, I find it difficult to draw strong conclusions based on a single instance.

Because people differ on what constitutes a well-written objective, it is difficult for me to make a formal recommendation regarding this matter. However, I hope that Ohio will consider initiating a campaign to promote preparation of objectives that more closely approximate the abundant guidance about how to prepare simple, sensible, and useful IEP objectives.12
The Ohio IEP form lists 11 ways of monitoring progress toward annual goals. These methods (and, in parentheses, the number of times each was to be employed) include curriculum based assessment (2), portfolios (0), observations (4), anecdotal records (3), short-cycle assessments (0), performance assessments (3), checklists (4), running records (4), work samples (1), inventories (0), and rubrics (0). Almost certainly, these methods vary in both their inherent rigor and the rigor with which they are applied. From the available data, it is not possible to assess the extent to which Ohio is employing appropriate progress-monitoring procedures.

12 See, for example, http://www.wrightslaw.com/bks/feta/ch12.ieps.pdf, B. D. Bateman & C. M. Herr, Writing Measurable IEP Goals and Objectives (Verona, WS: Attainment), or similar sources.

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7.b. In developing or modifying the IEP, the State shall ensure that: the IEP reﬂects the individualized educational needs of the youth and that services are provided accordingly; each IEP includes documentation of the teamʼs consideration of the youthʼs need for related services and transition planning, and identiﬁes the party responsible for providing such transition services; the studentsʼ educational progress is monitored; teachers are trained on how to monitor progress toward IEP goals and objectives; and teachers understand and use functional behavioral assessment and behavior intervention programs in IEP planning and implementation.
Ohio Department of Education provides a “tool” for local education agencies to use in their work with students with disabilities. It is called “Data Collection Tool for Students with Suspected/Identified Disabilities” and includes fundamental data such as dates by which parts of the IEP process must be or were completed. These data can be reported in Ohio’s Education Management Information System.
I asked teachers whether they had received professional development about goals, objectives, behavior intervention plans, monitoring progress, and other typical aspects of IEPs. They reported that they had received extensive training, but their answers may have referred to the sheer quantity of professional development, not to the specific content.
Ohio provided data documenting the professional development provided under its StARR grant. Although the topics covered in the three-year program, which is predicated on principles promoted by popular author and lecturer Robert J. Marzano, are diverse and relevant to providing educational services, they do not directly address important topics in special education.
Of special concern was the lack of clear, explicit, and systematic procedures for monitoring students’ progress. It appears that professionals in Buckeye United Schools are not receiving adequate professional development in designing systems to monitor student progress. In particular, the IEP forms used by Ohio (and this is probably not just relevant to the Buckeye United Schools) refer to generic and, in my view, inadequate methods for monitoring progress. For each measurable annual goal, there is a checklist of 11 methods for measuring students’ progress toward meeting the goal. None of the IEPs I reviewed included curriculum-based assessment as a means of measuring progress; most referred to subjective and informal methods of assessing progress. Teachers who use systematic methods for monitoring progress have students who have remarkably better outcomes than the students of teachers who do not use such methods.13
Other parts of the training data Ohio provided are more precisely relevant to the provision of appropriate special education. For example, the slides about the “Manifestation Determination
13 See, among others, Fuchs, L. A., & Fuchs, D. (1986). Effects of systematic formative evaluation: A meta-analysis. Exceptional Children, 53, 199-208; and Stecker, P. M., & Fuchs, L. S. (2000). Effecting superior achievement using curriculum-based measurement: The importance of individual progress monitoring. Learning Disabilities Research and Practice, 15, 128-134.

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Process” from a session delivered by Gale F. Kingsley 7 April 2009 show that participants were told important ideas about functional behavioral assessments, behavior intervention plans, and related concepts.
Recommendation 7: Ohio should continue to provide professional development to members of faculty and staff for Buckeye United Schools. Although broad and general programs such as those provided via e-Read Ohio and the Ohio Department of Education Office of Literacy should not be omitted, because the faculty and staff of Buckeye United Schools face special and unique challenges, professional development for them should focus on core and critical matters. Included among those matters should be topics such as preparing behavioral objectives; conducting FBAs; designing and implementing BIPs; systematically, rigorously, and objectively monitoring social-behavioral and academic progress; and similar topics that are related to special education.
8. Vocational Education: The State shall provide appropriate vocational services that are required transition services for disabled youth under the IDEA. A report prepared by R. Linn Davey 14 of the ODYS did not explicitly show results for the
students who receive special education services, but it did document increasing percentages of enrollment in vocational education classes across the facilities maintained by OYDS. It documents, at least, that there are vocational services being provided by Buckeye United Schools. These services are in alignment with the Ohio policies (504.05) regarding provision of career-technical education opportunities.
The first classroom that the administrators at William K. Wills School recommended I see during my tour housed a third-period class on office technology. The class was geared to prepare students for certification (Microsoft Office Specialist). Special education students participated alongside their non-disabled peers. Although there were only five students present during my observation, I understand there were more students enrolled in the class. The classroom was well equipped, the teacher seemed well prepared, and the students appeared appropriately engaged for the most part.
My observation of Ms. M.’s class was encouraging, but it is only a individual case. I cannot say whether the case is representative of all the vocational education services provided in the Buckeye United Schools.
Recommendation 8: Buckeye United Schools should continue its efforts to prepare youth for the world of work, especially programs such as the one I observed at William K. Wills School that help students acquire skills that will be valuable in contemporary work situations.
14 Ohio Department of Education Ofﬁce of Career-Technical Education: Youth Corrections CareerTechnical Program Performance Review, Executive Summary. FY 2008. http://www.ode.state.oh.us/GD/ DocumentManagement/DocumentDownload.aspx?DocumentID=69013.

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9. Forwarding Screening and Assessment Information upon Transfer: The State shall ensure that, when a youth is discharged from the Facilities before the interventions or educational evaluations required in Section III.E.6 above are complete, the Facilities shall forward to the superintendent of the youthʼs receiving school district all information regarding screening and evaluations completed to date, noting what evaluations are yet to be performed. Members of the staff at Scioto told me that IEPs and GED information are consistently
sent to receiving schools when students transition out of Buckeye United Schools. Ohio policies and procedures for ensuring that relevant special education materials (e.g., a student’s IEP) exist (504.07, Educational Records Management).
Although it has other features that seem potentially valuable, the ODYS statement about principles for guiding development of plans for reintegrating youths into their communities upon discharge does not even mention education, let alone prescribe efforts for ensuring that students with disabilities have a clear transition plan for their special education needs.15 That ODYS focuses on youths social-behavioral re-integration is understandable, but it should not do so to the exclusion of their educational needs.
Recommendation 9.1: Ohio should continue to promote rapid and efficient transfer of records between Buckeye United Schools and the schools from which students come and to which students return.
Recommendation 9.2: Ohio should revise its “roadmap” so that it includes consideration of students’ special education plans and needs.
10. Training and Quality Assurance: The State shall design and implement adequate annual training requirements for special education staff. Ohio’s standard operating procedures require annual in-service plans for teachers
(504.02.07). Teachers at William K. Wills School said that they completed extensive professional development courses. During my tour, members of the staff mentioned training, too.
Ohio provided substantial documentation about the staff development it has provided. As noted previously, I found instances of relevant and seemingly valuable staff development activities (e.g., G. F. Kingsley’s session entitled “Manifestation Determination Process”), but the bulk of the documents Ohio provided only referred to general content.
Members of the faculty and staff need to be up to date on important practices in special education. Explicit and systematic training in, for example, using progress-monitoring data to make instructional decisions is critical for provision of special education.
15 The report, DYS Reentry Roadmap: A 25-Point Strategy Toward Restoration, is available from the ODYS Web site at http://www.dys.ohio.gov/DNN/LinkClick.aspx?ﬁleticket=s1ZeMf/hYG4=&tabid=106.

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Recommendation 10: Ohio should ensure that faculty and staff of the Buckeye United Schools receive competency based professional development, as described in Recommendation 7.1.
11. Transition Services: The State shall comply with any IDEA requirements for providing transition assistance. The State shall provide transition assistance to students by providing counseling and concrete information regarding appropriate community resources, and how to pursue post-secondary opinions, re-enroll in school or complete the GED. Transition planning is required for youths receiving special education, beginning no later
than the first IEP to be in effect when the student is 16 years of age. In IDEA,16 “transition services” refers to an integrated set of activities designed for individuals with disabilities that facilitate the student’s change from school to post-school activities. The services should be based on each student’s individual needs and on her strengths, preferences, and interests and provide instruction and other activities that promote such outcomes as employment, post-secondary education, and (as appropriate) adult living competence. The National Secondary Transition Technical Assistance Center provides guidelines for self-monitoring of compliance with IDEA.17 Ohio is required to submit data about its performance in this area.
Members of the staff at Scioto emphasized that there are transition plans for “each student.” They said that monitoring data collected by Ohio (presumably the Department of Education for 2009) showed 100% compliance. The monitoring data (see Table 1) for 2008 show that the data were not reported.
Given that the average age of students in the Buckeye United Schools is greater than 16.8 years of age18 (and presuming that the “average” refers not just to the mean, but also the median), at least half of the students with disabilities should have transition plans in their IEPs. All of the IEPs I reviewed included acceptable transition planning. The ODYS report shows that 306 or about 19% of youths in the facilities in 2008 earned a GED, one of the outcomes that would indicate that youths are benefitting from transition services. During the tour, one of the staff members told me that there had been 249 GEDs and 74 diplomas awarded during the 2008-2009 school year, and I later received a copy of an e-mail message reporting the same counts. However, these data are not disaggregated by special education status, so it is not possible to determine from them whether the ODYS and Buckeye United Schools are helping students with disabilities to achieve such desirable outcomes.
16 See 34 CFR 300.43 (a) and 20 U.S.C. 1401(34)
17 National Secondary Transition Technical Assistance Center (NSTTAC) September, 2006; updated July, 2009
18 See statistics for 2008 from the ODYS Web site: http://www.dys.ohio.gov/dnn/AgencyInformation/ Statistics/tabid/117/Default.aspx

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Recommendation 11: Justice should request that Buckeye United Schools provide, disaggregated by special education status, counts of the number and percentage of students receiving (a) GED and (b) academic diplomas for Buckeye United Schools for each of the past five years. Buckeye United Schools should also provide any available documents that guide the faculty and staff’s provision of transition counseling and services for youths enrolled in the Buckeye United Schools.

General Concerns

As I reported in 2005, I am concerned about the amount of active, effective instruction that the students in the

Class Enrolled Present

Buckeye United Schools receive. The official data that

A

5

5

William K. Wills School provided showed 85-90% attendance, but as I spoke with teachers I often asked how

B

4

2

many students they had on the rolls for the classes I

C

3

2

observed. As shown in Table 2, one of six classes had 100%

D

7

6

attendance. If students are not attending classes, they

probably are not learning the content and skills being taught.

E

3

1

According to data provided by William K. Wills School about attendance for special education and general education

Table 2: Expected and observed attendance

students for the weeks of 7 September, 15 October, and 1

November 2009, students with IEPs miss no more school

(about 12-13% of classes) than their peers in general education. This is still a significant amount

of missed opportunity for education for youths in both groups.

I was encouraged to find that Buckeye United Schools was employing a comprehensive, individualized core curriculum. Although the core curriculum represents an improvement over the situation I observed previously, there is still a need for highly effective remedial instruction for many of the students. During the tour I was told that William K. Wills School was employing the Read 180 reading program, an evidence-based literacy curriculum. Read 180 has generally been found to be an effective remedial program; if Buckeye United Schools is employing it with fidelity, that is a notable improvement.19

Although the core curriculum permits self-paced progress and Read 180 incorporates systematic monitoring of student progress, I did not see evidence of rigorous monitoring of progress toward IEP goals and objectives. Surely, some students have IEP goals and objectives related to social-behavioral problems. I do not know how Buckeye United Schools monitors progress for those outcomes in a systematic, objective fashion. This is a serious concern, as it

19 See two sources of reviews: http://ies.ed.gov/ncee/wwc/reports/adolescent_literacy/read180/index.asp and http://www.fcrr.org/FCRRReports/PDF/READ180Final.pdf.

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Scioto Special Education Page 17 of 18
goes to the heart of the IEP process: Set goals; implement procedures to reach those goals; assess progress; continue or change procedures depending on evidence of progress.
Special education in Buckeye United Schools seems to be hidden within the larger context of special education in Ohio. The preponderance of missing data in the Annual Performance Report for Buckeye United Schools illustrates this observation. The lack of documentation about specific training for special education issues for faculty and staff underscore it. I hope that Ohio will refocus on ensuring provision of free and appropriate special education for the special education students in Buckeye United Schools.

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Scioto Special Education Page 18 of 18

Appendix A: List of DYS Contacts and School Data

Department of Youth Services" 51 N High St Fl 4TH" Columbus, OH 43215" SUPT: Jerry C. McGlone TREAS: Joseph M. Cavinee

IRN: 060988 VEPD: 600 PHONE: (614)728-2489 FAX: (614)728-6074

Indian River (Irjcf) High Scho (7-12)" 2775 Indian River Rd" Massillon, OH 44647" PRIN: Anthony Korzan"

IRN: 067801 PHONE: (330)837-4211 FAX: (330)837-4180" ENROL: 248" TCHR: 15

Louis Bromﬁeld (Mojcf) High S (7-12)" 1012 Odnr Mohican 51" Perrysville, OH 44864" PRIN: James M. Lucas"

IRN: 061069 PHONE: (419)994-4127 FAX: (419)994-5137" ENROL: 94" TCHR: 16

Luther E Ball (Chjcf) High Sch (7-12)" 4321 Green Rd" Highland Hills, OH 44128" PRIN: Gretchen M. Derethik"

IRN: 064436" PHONE: (216)464-8200 FAX: (216)464-3540" ENROL: 204" TCHR: 32

Ralph C Starkey (Cjcf) High Sc (7-12)" 640 Island Rd PO Box 598" Circleville, OH 43113" PRIN: Robert T. McQuate

IRN: 095646 PHONE: (740)477-2500 FAX: N/A ENROL: 100" TCHR: 25

Scioto River (Sjcf) High School (7-12)" 5993 Home Rd" Delaware, OH 43015" PRIN: Joseph W. Becker

IRN: 095653 PHONE: (740)881-3250 FAX: (740)881-3518" ENROL: 134" TCHR: 7

Tecumseh (Orvjcf) High School (7-12)" 4696 Gallia Pike" Franklin Furnace , OH 45629" PRIN: Patrick W. Buchanan

IRN: 123422 PHONE: (740)354-7000 FAX: (740)354-7033" ENROL: 253" TCHR: 20

William K Willis (Sjcf) High S (7-12)" 5993 Home Rd" Delaware, OH 43015" PRIN: Joseph W. Becker

IRN: 033845

PHONE: (740)881-3250 FAX: (740)881-1324"

ENROL: 46"

TCHR: 17

 Case: 2:08-cv-00475-ALM-MRA Doc #: 72-1 Filed: 02/08/11 Page: 1 of 57 PAGEID #: 879

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, )

Plaintiff,

)

v.

) CIVIL ACTION NO:

) 2:08-CV-475-ALM

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

SECOND COMPLIANCE REPORT
Pursuant to provision V.H. of the Consent Order in U.S. v. Ohio, 2:08-CV475, the United States, as Monitor, submits its second report of its assessment of the State of Ohio’s (“State”) compliance with the June 4, 2008 Consent Order. For each substantive provision of the Consent Order, a recitation of the provision is provided, followed by a narrative describing the United States’ analysis of the State’s compliance efforts, and a compliance rating. Where possible, the United States provides recommendations to assist the State attain substantial compliance with a particular provision.
This Compliance Report represents the United States’ assessment of the State’s compliance with provisions A.1-7, C.1-10, D.1-3, E.1-11, F.1-2, and G. 1-2, which relate to Ohio Department of Youth Services (“ODYS”) policies, procedures, and practices governing the protection of youth from harm, general medical care, grievances, special education, programming and documentation for youth at Scioto Juvenile Correctional Facility (“Scioto”). Provisions B.1-B.18, which pertain to mental health, will be covered in an addendum to this compliance report.1 The

1 The mental health provision will be addressed through a separate addendum due in part to a delay in receiving necessary documentation from the State. The addendum regarding the mental health provision will be accompanied by an expert report from Dr. Daphne Glindmeyer.

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Second Compliance Report is organized in this order and follows the structure of the Consent Order.
The United States’ assessment is based upon document review (including, but not limited to, policies, procedures, training documents, youth records, incident reports, and grievances), expert reports from Drs. Kelly Dedel and Michelle StaplesHorne, youth interviews, and two on-site compliance tours in October and November 2010. We have attached to this Compliance Report the expert reports2 of Drs. Dedel and Staples-Horne. The United States intends to provide a third compliance report regarding the status of the State’s compliance with all provisions following its upcoming compliance tour on February 22-24, 2011. Consistent with the U.S. v Ohio Consent Order, the United States provided the State with a draft version of this Compliance Report and expert reports two weeks3 prior to filing with the Court.
EXECUTIVE SUMMARY OF COMPLIANCE RATINGS We are pleased to report that of the 35 provisions reviewed4 in this Compliance Report, the State has achieved substantial compliance5 with 60 % (21
2 Dr. Dedel prepared her second protection from harm report (“Dedel Second PFH Report”) and her first special education report (“Dedel First SPED Report”) which are labeled as Attachments A and B, respectively. Dr. Staples-Horne prepared her First General Medical Care Report (“Staples-Horne First Medical Report”) labeled as Attachment C.
3 On January 20, 2011, the United States sent the State a Draft version of the compliance report and expert reports. On February 2, 2011, the State requested an extension until the end of the business day on February 7, 2011 to comment. The United States agreed to provide until the end of the business day on February 4, 2011. The United States received the State’s comments on February 4, 2011, reviewed and considered the State’s comments prior to filing this second compliance report.
4 The mental health section of the U.S. v Ohio Consent Order contains 18 provisions. The addendum to this compliance report for mental health will address the 18 provisions.
2

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provisions), partial compliance with 34.28% (12 provisions), and beginning compliance with 5.71% (two provisions). Overall, the State has continued to demonstrate a strong effort to improving the safety and well being of youth held at Scioto. Specifically, the State has made the most progress in the area of grievances and has successfully maintained a rating of substantial compliance with 100% of those provisions. The State also has improved its rating in protection from harm (“PFH”) provisions. Presently, the State is in substantial compliance with 57% of the PFH provisions and in partial compliance with the remaining 43%. Previously, the State was in substantial compliance with only 42% of the PFH provisions. In the area of Special Education (“SPED”), the State has reached substantial compliance with 63% of the provisions and is in partial compliance with the remaining 37%. This is also an improvement from September 2010, when the State was rated as being in substantial compliance with no provisions and in partial compliance with 63%. Since our September 2010 compliance report, the State remains in partial compliance with all programming provisions. We note that the State’s general medical care provisions were not rated in September 2010. Based on our most recent review, the State has achieved substantial compliance with 70% of the general medical care provisions and is in partial compliance with the remaining 30%.
Although achieving substantial compliance with some provisions in the Consent Order will require time and effort, it is important to recognize and commend the State’s progress and significant efforts to date in working towards achieving substantial compliance with all the provisions in the Consent Order.
5 “Substantial Compliance” indicates that the State has met or achieved all of the components of a particular provision. “Partial compliance” indicates that the State has made notable progress in achieving compliance with the key components of the provision, but substantial work remains. Beginning compliance” means that the State has made notable progress in achieving compliance with a few, but less than half, of the key components of the provision. “Non compliance” means that State has made no notable progress in achieving compliance on any of the key components of the provision.
3

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COMPLIANCE ASSESSMENTS AND RATINGS
I. PROTECTION FROM HARM A.1 GENERAL PROTECTION FROM HARM
The State shall, at all times, provide youth in the facilities with safe living conditions. As part of this requirement, the State shall take appropriate measures to ensure that youth are protected from abuse and neglect, use of excessive force, undue seclusion, undue restraint, and over-familiarization. (See Consent Order III.A.1) In assessing this provision, we reviewed the State’s self-assessment, the Superintendent’s monthly reports (January through October 2010), ODYS average population by facility and month for 2010, and interviewed youth. Based on our review, we were impressed with the level of detail and effort reflected in the State’s assessments regarding youth violence, use of restraint, use of seclusion and allegations of child abuse. In the future, we recommend that the State also focus on interpreting the data it has collected to determine trends and root causes.
We base this recommendation in part on the fact that there was an increase in youth violence at Scioto, yet a decrease in such violence at other ODYS facilities, and it appeared that the State was somewhat unaware that the Scioto trend was contrary to the direction of the ODYS facilities as a whole. We agree with Dr. Dedel’s suggestion that the State should discern the underlying causes of the increase in youth violence and enact specific strategies designed to address conditions that may provide the opportunity for violence. (See Dedel Second PFH Report at 4). We further note and agree with Dr. Dedel’s comments that, without addressing the violence issue, it is unlikely that the State will be able to continue to decrease its use of restraint and seclusion at Scioto. (See Dedel Second PFH Report at 4).
We note that we raised our concerns in this area through a letter dated November 22, 2010 to the State. On December 13, 2010, the State informed us that the State had commenced a self-audit to determine possible causes for the increase
4

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in violence. The State noted that it had begun responding to this issue shortly after it was raised by Dr. Dedel during her exit briefing on November 5, 2010. We commend the State on its prompt response and look forward to learning what the State has found as a result of its audit.
As discussed below in the remaining PFH provisions, A.2-A.7, we believe that the State has made great progress in the area of protection from harm. Notably, while there was an increase in the rate of youth violence, the use of restraint and seclusion appeared to be appropriately tempered. We were also encouraged that while the use of seclusion has increased, it did so at a slower pace than the increase in youth violence. This suggests that the alternatives ODYS has to seclusion are regularly being employed as disciplinary measures. (See Dedel Second PFH report at 4). Additionally, the State has maintained a high rate of training in behavior managment—both annual and pre-service—for its direct care workers.
Nevertheless, since provision A.1, “General Protection From Harm,” is composed of the subject areas in provisions A.2-A.7 (Use of Force, Seclusion, Restraint, Investigation of Serious Incidents, Staff training, and Employment Practices), compliance in A.1 is dependent upon the State’s achievement of substantial compliance with all of these provisions In this regard, of the remaining six provisions under PFH, the State is in substantial compliance with four and only two remain in partial compliance: Seclusion and Investigation of Serious Incidents. Both provisions are discussed below. We commend the State on its progress thus far.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
In addition to the recommendations regarding provisions A.2-A.7, discussed below, in its next self-assessment the State should include facility-level and aggregate data focusing on the findings from the State’s self-audit regarding the
5

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increase in youth violence and a discussion of how the State intends to respond based on its audit findings.
A.2 USE OF FORCE The State shall develop and implement comprehensive policies, procedures, and practices limiting use of force on youth to situations where it is objectively reasonable and necessary. Staff shall be required to adequately and promptly document and report all uses of force. (See Consent Order III.A.2) In our assessment of this provision, we reviewed the State’s self-assessment,
Superintendent monthly reports for January through October 2010, incident reports and interviewed youth and staff. Consistent with our September 2010 Compliance Report, the State is in substantial compliance with this provision. We commend the State for maintaining its compliance rating.
Based on our review, we determined that the State’s frequency of training in Use of Force (“UOF”) continues to exceed that of generally accepted practices and relevant policies and procedures continue to meet the language of provision A2. We also found that the State undertook various efforts to ensure that UOF occurrences were promptly and completely documented. Our expert reviewed the 10 most recent (to our November 2010 tour) incident reports involving UOF and found that the quality of the documentation has improved. During our November 2010 on-site tour we also learned that the State recently appointed a Facility Intervention Administrator (“FIA”) to conduct internal reviews of all UOF incidents. The FIA determines whether the documentation meets ODYS policy requirements, whether staff require additional coaching or training regarding documentation, and whether the incident should be referred for investigation. Further, the FIA reviews are of high quality—finding gaps in the narratives and requesting clarification or further information—which may be one cause for the improved UOF documentation. (See Dedel Second PFH Report at 7). Separately, each incident is also reviewed by the Operations Administrator and the Deputy for Direct Services. Ten percent of the UOF incidents are also reviewed by the Superintendent. This activity
6

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unquestionably reflects a serious and thoughtful effort to ensure that all incidents of UOF on youth are limited to situations in which it is objectively reasonable and necessary. The State’s accomplishments in this area are of fundamental importance to the safety of youth and staff and reflect a wholesale change from when our investigation of Scioto began.
Although the State is in substantial compliance with this provision, we agree with Dr. Dedel’s suggestion that, in its next self-assessment, the State should describe the trends and interpret the meaning of UOF incidents at Scioto. We believe that such analysis could be helpful to the State in its own long-term goal of sustaining all the improvements it has accomplished thus far. (See Dedel Second PFH Report at 8-9).
Compliance Rating: Substantial Compliance
A.3 SECLUSION
The State shall develop and implement policies, procedures and practices so that staff use seclusion only in accordance with policy and in an appropriate manner and so that staff document fully the use and administrative review of any imposition of seclusion, including the placing of youth in their rooms outside normal sleeping hours. (See Consent Order III.A.3) In our assessment of this provision, we reviewed the State’s self-assessment, ODYS policies and procedures, 50 consequence logs, five random Individualized Response to Acts of Violence6 (“IRAV”) assessment forms, seclusion data, monitoring logs for three youths, facility-level investigations and interviewed staff and youth. Based on our review, we found that the State demonstrated marked improvement with regard to meeting the language in provision A.3 and has improved from a rating of beginning compliance to partial compliance. The basis for
6 IRAV, the State’s new program which provides an array of individualized sanctions for youth violence, is discussed in more detail in the United States’ September 2010 Compliance Report (Dkt. # 61 at 8-9).
7

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the new rating is that the rates, duration, and causes for all types of seclusion (disciplinary, prehearing confinement, and regular seclusion) have been significantly reduced. The State also demonstrated that it has benefited greatly from its shift to non-confinement sanctions in response to non-violent misconduct. Further, the State has made a commitment to hold intervention hearings as quickly as possible in order to address a youth’s behavior promptly. Further, we found that the research used by ODYS to develop IRAV policies and procedures is methodologically sound. Accordingly, we no longer found evidence of long periods of seclusion as we did during our April 2010 on-site compliance tour.7
The State’s success with this provision is undercut, however, because we found that some third shift staff are inconsistently monitoring youth on seclusion. As we noted in our November 22, 2010 letter to the State, during the tour we received complaints from youth alleging that staff on the third shift were not conducting their nightly watches as required. In fact, when we interviewed youth in the female mental health cottage, it was alleged that, just the night before (Thursday, November 4, 2010), the third shift staff had watched television instead of conducting their watch. We then asked Dr. Dedel to review the surveillance videos, and she was able to confirm the allegations. We also heard similar complaints about third shift from other units. Our additional concern is that some third shift staff likely are falsifying documentation to wrongly indicate that they are conducting monitoring watches that they actually are not performing. We raised similar concerns in our September 2010 Compliance Report, indicating that this is a long standing problem at Scioto.
As Dr. Dedel discusses in her report, anytime that a youth is placed behind a closed door, the risk of self harm increases. A youth who is intent on harming himself will keep track of when staff conduct their checks and act as soon as the
7 See United States’ September 2010 Compliance Report (Dkt. # 61 at 9). 8

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staff member moves on. For this reason, long gaps between monitoring checks and falsification of monitoring logs is of great concern and must be addressed immediately. (See Dedel Second PFH Report at 13-14). During an exit briefing on November 5, 2010, Dr. Dedel spoke about this concern.
On December 13, 2010, the State and ODYS informed us that the State had recently revised its quality assurance procedure, and the State now randomly selects two units each week to verify that staff are conducting the required safety checks. Previously, the State selected one unit each week. It is our understanding from the State’s February 4, 2011, comments to the draft compliance report that the State now shuts off the televisions in all units at 11:00 p.m. While we cannot verify this assertion and other steps that the State has informally indicated it is taking, at this point, we will do so during our next compliance tour in February 2011. We appreciate the State’s prompt action in response to this problem and notification to the United States about its response.
From our walking tour of the units, we saw that the video cameras are clearly visible throughout the units; staff are, or certainly should be, aware of their presence. Nevertheless, Dr. Dedel’s video review made clear that some staff have such little regard for their duties that they will watch television in front of the video cameras while on duty. We are concerned about this open dereliction of duty because such behavior by staff often signals a deeper problem—that staff believe they will not be held accountable by their supervisors. We are also concerned because we and the S.H. monitoring team have identified video evidence of similar derelictions at Scioto since 2009. To be clear, the State improved its practice since our last Compliance Report and accordingly is now rated to be in partial compliance, but this is an area that obviously warrants continued attention.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
9

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As discussed above, in order to reach substantial compliance, the State must address the issues involving third shift staff failing to monitor youth in seclusion. We look forward to reviewing this provision during our next on-site compliance tour. A.4 RESTRAINT
The State shall develop and implement policies, procedures and practices so that only safe methods of restraint are used at the facility and only in those circumstances necessary for safety and security and, to the extent possible, when less restrictive means have been properly, but unsuccessfully, attempted or with respect to therapeutic restraints pursuant to a medical order to protect the health of the youth. (See Consent Order III.A.4) In our assessment of this provision, we reviewed the State’s self-assessment, 10 UOF incident reports, six facility-level investigations involving restraints, and interviewed youth. Based on our review, we find that the State has further strengthened its efforts to ensure that staff are well-trained in safe methods of restraint and that the training is resulting in positive results. By early November 2010, 85% of the Scioto direct care staff had received all the required Managing Youth Resistance (“MYR”) training.8 The MYR training is now required once a quarter rather than annually. Dr. Dedel reviewed 10 UOF incident reports previously reviewed by the State’s internal auditing process and found that the reviews were appropriate. (See Dedel Second PFH Report at 15). Lastly, when we interviewed youth, they corroborated that staff attempt to break up fights between youth first using verbal commands and if that fails, they intervene physically. The methods described by the youth appeared to be consistent with the MYR curriculum. We note that the ODYS policies and procedures for the use of restraint were in substantial compliance during our last review and remain the same. Accordingly, the State continues to be in substantial compliance with this provision. We commend the State on its continued success under this provision.
Compliance Rating: Substantial Compliance
8 The State reported that by the end of 2010 all staff were scheduled to have completed the required training.
10

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A.5 INVESTIGATION OF SERIOUS INCIDENTS The State shall develop and implement policies, procedures and practices so that appropriate investigations are conducted of all incidents of: use of force; staff-on-youth violence; serious youth-on-youth violence; inappropriate staff relationships with youth; sexual misconduct between youth; and abusive institutional practices. Investigations shall be conducted by persons who do not have direct or immediate indirect responsibility for the employee being investigated. (See Consent Order II.A.5)
In our assessment of this provision, we reviewed the State’s self-assessment, investigations by the Chief Inspector’s Office (“CIO”), facility level investigations, policies and procedures, child abuse reports, and interviewed youth. Based on our review, we determined that the State remains in partial compliance with this provision. Consistent with our September 2010 Compliance Report, the State’s policies, procedures, and investigations manual sufficiently address the investigatory process and timing and meet the requirements of provision A.5. Separately, we found that most investigations conducted by the CIO are of high quality and the facility-level investigations have improved since September 2010.
In our September 2010 Compliance Report we noted that there were some deficiencies in the facility level investigations. During our most recent on-site tours, we found that the quality of most investigations had improved. We did find that three of the six UOF investigations were not completed within the prescribed 14 day timeline. According to the investigation tracking log, extensions were requested in the completion of three investigations. While it appears that the extensions granted were most likely appropriate, we strongly recommend that, in the State’s next selfassessment regarding this provision, the State discuss the reasons for extensions (if any) granted to investigations. The State’s self-assessment did not detail the rationale or basis for the extensions.
11

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Notwithstanding these findings, we take this opportunity to discuss our concerns regarding a particular series of allegations by female youth and how they were handled at the facility level, and the CIO investigation of that incident. During our November 2010 on-site compliance tour, we spoke with various female youth, and some mentioned two direct care workers who allegedly had either attempted to touch a female youth inappropriately or had inappropriate conversations of a sexual nature with female youth. On November 9, 2010, following the exit briefing from Dr. Dedel, the United States brought these allegations to the attention of the State and its counsel. The United States memorialized its concerns to the State through a letter dated November 22, 2010. On December 13, 2010, the State informed us that the CIO had concluded its investigation (Case Number: 1001100102) and subsequently provided the United States with a copy of the investigation. (See Attachment D). 9 Below, we provide our concerns regarding the CIO investigation and the initial handling of the allegations by Scioto.
CIO Investigation Report We appreciate the CIO’s prompt investigation, including interviewing
numerous staff and youth. However, given the serious nature of the allegations, we identified three concerns with the CIO investigation. Those concerns are: (1) investigators used a line of questioning that inappropriately focused on confidential communications between youth and the United States, (2) investigators failed to interview or follow up with all relevant individuals, and (3) investigators failed to probe and adequately analyze certain facts. Each of these shortcomings is troubling. We discuss them in more detail below.
9 Attachment D is submitted to the Court under seal, as the document contains personal identifying information about the youth and the direct care workers.
12

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First, the CIO’s investigation report states that the investigator consistently and specifically questioned all youth about what they had “reported to the DOJ regarding”10 the two direct care workers. The United States is entitled to confidential communication with youth pursuant to the Consent Decree. (VI.6). When Department of Justice attorneys interview youth about their concerns, we assure them that any information they reveal is confidential, unless maintaining confidentiality would jeopardize an individual’s safety or facility security. In keeping with this promise to youth to maintain confidentiality, section attorneys interviewed all female youth in the unit separately and in a private setting. Further, the section attorneys did not disclose the names of the youth and only revealed the general nature of the allegations—touching (hug) and inappropriate conversations of a sexual nature—to the State. The line of questioning followed by the CIO investigator is improper and will most likely have a chilling effect upon youth in revealing concerns to the United States in the future, or perhaps to any individuals in positions of authority. We find this lack of judgment troubling, particularly given the sensitive nature of allegations of sexual misconduct. We advise the State to inform all investigators (CIO and facility-level) to refrain from making a communication between the United States and youth at the Scioto the focus for questions when interviewing youth.
Second, the CIO investigation notes that a facility psychologist reportedly informed a facility operations staff person that a female youth was feeling uncomfortable with a direct care worker due to his alleged conversation of a sexual nature with another youth. (See CIO Investigation at 17). Despite identifying the operations individual in the report, the CIO investigator never interviewed the operations individual. We find this odd, since that person could help explain whether administration knew about problems with that particular staff member
10 This line of questioning to youth is consistent throughout the CIO investigative report. (See CIO Investigation at 3,4,5,7, and 8).
13

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and to what extent. This failure is also troubling since the CIO investigation determined that one female direct care staff worker stated that she switched shifts with a male staff member—the same worker who allegedly made sexually inappropriate comments to a youth—to “make management happy.” (See CIO Investigation at 19). The fact that the CIO investigator uncovered this commentary is evidence that the CIO investigator did more than a superficial investigation. However, the CIO investigator failed to probe further about what the comment meant or seek corroborating statements from other workers about what was known about the male direct care worker.
Third, the CIO investigation’s recounting of the youths’ allegations differ somewhat from the information that the youth provided to the United States in a manner indicating that either the youth reported the context of the events differently or the CIO investigators characterized it more favorably from the male direct staff worker’s perspective. We do not opine on the latter possibility’s likelihood, but this inconsistency compels us to emphasize that CIO investigators must ensure they have captured facts accurately.
We are encouraged by the quarterly audits performed by the CIO and believe that they are instrumental in improving the quality of investigations from the CIO’s office. Based on our comments above regarding investigation #1001100102, we strongly suggest the CIO consider reminding its investigators to always interview youth in non intimidating manner, ensure that all noted individuals are interviewed and all leads are probed, and ensure that all narratives are consistent with the witnesses’ statements.
Facility level investigations
14

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While the State’s policies and procedures have met the requirements of provision A5, it appears that its practices are not yet compliant with this provision. In our review of the CIO’s investigation into incident # 1001100102, we found that the facility missed various opportunities to address the allegations in May 2010, when the youth alleged the incidents occurred. In particular, we found, based on the CIO’s investigation, that there may have been some carelessness or confusion at the facility level as to what should have been done. We are troubled by the following set of facts noted in the CIO investigation:
• The female direct care staff worker who first spoke with the youth informed the unit manager and the psychologist, and asked the girls to write a statement, yet reportedly, the allegations were never forwarded to the superintendant. (CIO Investigation at 18);
• The same female care worker who attempted to draw attention to the matter noted that she later switched shifts with the male staff worker to “make management happy.” Such a statement implies that management may have known there were problems with the male staff member and failed to act. (CIO Investigation at 19);
• The psychologist states that she may have received a statement from the youth, but now cannot locate it, has no comment in her case notes, does not remember whom she spoke with in operations, and did not follow up (CIO Investigation at 16-17);
• When the unit manager was asked about whether a youth having photos of staff was proper, he answered that “if the photo of the staff was taken in the facility and given to the youth by the individual who took the picture than [sic] that would be ok.” (CIO Investigation at 15);
• When interviewed, the same unit manager said that when two youths told him they did not want a direct care worker on their unit because he was a “pervert,” the unit manager asked for statements from each youth, but received none and
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apparently did not follow up. The unit manager stated that he did not know if any statement were turned into operations. (CIO investigation at 15); and • The psychologist claims that she told the unit manager and a social worker about a youth reporting that the direct care worker engaged in a sexual conversation with another youth, yet nothing was logged into the facility’s reporting system (CIO investigation page 17).
During our December 13, 2010, conversation with the State, the Chief Inspector aptly characterized the loss of the youth’s statement as the facility having “dropped the ball” on this matter. The United States agrees. Ultimately, it appears that, but for the United States presenting the allegations to the State’s attention, the allegations of sexual misconduct by direct care workers might never have been investigated. We believe that the Superintendent at Scioto is dedicated to the youth in her care. The Superintendent, however, is one individual and must depend on her staff to provide her the necessary information for her to make an informed decision. At least in this instance, there appears to have been a serious breakdown in communication at Scioto. We note that, pursuant to ODYS procedures, the facility level investigation was due on January 9, 2011, which is 30 days from the date of the CIO investigation, December 9, 2010. We look forward to reviewing the findings of the facility-level investigation.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
In addition to our recommendations above about CIO level investigations, we recommend that the State regularly audit facility level investigations for completeness. Further, the State should take measures to remind its staff of the importance of relaying serious allegations to facility operations, whether these allegations are conveyed by youth orally or in writing.
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A.6 STAFF TRAINING IN BEHAVIOR MANAGEMENT, DE-ESCALATION MANAGEMENT, DE-ESCALATION AND CRISIS INTERVENTION
The facilities shall train all staff in behavior management, de-escalation techniques, appropriate communication with youth and crisis intervention before staff may work in direct contact with youth. (See Consent Order III.A.6) In order to assess the provision, we reviewed the State’s self-assessment and the relevant policy. Based on our review of these documents, we found that the State continues to be in substantial compliance with this provision. Consistent with our September 2010 Compliance Report, the State’s training and development program in this area exceeds generally accepted practice. Additionally, based on a review of training documents, we found that 100% of the new Scioto staff have completed the required training and passed all competency based assessments. Further, veteran staff all received, and most exceeded, the annual 40 hours of inservice training. In our September 2010 Compliance Report we noted that we would assess the training that staff had received with regard to the Strength Based Behavior Modification System (“SBBMS”) during our October and November 2010 compliance tours. We are pleased to report that we found that 93% of the Scioto staff received the SBBMS training as of November 2010. We commend the State on its commitment to training.
Compliance Rating: Substantial Compliance
A.7 EMPLOYMENT PRACTICES
The State shall use reasonable measures, including background checks and criminal records checks, to determine applicants’ fitness to work in a juvenile facility prior to hiring employees for positions at the facility. (See Consent Order III.A.7) In our assessment of this provision, we reviewed the State’s self-assessment, the relevant policies and procedures, and documentation created by the facility to track its background checks of potential employees. Pursuant to the relevant procedure, if a candidate is being recommended for employment after completing
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the screening and interview procedures, that candidate is required to pass a criminal background check prior to being employed. Candidates with various serious offenses are excluded from employment, while those with certain less serious offenses may be eligible pursuant to other requirements. In the last 21 months, prior to our November 2010 on-site tour, Scioto hired 18 new employees. All employees passed their background check and did not have any criminal records for any offenses that would bar their employment according to ODYS regulations. Consistent with our September 2010 Compliance Report, the State has maintained its substantial compliance rating with this provision. We commend the State on the proper screening practices of prospective employees.
Compliance Rating: Substantial Compliance
II. GENERAL MEDICAL CARE Juveniles in the custody of state correctional facilities have a due process
right to adequate medical care. In order to assess the General Medical Care provisions, we reviewed the State’s self-assessment, relevant policies and procedures, staffing schedules, health care staff resumes and curriculum vitas, staff training curricula, the health records of 18 youth, and interviewed youth during our October and November 2010 tours. We have attached the findings of our subject matter expert, Dr. Michelle Staples-Horne, to this Compliance Report. (See Staples-Horne First Medical Report at Attachment C).
C.1 GENERALLY The Facilities shall ensure that the individuals they serve receive routine, preventive, and emergency medical and dental care consistent with current, generally accepted professional standards. The Facilities shall ensure that individuals with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care. We are pleased to report that the State provides quality medical care to the
youth at Scioto. In particular, the State provides youth with a thorough intake
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screening process, unhindered access to medical services and appropriate management of chronic illnesses. However, the State will need to improve certain aspects of its medical care services in order to reach substantial compliance with all of the General Medical Care provisions of the Consent Order. Specifically, the State must significantly improve the quality of dental record-keeping and ensure that youth receive restorative dental services in a timely manner. In addition, the State must expand health care staff’s access to youths’ complete health record. Our recommendations for reaching substantial compliance with the Health Records and Dental Care provisions are discussed more fully on pages 22 and 30 of this Compliance Report, respectively.
The ODYS medical policies and procedures meet the American Correctional Association (“ACA”) and the National Commission on Correctional Health Care (“NCCHC”) standards for providing health care to youth housed in juvenile facilities. According to the staffing schedules, Scioto has two contract primary care physicians, four contract obstetrics/gynecology physicians, two contract psychiatrists, one certified midwife, twelve Registered Nurses (“RNs”), including the Health Planning Administrator, two Licensed Nurse Practitioners (“LPNs”), one phlebotomist, one dentist, one dental assistant and one dental hygienist. The contract physicians are Pediatrics and Family Medicine Board Certified to provide primary care and OB/GYN Board Certified to provide services to female youth. The medical staff possesses the qualifications necessary to provide the appropriate level of medical care. The average length of stay for males is 226 days and for females is 46 days. Based on the average length of stay, the average daily population, the nursing staffing schedule provided, and evidence of care documented in the youth medical records, the medical staffing at Scioto is appropriate and adequate.
Youth health records demonstrate that the State is generally providing youth with adequate medical care that is consistent with current professional standards, including routine, preventative and emergency care. Youth health records reflect routine care through a thorough and consistent intake screening process, which includes initial medical, dental, and mental health assessments. At least two youth
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health records contained documentation of emergency transport and care at Berger and Grady Memorial Hospitals. Youth health education was also heavily documented in the health records. Examples included materials provided to youth on their chronic medical conditions, vaccine information, information regarding medication side effects, and dental hygiene instructions.
In general, youth with medical problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care. For example, the State is ensuring that youth have access to health services through an unimpeded sick call process. The State’s sick call process is discussed more fully in section C.5 (“Access to Health Services”). Youth with injuries – whether self-inflicted or otherwise – are being assessed by nurses utilizing a Youth Injury and Assessment Form. This form is also used to document the medical conditions of youth involved in physical response and use of restraints by facility staff. Photographs of youth injuries are included in the health record. Nurses also see and assess youth in seclusion.
Chronic diseases are monitored and addressed appropriately according to community accepted practices. Youth receive appropriate diagnostic services, such as laboratory and radiology, in a timely manner. Preventative services are reflected by immunization administration updates, including influenza vaccination and dental prophylaxis. The State provides comprehensive health services specific to females, including complete gynecological examinations, Pap smears, Gardasil immunizations against human papillomavirus (“HPV”), pregnancy testing and care and family planning. The State has made commendable progress in the area of medical services, and we look forward to seeing continued advances in these areas.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
Because C.1 requires the State to provide dental care consistent with current, generally accepted professional standards, the State cannot reach substantial
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compliance with provision C.1 until it is in substantial compliance with provision C.7 (“Dental Care”). In addition, we suggest that the State provide regular training to all health care staff to ensure that they are aware of the current accepted professional standards of care. The training the State currently provides to health care staff includes CPR/first aid, universal precautions, emergency response, strength based behavior, youth conduct, release authority, self injury, intervention verbal strategies, structured programming, and psychiatrist nurse training. The NCCHC standard Y-C-03 recommends that health care staff attend in-service programs or conferences focusing on topics related to correctional health care. Although the curriculum provided by the State is appropriate and adequate to address the general care of juveniles confined at Scioto, few programs are specifically geared towards training health care staff. Moreover, the State did not submit any documentation of health care provider continuing education for review. We encourage the State to provide presentations and trainings on the special health needs of adolescents as periodic in-service training. The State should include documentation of these trainings in the employee records at the facility.
Finally, ODYS health related policies and procedures should be reviewed at least annually and updated as needed. Medical, mental health and dental staff should be involved in the process, as well as representatives from administration and security. While ODYS Policy #403.08, “Section VI Monitoring,” requires that ongoing reviews be conducted by the designated Interdisciplinary Team on a quarterly basis as a part of the Department’s Continuous Quality Improvement (“CQI”) process, the only evidence we received indicating that the CQI is occurring is a roster of medical staff who received Quality Improvement training on May 21, 2010. The goal of CQI is to achieve changes in practice that can improve patient outcome. The NCCHC 2004 Standards for Health Services in Juvenile Detention and Confinement Facilities provide guidance in the development of a CQI program. Although a quality assurance component was not included in the Consent Order’s requirements, we note that it is an essential part of any medical program that aims for continuous quality improvement. Including a CQI program through a
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structured format will assist the State maintain its medical program in substantial compliance with this provision.
C.2 HEALTH RECORDS
The State shall develop and implement policies, procedures, and practices to ensure that, consistent with state and Federal law, at a minimum, the juvenile courts in the State, all juvenile detention facilities, and all placement settings from which youth are committed shall timely forward to Scioto, or to the facility of placement (if the records arrive after the youth has been placed), all pertinent youth records regarding medical and mental health care. The Facilities shall develop and implement policies, procedures, and practices to ensure that health care staff, including mental health care staff, have access to documents that are relevant to the care and treatment of the youth. In order to assess this provision, we reviewed the relevant policies and procedures,11 the State’s self-assessment, and the health records of 18 youth. In general, the State’s policies, procedures and practices related to the transfer of records to and from other facilities and institutions demonstrate a commitment to continuity of care for Scioto’s youth. The policies and procedures adequately address the confidentiality of health records, delineate the required components of each health record, and explain the records transfer process. The State’s practice is consistent with its policies and procedures. Specifically, youth health records are arranged according to the policy, and the large majority of the records contain documentation consistent with the records transfer process. In addition, the records contain information from outside consultations and discharge summaries for health care services provided after release from the facility. Health information regarding current medications and community provider appointments are appropriately faxed to the relevant persons at discharge. A few
11The relevant policies for this provision are Policy #403.05, “Health Records and Confidentiality,” and SOP #403.05.01, “Medical Records and Documentation.” The policies and procedures were updated on March 31, 2010.
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health records were missing health information from the transferring juvenile detention center, court, or other placement. However, these youth may be direct admissions to the facility. In all cases, medical staff conducted health assessments on the day of admission.
Although we are pleased with the State’s records transfer process, we are concerned that the State has not yet developed and implemented policies, procedures, and practices to ensure that all health care staff at the facility have access to documents relevant to the care and treatment of the youth. Specifically, youth health records contain medical and psychiatric records, but do not include any psychological records. The State’s self-assessment appears to confirm this finding. According to the self-assessment for this provision, nurses, physicians and psychiatrists have access to the youth’s full medical record, but psychology staff only have access to transcribed psychiatric reports via an online database. Likewise, medical and psychiatric staff cannot access psychology records in the health records.
When the United States assessed the State’s medical programs in 2007, we determined that the State’s health records were inadequate because they did not contain a problem list identifying all active health problems.12 The State now includes a medical problem list in each health record, ensuring that health care staff can easily and quickly identify a youth’s medical concerns. However, these lists only include medical diagnoses. The State should include all mental health diagnoses on the problems list. In addition, although allergies were consistently noted within the health record, the State should also note allergies prominently on the front cover of youth health records. Such a practice is consistent with generally accepted standards.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
12 See United States’ May 9, 2007 Findings Letter at 8. 23

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We recommend that the State begin including both medical and mental health diagnoses on problem lists and continue moving towards a system that will combine all health records, including psychology records. The development of an electronic health record would improve the capability of sharing critical health information by giving health record access to medical, dental and mental health staff simultaneously. In consideration of moving toward an electronic format, the State should also consider linking health records transferred from detention centers and other outside providers. To the extent privacy considerations and compliance with the Federal Health Information Portability and Accountability Act (HIPAA) limit the sharing of health records, the State can restrict the access of certain health care staff through programming and password protection. The Unites States can make Dr. Staples-Horne available via conference call to provide technical assistance.
C.3 CONFIDENTIAL HEALTH CARE The Facilities shall provide health care and assessment in a setting that maintains health care confidentiality, by placing non-medical staff out of line of sight and hearing of the health care assessment or treatment, except in circumstances where documented safety considerations posed by a particular youth require enhanced, non-medical supervision. In order to assess this provision, we reviewed the relevant policy,13 the
State’s self-assessment, the health records of 18 youth, and interviewed youth. Youth consistently reported that all visits with medical staff were conducted confidentially. Specifically, youth reported that correctional staff is not within earshot during health care treatment and assessment. If youth are receiving an examination that requires them to undress, the door to the exam room is closed and non-medical staff are out of the line of sight. The State’s self-assessment confirms that healthcare encounters are conducted in an exam room that contains a curtain and a door for privacy. One youth did mention that she was able to read other
13The relevant policy for this provision is Policy #403.04 “Medical Facilities, Equipment and Supplies.”
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youths’ health charts and their reasons for requesting sick calls. However, it appears that this was an isolated incident.
Compliance Rating: Substantial Compliance
While the State’s practice conforms to the requirements of this provision, the current policy only requires the State to maintain an examination room that allows for the private examination of youth at the medical clinic. It does not provide any specific guidance regarding the conduct of non-medical staff. NCCHC Standard YA-09 Privacy of Care Compliance indicator #4 requires that non-medical staff should only be present if the patient poses a probable risk to the safety of the health care provider or others. The standard further recommends that any non-medical staff who observe or hear health encounters should be instructed on maintaining confidentiality. We urge the State to amend Policy #403.04 to reflect the State’s actual practice and to provide additional guidance to medical and non-medical staff. The State may choose to adopt the language in the provision requiring that nonmedical staff be out of the line of sight and hearing of youth health care assessment and treatment, except in circumstances where documented safety considerations posed by a particular youth require enhanced, non-medical supervision. Finally, given that one youth was able to view confidential health information, the State’s health care staff should endeavor to keep all health related documents secure to prevent future breaches of confidentiality.
C.4 INITIAL HEALTH ASSESSMENT
The Facilities shall ensure that initial health assessments are complete and include: use of growth and weight charts; laboratory test results placed in the youth’s health records before the youth is transferred out of reception; results of all laboratory tests, to be provided for each test within 20 days of its performance; testing of all youth for sexually transmitted diseases; and a problem list and a plan of care for each problem identified at reception.
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In order to assess this provision, we reviewed the relevant policies and procedures,14 the State’s self-assessment, and the health records of 18 youth. Initial health assessments were completed in 100% of youth health records reviewed. These assessments included the nurse intake screening/assessment, a physical exam, screening for tuberculosis, and gathering information related to mental health and substance abuse concerns. Registered Nurses completed the intake assessments on the day of intake and the Primary Care Physician typically completed physical examinations within one week of admission. Growth and weight charts were included in 16 of the 18 health records reviewed. Laboratory tests are completed on all youth at intake and, with the exception of one record, test results were returned within 20 days of performance. When applicable, medical staff conducted gynecological exams. The OB/GYN usually conducted these exams within one week of admission.
While most youth were tested for sexually transmitted diseases (STDs) at intake, such testing was missing in three of the 18 health records reviewed. In one health record, the youth was tested for STDs at the detention center, but no result was documented in the health record. Another youth had been transferred from another facility without any documentation of testing and results. The third youth stated she had not been sexually active while released. However, despite the missing testing information, this is not an indication that the State has failed to meet the requirements of this provision. Rather, the State should institute quality improvement procedures to ensure that STD results are properly documented in health records. All of the youth who tested positive received appropriate treatment.
Vision and hearing screenings were consistently completed in all records. Youth failing the vision test were referred to the Optometrist for evaluation and
14The relevant policies and procedures for this provision are #403.10 “Reception Center Nursing Screening/Assessment,” #403.11 “Health Care Physical Examination-Intake,” #403.12 “Transfer Health Screening,” #403.14 “Female Health Care,” policy #403.06, SOP #403.12.01 “Transfer Nurse Screening/Assessment” and consent form #403.06A. These policies were updated on March 31, 2010.
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received glasses. All health records included a problem list that included medical diagnoses. A plan of care for each problem identified at intake was followed up by health care staff except in one instance, where a youth failed a hearing test. The youth was identified as failing the hearing test from the school transfer records and was retested by ODYS staff, but failed again. There was no documented referral or audiologist evaluation in the youth’s health record. Quality improvement procedures would help prevent such lapses.
Compliance Rating: Substantial Compliance Although the State’s practice conforms to the requirements of this provision,
the State should consider amending certain policies and instituting a quality improvement program to ensure that all youth have documented STD tests and all youth receive necessary referrals after a medical problem is identified. The State’s current policy controlling medical services related to STDs and pregnancy states that youth are only authorized to release health information if they are over 18 years of age – there is no provision authorizing minors to release STD and pregnancy related information to parents or others. However, minors are legally authorized to consent to medical services related to STDs and to release such information. The relevant ODYS policies and forms should be revised to reflect this practice. Further, the State should amend Policy #403.11 “Health Care Physical Examination-Intake” to reflect the facility’s practice of conducting hearing and vision screenings. C.5 ACCESS TO HEALTH SERVICES
The Facilities shall ensure that youth can request to be seen by medical staff confidentially and independent from JCOs and custodial staff.
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In order to assess this provision, we reviewed the relevant policies and procedures,15 the health records of 18 youth, and interviewed youth. Scioto’s policy and procedures address non-emergency requests for medical services and provide for daily access to sick call and RN triage, and at least one physician visit each week. Sick call visits were also required each shift for youth in seclusion. The policy and procedures also require that youth be provided with information about the sick call process and sick call box locations during orientation. Confidentiality requirements are also addressed in the policy. On August 4, 2010, the State revised the Youth Welcome Letter, which outlines the process for youth to access sick call. While the previous version of the welcome letter stated that sick call only operates Monday through Friday, the current letter is consistent with the State’s policy and practice.
Youth consistently reported that they were satisfied with the sick call system. Most youth reported that if they submitted a sick call slip for a nonemergency, they would see medical staff the following day. Our review of the health records confirmed that, when youth submitted health related complaints through the sick call process, their concerns were addressed appropriately and in a timely manner. Sick calls were usually addressed the same day, including weekends. While youth are aware that they can confidentially complete a sick call form without the intervention of JCOs or custodial staff, in practice, youth frequently seek assistance from staff instead of completing a sick call form. Interdisciplinary progress notes reflect that youth are being seen on numerous occasions on a walk-in basis after being referred by security or school staff. Health care staff provided follow up care and referrals when needed.
Compliance Rating: Substantial Compliance
15The relevant policies and procedures for this provision are Policy #403.08 “Access to Health Care,” SOP #403.08.01 “Institutional Health Care,” Scioto Local Operating Procedures #403.08.01.01 “Access to Health Care,” and nursing protocol #403.07.
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While Scioto is in substantial compliance with this provision, the State should consider making several changes in order to improve youths’ access to health care services. For instance, Scioto submitted Standing Order #403.07, which is used by nursing staff to address sick call, for review. While the contents were appropriate, we would recommend that Scioto should change the title from “Standing Order” to “Nursing Protocols.” This change would be consistent with the National Commission on Correctional Health Care’s Standard Y-E-11. Scioto should also ensure that sick call health assessments are being completed by RNs and not LPNs since health assessments are not within the scope of LPNs’ practice or license. This should be specified in Scioto’s policies. If Scioto requires the person conducting the assessment to provide their printed name, title and signature, this will allow for easier identification of which provider completed the assessment. Finally, ODYS reviewed and updated its sick call policies and procedures in March of 2010. Prior to 2010, ODYS last updated its policies in 2006 and 2007. ODYS should review its policies and procedures at least annually, and update them as needed.
C.6 MEDICATION MANAGEMENT The Facilities shall not discontinue a chronically ill youth’s usual medication for non-medical reasons, including that the medication is not on the Facilities’ formulary. In order to assess this provision, we reviewed the ODYS Formulary, the
State’s self-assessment, the relevant policies,16 and the health records of 18 youth. Based on our review, it appears that Scioto continues the medication of chronically ill youth in its custody. When chronically ill youth arrive at Scioto, their medications are reviewed and continued in a timely manner by the Physician. Scioto’s formulary includes adequate coverage of drugs commonly required for the
16The relevant policies for this provision are Policy #403.09 “Administration of Medical Treatment-Medications,” #403.18 “Pharmaceutical Management and Standard Operating Procedure,” and #403.18.01 “Prescribing Procedures and Documentation.” These policies were reviewed in draft form.
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youth population at Scioto. The prescriber’s orders for medications and medication administration records were complete and present in all the youth health records reviewed. According to the youth health records, medications are being administered and documented by nurses as ordered. Scioto has even documented hot weather precautions for youth who are taking medications that predispose them to heat sensitivity. When applicable, consent forms for psychotropic medications are present in the youth health records. Abnormal Involuntary Movement Scale (“AIMS”) were also documented for youth on psychotropic medications.
According to the State’s self-assessment, the State does not alter any youth’s prescriptions unless medically warranted. Specifically, if a particular medication is not available on the formulary, Scioto obtains the medication from a local pharmacy. We applaud this practice. While the State has met all of the components of this provision, we recommend that the State modify its current policy to reflect Scioto’s practice for securing medications not listed on the formulary. Compliance Rating: Substantial Compliance
C.7 DENTAL CARE The Facilities shall ensure that:
a. Dental restorative needs are listed on a dental treatment plan for the youth, tracked by the dental program, and treated on a timely basis consistent with generally accepted professional standards of care;
b. Prosthetic dental services are provided based on need, as determined by the treating dentist, with appropriate consideration for the replacement or repair of missing front teeth, according to generally accepted professional standards of care;
c. Youth experiencing dental pain are not denied adequate pain medication;
d. Health records contain adequate documentation of all outside dental consults, including the clinical examination, treatment plan, procedures performed, orders for management after the procedures, and any followup appointment or plan; and
e. Dental staffing is adequate to meet the restorative dental needs of the Facilities’ populations.
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In order to assess this provision, we reviewed the relevant policies and procedures,17 the State’s self-assessment, and the dental records of 16 youth. In all cases where dental records were present, youth had received a dental examination in a timely manner, usually within several days of admission. Scioto’s dental staff routinely completed dental prophylaxis, usually at the time of the dental examination. Scioto conducts simple dental extractions on-site and appropriately refers third molar extractions to an off-site oral surgeon with follow up care and treatment at the facility. Youth experiencing dental pain are not denied adequate pain medication. These youth are promptly seen by the dentists and are provided with adequate pain management. The State’s dental policies and procedures are detailed and comprehensive. Moreover, the nursing standing orders address the management of dental pain and the medications administered. In addition, while not required by the consent order, we recognize that the State is providing dental education to youth, though sometimes several weeks after the dental examination.
Although the State addresses youth dental pain and provides adequate dental staffing, it has not reached substantial compliance with this provision for several reasons. First, the State’s dental record-keeping is inadequate. Two of the 18 youth health records provided by the State did not include documentation of any dental examinations and treatment. In the 16 records where documentation was present, it was difficult to assess the quality of dental care due to the consistently poor legibility of the handwriting. None of the 16 youth whose files were reviewed appeared to require prosthetic dental services. However, the illegibility of the files was a barrier to fully assessing the provision of prosthetic dental service.
17 The relevant policies and procedures for this provision are Policy #403.13 “Dental Services,” SOP #403.13.01 “Dental Radiology,” SOP #403.13.02 “Dental Sterilization and Infection Control,” SOP # 403.13.03 “Dental Examinations,” SOP #403.13.04 “Nursing Protocol for Screening Assessment and Stabilization of Dental Condition,” and SOP #403.13.05 “Removal of Dental Precious Metals.”
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Nevertheless, it appears that the State has adequate policies and procedures to address the possibility.
Second, while restorative needs are listed on the dental treatment plan with follow up dates, we are concerned that the follow up dates for operative procedures – specifically, fillings – may be set too far out in the future to ensure completion prior to youths’ release. In fact, we could not find any documentation in the records that fillings actually had been completed. There was no legible evidence present in the dental records reviewed demonstrating that restorations, such as fillings or prosthetic dental services, are being provided. Moreover, Scioto’s self-assessment does not specifically provide any data addressing the provision of dental restorative services or the time periods within which these services are provided to youth.
Finally, we can determine that dental staffing is adequate to meet the restorative dental needs of the Facilities’ populations based on the records we have received thus far.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
The State did not provide detailed and legible information on the way in which it has met its obligation to provide treatment for dental restorative needs. In its next self-assessment, the State should consider providing statistical reports of the dental care provided to youth, including the full range of treatment services and the number of restorative procedures. These data should include an analysis of the time frame between youths’ admission and the facility’s provision of these treatment services. In addition, the State should provide detailed staffing schedules documenting the number of hours worked by dental staff.
Finally, the State should consider continuing to move towards electronic health records in order to alleviate the need to decipher illegible or incomplete dental records. We recommend that the State adopt an electronic system that
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permits the State to run queries and cull data regarding the dental services provided and utilizes standardized forms that can be completed electronically by dental staff.
C.8 MANAGEMENT OF CHRONIC ILLNESSES The Facilities shall ensure that:
a. Chronic disease policies, protocols, and practices are appropriate for chronically ill adolescents;
b. Youth with chronic asthma are continued on their established medicines on admission unless the youth’s condition warrants a change in treatment; and
c. Youth who frequently use rescue inhalers are appropriately monitored and treated by physicians to minimize preventable asthma hospitalization resulting from acute respiratory crisis that follows an inadequately treated exacerbation of chronic asthma.
In order to assess this provision, we reviewed the relevant policies and procedures,18 the State’s self-assessment, and the health records of 15 youth. The youth whose records we reviewed have the following chronic illnesses: hypertension, asthma, cardiac and renal conditions, hepatitis C, seizure disorder, hypothyroidism, chronic migraine headache, and a blood clotting disorder. Most of the youth also had comorbid chronic mental health disorders.
In our May 9, 2007 findings letter, we determined that the care provided to chronically ill youth substantially departed from generally accepted professional standards.19 The State’s management of chronic illnesses has significantly improved since our previous assessment of medical care at Scioto. The State’s current chronic disease policies, protocols, and practices are appropriate for
18The relevant policies and procedures for this provision are Policy #403.15, “Health Care Treatment Plans for Youth with Special Health Needs,” and SOP #403.15.01, “Chronic Care.”
19 Specifically, we determined that Scioto nurses failed to “clinically assess youth when administering rescue inhalers, and youth who use such inhalers frequently are not referred to the physician for more intense treatment.” See United States’ May 9, 2007 Findings Letter at 9.
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chronically ill adolescents. In all of the medical records we reviewed, we found that Scioto’s health staff identified youth with chronic medical conditions at intake, then continued and documented disease management. The physician conducts a baseline assessment of all youth with chronic medical conditions. This assessment includes physical findings, the use of a symptoms checklist, the development of a treatment plan, youth education, and verification that youth understand the assessment. Scioto did not discontinue the administration of medications in any of the health records reviewed. Scioto continues inhalers for youth with asthma, and the facility physician appropriately treats and monitors these youth. One youth we interviewed reported that one evening she had difficulty breathing and began banging on her door to get the attention of the direct care staff. She asked the staff to get her inhaler from the clinic. The direct care staff refused, instructed her to sit on her bed and relax, and never brought her the inhaler. While this incident is troubling, it appears that this was an isolated incident that reflects a potential problem with the responsiveness of direct care staff, not the medical staff.
Medical staff consistently obtains both subjective and objective information specific to each youth’s condition. The nurse obtains subjective information through interviews of youth with chronic illnesses. The nurse also provides youth education and verifies and documents youth understanding. Medical staff obtains objective information pertinent to the chronic condition through physical examinations and labs. Medical staff documents and executes appropriate treatment plans and referrals, including outside medical consultations. Each chronic care management plan was signed by an RN and Medical Doctor (“MD”).
Chronic care flow sheets reflect monitoring of medical indicators such as blood pressure, heart rate, weight and height, side effects of medications and youth compliance. Special diets are ordered, if required for special needs. Chronic care treatment plans are specific to the chronic illness being treated.
While the State’s policy requires youth with chronic illnesses to be seen by the physician every three months, in practice almost all youth with chronic illnesses are seen monthly. There is a single exception: one youth with mild intermittent
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asthma was seen every two to three months. All treatment and care reviewed are clinically appropriate. Health care plans and medical instructions are appropriately shared with non-medical staff. For example, non-medical staff are appropriately advised of a youth’s the need for a bottom bunk or diet and activity restrictions for a youth with seizure disorder.
Compliance Rating: Substantial Compliance
C.9 ACCESS TO SPECIALTY CARE Absent clinically justified rationale, the Facilities shall not withhold access to specialist services recommended by a treating physician and shall ensure that: prior approval of specialty medical consultations is made by a physician trained and qualified in pediatrics and adolescent medicine; and assessment criteria for the necessity of specialty consultations are based on pediatric and adolescent medicine. In order to assess this provision, we reviewed the relevant policies and
procedures,20 and the health records of 18 youth. The facility Physician is trained and certified in pediatrics and adolescent medicine. The Physician indentified several youth who were in need of specialty care based on the appropriate criteria. In each case, the youth was referred to an outside specialist, transported to appointments, and the youth returned to the facility with documented treatment plans. Scioto’s health care staff provided follow up care as recommended by the specialist. Some examples of medical specialty consultations documented in the health records reviewed included cardiologists for Holter monitoring, colposcopy for abnormal Pap smears, orthopedic consults for fractures, and renal consult and ultrasound for kidney stones.
20The relevant policies for this provision are Policy #403.15 “Health Care Treatment Plans for Youth with Special Health Needs” and #403.17 “Medical Consultation and Hospitalization.”
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We reviewed the records of three youth who were pregnant when admitted to Scioto. Pregnant females received appropriate prenatal care as documented by nursing care records, OB progress notes and the completion of the American College of Obstetrics and Gynecology (“ACOG”) recommendations for ante partum care documented in flow sheets. Appropriate time frames were met for completion of labs and fetal ultrasound studies. Consultations, emergency and inpatient care were provided as necessary and health care plans and diets were documented.
Compliance Rating: Substantial Compliance
C.10 IMMUNIZATIONS The State shall make reasonable efforts to obtain immunization records for all youth who are detained at the facilities for more than one (1) month. The State shall ensure that medical staff update immunizations for such youth in accordance with nationally recognized guidelines and state school admission requirements. The physicians who determine that the vaccination of a youth is medically inappropriate shall properly record such determination in the youth’s medical record. In order to assess this provision, we reviewed the relevant policy and
procedure,21 the State’s self-assessment, and the health records of 18 youth. The State’s immunization program has significantly improved since we last assessed it in 2007. At that time, fifteen percent of Scioto’s youth had incomplete immunizations and youth were not fully immunized for their age.22 Medical staff has updated all youth immunizations in accordance with the Center for Disease Control and Prevention’s and the Advisory Committee on Immunization Practices’ recommendations. The appropriate immunizations for this population – including Hepatitis A, Hepatitis B, Meningitis, HPV, Varicella and Influenza vaccines – are all appropriately administered and documented upon intake.
21 The relevant policies for this provision are Policy #403.21 “Communicable Disease Management” and SOP #403.21.06 “Immunization Program.” 22 See United Sates’ May 9, 2007 Findings Letter at 9.
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Immunization records from the schools that youth previously attended and, in some cases, records from private providers were present in most youth health records for facility provider review. Scioto consistently withheld certain vaccinations inappropriate for pregnant youth until after the pregnancy. The State’s self-assessment confirms that females with a known pregnancy are not administered certain vaccinations, such as the Tdap. Scioto’s medical staff provided youth with chronic conditions with additional recommended immunizations. Finally, Vaccine Information Sheets (“VIS”) were present in the youth health records and reviewed with youth prior to administration of vaccines.
Compliance Rating: Substantial Compliance
In practice, the State provides immunizations for youth in accordance with nationally recognized guidelines and state school admission requirements. However, the State should consider updating the relevant policy and procedure. The State’s policy and standard operating procedure were last revised January 3, 2006. Accordingly, they do not reflect the current practice of providing all recommended vaccinations.
III. GRIEVANCES D.1 GRIEVANCES
The State shall develop and implement policies, procedures and practices to ensure that the facility has an adequate grievance system including: no formal or informal preconditions to the completion and submission of a grievance; review of grievances by the chief inspector; timely initiation and resolution of grievances; appropriate corrective action; and written notification provided to the youth of the final resolution of the grievance. (See Consent Order III.D.1) In our assessment of this provision, we reviewed the State’s self-assessment, ODYS policy and procedure, grievance logs for May to September 2010, and 183 grievance summaries, and we interviewed youth. Consistent with our September 2010 Compliance Report, we find that the State is in substantial compliance with
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this provision. In her report, Dr. Dedel notes that the State’s Quarterly Cumulative Report from May to July 2010 shows that 99% of the grievances at Scioto were handled in a timely manner. (See Dedel Second PFH Report at 23). Further, consistent with the Consent Order, there are no preconditions to filing a grievance, youth receive notification of the grievance resolutions, grievances are picked up each weekday, and all grievances are reviewed by the Chief Inspector’s Office. Despite the State’s success in maintaining a rating of substantial compliance, we encourage the State to investigate why a percentage of youth feel there is a bias when the grievance involves allegations of mistreatment by staff. On November 22, 2010, through a letter, the United States memorialized its concerns and offered suggestions about how to begin to address the distrust demonstrated by some youth. On December 13, 2010, the State informed us that it intends to conduct an audit—similar to a customer survey—during the second quarter of 2011 focusing on grievances and youths’ perceptions about grievances. We look forward to learning the results of the audit.
Compliance Rating: Substantial Compliance
D.2 GRIEVANCE EXPLAINED TO YOUTH A clear explanation of the grievance process shall be provided to each youth upon admission to the facilities during orientation and to their parents or guardians, and the youth’s understanding of the process shall be at least verbally verified. (See Consent Order III.D.2) In our assessment of this provision, we reviewed the State’s self-assessment,
the relevant policy, and the revised Youth Handbook, and we interviewed youth. The relevant ODYS policy requires that, when youth are admitted to Scioto, staff shall provide youth with a copy of the Youth Grievance Handbook, instruct the youth on the grievance system, and ensure the youth sign a letter of understanding regarding the process. Consistent with our finding in September 2010, youth interviewed in October and November 2010 reported having received a copy of the Handbook and could describe the mechanics of the youth grievance process. Based
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on our review, the State has maintained its rating of substantial compliance with this provision. We commend the State on its success.
Compliance Rating: Substantial Compliance
D.3 GRIEVANCE PROCESS Without any staff involvement, youth shall easily be able to obtain grievance forms and submit grievances. (See Consent Order III.D.3) In order to assess this provision, we reviewed the State’s self-assessment,
interviewed youth, and visited the living areas of youth. Consistent with our various on-site compliance tours in 2010, we found grievance forms and locked boxes located throughout Scioto. We also found that the grievance forms are readily accessible to youth without any staff involvement. Youth interviewed acknowledged knowing how to obtain a grievance form and how to submit that form. Youth interviewed did not report any concerns regarding their ability to participate in the process. The State has maintained its substantial compliance rating with this provision.
Compliance Rating: Substantial Compliance
VI. SPECIAL EDUCATION
E. 1 PROVISION OF SPECIAL EDUCATION
The State shall, at all times, provide all youth confined at the Facilities with adequate special education in compliance with the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006), and regulations promulgated there under, and this Stipulation. (See Consent Order III.E.1) In our assessment of this provision, we reviewed the State’s self-assessment, toured the school building, and interviewed youth and staff. The State’s selfassessment provided a sufficient discussion regarding the State’s provision of a full school day to students in the general population, the intake process, scheduling procedure, teacher certifications, curriculum development, and parental/guardian
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involvement in a youth’s educational plan. We commend the State on its improved self-assessment efforts.
During our tour, we observed that the State has invested resources— smartboards and software—in order to ensure youth have an appropriate curriculum for their grade level. It is evident that State takes seriously its responsibility to provide all qualified youth confined at Scioto an adequate special education. Accordingly, we have determined that, for the most part, the State has a sufficient foundation for an effective special education program at Scioto. (See Dedel First SPED Report at 4-6). Nevertheless, based on our review during the October 2010 on-site tour and concerns raised in the S.H. v Stickrath matter, we share Dr. Dedel’s concerns about: (1) whether the State is providing youth in disciplinary isolation regular, dependable access to class assignments and instruction, and (2) the extent to which the ABC (in school suspension program) is implemented effectively. In preparation for the next on-site compliance tour, the State should collect and interpret the various indicators listed by Dr. Dedel. (See Dedel First SPED Report at 4).
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
We note that provision E.1 requires compliance with the IDEA, the related regulations and the provisions E.2-E.11 of the U.S. v Ohio Consent Order (oversight, special education upon intake, parent and guardian involvement, staffing, screening for special education, individual educational plans, vocational education, forwarding screening and assessment information, training and quality assurance and transition services). Substantial compliance with E.1, “Provision of Special Education,” is therefore partially dependent upon the State reaching substantial compliance with provisions E.2 through E.11. Fortunately, not including E.1, the State is already in substantial compliance with seven of the eleven provisions and in partial compliance with the three remaining provisions:
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E.7 (Individual Educational Plans), E.8 (Vocational education) and E.11 (Transitional Services). Below, we provide the State with specific recommendations with regard to provisions E.7, E.8, and E.11. We encourage the State to consider these recommendations and those made by Dr. Dedel throughout her SPED Report.
E.2 OVERSIGHT The State shall provide adequate oversight of special education at the Facilities. (See Consent Order III.E.2) In our assessment of this provision, we reviewed the State’s self-assessment
and interviewed staff. Based on our review, we find that the documentation provided by the State regarding its SPED policies and procedures support finding that ODYS provides sufficient oversight over the SPED program at Scioto. Specifically, the State has demonstrated that it has an oversight strategy that operates at both the external and internal level. As described by Dr. Dedel, both levels of oversight are impressive and underscore the State’s dedication to achieving compliance with this provision. (See Dedel First SPED Report at 8-9). The State has thus reached substantial compliance with this provision. In our September 2010 compliance report, the State was rated as being in beginning compliance with this provision. We commend the State on its success.
Compliance Rating: Substantial Compliance
E.3 SPECIAL EDUCATION UPON INTAKE The State shall ensure that all students who qualify for special education services receive such services within a reasonable time following intake at the Facilities. (See Consent Order III.E.3) In our assessment of this provision, we reviewed the State’s self-assessment,
youth special education files, and the State’s October 1, 2010 response to the United States’ September 2010 Compliance Report, and interviewed youth and staff. Based on our review, we found that all youth were enrolled and attending school within three school days, provided they were admitted when school was in session. For all
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other youth, they began attending school on the first day school was in session. Dr. Dedel further confirmed this finding through her interviews with youth. Through its self-assessment, the State provided a detailed description of its efforts and process to ensure that all students who qualify for SPED receive such services upon admission. Additionally, Dr. Dedel ascertained that the student’s class schedules reflected the services prescribed by the Individual Educational Plans (“IEPs”) available at the time of the youths’ admission to Scioto. (See Dedel First SPED Report at 10). In our September 2010 Compliance Report, the State was rated as being in partial compliance with this provision. We commend the State for successfully achieving substantial compliance with this provision.
We strongly suggest that as part of its next self-assessment, the State include data recommended by Dr. Dedel. (See Dedel First SPED Report at 10).
Compliance Rating: Substantial Compliance
E.4 PARENT AND GUARDIAN INVOLVEMENT
The State shall develop and implement policies, procedures, and practices to appropriately notify and involve parents or guardians in the provision of special education services, wherever possible. (See Consent Order III.E.4) In our assessment of this provision, we reviewed the State’s self-assessment, the State’s October 1, 2010 response to the United States’ September 2010 Compliance Report, and special education files, and interviewed youth and staff. Based on our review, we found that the State involves parents or guardians in the educational planning of Scioto youth. Specifically, we found documentation of attempts to contact parents or guardians via mail and telephone, with ample documentation about the response or lack of response by parents or guardians. The files we reviewed were orderly and also presented strong efforts to inform parents or guardians of a student’s progress. Notwithstanding these observations, we agree with Dr. Dedel that the quality of information in the progress reports may need improvement (See Dedel First SPED Report at 12-13). This is discussed under
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provision 7 on pages 47-48 of this Compliance Report. In our September 2010 Compliance Report, the State was rated as being in partial compliance with this provision. We commend the State for achieving substantial compliance with this provision.
We strongly suggest that, as part of its next self-assessment, the State include the data recommended by Dr. Dedel. (See Dedel First SPED Report at 12).
Compliance Rating: Substantial Compliance
E.5 STAFFING The State shall develop and implement an education staffing plan to ensure adequate staff to comply with the terms of this Stipulation. (See Consent Order III.E.5)
In our assessment of this provision, we reviewed the State’s self-assessment, and the State’s October 1, 2010 response to the United States’ September 2010 Compliance Report, and we interviewed staff. Based on our review, we found that the State employs an adequate formula to ensure that it meets the 1:12 teacher to student ratio required by the Ohio Department of Education. Further, it appears that Scioto has successfully attracted and maintained a body of well-qualified educators. Collectively, the State is able to ensure that all students have full access to the education program at Scioto. The State is to be commended for its continued efforts to improve staffing under this provision. For example, Scioto recently converted the school psychologist position to a full-time position. We note that, at the time of our November on-site tour, there were two vacant positions, the speech language pathologist and transition skills teacher positions. We detail our concerns about the lack of a transition skills teacher under provision 11 on page 48 of this Compliance Report. We look forward to being updated about these vacancies during
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our next on-site tour. We commend the State on achieving substantial compliance with this provision.
Compliance Rating: Substantial compliance
E.6 SCREENING FOR SPECIAL EDUCATION NEEDS
The State shall provide prompt and adequate screening of youth for special education needs and shall identify youth who, upon admission to the Ohio Department of Youth Services, were receiving special education in their home school districts or who may be eligible to receive special education services but have not been so identified in the past.
The State shall ensure that those staff conducting the screening, assessment and evaluation processes are qualified to do so. (See Consent Order III.E.6)
In our assessment of this provision, we reviewed eight students’ general education files, the State’s self-assessment, and the State’s October 1, 2010 response to the United States’ September 2010 Compliance Report, and we interviewed staff. Based on our review, we found the State’s intake process to be appropriate and detailed. Specifically, the intake process requires youth to be interviewed and youth records to be immediately requested from the youth’s prior schools. For those youth not currently eligible for special education upon entrance to Scioto, the State also has a detailed method to determine whether a referral is appropriate. We commend the State for successfully attaining substantial compliance with this provision. Previously, the State was rated as being in beginning compliance with this provision.
We strongly suggest that, as part of its next self-assessment, the State include the data recommended by Dr. Dedel. (See Dedel First SPED Report at 16).
Compliance Rating: Substantial Compliance
E.7 INDIVIDUAL EDUCATION PLANS The State shall develop an IEP as defined in 34 C.F.R §300.320 for each youth who qualifies for an IEP. Following development of the IEP, the State shall 44

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implement the IEP as soon as possible. As part of satisfying this requirement, the State shall conduct required annual reviews of IEPs, adequately document the provision of special education services, and comply with requirements regarding participation by the professional staff, parents, and student in the IEP process. The State shall, if necessary, develop, review or revise IEPs for qualified special education students.
In developing or modifying the IEP, the State shall ensure that: the IEP reflects the individualized educational needs of the youth and that services are provided accordingly; each IEP includes documentation of the team’s consideration of the youth’s need for related services and transition planning, and identifies the party responsible for providing such transition services; the students’ educational progress is monitored; teachers are trained on how to monitor progress toward IEP goals and objectives; and teachers understand and use functional behavioral assessment and behavior intervention programs in IEP planning and implementation. (See Consent Order III.E.7)
In our assessment of this provision, we interviewed staff and reviewed the State’s self-assessment, seven special education files,23 and the State’s October 1, 2010 response to the United States’ September 2010 Compliance Report. In our September 2010 Compliance Report we explained that the ODYS IEP policies detailed methods of monitoring and provided an adequate framework for tracking progress and achieving goals. During our October 2010 on-site tour, we found that the ODYS procedures were sufficiently detailed and followed in most areas. Overall, we found that most IEPs were of adequate quality. However, as further discussed by Dr. Dedel, the quality of the annual IEP goals and the progress reports were both lacking and are of concern. (See Dedel First SPED Report at 20-21). For these reasons, the State remains in partial compliance with this provision. Nevertheless, we are encouraged that the State is investing in further professional training and development for special education staff in the areas of measurable goal writing and monitoring student progress. We look forward to assessing this provision during our next compliance tour.
Compliance Rating: Partial Compliance
23 The seven files reviewed represented 18% of the files for special education youth at Scioto.
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Recommendation(s) to reach substantial compliance:
We suggest the State continue its current revisions of IEP goals to ensure that they are clear, appropriate, and assist in monitoring the youth’s progress. Further, we agree with Dr. Dedel’s suggestion that the State should increase teachers’ skills in monitoring and reporting progress in order to determine whether and to what extent the IEP resulted in improved outcomes. (See Dedel First SPED Report at 21).
E.8 VOCATIONAL EDUCATION The State shall provide appropriate vocational services that are required transition services for disabled youth under the IDEA. (See Consent Order III.E.8) In our assessment of this provision, we reviewed the State’s self-assessment
and the State’s October 1, 2010 response to the United States’ September 2010 Compliance Report, and we interviewed youth and staff. Currently, the State provides one vocational class, Administrative Office Technology, as its vocational services to youth. Apparently, obstacles to expanding the course offerings include financial constraints, but are further complicated by the short lengths of stays for Scioto youth. The ODYS Superintendent is aware of the lack of vocational options at Scioto and is researching alternatives, such as short-term vocational courses that involve some level of certification. Based on this review, the State is in partial compliance with this provision.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
We agree with Dr. Dedel’s comment that “the dearth of meaningful careeroriented options for students at Scioto is problematic.” (See Dedel First SPED
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Report at 22). We recommend that the State reach out to local resources to enrich its program while it takes steps to bolster its vocational course offerings. For example, one youth who had resided at another ODYS facility mentioned his disappointment that Scioto did not have barbery or horticulture classes, currently available at other ODYS facilities. As the State reinvigorates its vocational services, it may wish to have vocational educators from other facilities visit, if only for introductory classes. The State may wish to inquire if nearby community colleges have on-line courses that the Scioto youth could audit. Additionally, since Scioto has a well-established volunteer program, the State may wish to inquire into whether any volunteers could provide presentations about their own jobs, again if only to introduce youth to possible career options. We look forward to re-assessing this provision during our next compliance tour.
E.9 FORWARDING SCREENING AND ASSESSMENT INFORMATION UPON TRANSFER
The State shall ensure that, when a youth is discharged from the Facilities before the interventions or educational evaluations required in Section III.E.6 above are complete, the Facilities shall forward to the superintendent of the youth’s receiving school district all information regarding screening and evaluations completed to date, noting what evaluations are yet to be performed. (See Consent Order III.E.9) In our assessment of this provision, we reviewed general education files and the State’s self-assessment, and we interviewed staff. Based on our review we verified that, consistent with ODYS policy, educational records are regularly forwarded to receiving schools when a youth is transitioned out of the ODYS system. We commend the State on achieving substantial compliance with this provision.
Compliance Rating: Substantial Compliance
E.10 TRAINING AND QUALITY ASSURANCE
The State shall design and implement annual training requirements for special education staff. (See Consent Order III.E.10)
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In our assessment of this provision, we reviewed the State’s self-assessment and the Scioto Professional Development Calendar for 2008 to 2010, and we interviewed staff. The State’s comprehensive training program offers teachers valuable opportunities to further develop skills and effectively incorporate new techniques into their teaching. We commend the State for providing relevant training to its education staff and for working with an educational consultant to provide additional skill-building opportunities.
We encourage the State to consider compiling data that tracks and assess its training program for educators. Please see Dr. Dedel’s report for a list of suggested data that can assist the State in this endeavor. (See Dedel First SPED Report at 24). Consistent with our concerns regarding goals in youth IEPs (provision E.7 above) we suggest the State research any relevant training opportunities for SPED educators.
Compliance Rating: Substantial Compliance
E.11 TRANSITION SERVICES The State shall comply with any IDEA requirements for providing transition assistance. The State shall provide transition assistance to students by providing counseling and concrete information regarding appropriate community resources, and how to pursue post-secondary options, re-enroll in school or complete the GED. (See Consent Order III.E.11) In our assessment of this provision, we reviewed the State’s self-assessment
and the State’s October 1, 2010 response to the DOJ September 2010 Compliance Report, and we interviewed staff. Based on our review, it appears that the State has a solid foundation in place to provide transition services to Scioto youth. Scioto has a “Transition Skills” course which is designed to encourage youth to join the workforce and ensure they have access to necessary documentation in order to apply for employment. Scioto also has a position, “Transition Coordinator,” which tasks an individual with assisting youth to interact with outside resources to smooth the youth’s re-entry back into the community. Although both efforts are commendable,
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the State is rated as being in Partial Compliance because the position of Transition Skills instructor is currently vacant. Accordingly, the vacancy should be filled as soon as possible and the State should endeavor to create a “back up delivery system” to ensure that students’ access to this course is not compromised when the instructor is temporarily unavailable.(See Dedel First SPED Report at 25).
Compliance Rating: Partial Compliance
Recommendation(s) to reach Substantial Compliance:
The State should fill the vacant position as soon as possible with an individual having the required skills to meet the needs of the Scioto youth. Additionally, we encourage the State to inform youth, or remind youth, that 10 weeks prior to their release date they will begin to receive transition services. Several youth interviewed did not appear to know about transition services. Additionally, the State should continue to monitor transition services and examine the benefits to special education students. (See Dedel First SPED Report at 25).
V. PROGRAMMING F.1 STRUCTURED PROGRAMMING
The State shall provide adequate structured rehabilitative services, including an appropriate mix of physical, recreational or leisure activities during nonschool hours and days. The State shall develop and implement structured programming from the end of the school day until youth go to bed, and on weekends. For youth housed in closed-cell environments, programming shall be designed to ensure that youth are not confined in locked cells except: (a) from after programming to wake up; (b) as necessary where youth poses an immediate risk of harm to self or others; (c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The programming shall be designed to modify behaviors, provide rehabilitation to the types of youth committed at the facility, address general health and mental health needs, and be coordinated with the youth’s individual behavioral and treatment plans. The State shall use teachers, school administrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualified assistance to develop and implement structured programming.
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The State shall provide youth with access to programming activities that are required for parole eligibility. (See Consent Order III.F.1). In our assessment of this provision, we reviewed the State’s self-assessment narrative and relevant policies and procedures, and we interviewed staff and youth. Consistent with our finding in September 2010, we found that the State has developed a significant programmatic framework to reduce idleness and provide structured opportunities for youth. We commend the State for its continued success in this area. It appears that, more recently, direct care workers at Scioto are more open to community volunteers, which is a welcome change. This change has enabled Scioto to overcome the problem we found during our last tour, namely that safety concerns and logistical obstacles hindered youths’ ability to take full advantage of the programming opportunities. It is our understanding that currently there are fewer delays in transporting youth to their activities. We commend the State on changing staff’s perception of programming activities for youth.
Despite the State’s commitment to other forms of programming, the State again failed to demonstrate how its programming activities address criteria required for parole eligibility, as this is a specific component of provision F.1. During our on-site visit in November 2010, Dr. Dedel expressly requested any data, documentation, or verification that the State was meeting this requirement. The State failed to provide any related documentation despite an extended deadline to do so of December 10, 2010.24 Until the State can demonstrate that it is currently meeting this aspect of the provision, it will not achieve substantial compliance with
24 Due to the State’s difficulties in producing documents requested for the November on-site tour, on December 6, 2011, the United States informed the State that it would not consider any documentation for this Compliance Report that was received after 9:00 a.m. on December 10, 2010. On January 10, 2011, the State provided the United States with data and documentation that it represented satisfied our request for programming required for parole eligibility. The United States will consider the parole programming documentation in its next Compliance Report following its February 2011 tour.
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provision F.1 As always, we look forward to assessing activities designed to address parole eligibility criteria during our next tour in February 2011 tour.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
The State should make available for our review its efforts towards providing programming activities required for parole eligibility. We strongly recommend that the State produce monthly reports of all programs required by provision F.1 in order to facilitate assessment of this provision. These type of data can also be used to determine if the schedule of activities offered is balanced.
F.2 ORIENTATION
Admissions Intake and Orientation. The State shall develop and implement policies, procedures and practices to establish a consistent, orderly admissions intake system, conducive to gathering necessary information about youth, disseminating information to staff providing services and care for youth, and maintaining youth safety. The orientation shall also clearly set forth the rules youth must follow at the facility, explain how to access medical and mental health care and the grievance system, and provide other information pertinent to the youth’s participation in the facility’s programs. (See Consent Order III.F.2(a))
Notice to Youth of Facility Rules and Incentives/Consequences for Compliance. The State shall explain the structured programming to all youth during an orientation session that shall set forth the facility rules, the positive incentives for compliance and good behavior and the sanctions for rule violations. The State shall provide the facility rules in writing. (See Consent Order III.F.2(b))
Introductory Handbook, Orientation and Reporting Abuse. Each youth entering the facilities shall be given an orientation that shall include simple directions for reporting abuse and assuring youth of his/her right to be protected from retaliation for reporting allegations of abuse. (See Consent Order III.F.2(c))
In our assessment of this provision, we interviewed youth and staff and reviewed the revised youth handbook (dated August 2010) and policies and procedures. Consistent with our September 2010 Compliance Report, we find that
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that orientation process at Scioto provides youth with an adequate overview of institutional rules, the process for accessing mental health, medical care, grievance system and opportunities to participate in treatment, recreation and educational programs. We note, however, that the handbook and orientation do not adequately explain youths’ rights regarding practicing their religion. We address this issue below.
The Programming provisions of the Consent Order require the State to develop an orientation that “clearly set[s] forth the rules youth must follow at the Facility . . . and provide[s] other information pertinent to the youth’s participation in the Facility’s programs,” (V.F.2.a), “provide the Facility rules in writing,” (V.F.2.b),” and provide an introductory handbook. (V.F.2.c). The “Youth Orientation Handbook” claims to “contain information [youth] will need to know during [their] stay at ODYS.” (page 6 of Youth Orientation Handbook). While the Handbook informs youth that they have the right not to be discriminated against because of religion, the section covering “Religious Services” may not fully comply with the Religious Land Use and Institutionalized Persons Act,25 42 U.S.C. § 2000cc (“RLUIPA”). RLUIPA protects the religious exercise of persons confined to institutions, including youth confined in juvenile correctional facilities. RLUIPA prohibits the State from substantially burdening the religious exercise of youth in juvenile correctional facilities, even if the burden results from a rule of general applicability. For example, while the State’s Youth Handbook states that youth who wear “[p]ersonal clothing not authorized by the state” will be subject to discipline (page 21), RLUIPA may require that a Jewish youth be permitted to wear a yarmulke or a Muslim youth be permitted to wear a hijab in observance of his or her religious practices. Regulations amounting to a substantial burden will only be permitted if the State demonstrates that the regulation furthers a “compelling
25 See http://www.justice.gov/crt/about/spl/rluipa.php (last visited January 12, 2011).
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government interest” and is the least restrictive means available to further that interest.
In our September 2010 Compliance Report, we noted that the handbook provides a comprehensive list of facility rules, but lacked detailed descriptions of the consequences for violating those facility rules. We, therefore, recommended revising the handbook to adopt the new policies and procedures regarding alternative sanctions and behavior modification under the new SBBMS. The State has since modified the handbook accordingly. We commend the State on its prompt action to remedy the deficiency in its handbook.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
To ensure that the State is accommodating youth’s religious needs, the State should make certain that the information conveyed to youth is consistent with the State’s religious accommodations policy and practice. For instance, the State’s Standard Operating Procedure 507.02.06 requires a youth to fill out and return a “Request for Accommodation of Religious Belief or Practice” form if he or she wishes to have an accommodation for a religious rite, practice, or observance. However, this form is not mentioned in the section of the youth handbook covering religious services.
Moreover, the State should ensure that all relevant personnel are familiar with RLUIPA’s requirements. Under the current procedure, youth are instructed to present all religious needs to the Chaplain for approval, including religious materials, holy texts, and pastoral visits. Given the critical role the Chaplain plays in determining the religious accommodations that Scioto will make for youth in its custody, the State must ensure that the Chaplain is familiar with the requirements of RLUIPA. Direct care staff should also be familiar with RLUIPA’s mandates and
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the State’s religious accommodations policy. We look forward to assessing a revised handbook during our next tour.
VI. DOCUMENTATION G.1 PROGRESS NOTES
The Facilities shall promulgate and implement a policy requiring that all health professionals be required to create and use progress notes to document, on a regular basis, interactions and each assessment of youth with mental/behavioral health or substance abuse needs. In particular, progress notes shall:
a. In the assessment, address the efficacy of interventions, currently presenting problems, and the available options to address those problems; and
b. Provide thorough documentation of all crisis interventions or, if not thoroughly documented in the progress notes, provide a reference to alert staff to another document in the youth’s file containing the details of the crisis intervention. (See Consent Order III.G.1).
In order to assess this provision, we reviewed the State’s policies, procedures, and practices regarding progress notes. We recognize that the provisions under G, “Documentation,” do not fall squarely under any of the other sections, but rather touch on mental health, medical care, and education. For this reason, we have asked each of our experts to comment on these provisions. Going forward, we recommend the State provide a discussion in its self-assessment of how it meets the criteria of provisions G.1 and G.2.
The State has provided at draft policy, entitled “Behavioral Health Documentation Guidelines,” which is relevant to our assessment of mental health progress notes. However, it is unclear whether this policy has been implemented yet. A review of youth records revealed that mental/behavioral health progress notes are generally of fair quality. Specifically, while progress notes are plentiful, the notes do not always address the youth’s specific treatment goals as outlined in treatment planning documents. Documentation regarding mental/behavioral
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health crisis interventions was generally of better quality than progress notes, but limited in that it was difficult to determine when emergency consultations were requested and to determine the elapsed time until actual clinical contact was made with the youth in crisis.
The relevant medical policies and SOPs appropriately address content organization and format, confidentiality requirements, and health care professionals’ access to records. Physicians and nurses appropriately document progress notes in chronological order in youth health records. At intake, nursing staff properly document substance use history on all youth. The Medical Release and Transfer Summaries Policy require health staff to complete a Medical Transfer Summary and a Medical Release Summary for youth who are discharged or transferred out of the facility. Both forms contain lines to document required or scheduled medical and dental referrals. The Medical Release form also designates whether psychiatry follow up is required immediately or within another time frame, and whether a parent should be advised. Medical staff adequately document health information on the above-mentioned documents according to policy. However, medical records related to crisis intervention did not include documentation by psychologists or information regarding substance abuse treatment. We look forward to reviewing this provision during our next compliance tour.
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance: The quality of mental/behavioral health progress notes can be accomplished
by the implementation of quality assurance measures and a peer review process, as well as clinical supervision. The State cannot reach substantial compliance on this provision while some of the relevant policies and procedures are still in flux. As stated earlier, it is unclear whether the “Behavioral Health Documentation Guidelines” have been implemented. In addition, the State indicated that it
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planned to begin use of an Integrated Treatment Plan beginning January 1, 2011. The development of the Integrated Treatment Plan may facilitate the State’s level of compliance with this provision. Specifically, the quality of progress notes may improve if each youth has one overarching treatment plan and treatment providers form a cohesive treatment team unit. At this juncture, a rating of substantial compliance is premature.
G.2 ACCESSIBILITY OF RELEVANT INFORMATION The Facilities shall ensure that youth records are organized in a manner providing treatment teams prompt access to relevant, complete, and accurate documentation regarding the youth’s status. (See Consent Order III.G.2) The State’s current medical policies generally outline medical and psychology
record content and format in a manner that provides treatment teams with prompt access to documentation regarding the youth’s status. However, according to current policy, staff must review and provide documentation related to the behavioral/mental health treatment of youth in at least two separate records, since medical records do not include any psychology-related information. Given the current state of flux of the mental health program, we will have to further assess this provision during our next tour.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
As we discussed in C.2 (“Health Records”), the State should adopt a documentation system that combines all health records, including psychology records. Please review Dr. Staples-Horne’s Report for a further discussion on this topic. (See Staples Horne First Medical Report at 11).
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NEXT TOUR and COMPLIANCE REPORT
The United States intends to conduct a compliance tour of Scioto on February 22-24, 2011. Our goal is to provide a third complete compliance report based on the February 2011 compliance tour to the Court on or before May 9, 2011.
Respectfully submitted this 8th day of February, 2011.

FOR THE UNITED STATES:

THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Section Chief Special Litigation Section U.S. Department of Justice Civil Rights Division
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section U.S. Department of Justice Civil Rights Division
s/ Silvia J. Dominguez______________ Silvia J. Dominguez Rashida Ogletree Trial Attorneys Special Litigation Section U.S. Department of Justice. Civil Rights Division 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530

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IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, )

Plaintiff,

)

v.

) CIVIL ACTION NO:

) 2:08-CV-475-ALM

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

ADDENDUM TO SECOND COMPLIANCE REPORT
Pursuant to provision V.H. of the Consent Order in U.S. v. Ohio, 2:08-CV475, the United States, as Monitor, submits its addendum to its second report of its assessment of the State of Ohio’s (“State”) compliance with the June 4, 2008 Consent Order. For each mental health provision, a recitation of the provision is provided, followed by a narrative describing the United States’ analysis of the State’s compliance efforts, and a compliance rating. Where possible, the United States provides recommendations to assist the State attain substantial compliance with a particular provision.

On February 8, 2011, the United States submitted to this Court its Second Compliance Report. It noted in the introduction that the addendum would follow. (See Dkt. # 72 at 1). This Addendum to the Second Compliance Report represents the United States’ assessment of the State’s compliance with provisions B.1-18, which relate to Ohio Department of Youth Services (“ODYS”) policies, procedures, and practices governing the mental health services for youth at Scioto Juvenile Correctional Facility (“Scioto”). The Addendum is organized in this order and follows the structure of the Consent Order.

The United States’ assessment is based upon document review (including, but not limited to, policies, procedures, training documents, youth records, and the

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State’s self-assessment), the expert report from Dr. Daphne Glindmeyer, youth and staff interviews, and an on-site compliance tour in November 2010. We have attached to this Addendum the expert report of Dr. Glindmeyer. 1 The United States intends to provide a third compliance report regarding the status of the State’s compliance with all provisions following its upcoming compliance tour on February 22-24, 2011. Consistent with the U.S. v Ohio Consent Order, the United States provided the State a draft version of this Addendum to the Second Compliance Report and the expert report two weeks prior to filing with the Court.
EXECUTIVE SUMMARY OF MENTAL HEALTH COMPLIANCE RATINGS
The State is in partial compliance with 16.66% of the mental health provisions (3 of the 18 provisions), is in beginning compliance with 66.67% (12 of the 18) and is in non-compliance with 16.67% (3 of the 18) of the provisions. The State has not achieved substantial compliance with any provision. 2
Achieving “substantial compliance” with some of the mental health provisions in the Consent Order will require significant effort and resources going forward. In particular, the State will need to focus its efforts on the five provisions rated as noncompliant. In this regard, we remain committed to working with the State through technical assistance.
1 Dr. Glindmeyer prepared her First Mental Health Report (“Glindmeyer First Mental Health Report”) labeled as Attachment E.
2 “Substantial Compliance” indicates that the State has met or achieved all of the components of a particular provision. “Partial compliance” indicates that the State has made notable progress in achieving compliance with the key components of the provision, but substantial work remains. “Beginning compliance” means that the State has made notable progress in achieving compliance with a few, but less than half, of the key components of the provision. “Non compliance” means that State has made no notable progress in achieving compliance on any of the key components of the provision.
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BACKGROUND TO MENTAL HEALTH SERVICES AT SCIOTO In our May 9, 2007 Findings Letter, the United States addressed the mental health care services provided at Scioto. In short, the United States found that the “mental health care at Scioto’s intake facility and girls’ facility is constitutionally inadequate.” See United States’ May 9, 2007 Findings Letter at 10.3 Specifically, the United States found that the mental health intake assessments suffered from poor data gathering and recording and often failed to address important considerations such as cognition problems, impact of trauma, school history, past treatment experiences, past treatment responses, and dysphoric moods. Id. at 11. The United States found Scioto’s psychological assessments to be inadequate because they rarely included specific treatment recommendations or considered multiple concurrent conditions, despite the prevalence of such conditions among Scioto’s population at the time. Id. at 12. The psychological assessments also failed to consider alternative diagnostic hypotheses and did not link the diagnoses to likely functional problems, such as socialization problems or aggressiveness. The United States found that a number of obvious candidates for psychiatric care were not referred for psychiatric assessments. Id. We found that Scioto’s overall mental health staffing was inadequate, allowing for only superficial assessments without any routine follow up. Id. Consequently, youth’s mental health needs were often untreated or inappropriately treated, resulting, among other things, in no treatment, counterproductive treatment, exposure to inappropriate or unnecessary medications posing serious physical or other side effects, longer periods of confinement, and needlessly greater potential for recidivism. Id. Further, based on a review of randomly selected files, the United States found that Scioto’s process for identifying youth with mental illness was inadequate and that girls with significant mental disorders often went unidentified and untreated. Id. at 13. For those youth with identified mental disorders, the United States found that they did not receive “regular, scheduled treatment sessions, allowing these disorders to go neglected.”
3 The May 9, 2007 Findings Letter is labeled as Attachment F. 3

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Id. This is not an exhaustive list of our 2007 findings, but is intended to present to the Court the bases for the requirements of the mental health provisions of the U.S. v Ohio Consent Order.
Since the Consent Order became effective in June 2008, the State has had over two and half years to improve its mental health program. Unfortunately, the State is not yet in substantial compliance with any of the 18 mental health provisions. Moreover, the State provided a self-assessment for these 18 provisions in which it claims to have already reached substantial compliance with some provisions as early as 2004—four years prior to the date of the U.S. v Ohio Consent Order and the agreement in the related case S.H. v Stickrath. We strongly recommend that the State commit to improving its mental health services with as much vigor as it did with regard to protection from harm and educational services. Based on our communications with the State in December 2010, it appears that the State recognizes that it has not made as significant progress in mental health as compared to protection from harm and that the State is eager to improve. We are encouraged that the State aspires to improve. We look forward to learning what progress the State believes that it has made since our November 2010 tour.
GLOBAL RECOMMENDATIONS
As discussed further below, we recommend that the State consider incorporating a quality assurance monitoring mechanism (“QA”) as it revamps its mental health policies, procedures, and practices. As described by Dr. Glindmeyer in her report, there are various respects in which a QA mechanism would be helpful to the State. (See, e.g. Glindmeyer First Mental Health Report at 3). We also recommend that the State seek assistance as it overhauls much of its mental health services program. In September 2010, the State requested that the United States, through Dr. Glindmeyer, provide technical assistance regarding the State’s draft behavioral health policies. We were pleased to do so and are open to providing similar technical assistance in the future.
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COMPLIANCE ASSESSMENTS AND RATINGS I. MENTAL HEALTH B.1 MENTAL HEALTH SCREENING
The State shall develop and implement policies, procedures, and practices to ensure that all youth admitted to the Facilities are comprehensively screened for mental disorders, including substance abuse, depression, and serious mental illness, within twenty-four hours of admission. This screening shall be performed by qualified personnel, as part of the intake process, consistent with generally accepted professional standards of care. (See Consent Order III.B.1)
In assessing this provision, we reviewed the State’s self-assessment, current and draft policies and procedures, and youth records. Based on our review, it appears that the current ODYS policies and procedures meet most of the requirements of provision B.1. Due to the lack of reception risk interviews, however, we were unable to assess the State’s actual screening practice. We received assessment summaries, which were of varying quality, but did not receive any reception interviews. Without the reception interviews, it is difficult to assess the quality of the overall screening. In the future, we encourage the State to ensure that all necessary documentation to assess mental health screenings is available for our review.
We understand that the State intends to implement a new policy, “Behavioral Health Assessment, Screening, Appraisal and Evaluation,” which, as the name implies, will address different aspects of a youth’s behavioral health assessments including screenings. The new policy includes a plan for the creation of a Behavioral Health Review Panel to assess intake data and make recommendations about future housing, programming and treatment needs. This would be a positive step, as it would begin the interdisciplinary review and treatment process at the time of admission. In addition, we understand that the State intends to finalize and implement a policy regarding quality assurance. We recommend that the State continue to develop and implement this policy.
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Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
The State is encouraged to seek technical assistance regarding its new youth screening policies and procedures. We look forward to reviewing this provision and the State’s self-assessment (both written and oral) as it relates to this provision during our next compliance tour.
B.2 IMMEDIATE REFERRAL TO A QUALIFIED MENTAL HEALTH PROFESSIONAL
If the mental health screen identifies an issue that places the youth’s safety at immediate risk, the youth shall be immediately referred to a qualified mental health professional for assessment, treatment, and any other appropriate action, such as transfer to another, more appropriate setting. The State shall ensure that, absent extraordinary circumstances, qualified mental health professionals are available for consultation within 12 hours of such referrals. (See Consent Order III.B.2)
In assessing this provision, we reviewed the State’s self-assessment, policies, procedures, youth schedules and psychology staff schedules. Based on our review, we found that the State’s current policies and procedures are adequate, but we were unable to assess the State’s practice. While some assessment summaries were found to be of good quality, the State did not provide documentation regarding the referral process.4 Specifically, the State’s documentation was insufficient to assess
4 On June 29, 2010, the United States provided the State with its request for mental health documents to be produced during the November 2-5, 2010 on-site tour. The State and the United States disagree as the reason why documentation was delayed. In order to avoid any similar problems in the future, on December 15, 2010, the United States informed the State that, for its upcoming February 2011 tour, the United States would only accept documents that are available on the first day of the tour, February 22, 2011. The United States provided the State its document request on January 19, 2011 and made Drs. Dedel, Staples-Horne and Glindmeyer available to answer any questions about the document request.
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the elapsed time between the request for service and the response to that request. Since the language of the provision explicitly requires that, absent extraordinary circumstances, a qualified mental health professional (“QMHP”) be “available for consultation within 12 hours of such referral” such documentation is critical to the State demonstrating its compliance. We agree with Dr. Glindmeyer’s suggestion that a QA mechanism regarding the length of time to provide the consultation would benefit the State. (See Glindmeyer First Mental Health Report at 3).
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
We recommend that in its next self-assessment, the State discuss and demonstrate its efforts to reach substantial compliance with provision B.2. In particular, the State should present documentation that the State meets the requirement to have QMHP available for consultation within 12 hours of a referral, absent exigent circumstances. We look forward to assessing the State’s compliance with this provision in the future.
B.3 IDENTIFICATION OF PREVIOUSLY UNIDENTIFIED YOUTH WITH MENTAL DISORDERS
The Facilities shall implement policies, procedures, and practices consistent with generally accepted professional standards of care to identify and address potential manifestations of mental or behavioral disorder in youth who have not been previously identified as presenting mental health or behavioral needs requiring treatment. (See Consent Order III.B.3)
In assessing this provision, we reviewed the State’s self-assessment, policies and procedures, youth records and draft policies and procedures. Based on our review, we found that the State’s self-assessment fails to address the heart of the provision. Specifically, the self-assessment discussion does not speak to identifying youth who were not previously identified as presenting mental health or behavioral
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needs requiring treatment. The State’s self-assessment requires monitoring youth who are in seclusion to evaluate for decompensation, which is appropriate, but does not cover all youth. We agree with Dr. Glindmeyer’s interpretation that the goal of provision B.3 is to ensure that youth who may not present with “a history of mental illness and who are not identified at the time of the initial assessment . . . are monitored over the course of their incarceration for exacerbations of symptoms and referred for mental health treatment.” (See Glindmeyer First Mental Health Report at 5).
It is our understanding that the State intends to implement a new policy, “Behavioral Health Assessment, Screening, Appraisal and Evaluation.” Based on the draft language provided, we are concerned about the policy’s overall generic tone. We recommend adding language that addresses previously unidentified youth. We note that the draft policy requires an evaluation within 24 hours of submission for an urgent referral, and within 7 days of submission for a routine referral. (See Glindmeyer First Mental Health Report at 5). Based on the State’s recent mental health staffing shortages, discussed below under provision B.11, full implementation of the State’s proposed 24 hour and 7 day deadlines will be difficult to meet. While there is no certainty that the State will not be able to meet the deadlines, we highlight the possibility so the State can develop any necessary safeguards or responses. We look forward to reviewing this provision during our next compliance tour.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
As noted above, we recommend that the State ensure that the new draft policy regarding screenings, evaluations, appraisals and re-evaluations capture previously unidentified youth. Accomplishing this task will enable the State to begin its progress towards substantial compliance with provision B.3.
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B.4 MENTAL HEALTH ASSESSMENT
The State shall implement policies, procedures, and practices to ensure that, as part of an overall assessment of the youth’s health, risk, strengths and needs, youth who are identified in screening as having possible mental health needs receive timely, comprehensive, and accurate assessments by qualified mental health professionals, consistent with generally accepted professional standards of care. Assessments shall be designed and implemented so as to identify youth with mental disorders in need of specific treatment and contribute to a full plan for managing the youth’s risk. Assessments shall be updated as additional diagnostic and treatment information becomes available. (See Consent Order III.B.4)
In assessing this provision, we reviewed the State’s self-assessment, youth records, and ODYS policies and procedures. Based on our review, we found that the State is currently performing mental health assessments and appraisals at intake/reception. The initial assessments reviewed provided useful information, but were found to be of varying quality. We refer the State to Dr. Glindmeyer’s specific comments regarding particular assessments. (See Glindmeyer First Mental Health Report at 7).
We are encouraged to see that the State already plans to establish clinical review teams to provide formal recommendations. Lastly, it is our understanding that the draft policy, “Behavioral Health Assessment, Screening, Appraisal and Evaluation,” discussed above under provision B.3, is anticipated to also address the requirements of provision B.4. We look forward to reviewing the final policy and procedure as well as documentation that demonstrates their implementation.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
We agree with Dr. Glindmeyer’s recommendation that QA in this area would benefit the State. (See Glindmeyer First Mental Health Report at 8). We also
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recommend that the State implement its draft policy, “Behavioral Health Assessment, Screening, Appraisal and Evaluation.”
B.5 ADEQUATE MENTAL HEALTH CARE ANDTREATMENT
The State shall implement policies, procedures, and practices to ensure that adequate mental health and substance abuse care and treatment services (including timely emergency services), and adequate rehabilitative services are provided to youth in the Facilities by qualified mental health professionals consistent with generally accepted professional standards of care. (See Consent Order III.B.5)
In assessing this provision, we reviewed the State’s self-assessment, youth records, ODYS policies and procedures, and group schedules. Based on our review, we determined that some treatment is currently being provided at Scioto. But we noted that the group treatment for female youth outpaced that of male youth. It is our understanding that the male mental health unit began in May 2010 in Scioto and therefore the State is creating such treatment from scratch. Nevertheless, the State must meet its obligation to provide appropriate treatment to the male mental health youth at Scioto. During our next on-site tour, we look forward to observing any evidence based group interaction scheduled for youth.
In her report, Dr. Glindmeyer discusses two group therapies that she witnessed during the compliance tour and describes youth as engaged and the facilitators as prepared. (See Glindmeyer First Mental Health Report at 9-10). Dr. Glindmeyer was particularly impressed with the level of organization by the facilitators and engagement by the youth. We commend the State on the successful group therapies observed and encourage it to make more courses available to the male youth. Despite the loss of mental health staff, group therapeutic interactions have remained relatively stable from 2009 to 2010. However, we are concerned that the loss of mental health staffing is severely reducing the number of individual
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therapeutic interactions, including individual counseling, received by mental health youth. 5
In addition, we recommend that the State ensure that the documentation in youth records clearly articulate the youth’s progress towards goals in that youth’s treatment plan and that youth reports incorporate or discuss targeted interventions in that youth’s treatment plan. Our review of documentation found that the quality of treatment plans was of varying quality.
Despite these findings, we are encouraged by the fact that the State is already making strides towards improving its treatment program. During our November 2010 on-site tour, we were informed that the State would be implementing its new treatment program, “New Freedom Phoenix” in January 2011. We look forward to assessing the New Freedom Phoenix program and any data the State can provide regarding the efficacy of the program. We also note that the State intends to expand its treatment modalities. We look forward to reviewing the new policies and procedures for the New Freedom Phoenix program. In particular, we hope to see that the policies and procedures address the requirements of provision B.5 and ensure that QMHPs provide adequate mental health, substance abuse, treatment services, and rehabilitative services.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
In addition to our recommendations above, we strongly suggest the State take steps to improve its documentation of group and individual interactions, ensure the provision of evidence-based group therapeutic interactions, and ensure
5 Dr. Glindmeyer found that, as compared to the year before, in 2010, there was an 18% reduction in the number of individual therapeutic interactions. (See Glindmeyer First Mental Health Report at 11).
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that rehabilitative and substance abuse services are also included in the new treatment program.
B.6 TREATMENT PLANNING The State shall develop and implement policies, procedures, and practices so that treatment service determinations, including ongoing treatment and discharge planning, are consistently made by an interdisciplinary team through integrated treatment planning and embodied in a single, integrated treatment plan. (See Consent Order III.B.6)
In assessing this provision, we reviewed the State’s self-assessment and existing and draft policies and procedures, and we interviewed staff. Based on our review, it is our understanding that the State is in the process of revising its policies and procedures regarding the interdisciplinary treatment team and how its treatment planning will be documented. At the time of our tour, the State provided information about some interdisciplinary treatment (“IDT”) team meetings that were being held. As discussed further in provision B.7 below, it appears that no psychiatrist attended the IDT meetings. This is problematic. Also, while the State is currently developing and revising its integrated treatment plan model, it is not yet complete. It is troubling that, after more than two and half years, the State has not made tangible progress in this fundamental area. The State is currently noncompliant with this provision.
Compliance Rating: Non-Compliance
Recommendation(s) to reach substantial compliance:
The State is encouraged to seek technical assistance with this provision to accelerate its compliance efforts.
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B.7 TREATMENT TEAMS At a minimum, the interdisciplinary treatment team for each youth in need of mental/behavioral health and/or substance abuse treatment should:
a. Be guided by a trained treatment professional who shall provide clinical oversight and ensure the proper functioning of treatment team meetings;
b. Consist of a stable core of members, including at least the youth, the social worker, a JCO, one of the youth’s teachers, the Unit Managers, and as warranted by the needs of the youth, the treating psychiatrist, the treating psychologist, registered nurse, and, as appropriate, other staff;
c. Ensure that needed psychiatric evaluations are conducted on a youth before administering psychotropic medications to the youth;
d. Monitor as appropriate but at least monthly, the efficacy and the side effects of psychotropic medications, including consultation with the facility medical, counseling, and other staff who are familiar with the youth;
e. For youth under a psychiatrist’s care: ensure the provision of individual counseling and psychotherapy when needed, in coordination with facility psychologists; ensure that all youth referred as possibly in need of psychiatric services are evaluated and treated in a timely manner; and provide adequate documentation of treatment in the facility medical records;
f. Include, to the fullest extent practicable, proactive efforts to obtain the participation of parents or guardians, unless their participation would be inappropriate for some reason (e.g. the child has been removed from the parent’s custody), in order to obtain relevant information, understand family goals and concerns, and foster ongoing engagement;
g. Meet to assess the treatment plan’s efficacy at least every 30 days, and more often as necessary; and
h. Document treatment team meetings and planning in the youth’s mental health records. (See Consent Order III.B.7)
In assessing this provision, we reviewed the State’s self-assessment, Interdisciplinary Team minutes, and youth records, and we interviewed staff and observed an IDT team meeting. Based on our review, it appears that the State’s draft policies do not meet all of the requirements of provision B.7. The provision lists the individuals that must be the “stable core of members” of the treatment team, such as the youth, one of the youth’s teachers, and the unit manager. We found that inclusion of a direct care worker and a social worker was left to the
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discretion of the treatment team leader. In addition, it did not appear that the State’s policy considers situations where parental involvement would be inappropriate. The language in provision B.7 states that proactive efforts should be made to involve the parent or guardian “unless their participation would be inappropriate for some reason (e.g. the child has been removed from the parent’s custody).” We recommend the State ensure that parents will not be involved in the youth’s treatment meeting if inappropriate. Additionally, it was unclear whether the State intends to provide the same IDT to youth with substance abuse issues in accordance with the language of provision B.7.
During the November 2010 on-site tour, Dr. Glindmeyer observed an IDT meeting. In her report, she discusses that staff and youth appeared interested and engaged. We were pleased that important topics such as the youth’s psychotropic medication were discussed in the meeting. Please see Dr. Glindmeyer’s report for her full discussion. (See Glindmeyer First Mental Health Report at 14).
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
As discussed above, the lack of psychiatry staff participation in the IDT is troubling. We note that, prior to September 2010, psychiatrists participated in IDT meetings. We recognize that the psychiatry staff at Scioto is currently in flux and that the State is making efforts to replenish this staff. We strongly urge the State to make this a priority. Based on our review of the IDT documentation in youth records, we found that they were of variable quality. This may indicate a need for QA and re-training or simply reflect the strains from low staffing. We note that the proposed draft policy also has new documentation requirements. We look forward to reviewing this during our next compliance tour.
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B.8. INTEGRATED TREATMENT PLANS
The State shall ensure that each youth in need of mental/behavioral health and/or substance abuse treatment shall have an appropriate, integrated, treatment plan, including an appropriate behavioral management plan, that addresses such needs. The integrated treatment plan shall be driven by individualized risks and needs, be strengths-based (i.e. builds on an individual’s current strengths), account for the youth’s motivation for engaging in activities contributing to his/her wellness, and be reasonably calculated to lead to improvement in the individual’s mental/behavioral health and well being, consistent with generally accepted professional standards of care. (See Consent Order III.B.8)
In order to assess this provision, we reviewed the State’s self-assessment, draft policies and procedures, youth records and interviewed staff. Based on this review, we found the State’s current multi-level process to compose youth’s treatment plans to be confusing. It is our understanding that the State is currently revising this process, and we support the State’s plan to integrate the three processes into one method. Similar to our discussion in provision B.6, it is troubling that, after two and a half years, the State has yet to make any substantive progress in creating an integrated treatment plan for youth with mental health, behavioral health and/or substance abuse needs. The State is non-compliant with this provision.
Compliance Rating: Non-Compliance
Recommendation(s) to reach substantial compliance:
We recommend that the State consider the recommendations made by Dr. Glindmeyer in her report regarding the new IDT plan model. (See Glindmeyer First Mental Health Report at 16). In addition, we remind the State that its IDT plans should also be available to youth with substance abuse needs. We look forward to reviewing the new policies, procedures, and practices during our
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upcoming tour. We encourage the State to detail in its self-assessment (both oral and written) how the new IDT plan model meets the language of provision B.8.
B.9 ACCESS TO A QUALIFIED MENTAL HEALTH PROFESSIONAL
The State shall develop and implement policies, procedures, and practices to ensure that youth who seek access to a qualified mental health professional are provided appropriate access in a timely manner. ((See Consent Order III.B.9)
In order to assess this provision, we reviewed the State’ self-assessment, policies and procedures, and youth records. Based on our review, we found that the current policies and procedures for referrals detail steps for staff to refer youth for a mental health assessment. The policy did not, however, address the requirements in provision B.9, namely that Scioto youth be able to seek access to a QMHP in a timely manner. In its self-assessment, the State relies on particular language in the Youth Handbook which directs a youth to complete a “Request for Services” for routine concerns and to immediately tell a staff member if they feel like hurting themselves or others, and the staff member “will see the issue is addressed.” While we recognize that Scioto has readily available “Request for Services” forms, we are concerned by the generic and vague description of staff’s role in obtaining assistance for the youth. More importantly, we share Dr. Glindmeyer’s concern that youth must go through staff in order to access care. (See Glindmeyer First Mental Health Report at 19).
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
While the State appears to have a detailed process for staff to refer youth to a QMHP, there does not appear to be a self-referral process that does not rely on staff involvement. We recommend the State revise its policies as needed and seek technical assistance.
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B.10 MENTAL HEALTH INVOLVEMENT IN HOUSING AND PLACEMENT DECISIONS The State shall develop and implement a system for ensuring that significantly mentally ill youth who do not have the adaptive functioning to manage the activities of daily living within the general population are provided appropriate housing and supports to assist them in managing within the institutional setting. (See Consent Order III.B.10)
In order to assess this provision, we reviewed the State’s self-assessment, relevant draft policies and procedures, and 16 youth records. At the time of the November 2010 monitoring tour, the facility employed two mental health units on campus: one designated for female youth (the Davey Unit, capacity 12 youth), the other for male youth (the Buckeye Unit, capacity 18 youth). According to the State’s self-assessment, there is policy and procedure entitled “Mental Health Referral, Evaluation, and Disposition.” This policy “identifies the process for consideration and referral for mental health treatment, including placement on a mental health unit when determined to be necessary.” The State provided an additional draft policy entitled “Behavioral Health-Special Services Living Units,” which provides “guidelines for the referral of youth identified through clinical assessment as needing specialized housing and programming for the stabilization of the symptoms of an identified mental illness and program modifications due to cognitive and/or developmental limitations.” This policy proposed the development of a “Behavioral Health Review Panel,” which would be responsible for “review[ing] information obtained in the reception process and determin[ing] the best options for each youth in regard to housing, programming.” While we cannot yet determine the efficacy of these draft policies, the adoption of a review panel would be a positive step. See B.1.
Youth records included Reception Assessment Summaries that documented the State’s housing determinations. A review of documentation provided for youth 999 included the Reception Assessment Summary created June 25, 2010. Staff recommended that the youth be placed in the “Intensive Mental Health Unit.”
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Following completion of intake, this youth was transferred to the Davey Unit. A review of documentation provided for youth 220 included the Reception Assessment Summary created February 16, 2010. Staff recommended that youth 220 be “consider[ed] for Intensive Mental Health Unit.” This youth is currently residing on the Davey Unit; however, it was difficult to discern via records provided if this residence occurred immediately following the completion of the intake assessment. Review of additional youth records provided for off-site review revealed similar recommendations with youth placement in mental health units. “Mental Health Transfer Fact Sheets,” which outlined the youth’s specific treatment needs, accompanied these recommendations. It was apparent that mental health staff make housing recommendations during the intake/assessment period based on the results of the youth’s assessment.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance: While the youth placed in the mental health unit were appropriately placed,
it does not appear that the State has implemented a system – supported by final policies and procedures – for ensuring that significantly mentally ill youth are provided appropriate housing and supports. The State should continue to implement the relevant draft policies and procedures, including the development of the proposed “Behavioral Health Review Panel.” We also encourage the State to consider QA measures to review the accuracy and completeness of its assessments and placement decisions.
B. 11 STAFFING
The State shall staff, by contract or otherwise, the Facilities with adequate numbers of psychiatrists, psychologists, social workers, and other mental health professionals qualified through training and practical experience to meet the mental health needs of youth residents, as determined by the acuity of those needs. Mental health care shall be integrated with other medical and
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mental health services and shall comport with generally accepted practices. The State shall ensure that there are sufficient numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming. (See Consent Order III.B.11).
In order to assess this provision, we reviewed the State’s self-assessment, relevant policies and procedures, 16 youth records, and staff schedules, and we interviewed staff. Based on our review, we determined that there are staff shortages at the Scioto facility that are compromising youth’s mental health care. The administrative psychiatrist (board certified in child and adolescent psychiatry) has been providing one day of direct clinical services per week (0.2 Full Time Equivalent (“FTE”)). The State recruited a second psychiatrist to provide 20 hours of direct clinical services per week (0.5 FTE) via an emergency services agreement. At the time of the November 2010 on-site tour, the facility was stretched with regard to psychiatric resources, as it then had a total of 0.7 FTE and was in the process of recruiting additional staff. Unfortunately, the State did not provide the curriculum vitae (“CV”) of the current psychiatric staff; so we cannot assess their qualifications at this time.
Prior to September 30, 2010, the facility had two psychiatric physicians (a total of 1 FTE) providing care. It is our understanding that the two individuals resigned. Once new staff are hired and in place, the State should determine whether 1 FTE of psychiatry will be sufficient to meet the facility’s needs. These needs include psychiatric evaluation, medication management, participation in IDT team, administrative responsibilities, and emergency management. We recognize that the Scioto psychiatry and psychology staff are making a great effort to compensate for losing staff members. To be clear, the current stress on staff is not a sustainable long-term solution.
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With regard to psychology, the State’s self-assessment reported a total of four psychologists and five psychology assistants on staff. According to interviews conducted during the November 2010 facility tour, Scioto employs a total of seven psychologists (three licensed), a psychology supervisor, and two psychology assistants. Of the seven psychologists, five were assigned to the assessment units, the remainder to the program units. Dr. Glindmeyer’s interviews with staff revealed unmanageable caseloads. (See Glindmeyer First Mental Health Report page 22). Other staff noted concerns regarding the quality of treatment being provided to youth. Specifically, staff reported that “things are moving so fast … knee jerk reactions … the treatment planning is unwieldy … it is too much for show and not enough for efficacy.” We are very concerned about such comments.
The State’s self-assessment reported a total of 18 social workers on staff. According to interviews conducted during the tour, there were a total of 14 social workers on staff, with 4.5 assigned to the reception units and 9.5 assigned to the program units. There was one vacancy in the social work staff. Interviews with facility staff revealed concerns regarding the quality of social work staff. Specifically, staff reported that “all the licensed [social workers] are leaving … because of the schedule changes.” (See Glindmeyer First Mental Health Report page 23). Other interviews revealed that, until recently, there had been a lack of leadership in the social work division. It was reported that, in the first week of November 2010, a new supervisor was hired and began work at Scioto.
Additional mental health staff include mental health nurses and occupational therapists. At the time of the November 2010 tour, there were two full time mental health nurses providing services at Scioto, as well as two full time occupational therapists. Data regarding additional available FTE and current vacancies in these positions (if any) were unavailable at the time this report was authored.
According to observations and interviews, the current mental health divisions are not working together to create integrated treatment for the facility youth. At the time of the monitoring tour, three separate sets of documents existed to provide
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guidance for a youth’s mental health treatment: the Unified Care Plan, the Mental Health Treatment Plan, and the Interdisciplinary Treatment Team documents.
The State did not provide information regarding the integration of mental health and medical care in its self-assessment. Nor has the State provided data supporting a finding that there are adequate numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming at this time. The State is in beginning compliance with this provision.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance: According to staff interviews during the November 2010 tour, there are plans
to begin use of an Integrated Treatment Plan beginning January 1, 2011. We hope that the State’s implementation of the New Freedom Phoenix program, as well as the focus on behavioral health treatment modalities, including trauma-based treatment and cognitive behavioral therapies, will ensure that each youth has one overarching treatment plan and will help treatment providers form a cohesive treatment team unit. However, the State cannot reach substantial compliance with this provision until it recruits additional mental health staff and fills the current vacancies. The State should consider using objective data, such as workload indicators, to determine its staffing needs. In addition, the State must significantly improve coordination amongst the mental health staff in order to facilitate integrated treatment for Scioto’s youth. Finally, in its next self-assessment, the State should provide CVs for all current mental health professionals, and evidence demonstrating the integration of medical and mental health care and demonstrating that there is sufficient direct care and supervisory staff to allow youth reasonable access to structured programming.
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B.12 MEDICATION NOTICE
Before renewing a psychoactive medication prescription from a community provider or commencing the administration of a psychoactive medication to a youth, the State shall ensure that the youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, are provided with information regarding the goals, risks, benefits, and potential side effects of the medication and given an explanation of the potential consequences of not treating with the medication, and that the youth has an opportunity to consent to such medication.
a. Involuntary administration of psychotropic medication(s) to juveniles shall comply with applicable federal and state laws and regulations. The DYS clinical director, in consultation with the DYS medical director, shall review any request with DYS Legal Services prior to the approval for involuntary administration. (See Consent Order III.B.12).
In order to assess this provision, we reviewed the State’s self-assessment, relevant policies and procedures, and 16 youth records. According to the ODYS policy entitled “Psychotropic Medication, Use and Management,” the State educates each youth and his or her parent or guardian about “the goals, risks, benefits, and potential side effects” associated with any medication prescribed by the physician. In addition, the prescribing physician provides an explanation of the potential consequences of not taking the medication and explains that the youth has an opportunity to consent or withhold consent to be treated. The policy also “provides guidelines within which medical professionals may petition the court to authorize involuntary administration of psychotropic medication.”
A review of youth records revealed varying quality of documentation regarding risks, benefits, side effects and alternatives to treatment. The bulk of psychiatric documentation in youth records was attributable to prior treatment providers who ended their association with the facility September 30, 2010. The record of youth 999 revealed a psychiatric evaluation performed June 24, 2010, which documented a discussion consistent with obtaining informed consent with both the youth and her mother, inclusive of a documented review of some side effects. The youth completed a form entitled “Information about Medications for Youth with Mental Health Diagnoses.” Although the information was incomplete, it
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was apparently filled out by the youth and demonstrated some knowledge regarding side effects of the prescribed medications.
More recently, youth 110 received a psychiatric evaluation on October 8, 2010. There was basic documentation of informed consent. The records state that “risks, benefits, and side effects of medication were discussed. Consent was obtained by [sic] him, mom … was agreeable to medication as well.” The “Information about Medications for Youth with Mental Health Diagnoses” form was included, and while completed, did not reveal a good understanding of potential side effects.
Youth 888 was admitted to the facility on October 12, 2010 and was prescribed psychotropic medication consisting of Geodon and Depakote. This youth’s record included the “Information about Medications for Youth with Mental Health Diagnoses” form. It was incomplete in that it did not designate the diagnosis, did not identify specific side effects, and was not signed by the youth. The psychiatric evaluation performed at admission did not document review of informed consent issues, nor did it document contact with the youth’s parent or guardian. While the documentation needs improvement, interviews with youth revealed that youth were able to name some of the medications prescribed and some side effects of the medications.
Finally, the documentation contained no information regarding petitions for authorizations to involuntary administer medications. Additional information regarding this issue will be requested for the next monitoring tour.
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance: While it is a positive sign that youth were able to name some of the
medications prescribed and some of the side effects, the State must document that youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, are informed of the goals, risks, benefits, and potential side effects of
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medication. The State must also document that youth are given informed explanations of the potential consequences of refusing medication and that the youth have an opportunity to consent to such medication. The State cannot reach substantial compliance until it improves the quality and consistency of this documentation. We encourage the State to consider a peer review process for informed consent and other psychiatric documentation. In addition, the State should consider the development of information regarding side effects of psychotropic medication that is written in language that youth can understand. We note that such information is also available commercially.
B. 13 MENTAL HEALTH MEDICATIONS
The State shall develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices. The State shall provide regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy. The State shall issue and implement policies and procedures for the administration of appropriate tests (including, for example, blood tests, EKGs, and Abnormal Involuntary Movement Scale tests) to monitor the efficacy and any side effects of psychoactive medications in accordance with generally accepted professional standards. The State shall also: a. Share medication compliance data with the psychiatrist and document the
sharing of this information; and b. Not withhold the provision of psychostimulants to youth when such
treatment is clinically warranted. (See Consent Order III.B.13)
In order to assess this provision, we reviewed the State’s self-assessment, relevant policies and procedures, lists of youth prescribed medication, mental health caseload documentation, and 16 youth records, and we conducted clinical observations and interviewed youth and staff. Scioto has a policy in place entitled “Psychotropic Medication, Use and Management,” which “provides the parameters for using medication for psychiatric purposes … education addressing the goals, risks, benefits, and potential side effects associated with any given medication.”
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Scioto also has a document entitled, “Recommended Laboratory Monitoring Frequency Guidelines.”
While the Consent Order requires the State to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, psychiatric services at Scioto are limited. See B.11 (“Staffing”). Given the departure of the two long term psychiatric providers, and the lack of clinical resources, the psychiatry clinic at the Scioto facility was not fully functional at the time of the tour. According to staff interviews, the psychiatrists had been unable to attend interdisciplinary treatment team meetings, and were reduced to receiving “snippets of information for clinic from school, psychology and direct care.” (See Glindmeyer First Mental Health Report at 27). Psychiatric administration reported that, as a “stop gap” measure, a noon meeting had been established between psychiatry and other disciplines for the purposes of reporting information and responding to staff queries.
As stated above, our review of selected youth records revealed that the majority of documentation was attributable to the prior treatment providers. In older files, psychiatric evaluations and progress notes documented the rationale for treatment with a specific psychotropic medication, the identification of target symptoms and discussions regarding the risks, benefits, side effects, and alternatives to treatment with a particular medication, documented attempts or actual contact with a youth’s parent or guardian, documented review of laboratory examinations and abnormal involuntary movement monitoring (youth 444, youth 555, youth 999). More recent psychiatric documentation was not as complete, in that there was no documentation of abnormal involuntary movement monitoring, laboratory review, or parent contact. This may be reflective of diminished clinical resources. Interviews with youth performed during the monitoring tour revealed that they had acceptable knowledge regarding their prescribed medication and potential side effects.
The psychiatrist reported taking after-hours calls for psychiatric emergencies at the facility. This report of on-call duty contradicted information
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received from a document request, which indicated that psychiatry did not have oncall responsibilities at the facility. In addition, it was reported that there is no formal process for informing the psychiatrist when a youth is placed on suicide watch or other restriction. This is an area in need of improvement. The generally accepted practice is that the psychiatrist would be informed and aware that a youth on his or her caseload required enhanced supervision.
On the positive side, the psychiatrist reported good access to laboratory examinations following a physician order and good communication between the lab and the physician when abnormal laboratory results are found. The psychiatry clinic was observed during the monitoring tour, and the psychiatrist did a good job of establishing rapport with the youth. He queried the youth regarding side effects associated with a particular medication and also elicited information from the youth regarding expected medication benefits. The psychiatrist reviewed the youth’s medical record inclusive of school and behavioral information.
During the clinic observation, the psychiatrist dictated clinical contact notes for three youth prescribed medication. However, the psychiatrist did not document the three youth’s weight, vital signs, laboratory examinations, or the results of abnormal involuntary movement monitoring. This was concerning, as psychotropic medications can have serious metabolic side effects, and generally accepted practice requires monitoring of these and other parameters.
In the record of youth 555 there was an example of the sharing of information regarding medication compliance. This youth was reportedly planning to refuse medication due to side effects. This youth was seen five days following an email reporting his concerns. Given the current staff shortage at the facility, this is an acceptable delay; however, the facility should attempt to shorten the wait between a referral for services and actual clinical contact. This will require the recruitment of full time psychiatric staff.
At the time of the November 2010 tour, there were 141 youth housed on campus. Of these, 49 or 35%, were prescribed psychotropic medication. Of these,
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ten were prescribed stimulant medications as a result of diagnoses including Attention Deficit Disorder (“ADD”), Attention Deficit Hyperactivity Disorder (“ADHD”) or other Axis 1 mental health disorders. An additional two youth were prescribed Strattera, a non-stimulant medication used for the treatment of ADD and/or ADHD.
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance: We commend the State for ensuring that the psychiatrist has adequate
access to laboratory examinations following a physician order and for maintaining good communication between the lab and the physician when abnormal lab results are found. However, in order to reach substantial compliance, the State must recruit psychiatric physicians to fill the available positions. Without sufficient mental health staffing, the State cannot ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices. The State should determine the number of FTEs required to perform necessary psychiatric duties, including clinics and attendance at treatment team meetings. In addition, we recommend that the State develop a formal process for informing the psychiatrist when a youth is placed on suicide watch or other restriction. We also recommend that the State improve psychiatric documentation and consider QA monitoring or a peer review process. Finally, it does not appear that the State is providing regular training to all health and mental health staff on current issues in psychopharmacological treatment as required by the stipulation. We strongly urge the State to devise a training schedule to meet this obligation.
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B.14 MENTAL HEALTH AND DEVELOPMENTAL DISABILITY TRAINING FOR DIRECT CARE STAFF
The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents in order to supervise them appropriately. (See Consent Order III.B.14)
In order to assess this provision, we reviewed the State’s self-assessment, the training module curriculum, and other training documentation provided by the State. A review of the provided documentation regarding training revealed that the State provided the bulk of formal training prior to and during 2009. The State only conducted three trainings during 2010:
• Unit and treatment staff for the boys Mental Health Unit received six days of training in the strengths based behavioral management system (“SBMMS”) and Mental Health Treatment in Corrections prior to the inception of this Unit in 2010;
• Staff on the girls Mental Health Unit received training on Borderline Personality Disorder in 2010; and
• All facility staff received training in “Understanding and Responding to SelfInflicted Injury” and “Use of Mechanical Restraints for Psychiatric Purposes” in 2010. The training documentation provided revealed that there was training
entitled “Cognitive Disability Lesson Plan,” which the State last provided in September 2009. The curriculum provided for this lesson plan referred to handouts. However, the State did not include the handouts in the documents provided, so a review of this training could not be performed. Training curriculum entitled “Axis II diagnoses” covered material regarding personality disorders and mental retardation. This curriculum was dated March 2010. This training material focused on the diagnostic characteristics for various disorders, and provided some tips for managing youth. For direct care staff, less diagnostic information and more management strategies would be beneficial. The State provided other training
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modules from the National Center for Mental Health and Juvenile Justice for review. Unfortunately, in its self-assessment, the State did not provide a spreadsheet or list of staff attendance and training completion. We have included this in the document request for the upcoming monitoring tour.
In its self-assessment, the State referred to trainings that took place as early as 2006 – two years prior to the US v. Ohio Consent Order. In a recent investigation by the Chief Inspector’s Office (“CIO”), Deputy Superintendent of Program Services, Nan Hoff, reported that Scioto has not offered training on how staff should work with the female youth population in about 3-4 years. (See Second Compliance Report, Attachment D). Finally, the State described additional informal efforts by facility mental health staff to provide educational/training opportunities to other facility staff via providing articles for their perusal. While informal efforts at increasing staff knowledge are laudable, they cannot take the place of formal training.
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance: The goal of this provision is to provide training to facility staff such that they
have a working knowledge of the youth’s challenges (both from a mental health and developmental perspective) and to provide them with strategies to assist in their daily supervisory tasks with the youth. Training for direct care staff is important, as, in a correctional setting, they function as the de facto parents of the youth in their care. As direct care staff are an integral part of the youth’s treatment team, they should be aware that, due to specific mental health diagnoses, youth may have special needs (e.g., a youth diagnosed with ADHD may not respond the first or even second time that staff call his name because he is distracted by extraneous stimuli). They should also be aware of which youth are being treated with psychotropic
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medication and have a basic knowledge of the potential side effects of the medication so that they can monitor the youth in their care.
While the trainings the State provided in 2010 are a start, they are not sufficient to meet the requirements of this provision. The State should make an appraisal of its staff training needs and develop a curriculum to address these needs. Based on that appraisal, the State should continue the development of Mental Health Unit training and develop a mandatory training schedule for staff who provide care to youth on the mental health case load.
Unfortunately, in its self-assessment, the State did not provide a spreadsheet or list of staff attendance and training completion. Accordingly, we cannot assess the level of staff participation in the State’s training programs. Going forward, the State should create a spreadsheet that delineates staff attendance and completion of required training modules.
B.15 STAFF MENTAL HEALTH TRAINING The Facilities shall train:
a. All staff who directly interact with youth (e.g. JCO’s, social workers, teachers, etc.) on: (i) basic mental health information (e.g. diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern) and recognition of signs and symptoms evidencing a response to trauma; and (ii) teenage development, strength-based treatment strategies, suicide, and, for staff who work with female youth, female development.
b. Clinical staff on the prevalence, signs, and symptoms of Post Traumatic Stress Disorder and other disorders associated with trauma. (See Consent Order III.B.15)
In order to assess this provision, we reviewed the State’s self-assessment, the training module curriculum, and other training documentation provided by the State. The State’s policy entitled “New Employee Orientation and Basic Academy Training” outlines specific pre-service training topics for new staff. These include
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basic mental health information: diagnosis, specific problem behaviors, psychiatric medication, recognition of signs and symptoms of mental illness and response to trauma, teenage development, strength-based treatment strategies, suicide, and others.
The State provided specific training modules for review in preparation for this monitoring report. These included: “Suicide Precautionary Equipment and Restraints”; “Understanding and Responding to Self-Inflicted Injury”; “Training Module for Girls Programming”; “The interface between the Juvenile Justice and Mental Health Systems”; “Psychopharmacology”; “Staff Roles and Responsibilities”; Therapeutic Milieu”; “Verbal Strategies”; “Axis II Diagnoses”; and modules from the National Center for Mental Health and Juvenile Justice, including “The Developmental Process”, “Mental Health Disorders”, “Treatment of Youth with Mental Health Disorders.” The in-service training provided in 2010 is listed above in provision B.14. Given the State’s planned addition of trauma/grief based treatment, and focus on creating a trauma based treatment environment, increased training regarding this subject matter is needed.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance: As stated in the previous provision, the State should appraise its training
needs, continue the development of Mental Health Unit training, and develop a mandatory training schedule for staff that provide care for youth on the mental health case load. In addition, the State should create a spreadsheet that delineates staff attendance and completion of required training modules.
B.16 SUICIDE PREVENTION
The State shall review, and, as appropriate, revise current suicide prevention practices to ensure that suicide preventions and interventions are implemented
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consistently and appropriately, consistent with generally accepted professional standards of care. (See Consent Order III.B.16)
In order to assess this provision, we reviewed the State’s self-assessment, the relevant policies and procedures, and the data graphs regarding suicide prevention. We reviewed the provided policy and procedure entitled “Suicide Prevention and Response.” Additionally, according to the State’s self-assessment, the State is preparing to implement a revised policy entitled “Behavioral Health Services,” which was in draft form at the time of the November 2010 tour. Once these revised policies are fully implemented, ongoing monitoring to ensure consistent implementation of policy and procedure will be necessary. Scioto collects statistics regarding facility wide suicidal behavior, as part of the monthly Psychology Director’s report. The State provided these statistics/graphs for our review. Unfortunately, poor copy quality rendered them illegible. During the upcoming tour, we intend to examine any reports, quality assurance measures or data the State has collected regarding suicide prevention with respect to this paragraph.
Compliance Rating: Non-compliance
Recommendation(s) to reach substantial compliance: At this time, the State has not provided us with sufficient information to
determine that the State has begun to comply with this provision. The State should implement its draft policy regarding Behavioral Health Services and review any quality assurance and suicide prevention efforts in place. We ask that, in its next Self-Assessment, the State provide readable data regarding suicidal behavior and any final policies or procedures regarding suicide prevention. In addition, as stated under provision III.B.13, the State should improve communication with the psychiatrist when a youth requires placement on suicide watch or enhanced supervision.
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B.17 TRANSITION PLANNING
The State shall ensure that staff create transition plans for youth leaving the Facilities consistent with generally accepted professional standards of care. (See Consent Order III.B.17)
In order to assess this provision, we reviewed the State’s self-assessment, ten medical release summaries, and six psychological service summaries used as part of transition and discharge plans, and we interviewed staff. In the medical release summaries, staff document youth’s mental health diagnosis, current medication regimen, and what follow up community appointments have been recommended and/or scheduled for the youth. Based on our review, we have determined that these documents are not consistent with generally accepted practices. The ten medical release summaries we reviewed lack information regarding the need for ongoing mental health counseling or the types of treatment that the treatment team is recommending. Mental health staff does not included information regarding educational or other needs in the release summaries. For example, in the case of youth 111, discharged on August 2, 2010, Scioto staff prescribed the medications Lithium and Depakote at discharge. However, staff did not note the youth’s diagnosis on the medical release summary. In addition, mental health staff prescribed the medication for “psych issues” and recommended psychiatry follow-up, but did not include referral resources in the medical release summary. Youth 222 was prescribed Zonegran and Sertraline for “psych problems.” (See Glindmeyer First Mental Health Report page 34). Again, mental health staff recommended psychiatry follow-up; however, they did not include any referral resources in the medical release summary. Youth 333 was prescribed Risperdal and Prozac for “psych dxs.” (See Glindmeyer First Mental Health Report page 34). Again, while staff recommended psychiatry follow-up, they did not include any referral resources in the medical release summary. In the remaining medical release summaries we reviewed, staff identified prescribed medications and listed diagnoses. However, staff recommended psychiatric follow-up, but failed to document resources.
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In addition to medical release summaries, the State includes psychological service summaries in its transition and discharge plans. According to youth 111’s psychological service summary, the youth had a history of experiencing severe mental health symptoms during his stay at Scioto. This culminated in an inpatient psychiatric hospitalization. Diagnoses for this youth include mental retardation. However, staff did not document the method by which this diagnosis had been obtained, or the required IQ and adaptive functioning scores required to meet criteria for this particular diagnosis. The psychological service summary includes a section entitled “plan/recommendations.” Recommendations consisted of “wrap around services…connection with MRDD services … support for the family.” (See Glindmeyer First Mental Health Report page 34-35). Unfortunately, staff did not recommend any specific treatment modalities or provide specific resources. Of the six psychological service summaries we reviewed, four offered generic recommendations similar to those proffered for youth 111. The other two summaries were more individualized and inclusive, providing some detail regarding the youth’s specific needs.
According to the State’s self-assessment, the policy governing this provision entitled “Behavioral Health Services” is currently in draft form, pending approval and implementation. Staff interviews conducted on-site revealed plans to implement a “discharge summary” for youth transitioning out of the facility beginning January 1, 2011.
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance: Transition planning for all youth should include referral to appropriate
community resources. For mentally ill youth this is especially important, and must include linkages to community mental health clinics and a scheduled appointment so that youth can access follow up care without an interruption in medication treatment. The State must significantly improve the quality of youth’s transition
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planning before it can reach substantial compliance with this provision. In addition, the State must implement and monitor the efficacy of Revised Policy 404.01 Behavioral Health Services and finalize the policy and procedure regarding transition/discharge planning.
B.18 OVERSIGHT OF MENTAL HEALTH SERVICES The Facilities shall ensure that youth receive the care they need by developing and implementing an adequate mental health Quality Assurance/Improvement Program; annually assessing the overall efficacy of the staffing, treatments, and interventions used at the Facilities; and, as appropriate, revising such staffing, treatments and interventions. (See Consent Order III.B.18)
In order to assess this provision, we reviewed the State’s self-assessment, and a monthly report, and we interviewed staff. According to the State’s selfassessment, the psychology supervisor is providing a monthly report of the status of service delivery at the facility. The State provided an electronic copy of one such report for our review. The monthly report was not dated. However, it indicated that the previous psychiatric treatment providers were providing services and, as stated earlier, their tenure at the facility ended in September 2010. Nevertheless, the monthly report provided information regarding the number of youth admitted and discharged from the facility during the reporting period, the number of youth assigned to the mental health caseload, specific caseload numbers for psychology staff, the total number of available psychiatric clinical hours, the number of youth housed at the facility who are prescribed psychotropic medication, the number of youth receiving involuntary medication or requiring inpatient hospitalization, the number of critical suicide attempts, the number of missing or late treatment plans, the number and length of psychiatric contacts with youth, and any training provided to mental health staff. The monthly report does not specifically provide QA monitoring and the required assessment of the overall efficacy of the staffing, treatment and interventions utilized at the facilities.
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The State provided draft policies regarding Quality Assurance and Clinical Supervision. However, the State did not provide the relevant policy or procedure in final form. Accordingly, it was difficult to determine the current requirements for QA monitoring. Compliance Rating: Beginning compliance Recommendation(s) to reach substantial compliance:
At the time of the November 2010 monitoring tour, the New Freedom Phoenix program had not yet been implemented. Given the State’s planned implementation of expanded services, QA monitoring is currently in flux at Scioto. In order to move towards substantial compliance, the State must complete staff training and implement the New Freedom Phoenix program and other planned mental health treatment programs. Following the implementation of these programs, the State should begin QA monitoring to assess the efficacy of staffing, treatment and interventions. Finally, the State should provide the United States with finalized policies and procedures relevant to this paragraph for review.
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NEXT TOUR AND COMPLIANCE REPORT
The United States intends to conduct a compliance tour of Scioto on February 22-24, 2011, with our expert Dr. Daphne Glindmeyer on-site and Dr. Kelly Dedel off-site. Our goal is to provide a third complete compliance report, based on the February 2011 compliance tour, to the Court on or before May 9, 2011.
Respectfully submitted this 16th day of February 2011. FOR THE UNITED STATES:
THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Section Chief Special Litigation Section U.S. Department of Justice Civil Rights Division
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section U.S. Department of Justice Civil Rights Division
s/ Rashida J. Ogletree Rashida J. Ogletree Silvia J. Dominguez Trial Attorneys Special Litigation Section U.S. Department of Justice. Civil Rights Division 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530
Attorneys for the Plaintiff
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ATTACHMENT E

Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 2 of 39 PAGEID #: 1059
United States of America v. The State of Ohio Case No. 2:08-cv-475
Review of the Scioto Juvenile Correctional Center Mental Health Services
Dr. Daphne Glindmeyer January 25, 2011
Dr. Daphne Glindmeyer is a board-certified psychiatrist with more than 14 years of experience treating youth and adults in correctional settings. She received her Medical Degree from the Louisiana State University Health Services Center in New Orleans and is board-certified as an adult psychiatrist, forensic psychiatrist and child and adolescent psychiatrist. Her clinical background includes extensive work with juvenile offenders. This includes her work as a clinical psychiatrist at the Bridge City Center for Youth, a secure juvenile facility in
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Case: 2:08-cv-00475-ALM-MRA Doc #: 74-2 Filed: 02/16/11 Page: 3 of 39 PAGEID #: 1060 Louisiana, and past work with the Louisiana State University Health Sciences Center Juvenile Corrections Program, where she served as the Director of Psychiatry and the Director of Clinical Operations, and with the Jefferson Parish Juvenile Drug Court Program, where she served as the Medical Director. She has also provided compliance monitoring regarding mental health and rehabilitative services for several jurisdictions — including monitoring in Mississippi regarding its secure juvenile correctional facilities, in Los Angeles County regarding its secure juvenile correctional facilities, in Texas regarding five developmental centers in the state, and in Indiana regarding the South Bend Juvenile Correctional Center. Dr. Glindmeyer is a fellow of the American Psychiatric Association, the current president of the Louisiana Council of Child and Adolescent Psychiatry, and a past president of the Louisiana Psychiatric Medical Association.
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1. Discussion

Mental Health Screening: The State shall develop and implement policies, procedures, and practices to ensure that all youth admitted to the Facilities are comprehensively screened for mental disorders, including substance abuse, depression, and serious mental illness, within twenty-four hours of admission. This screening shall be performed by qualified personnel, aspart of the intake process, consistent with generally accepted professional standards of care.
Per facility policy and procedure entitled, “Mental Health Screenings”, a mental health screening is to be performed within 24 hours of admission by mental health trained or qualified mental health personnel to assess presence of current suicidal ideation, history of self injurious behavior, current prescription of psychotropic medication, current mental health issues, current treatment for mental health diagnoses, history of any type of mental health treatment and history of substance abuse.

Review of youth records available for off site review revealed a document entitled “reception assessment summary.” T he reception risk interview was not included for review. A dditional information regarding this paragraph will be requested during the next monitoring tour. T he facility staff reported plans to implement a newly developed policy entitled, “Behavioral Health Assessment, Screening, Appraisal and Evaluation.” T his policy would revise the current practices in the reception area, including but not limited to the creation of a Behavioral Health Review Panel to review a youth’s intake data and make recommendations regarding future housing, programming and treatment needs.

Review of the provided reception assessment summary document revealed that they were variable in quality. Some provided excellent detail regarding a youth’s history and diagnoses, whereas others were scanty, and did not provide enough information. P lease see the discussion in Provision 4 for additional information.

Recommendations

. Implementation of policy and procedure “Behavioral Health Assessment, Screening, Appraisal and Evaluation.”
. Begin quality assurance monitoring or clinical supervision regarding the reception assessment summary documents.

Evidentiary Basis . Review of provided documents (e.g. policy and procedure, draft policy and procedure, youth records)
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2. Discussion

Immediate Referral to a Qualified Mental Health Professional: If the mental health screen identifies an issue that places the youth’s safety at immediate risk, the youth shall be immediately referred to a q ualified mental health professional for assessment, treatment, and any other appropriate action, such as transfer to another, more appropriate setting. T he State shall ensure that, absent extraordinary circumstances, qualified mental health professionals are available for consultation within 12 hours of such referrals.
Per the facility self-assessment and a review of policy and procedure, the Policy and Procedure entitled, “Referrals to Mental Health Services” delineates the referral process for youth to access mental health services, stating, “referral can take place in reception or on a programming unit, and is made via the psychology supervisor. When a youth has expressed suicidal or self-injurious thoughts, intent or plans, or when a unit staff member develops concerns for a youth’s functioning on t he unit, referral for an assessment can be immediate by phone with the psychology staff assigned to the relevant living unit or by email... In the event that psychology staff are not available on grounds, Operations staff are notified and they call the psychology supervisor by phone and discuss the concerns.” Per staff interview, the psychology supervisor is on c ontinuous call. A review of the psychology staff schedule revealed that psychology staff are assigned both evening and weekend hours to provide youth access to services.
Review of provided documentation revealed an example of a referral for mental health referral in the case of Youth 440. This youth was referred via email to psychology staff and a completed progress note was documented the day of referral. A review of the youth records available off site revealed documentation of individual contact with youth that was documented as per a staff referral or per a youth request. The actual referral documents were not included in the documentation, so it w as impossible to determine the elapsed time between the request for services and response to the request. Quality assurance monitoring regarding the time elapsed would be useful to ensure that emergent and routine requests were addressed in a t ime period consistent with that outlined in policy and procedure. Additional concerns regarding the youth’s ability to independently access mental health services are included in the discussion regarding paragraph 9.

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Recommendations . Quality assurance monitoring regarding the elapsed time between requests for and provision of services.

Evidentiary Basis

. Review of provided documents (policy and procedure, youth records, psychology staff schedules)
. Staff interview

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3. Discussion

Identification of Previously Unidentified Youth with Mental Disorders: T he Facilities shall implement policies, procedures, and practices consistent with generally accepted professional standards of care to identify and address potential manifestations of mental or behavioral disorder in youth who have not been previously identified as presenting mental health or behavioral needs requiring treatment.
Review of the facility self-assessment revealed a f ocus on improvements in restraint and seclusion practices and enhanced mental health monitoring for youth during the restraint and seclusion period. Per the self-assessment, facility mental health staff engaged in education of facility personnel regarding the appropriate use of restraints and seclusion thus resulting in an overall reduction in the reliance on these measures. W hile data regarding the incidence of restraint and seclusion in the facility was provided via the document review, the copy quality was poor, and these documents were not legible.
While it is agreed that a youth who experiences disciplinary problems in the facility milieu may be suffering from other mental health sequelae, the facility self assessment does not specifically address the topic of a referral for a re-evaluation of this youth’s mental health needs following the initial evaluation. The self-assessment does indicate mental health monitoring during a period of seclusion in order to evaluate for decompensation. T he goal of this provision, however, is to ensure that youth who may not present with a history of mental illness and who are not identified at the time of initial assessment as being at risk for mental illness or behavioral challenges, are monitored over the course of their incarceration for exacerbations of symptoms and referred for mental health treatment.
Per review of draft policy entitled “Behavioral Health Assessment, Screening,
Appraisal and Evaluation” the process for this re-evaluation would be via a staff referral for evaluation. “A staff member concerned about the mental health of a youth may make a referral to psychology staff for evaluation… A Psychologist or psychiatrist shall evaluate a youth within 24 hour s of submission for an urgent referral, and within 7 days of submission for a routine referral. Documentation of the evaluation and, when appropriate, recommendations shall be entered into the youth’s record. If additional assessment or testing is recommended, this shall also be documented, including a reasonable
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timeline by which the additional assessment or testing shall be completed.”

Recommendations

. Implementation of draft policy entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation.”
. Quality assurance monitoring regarding re-evaluation of youth who experience an exacerbation of mental health symptoms or behavioral challenges.

Evidentiary Basis . Review of provided documents (e.g. Policy and Procedure, draft Policy and Procedure, youth records, facility self-assessment)

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4. Discussion

Mental Health Assessment: The State shall implement policies, procedures, and practices to ensure that, as part of an overall assessment of the youth’s health, risks, strengths and needs, youth who are identified in screening as having possible mental health needs receive timely, comprehensive, and accurate assessments by qualified mental health professionals, consistent with generally accepted professional standards of care. Assessments shall be designed and implemented so as to identify youth with mental disorders in need of specific treatment and contribute to a full plan for managing the youth’s risk. Assessments shall be updated as additional diagnostic and treatment information becomes available.
Currently, the facility is performing mental health screening and mental health appraisals per like named policy. T here was a d raft policy provided entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation” which is pending implementation.
A review of youth records available for off site review revealed reception assessment summaries and mental health appraisals performed at the time of admission. While these documents provided useful information for the determination of placement and initial treatment planning, they were variable in quality. All proffered mental health diagnoses, however the inclusion of a statement of specific diagnostic criteria indicating what specific symptoms the youth was experiencing now or in the past that justified the diagnosis was not always included (youth 550 and youth 888 di agnoses not justified, youth 220 g ood case conceptualization, youth 660 f air justification of some diagnosis, however, no remarks regarding a history of a previously diagnosed pervasive developmental disorder, specifically Asperger’s disorder, and how this could affect the youth’s ability to engage in programming or integrate into the facility milieu). This is an area that would be amenable to quality assurance, peer review process and clinical supervision. P er the facility self assessment, there are plans to establish “clinical review teams on each reception unit to meet regularly for the purpose of providing a formal, integrated set of recommendations for the receiving institution.” This is planned to occur with implementation of the draft policy discussed above, entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation.”

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Recommendations

. Implement draft policy entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation.”
. Consider quality assurance measures including a peer review process and clinical supervision

Evidentiary Basis

. Review of policy and procedure . Review of youth record . Review of other provided documents

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5. Discussion

Adequate Mental Health Care and Treatment: The State shall implement policies, procedures, and practices to ensure that adequate mental health and substance abuse care and treatment services (including timely emergency services), and adequate rehabilitative services are provided to youth in the Facilities by qualified mental health professionals consistent with generally accepted professional standards of care.
Per the facility self-assessment and the monitoring tour, the facility implemented the Strengths Based Behavior Management System as of May 2010. The facility was in the process of revamping the mental health treatment program with the intent of implementing the New Freedom Phoenix program, reportedly cognitive behavioral based, as the overarching treatment program for all facility youth. A dditional information regarding this program will be requested in the next monitoring tour.
With regard to specific mental health treatment, the facility staff indicated plans to expand treatment modalities for female youth to include Trauma and Grief Component Therapy for Adolescents (planned to begin 1.1.11), which would be added to currently provided group modalities including Girls Circle, Anger Management, Voices, Process group, Cage Your Rage for Teens, Conflict Management, and Victims of Sexual Abuse, and Substance Abuse Education. A review of the schedule of therapeutic groups conduced in the month of October 2010 revealed group therapies conducted by social services staff in these modalities. For male youth, the schedule of therapeutic groups conducted by social services in the month of October 2010 revealed modalities including Cognitive Behavioral Therapy orientation and Process Group. Given the review of the current group course selection, it is obvious that the options for male youth are limited when compared to those for females. This is an area in need of expansion.
A review of the group progress notes in the records available for off site review revealed that the majority of the group progress notes were related to a review of the Strengths Based Behavior Management System. O ther group progress notes located documented group interventions that did not include the modalities listed above. A review of the records of female youth available for off site review revealed several group progress notes for each youth. A similar review of the records of male youth did not reveal group progress notes. Interviews with staff revealed that historically, psychology
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staff have been more active in assessment, crisis management and individual counseling whereas social services staff were more active in the provision of group therapies. In order to create a cohesive mental health management team, there must be a m ore interdisciplinary approach to the provision of services (e.g. co facilitation of groups).
During the tour, two group therapy interactions were observed. This group was led by psychology and occupational therapy. The focus of the group was “Brain Gym.” The group leaders actively engaged the youth in group, and had obviously spent time preparing the group interaction. T he focus of the group was to teach the youth physical interventions to reduce stress and improve focus and concentration. The group leaders utilized good examples that the youth were able to identify with.
A second group interaction, also led by occupational therapy and psychology staff also focused on s tress reduction. T here was a teaching portion of the exercise, where youth were provided written materials regarding stress reduction, as well as hands on a ctivity where the youth made their own stress reduction balls. A gain, the youth were engaged and appeared to enjoy the interaction. W hile these two group observations revealed actively engaged youth, the evidence-based data were not reviewed. During the next monitoring tour, observation of additional evidence based group interactions is planned.
Review of the youth records available for off site review revealed documentation of individual contact with youth via psychology services. M uch of this documentation was in regard to crisis management or the difficulties that the youth was experiencing on that particular day. Review of the documentation did not allow the reader to discern the youth’s progress toward goals purported in the treatment plan, nor did they reference specific targeted interventions proposed in the youth’s treatment plan. It is hoped that with the planned change to an Integrated Treatment Plan that this information will logically flow into the progress notes.
Given the above, it is apparent that while some treatment is occurring, improvements to the overall treatment program ( already planned by the facility) and documentation of treatment provided will be necessary for the facility to meet the requirements of this provision. In the upcoming monitoring tour, additional information regarding the
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facilities mental health treatment program will be requested and reviewed.

Staffing is crucial to the facilities ability to provide adequate mental health care and treatment. T his issue is covered in the discussion regarding paragraph 11 below. Per the facility self-assessment, in the first half of 2010, t here have been a total of 187 individual mental health contacts, 131 per the psychology assistant and 56 per the social service staff. This is an apparent reduction from 2009, where a total of 455 individual contacts were performed over the course of the year. Extrapolated, the facility is on t arget to provide 374 i ndividual contacts in 2010. With regard to group contacts, the facility provided a total of 477 contacts in the first half of 2010, 197 per the psychology assistant and 280 per social service staff. T his is again a r eduction from 2009 w here a total of 1029 g roup contacts were provided. Extrapolated, the facility is on target to provide 954 group contacts in 2010. W hile it appears that group contacts have remained relatively stable from 2009 t o 2010, there has been an 18% reduction in individual contacts. It is unclear if this reduction was due to a decrease in overall population, with a subsequent increase in the focus on group therapy.

Recommendations

. Implement planned mental health programming . Improve documentation of group therapeutic interaction . Improve documentation of individual therapeutic interaction . Ensure the provision of evidence based group therapeutic interactions . Expansion of the group curriculum available for male youth. . Improved integration of treatment provider disciplines in order to
achieve an interdisciplinary model.

Evidentiary Basis

. Review of provided documents (e.g. group schedule, youth records, policy and procedure, description of treatment modalities, facility self-assessment)
. Observation of two group interactions . Youth interview . Staff interview

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6.

Treatment Planning: The State shall develop and implement

policies, procedures and practices so that treatment service

determinations, including ongoing treatment and discharge

planning, are consistently made by an interdisciplinary team

through integrated treatment planning and embodied in a single,

integrated treatment plan.

Discussion

Per staff interview and document review, the facility is planning to implement new draft policy regarding the Interdisciplinary Treatment Team as well as a r evised format/process for the documentation of treatment planning, via the creation of an Integrated Treatment Plan. It was reported that the facility plans to adopt these draft policies beginning 1.1.11. For additional information regarding Treatment Planning, please see the discussion regarding the two following paragraphs (7 and 8). Given these impending changes, an assessment of the treatment planning process at the facility is premature at this time. T his issue will be addressed in future monitoring tours scheduled following the implementation of new policy.

Recommendations

1. Implementation of revised policy regarding the Interdisciplinary Treatment Team.
2. Implementation of the new Integrated Treatment Plan.
3. Once these processes are established, begin Quality Assurance monitoring of the process and documentation.

Evidentiary Basis

. Staff interview . Review of provided documents (e.g. existing and draft Policy and
Procedure)

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7. Discussion

Treatment Teams: At a minimum, the interdisciplinary treatment team for each youth in need of mental/behavioral health and/or substance abuse treatment should: a. Be guided by a trained treatment professional who shall provide clinical oversight and ensure the proper functioning of treatment team meetings;b. Consist of a stable core of members, including at least the youth, the social worker, a J CO, one of the youth’s teachers, the Unit Manager, and as warranted by the needs of the youth, the treating psychiatrist, the treating psychologist, registered nurse, and, as appropriate, other staff;c. Ensure that needed psychiatric evaluations are conducted on a you th before administering psychotropic medications to the youth;d. Monitor as appropriate but at least monthly, the efficacy and the side effects of psychotropic medications, including consultation with the facility medical, counseling, and other staff who are familiar with the youth; e. For youth under a psychiatrist’s care: ensure the provision of individual counseling and psychotherapy when needed, in coordination with facility psychologists; ensure that all youth referred as possibly in need of psychiatric services are evaluated and treated in a timely manner; and provide adequate documentation of treatment in the facility medical records;f. Include, to the fullest extent practicable, proactive efforts to obtain the participation of parents or guardians, unless their participation would be inappropriate for some reason (e.g., the child has been removed from the parent’s custody), in order to obtain relevant information, understand family goals and concerns, and foster ongoing engagement;g. Meet to assess the treatment plan’s efficacy at least every 30 days, and more often as necessary; andh. Document treatment team meetings and planning in the youth’s mental health records.
Per a review of the provided documents, the facility was operating under a policy entitled Interdisciplinary Team, however, a revised draft policy had been proposed for implementation beginning 1.1.11. Per the new policy, the Interdisciplinary Team should consist of, “a unit manager, Clinician(s), Provider(s), and staff from Mental Health Services, Psychiatry, Education, Psychology and Recreation. Other participating staff may be included, such as from medical services, religious services or administration.” P er policy, the team will meet regarding each youth “at least monthly” and meetings should include the youth and their parent or guardian.
At the time of the monitoring tour, there were functioning Interdisciplinary Teams (IDT) on the designated mental health units
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for both male and female youth. A meeting was observed during the tour regarding youth 888. T his was the first IDT meeting for this particular youth. A t the start of the meeting, psychology staff reviewed the purpose and intent of the staffing. Staff present included psychology, occupational therapy, unit director, mental health nurse, unit psychologist and the youth specialist. S taff appeared interested and knowledgeable regarding the youth. T he youth’s specific behavioral challenges as well as the hypothesis for these challenges were discussed with her. S pecific target symptoms that the youth experiences were discussed and described to direct care staff for observation and monitoring of these symptoms. B oth the youth and staff asked specific questions regarding the youth’s psychotropic medication regimen in attendance. G iven the lack of available psychiatric resources at the facility, psychiatry has not been attending IDT meetings.
Documentation regarding IDT meetings was provided per the document request. These meeting minutes included general information regarding the unit and scheduling of activities as well as a listing of youth who were scheduled for a “progress review.” Attached to the meeting minutes were bullets of information regarding the discussion of the youth’s treatment progress. T he quality of documentation was variable between the units. S ome units documented discussion regarding the youth goals, while others had briefer documentation. The better documentation was noted in for those teams functioning on designated mental health treatment units.
Per the facility self assessment, “while the department continues to work on t he development of the Integrated Treatment Plan, the IDT functions in a manner consistent with the intent and spirit of that plan. There is a continual feedback loop of information sharing and discussion that occurs among team members, and treatment and intervention on the unit is adjusted, modified or changed as different needs and circumstances arise. The IDT on the girls’ mental health unit has been functioning in this manner for some time…A recent IDT meeting on the boys’ mental health unit provides a current illustration of how this is developing on that relatively new unit.”
Following full implementation of the draft policy entitled “Behavioral Health Services” wherein the documentation requirements for the Integrated Treatment Plan is outlined, the IDT will then document youth progress and information gleaned during the IDT meeting via this document, thus closing the loop regarding the documentation of
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Recommendations

. Implement draft policy regarding Behavioral Health Services
. Implement revised Interdisciplinary Treatment Team policy and procedure
. Ensure psychiatric resources are available to allow participation in Interdisciplinary Treatment Team meetings.
. Following policy implementation, begin Quality Assurance monitoring of treatment planning efforts and IDT meetings.

Evidentiary Basis

. Staff Interview . Observation of Interdisciplinary Treatment Team meeting . Review of provided documents (e.g. IDT meeting minutes, review of
youth records).

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8. Discussion

Integrated Treatment Plans: The State shall ensure that each youth in need of mental/behavioral health and/or substance abuse treatment shall have an appropriate, integrated, treatment plan, including an appropriate behavior management plan, that addresses such needs. The integrated treatment plan shall be driven by individualized risks and needs, be strengths-based (i.e., builds on an individual’s current strengths), account for the youth’s motivation for engaging in activities contributing to his/her wellness, and be reasonably calculated to lead to improvement in the individual’s mental/behavioral health and well being, consistent with generally accepted professional standards of care.
Interviews conducted during the monitoring tour revealed that currently, the facility is utilizing three parallel processes to guide the youth’s treatment, specifically the Unified Case Plan, the Mental Health Treatment Plan and the Interdisciplinary Treatment Team process. In addition, youth with specific behavioral challenges can also receive services via a S pecial Management Plan. T here were plans to collate the treatment recommendations into one document, entitled the Integrated Treatment Plan.
Per the draft policy entitled “Behavioral Health Services” the Integrated Treatment Plan is “a formal strategy developed to address the habilitation, education, rehabilitation, social, mental health and psychiatric needs of a specific youth. T he plan is developed by an assigned Clinician or Provider in collaboration with the youth and the Interdisciplinary Team (IDT), and is implemented by both the youth and all Behavioral Health Services staff who work with the youth.” Per interviews, the facility planned to implement the draft policy beginning 1.1.11. A s such, a review of the treatment plan documentation at the Scioto facility was premature at the time of this monitoring tour.
Integrated treatment plans authored per the requirements of this paragraph and via the newly implemented policy and procedure will be requested for review during the next monitoring tour. Acceptable Integrated Treatment Plans must include measurable goals and objectives, with available targeted interventions to address each goal. Progress notes authored regarding the youth’s treatment should refer to the youth’s treatment goals and document the response (or lack thereof) to the prescribed interventions. Integrated treatment plans should be reviewed at each Interdisciplinary Treatment Team meeting
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scheduled for the youth, and must be authored and reviewed with the participation of the youth and their parent or guardian (if appropriate).

Recommendations . Implementation of policy entitled Behavioral Health Services
. Begin quality assurance monitoring of treatment plan documentation, and implementation.

Evidentiary Basis

. Staff interview . Review of provided documents (e.g. draft policy and procedure) . Review of youth records

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9. Discussion

Access to a Qualified Mental Health Professional: The State shall develop and implement policies, procedures, and practices to ensure that youth who seek access to a qualified mental health professional are provided appropriate access in a timely manner.
Per the facility self- assessment, policy and procedure entitled “Mental Health Referral, Evaluation and Disposition,” and the associated policy entitled “Referrals to Mental Health Services” outline the process for any facility staff to refer a youth for an assessment to determine the need for mental health services. T here are designated time limits for response to requests. Psychology must respond within five working days, psychiatry within ten working days and if the request is for additional evaluation, there is a fourteen working day response window. In the upcoming monitoring tour, additional information will be requested regarding the actual time elapsed between a request for services and when the youth is seen by a mental health professional.
Given the following information from the facility self-assessment, it would seem that there would be a faster response to the youth, while paperwork could take a longer period of time to complete, “Psychology and Social Work staff members each are assigned to living units…with recent changes in scheduling for both disciplines, access to mental health personnel has been enhanced greatly… current scheduling for psychology staff includes weekend and evening hours until 8:00 p.m… members of the psychology staff are on-site between 8:00 a.m. and 8:00 p.m. Monday through Friday, and 8:30 a.m. and 4:30 p.m. on weekends… The improvement in accessibility for Social Workers is similar. Clearly this makes it e asier for youth to access mental health personnel and likely improves the response time.” There was documentation provided which indicated that a youth referred for an emergency assessment was seen on the same day of referral.
These policies do not indicate the method by which youth can independently access mental health services. Per these policies, access is limited to youth who are referred by other staff members. However, per the self assessment, “all youths in the care of DYS, whether they are on t he mental health caseload or not, have been given direction on h ow to access psychological help if and when needed. The initial direction is provided within the first 24 hour s of admission to SJCF.” Per the youth handbook, “Should you need to
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speak with psychology staff you can complete a “Request for Services” form which is available on each of the housing units. This form should be completed and given to your unit staff for any routine concerns. If it is an emergency situation, for example you feel like hurting yourself or someone else, you need to tell staff immediately and they will see that the issue is addressed.” It is concerning that youth must go through staff in order to access care. T here are situations where staff could unfortunately impede a youth’s access.

Additional information regarding the youth’s ability for self referral, the statistics regarding mental health treatment requests and quality assurance monitoring regarding the time to the youth’s receipt of a response from mental health staff will be requested in the next monitoring tour.

Recommendations

. Determination of method by which a youth can independently request mental health services
. Quality assurance monitoring regarding the time elapsed between a request for services and clinical contact with the youth
. Ensure the youth’s open access to mental health services

Evidentiary Basis . Facility self-assessment . Review of provided documents

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10. Discussion

Mental Health Involvement in Housing and Placement Decisions: The State shall develop and implement a system for ensuring that significantly mentally ill youth who do not have the adaptive functioning to manage the activities of daily living within the general population are provided appropriate housing and supports to assist them in managing within the institutional setting.
Per the facility self-assessment, there is policy and procedure entitled “Mental Health Referral, Evaluation, and Disposition.” T his policy “identifies the process for consideration and referral for mental health treatment, including placement on a mental health unit when determined to be necessary. Youth demonstrating serious mental health issues and/or who are determined to be unable to adequately manage the demands of living in the general population are referred for placement on an alternative living unit.”
Additional draft policy provided for review entitled, “Behavioral Health-Special Services Living Units” indicated “guidelines for the referral of youth identified through clinical assessment as needing specialized housing and programming for the stabilization of the symptoms of an identified mental illness and program modifications due to cognitive and/or developmental limitations.” T his policy proposed the development of a “Behavioral Health Review Panel” whose responsibility would be to “review information obtained in the reception process and determine the best options for each youth in regard to housing, programming…” This would be a positive step, as it would begin the interdisciplinary review and treatment process at the time of admission.
At the time of this monitoring tour, there were two mental health units on campus; one designated for female youth (Davey capacity 12 youth), the other for male youth (Buckeye capacity 18 youth).
A review of documentation provided for youth 999 i ncluded the Reception Assessment Summary created 6.25.10. T his revealed a placement recommendation of “Intensive Mental Health Unit.” Following completion of intake, this youth was transferred to Davey Unit.
A review of documentation provided for youth 220 i ncluded the Reception Assessment Summary created 2.16.10. T his revealed a
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placement recommendation of “consideration for Intensive Mental Health Unit.” T his youth is currently residing on the Davey Unit; however, it was difficult to discern via records provided if this residence occurred immediately following the completion of the intake assessment.

Review of additional youth records provided for off-site review revealed similar recommendations with youth placement in mental health units. “Mental Health Transfer Fact Sheets” which outlined the youth’s specific treatment needs accompanied these recommendations. It was apparent that mental health staff makes housing recommendations during the intake/assessment period based on the results of the youth’s assessment.

Recommendations

. Implement the policy entitled “Behavioral Health-Special Services Living Units”
. Consider quality assurance measures to review the accuracy and completeness of the assessment

Evidentiary Basis

. Review of the facility self-assessment . Review of provided documents (e.g. Policy and Procedure) . Review of youth records

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11. Discussion

Staffing: The State shall staff, by contract or otherwise, the Facilities with adequate numbers of psychiatrists, psychologists, social workers, and other mental health professionals qualified through training and practical experience to meet the mental health needs of youth residents, as determined by the acuity of those needs. Mental health care shall be integrated with other medical and mental health services and shall comport with generally accepted practices. The State shall ensure that there are sufficient numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming.
Per staff interview during the monitoring tour, review of the facility self assessment, and a review of the provided documents, there were staff shortages at the Scioto facility which were compromising youth mental health care. For example, until September 30, 2010, t he facility had psychiatric physician coverage at one full time equivalent (FTE). At the time of the tour, the facility was stretched with regard to psychiatric resources, as they currently had a total of 0.7 FTE and were in the process of attempting to recruit additional staff. Once new staff are hired and in place, the facility needs to make a determination of 1 FTE of psychiatry is sufficient to meet the needs (i.e. psychiatric evaluation, medication management, participation in interdisciplinary treatment team, administrative responsibilities, emergency management). In order to determine this, the use of objective data (e.g. workload indicators) could be helpful.
With regard to psychology, the facility self-assessment reported a total of four psychologists and five psychology assistants on staff. Per interviews conducted during the facility tour, there were a total of seven psychologists (three licensed) plus a psychology supervisor. There were two psychology assistants. O f the seven psychologists, five were assigned to the assessment units, the remainder to the program units. Interviews with staff revealed caseloads that were not manageable, “up until last week we had caseloads of over twenty youth…this week some staff are back, so they are more manageable…around eleven each.” O ther staff noted concerns regarding treatment “things are moving so fast…knee jerk reactions…the treatment planning is unwieldy…it is too much for show and not enough for efficacy.”
The facility self-assessment reported a total of 18 social workers on staff. Per interviews conducted during the tour, there were currently a
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total of 14 social workers on staff, with 4.5 assigned to the reception units and 9.5 assigned to the program units. There was one vacancy in the social work staff. Interviews with current facility staff revealed concerns regarding the quality of social work staff “all the licensed ones are leaving…because of the schedule changes.” Other interviews revealed that until recently, there had been a l ack of leadership in the social work division. A new supervisor was hired and began work the week of this monitoring tour.
Additional mental health staff include mental health nurses and occupational therapists. A t the time of the tour, there were two full time mental health nurses providing services at the facility as well as two full tine occupational therapists. D ata regarding additional available FTE and current vacancies in these positions (if any) was unavailable at the time this report was authored.
Per observation and interview, the current mental health divisions are not working together to create integrated treatment for the facility youth. At the tine of this monitoring tour, there were three separate things providing guidance for a youth’s mental health treatment, the Unified Care Plan, the Mental Health Treatment Plan and the Interdisciplinary Treatment Team documents. Per staff interview, there are plans to begin use of an Integrated Treatment Plan beginning January 1, 2011. It is hoped that with the roll out of the New Freedom Phoenix program as well as the focus on behavioral health treatment modalities including trauma based treatment and cognitive behavioral therapies, and the treatment integration required in the creation of one overarching treatment plan that the treatment providers can form a cohesive treatment team unit.

Recommendations

. Recruit and fill current vacancies . Determine the need for additional staff via workload indicators . Improve coordination between staff disciplines . Implement plans for the Integrated Treatment Plan

Evidentiary Basis

. Staff interview . Facility Self Assessment . Review of provided documents

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12. Discussion

Medication Notice: Before renewing a psychoactive medication prescription from a community provider or commencing the administration of a psychoactive medication to a youth, the State shall ensure that the youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, are provided with information regarding the goals, risks, benefits, and potential side effects of the medication and given an explanation of the potential consequences of not treating with the medication, and that the youth has an opportunity to consent to such medication. a. Involuntary administration of psychotropic medication(s) to juveniles shall comply with applicable federal and state laws and regulations. The DYS clinical director, in consultation with the DYS medical director, shall review any request with DYS Legal Services prior to the approval for involuntary administration.
Per the policy and procedure entitled “Psychotropic Medication, Use and Management” education including “addressing the goals, risks, benefits, and potential side effects associated with any given medication is given to each youth and his or her parent or guardian… the prescribing physician provides an explanation of the potential consequences of not taking the medication and explains that the youth has an opportunity a consent or withhold consent to be treated…provides guidelines within which medical professionals may petition the court to authorize involuntary administration of psychotropic medication.”
Review of youth records revealed varying quality of documentation regarding risks, benefits, side effects and alternatives to treatment. During document review, the bulk of psychiatric documentation was attributable to prior treatment providers who ended their association with the facility September 30, 2010.
The record of youth 888 admitted to the facility 10.12.10 prescribed psychotropic medication consisting of Geodon and Depakote revealed a form entitled “Information about Medications for Youth with Mental Health Diagnoses.” T his form was incomplete in that it d id not designate the diagnosis, did not identify specific side effects and was not signed by the youth. The psychiatric evaluation performed at admission did not document review of informed consent issues, nor did it document contact with the youth’s parent or guardian.
The record of youth 999 revealed a psychiatric evaluation performed
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6.24.10, which documented a discussion consistent with obtaining informed consent with both the youth and her mother inclusive of a documented review of some side effects. The youth completed a form entitled “Information about Medications for Youth with Mental Health Diagnoses,” although the information was incomplete, it was apparently filled out by the youth and demonstrated some knowledge regarding side effects of the prescribed medications.
The record of youth 110 revealed a psychiatric evaluation performed 10.8.10. There was basic documentation of informed consent “risks, benefits, and side effects of medication were discussed. Consent was obtained by [sic] him, mom…was agreeable to medication as well.” The form entitled “Information about Medications for Youth with Mental Health Diagnoses” was included, and while completed, did not reveal a good understanding of potential side effects.
Interviews with youth performed during the monitoring tour revealed that youth were able to name some of the medications prescribed. They were also able to name some side effects of the medication.
There was no i nformation located in the documents regarding petitions for authorizations to involuntary administer medications. Additional information regarding this issue will be requested for the next monitoring tour.

Recommendations

. Improve documentation regarding informed consent . Consider a peer review process for informed consent and other
psychiatric documentation . Consider the development of or use of commercially available
information regarding side effects of psychotropic medication that is written in language that youth can understand

Evidentiary Basis

. Youth record review . Review of provided documents (e.g. Policy and Procedure, Facility
Self-Assessment) . Youth interview

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13. Discussion

Mental Health Medications: The State shall develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices. The State shall provide regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy. The State shall issue and implement policies and procedures for the administration of appropriate tests (including, for example, blood tests, EKGs, and Abnormal Involuntary Movement Scale tests) to monitor the efficacy and any side effects of psychoactive medications in accordance with generally accepted professional standards. The State shall also: a.) Share medication compliance data with the psychiatrist and document the sharing of this information; and b.) Not withhold the provision of psychostimulants to youth when such treatment is clinically warranted.
Per the facility self-assessment and document review, the facility has policy and procedure in place entitled, “Psychotropic Medication, Use and Management.” This policy “provides the parameters for using medication for psychiatric purposes…education addressing the goals, risks, benefits, and potential side effects associated with any given medication.” T he Ohio Department of Youth Services also has a document entitled, “Recommended Laboratory Monitoring Frequency Guidelines.”
At the time of this monitoring tour, psychiatric services at the facility were limited. There were two psychiatric physicians (a total of 1 Full Time Equivalent (FTE)) previously providing care, however, they terminated services at the facility as of September 30, 2010. Since that time, the administrative psychiatrist (board certified in child and adolescent psychiatry) has been providing one day of direct clinical services per week (0.2 FTE). A second psychiatrist was recruited via an emergency services agreement to provide 20 hour s of direct clinical services per week (0.5 FTE). Unfortunately, the response to the document request regarding psychiatric curriculum vitae (CV) revealed the CV’s of the previous psychiatric physicians, therefore, the qualifications of the newly recruited psychiatric physician are not known at this time.
Given the departure of the two long time psychiatric providers, and
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the lack of clinical resources, the psychiatry clinic at the Scioto facility was not fully functional at the time of the tour. T he psychiatrists had been unable to attend interdisciplinary treatment team meetings, and were reduced to receiving “snippets of information for clinic from school, psychology and direct care.” Psychiatric administration reported that as a “stop gap” measure, a noon meeting had been established between psychiatry and other disciplines for the purposes of reporting information and responding to staff queries. There were plans to dissolve this meeting once more clinical resources were available allowing the psychiatric physicians to attend the interdisciplinary treatment team meetings.
The psychiatrist reported good ability to obtain laboratory examinations following a physician order, and that abnormal lab results were communicated via a telephone call to the physician. The psychiatrist reported taking after hours call for psychiatric emergencies at the facility, however, it was reported that there was no formal process for informing the psychiatrist when a youth is placed on suicide watch or other restriction. This report of on call duty was in conflict with information received via the document request, which indicated that psychiatry did not have on call responsibilities at the facility. T his is an area in need of improvement, generally accepted practice is that the psychiatrist would be informed and aware that a youth on his or her caseload required enhanced supervision.
Psychiatry clinic was observed during the monitoring tour. T he psychiatrist did a good job establishing rapport with the youth. H e queried the youth regarding side effects associated with a p articular medication and also elicited information from the youth regarding expected medication benefits. T he physician reviewed the youth’s medical record inclusive of school and behavioral information. During the clinic observation, the psychiatrist dictated clinical contact notes for three youth prescribed medication. In none of the three dictations were weight, vital signs, laboratory examinations or abnormal involuntary movement monitoring noted. This was concerning as psychotropic medications can have serious metabolic side effects, and generally accepted practice requires monitoring of these and other parameters.
Review of selected youth records revealed that the majority of documentation was attributable to the prior treatment providers. There were psychiatric evaluations and progress notes that documented the rationale for treatment with a specific psychotropic medication, the identification of target symptoms and discussions
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regarding the risks, benefits, side effects and alternatives to treatment with a particular medication, documented attempts or actual contact with a youth’s parent or guardian, documented review of laboratory examinations and abnormal involuntary movement monitoring (youth 444, youth 555, youth 999). M ore recent psychiatric documentation was not as complete, in that there was no documentation of abnormal involuntary movement monitoring, laboratory review or parent contact. This may be reflective of diminished clinical resources (youth 777, youth 888). Interviews with youth performed during the monitoring tour revealed that they had acceptable knowledge regarding their prescribed medication and potential side effects.
In the record of youth 555 there was an example of the sharing of information regarding medication compliance. T his youth was reportedly planning to refuse medication due to side effects. T his youth was seen five days following an email reporting his concerns. Given the current staff shortage at the facility, this is an acceptable delay, however, the facility should attempt to decrease the amount of time between a referral for services and actual clinical contact. This will require the recruitment of full time psychiatric staff.
At the time of the monitoring tour, there were 141 youth housed on campus. O f these, 49 w ere prescribed psychotropic medication. O f these ten were prescribed stimulant medications as a r esult of diagnoses including Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder or other Axis 1 m ental health disorders. An additional two youth were prescribed Strattera, a non-stimulant medication used for the treatment of ADD and/or ADHD.

Recommendations

. Recruit psychiatric physicians to fill available positions . Determine the number of FTE required to perform necessary
psychiatric duties (i.e. clinic, attendance at treatment team meetings). . Improve psychiatric documentation (consider quality assurance
monitoring or a peer review process).

Evidentiary Basis

. Staff interview . Clinic observation . Youth record review . Review of provided documents (e.g. policy and procedure, lists of
youth prescribed medication and mental health caseload documentation, Facility Self-Assessment) . Youth interview

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14. Discussion

Mental Health and Developmental Disability Training for Direct Care Staff: The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents in order to supervise them appropriately.
Per the facility self-assessment, formal training presentations have occurred at the facility. A review of the provided documentation regarding training revealed that the bulk of formal training was provided prior to and during 2009. P lease see the discussion in paragraph 15 be low for further information. There were three trainings mentioned that occurred during 2010, which included:
Unit and treatment staff for the boys Mental Health Unit received 6 days of training in strengths based behavioral management system (SBMMS) and Mental Health treatment in Corrections prior to the inception of unit in 2010. Staff on Girls Mental Health Unit received training on Borderline Personality Disorder in 2010.
All facility staff received training in “Understanding and Responding to Self-Inflicted Injury” and “Use of Mechanical Restraints for Psychiatric Purposes” in 2010.
The facility self-assessment described additional informal efforts by facility mental health staff to provide educational/training opportunities to other facility staff via providing articles for their perusal. W hile informal efforts at increasing staff knowledge are laudable, they cannot take the place of formal training.
The goal of this provision paragraph is to provide training to facility staff such that they have a working knowledge of the youth’s challenges (both from a mental health and developmental perspective) and to provide them with strategies to assist in their daily supervisory tasks with the youth. Training for direct care staff is important as in the correctional setting; they function as the de facto parents of the youth in their care. As direct care staff are an integral part of the youth’s treatment team, they should be aware that due to specific mental health diagnoses, youth may have special needs (i.e. a youth diagnosed with ADHD may not respond to you the first or even second time that you call his name because he is distracted by extraneous stimuli). They should also be aware of which youth are
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being treated with psychotropic medication and have a basic knowledge of the potential side effects of the medication so that they can monitor the youth in their care.

The training documentation provided revealed that there was training entitled “Cognitive Disability Lesson Plan” which was last provided in September 2009. The curriculum provided for this lesson plan referred to handouts, however, the handouts were not included in the documents provided, so a review of this training could not be performed. Training curriculum entitled Axis II diagnoses covered material regarding personality disorders and mental retardation. This training material focused on the diagnostic characteristics for various disorders, and provided some tips for managing youth. For direct care staff, less diagnostic information and more management strategies would be beneficial. This curriculum was dated March 2010. Other training modules from the National Center for Mental Health and Juvenile Justice were provided for review. Unfortunately, the document request did not include a requirement for the production of a spreadsheet of staff attendance and training completion. This will be included in the document request for the upcoming monitoring tour.

Recommendations

. Continue development of Mental Health Unit training
. Create a s preadsheet that delineates staff attendance and completion of required training modules.
. Develop a mandatory training schedule for staff who provide care to youth on the mental health case load.
. Facility should make an appraisal of their staff training needs and develop curriculum to address these needs.

Evidentiary Basis

. Review of provided training module curriculum . Review of facility self assessment . Review of provided training documentation

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15. Discussion

Staff Mental Health Training: The Facilities shall train: a. All staff who directly interact with youth (e.g., JCOs, social workers, teachers, etc.) on: (i) basic mental health information (e.g., diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern) and recognition of signs and symptoms evidencing a response to trauma; and (ii) teenage development, strength-based treatment strategies, suicide, and, for staff who work with female youth, female development.
b. Clinical staff on the prevalence, signs, and symptoms of Post Traumatic Stress Disorder and other disorders associated with trauma.
Per the facility self-assessment, policy and procedure entitled “New Employee Orientation and Basic Academy Training” outlines specific pre-service training topics for new staff. T hese include: b asic and fundamental mental health information: diagnosis, specific problem behaviors, psychiatric medication, recognition of signs and symptoms of mental illness and response to trauma, teenage development, strength-based treatment strategies, suicide, and others.
Specific training modules were provided for review in preparation for this monitoring report. T hese included: “Suicide Precautionary Equipment and Restraints”; “Understanding and Responding to SelfInflicted Injury”; “Training Module for Girls Programming”; “The interface between the Juvenile Justice and Mental Health Systems”; “Psychopharmacology”; “Staff Roles and Responsibilities”; Therapeutic Milieu”; “Verbal Strategies”; “Axis II Diagnoses”; and modules from the National Center for Mental Health and Juvenile Justice including “The Developmental Process”, “Mental Health Disorders”, “Treatment of Youth with Mental Health Disorders.” Unfortunately, the document request did not include a requirement for the production of a spreadsheet of staff attendance and training completion. T his will be included in the document request for the upcoming monitoring tour. Attendance documents that were provided for review included participation and attendance until December 2009. Given changes in programming and staff turnover, more recent training documentation is required.
Per the facility self assessment, in service training held in 2010 included:
Unit and treatment staff for the boys Mental Health Unit received 6 days of training in SBMMS and Mental Health treatment in
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Corrections prior to the inception of unit in 2010. Staff on Girls Mental Health Unit received training on Borderline Personality Disorder in 2010.
All facility staff received training in “Understanding and Responding to Self-Inflicted Injury” and “Use of Mechanical Restraints for Psychiatric Purposes” in 2010.
Given the planned addition of trauma/grief based treatment and focus on creating a trauma based treatment environment, increased training regarding this subject matter is needed.

Recommendations

. Continue development of Mental Health Unit training . Create a s preadsheet that delineates staff attendance and completion
of required training modules. . Develop a mandatory training schedule for staff that provide care for
youth on the mental health case load.

Evidentiary Basis

1. Review of provided training module curriculum 2. Review of facility self assessment 3. Review of provided training documentation

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16. Discussion

Suicide Prevention: The State shall review and, as appropriate, revise current suicide prevention practices to ensure that suicide preventions and interventions are implemented consistently and appropriately, consistent with generally accepted professional standards of care.
The provided policy and procedure entitled “Suicide Prevention and Response” was reviewed. Additionally, per the facility selfassessment, they are preparing to implement revised policy entitled Behavioral Health Services, which was in draft form at the time of the facility tour. O nce these revised policies are fully implemented, ongoing monitoring to ensure consistent implementation of policy and procedure will be necessary.
Currently, there are statistics regarding facility wide suicidal behavior being reported as part of the monthly Psychology Director’s report. These statistics/graphs were included in the documents provided, however, were difficult to interpret given poor copy quality. During the upcoming tour, any reviews, quality assurance or data collected regarding suicide prevention will be requested for review with respect to this paragraph.
For additional information regarding this provision, please see the discussion under provision 13 r egarding communication with the psychiatrist and psychiatric referral resulting when a youth requires placement on suicide watch or enhanced supervision.

Recommendations . Implementation of policy regarding Behavioral Health Services
. Continue review and quality assurance efforts regarding suicide prevention.

Evidentiary Basis

1. Review of policy and procedure 2. Review of data graphs regarding suicide prevention

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17. Discussion

Transition Planning: The State shall ensure that staff create transition plans for youth leaving the Facilities consistent with generally accepted professional standard of care.
In response to a document request for transition plans for the last ten youth prescribed psychotropic medication discharged from the facility, the monitor was provided with medical release summary documents for the youth. T hese documents provided information regarding the youth’s mental health diagnosis, current medication regimen, and what follow up a ppointments have been recommended and/or scheduled.
The medical release summary documents were not consistent with generally accepted practices. F or example, in the case of youth 111discharged 8.2.10, t he medications Lithium and Depakote were prescribed at discharge. There was no diagnosis noted, and per this document, the medications are prescribed for “psych issues.” Psychiatry follow-up was recommended, however, there were no referral resources included in this document. Y outh 222 w as prescribed Zonegran and Sertraline for “psych problems.” Again, psychiatry follow-up was recommended, however, there were no referral resources included in this document. Youth 333 was prescribed Risperdal and Prozac for “psych dxs.” A gain, while psychiatry follow-up was recommended, no resources were identified on the document. T he additional six examples noted prescribed medications as well as a listing of diagnoses. Again, while psychiatric follow-up was recommended, there were no resources documented.
These documents are only a part of the transition planning documentation required for youth being discharged from the facility. The medical release summary does not include information regarding the need for ongoing mental health counseling or the types of treatment that the treatment team is recommending. Information regarding educational or other needs were also not included. Further review of the documentation provided for off site review revealed “psychological service summaries used as part of transition and discharge plan.” This information was reviewed for youth 111. P er the documentation, the youth had a history of experiencing severe mental health symptoms during his stay at Scioto. This culminated in an inpatient psychiatric hospitalization. D iagnoses for this youth included mental retardation, however, there was no not e of the method by which this diagnosis had been obtained, or the required IQ and adaptive functioning scores required to meet criteria for this
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particular diagnosis.

A section entitled “plan/recommendations” was included as part of the psychological service summary. R ecommendations consisted of “wrap around services…connection with MRDD services…support for the family.” Unfortunately, no specific treatment modalities were recommended, nor were specific resources provided. T he six documents provided were reviewed. O f these, four offered generic recommendations similar to those proffered for youth 111. The other two were more individualized and inclusive, providing some detail regarding the youth’s specific needs.

Transition planning for all youth should include referral to appropriate community resources. For mentally ill youth this is especially important, and must include linkages to community mental health clinics and a scheduled appointment such that youth can access follow up care without an interruption in medication treatment.

Per the facility self-assessment, the policy governing this provision entitled “Behavioral Health Services” is current in draft form, pending approval and implementation. Staff interview conducted on site revealed plans to implement a “discharge summary” for youth transitioning out of the facility beginning 1.1.11.

Recommendations . Finalization of the policy and procedure regarding transition/discharge planning.
. Implementation and monitoring of Revised Policy 404.01 Behavioral Health Services.

Evidentiary Basis

. Review of ten medical release summaries . Review of six psychological service summaries used as part of
transition and discharge plan . Staff interview

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18. Discussion

Oversight of Mental Health Services: The Facilities shall ensure that youth receive the care they need by developing and implementing an adequate mental health Quality Assurance/Improvement Program; annually assessing the overall efficacy of the staffing, treatments, and interventions used at the Facilities; and, as appropriate, revising such staffing, treatments and interventions.
Per the facility self-assessment dated November 1, 2010, the Psychology Supervisor is providing a monthly report of the status of service delivery at the facility. An electronic copy of one such report was provided for review in preparation for this monitoring report. This report was not dated, however, it indicated that the previous psychiatric treatment providers (Drs. Niedermier and Klisovic) were providing services, and their tenure at the facility ended in September 2010.
The document provided information regarding the number of youth admitted and discharged from the facility during the reporting period, the number of youth assigned to the mental health caseload, specific caseload numbers for psychology staff, the total number of available psychiatric clinical hours, the number of youth housed at the facility who are prescribed psychotropic medication, the number of youth receiving involuntary medication or requiring inpatient hospitalization, the number of critical suicide attempts, the number of missing or late treatment plans, the number and length of psychiatric contacts with youth, and any training provided to mental health staff. This report does not specifically provide quality assurance monitoring and the required assessment of the overall efficacy of the staffing, treatment and interventions utilized at the facilities.
The facility policy and procedures 404.04 and 404.05 regarding Quality Assurance and Clinical Supervision as noted in the facility self assessment were obtained via a requested policy and procedure review performed prior to this monitoring tour. Final policy and procedure documents were not included in the policy and procedures requested during the tour. As such, it was difficult to determine the requirements for quality assurance monitoring per these documents, as there is not a final policy for review.
Regardless of the above, at the time of this monitoring tour, the New Freedom Phoenix program, which will reportedly be the overarching
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treatment program for the facility youth had not been implemented. In addition, there were reportedly plans to expand the mental health treatment programs at the facility to include trauma/grief based treatment protocols.
Staff were reportedly being trained on the new treatment model at the time of the tour, with a schedule to implement the New Freedom Phoenix program in Cedar dormitory in December 2010. It was reported that there were plans to expand this implementation to the units housing female youth in January or February 2011. Further expansion to include the mental health units was planned to follow the February 2011 implementation.
Given this planned implementation of expanded services, quality assurance monitoring was premature at the time of this facility tour. For the upcoming tour, information regarding quality assurance monitoring will be requested.

Recommendations

. Complete staff training and implement the New Freedom Phoenix program.
. Implement the planned mental health treatment program.
. Following the implementation of these programs, begin quality assurance monitoring to assess the efficacy of staffing, treatment and interventions.
. Provide the monitor with finalized policy and procedure regarding this paragraph for review (e.g. 404.04 a nd 404.05 addressing Quality Assurance and Clinical Supervision).

Evidentiary Basis

. Staff Interview . Review of the provided documents . Review of the facility self assessment

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 Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 1 of 88 PAGEID #: 1567

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, )

Plaintiff,

)

v.

) CIVIL ACTION NO:

) 2:08-CV-475-ALM

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

___________________________________ )

THIRD COMPLIANCE REPORT
Pursuant to provision V.H. of the Consent Order in U.S. v. Ohio, 2:08-CV475, the United States, as Monitor, submits its third report of its assessment of the State of Ohio’s (“State”) compliance with the June 5, 2008 Consent Order. For each substantive provision of the Consent Order, a recitation of the provision is provided, followed by a narrative describing the United States’ analysis of the State’s compliance efforts, and a compliance rating. Where possible, the United States provides recommendations to assist the State in attaining substantial compliance with a particular provision.

This compliance report represents the United States’ assessment of the State’s compliance with all the provisions of the Consent Order, which relate to Ohio Department of Youth Services (“ODYS”) policies, procedures, and practices governing the protection of youth from harm, mental health care, general medical care, grievances, special education, programming, and documentation for youth at the Scioto Juvenile Correctional Facility (“Scioto”). The Third Compliance Report is organized in this order and follows the structure of the Consent Order.

The United States based its assessment on document review (including, but not limited to, policies, procedures, training documents, youth records, incident reports,

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-1 Filed: 05/09/11 Page: 2 of 88 PAGEID #: 1568
grievances, medical records, and education documents), expert reports from Drs. Kelly Dedel, Michelle Staples-Horne, and Daphne Glindmeyer, youth interviews, and an on-site compliance tour on February 22-24, 2011. We have attached to this compliance report the expert reports1 of Drs. Dedel, Staples-Horne, and Glindmeyer. Consistent with the U.S. v Ohio Consent Order, the United States provided the State with a draft version of this Compliance Report and expert reports two weeks2 prior to filing with the Court. On April 26, 2011, the State provided the United States with its comments to the draft third compliance report. In sum, the State disagrees that any current and ongoing violations of federally protected rights have been identified in the draft third compliance report.
EXECUTIVE SUMMARY OF COMPLIANCE RATINGS
We report that of the 53 provisions in the U.S. v. Ohio, the State has achieved substantial compliance3 with 39.62% (21 provisions), partial compliance with 30.18 % (16 provisions), beginning compliance with 28.30% (15 provisions), and noncompliance with 1.88% (1 provision). Overall, the State faces the greatest
1 Dr. Dedel prepared her third Protection From Harm (“PFH”) report (“Dedel Third PFH Report”) and her second special education report (“Dedel Second SPED Report”), labeled as Attachments A and B respectively. Dr. Glindmeyer prepared her Second Mental Health Report (“Glindmeyer Second Mental Health Report”), labeled as Attachment C. Dr. Staples-Horne prepared her Second General Medical Care Report (“Staples-Horne Second Medical Report”), labeled as Attachment D..
2 On April 8, 2011, the United States sent the State a draft version of the compliance report and expert reports. The draft version did not include mental health. The United States provided the State the mental health portion of the draft third compliance report on April 13, 2011.
3 “Substantial Compliance” indicates that the State has met or achieved all of the components of a particular provision. “Partial compliance” indicates that the State has made notable progress in achieving compliance with the key components of the provision, but substantial work remains. “Beginning compliance” means that the State has made notable progress in achieving compliance with a few, but less than half, of the key components of the provision. “Non compliance” means that State has made no notable progress in achieving compliance on any of the key components of the provision.
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challenges in the area of mental health, where the bulk of the provisions (77.77%) were rated as being in beginning compliance. This is due in part to challenges in maintaining sufficient mental health staff. The State is actively recruiting new mental health staff, in particular psychiatrists. The State has demonstrated strong improvement in medical and special education and is compliance with 80% and 72.72% of those provisions, respectively. We recognize and commend the State’s progress and significant efforts to date in working towards achieving substantial compliance with all the provisions in the Consent Order. We note, however, that ODYS recently announced the closing of the Ohio River Valley Juvenile Correctional Facility (“ORV”), which most likely will result in at least some youth being transferred to Scioto. Accordingly, the State should begin to prepare now for the increase in population and with it an increase in demand for mental health, medical, and special education services.

The chart below represents the most recent compliance rating and percentage of type of compliance for each subject matter area of the U.S. v Ohio stipulation. A detailed discussion is provided throughout the remainder of this compliance report.

Protection From Harm Mental Health Medical Care Special Education Programming Grievances
Documentation TOTAL:

COMPLIANCE RATINGS

Substantial 57.4% (4 provisions) N/A
80% (8 provisions) 72.72% (8 provisions) N/A
33.3% (1 provision) N/A
39.62% (21 of 53 provisions)

Partial
42.85% (3 provisions) 16.66% (3 provisions) 20% (2 provision)

Beginning N/A
77.77% (14 provisions) N/A

18% (2 provisions) 100% (2 provisions) 66.6% (2 provision)
100% (2 provisions) 30.18% (16 of 53 provisions)

9% (1 provision) N/A N/A
N/A 28.30% (15 of 53 provisions)

Non Compliance N/A 5.5% (1 provision) N/A N/A N/A N/A
N/A 1.88% (1 provision)

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I. PROTECTION FROM HARM
A.1 GENERAL PROTECTION FROM HARM
The State shall, at all times, provide youth in the facilities with safe living conditions. As part of this requirement, the State shall take appropriate measures to ensure that youth are protected from abuse and neglect, use of excessive force, undue seclusion, undue restraint, and over-familiarization. (See Consent Order III.A.1)
In assessing this provision, we reviewed the State’s self-assessment and documents requested prior to tour, and interviewed youth and staff. Based on our review, we were again impressed with the level of detail and effort reflected in the State’s assessments regarding youth violence, use of restraint, use of seclusion, and allegations of child abuse. In our Second Compliance Report, due to the increase in youth violence at Scioto, yet decrease in such violence at other ODYS facilities, we recommended the State focus on interpreting the data it collects to determine trends and root causes. In her second report, Dr. Dedel suggested that the State discern the underlying causes of the increase in youth violence and enact specific strategies to address conditions that may provide the opportunity for violence. In late 2010, the State undertook such analysis and, in summary, found that a combination of workforce stability issues (fluctuating staffing levels for social workers, unit managers, psychologists and psychiatrists) and the lack of special management plans for certain specific youth were collectively responsible, at least in part, for the increase in violence. The State is to be commended for its prompt and exemplary efforts towards investigating the source for the increase in violence. Most importantly, once the State uncovered these causes, it then instituted changes/steps to begin to address the problems. (See Dedel Third PFH Report at 45). We commend the State for its efforts and success.
As noted above, provision A.1 of the U.S. v. Ohio Stipulation requires the State to “ensure that youth are protected from abuse and neglect, use of excessive force, undue seclusion, undue restraint, and over familiarization.” On February 25, 2011, Drs. Dedel and Glindmeyer provided exit briefings about their preliminary
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findings based on the February 2011 compliance tour. In a separate call, on that same day, the United States informed the State of general concerns it had based on interviews with Scioto youth in February 2011. Through a letter dated March 11, 2011, the United States memorialized the same concerns. Due to the nature and importance of these allegations we note them for the Court below.
During the February 2011 compliance tour, the United States visited six housing units and interviewed 25 youth.4 Our interviews indicated that many Youth Specialists (“YS”) engage professionally with youth and care about their well-being. Also, most Chief Inspectors Office (“CIO”) investigations about alleged abuse and neglect investigations about YS staff are generally well done. (This is discussed in further detail under provision A.5.) However, and deeply troubling, our youth interviews indicate that a significant number of YS staff manifest indifference to the risk of being held accountable for mistreating youth. The allegations we received indicate that cultural change at Scioto is incomplete, and that significant shortcomings remain in the State’s ability to protect Scioto youth from harm.
The United States does not endeavor to corroborate each of the allegations identified. However, the general consistency of the allegations, the existence of corroborating evidence in some cases, and the documented high rates of staff noncompliance with basic safety checks (discussed under section A.3 below) are strong evidence that supervision and accountability of staff at Scioto are insufficient to protect youth from harm. Contributing to this problem is a widespread distrust in the grievance process (discussed under sections D.1 and D.2 below).
Among the allegations that we received from youth at Scioto are that some YS staff:
4 The 25 youth represent approximately 18% of the youth at Scioto during the February 22-24, 2011 tour.
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• Attempt to enter sexual relationships with youth and engage youth in discussions about sexual activity;
• Intentionally provoke youth by taunting them and then “write them up” for fighting;
• Threaten youth not to cooperate with investigations by the CIO or Scioto investigators;
• Berate or talk down to youth by calling them inappropriate terms such as “bitch,” “ho,” or “retard,” or talk inappropriately about their mothers; and
• Bribe youth with food, snacks, or extra free time in exchange for services by the youth. These services include writing a grievance against a disfavored YS or attacking or fighting a disfavored youth.
The United States recommended to the State that Scioto administration remind all staff (YS, medical, mental health, recreation, etc.) that mistreatment of youth will not be tolerated and that all staff are responsible for reporting their colleagues if they witness such behavior.
In the same March 11, 2011 letter, we also described problems with thirdshift supervision not executing their rounds, delays in receiving medical care (sick calls filled), the quality of mental health care remaining significantly below minimum standards required by the Consent Order, and complaints from youth that they spend an inordinate amount of time engaged in activites such as playing cards or locked up in their rooms. We discuss these issues throughout this compliance report.
Since provision A.1, “General Protection From Harm,” is composed of the subject areas in provisions A.2-A.7 (Use of Force, Seclusion, Restraint, Investigation of Serious Incidents, Staff training, and Employment Practices), compliance in A.1 is dependent upon the State’s achievement of substantial compliance with all PFH provisions. As noted above, the State faces challenges with provisions A.3 (Seclusion) and A.5 (Investigation of Serious Incidents). This is consistent with our Second Compliance Report based on our tours in October and November 2010. We discuss both provisions below.
Compliance Rating: Partial Compliance
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Recommendation(s) to reach substantial compliance:
The State must actively address its failure to comply fully with provisions A.1, A.3 and A.5. Specifically, the State needs to address the belief among some YS staff that they will not be held accountable for mistreating or threatening to mistreat youth (A.1 prohibits abuse and neglect of youth), and ignoring their duty to conduct security checks (required by provision A.3). The State also needs to improve the quality of investigations regarding alleged staff misconduct and address any retaliatory threats by YS staff against youth for cooperating in investigations (required by provision A.5). These are chronic problems that the United States described in its findings letter to the State in 2007. To be clear, until the State addresses these serious risks to the youth under its custody, it will not reach substantial compliance with provision A.1.
A.2 USE OF FORCE The State shall develop and implement comprehensive policies, procedures, and practices limiting use of force on youth to situations where it is objectively reasonable and necessary. Staff shall be required to adequately and promptly document and report all uses of force. (See Consent Order III.A.2)
In our assessment of this provision, we reviewed the State’s self-assessment and documents requested prior to tour, and interviewed youth and staff. Consistent with our Second Compliance Report, the State is in substantial compliance with this provision. We commend the State for maintaining its compliance rating.
Based on our review, the State’s frequency of training in Use of Force (“UOF”) continues to exceed that of generally accepted practices and relevant policies and procedures continue to meet the language of provision A2. Similar to our November 2010 compliance tour, we determined that the State undertakes various efforts to ensure that UOF occurrences were promptly and completely documented. In our Second Compliance Report, we described the appointment in Fall 2010 of a Facility Intervention Administrator (“FIA”) to conduct internal
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reviews of all UOF incidents. The FIA determines whether the documentation meets ODYS policy requirements, whether staff require additional coaching or training regarding documentation, and whether the incident should be referred for investigation. Separately, each incident is also reviewed by the Operations Administrator and the Deputy for Direct Services. Ten percent of the UOF incidents are also reviewed by the Superintendent. This activity unquestionably reflects a serious and thoughtful effort to ensure that all incidents of UOF on youth are limited to situations in which it is objectively reasonable and necessary. We note that two incidents we learned about from youth during the February 2011 tour and brought to the attention of the Deputy for Direct Services had already been identified for investigation internally by Scioto.
We agree with Dr. Dedel’s suggestion that the State should investigate the cause for the reduced rate of physical restraint for the period August 2010 to January 2011 as compared to February 2010 to July 2010. We believe that such analysis could be helpful to the State in its own long-term goal of sustaining all the improvements it has accomplished thus far. (See Dedel Third PFH Report at 6). As mentioned by Dr. Dedel, youth who resided at Scioto in the past and who had recently returned noted that direct care staff now consistently attempt to deescalate youth acting out prior to attempting a physical restraint. (See Dedel Third PFH Report at 7). This is an important factor in protecting youth from harm and we commend the State on its continued success.
Compliance Rating: Substantial Compliance
A.3 SECLUSION The State shall develop and implement policies, procedures and practices so that staff use seclusion only in accordance with policy and in an appropriate manner and so that staff document fully the use and administrative review of any imposition of seclusion, including the placing of youth in their rooms outside normal sleeping hours. (See Consent Order III.A.3)
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In our assessment of this provision, we reviewed the State’s self-assessment and documents requested prior to tour, and interviewed staff and youth. Based on our review, we found that the State continues to demonstrate reduced rates of all types of seclusion (regular, pre-hearing confinement, and disciplinary). As detailed in Dr. Dedel’s report, during the period from August 2010 to February 2011, almost one third of the youth placed in regular seclusion (which can last between 1 to 3 hours) were placed for less than one hour. For youth who engaged in violent misconduct and were placed in pre-hearing seclusion, approximately 80% were not required to remain secluded pending their disciplinary hearing. For the same time period from August 2010 to February 2011, the use of disciplinary seclusion has been low when compared to the number youth on youth incidents. Dr. Dedel found that disciplinary seclusion was imposed in about 60% of the incidents and the remaining 40% of the youth received an alternative consequence. (See Dedel Third PFH Report at 8). We commend the State for its success in limiting the different types of seclusion. We do suggest that more thought be given to the types of alternative consequences. For example, while some youth are tasked with writing an apology letter to another youth they assaulted (a constructive and meaningful act) other youth reported that they are easily and frequently subjected to sanctions such as repeatedly (hundreds of times) writing the facility rules, an act that has limited if any redeeming value or benefit to the youth.
Consistent with our findings in our Second Compliance Report, the State’s success with this provision is undercut by failures by some third shift staff who inconsistently monitor youth during the nighttime. During the February 2011 tour we received complaints from youth alleging that YS staff on the third shift were not conducting their nightly watches as required. In February 2011, we received multiple complaints that some third shift (10:00 p.m. to 6:00 a.m.) staff ignore youth who want to use the bathroom. A few youth further alleged that they or other youth they know have resorted to urinating on the floor of their room or on themselves because third shift staff did not open their room door soon enough. Youth made
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similar allegations in their grievances for the time period November 1, 2010 to February 1, 2011. We heard similar complaints in November 2011, when youth alleged that staff did not conduct their watches because they were too busy watching television. We appreciate the State’s efforts to resolve this problem—such as cutting cable programming signals to television sets after 11:00 p.m. and increasing the number of random videos they check weekly from one to two—but ultimately the problem is one of supervision and accountability. This is illustrated by recent allegations from numerous youth that some third shift staff have simply switched to watching DVDs instead of television programs.
In order to corroborate these allegations, during our February 2011 compliance tour, we asked to see three randomly selected third shift videos. The United States viewed these videos with the State’s counsel and the Deputy for Direct Services. One of the three third shift videos demonstrated that the only YS staff member assigned to the unit performed no checks at all from 12:00 a.m. to 6:00 a.m. The State indicated that it would check the video footage from the beginning of the shift (reportedly 10:00 p.m.) until 12:00 a.m., but any checks during that twohour period would not negate the dereliction of duty observed for a full six hours. While the other two randomly selected videos demonstrated staff appropriately conducting their rounds, it appears that the State’s current efforts to deter YS staff from ignoring their duties are still falling short. On April 6, 2011, the United States received a response letter to the March 11, 2011 post-tour letter thanking the United States for its recommendations and stating in part that “[a]dditional time, effort, and resources will be needed to determine exactly what improvements are most appropriate for the youth at Scioto JCF, and how best to implement them.” We did not receive any further information regarding the two-hour period of the video watched in which no checks were performed.
With regard to security checks conducted in general, Dr. Dedel notes that during the time period from November 1, 2010, to February 1, 2011, eight of the 17
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shifts (47%) randomly checked by Scioto administration evidence some problem with staff completing safety checks of youth in their rooms. (See Dedel Third PFH Report at 9-10).
As Dr. Dedel discussed in her first and second PFH reports, anytime a youth is placed behind a closed door, the risk of self harm increases. (See Dedel Second PFH Report at 13). A youth who is intent on harming himself will keep track of when staff conduct their checks and act as soon as the staff member moves on. For this reason, long gaps between monitoring checks are of great concern and must be addressed immediately. Since the State has not improved its monitoring of youth during bedtime hours it has not met the language in provision A.3 and remains in partial compliance.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
As discussed above, in order to reach substantial compliance, the State must address the issues involving security checks during periods of seclusion and night time checks during third shift when youth are in bed. The State should also consider creating a set of approved consequences that are meaningful and appropriately calibrated to the severity of the youths’ misconduct.
A.4 RESTRAINT The State shall develop and implement policies, procedures and practices so that only safe methods of restraint are used at the facility and only in those circumstances necessary for safety and security and, to the extent possible, when less restrictive means have been properly, but unsuccessfully, attempted or with respect to therapeutic restraints pursuant to a medical order to protect the health of the youth. (See Consent Order III.A.4)
In our assessment of this provision, we reviewed the State’s self-assessment and documents requested prior to tour, and interviewed youth and staff. Based on our review, we found that the State has continued to strengthen its efforts to ensure
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that staff are well-trained in safe methods of restraint and that the training results in positive results. In 2010, at least 90% of the Scioto direct care staff received all the required Managing Youth Resistance (“MYR”) training. (See Dedel Third PFH Report at 11). We encourage the State to ensure that the remaining 10% of staff receive the MYR training in the near future. The MYR training is now required once a quarter rather than annually. In November 2010, Dr. Dedel reviewed 10 UOF incident reports previously reviewed by the State’s internal auditing process and found that the reviews were appropriate. We understand that the internal auditing process has not been changed or modified. Lastly, when we interviewed youth, they generally corroborated that staff attempt to break up fights between youth first using verbal commands and if that fails, they intervene physically. The methods described by the youth appeared to be consistent with the MYR curriculum. We note that the ODYS policies and procedures for the use of restraint were in substantial compliance during our last review and remain the same. Accordingly, the State continues to be in substantial compliance with this provision. We commend the State on its continued success under this provision.
Compliance Rating: Substantial Compliance
A.5 INVESTIGATION OF SERIOUS INCIDENTS The State shall develop and implement policies, procedures and practices so that appropriate investigations are conducted of all incidents of: use of force; staff-on-youth violence; serious youth-on-youth violence; inappropriate staff relationships with youth; sexual misconduct between youth; and abusive institutional practices. Investigations shall be conducted by persons who do not have direct or immediate indirect responsibility for the employee being investigated. (See Consent Order II.A.5)
In our assessment of this provision, we reviewed the State’s self-assessment, documents requested prior to tour, and interviewed youth. Based on our review, we determined that, while the State’s policies, procedures, and investigations manual appear to sufficiently address the investigatory process and timing and meet the
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requirements of provision A.5., the level of investigations at the facility level continue to be lacking.
In our Second Compliance Report, we discussed our various concerns regarding a series of allegations by female youth about inappropriate sexual comments from male staff. In particular, we detailed how the facility administration appeared to be unaware of the allegations of inappropriate sexual comments from staff until we informed them, how the facility had allegedly lost or misplaced the youth’s statement reporting the allegation, and how when CIO investigated the matter, they asked youth about privileged conversations the youth had with the United States. When we interviewed female youth during our February 2011 tour, we learned that since November 2010, Scioto staff have been more proactive about reporting and addressing instances of other staff exhibiting inappropriate relationships with youth. We are hopeful that Scioto’s administration will aggressively pursue sanctions against staff who prey on any youth at Scioto, since such behavior is not only illegal, but contrary to the very rehabilitative purpose of Scioto.
While the State’s policies and procedures have met the requirements of provision A5, its practices are not yet compliant with this provision. In her review of 15 investigations investigated from November 1, 2010 to February 1, 2011, Dr. Dedel found that the facility level investigations continued to be problematic. (See Dedel Third PFH Report page 12-13). Dr. Dedel notes that several of these investigations the investigatory protocol “lacked the necessary vigor to ensure a reasonable finding” and that two investigations were so poorly written that it was difficult for her to discern the basis for the investigator’s conclusions.
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For the same time period, there were four allegations of inappropriate relationships between staff and youth,5 10 allegations of inappropriate or excessive UOF, and one allegation of verbal abuse. (See Dedel Third PFH Report at 12). According to Dr. Dedel’s review of these investigations, the CIO investigations were of high quality. Id. We are encouraged by the quarterly audits performed by the CIO and believe that they are instrumental in improving the quality of investigations from the CIO’s office. We were also pleased to learn that the CIO plans to provide training to Scioto investigators.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
Consistent with our Second Compliance Report, we recommend the State regularly audit facility level investigations for completeness. Further, the State should take measures to remind its staff of the importance of relaying serious allegations to facility operations, whether youth convey these allegations orally or in writing. Lastly, we echo Dr. Dedel’s recommendations to train all Scioto investigation staff on proper investigatory protocol, ensure that all investigations of employee misconduct and youth mistreatment meet generally accepted standards, and that the Staff provide feedback to youth about investigations that stem from an allegation or grievance about staff mistreatment. (This last point is discussed in further detail below in section D.2.) (See Dedel Third PFH Report at 13)
A.6 STAFF TRAINING IN BEHAVIOR MANAGEMENT, DE-ESCALATION MANAGEMENT, DE-ESCALATION AND CRISIS INTERVENTION The facilities shall train all staff in behavior management, de-escalation techniques, appropriate communication with youth and crisis intervention before staff may work in direct contact with youth. (See Consent Order III.A.6)
5 During our February 2011 on site tour, we interviewed youth who alleged that recently YS staff on their unit have propositioned youth and/or attempted to enter into sexual relationships with youth.
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In order to assess the provision, we reviewed the State’s self-assessment, documents requested prior to tour, and interviewed youth. Based on our review of these documents, we found that the State continues to be in substantial compliance with this provision. Consistent with our Second Compliance Report, the State’s training and development program in this area exceeds generally accepted practice. Additionally, based on a review of training documents, Dr. Dedel found that in 2010 92% of veteran staff completed all 24 separate training courses. (See Dedel Third PFH Report at 14). In our Second Compliance Report, we assessed staff training with regard to the Strength Based Behavior Modification System (“SBBMS”). As of November 2010, 93% of the Scioto staff received the SBBMS training. While we did not assess this training during our February 2011 tour, we encourage the State to maintain its high rate of training. Overall, we commend the State on its commitment to staff training.
Compliance Rating: Substantial Compliance
A.7 EMPLOYMENT PRACTICES The State shall use reasonable measures, including background checks and criminal records checks, to determine applicants’ fitness to work in a juvenile facility prior to hiring employees for positions at the facility. (See Consent Order III.A.7)
In our assessment of this provision, we reviewed the State’s self-assessment and documents requested prior to tour. Pursuant to the relevant procedure, if a candidate is being recommended for employment after completing the screening and interview procedures, that candidate is required to pass a criminal background check prior to being employed. Candidates with various serious offenses are excluded from employment, while those with certain less serious offenses may be eligible pursuant to other requirements. During the period from November 1, 2010 to February 1, 2011, Scioto hired four new employees. All four employees passed their background check and did not have any criminal records for any offenses that would bar their employment according to ODYS regulations. Consistent with our
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Second Compliance Report, the State has maintained its substantial compliance rating with this provision. We commend the State on the proper screening practices of prospective employees.
Compliance Rating: Substantial Compliance
II. MENTAL HEALTH
B.1 MENTAL HEALTH SCREENING
The State shall develop and implement policies, procedures, and practices to ensure that all youth admitted to the Facilities are comprehensively screened for mental disorders, including substance abuse, depression, and serious mental illness, within twenty-four hours of admission. This screening shall be performed by qualified personnel, as part of the intake process, consistent with generally accepted professional standards of care. (See Consent Order III.B.1)
In assessing this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment,6 new draft policies and procedures, and youth records, and we interviewed youth. Based on our review, it appears that the new ODYS policies and procedures, “Mental Health Screenings,” meet most of the requirements of provision B.1. Specifically, the procedure requires that a mental health trained or qualified mental health personnel (“QMHP”) assess a youth’s suicidal ideation, self injurious behavior, prescription of psychotropic medication, mental health issues, diagnoses, treatment and history of substance abuse within 24 hours of the youth’s admission. However, the State’s intake assessment documentation is of variable quality. (See Glindmeyer Second Mental Health Report at 2). Accordingly, while the relevant policy and procedure are consistent with the requirements of provision
6 For the February 2011 compliance tour, the State elected to present a verbal selfassessment only. We encourage the State to produce a written self-assessment as it did for the November 2010 compliance tour as it will allow the State to satisfy its duty to demonstrate compliance. (See U.S. v Ohio Consent Order at IV.E (requiring the State to analyze and assess its compliance with each provision); (id. at V.H (requiring the Monitor to provide compliance reports that specify “the selfassessment steps the facility undertook to assess compliance and the results thereof.”)).
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B.1, the facility’s practice has not yet reached full compliance. We further discuss the quality of the assessment documents in provisions B.3 and B.4.
In our Second Compliance Report, we explained that the State informed us that it intended to implement on January 1, 2011 a new policy, “Behavioral Health Assessment, Screening, Appraisal and Evaluation,” which, as the name implies, would address different aspects of a youth’s behavioral health assessments including screenings. The new policy included a plan for the creation of a Behavioral Health Review panel to assess intake data and make recommendations about future housing, programming, and treatment needs. During our February 2011 compliance tour, the State informed Dr. Glindmeyer that it intended to introduce a new “Behavioral Health Appraisal” document, which it had not yet been tested but expected to be fully implemented as of March 15, 2011. The State anticipates that “Behavioral Health Appraisal” document would provide improved case conceptualization and diagnostic clarification with recommendations for treatment. Based on the nascent nature of the appraisal document, it was not possible to assess its effectiveness. Accordingly, the State remains in partial compliance with this provision.
Compliance Rating: Partial Compliance
Recommendation(s) to reach Substantial Compliance:
We encourage the State to develop and begin quality assurance review of, or clinical supervision for, assessment summary documents. The State should fully implement all relevant policies, procedures, and forms related to mental health screenings.
B.2 IMMEDIATE REFERRAL TO A QUALIFIED MENTAL HEALTH PROFESSIONAL If the mental health screen identifies an issue that places the youth’s safety at immediate risk, the youth shall be immediately referred to a qualified mental
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health professional for assessment, treatment, and any other appropriate action, such as transfer to another, more appropriate setting. The State shall ensure that, absent extraordinary circumstances, qualified mental health professionals are available for consultation within 12 hours of such referrals. (See Consent Order III.B.2)
In assessing this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, policies, procedures, and psychology staff schedules, relevant Ohio statute, and youth records, and we interviewed youth and staff. Based on our review, we found that the relevant policies and procedures adequately describe procedurally how and under what circumstances a referral is to be made. It appears that, in order to have 12-hour weekday and 8-hour weekend coverage, the State relies heavily on its psychology staff and requires the psychology supervisor to be on-call continuously. We strongly suggest the State consider seeking some form of staffing relief in order to account for staff illness, vacation, and unexpected absences. Further, in keeping with Ohio Rev. Code Sec. 4757.02(A)(5), the State allows unlicensed staff, such as social workers, to qualify as the qualified mental health professional (“QMHP”) required by provision B.2. Given that Scioto lacks sufficient psychiatric staff to provide social workers with support and supervision, we are concerned that unlicensed staff serve as QMHPs.
Between November 11, 2010 and February 11, 2011, Scioto staff conducted capacity assessments of 26 youth. With one exception, staff completed the assessments on the same day as the request. Staff completed the remaining assessment within two days after the request. During the same period, intake staff referred 32 youth for risk assessments. Mental health staff conducted all of the assessments on the same day as the referrals. However, staff did not note the times of the requests and the assessments on the documentation, so we could not determine whether staff completed the assessments within the four-hour time frame required by the State’s procedure. Finally, according to the State, only four youth submitted written requests for mental health services between November 11,
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2010 and February 11, 2011. Staff saw all four youth within four hours of their requests.
We note that the information above does not include referrals for mental health interventions that other mental health staff generate. Going forward, it would be helpful for the State to keep track of those requests as well since, based on the documentation we received from the State, youth do not frequently request mental health services in writing. This issue is discussed in more detail under provision 9, “Access to Qualified Mental Health Professional.”
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
The State should create quality assurance measures to ensure that all requests for mental health services by both mental health and other staff and provisions of services are made within the appropriate time frames.
B.3 IDENTIFICATION OF PREVIOUSLY UNIDENTIFIED YOUTH WITH MENTAL DISORDERS The Facilities shall implement policies, procedures, and practices consistent with generally accepted professional standards of care to identify and address potential manifestations of mental or behavioral disorder in youth who have not been previously identified as presenting mental health or behavioral needs requiring treatment. (See Consent Order III.B.3)
In assessing this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, policies and procedures, and youth records, and we interviewed youth and staff. Based on our review, we found that the State has made little progress in meeting the requirements of provision B.3. In November 2010, the State’s written self-assessment for provision B.3 did not address the identification of youth who were not previously identified as presenting mental health or behavioral needs requiring treatment. Instead, the State discussed the monitoring for decompensation of youth who are in seclusion, which is appropriate,
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but insufficient. We agree with Dr. Glindmeyer that the goal of provision B.3 is to ensure that all youth who may not present with “a history of mental illness and who are not identified at the time of the initial assessment . . . are monitored over the course of their incarceration for exacerbations of symptoms and referred for mental health treatment” as clinically appropriate. (See Glindmeyer Second Mental Health Report at 5-6).
The State provided us with one example of a youth, Youth 330, who was placed in the general population upon her admission to Scioto in May 2010, but began to experience mental health symptoms fourth months later. While the State appropriately identified this youth as in need of mental health care, this example is not sufficient to establish that the State has made notable progress in achieving compliance with the key components of this provision. Specifically, due to the State’s inadequate recordkeeping, we question the accuracy of the interventions the State reported in Youth 330’s case. Specifically, once the youth began to decompensate in September 2010, staff conducted a mental health assessment, but staff did not document any treatment that Youth 330 received from late September through October 2010. Instead, on November 1, 2010 – the day before our compliance tour – staff entered approximately ten late mental health entries into this youth’s chart. According to these late entries, the State provided this youth with generic, but ultimately sufficient care. Youth 330’s health record reflected a disturbing pattern of mental health staff entering notes in youth records well after their contact with the youth actually occurred. Such a practice falls well below generally accepted standards of care, makes it impossible for staff to follow a youth’s mental health treatment over time, and inhibits decision making. During our February 2011 compliance tour, facility staff candidly noted that they were aware of the need for ongoing and improved quality assurance to review documentation and the decision-making process regarding the mental health needs of youth. (See Glindmeyer Second Mental Health Report at 6).
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We understand that the State is beginning implementation of its new policy,7 “Behavioral Health Assessment, Screening, Appraisal and Evaluation.” As of the time of the February 2011 compliance tour, the State had begun using the new policy and procedure to review assessments performed on Tuesdays, with the expectation of a complete expansion to review all intake assessments by April 1, 2011.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
As noted above, the State has not provided us with adequate information to determine that, in practice, it identifies and provides treatment to previously unidentified youth in a manner consistent with generally accepted professional standards of care. We recommend that the State ensure that the new draft policy regarding screenings, evaluations, appraisals, and re-evaluations captures previously unidentified youth, not merely youth in seclusion. The State must also ensure that staff complete documentation of mental health treatment provided to youth, including previously unidentified youth, in a timely manner. Late documentation does not have the richness of documentation completed immediately following a mental health contact. Finally, the State should engage in quality assurance monitoring regarding the reevaluation of youth who experience an exacerbation of mental health symptoms or behavioral challenges.
B.4 MENTAL HEALTH ASSESSMENT The State shall implement policies, procedures, and practices to ensure that, as part of an overall assessment of the youth’s health, risk, strengths and needs, youth who are identified in screening as having possible mental health needs receive timely, comprehensive, and accurate assessments by qualified
7 Based on the draft language provided, we are concerned about the policy’s overall generic tone. We recommend adding language that addresses previously unidentified youth.
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mental health professionals, consistent with generally accepted professional standards of care. Assessments shall be designed and implemented so as to identify youth with mental disorders in need of specific treatment and contribute to a full plan for managing the youth’s risk. Assessments shall be updated as additional diagnostic and treatment information becomes available. (See Consent Order III.B.4)
In assessing this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, youth records, and ODYS policies and procedures, and interviewed staff and youth. Based on our review, we found that the State is currently performing mental health assessments and appraisals at intake/reception. The initial assessment summaries and mental health appraisal reviewed provided useful information for placement and initial treatment planning, but were of varying quality. During the State’s verbal self-assessment, the State acknowledged that youth charts had not changed significantly since our November 2010 tour, with the exception of charts’ increased fidelity to the subjective, objective, assessment, and plan (“SOAP”) note format, more in-depth assessments, and possible inclusion of diagnostic criteria review and case conceptualization. (See Glindmeyer Second Mental Health Report at 7). Our review of recent intake assessments revealed that, while staff generate multiple assessment forms for youth, mental health staff’s case conceptualization is still weak and the staff fails to tie all of the information obtained into a coherent package for the reader. Moreover, the intake assessments did not consistently provide a statement of specific diagnostic criteria justifying the diagnosis.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
We are encouraged to learn that the State has begun to establish clinical review teams to provide formal recommendations. The State should continue and expand its quality assurance measures to include a peer review process and clinical supervision. These quality assurance measures should be geared towards ensuring
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that mental health staff accurately document all diagnostic formulations and develop a case conceptualization for each youth that ties together information obtained through the assessment process. (See Glindmeyer Second Mental Health Report at 7-8).
B.5 ADEQUATE MENTAL HEALTH CARE AND TREATMENT
The State shall implement policies, procedures, and practices to ensure that adequate mental health and substance abuse care and treatment services (including timely emergency services), and adequate rehabilitative services are provided to youth in the Facilities by qualified mental health professionals consistent with generally accepted professional standards of care. (See Consent Order III.B.5)
In assessing this provision, we reviewed the State’s verbal self-assessment, youth records, ODYS policies and procedures, and descriptions of treatment modalities, observed three group interactions, and interviewed youth and staff. While the State has begun to implement its new mental health policies since our last review, the State has not yet made notable progress in achieving compliance with the key components of provision B.5. Specifically, in addition to the State’s failure to develop adequate diagnostic formulations and case conceptualizations, detailed above, our review revealed numerous deficiencies with regard to the State’s provision of treatment planning, individual therapy, group therapy, and the quality of Scioto’s mental health staff.
The State reported during the February 2011 compliance tour that the New Freedom Phoenix program, which is the overarching treatment program for all Scioto youth, was fully functional in one housing unit and will expand into all units by April 1, 2011. All Scioto staff have completed the training required for the “Trauma and Grief Component Therapy for Adolescents.” We observed the first group meetings for this group therapy on the boys and girls mental health units. The group leaders were well-prepared and effective and youth were engaged in the group process. (See Glindmeyer Second Mental Health Report at 9-11). Social work and psychology staff are working together to co-facilitate cognitive behavioral
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therapy (“CBT”) based groups. However, CBT trained YS staff demonstrated limited investment and involvement in the group process. This issue is discussed further under provision B.7, “Treatment Teams.”
Although youth receive group therapy, the State has not demonstrated that youth are receiving adequate assessments and treatment through this process. Specifically, documents tracking youths’ progress during group therapy were identical for several consecutive sessions, demonstrating that staff failed to conduct individualized assessments. We did not assess the mental health group notes for boys because the most recent documentation that the State provided us was from August 2010.
Our review of records related to individual therapeutic interactions, including individual counseling, revealed similar deficiencies. While psychology staff engage in and document crisis management, there is little evidence that they currently track youths’ progress toward their treatment plan goals as they participate in individual therapeutic interactions. Nor do staff incorporate the treatment plan’s specific targeted interventions into these individual sessions. We hope that the State will address these deficiencies as it moves towards developing an Integrated Treatment Plan (“ITP”) for each youth.
Finally, administrative staff reported concerns about the quality of work provided by some members of the mental health staff, particularly with regard to documentation. The administrative staff estimated that three social workers were “not functional” and one psychology staff “lags behind.” (See Glindmeyer Second Mental Health Report at 10). Administrators discussed plans to utilize the disciplinary process and performance evaluations in order to remedy these deficiencies.
Our review of documentation found that the quality of treatment plans varied. (See B.8 (“Integrated Treatment Plans”)). According to the State’s verbal
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self-assessment, in recent months, Scioto staff diligently worked to complete treatment plans for youth in the new integrated format. Ongoing clinical supervision and quality assurance may be helpful for staff when adjusting to these new documentation criteria.
Despite these findings, we are encouraged by the fact that the State is already making strides towards improving its treatment program. Going forward, we look forward to learning about the full implementation of the New Freedom Phoenix program and any data the State can provide regarding the efficacy of the program. We also hope to see that the policies and procedures address the requirements of provision B.5 and ensure that QMHPs provide adequate mental health, substance abuse, treatment services, and rehabilitative services.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
Consistent with our Second Compliance Report, we recommend that the State ensure that the documentation in youth records clearly articulates the youth’s progress towards goals in that youth’s treatment plan and that youth reports incorporate or discuss targeted interventions in that youth’s treatment plan. In particular, staff should consistently track youth’s progress towards their treatment plan goals as they participate in group and individual interactions. Staff should conduct meaningful, individualized assessments and, as recommended in B.4, the State should document all diagnostic formulations and develop a case conceptualization for each youth. The State should also ensure the provision of evidence-based group therapeutic interactions and ensure that rehabilitative and substance abuse services are included in the new treatment program. The State should also expand the group curriculum available to male youth and engage and encourage direct care staff to participate in group modalities.
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B.6 TREATMENT PLANNING The State shall develop and implement policies, procedures, and practices so that treatment service determinations, including ongoing treatment and discharge planning, are consistently made by an interdisciplinary team through integrated treatment planning and embodied in a single, integrated treatment plan. (See Consent Order III.B.6) In assessing this provision, we reviewed the State’s verbal self-assessment,
integrated treatment plans, and policies and procedures, and we interviewed staff. Based on document review and interviews with staff, we understand that, as of January 1, 2011, the State has begun to implement its interdisciplinary Treatment Team policy and its revised format for documenting treatment team planning by creating an “Integrated Treatment Plan.” As discussed further in provision B.7 below, it appears that there was limited psychiatrist attendance at IDT meetings. While this is an improvement since our last compliance visit in November 2010, this remains problematic.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
We encourage the State to complete the Integrated Treatment Plan for all youth and begin quality assurance monitoring of the treatment planning process to ensure that treatment teams operate in an interdisciplinary fashion, with sufficient participation by all relevant disciplines, to generate a single, integrated treatment plan that meets the youth’s needs. (See Glindmeyer Second Mental Health Report at 12). We also recommend that the State seek technical assistance with this provision to accelerate its compliance efforts.
B.7 TREATMENT TEAMS At a minimum, the interdisciplinary treatment team for each youth in need of mental/behavioral health and/or substance abuse treatment should:
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a. Be guided by a trained treatment professional who shall provide clinical oversight and ensure the proper functioning of treatment team meetings;
b. Consist of a stable core of members, including at least the youth, the social worker, a JCO, one of the youth’s teachers, the Unit Managers, and as warranted by the needs of the youth, the treating psychiatrist, the treating psychologist, registered nurse, and, as appropriate, other staff;
c. Ensure that needed psychiatric evaluations are conducted on a youth before administering psychotropic medications to the youth;
d. Monitor as appropriate but at least monthly, the efficacy and the side effects of psychotropic medications, including consultation with the facility medical, counseling, and other staff who are familiar with the youth;
e. For youth under a psychiatrist’s care: ensure the provision of individual counseling and psychotherapy when needed, in coordination with facility psychologists; ensure that all youth referred as possibly in need of psychiatric services are evaluated and treated in a timely manner; and provide adequate documentation of treatment in the facility medical records;
f. Include, to the fullest extent practicable, proactive efforts to obtain the participation of parents or guardians, unless their participation would be inappropriate for some reason (e.g. the child has been removed from the parent’s custody), in order to obtain relevant information, understand family goals and concerns, and foster ongoing engagement;
g. Meet to assess the treatment plan’s efficacy at least every 30 days, and more often as necessary; and
h. Document treatment team meetings and planning in the youth’s mental health records. (See Consent Order III.B.7)
In assessing this provision, we reviewed the youth records, Interdisciplinary
Team (“IDT”) meeting minutes, observed group therapies and treatment teams, and
interviewed youth and staff. Based on our review, it appears that the State’s newly
implemented standard operating procedure, “Interdisciplinary Team,” 404.02.01,
meets the requirements of provision B.7. Previously, the procedure did not include
in the interdisciplinary team all individuals listed by provision B.7. The revised
procedure, which went into effect on January 1, 2011, defines the “interdisciplinary
team” as minimally consisting of “a unit manager, Clinician(s), Provider(s), Youth
Specialist(s) and staff from Mental Health Services, Psychiatry, Education,
Psychology and Recreation. Other participating staff may be included, such as from
medical services, religious services, or administration.” SOP 404.02.01(III).
Further, the procedure states that “[w]henever possible family members will be
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included in IDT meetings. Teleconference shall be made available to family members unable to travel to the facility.” SOP 404.02.01 (IV.C). We commend the State on its use of telecommunication to further parental involvement in interdisciplinary team meetings.
Our review of IDT team meeting minutes revealed that, there was limited psychiatric involvement in the IDT, most likely due to the limited psychiatric resources at Scioto. Specifically, for IDT meetings from November 11, 2010 to January 13, 2011, there were no psychiatrist attendance signatures. (See Glindmeyer Second Mental Health Report at 14). Youth confirmed the lack of psychiatric involvement in IDT meetings. One youth stated that the psychiatrist “comes to my team sometimes” while other youth noted that the “psychiatrist had not attended their IDT meetings.” Id.
Separately, we are troubled by the lack of consistent participation of YS staff in IDT meetings. During one IDT meeting, the YS appeared to be listening to the conversation but was pulled away by duties to answer the phone and respond to other YS staff who approached her. Id. YS staff appeared to be not interested or indifferent to group therapy sessions. For example, a group of male YS staff who were seated in the back of the room were talking and laughing amongst themselves as a female youth was discussing being gang raped. (See Glindmeyer Second Mental Health Report at 17). The YS staff actions were disruptive, counter therapeutic, insensitive and dismissive of the youths’ experiences. We reported this issue to Scioto administration immediately. However, they chose to relocate the group therapy session rather than deal with the YS staff issue. Id. We note that mental health staff indicated that this type of disruptive behavior by YS staff was a frequent occurrence. Id. Rather than being a disruption, YS staff should meaningfully participate as “full-fledged” functioning members of the IDT. (See Glindmeyer Second Mental Health Report at 14)
Compliance Rating: Beginning Compliance
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Recommendation(s) to reach substantial compliance:
As discussed above, the continued lack of psychiatry staff participation in the IDT is troubling. The State should ensure that psychiatrists are sufficiently available to allow their participation in Interdisciplinary Treatment Team meetings. We strongly urge the State to educate all staff regarding the importance of the group therapeutic process and ensure that direct care staff are treated as valued members of the IDT. The State should consider quality assurance monitoring of treatment planning efforts and IDT meetings.
B.8. INTEGRATED TREATMENT PLANS
The State shall ensure that each youth in need of mental/behavioral health and/or substance abuse treatment shall have an appropriate, integrated, treatment plan, including an appropriate behavioral management plan, that addresses such needs. The integrated treatment plan shall be driven by individualized risks and needs, be strengths-based (i.e. builds on an individual’s current strengths), account for the youth’s motivation for engaging in activities contributing to his/her wellness, and be reasonably calculated to lead to improvement in the individual’s mental/behavioral health and well being, consistent with generally accepted professional standards of care. (See Consent Order III.B.8)
In order to assess this provision, we reviewed the State’s policies and procedures and youth records, and interviewed staff. Based on this review, we found that the State is in the process of collating multiple treatment and case planning documents into one overarching document called the Integrated Treatment Plan (“ITP”). The relevant policy, “Behavioral Health Services,” describes the ITP document as a formal plan to address youth’s various needs (including but not limited to mental health, rehabilitation and psychiatric). Scioto first implemented this policy on January 1, 2011. We are encouraged by the State’s progress towards implementing this policy, since it requires the treatment team to consistently document youth progress and information gleaned during treatment team meetings. At the time of our February 2011 tour, mental health staff gave various estimates as to the number of youth whose plans had been re-written to
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meet the new policy requirements. The State indicated that it aimed to complete the process for all youth plans by March 1, 2011. (See Glindmeyer Second Mental Health Report at 19).
During treatment team meetings, mental health staff appeared to be interested and knowledgeable about the youth, but the “rich discussion observed in treatment team” did not translate into an intervention and practice regarding the youth. (See Glindmeyer Second Mental Health Report at 15.) For example, at the time of our tour, one particular youth (110) had been in his room for four days and was apparently decompensating. The individualized behavioral plan for this youth provided nothing with regard to reward for positive behaviors that related to the January 15, 2011 goal of having the youth leave his room. While the youth responded to treatment with injections of neuroleptic medication, he began experiencing extra pyramidal side effects (typically tremors, slurred speech, anxiety, paranoia and akathisia). (See Glindmeyer Second Mental Health Report at 15). Rather than address the youth’s side effects through medications commonly used to ameliorate side effects, the psychiatrist discontinued the injections, which had kept the youth relatively stable. As a result, the youth decompensated. Youth 110 began refusing oral medications and was reportedly unable to tolerate the stimulating environment of the unit and thus preferred to stay in his room. The facility’s lack of psychiatric resources may have contributed to this pharmacological mistake. (See Glindmeyer Second Mental Health Report at 15-16). Had the State provided more resources and attention to Youth 110, the treatment team may have considered alternative modalities.
Although the mental health staff acknowledged that they should have developed alternatives instead of permitting the youth to remain in his room (the youth had begun to refuse to leave, bathe, or take psychotropic medication) the mental health staff struggled with creating a workable treatment intervention as they awaited permission to involuntarily medicate the youth. Ultimately, the
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mental health staff created a new individual behavior management plan and the youth was relocated to another unit with limited stimuli. However, the YS staff had no written instructions available to them and reportedly had not received any training regarding the management of this youth’s needs. (See Glindmeyer Second Mental Health Report at 16).
The 10 ITPs that the State provided us were of variable quality. The plans had admiral goals for youth, but the goals themselves were not measurable. For example, Youth 888’s ITP goals included “reduc[ing] mental health symptoms and their impact on my daily life.” (See Glindmeyer Second Mental Health Report at 19-20). Similarly, each goal included objectives, but only some objectives were measurable. Separately, one youth reported that the development of treatment goals was rushed and “tacked on to the end of the meeting.” (See Glindmeyer Second Mental Health Report at 14).
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
The State should begin quality assurance monitoring of treatment plan documentation and implementation to ensure compliance with the requirements of this provision. (See Glindmeyer Second Mental Health Report at 20).
B.9 ACCESS TO A QUALIFIED MENTAL HEALTH PROFESSIONAL The State shall develop and implement policies, procedures, and practices to ensure that youth who seek access to a qualified mental health professional are provided appropriate access in a timely manner. (See Consent Order III.B.9) In order to assess this provision, we reviewed the State’s verbal self-
assessment, policies and procedures, documents requested prior to tour, and youth records, and interviewed youth and staff. Consistent with our Second Compliance Report, we found that the current policies and procedures for referrals detail steps
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for staff to refer youth for a mental health assessment. The policy did not, however, address the requirements in provision B.9, namely that Scioto youth can independently access a QMHP in a timely manner. Also, consistent with our Second Compliance Report, Dr. Glindmeyer confirmed that access to mental health services continues to be dependent on whether a YS staff member is willing to call and request the service for the youth. Dr. Glindmeyer notes that of the youth she interviewed, “some youth indicated that they had to access mental health services via direct care staff, and ‘sometimes they don’t like you and don’t want to do it.’ Another youth reported, ‘we don’t fill out the request because [psychology staff] is there . . . but if they aren’t staff has to call . . . and sometimes they don’t want to do it . . . your regular staff usually will, but others could care less.’” (See Glindmeyer Second Mental Health Report at 21-22).
In the State’s written self-assessment for our November 2010 compliance tour, the State relied on particular language in the Youth Handbook that directs a youth to complete a “Request for Services” for routine concerns and to immediately tell a staff member if they feel like hurting themselves or others, and the staff member “will see the issue is addressed.” In our Second Compliance Report, we stated that, while we recognize that Scioto has readily available “Request for Services” forms, we were nevertheless concerned by the generic and vague description of staff’s role in obtaining assistance for the youth. More importantly, we expressed our concern that youth must go through staff in order to access care. (See United States’ Addendum to Second Compliance Report at 16). During our February 2011 tour, mental health staff explained that YS staff “verbally instructed” the youth to place the “Request for Services” form in the sick call box. (See Glindmeyer Second Mental Health Report at 22). The State must delineate this process and instruct youth on how to access mental health care without going through staff. Accordingly, the State remains in beginning compliance with this provision.
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Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
The process for youth to self-refer to a QMHP should not rely on staff involvement. The State should revise its handbook to clearly state that youth need not go through staff to seek mental health services and delineate the process that they can follow to self-refer that does not involve YS staff involvement.
B.10 MENTAL HEALTH INVOLVEMENT IN HOUSING AND PLACEMENT DECISIONS The State shall develop and implement a system for ensuring that significantly mentally ill youth who do not have the adaptive functioning to manage the activities of daily living within the general population are provided appropriate housing and supports to assist them in managing within the institutional setting. (See Consent Order III.B.10)
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, relevant policies and procedures, and youth records. On January 1, 2011, the State implemented its “Behavioral Health-Special Services Living Units” policy, which guides the development of the Behavioral Health Review Panel. As we stated in our last report, we encourage the implementation of this policy because it requires that the interdisciplinary review and treatment process begin at the time of the youth’s admission. As stated earlier, the Behavioral Health Review Panel has started reviewing intake data for youth who arrive on Tuesday of each week and making recommendations about youth’s housing, programming, and treatment needs. Staff indicated that they plan to expand the responsibilities of the Behavioral Health Review Panel to include the review of the reception summaries of all youth admitted to Scioto. We commend the State for moving forward with the requirements of this provision.
The Youth intake screenings and completed intake assessments for the 10 most recently admitted youth indicate that staff recommended that they all go to
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general population. (See Glindmeyer Second Mental Health Report at 23-24). In some of these 10 cases, staff recommended additional treatment modalities, including substance abuse treatment. The State should assess whether all of the youth placed in general population belong in the general population. Specifically, the State should track youth who are initially recommended for general population, but ultimately require an increased level of care.8 Such an assessment will reveal whether the State is adequately capturing all youth in need of mental health services and may prompt changes in the intake assessment process.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
We commend the State for finalizing and implementing the “Behavioral Health-Special Services Living Units” policy and beginning to implement the Behavioral Health Review Panel. The State has moved from beginning compliance to partial compliance with this provision. In order to reach substantial compliance, we encourage the State to monitor and track the efficacy of its policies and institute QA measures to review the accuracy and completeness of its assessments and placement decisions.
B. 11 STAFFING The State shall staff, by contract or otherwise, the Facilities with adequate numbers of psychiatrists, psychologists, social workers, and other mental health professionals qualified through training and practical experience to meet the mental health needs of youth residents, as determined by the acuity of those needs. Mental health care shall be integrated with other medical and mental health services and shall comport with generally accepted practices. The State shall ensure that there are sufficient numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming. (See Consent Order III.B.11).
8 This is consistent with Dr. Glindmeyer’s recommendations for provisions C.3 (“Identification of Previously Unidentified Youth with Mental Disorders”).
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In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, relevant policies and procedures, youth records, staff schedules, and interviewed staff. In our Second Compliance report, we determined that staff shortages existed at Scioto that compromised youth’s mental health care. We cautioned the State that the associated stress on staff was not sustainable. Unfortunately, in the intervening months since our last assessment, the State has not improved in this area. Instead, Scioto has lost critical mental health staff. Specifically, while in November 2010, Scioto had a total psychiatric physician coverage of .7 Full Time Equivalent (“FTE”) – which was insufficient coverage to meet the mental health needs of Scioto youth – Scioto now only has .42 FTE psychiatric coverage. While Scioto had an administrative psychiatrist on staff at the time of our last review, that position is now vacant.
The one psychiatric physician at Scioto only provides a total of 17 hours of clinical services per week. A review of the current psychiatrist’s curriculum vitae revealed that he completed a fellowship in child and adolescent psychiatry, and is board certified in adult psychiatry by the American Board of Psychiatry and Neurology. Although the psychiatrist is not board certified in child and adolescent psychiatry, he is board eligible.
According to staff, this psychiatric physician interviewed for a potential fulltime position at the facility and received an offer of full-time employment in late February 2011. However, even if the part-time psychiatric provider accepts fulltime employment, Scioto does not have adequate psychiatric coverage if this psychiatrist is unavailable for any reason, including vacation, illness, or an unexpected absence. Moreover, the peer review process we have consistently recommended to the State requires at least two psychiatric providers.
Youth expressed variable levels of satisfaction with psychiatric care. Some youth were frustrated and indicated that they had to wait long periods to see the pyschiatrist. For example, staff identified one youth at admission as in need of a
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psychiatric evaluation but, due to limited resources, staff did not conduct the evaluation until six weeks later. One youth reported that, while the youth saw the psychiatrist at a reasonable interval, “he is just so busy . . . that he doesn’t listen . . . and sometimes I think he blows me off.” (See Glindmeyer Second Mental Health Report at 31). Another youth had a more positive report, stating “the doctor comes to my treatment team.” Id.
The State provided us with an analysis of its resource requirements. In this February 22, 2011 document, entitled “Rationale for the Distribution of Psychiatry Hours,” the State assumed that approximately 50% of the youth committed to DYS will receive mental health services. However, based on the relevant literature, this is an underestimation of the number of youth who need services. (See Glindmeyer Second Mental Health Report at 30). The State further assessed how many youth would require minimum, moderate, or high levels of mental health care. The State ultimately calculated that one FTE of psychiatric coverage would be sufficient to cover the 2496 annual hours of direct and indirect clinical service requirements to meet the needs of Scioto youth. One FTE is not likely sufficient to meet these youths’ mental health needs. Id. The State should re-evaluate the need for additional resources at Scioto.
With regard to psychology, the State reported that it has a total of four psychologists and six psychology assistants on staff. According to staff interviews, the facility employs a total of seven psychologists, three of whom are licensed, plus a psychology supervisor and two psychology assistants. Of the seven psychologists, five are assigned to the assessment units and the remainder are assigned to the program units. This level of staffing is consistent with our last review.
During our last assessment, 14 social workers provided services to Scioto youth. While there are still 14 social workers officially on Scioto’s staff, staff reported that three social workers were absent from the facility for various reasons, leaving 11 social work staff actually on-site and providing services. As noted in the
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Protection From Harm section of this report, the State has acknowledged recent instability in social work staffing. See pages 4-5. At the time of the tour, Scioto also had two full-time mental health nurses and two full-time occupational therapists on staff.
In our Second Compliance report, we determined that the psychiatry, psychology and social work staff were not working together to create integrated treatment for the facility youth. Specifically, three separate sets of documents existed to provide guidance for a youth’s mental health treatment: the Unified Care Plan, the Mental Health Treatment Plan, and the Interdisciplinary Treatment Team documents. Since our last assessment, psychiatry, psychology, and social work staff have increased their efforts to work together to integrate treatment for Scioto youth. As discussed earlier, Scioto is in the process of consolidating treatment planning documentation into one overarching document, the Integrated Treatment Plan. However, during interviews, staff provided inconsistent estimates regarding the number of youth who had actually received an Integrated Treatment Plan.
The State has not provided data supporting a finding that there are adequate numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming as required by this provision.
Finally, we appreciate that the State has made efforts to remedy the staffing problems at Scioto. The State is engaging in active recruitment attempts to fill the administrative psychiatry position, which might allow for sufficient coverage. In the interim, in an effort to provide peer review and coverage, administrative staff is exploring the possibility of a contract with a local hospital. We look forward to assessing the results of the State’s efforts in our next compliance report.
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance: 37

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The State cannot reach substantial compliance with this provision until it recruits additional mental health staff and fills the current vacancies. The State must significantly increase its psychiatric coverage in order to meet the mental health needs of Scioto youth. The lack of adequate psychiatric staffing at Scioto has hurt the quality of mental health services, as indicated in several other provisions, including B.7 (“Treatment Teams”), B.12 (“Medication Notice”) and B.13 (“Mental Health Medications”). The State should consider re-evaluating its staffing needs based on the technical assistance provided by Dr. Glindmeyer on-site and in her report. On the other hand, we are encouraged by the improved coordinated between psychiatry, psychology and social work staff and the State’s initial efforts to implement the Integrated Treatment Plan.
B.12 MEDICATION NOTICE
Before renewing a psychoactive medication prescription from a community provider or commencing the administration of a psychoactive medication to a youth, the State shall ensure that the youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, are provided with information regarding the goals, risks, benefits, and potential side effects of the medication and given an explanation of the potential consequences of not treating with the medication, and that the youth has an opportunity to consent to such medication.
a. Involuntary administration of psychotropic medication(s) to juveniles shall comply with applicable federal and state laws and regulations. The DYS clinical director, in consultation with the DYS medical director, shall review any request with DYS Legal Services prior to the approval for involuntary administration. (See Consent Order III.B.12).
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, relevant policies and procedures, and youth records, and interviewed youth and staff. During our February 2011 tour, staff acknowledged that the current psychiatric practitioner is not obtaining informed consent for youth who are already receiving prescribed psychotropic medications when they enter the facility. This provision requires the State to document youth’s informed consent for treatment with psychotropic medication, whether the youth’s prescription is new or a continuation of care from another provider. The psychiatric
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provider reported that he does attempt to contact the youth’s parent or guardian regarding new medication prescriptions.
In our Second Compliance Report, we determined that the State was in beginning compliance with this provision. Specifically, our review of youth records revealed that documentation regarding risks, benefits, side effects, and alternatives to treatment was present in youth’s files but of varying quality. Our more recent review of youths’ initial psychiatric evaluations revealed that there is no documentation of informed consent in the files of youth who enter the facility on prescribed medications and no documentation of the appropriate elements of informed consent in the files of youth who are prescribed psychotropic medications post-admission. (See Glindmeyer Second Mental Health Report at 27-28). Given the lack of documentation in youth’s files, coupled with the staff’s concession that informed consent is not occurring, we must find that the State is non-compliant with this provision.
Scioto staff are aware of the challenges and deficiencies in the area of informed consent for psychotropic medication. During interviews, staff expressed the desire to see more consistency in documentation of informed consent, but also expressed concern regarding the limited psychiatric coverage. (See Glindmeyer Second Mental Health Report at 28). Staff further reported they are in the process of developing information for the youth and their parents on side effects of the psychiatric medications. Id. Interviews with youth revealed that youth are able to name some of the medications prescribed and some side effects of the medications.
Finally, the State has not filed any petitions for authorizations to involuntarily administer medications.
Compliance Rating: Non-compliance
Recommendation(s) to reach substantial compliance:
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The State cannot reach substantial compliance with this provision until it consistently documents the presence of informed consent. The State must also document that it notifies youth that they have an opportunity to refuse such medication and that they received informed explanations of the potential consequences of refusing medication. While it is a positive sign that youth continue to be able to name some of the medications prescribed and some of the side effects, the State must document that it is consistently providing youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, with information regarding the goals, risks, benefits, and potential side effects of medication. The State has not made any progress in this regard since our last assessment. In fact, likely due to staffing limitations, the State’s documentation of informed consent has worsened. In our Second Compliance Report, we encouraged the State to consider a peer review process for informed consent and to develop information regarding side effects of psychotropic medication that is written in language that youth can understand. We continue the urge the State to adopt these recommendations.
B. 13 MENTAL HEALTH MEDICATIONS
The State shall develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices. The State shall provide regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy. The State shall issue and implement policies and procedures for the administration of appropriate tests (including, for example, blood tests, EKGs, and Abnormal Involuntary Movement Scale tests) to monitor the efficacy and any side effects of psychoactive medications in accordance with generally accepted professional standards. The State shall also: a. Share medication compliance data with the psychiatrist and document the
sharing of this information; and b. Not withhold the provision of psychostimulants to youth when such
treatment is clinically warranted. (See Consent Order III.B.13)
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, relevant policies and procedures, lists of youth
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prescribed medication, mental health caseload documentation, 10 youth records, clinical observations, and interviewed youth and staff. Since our last review, the State has updated and approved the “Recommended Laboratory Monitoring Frequency Guidelines.” While this policy is adequate, the State should ensure that it reviews this policy annually so that it remains consistent with generally accepted practices. We applaud the State for finalizing this draft policy. However, the State’s ability to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices, is limited due to the current shortages in psychiatric coverage. Consistent with our last review, the psychiatry clinic at Scioto is not yet fully functional. The psychiatrist is making efforts to perform initial psychiatric evaluations, provide ongoing medication management, and attend some interdisciplinary team meetings. While we commend the psychiatrist’s efforts, the State cannot reach substantial compliance with this provision with its current psychiatric coverage.
Documentation regarding the most recent ten youth admitted to the facility who were prescribed psychotropic medication revealed consistent deficiencies. Youth psychiatric records lacked critical information, including weight and vital signs, monitoring for abnormal involuntary movements, information regarding laboratory examinations, the basis for the psychiatrist’s diagnosis (the “diagnostic formulation”), or the youth’s symptoms that formed the basis for prescribing the medication(s). (See Glindmeyer Second Mental Health Report at 31-33).
However, youth psychiatric records include adequate documentation of the youth’s historical information. In addition, most youth we interviewed were knowledgeable about most of their prescribed medications and were able to articulate the symptoms that some of the medications are addressing and some basic side effects. Youth also indicated that laboratory examinations had been performed during their stay at Scioto. Other positive aspects of psychiatric care
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that we identified during our last review remain in place. For example, the psychiatrist again reported good access to laboratory examinations and reported taking after-hours calls for psychiatric emergencies at the facility. Also consistent with our last review, the psychiatrist did a good job establishing rapport with the youth during clinics, queried the youth regarding signs and symptoms of mental illness, inclusive of historical data, and reviewed the youth’s medical record, inclusive of school and behavioral information.
At the time of the February 2011 tour, there were 138 youth housed on campus. Of these, 33 (or 24%) were prescribed psychotropic medication. Of these 33 youth, 9 were prescribed stimulant medications associated with diagnoses including Attention Deficit Disorder (“ADD”), Attention Deficit Hyperactivity Disorder (“ADHD”), or other Axis 1 mental health disorders.
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance:
In order to reach substantial compliance with this provision, the State must recruit psychiatrists to fill the available positions. As youths’ psychiatric records demonstrate, the State cannot ensure and document that psychoactive medications are prescribed, distributed, and monitored properly and safely without sufficient mental health staffing. Specifically, the documentation deficiencies we discovered are likely the result of diminished clinical resources. We continue to recommend that the State improve psychiatric documentation through quality assurance monitoring or a peer review process. In addition, the State should ensure that it provides regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy, as required by this provision.
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B.14 MENTAL HEALTH AND DEVELOPMENTAL DISABILITY TRAINING FOR DIRECT CARE STAFF The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents in order to supervise them appropriately. (See Consent Order III.B.14)
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment and training documents. The State has provided an update on the behavioral health policy and procedure for all staff, trauma training for staff assigned to the girls units and the boys mental health unit, and training regarding self injurious behavior for staff assigned to the girls units and the boys mental health unit. The State also provided a three-day mental health intensive training to assist staff with the treatment team process. However, mental health staff excluded direct care staff from this training. Direct care staff would have benefited from this information. Direct care staff are an important part of the youth’s treatment team.
The State’s failure to include direct care staff in treatment team training is indicative of a larger problem at Scioto. It is apparent that direct care staff do not consider themselves to be an integral part of the treatment program. (See B.7 (“Treatment Teams”)). Dr. Glindmeyer provided the State with technical assistance on this matter during and after the tour. This is an area that will require a cultural shift at the facility, and will require teamwork, integration, and training.
Despite our request for a spreadsheet indicating all trainings attended by Scioto staff and dates of completion, the State failed to provide this information. During interviews, staff conceded that they have “not had the time to address the requirements of provision 14 or 15 thoroughly.” (See Glindmeyer Second Mental Health Report at 34). At this time, we have insufficient evidence to determine that the State has made significant improvements with regard to this provision.
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Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance:
We urge the State to fully integrate direct care staff into youths’ treatment teams. We continue to recommend that the State appraise its staff training needs and develop a curriculum to address these needs. Based on that appraisal, the State should continue the development of Mental Health Unit training and develop a mandatory training schedule for staff who provide care to youth on the mental health case load. Going forward, the State should create a spreadsheet that delineates staff attendance and completion of required training modules.
B.15 STAFF MENTAL HEALTH TRAINING
The Facilities shall train:
a. All staff who directly interact with youth (e.g. JCO’s, social workers, teachers, etc.) on: (i) basic mental health information (e.g. diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern) and recognition of signs and symptoms evidencing a response to trauma; and (ii) teenage development, strength-based treatment strategies, suicide, and, for staff who work with female youth, female development.
b. Clinical staff on the prevalence, signs, and symptoms of Post Traumatic Stress Disorder and other disorders associated with trauma. (See Consent Order III.B.15)
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, and training documentation. As noted in provision B.14, Scioto staff frankly acknowledged that they have not had time to thoroughly address the requirements of this provision. The documentation provided by the State to demonstrate compliance with this provision supports the staff’s statements. In our document request, we asked the State to provide a spreadsheet indicating which staff had completed training programs relevant to this provision with completion dates. In response, the State provided a list of 11 employees,
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presumably all mental health staff, who had attended trainings on youth advocate training, MYR policy review, MYR practice, and mechanical restraints. In the future, the State should provide data regarding training in the required mental health subject matter areas delineated in this provision. This data must include not only training for mental health staff, but training for “all staff who directly interact with youth,” including direct care staff and teachers.
The State reported that it has trained staff on the new cognitive behavioral and trauma based treatment programs; however, the State did not include documentation of these trainings in the records provided for our review. The State provided numerous other training modules, including “Suicide Precautionary Equipment and Restraints,” and “Treatment of Youth with Mental Health Disorders.”9 However, we have no means of assessing staff attendance and training completion. Staff indicated that they have plans to develop a curriculum, a schedule, and a quarterly training regarding specific mental health issues in the future. (See Glindmeyer Second Mental Health Report at 36).
Compliance Rating: Beginning Compliance
Recommendation(s) to reach substantial compliance:
We urge the State to provide adequate evidence of its compliance with the requirements of this provision in the future, including a spreadsheet that delineates staff attendance and completion of the required training modules. We recommend that the State track and provide us with information that is directly relevant to its implementation of the requirements of the provision. As stated in the previous provision, the State should continue the development of Mental Health Unit training, and develop a mandatory training schedule for staff that provide care for youth on the mental health caseload.
9 A complete list is available in Dr. Glindmeyer’s report. (See Glindmeyer Second Mental Health Report at 37).
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B.16 SUICIDE PREVENTION The State shall review, and, as appropriate, revise current suicide prevention practices to ensure that suicide preventions and interventions are implemented consistently and appropriately, consistent with generally accepted professional standards of care. (See Consent Order III.B.16)
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, draft policies and procedures, quality assurance documents, and lists of youth on suicide precautions, and interviewed staff. The State provided its policy entitled “Suicide Prevention and Response.” However, it appears that this policy is still pending. Mental health staff reported that, on a weekly basis, they review the list of youth on precautionary status and monitor youth on suicide status. Between January 11, 2010 and February 11, 2010, there were 36 instances in which staff placed youth on precautionary status. Of these 36 instances, four youth required precautions a total of two times, two youth required precautions a total of three times, and one youth required precautions a total of four times. Accordingly, six youth accounted for 16 instances of placement on precautionary status. These data indicate that a subset of youth may require additional mental health intervention and suicide precautions.
In our Second Compliance Report, we requested that the State provide quality assurance measures regarding suicide prevention. The State provided an example of an audit tool and an example of a compliance summary regarding suicide prevention. We appreciate the State’s response to our request. However, these documents are of limited utility. Both documents were undated, so we could not determine when the State conducted the audit or the compliance summary. In addition, it was difficult to determine the sample size reviewed in the reports. Specifically, while the forms for the audit tool indicated that the sample size should be “10% of youth population and/or no less than 10 samples,” the documents also indicated that “all CBT youth and females MH records” were audited, but did not specify a total number of records reviewed. The State’s quality assurance measures
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indicated 100% compliance across five areas related to suicide prevention. Yet, the compliance summary stated that the sample size was only three youth.
Staff noted anecdotally that the number of youth requiring precautionary status had decreased in the weeks prior to the tour. However, a decrease in the number of youth identified as at risk of committing suicide is likely multi-factorial. Specifically, while the decrease may be the result of improved treatment and intervention or, as Scioto staff hypothesized, the result of youth housed on mental health units settling into the facility milieu, the State must ensure that the reduction is not the result of the State’s failure to identify youth at risk of selfinjury.
Finally, in our Second Compliance Report, we alerted the State that its failure to develop a formal process for informing the psychiatrist when a youth is placed on suicide watch or other restriction fell below generally accepted standards of care. The State has not addressed this problem, and a formal process is still not in place.
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance:
In our Second Compliance Report, we determined that the State had not provided us with sufficient information to assess this provision. Accordingly, we determined that the State was non-compliant. We appreciate that the State has provided data regarding the number of youth on suicide precautions and has made efforts towards developing quality assurance measures. We encourage the State to continue its quality assurance efforts and ensure that assessments include a representative sample of all youth and that results are dated. In addition, the State must ensure that it adequately identified and monitors youth requiring precautionary status. We urge the State to consider the need for additional mental health interventions for the subset of youth requiring frequent precautionary
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status. We reiterate our concern that Scioto does not have a formal process in place to alert the psychiatrist if a youth in his care is placed on suicide watch. Finally, it does not appear that the State has finalized its suicide prevention policy since our last review. The State cannot reach substantial compliance with this provision until it finalizes and implements its suicide prevention policies and procedures.
B.17 TRANSITION PLANNING The State shall ensure that staff create transition plans for youth leaving the Facilities consistent with generally accepted professional standards of care. (See Consent Order III.B.17)
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, ten medical release summaries and psychological service summaries, one discharge plan, and interviewed staff. During our February 2011 tour, staff acknowledged that Scioto is “in the infancy stages of transition planning.” (See Glindmeyer Second Mental Health Report at 41). Staff expressed plans to work with social services staff to develop discharge plans and to begin planning youth’s discharge upon their admission to the facility.
Our review of recent medical release summaries revealed some improvement in the State’s documentation of transition planning, but many of the deficiencies we identified during our last review persist.10 For example, the medical release summary of Youth 111 included a listing of psychotropic medication, documentation of a 30-day supply of medication, and a listing of diagnoses. However, the youth’s psychiatric diagnoses still included two “rule out” diagnoses at discharge, signaling that mental health staff had not finalized this youth’s diagnostic assessment despite his two years of incarceration at Scioto. In addition, mental health staff documented concerns regarding this youth’s mental health status and history of significant mental health symptoms, yet failed to document concrete mental health
10 Some of the medical release summaries the State provided were dated prior to our November 2010 tour, so we did not include those forms in the instant assessment.
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referrals or linkages to community supports. Youth 222’s medical release summary listed diagnoses and medications, but did not specify the amount of the medication the youth was prescribed at discharge. While mental health staff recommended community services, staff did not document how the youth would link with these community services or with whom or where her community psychiatric appointment would occur.
Since our last review, the State has finalized the “Behavioral Health Services” policy. This policy, if appropriately implemented, will help the State meet the requirements of this provision. The subsection on “Discharge Planning” requires the development of a staffing team responsible for creating youth’s discharge summary. We reviewed one such discharge summary, dated January 12, 2011, regarding Youth 333. The diagnoses listed on the discharge summary differed from the diagnoses listed on the youth’s medical release summary. In addition, two critical pieces of information on the discharge summary were incomplete – the “continuity of care/referral information” and “after care options.”
Compliance Rating: Beginning compliance
Recommendation(s) to reach substantial compliance:
We continue to urge the State to develop transition planning services, including concrete linkages with community resources for all youth. Given the staff’s verbal self-assessment, it is clear that the State is aware that it has significant work to do to reach substantial compliance with this provision. We encourage the State to proceed with its plans to begin discharge planning at the time of admission. The State should also ensure that staff complete all sections of the discharge summary form. We further recommend that the State begin quality assurance monitoring regarding the quality of documentation of discharge information and the integration of this information with the medical release summary.
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B.18 OVERSIGHT OF MENTAL HEALTH SERVICES
The Facilities shall ensure that youth receive the care they need by developing and implementing an adequate mental health Quality Assurance/Improvement Program; annually assessing the overall efficacy of the staffing, treatments, and interventions used at the Facilities; and, as appropriate, revising such staffing, treatments and interventions. (See Consent Order III.B.18)
In order to assess this provision, we reviewed the State’s PowerPoint presentation, verbal self-assessment, quality assurance reviews, and interviewed staff. At the time of our last review, the State’s policies and procedures regarding Quality Assurance and Clinical Supervision were still in draft form. Staff reported that these policies and procedures became effective January 1, 2011. This policy does not clearly outline how the State should document its quality assurance reviews. While this policy may be purposefully vague, the State should consider reevaluating and clarifying the policy if the documentation deficiencies we identify below persist.
The State provided quality assurance reviews regarding “Integrated Treatment and Service Delivery.” The reviews were not dated, so we cannot determine the dates or time periods of review. The documents listed multiple headings of subject matter reviews, including Individual Treatment Planning and Mental Health Referrals and Services.11 The documents list standards below each of these headings. However, the documents do not define what the standards are, nor did the State provide a copy of the guiding document defining the standards. Accordingly, we could not assess the State’s compliance with specific areas.
Despite these deficiencies, the Integrated Treatment and Service Delivery review was informative. Facility reviewers assigned numerous areas compliance ratings of 70% or below. For example, reviewers assessed seven items related to Individual Treatment Planning. Of these seven items, reviewers rated one at 100%,
11 A complete list is available in Dr. Glindmeyer’s report. (See Glindmeyer Second Mental Health Report at 44).
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but reviewers rated the remaining six at below 68%. Of those six below 68%, reviewers rated two items at 0% and two items at 12%. Overall, the average rating for Individual Treatment Planning was 35.4%. Dr. Glindmeyer provides a thorough assessment of the results of the State’s analysis in her report. (See Glindmeyer Second Mental Health Report at 45).
The State also provided a December 15, 2010, performance review for one mental health provider and the social services weekly report. The State did not provide documentation regarding regular clinical supervision of providers. The social services weekly report demonstrated that a small subset of Scioto’s treatment staff exhibit a lack of commitment to the overall mental health treatment program. For instance, some staff missed multiple group therapy sessions. According to the weekly report for the week ending January 10, 2011, one provider did not have any documentation of individual sessions with youth documented in the case notes for the previous month. According to the report for the week ending December 20, 2010, treatment staff did not conduct any individual sessions regarding Youth 111 for the previous week. This finding is problematic, given Youth 111’s serious mental health issues, which, as stated above, led the treatment team to place him in isolation without time out of his room for a period of four days.
As required by the newly implemented policies, the first quality improvement meeting took place on February 8, 2011. The State did not provide the minutes of this meeting, so we cannot yet assess the efficacy of this aspect of the policy’s implementation.
During our February 2011 tour, staff reported that they are keeping statistics, but do not have a system in place to manage and analyze data. Staff also indicated that they have created a database for quality assurance information, and have hired a data manager. We recognize that the State is in the early stages of developing and implementing the framework for its new mental health care system.
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However, since our last review, the State has made notable progress by developing mechanisms to track data and hiring a data manager.
Compliance Rating: Partial compliance
Recommendation(s) to reach substantial compliance:
In order to reach substantial compliance with this provision, the State should complete staff training and implement the planned mental health administrative structure, meetings and treatment modalities. Following the full implementation of these programs, the State should renew its efforts to engage in quality assurance monitoring to assess the efficacy of staffing, treatment and interventions. Finally, when providing quality assessment results, the State should ensure that it dates the documents and describes the standards it is monitoring.
III. GENERAL MEDICAL CARE Juveniles in the custody of state correctional facilities have a due process
right to adequate medical care. In order to assess the General Medical Care provisions, we reviewed relevant policies and procedures, staffing schedules, statistical data regarding completed dental procedures, staff training curricula, the health records of 12 youth, and interviewed youth during our February 2011 tour. We have attached the findings of our subject matter expert, Dr. Michelle StaplesHorne, to this Compliance Report. (See Staples-Horne Second Medical Report at Attachment D).
C.1 GENERALLY The Facilities shall ensure that the individuals they serve receive routine, preventive, and emergency medical and dental care consistent with current, generally accepted professional standards. The Facilities shall ensure that individuals with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care.
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We are pleased to report that the State continues to provide quality medical care to the youth at Scioto. Youth receive routine, preventive, and emergency medical care consistent with current, generally accepted professional standards and youth with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care. Moreover, the ODYS medical policies and procedures continue to meet the American Correctional Association (“ACA”) and the National Commission on Correctional Health Care (“NCCHC”) standards for providing health care to youth housed in juvenile facilities.
According to staffing schedules, Scioto has two primary care physicians – one serves the male population and one serves the female population. The two primary care physicians provide coverage each day of the week, except Wednesday and Sunday, for a combined total of approximately 1 Full Time Equivalent (“FTE”). Consistent with our last assessment, the physicians are Pediatrics and Family Medicine Board Certified to provide primary care and OB/GYN Board Certified to provide services to female youth. While Scioto had two contract psychiatrists at the time of our last review, Scioto now only has one contract psychiatrist. See page 35.
Scioto has two obstetrics/gynecology Medical Doctors (“MD”), two obstetrics/gynecology Doctors of Osteopathy (“DO”), and one certified midwife. These five rotating staff provide obstetrics/gynecology services three hours a week. Scioto has one health information technician/phlebotomist, one dentist, one dental assistant, one dental hygienist, and one optometrist. The optometrist sees youth the second and third Friday of each month. We address dental staffing in more detail in section C.7 (“Dental Care”). Scioto’s nursing staff has remained stable since our last review. Eleven Registered Nurses (“RN”) and one Licensed Nurse Practitioner (“LPN”) staff the clinic, and one RN and one LPN serve the reception area. Scioto also has a Health Services Administrator, who is also a RN, and an administrative assistant. This staffing pattern can provide coverage with at least
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three registered nurses on the first and second shifts and two nurses on the third shift, seven days a week, without including the Health Services Administrator in any direct patient care responsibilities.
Based on the average length of stay, the average daily population, the staffing schedules the State provided, and evidence of care documented in the youth medical records, the medical staffing at Scioto continues to be appropriate and adequate. Moreover, the medical staff possesses the qualifications necessary to provide the appropriate level of medical care.
Youth health records continue to demonstrate that the State is generally providing youth with adequate routine, preventative and emergency care. Consistent with our last review, youth health records reflect routine care through a thorough and consistent intake screening process, which includes initial medical, dental, and mental health assessments. While some youth reported delayed access to sick call, our review of health records indicates that medical staff are appropriately addressing and documenting youth’s medical complaints. The State’s sick call process is discussed more fully in section C.5 (“Access to Health Services”).
Medical staff assess youth with injuries in a timely manner. One health record included documentation of adequate emergency care. Medical staff monitor and address chronic diseases appropriately and according to accepted practices. Youth continue to receive appropriate diagnostic services, preventative services, and health education. The State continues to provide comprehensive health services specific to females, including complete gynecological examinations, pelvic examinations, and family planning and pregnancy-related services.
In our Second Compliance Report, we determined that the State could not reach substantial compliance with C.1 until it reached substantial compliance with provision C.7 (“Dental Care”). As discussed in C.7, the State has provided improved documentation of its dental care practices, and is now in substantial compliance
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with the Dental Care provision. Accordingly, the State is now in substantial compliance with C.1. We applaud the State’s progress in this area.
Compliance Rating: Substantial Compliance
In our Second Compliance Report, we suggested that the State provide regular training to all health care staff to ensure that they are aware of the current accepted professional standards of care. The NCCHC standard Y-C-03 recommends that health care staff attend in-service programs or conferences focusing on topics related to correctional health care. The State submitted training records for 14 nurses and one phlebotomist. The training primarily consisted of courses relevant to the general correctional staff. Examples include Managing Youth Resistance, Information Technology, Cultural Competency and Planned Intervention. The State did not submit any evidence of continuing education designed for health care professionals. We continue to encourage the State to provide health care staff with continuing education, presentations and trainings on the special health needs of adolescents.
Finally, in our last report, we recommended that the State implement an adequate Continuous Quality Improvement (“CQI”) process. The State reported that its quality assurance policy is awaiting final approval. Although a CQI component is not expressly included in the Consent Order’s requirements, we note that it is an essential part of any medical program that aims to provide quality care. We encourage the State to finalize and implement its CQI policy. Such a policy will help the State maintain its medical program in substantial compliance with this provision.
C.2 HEALTH RECORDS The State shall develop and implement policies, procedures, and practices to ensure that, consistent with state and Federal law, at a minimum, the juvenile courts in the State, all juvenile detention facilities, and all placement settings from which youth are committed shall timely forward to Scioto, or to the
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facility of placement (if the records arrive after the youth has been placed), all pertinent youth records regarding medical and mental health care. The Facilities shall develop and implement policies, procedures, and practices to ensure that health care staff, including mental health care staff, have access to documents that are relevant to the care and treatment of the youth.
In order to assess this provision, we reviewed the relevant policies and procedures, and the health records of 12 youth. The State’s policies, procedures and practices related to the transfer of records to and from other facilities and institutions continue to demonstrate a commitment to continuity of care for Scioto’s youth. The policies and procedures delineate the required components of each health record and explain the records transfer process. The State’s practice continues to be consistent with its policies and procedures. Specifically, youth health records are arranged according to the policy and the records contain documentation consistent with the records transfer process, information from outside consultations, and discharge summaries.
In our last report, we recommended that the State include all mental health diagnoses on the problem list. The State has improved this practice and now routinely includes mental health diagnoses on the problem list. We did review one health record where the State failed to include a major medical diagnosis on the problem list. However, we do not believe this one failure is a reflection of the State’s practice as a whole.
Despite the State’s compliance with certain aspects of this provision, the State has not adopted our recommendation to combine medical and psychology records. While health records include psychiatric evaluations and chronological psychiatric progress notes, records still do not include psychological records, such as case notes. Some progress notes in health records indicate that youth are participating in groups, but the progress notes provide no other details. Accordingly, the State has not yet developed and implemented policies, procedures, and practices to ensure that all health care staff at the facility have access to documents relevant to the care and treatment of the youth.
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Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
In order to reach substantial compliance with this provision, the State must continue moving towards a system that will combine all health records, including psychology records. We recognize that the Consent Order does not mandate an electronic recordkeeping system. However, such a system would improve Scioto’s ability to access critical health information by giving health record access to medical, dental, and mental health staff simultaneously. The State reports that it has collaborated with Ohio State University to explore using the “EPIC” electronic health record program that is currently used by the Ohio Department of Rehabilitation and Corrections. We commend the State for taking steps towards the adoption of an electronic system. In addition, we renew our offer to make Dr. Staples-Horne available to provide technical assistance.
C.3 CONFIDENTIAL HEALTH CARE The Facilities shall provide health care and assessment in a setting that maintains health care confidentiality, by placing non-medical staff out of line of sight and hearing of the health care assessment or treatment, except in circumstances where documented safety considerations posed by a particular youth require enhanced, non-medical supervision. In order to assess this provision, we reviewed the relevant policy and
interviewed youth. Youth continue to report that all visits with medical staff are conducted confidentially. Specifically, youth reported that correctional staff is not within earshot during health care treatment and assessment. If youth are receiving an examination that requires them to undress, the door to the exam room is closed and non-medical staff are out of the line of sight.
Compliance Rating: Substantial Compliance
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While the State’s practice conforms to the requirements of this provision, the current policy only requires the State to maintain an examination room that allows for the private examination of youth at the medical clinic. It does not provide any specific guidance regarding the conduct of non-medical staff. In our Second Compliance Report, we urged the State to amend Policy #403.04 to reflect the State’s actual practice and provide additional guidance to medical and non-medical staff. The State has not modified Policy #403.04. While not expressly required by this provision, we again encourage the State to amend its policy to provide additional guidance to Scioto staff.
C.4 INITIAL HEALTH ASSESSMENT
The Facilities shall ensure that initial health assessments are complete and include: use of growth and weight charts; laboratory test results placed in the youth’s health records before the youth is transferred out of reception; results of all laboratory tests, to be provided for each test within 20 days of its performance; testing of all youth for sexually transmitted diseases; and a problem list and a plan of care for each problem identified at reception.
In order to assess this provision, we reviewed the relevant policies and procedures and the health records of 12 youth. Medical staff completed initial health assessments in 100% of the youth health records reviewed. These assessments included the nurse intake screening/assessment, a physical exam, screening for tuberculosis, and gathering information related to mental health and substance abuse concerns. Registered Nurses continue to complete the intake assessments on the day of intake and the Primary Care Physician typically completes physical examinations within one week of admission. All of the records we reviewed included growth and weight charts. Laboratory tests are completed on all youth at intake and test results were returned well within the 20 days required by the provision. When applicable, medical staff conducted gynecological exams in a timely manner. In all of the health records we reviewed, youth were tested for sexually transmitted diseases (“STDs”) at intake and received vision and hearing screenings.
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Compliance Rating: Substantial Compliance
In our Second Compliance Report, we urged the State to consider amending its policy controlling medical services related to STDs and pregnancy. Specifically, the policy does not authorize minors to release STD and pregnancy-related information to parents or others although minors are legally authorized to release such information. We also recommended that the State amend Policy #403.11 “Health Care Physical Examination-Intake” to reflect the facility’s practice of conducting hearing and vision screenings. The State has not amended these policies since our last review. We recognize that these changes are not required by this provision. However, we continue to recommend these changes as technical assistance.
C.5 ACCESS TO HEALTH SERVICES The Facilities shall ensure that youth can request to be seen by medical staff confidentially and independent from JCOs and custodial staff.
In order to assess this provision, we reviewed the relevant policies and procedures, the health records of 12 youth, and interviewed youth. Scioto’s policy and procedures remain the same since our last assessment. Our review of health records indicated that medical staff documented many more assessments of youth in the progress notes than there were sick call forms. Of the 12 health records we reviewed, two did not contain any sick call request forms and one record had only one handwritten request. Either youth are approaching nurses directly with medical complaints instead of completing a sick call form or medical staff are not placing the sick call request forms in the health record. For example, a progress note documented a case where a youth complained of a toe injury while the nurse was on the unit. The RN on the unit evaluated the youth and the youth received further care in the clinic later that day and the following day.
Dr. Staples-Horne’s review or health records indicated that, when appropriate, nursing staff refer youth to the physician. The physicians saw youth
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and documented these visits in all of the records she reviewed. In one case, the physician completed a minor surgical procedure to incise and drain a boil. One youth complained of ear pain one day and the nurse saw the youth the next day, gave the youth Tylenol and referred the youth to the physician. The following day, the physician diagnosed and treated the youth.
While the dates on the sick call request forms Dr. Staples-Horne reviewed indicated that medical staff see youth in timely manner – usually the following day, numerous youth reported that they experienced delays with the sick call system. Specifically, youth alleged that they had waited three or more days to have a sick call request filled. Other youth alleged that their sick call requests went ignored. For example, one youth alleged that after playing in the gym, she suffered toe pain and submitted two sick call requests that were not answered. She then verbally asked three times to go to the medical unit and was not sent. Finally, two weeks after the youth filed the original sick call request, a nurse saw the youth, performed x-rays, and determined that the youth had a fractured toe. The youth was given pain medication, but should never have been forced to walk on a fractured toe for weeks. We notified the State of these concerns in a March 11, 2011 letter.
In our Second Compliance Report, we determined that the State had reached substantial compliance with this provision. However, we are concerned that youth reported experiencing significant delays when seeking medical care through the sick call system. We strongly urge the State to implement quality assurance mechanisms to address youth’s concerns expressed during our February 2011 tour.
Compliance Rating: Partial Compliance
The State must ensure that youth have unimpeded access to medical care. As stated above, we encourage the State to implement quality assurance measures. In addition, in our last compliance report, we made several recommendations that would improve youth’s access to health care services at Scioto. We recommended
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that the State change its sick call Standing Order #403.07 from “Standing Order” to “Nursing Protocols” in accordance with the NCCHC’s Standard Y-E-11. We further recommended that the State ensure that sick call health assessments are completed by RNs and not LPNs and specify this change in its policies. The State has not implemented these changes. We continue to urge the State to implement these changes to ensure that youth have unfettered access to quality care. Finally, we recommended that the State review its policies and procedures at least annually, and update them as needed. While the State updated its sick call procedures in March of 2010, the State had not reviewed these procedures for the previous three or four years. We encourage the State to consider reviewing this procedure soon since more than a year has elapsed since the State’s last review.
C.6 MEDICATION MANAGEMENT The Facilities shall not discontinue a chronically ill youth’s usual medication for non-medical reasons, including that the medication is not on the Facilities’ formulary.
In order to assess this provision, we reviewed relevant policies and the health records of 12 youth. Based on our review, it appears that Scioto continues to provide medication to chronically ill youth in its custody. The prescriber’s orders for medications and medication administration records continue to be complete and present in all youth health records. Nurses are administering and documenting medications as ordered. Progress notes adequately document treatment refusals made by youth. Scioto continues to document hot weather precautions for youth who are taking medications that predispose them to heat sensitivity and Abnormal Involuntary Movement Scale (“AIMS”) for youth on psychotropic medications.
In our last assessment, we recommended that the State modify its current policy to reflect Scioto’s practice for securing medications not listed on the formulary. Specifically, if a particular medication is not available on the formulary, Scioto obtains the medication from a local pharmacy. The State has not yet modified its current policy. While we believe this practice is beneficial and should
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be documented in the State’s policy, we recognize that the State has met the requirements of this provision.
Compliance Rating: Substantial Compliance
C.7 DENTAL CARE
The Facilities shall ensure that:
a. Dental restorative needs are listed on a dental treatment plan for the youth, tracked by the dental program, and treated on a timely basis consistent with generally accepted professional standards of care;
b. Prosthetic dental services are provided based on need, as determined by the treating dentist, with appropriate consideration for the replacement or repair of missing front teeth, according to generally accepted professional standards of care;
c. Youth experiencing dental pain are not denied adequate pain medication;
d. Health records contain adequate documentation of all outside dental consults, including the clinical examination, treatment plan, procedures performed, orders for management after the procedures, and any followup appointment or plan; and
e. Dental staffing is adequate to meet the restorative dental needs of the Facilities’ populations.
In order to assess this provision, we reviewed the relevant policies and procedures, data provided by the State, and the dental records of 12 youth. In our Second Compliance report we determined that the State had not reached substantial compliance because the State’s dental record-keeping was inadequate and did not consistently include documentation of dental examinations and treatment. We also expressed our concern that the follow up dates for restorative procedures – specifically, fillings – may be set too far out in the future to ensure completion prior to youth’s release. Finally, we could not determine whether dental staffing was adequate to meet the restorative dental needs of the Facility’s population.
The State has now provided adequate information to support a determination that it has reached substantial compliance with this provision. The State provided
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statistical data for dental services completed and dental staffing schedules. The dental hygienist works up to 16 hours per week and averages one to two dental prophylaxes per hour. The dentist and dental assistant work up to 30 hours per week and complete an average of 97 examinations and 34 restorations per month. Dental staffing appears to be adequate. However, our review revealed that there was a downward trend in the number of youth dental staff examined between September and December 2010 compared to the previous months of 2010. We do not have data to determine the cause of this shift and whether the trend has continued into 2011.
Our review of health records revealed that each youth received three to four dental x-rays each. Appropriately, dental staff conducted far more restorations than extractions. Dental staff documented that they provided youth with sealants and dental appliances (night guards) and made appropriate referrals. Scioto’s provision of night guards is an example of prosthetic dental services. Youth experiencing dental pain were seen by the nurse and given pain medication until seen by the dentist, usually the following day. One youth submitted more than one sick call request complaining of dental pain. However, the nurse documented in the progress note that the youth had admitted that she had seen the dentist, but refused to get fillings because she was afraid of needles.
Based on the data submitted by the State, the State has reached substantial compliance with this provision. We applaud the State for providing quality dental care to Scioto youth.
Compliance Rating: Substantial Compliance
While the State has reached substantial compliance with this provision, we encourage the State to continue to track the number of youth examined by dental staff and to investigate potential causes of the downward trend that began to occur between September and December 2010.
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C.8 MANAGEMENT OF CHRONIC ILLNESSES
The Facilities shall ensure that: a. Chronic disease policies, protocols, and practices are appropriate for chronically ill adolescents; b. Youth with chronic asthma are continued on their established medicines on admission unless the youth’s condition warrants a change in treatment; and c. Youth who frequently use rescue inhalers are appropriately monitored and treated by physicians to minimize preventable asthma hospitalization resulting from acute respiratory crisis that follows an inadequately treated exacerbation of chronic asthma.
In order to assess this provision, we reviewed the relevant policies and procedures and the health records of 12 youth. The youth whose records we reviewed have the following chronic illnesses: hypertension, seizure disorder, hypothyroidism, renal disease, asthma, hepatitis C, latent tuberculosis, and a cardiac condition. We also reviewed the health records of two pregnant females. The State continues to provide quality medical care to youth with chronic illnesses. One pregnant youth’s care was particularly challenging due to her additional diagnoses of hypertension, renal disease, and asthma. Scioto provided prenatal care consistent with the accepted standard of care. Medical staff provided a youth with hepatitis C with extensive education regarding her disease, liver ultrasound studies, appropriate laboratory tests, and immunizations.
Of the files we reviewed, four youth’s records indicated a history of asthma. Three of these youth have mild asthma. One of these three youth did experience an exercise induced asthma attack, and medical staff appropriately changed this youth’s medication order to allow the youth to use the inhaler prior to exercise. The fourth youth had severe persistent asthma, required multiple medications and had a history of numerous hospitalizations. Medical staff managed the care of this youth well and provided the youth with routine visits to an outside allergist for Xolair medication injections.
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The State provides excellent continuity of care for youth with chronic diseases. Medical staff include medical records from community providers in youth’s health records as well as care plans when youth are nearing release back into the community. The State remains in substantial compliance with this provision.
Compliance Rating: Substantial Compliance
C.9 ACCESS TO SPECIALTY CARE Absent clinically justified rationale, the Facilities shall not withhold access to specialist services recommended by a treating physician and shall ensure that: prior approval of specialty medical consultations is made by a physician trained and qualified in pediatrics and adolescent medicine; and assessment criteria for the necessity of specialty consultations are based on pediatric and adolescent medicine.
In order to assess this provision, we reviewed the relevant policies and procedures and the health records of 12 youth. Scioto continues to provide youth with adequate access to specialty care. The facility physician is trained and certified in pediatrics and adolescent medicine and appropriately referred youth to outside consultations with Nephrology, Cardiology, Neurology and Obstetrics specialists. Youth received optometry care and the State routinely purchased glasses when youth failed the vision screening. The State provided other diagnostic studies, including x-rays, ultrasounds, and EKGs where appropriate. Pregnant females received appropriate prenatal care as documented by the completion of the American College of Obstetrics and Gynecology (“ACOG”) recommendations for ante partum care.
Compliance Rating: Substantial Compliance
C.10 IMMUNIZATIONS The State shall make reasonable efforts to obtain immunization records for all youth who are detained at the facilities for more than one (1) month. The State shall ensure that medical staff update immunizations for such youth in
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accordance with nationally recognized guidelines and state school admission requirements. The physicians who determine that the vaccination of a youth is medically inappropriate shall properly record such determination in the youth’s medical record.
In order to assess this provision, we reviewed the relevant policy and procedure and the health records of 12 youth. Consistent with our last review, youth continue to receive appropriate immunizations in accordance with the Center for Disease Control and Prevention’s and the Advisory Committee on Immunization Practices’ recommendations, including HPV and influenza vaccines. Eleven of the 12 health records we reviewed included immunization records. Of the 11 youth files with health records, one youth was not brought current on her immunizations while at Scioto, but her immunization records from a previous facility or school were present in her health record. The one youth who had no immunization records in her health record had recently entered the facility. Scioto continues to update immunizations for youth who are detained for more than one month. The State continues to be in substantial compliance with this provision.
Compliance Rating: Substantial Compliance
We continue to urge the State to update the relevant immunization policy and procedure. The State’s policy and standard operating procedure were last revised January 3, 2006. Accordingly, they do not reflect the current practice of providing all recommended vaccinations.
IV. GRIEVANCES
D.1 GRIEVANCES
The State shall develop and implement policies, procedures and practices to ensure that the facility has an adequate grievance system including: no formal or informal preconditions to the completion and submission of a grievance; review of grievances by the chief inspector; timely initiation and resolution of grievances; appropriate corrective action; and written notification provided to the youth of the final resolution of the grievance. (See Consent Order III.D.1)
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In order to assess this provision, we reviewed the State’s self-assessment, documents requested prior to tour, 106 grievances submitted between November 1, 2010 to February 1, 2011, and interviewed youth. In her report, Dr. Dedel notes that all grievances reviewed during the relevant time period were handled in a timely manner, youth received notification, and that the CIO requested additional follow up regarding 15% of the grievances. (See Dedel Third PFH Report at 16). Further, consistent with language in the provision, the policy has no preconditions for filing a grievance, youth receive notification of the grievance resolutions, grievances are picked up each weekday, and all grievances are reviewed by the Chief Inspector’s Office.
Based on our February 2011 interviews with youth12, we are concerned, however, that there is a de facto precondition or limitation to completing and submitting grievances alleging staff mistreatment. The de facto precondition exists for two reasons: (1) some YS staff routinely inform youth13 that Scioto prohibits youth from grieving any action by staff and (2) Scioto’s explanation to youth about grievances is incomplete or inadequate (discussed in D.2 below.) Combined, the intentional misinformation by some YS staff and the incomplete explanation about how the facility handles grievances (including staff mistreatment) create a perception to youth that the grievances about staff mistreatment are not accepted
12 During our February 22-24, 2011, 19 of the 25 youth interviewed voiced a deep mistrust of the grievance system. Youth alleged that YS staff told them that Scioto prohibits youth from grieving about staff mistreatment, or grieving the consequences and punishments received from staff. The number and consistency of these allegations are problematic, and place Scioto at odds with even its own Youth Handbook (discussed below in F.2), which only prohibits youth from filing a grievance against the sentence they received from the Court. Due to this confusion and inconsistency, through a letter dated March 11, 2011, the United States suggested the State provide a “refresher training” for all youth and staff about the grievance system.
13 Some youth interviewed alleged that some YS staff tell youth that they (the youth) can “file a grievance, but nothing will happen,” in effect stating that the facility will ignore the grievance.
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or investigated. Further compounding the perception is that when a youth does file a grievance against a staff member, the facility’s procedures re-route such grievances from the grievance officer to the CIO. Independently, the re-routing of such serious grievances to CIO is not the issue. Instead, the problem lies in that youth receive no update from the grievance officer, the one individual who youth know handles grievances, or the CIO about the grievance. In other words, while the CIO may be diligently investigating the mistreatment grievance, the youth do not know this and never receive a notification about the resolution. This reinforces the youth’s perception that the facility does not permit or handle grievances against staff.
Compliance Rating: Partial Compliance
Recommendations for reaching Substantial Compliance:
The State must clarify its education of youth about the grievance process, rules, procedures, and roles of individuals. To implement such change, the State should revise its youth handbook and orientation presentation to youth to unequivocally explain to them how: (1) grievances are accepted, (2) handled, (3) processed, and (4) investigated. Further, youth should be able to discern from the handbook what their rights are regarding grievances (notification and time frames). In particular, youth must be educated about how a complaint/grievance/allegation about any staff mistreatment will be treated by Scioto and the CIO’s office and that, despite a youth’s unwillingness to cooperate, the investigation about staff mistreatment will proceed.
Separately, all staff should be advised about: (1) the consequences for intentionally misinforming youth about their rights, especially grievances, (2) the consequences for observing and failing to report staff mistreatment, (3) how staff mistreatment grievances will be handled, and (4) how youth will be informed about the investigation of a grievance that involves staff mistreatment.
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D.2 GRIEVANCE EXPLAINED TO YOUTH A clear explanation of the grievance process shall be provided to each youth upon admission to the facilities during orientation and to their parents or guardians, and the youth’s understanding of the process shall be at least verbally verified. (See Consent Order III.D.2) In our assessment of this provision, we reviewed the State’s self-assessment,
the relevant policy, the revised October 2010 Youth Handbook, and interviewed youth. The relevant ODYS policy requires that, upon admission to Scioto, staff shall provide youth with a copy of the Youth Handbook, instruct the youth on the grievance system, and ensure the youth sign a letter of understanding regarding the process. All but one youth interviewed reported having received a copy of the Handbook and all could describe the mechanics of the youth grievance process. Dr. Dedel notes in her report that the Scioto audit for youth admitted from November 1, 2010 to January 31, 2011 demonstrated that 100% of the youth received a complete orientation to Scioto, which included information about how to access the grievance system. We agree that the State provides youth an orientation upon their admission to Scioto. However, we are concerned that the grievance process is not fully explained to youth during that time. As addressed above in section D.1, it appears that youth do not receive a full explanation about how all grievances are handled. Specifically, the State fails to explain to youth that the CIO investigates grievances about staff misconduct. Further, it does not appear that youth understand that the CIO automatically investigates all grievances. Such information is vital, as it will educate youth that Scioto takes all grievances seriously.
Compliance Rating: Partial Compliance
Recommendations for reaching Substantial Compliance: See recommendations under D.1
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D.3 GRIEVANCE PROCESS Without any staff involvement, youth shall easily be able to obtain grievance forms and submit grievances. (See Consent Order III.D.3)
In order to assess this provision, we reviewed the State’s self-assessment, interviewed youth, and visited the living areas of youth. Consistent with our various on-site compliance tours in 2010, we found grievance forms and locked boxes located throughout Scioto. We also found that the grievance forms are readily accessible to youth without any staff involvement. Youth interviewed acknowledged knowing how to obtain a grievance form and how to submit that form. The State has maintained its substantial compliance rating with this provision.
Compliance Rating: Substantial Compliance
V. SPECIAL EDUCATION E. 1 PROVISION OF SPECIAL EDUCATION
The State shall, at all times, provide all youth confined at the Facilities with adequate special education in compliance with the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006), and regulations promulgated there under, and this Stipulation. (See Consent Order III.E.1)
In our assessment of this provision, we reviewed the State’s self-assessment and interviewed youth and staff. Consistent with our visit in October 2010, it is evident that the State takes seriously its responsibility to provide all qualified youth confined at Scioto an adequate special education. Accordingly, we determined that, for the most part, the State has a sufficient foundation for an effective special education program at Scioto. In our Second Compliance Report, we detailed our shared concerns with Dr. Dedel about: (1) whether the State is providing youth in disciplinary isolation regular, dependable access to class assignments and instruction, and (2) the extent to which the ABC (in-school suspension program) is implemented effectively. We note that this Court recently ruled in the SH v Stickrath matter that the State is required to develop policies and procedures for
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Alternative Education Opportunities (“AEO”) for youth in seclusion. In general, the State now provides educational services to youth as soon as possible after the onset of seclusion, contrary to the 10-day wait time applied previously. We look forward to assessing this aspect in the future.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
We note that provision E.1 requires compliance with the IDEA, the related regulations and the provisions E.2-E.11 of the U.S. v Ohio Consent Order (oversight, special education upon intake, parent and guardian involvement, staffing, screening for special education, individual educational plans, vocational education, forwarding screening and assessment information, training and quality assurance and transition services). Substantial compliance with E.1, “Provision of Special Education,” therefore partially depends upon the State reaching substantial compliance with provisions E.2 through E.11. Fortunately, not including E.1, the State is now in substantial compliance with eight of the remaining ten provisions, in partial compliance with the one remaining provision, E.7 (Individual Educational Plans), and in beginning compliance with one remaining provision, E.8 (Vocational Education). Below, we provide the State with specific recommendations with regard to provisions E.7 and E.8. We encourage the State to consider these recommendations and those made by Dr. Dedel throughout her Second SPED Report.
E.2 OVERSIGHT The State shall provide adequate oversight of special education at the Facilities. (See Consent Order III.E.2) In our assessment of this provision, we reviewed the State’s self-assessment
and interviewed staff. Consistent with our October 2010 compliance tour, we found that the documentation provided by the State regarding its SPED policies and
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procedures support finding that ODYS continues to provide sufficient oversight over the SPED program at Scioto. Specifically, the State has demonstrated that it has an oversight strategy that operates at both the external and internal level. As described by Dr. Dedel in her First SPED Report, both levels of oversight are impressive and underscore the State’s dedication to achieving compliance with this provision. In Dr. Dedel’s Second SPED Report, she details the regular communication and guidance the Special Education Director provides Scioto education staff. (See Dedel Second SPED Report at 5). The State has thus maintained substantial compliance with this provision. In our February 2011 compliance report, we rated the State as being in substantial compliance with this provision. We commend the State for maintaining this rating.
Compliance Rating: Substantial Compliance
E.3 SPECIAL EDUCATION UPON INTAKE The State shall ensure that all students who qualify for special education services receive such services within a reasonable time following intake at the Facilities. (See Consent Order III.E.3)
In our assessment of this provision, we reviewed the State’s self-assessment and interviewed youth and staff. Based on our review, we found that all 215 youth (100%) admitted from November 1, 2010 to February 1, 2011 were enrolled and attending school within 72 hours of their admission. Through its self-assessment, the State provided a detailed description of its efforts and process to ensure that all students who qualify for SPED receive such services upon admission. Consistent with our October 2010 tour, Dr. Dedel determined that the students’ class schedules were properly constructed and reflected the services prescribed by the Individual Educational Plans (“IEPs”) available at the time of the youths’ admission to Scioto. (See Dedel Second SPED Report at 6). In our February 2011 Compliance Report, we rated the State as being in substantial compliance with this provision. We commend the State for maintaining its substantial compliance rating with this provision.
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Compliance Rating: Substantial Compliance
E.4 PARENT AND GUARDIAN INVOLVEMENT The State shall develop and implement policies, procedures, and practices to appropriately notify and involve parents or guardians in the provision of special education services, wherever possible. (See Consent Order III.E.4)
In our assessment of this provision, we reviewed the State’s self-assessment and special education files, and interviewed youth and staff. Consistent with our findings in October 2010, we found that the State involves parents or guardians in the educational planning of Scioto youth. In October, we found documentation of attempts to contact parents or guardians via mail and telephone, with ample documentation about the response or lack of response by parents or guardians. We agree with Dr. Dedel’s concern regarding the low compliance across the last three IEP progress reports. (This is discussed under provision E.7 below.) (See Dedel Second SPED Report at 7). In our February 2011 Compliance Report, we rated the State as being in substantial compliance with this provision. We commend the State for maintaining substantial compliance with this provision.
Compliance Rating: Substantial Compliance
E.5 STAFFING
The State shall develop and implement an education staffing plan to ensure adequate staff to comply with the terms of this Stipulation. (See Consent Order III.E.5)
In our assessment of this provision, we reviewed the State’s self-assessment and we interviewed staff. Based on our review, we found that the State continues to use an adequate formula to ensure that it meets the 1:12 teacher-to-student ratio required by the Ohio Department of Education. Through the staffing plan, the State ensures that all students have full access to the education program at Scioto. We commend the State for its continued efforts to improve staffing under this provision. We note that during our November on-site tour, the speech language
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pathologist and transition skills teacher positions remained open. As Dr. Dedel notes in her March 2011 Report, the State resolved this issue by contracting with an individual who already provides speech language pathology services at another facility. At the time of our February 2011 tour, the State had approved hiring an individual transition skills teacher. We commend the State on maintaining substantial compliance with this provision.
Compliance Rating: Substantial compliance
E.6 SCREENING FOR SPECIAL EDUCATION NEEDS The State shall provide prompt and adequate screening of youth for special education needs and shall identify youth who, upon admission to the Ohio Department of Youth Services, were receiving special education in their home school districts or who may be eligible to receive special education services but have not been so identified in the past.
The State shall ensure that those staff conducting the screening, assessment and evaluation processes are qualified to do so. (See Consent Order III.E.6)
In our assessment of this provision, we reviewed the State’s self-assessment and interviewed staff. Consistent with our finding in our Second Compliance Report, we found the State’s special education intake process to be appropriate and detailed. Specifically, the intake process requires youth to be interviewed and youth records to be immediately requested from the youth’s prior schools. For those youth not currently eligible for special education upon entrance to Scioto, the State also has a detailed method to determine whether a referral is appropriate. During the November 1, 2010 to February 1, 2011 period, Scioto admitted a total of 215 students. Eighty-six students (40%) of the 215 were identified as needing special education services. During that time, 2 students in “regular” school were referred to the Intervention Assistance Team to identify a way to address academic difficulties and determine whether the youth is eligible for special education. We commend the State for maintaining substantial compliance with this provision.
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E.7 INDIVIDUAL EDUCATION PLANS
The State shall develop an IEP as defined in 34 C.F.R §300.320 for each youth who qualifies for an IEP. Following development of the IEP, the State shall implement the IEP as soon as possible. As part of satisfying this requirement, the State shall conduct required annual reviews of IEPs, adequately document the provision of special education services, and comply with requirements regarding participation by the professional staff, parents, and student in the IEP process. The State shall, if necessary, develop, review or revise IEPs for qualified special education students.
In developing or modifying the IEP, the State shall ensure that: the IEP reflects the individualized educational needs of the youth and that services are provided accordingly; each IEP includes documentation of the team’s consideration of the youth’s need for related services and transition planning, and identifies the party responsible for providing such transition services; the students’ educational progress is monitored; teachers are trained on how to monitor progress toward IEP goals and objectives; and teachers understand and use functional behavioral assessment and behavior intervention programs in IEP planning and implementation. (See Consent Order III.E.7)
In our assessment of this provision, we interviewed staff and reviewed the State’s self-assessment. In our Second Compliance Report, we explained that the ODYS IEP procedures were sufficiently detailed, and were followed in most areas. Further, most IEPs were of adequate quality. However, as further discussed by Dr. Dedel, the quality of the annual IEP goals and the progress reports to parents14 are still of concern. (See Dedel Second SPED Report at 10-11). We are encouraged that the State has taken on corrective action, such as: (1) training and development for special education staff in the areas of measurable goal writing and monitoring student progress, (2) requiring all progress reports to be scanned, and (3) having education staff review draft IEP language before the IEP meeting to improve the quality of the IEP goals. We look forward to assessing this provision during our next compliance tour. We are hopeful that these changes improve IEP development and implementation.
14 According to Dr. Dedel’s Second SPED Report, the State reported low compliance levels with sending progress reports. Specifically, the State’s compliance level for October 2010 was 30% and only 9% in January 2011.
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Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
We suggest the State continue its current revisions of IEP goals to ensure that they are clear, appropriate, and assist in monitoring the youth’s progress. Further, we agree with Dr. Dedel’s suggestion that the State conduct a more indepth review of the 10 sample student reviewed for the State’s self-assessment. Dr. Dedel suggests determining why less than 50% of the 26 goals were not met for these youth. (See Dedel Second SPED Report at 11).
E.8 VOCATIONAL EDUCATION The State shall provide appropriate vocational services that are required transition services for disabled youth under the IDEA. (See Consent Order III.E.8) In our assessment of this provision, we reviewed the State’s self-assessment
and interviewed youth and staff. Consistent with our finding in October 2010, the State provides one vocational class, Administrative Office Technology, as its vocational services to youth. Apparently, obstacles to expanding the course offerings include financial constraints, and youths’ short lengths of stays. During our October 2010 tour, the State informed us that the ODYS Superintendent was aware of the lack of vocational options and was researching alternatives, such as short-term vocational courses that involve some level of certification. During our most recent tour in February 2011, however, the State informed us that those plans had been cancelled. We are concerned and disappointed at the State’s lack of improvement. Considering the very likely increase in population and longer lengths of stay for that population, due to the closing of the ORV, we encourage the State to add vocational education as soon as feasible. Based on this review, the State is in beginning compliance with this provision.
Compliance Rating: Beginning Compliance
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Recommendation(s) to reach substantial compliance:
We believe that Dr. Dedel’s comment from her First SPED Report that “the dearth of meaningful career-oriented options for students at Scioto is problematic” remains appropriate. (See Dedel First SPED Report at 22). Again, we recommend that the State reach out to local resources to enrich its program while it takes other steps to bolster its vocational course offerings. As the State reinvigorates its vocational services, it may wish to have vocational educators from other facilities visit, if only for introductory classes. The State may wish to inquire if nearby community colleges have online courses that the Scioto youth could audit. Additionally, since Scioto has a well-established volunteer program, the State may wish to inquire into whether any volunteers could provide presentations about their own jobs — for example, small business owners — and what education or training they needed, again if only to introduce youth to possible career options. We look forward to re-assessing this provision during our next compliance tour.
E.9 FORWARDING SCREENING AND ASSESSMENT INFORMATION UPON TRANSFER
The State shall ensure that, when a youth is discharged from the Facilities before the interventions or educational evaluations required in Section III.E.6 above are complete, the Facilities shall forward to the superintendent of the youth’s receiving school district all information regarding screening and evaluations completed to date, noting what evaluations are yet to be performed. (See Consent Order III.E.9)
In our assessment of this provision, we reviewed the State’s self-assessment and interviewed staff. Based on our review, we verified that, consistent with ODYS policy, staff regularly forward educational records to receiving schools when a youth is transitioned out of the ODYS system. During our February 2011 tour, we learned that during the period from November 1, 2010, to February 1, 2011, six youth were referred for testing or re-evaluation to determine eligibility for special education. While the six youth were referred out of Scioto prior to the completion of testing, the State reported that it had successfully forwarded the students’ records to the
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receiving school districts. We commend the State on maintaining substantial compliance with this provision.
Compliance Rating: Substantial Compliance
E.10 TRAINING AND QUALITY ASSURANCE The State shall design and implement annual training requirements for special education staff. (See Consent Order III.E.10) In our assessment of this provision, we reviewed the State’s self-assessment
and interviewed staff. Consistent with our finding in our Second Compliance Report, the State’s comprehensive training program offers to teachers valuable opportunities to further develop skills and effectively incorporate new techniques into their teaching. We commend the State for providing relevant training to its education staff and for working with an educational consultant to provide additional skill-building opportunities. We were impressed that, in response to Dr. Dedel’s concern about training in behavior management techniques, ODYS invited a consultant to provide two training sessions on the use of SBBMS. (See Dedel Second SPED Report at 4).
We commend the State for maintaining its substantial compliance rating.
Compliance Rating: Substantial Compliance
E.11 TRANSITION SERVICES The State shall comply with any IDEA requirements for providing transition assistance. The State shall provide transition assistance to students by providing counseling and concrete information regarding appropriate community resources, and how to pursue post-secondary options, re-enroll in school or complete the GED. (See Consent Order III.E.11) In our assessment of this provision, we reviewed the State’s self-assessment
and we interviewed staff. Based on our review, it appears that the State continues to have a solid foundation in place to provide transition services to Scioto youth.
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During the time period from November 1, 2010, to February 1, 2011, 13 youth were released from Scioto and 92% (12 of the 13) reportedly worked with the transition coordinator. Scioto has a “Transition Skills” course designed to encourage youth to join the workforce and ensure they have access to necessary documentation in order to apply for employment. Scioto also has a position, “Transition Coordinator,” which tasks an individual with assisting youth to interact with outside resources to smooth the youth’s re-entry back into the community. As of the date of our February 2011 compliance tour, the second transition skills instructor was not filled. It is our understanding that the State had already identified an individual and anticipates filling the position in the near future. Based on this assertion and the high rate of compliance, we consider the State to be in substantial compliance.
Compliance Rating: Substantial Compliance
VI. PROGRAMMING
F.1 STRUCTURED PROGRAMMING
The State shall provide adequate structured rehabilitative services, including an appropriate mix of physical, recreational or leisure activities during nonschool hours and days. The State shall develop and implement structured programming from the end of the school day until youth go to bed, and on weekends. For youth housed in closed-cell environments, programming shall be designed to ensure that youth are not confined in locked cells except: (a) from after programming to wake up; (b) as necessary where youth poses an immediate risk of harm to self or others; (c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The programming shall be designed to modify behaviors, provide rehabilitation to the types of youth committed at the facility, address general health and mental health needs, and be coordinated with the youth’s individual behavioral and treatment plans. The State shall use teachers, school administrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualified assistance to develop and implement structured programming. The State shall provide youth with access to programming activities that are required for parole eligibility. (See Consent Order III.F.1).
In order to assess this provision, we reviewed the State’s self-assessment, and interviewed staff and youth. Consistent with our Second Compliance Report, the
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State continues to have a significant programmatic framework to reduce idleness and provide structured opportunities for most youth. The State intends to create a programming tracking system, called “Youth Activity Tracking” (“YAT”), which will track individual level programming and may be a mechanism to detect trends in attendance, hold YS staff and unit managers accountable, and assist in determining whether all youth receive equal access to programming and SBBMS positive reinforcements. We commend the State for its continued success and improvements in its programming efforts and we look forward to learning more about the YAT once implemented.
Despite the State’s variety of programming and high level of volunteer activity, during our February 2011 tour we again received youth complaints that not all youth have full access to all programming opportunities or benefit from the full range of rewards under the SBBMS program. We received similar complaints from different housing units. In particular, youth alleged that they receive insufficient notice from YS staff about available programming. While the facility has a set calendar of programming events posted on the unit, it is unclear how youth actually sign up for events. In an effort to curb youth frustration and/or concerns, we suggest the State formalize the process in order to make it more transparent. In any event, every effort should be made to include interested youth in programming, while not compromising youth or staff safety in transporting youth to activities.
Other complaints we received during our February 2011 tour included allegations from reception youth that not all programming opportunities are available to them. The same youth also claimed that they do not receieve the full benefit of the SBBMS program. Specifically, the youth reported that the only rewards offered to them are either an extra envelope for writing a letter home, a board game to play (which are often broken or missing pieces), or a later bedtime. Lastly, still other youth on other units complained about YS staff overusing early
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bed time (“EBT”), itself a form of seclusion, to avoid interacting with certain youth or to show their disfavor for youth. These youth alleged that the EBT is used for even small transgressions or applied to all youth on a unit even when the misconduct involved only one or two youth. These allegations, if true, are concerning because they tend to support other claims that some YS staff impose punishments without cause against disfavored youth. We note that documentation we reviewed also support this belief. Specifically, one set of interdisciplinary team minutes we reviewed expressly confirm that “units have ‘heavily used the consequence of no free time’…early to bed is also being used too often.’” (See Glindmeyer Second Mental Health Report at 11). We strongly suggest that the State track the use of EBT based on youth who received EBT, unit, staff person who imposed the EBT, time of the EBT, and alleged misconduct that led to the EBT. These data should be assessed as part of the facility’s larger quality assurance activities. Dr. Dedel notes in her most recent report that assignments that merely consume time without any substantive message are not effective behavior management tools. (See Dedel Third PFH Report at 19).
Lastly, based on Dr. Dedel’s review of 20 Re-Entry plans, we found that most non-treatment related parole eligibility requirements from the Release Authority were generic, such as following rules, developing social skills, decision making, attending school, and engaging in pro-social leisure time. We found that most of these parole eligibility requirements were met by the State’s programming or educational opportunities. (See Dedel Third PFH Report at 19). The remaining parole eligibility requirements, namely those that were treatment-related, are discussed under provisions B.5 (Adequate Mental Health Care and Treatment), and provision B.8 (Integrated Treatment Plans,) which address group and individual therapy opportunities and interdisciplinary treatment teams. In summary, the State’s group and individual therapies are still in the early stages of development and implementation. While some mental health staff demonstrate a strong dedication and creativity in providing such therapies and treatment, the State’s
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progress is delayed due to its lack of sufficient mental health staff and the fact that YS staff are not yet fully integrated into the treatment process. Accordingly, the State has met the non-treatment related parole eligibility requirements only.
Compliance Rating: Partial Compliance
Recommendation(s) to reach substantial compliance:
The State should: (1) ensure all youth have access to, and are offered, programming, consistent with safety precautions, (2) examine the use of sanctions such as EBT to determine relevancy and appropriateness to misconduct by youth, and (3) ensure the SBBMS program is fully implemented, especially the use of character coupons, throughout Scioto.
F.2 ORIENTATION
Admissions Intake and Orientation. The State shall develop and implement policies, procedures and practices to establish a consistent, orderly admissions intake system, conducive to gathering necessary information about youth, disseminating information to staff providing services and care for youth, and maintaining youth safety. The orientation shall also clearly set forth the rules youth must follow at the facility, explain how to access medical and mental health care and the grievance system, and provide other information pertinent to the youth’s participation in the facility’s programs. (See Consent Order III.F.2(a)) Notice to Youth of Facility Rules and Incentives/Consequences for Compliance. The State shall explain the structured programming to all youth during an orientation session that shall set forth the facility rules, the positive incentives for compliance and good behavior and the sanctions for rule violations. The State shall provide the facility rules in writing. (See Consent Order III.F.2(b)) Introductory Handbook, Orientation and Reporting Abuse. Each youth entering the facilities shall be given an orientation that shall include simple directions for reporting abuse and assuring youth of his/her right to be protected from retaliation for reporting allegations of abuse. (See Consent Order III.F.2(c))
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In our assessment of this provision, we interviewed youth and reviewed policies and procedures and the youth handbook, last revised in October 2010.
Admission Intake and Orientation
The youth intake and orientation process at Scioto provides youth with an adequate overview of institutional rules, the process for accessing mental health and medical care, and the available opportunities in treatment, recreation, and educational programs. However, as described under provisions D.1 and D.2, the orientation regarding the grievance process is incomplete and should be revised to provide all relevant information to incoming and already admitted youth.
Similarly, the handbook and orientation do not adequately explain youths’ rights regarding religious practices. As quoted above, F. 2 requires the State to develop an orientation that clearly sets forth the rules youth must follow at the facility and provides other information pertinent to the youth’s participation in the facility’s programs. It also requires that the facility provide rules in writing and an introductory handbook. The handbook claims to “contain information [youth] will need to know during [their] stay at ODYS.” (page 6 of youth handbook). While the handbook informs youth that they have the right not to be discriminated against because of religion, the section covering “Religious Services” may not fully comply with the Religious Land Use and Institutionalized Persons Act, 42 U.S.C. § 2000cc (“RLUIPA”). RLUIPA protects the religious exercise of persons confined to institutions, including youth confined in juvenile correctional facilities. 15 RLUIPA prohibits the State from substantially burdening the religious exercise of youth in juvenile correctional facilities, even if the burden results from a rule of general applicability.16 Regulations amounting to a substantial burden will only be
15 See http://www.justice.gov/crt/about/spl/rluipa.php (last visited January 12, 2011).
16 For example, while the youth handbook states that youth who wear “[p]ersonal clothing not authorized by the state” will be subject to discipline (page 21), RLUIPA
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permitted if the State demonstrates that the regulation furthers a “compelling government interest” and is the least restrictive means available to further that interest. We encourage the State to seek clarification from the United States if it should have any questions about RLUIPA.
Notice to Youth of Facility Rules and Incentives/Consequences for Compliance.
Based on our review of the youth handbook and interviews with youth, it appears that, upon intake, youth receive notice about Scioto facility rules and incentives/consequences for compliance. Specifically, youth were able to articulate the SBBMS system.
Introductory Handbook, Orientation and Reporting Abuse.
In our Second Compliance Report, we recommended that the State revise its handbook to be consistent with its religious accommodations procedure, SOP 507.02.06, which requires a youth to fill out and return a “Request for Accommodation of Religious Belief or Practice” form if he or she wishes to have an accommodation for a religious rite, practice, or observance. However, the youth handbook fails to mention this form in the section which discusses religious services. The handbook is thus incomplete and should be revised to describe the procedure for seeking a religious accommodation consistent with the SOP. One youth we interviewed alleged that she was prohibited from wearing religious garb that posed little safety risk, grieved about the infringement, but was never informed of her right to seek a religious accommodation. Ultimately, staff returned the youth’s garb to the religious advisor and allegedly told the youth that if she were allowed to wear the garb, all other youth would have to be allowed to wear baseball caps.
Compliance Rating: Partial Compliance
may require that a Jewish youth be permitted to wear a yarmulke or a Muslim youth be permitted to wear a hijab in observance of his or her religious practices.
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Recommendation(s) to reach substantial compliance:
As discussed in more detail in our Second Compliance Report, the State should revise its handbook to be consistent with the State’s religious accommodations policy, ensure that all relevant personnel are familiar with RLUIPA’s requirements, and ensure that the chaplain is familiar with the requirements of RLUIPA.
VII. DOCUMENTATION
G.1 PROGRESS NOTES
The Facilities shall promulgate and implement a policy requiring that all health professionals be required to create and use progress notes to document, on a regular basis, interactions and each assessment of youth with mental/behavioral health or substance abuse needs. In particular, progress notes shall:
a. In the assessment, address the efficacy of interventions, currently presenting problems, and the available options to address those problems; and
b. Provide thorough documentation of all crisis interventions or, if not thoroughly documented in the progress notes, provide a reference to alert staff to another document in the youth’s file containing the details of the crisis intervention. (See Consent Order III.G.1).
In order to assess this provision, we reviewed the State’s policies, procedures, and practices regarding progress notes. We recognize that the provisions under G, “Documentation,” do not fall squarely under any of the other sections, but rather touch on mental health, medical care, and education. For this reason, we asked our medical and mental health experts to comment on these provisions. In our Second Compliance Report, we recommended the State provide a discussion in its selfassessment of how it meets the criteria of provisions G.1 and G.2. The State did not provide any such self-assessment.
In preparation for our compliance tour in November 2010, the State provided a draft policy, entitled “Behavioral Health Documentation Guidelines,” relevant to
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our assessment of mental health progress notes. While the policy appears to adequately meet the requirements of provision G.1, in our Second Compliance Report, we noted that it was unclear whether this policy had been implemented. A review of youth records in November 2011 revealed that mental/behavioral health progress notes were generally of fair quality. During our most recent compliance tour in February 2011, we found that progress notes in the youth records revealed some improvement in the documentation of group interaction. We agree, however, with Dr. Glindmeyer’s observation that, in the context of integrated treatment plans, the progress notes reviewed did not consistently relate to treatment goals and/or document the response or lack thereof to prescribed interventions. (See Glindmeyer Second Mental Health Report at 13). In fact, during the verbal selfassessment on-site, the mental health administrative staff recognized that the progress notes that related to integrated treatment teams were in the beginning stages of implementation. (See Glindmeyer Second Mental Health Report at 13-14). Consistent with our Second Compliance Report, while we found that the youth records contained numerous progress notes, the progress notes did not consistently address the youth’s specific treatment goals as outlined in treatment planning documents.
The relevant medical forms, policies and SOPs remain the same since our last review. The policies and SOPs appropriately address content organization and format, confidentiality requirements, and health care professionals’ access to records. Physicians and nurses appropriately document progress notes in chronological order in youth health records. The Medical Release and Transfer Summaries Policy require health staff to complete a Medical Transfer Summary and a Medical Release Summary for youth who are discharged or transferred out of the facility. Both forms contain lines to document required or scheduled medical and dental referrals. The Medical Release form also designates whether psychiatry follow-up is required immediately or within another timeframe, and whether a
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parent should be advised. Medical staff adequately document health information on the above-mentioned documents according to policy. Compliance Rating: Partial Compliance Recommendation(s) to reach substantial compliance:
The State should implement quality assurance measures, a peer review process, and clinical supervision to improve the consistency and quality of mental/behavioral health progress notes. G.2 ACCESSIBILITY OF RELEVANT INFORMATION
The Facilities shall ensure that youth records are organized in a manner providing treatment teams prompt access to relevant, complete, and accurate documentation regarding the youth’s status. (See Consent Order III.G.2) While health records include psychiatric evaluations and chronological psychiatric progress notes, records still do not include psychological records, such as case notes. As stated in Section C.2. (“Health Records”), the State must continue moving towards a system that will combine all health records, including psychology records. Compliance Rating: Partial Compliance Recommendation(s) to reach substantial compliance: Until the State combines these records, treatment teams will not have prompt access to relevant, complete, and accurate documentation regarding the youth’s status.
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THIRD COMPLIANCE REPORT
As per section VII.E of the Consent Order, the U.S. v Ohio Stipulation terminates three years from its effective date, June 5, 2008. The State has not yet reached substantial compliance with all 53 provisions in the agreement. Accordingly, the United States and the State of Ohio are currently negotiating a possible extension of the U.S. v Ohio agreement.
Respectfully submitted this 9th day of May, 2011.

FOR THE UNITED STATES:

THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Section Chief Special Litigation Section U.S. Department of Justice Civil Rights Division BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section U.S. Department of Justice Civil Rights Division
s/ Silvia J. Dominguez______________ Silvia J. Dominguez Rashida Ogletree Trial Attorneys Special Litigation Section U.S. Department of Justice. Civil Rights Division 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530

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Attachment A

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U.S. Department of Justice v. The State of Ohio Civil Action No: 2:08‐cv‐475
3rd Protection from Harm Compliance Report
Kelly Dedel, Ph.D. One in 37 Research, Inc. 1608 NW Riverscape Street Portland, OR 97209 (503) 799‐0915 www.onein37.com
Draft Submitted March 1, 2011 Final Submitted March 29, 2011

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On June 4, 2008, The United States Department of Justice (DOJ) and the State of Ohio (the State) signed a stipulation for injunctive relief (the Stipulation) concerning conditions at the Scioto Juvenile Correctional Facility (Scioto) and the Marion Juvenile Correctional Facility (Marion). The Stipulation adopted the same monitoring team used in a concurrent suit, S.H. et al., v. Tom Stickrath (S.H.), led by Fred Cohen, Esq. This team was charged with monitoring the extent to which the State had effectively implemented the reforms required by the Stipulation and providing detailed reports to the Parties. After the Stipulation was signed, the State closed the Marion facility.
In late 2009, Mr. Cohen announced his intention to resign his position as the Monitor for the Stipulation, while continuing his duties as the lead monitor in S.H. On November 23, 2009, the Parties amended the Stipulation to assigning monitoring duties for Scioto to the DOJ. Both Parties agreed that I, Dr. Kelly Dedel, would serve as the DOJ’s expert for protection from harm and special education issues.
This is my third report on the 12 protection from harm related provisions. The DOJ opted for my assessment to be conducted remotely, and thus, while the State provided a large volume of useful information, I was limited in the extent to which I could verify the State’s data or delve further into certain issues. This report draws on the State’s self‐assessment materials submitted in late February 2011 and a series of follow‐up telephone calls and emails with various Scioto staff. For the sake of brevity, I have not reiterated information from previous reports that testified to the State’s compliance with each provision (e.g., discussions of policy and procedure; data analysis from previous monitoring periods; etc.). The reader is encouraged to read my 2nd Compliance Report for a complete discussion of these issues.
In March, 2011, the Ohio Legislature indicated its intention to close the Ohio River Valley (ORV) facility. The closure of this facility and the subsequent transfer of youth to other facilities in the State will have a significant impact on Scioto’s ability to sustain its progress in making the required reforms. The transfer of youth must be carefully planned and managed so that the negative outcomes experienced during the closure of other DYS facilities may be avoided. The State is encouraged to share its plans for the transfer of youth to Scioto and how its previous experiences with facility closures will inform the upcoming reassignment of youth and redeployment of staff.
Section V.H of the Stipulation requires the Monitor/expert to provide the Parties with reports “describing the steps taken by the State to implement [the] Stipulation and to evaluate the extent to which the State has complied with each substantive provision of the Stipulation.” The full text of each provision is provided in the following report, along with a detailed discussion of the State’s progress in each area. The report content required by the Stipulation is presented in italics below, along a description of the content in each section:
 “The self‐assessment steps the facility undertook to assess compliance and the results thereof.” In response to a detailed document request I crafted to focus on specific performance measures for each provision, the State presented a large volume of information and data to demonstrate its progress in meeting the requirements of the Stipulate to date. This information is summarized.
 “[My own] steps taken to assess compliance.” Because I did not travel to Scioto, I did not take any independent actions to assess compliance, other than to ask clarifying questions about the State’s self‐assessment or to analyze the data contained in it.

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 “Recommendations for facilitating or sustaining compliance.” These recommendations are generally outcome‐focused so as to reinforce the spirit of the provision itself, but also to permit the State sufficient flexibility to satisfy both this Stipulation and the requirements of S.H. The recommendations in this section are limited to those needed to demonstrate substantial compliance with the provision. Other recommendations toward best‐practice are included in the discussions of each provision, but are not necessarily required for substantial compliance in my opinion.
 “Sources of information that form the basis of [my] opinion.” The self‐assessment documents were organized by provision, and referenced accordingly.
Given that the DOJ has been appointed as the Monitor in this case, I have not offered specific compliance ratings for each of the provisions. Instead, I endeavored to describe the current state of affairs in each area as indicated by the State’s self‐assessment materials, along with my assessment of the steps needed, if any, for the State to meet the requirements of the provision.

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III.A.1 General Protection From Harm. The State shall, at all times, provide youth in the facilities with safe living conditions. As part of this requirement, the State shall take appropriate measures to ensure that youth are protected from abuse and neglect, use of excessive force, undue seclusion, undue restraint, and over‐familiarization.

Self Assessment

The Chart in Appendix 1 shows the rate of youth violence at Scioto for the past 12 months. Since May 2010, the facility’s rate of youth violence has increased, compared to the rates of violence in 2009 and early 2010. This trend was noted during my visit to Scioto in November 2010, when I recommended that the State delve into these data to determine the underlying causes of the increases. The resulting analysis was of very high quality and illuminated some important facility dynamics that needed to be addressed.

First, instability in staffing among the facility’s social workers, psychologists, psychiatrists, and Unit Managers appeared to underlie the increased rates of violence witnessed in the girls Mental Health unit and the boys Reception units. Not only did the instability disrupt the relationships between youth and staff that are fundamental to maintaining a safe facility, but the social worker shortages in Reception also caused a delay in completing required assessments, thus increasing the lengths of stay. (Reception units tend to have more violence because youth have not “settled in” and are anxious about their subsequent placements. An efficient transfer process to the youth’s permanent facility is essential.) Further, in addition to increasing the number of boys assigned to the mental health unit from 7 to 15 youth, instability in the Unit Manager position for that unit meant that direct care staff supervision lacked structure and consistency. Similar problems plagued the girls’ Mental Health unit, where the psychologist was absent for several months. In short, the facility’s struggle to maintain a consistent and stable workforce contributed in very tangible ways to the increased rate of violence witnessed during the last half of 2010.

In addition, as is typical in most facilities, the facility found that a relatively small number of youth were responsible for a vastly disproportionate amount of violence. Just 12 youth accounted for 64% of the total number of seclusion hours for the entire facility. Unfortunately, given the instability in staffing discussed above, many of these youth did not have Special Management Plans designed to address the underlying causes of their aggressive behavior.

Once armed with this information, the facility took steps to address the underlying causes of the increases in youth violence. A new Unit Manager was assigned to the boy’s mental health unit. According to my colleagues who were on site at Scioto (DOJ attorneys and Dr. Daphne Glindmeyer), the current Unit Manager received very positive reviews from the youth on that unit. Further, the State was authorized to pay overtime to social workers on the Reception units in order to address the backlog of assessments so that youth could move through the reception process more quickly. Finally, the Deputy Superintendent implemented a monthly data review with each Unit Manager. Those overseeing units housing youth with chronic violent misconduct are expected to discuss

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each youth’s Special Management Plan during that meeting.

The problem‐solving capability demonstrated by the analysis discussed above is exemplary. Moving forward, the facility should continue to assess the level of stability among the various professional groups at Scioto, the length of stay in the Reception units, and the extent to which Special Management Plans effectively suppress the aggressive behavior of identified youth. If each of these strategies is properly implemented, the rate of youth violence should decrease. If it does not, other dynamics are likely in play and the problem‐solving process should be reinstituted to identify and respond to these issues.

In addition, my colleagues on site at Scioto (DOJ attorneys and Dr. Daphne Glindmeyer) heard multiple reports from youth about abusive language by staff (See DOJ’s letter dated March 11, 2011, page 2). Approximately half of the 25 youth interviewed reported that certain staff regularly berated, antagonized, cursed, or otherwise verbally abused them. Dr. Daphne Glindmeyer observed such treatment of a youth in seclusion by a staff member who was shouting inappropriate comments to the youth through the door of the seclusion room. While the youth reported that some staff would intervene with staff displaying inappropriate conduct, for the most part, youth felt that Administrators were disconnected from what was happening on the units and that Unit Managers were too busy to hear or address their complaints. That these complaints about abusive language were so pervasive among the youth interviewed is a serious concern. The facility should take steps to identify the staff who engage in such behavior and should intervene with appropriate training or discipline as needed.

Steps Taken to Assess Compliance Recommendations
Sources of Information

Other topics covered by this provision—restraints, inappropriate relationships, and seclusion—are discussed in the specific provisions below.
As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.
To reach substantial compliance, it is recommended that the State: 1. Investigate and address staff’s inappropriate and verbally abusive language toward youth. 2. Reach substantial compliance with the other provisions related to protecting youth from harm.
 Self‐Assessment materials for Provision 1, prepared at my request  Follow‐up telephone conversations with the Deputy Superintendent  Consultation with DOJ Attorneys and Dr. Daphne Glindmeyer

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III.A.2 Use of Force. The State shall develop and implement comprehensive policies, procedures, and practices limiting use of force on youth to situations where it is objectively reasonable and necessary. Staff shall be required to adequately and promptly document and report all uses of force.

Self Assessment

Staff training on the proper use of physical and mechanical restraints is comprehensive and exceeds the generally accepted practice in this area. Managing Youth Resistance (MYR) training is conducted quarterly. In each of the four quarters in 2010, at least 90% of all staff attended the training (Q1 96%; Q2 90%; Q3 94%; Q4 96%).

As shown in the table below, the rate of physical restraint decreased approximately 16% in the latter part of 2010 (average rate .47) as compared to the first six months of the year (average .56). These monthly data are also presented in Chart 2 in the Appendix, along with data on the use of mechanical restraints.

Rate of Physical Restraint, February 2010 through January 2011

Month

Number of Restraints

Average Monthly Population

Rate of Physical Restraint

Feb 10

44

119

.40

Mar 10

56

140

.40

Apr 10

69

139

.50

May 10

81

134

.60

Jun 10

80

125

.64

Jul 10

108

128

.84

Average Rate

.56

Aug 10

64

122

.53

Sep 10

57

131

.44

Oct 10

62

128

.48

Nov 10

64

133

.48

Dec 10

75

150

.50

Jan 11

56

139

.40

Average Rate

.47

The reason for this decrease is unknown, but is worthy of investigation so that the factors leading to the decrease can be harnessed to produce additional reductions in the use of force. In particular, it would be useful to know whether the decreases have occurred in situations involving youth‐on‐youth violence or in those involving disruptive behavior.

The State provided data on the proportion of physical restraints in which the youth remained standing, versus those in which the youth is taken to the ground. These data illustrate the staff’s efforts to temper their use of restraint,

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using the minimum amount of force necessary to control the youth’s behavior. Over the past six months, youth were taken to the ground in only 15% of all physical restraints. This is very encouraging.

According to my colleagues who were on‐site at Scioto, youth who had been at Scioto multiple times noticed an improvement in staff’s commitment to de‐ escalating tensions, rather than proceeding directly to the most restrictive forms of physical restraint.

Steps Taken to Assess Compliance Recommendations
Sources of Information

Of course, there will always be situations in which staff do not conform to the expectation that only the minimum amount of force is used to regain control of youth. As discussed in the provision related to Investigations, below, the facility appears to have adequate measures for screening incidents involving the use of force and for referring those with questionable practices for further inquiry. The two incidents reported to my colleagues on‐site at Scioto had already been identified by the facility for investigation by the Chief Inspector’s Office.
As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.
The State’s policies, procedures and practices related to the use of force appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 2, prepared at my request  Follow‐up telephone conversations with the Deputy Superintendent  Consultation with DOJ Attorneys and Dr. Daphne Glindmeyer

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III.A.3 Seclusion. The State shall develop and implement policies, procedures and practices so that staff use seclusion only in accordance with policy and in an appropriate manner and so that staff document fully the use and administrative review of any imposition of seclusion, including the placing of youth in their rooms outside normal sleeping hours.

Self Assessment

The State presented data related to the three main types of seclusion that are used at Scioto: 1) Regular Seclusion—a period of isolation imposed in response to non‐violent misbehavior, usually between 1 to 3 hours in duration; 2) Pre‐ Hearing Seclusion—a period of isolation immediately following youth’s involvement in aggressive behavior. The duration is determined by the youth’s score on the IRAV Assessment; and 3) Disciplinary Seclusion—a period of isolation imposed by a Hearing Office as a sanction for aggressive behavior.

Regular Seclusion Over the past 9 months, the number of regular seclusions ranged between 35 and 57. While there were fluctuations from month to month, there were no clear patterns—the average number of seclusions for each of the 3‐month periods was 47. The rate of regular seclusion ranged between .3 and .5 seclusions per youth per month, a statistic which is difficult to interpret given that some youth are never secluded, while others are secluded multiple times. In general, the rate of regular seclusion is not particularly alarming, mainly because the majority are quite short. Over the past 6 months, nearly all seclusions (98%) lasted less than three hours, with 31% lasting under one hour. Given the facility’s commitment to reducing seclusion hours facility‐wide, it would be worth identifying the youth who are secluded often to determine whether an alternative method of de‐escalation might be as effective (it may not be—for some youth, a short time alone in their rooms is exactly what is needed for them to regain control of their behavior).

Pre‐Hearing Seclusion When youth are involved in violent misconduct, they are immediately confined to their rooms. Within 4 hours, their risk of subsequent misconduct is assessed using the IRAV assessment tool, which provides guidance as to when these youth may be safely returned to the general population. IRAV data for the past 6 months show that of the 219 youth placed in pre‐hearing seclusion, nearly half (46%) were classified into the C category (pre‐hearing seclusion is authorized for 4‐24 hours), one‐third (35%) were classified into the B category (pre‐hearing seclusion is authorized for 24‐56 hours), and one‐fifth (19%) were classified into the A category (pre‐hearing seclusion is required until the disciplinary hearing is held). In other words, approximately 80% of youth who engaged in violent misconduct were NOT required to remain secluded pending their disciplinary hearing. This is a massive change from several years ago when ALL youth were required to remain in pre‐hearing confinement pending their disciplinary hearings.

Among those eligible for release, approximately two‐thirds remained in pre‐ hearing seclusion for less than 24 hours (November 67%, December 57%, and

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January 65%). Again, this is a significant improvement from the era of CRAV, when youth commonly spent several days in seclusion awaiting their disciplinary hearings.

When reviewing the State’s data, I noted a change in the proportion of youth who spent less than 24 hours in pre‐hearing seclusion as compared to my last visit, when 85‐90% of youth were released prior to the 24‐hour mark. It turns out that the facility accidentally implemented the IRAV policy improperly. Instead of abiding by the requirement for B category youth to remain in seclusion for 24‐56 hours, they released them from pre‐hearing seclusion immediately. Interestingly, many of these B category youth quickly became involved in subsequent misconduct once released to the general population. In effect, the facility re‐validated the IRAV classification system, and confirmed the compelling safety risks posed by youth scoring in the B category. In November, the facility adjusted its practices to conform to the IRAV policy. This experience highlights the importance of regularly compiling and reviewing data related to the various provisions. Outliers in the data and anomalies like “90% of youth were released prior to the 24‐hour mark” should be immediately analyzed to determine the underlying causes.

Disciplinary Seclusion Over the past 6 months, the use of disciplinary seclusion has been relatively low when compared to the number of incidents involving youth‐on‐youth violence. In contrast to prior years when ALL youth involved in violent misconduct were placed in disciplinary isolation, seclusion is now imposed in about 60% of these incidents. The other 40% received an alternative consequence of some sort. This is a very positive development.

Over the past 6 months, approximately 17% of disciplinary seclusions lasted 24 hours or less; 56% lasted between 24 and 72 hours; and 26% lasted over 72 hours. While this variation is encouraging and suggests that the severity of the consequence is calibrated according to the severity of the incident, the facility is encouraged to continue its efforts to reduce the length of stay in seclusion. As discussed at length in my previous reports, isolation can only suppress behavior—it does nothing to address the underlying causes of the behavior. Attending to these underlying causes requires the youth to be engaged with the regular facility programming, and the sooner this can happen, the better.

Seclusion and the Risk of Self‐Harm The facility continues to address the problem of staff not conducting required safety checks to verify the welfare of youth who are in seclusion or locked in their rooms overnight. Videotaped footage of the housing units’ operation is reviewed on a regular basis. The State produced data indicating that of the 17 shifts reviewed over the past 3 months, 8 of the 17 (47%) revealed problems with staff attentiveness and their conducting required safety checks. Half of the problems occurred in November, while improved compliance was noted in December and January. However, when one of the DOJ attorneys reviewed

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videotape while on‐site, significant problems were noted. On February 7th, staff assigned to the unit reviewed did not make ANY safety checks between midnight and 6am, nor did the Operations Manager (OM) make rounds during that six hour period. [The State is looking into compliance with safety checks from 10pm to midnight of that same shift.] Further, my colleagues on site heard multiple complaints from youth about staff refusing or delaying their access to the restroom during the overnight hours. In some cases, these youth alleged they urinated in their rooms or on themselves (See DOJ’s letter dated March 11, 2011, page 3). Clearly, staff compliance in this area needs additional improvement.

Notably, around the holidays, the videotape reviews indicated the rates of compliance with safety check policies appeared to be quite good. The reasons for this improved level of compliance, particularly during a time in which staff compliance generally falls off, is unknown but is definitely worth investigating. Identifying the reasons that the problem does NOT exist is an important problem‐solving activity.

Steps Taken to Assess As discussed in the Introduction to this report, I did not conduct any on‐site

Compliance

inquiries.

Recommendations
Sources of Information

It is recommended that the State:
1. Ensure that staff conduct the required safety checks any time that youth are confined to their rooms, particularly on 3rd shift.
 Self‐Assessment materials for Provision 3, prepared at my request  Follow‐up telephone conversations with the Deputy Superintendent  Consultation with DOJ Attorneys and Dr. Daphne Glindmeyer

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III.A.4 Restraint. The State shall develop and implement policies, procedures and practices so that only safe methods of restraint are used at the facility and only in those circumstances necessary for safety and security and, to the extent possible, when less restrictive means have been properly, but unsuccessfully, attempted or with respect to therapeutic restraints pursuant to a medical order to protect the health of the youth.

Self Assessment

As discussed in Provision 2, above, staff training on the proper use of physical and mechanical restraints is comprehensive and exceeds the generally accepted practice in this area. Managing Youth Resistance (MYR) training is conducted quarterly. In each of the 4 quarters in 2010, at least 90% of all staff attended the training (Q1 96%; Q2 90%; Q3 94%; Q4 96%).

As discussed in my previous report, the State has implemented several procedures to screen incidents involving physical restraint (e.g., review by the Operations Administrator, review by the Facility Intervention Administrator (FIA) and the Superintendent’s Monthly Review) and to refer those with questionable practices for further inquiry. In November and December 2010, 10 incidents were referred for investigation to determine whether the use of force was inappropriate or excessive. Of these, only one was substantiated (#5501100358—staff was cited for picking a youth up in a bear hug and tossing him aside, when he should have taken more care to gently move the youth away from the altercation. The staff received a verbal reprimand for this incident).

Two more recent incidents were discussed during the teleconference debriefing with Scioto administrators on February 25, 2011. Both incidents were identified via the screening processes discussed above and referred for investigation.

Steps Taken to Assess As discussed in the Introduction to this report, I did not conduct any on‐site

Compliance

inquiries.

Recommendations
Sources of Information

The facility’s policies, procedures and practices related to Restraint appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 4, prepared at my request  Follow‐up telephone conversations with the Deputy Superintendent  Consultation with DOJ Attorneys and Dr. Daphne Glindmeyer

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III.A.5 Investigation of Serious Incidents. The State shall develop and implement policies, procedures and practices so that appropriate investigations are conducted of all incidents of: use of force; staff‐on‐ youth violence; serious youth‐on‐youth violence; inappropriate staff relationships with youth; sexual misconduct between youth; and abusive institutional practices. Investigations shall be conducted by persons who do not have direct or immediate indirect responsibility for the employee being investigated.

Self Assessment

The State submitted a chart detailing the number and type of incidents that were investigated over the past three months. Of the 15 investigations, 10 alleged the inappropriate or excessive use of force, one alleged verbal abuse by staff, and 4 alleged inappropriate relationships between staff and youth. No youth alleged physical abuse by staff during the past three months. Their various allegations of physical harm occurred during an incident involving physical restraint and thus were counted in the inappropriate/excessive use of force category. Although not required but good practice, in most of these situations, staff submitted suspected child abuse reports to local law enforcement and the child protective services agency.

One of the use of force allegations was substantiated (discussed in the previous provision) and one of the inappropriate relationship allegations was substantiated (#1001100101—staff received a written reprimand for inappropriate contact with youth (hugging) and inappropriate comments (“I love you”).

Steps Taken to Assess Compliance

I performed a content analysis of the 15 investigations submitted among the self‐assessment materials. Nine of these investigations were conducted by the Chief Inspector’s Office (CIO), and 5 were conducted by Scioto staff. The investigations conducted by the CIO were high‐quality and completed within the required timelines.

However, several of the investigations conducted by Scioto staff were of poor quality. In general, the investigatory protocol (e.g., types of questions asked, pursuit of additional witnesses or evidence, confronting witnesses with inconsistencies, etc.) lacked the necessary vigor to ensure a reasonable finding. Two of the investigations were very poorly written, to the point that it was difficult to discern the basis for the investigator’s conclusions.

These particular deficiencies were not evident in my previous investigation of this issue, although there was a problem with timeliness. I do not know the source of the current problem. A Scioto administrator reported that the CIO’s most recent audit revealed similar problems. In response, the CIO plans to offer investigation training to designated Scioto staff. Further, the facility administrator who oversees the investigations has begun to review each investigation and to request clarification and corrections from the assigned investigator.

Additionally, my colleagues on site at Scioto interviewed two youth who had been the alleged victims in two incidents that were investigated by the CIO. In

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Recommendations
Sources of Information

both cases, the youth reported threats and intimidation by staff once the youth’s allegations became known (see DOJ’s letter dated March 11, 2011, page 2). In one case, an uninvolved staff verbally threatened to harm “anyone who tried to mess with my money [her job].” In the other case, other youth on the unit reported to the alleged victim that the involved staff was “trying to get them to beat [the victim] up.” Neither victim chose to report these threats and intimidation to the facility administration, nor did they want their concerns to be reported at the conclusion of the interviews with my colleagues. Although the veracity of these allegations cannot be confirmed without the victims’ cooperation, it is worth reminding staff that they are prohibited from threatening, intimidating or otherwise discussing the substance of matters under investigation with youth.
It is recommended that the State: 1. Train all facility staff responsible for conducting investigations of the issues listed in this Provision. 2. Ensure that investigations produced by facility staff meet generally accepted practices for the investigation of employee misconduct and youth mistreatment. 3. Provide feedback to youth about the status of investigations triggered by a grievance or other report of staff mistreatment. As personnel regulations allow, inform youth of the outcome of the investigation once it is completed. (see discussion in Provision D.1, below).
 Self‐Assessment materials for Provision 5, prepared at my request  Follow‐up telephone conversations with the facility administrator who
oversees the investigations

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III.A.6 Staff Training in Behavior Management, De‐Escalation and Crisis Intervention. The facilities shall train all staff in behavior management, de‐escalation techniques, appropriate communication with youth and crisis intervention before staff may work in direct contact with youth.

Self Assessment

Detailed training records revealed that the facility’s training efforts remain comprehensive and exceed generally accepted practices in this area. Across the eight new staff who began working in the past three months, all completed the new employee training sessions required by this provision.

A total of 24 separate training courses were required for veteran staff in 2010. Across the 286 veteran staff, 92% completed all 24 training courses. Completion rates for individual courses ranged from 64% to 98% (the course with the 64% completion rate was added to the training requirements at the end of 2010). The average rate of completion across courses was 92%.

Steps Taken to Assess As discussed in the Introduction to this report, I did not conduct any on‐site

Compliance

inquiries.

Recommendations

The facility’s policies, procedures and practices related to staff training appear to meet the requirements of this provision.

Sources of Information

 Self‐Assessment materials for Provision 6, prepared at my request

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III.A.7 Employment Practices. The State shall use reasonable measures, including background checks and criminal records checks, to determine applicants’ fitness to work in a juvenile facility prior to hiring employees for positions at the facility.

Self Assessment

In the past three months, the facility hired four new employees. All of these passed the background check and did not have criminal records for any of the offenses that would bar their employment according to State personnel regulations. One staff was slated for employment but ultimately not hired because he did not pass the drug test.

Steps Taken to Assess As discussed in the Introduction to this report, I did not conduct any on‐site

Compliance

inquiries.

Recommendations

The facility’s policies, procedures and practices related to employment practices appear to meet the requirements of this provision.

Sources of Information

 Self‐Assessment materials for Provision 7, prepared at my request

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III.D.1 Grievances. The State shall develop and implement policies, procedures and practices to ensure that the facility has an adequate grievance system including: no formal or informal preconditions to the completion and submission of a grievance; review of grievances by the chief inspector; timely initiation and resolution of grievances; appropriate corrective action; and written notification provided to the youth of the final resolution of the grievance.

Self Assessment

As discussed in my previous report, the grievance process at Scioto addresses all of the components required by this provision: no preconditions, review by the chief inspector, timely initiation and resolution, appropriate corrective action, and written notification to youth of the final resolution.

Between November 2010 and January 2011, 106 grievances were submitted. All were resolved within the 14 days permitted by policy. The number of grievances submitted was comparable to previous periods of review, although the timeliness has improved. All of the grievances were reviewed by the CIO, which requested additional follow‐up in 15% of the cases. The CIO oversight is a solid mechanism for ensuring the quality of the response.

Steps Taken to Assess Compliance

Copies of the 106 handwritten grievances were submitted for my review. The responses to the grievances were timely and showed persistent efforts to understand the problem presented by the youth and to identify a fair and reasonable resolution.

Recommendations
Sources of Information

My colleagues on site (DOJ attorneys and Dr. Daphne Glindmeyer) heard concerns about the grievance process that echoed the concerns discussed in my previous report (see DOJ’s letter dated March 11, 2011, pages 3 and 4). Although I did not have the opportunity to talk to the youth myself, my sense is that locating their concerns within the grievance process could inadvertently misdirect the efforts toward solving the problem. Youth continue to be satisfied with the grievance process insofar as it addresses typical quality of life issues (e.g., clothing, behavior management decisions, food, disciplinary issues, etc.). Their dissatisfaction appears to be centered on the facility’s response to more serious complaints about staff mistreatment. Although the youth may voice the complaint using the grievance process, complaints of this type are always referred for investigation—they are not handled by the Grievance Coordinator. Labeling the concern as one about the grievance process is misleading; really, it is the investigations into staff misconduct or mistreatment with which the youth take issue. Discussions with facility administrators during the teleconference on February 25, 2011 included a discussion about this issue and the steps that the facility could take to ameliorate the youths’ concerns.
The facility’s procedures and practices related to the grievance system address all of the requirements of this provision. (Please see Recommendation #3 under Provision 5 that addresses the concern discussed above).
 Self‐Assessment materials for Provision D.1, prepared at my request  Follow‐up telephone conversations with the Grievance Coordinator  Consultation with DOJ Attorneys and Dr. Daphne Glindmeyer

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III.D.2 Grievance Explained to Youth. A clear explanation of the grievance process shall be provided to each youth upon admission to the facilities during orientation and to their parents or guardians, and the youth’s understanding of the process shall be at least verbally verified.

Self Assessment

The facility audited intake files for youth admitted in November and December 2010 and January 2011. Ten percent of the youth admitted during this time period were included in the sample (n=21 youth). The audit found that 100% of these youth received a complete orientation to the facility, which included information about how to access the grievance system.

Steps Taken to Assess As discussed in the Introduction to this report, I did not conduct any on‐site

Compliance

inquiries.

Recommendations

The State’s policies, procedures and practices related to explaining the grievance system to youth appear to meet the requirements of this provision.

Sources of Information

 Self‐Assessment materials for Provision D.2, prepared at my request

III.D.3 Grievance Process. Without any staff involvement, youth shall easily be able to obtain grievance forms and submit grievances.

Self Assessment

In my previous report, I noted that there are 19 grievance boxes throughout the Scioto campus, in each building where youth congregate. Grievance forms are stocked right next to each box. Youth are required to seek permission to use a pencil, but the Grievance Coordinator reported that she has never received a complaint from youth that they were denied permission. Further, in staff meetings, staff are consistently reminded that they are prohibited from impeding the grievance process in any way.

No additional self‐assessment was requested on this issue.

Steps Taken to Assess As discussed in the Introduction to this report, I did not conduct any on‐site

Compliance

inquiries.

Recommendations

The State’s policies, procedures and practices related to youth accessing the grievance system appear to meet the requirements of this provision.

Sources of Information

 No new information was collected or reviewed related to this provision.

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III.F.1 Structured Programming. The State shall provide adequate structured rehabilitative services, including an appropriate mix of physical, recreational or leisure activities during non‐school hours and days. The State shall develop and implement structured programming from the end of the school day until youth go to bed, and on weekends. For youth housed in closed‐cell environments, programming shall be designed to ensure that youth are not confined in locked cells except: a) from after programming to wake up; b) as necessary where youth poses an immediate risk of harm to self or others; c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The programming shall be designed to modify behaviors, provide rehabilitation to the types of youth committed at the facility, address general health and mental health needs, and be coordinated with the youth’s individual behavioral and treatment plans. The State shall use teachers, school administrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualified assistance to develop and implement structured programming. The State shall provide youth with access to programming activities that are required for parole eligibility.

Self Assessment

As discussed in my previous reports, the facility has brought a wide array of programs to the facility, relying heavily on the contributions of community volunteers and those from various faith‐based organizations. Most recently, the facility reported its intention to create a Youth Activity Tracking System (YATS) to track individual‐level program participation data. The YATS will also permit the facility to aggregate these data to look at facility‐wide trends. These data will be helpful to the facility’s efforts to minimize idle time, to ensure equal access to programming across units, to identify the types of programs that are of greatest interest to youth, and to hold Unit Managers and Youth Specialists accountable for following the unit schedules. My colleagues on site (DOJ Attorneys and Dr. Daphne Glindmeyer) heard several complaints from youth on the reception units that staff sometimes did not provide sufficient notice of the programs available to them (see DOJ’s letter dated March 11, 2011, page 6). They complained of excessive idle time on the weekends, in particular. Once implemented, the YATS should be used to discern whether programming opportunities on these units should be expanded and whether staff are following the proper procedures to ensure youth’s access to them.

Approximately 10% of the facility’s youth currently hold paid work positions at the facility (e.g., office assistant, storeroom, hairstylist, cosmetology assistant, cafeteria workers, recreation assistants, and school tutors). During the teleconference held on February 25, 2011, facility staff reported that two committees have been activated to increase the number of jobs available to Scioto youth. Their goal is to create sufficient job positions so that all youth holding a GED or diploma will have access to meaningful vocational opportunities. While employment opportunities are not specifically required by this provision, the effort to minimize the amount of unstructured time these youth experience throughout the school day is certainly relevant to the State’s efforts to comply with the requirements of this provision.

The Strength Based Behavior Management System (SBBMS) continues to experience the typical growing pains that accompany the implementation of behavior management programs. In my last report, I noted that the majority of the program appeared to have been properly implemented, but that the facility

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was struggling to ensure that staff completed the Character Coupons that serve as intermediate reinforcers of positive behavior. The self‐assessment information indicated that the implementation difficulties are located primarily in the Reception units, where the SBBMS program was most recently implemented. In addition to having less experience with this system, staff on these units are also not as program oriented as staff on the long‐term units. An individual from DYS’ headquarters is in the process of developing a training to increase staff skill in using the Character Coupons. The oversight (i.e., review of Character Coupon distribution in the weekly meetings) and on‐going training provided to support the full implementation are both essential to this task.

Problems with the SBBMS on the Reception units were echoed in the interviews conducted by my colleagues on site (see DOJ’s letter dated March 11, 2011, page 6). In addition to complaints about the lack of available programs, youth on the Reception units felt that the SBBMS was of limited value given the restricted range of incentives available to them. Youth complained that the only options available were an extra envelope for writing letters, the use of a board game, or a later bed time, and that these options were not particularly compelling. Further, their descriptions of the use of intermediate sanctions (e.g., early bed time (EBT), writing assignments) are of concern. Youth indicated that some staff imposed EBT as group punishment in response to a small group of youth acting out and that EBT was sometimes excessive (was imposed during the late afternoon or early evening). Other youth reported that they were required to given assignments to copy parts of the dictionary or to write and rewrite a set of rules. These assignments often took hours to complete and were judged to have no value. Although it is appropriate for staff to impose sanctions for minor misconduct, they should be encouraged to impose assignments that have some connection to the behavior itself (e.g., an apology letter to a staff the youth treated disrespectfully; an essay about why proper line movement is important; etc.). Assignments that simply consume time without any substantive message are not effective behavior management tools. Given these concerns, and those related to the newness of the SBBMS in the Reception units, it is recommended that the facility undertake an inquiry into the way in which intermediate sanctions are imposed to ensure that they are fairly and consistently implemented by staff, and to ensure that they are both relevant and proportional to the youth’s misconduct.

Steps Taken to Assess Compliance

As discussed in my previous report, this provision requires the State to provide access to programming required for parole eligibility. To investigate this issue, I reviewed the ReEntry Plans and case notes for 20 youth who were housed at Scioto during my last visit. Most of the parole requirements were generic and were fulfilled by programs that all youth now have access to at Scioto: following rules and developing social skills and decision making skills (via the SBBMS); attending school (youth attend school); and identifying pro‐social leisure time activities (youth have access to recreation and a variety of other programs). While there may be improvements to be made in each area to solidify these opportunities, for the most part, these programs target the issues of concern to the Release Authority. Other parole requirements pertained to treatment‐

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Recommendations
Sources of Information

related issues and are addressed by Dr. Glindmeyer’s review of the mental health program at Scioto.
To reach substantial compliance with this provision, the State should: 1. Ensure adequate programming opportunities are available to all youth at the facility, particularly those on the Reception units. 2. Fully implement the SBBMS across all units, particularly the use of Character Coupons. 3. Examine the imposition of intermediate sanctions by staff to ensure they are both relevant and proportional to the type of misconduct exhibited by youth.
 Self‐Assessment materials for Provision F.1, prepared at my request  Follow‐up telephone conversations with the facility administrator who
oversees programming  Consultation with DOJ Attorneys and Dr. Daphne Glindmeyer

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III.F.2 Orientation. (a) Admissions Intake and Orientation. The State shall develop and implement policies, procedures and practices to establish a consistent, orderly admissions intake system, conducive to gathering necessary information about youth, disseminating information to staff providing services and care for youth, and maintaining youth safety. The orientation shall also clearly set forth the rules youth must follow at the facility, explain how to access medical and mental health care and the grievance system, and provide other information pertinent to the youth’s participation in the facility’s programs. (b) Notice to Youth of Facility Rules and Incentives/Consequences for Compliance. The State shall explain the structured programming to all youth during an orientation session that shall set forth the facility rules, the positive incentives for compliance and good behavior and the sanctions for rule violations. The State shall provide the facility rules in writing. (c) Introductory Handbook, Orientation and Reporting Abuse. Each youth entering the facilities shall be given an orientation that shall include simple directions for reporting abuse and assuring youth of his/her right to be protected from retaliation for reporting allegations of abuse.

Self Assessment

The facility audited intake files for youth admitted in November and December
2010 and January 2011. Ten percent of the youth admitted during this time
period were included in the sample (n=21 youth). The audit found that 100% of
these youth received a complete orientation to the facility, which included,
among other things:  Youth Handbook  Orientation Video  Facility rules and consequences (IRAV)  Obtaining legal assistance  Sexual abuse and sexual assault information  Grievance system

The Youth Handbook was updated again in October 2010 to provide accurate information to youth about security classification procedures and unit descriptions, IRAV, and SBBMS. That the handbook is keeping pace with most of the changes to Scioto’s programming is very positive.

However, as noted in the DOJ’s previous compliance report, the Handbook does not adequately describe the youth’s rights related to practicing their religion of choice, particularly how they may seek accommodations for religious beliefs, practices or observance as described SOP #507.02.06.

Steps Taken to Assess As discussed in the Introduction to this report, I did not conduct any on‐site

Compliance

inquiries.

Recommendations

The facility’s orientation process appears to meet the requirements of this provision.

Sources of Information

 Self‐Assessment materials for Provision F.2, prepared at my request

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0.45 0.4
0.35 0.3
0.25 0.2 0.17
0.15

Chart 1. Rate of Youth on Youth Violence, Feb 2010‐Jan 2011
0.41 0.4 0.36 0.31 0.31 0.31
0.3

0.18 0.17

0.24 0.22

Rate Y Violence

0.1

0.05

0

Feb 10 Mar 10 Apr 10 May 10 Jun 10
Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11

USDOJ v The State of Ohio

Protection From Harm Compliance Report 22.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-2 Filed: 05/09/11 Page: 24 of 24 PAGEID #: 1678

Chart 2. Rate of Physical and Mechanical Restraint, Feb 2010‐Jan 2011
0.9 0.84
0.8

0.7 0.64
0.6 0.6

0.5 0.5

0.4

0.4

0.4

0.3

0.53

0.5

0.48

0.48

0.44

0.4

PR

MR

0.2

0.2

0.2

0.16

0.16

0.17

0.18

0.14 0.12

0.13

0.1

0.09

0.1

0.08

0

Feb Mar Apr May Jun
Jul Aug Sep Oct Nov Dec Jan

USDOJ v The State of Ohio

Protection From Harm Compliance Report 23.

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 1 of 16 PAGEID #: 1679
Attachment B

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U.S. Department of Justice v. The State of Ohio Civil Action No: 2:08‐cv‐475
2nd Special Education Compliance Report
Kelly Dedel, Ph.D. One in 37 Research, Inc. 1608 NW Riverscape Street Portland, OR 97209 (503) 799‐0915 www.onein37.com Draft Submitted March 1, 2011 Final Submitted March 29, 2011
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Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 3 of 16 PAGEID #: 1681
On June 4, 2008, The United States Department of Justice (DOJ) and the State of Ohio (the State) signed a stipulation for injunctive relief (the Stipulation) concerning conditions at the Scioto Juvenile Correctional Facility (Scioto) and the Marion Juvenile Correctional Facility (Marion). The Stipulation adopted the same monitoring team used in a concurrent suit, S.H. et al., v. Tom Stickrath (S.H.), led by Fred Cohen, Esq. This team was charged with monitoring the extent to which the State had effectively implemented the reforms required by the Stipulation and providing detailed reports to the Parties. Since the Stipulation was signed, the State closed the Marion facility.
In late 2009, Mr. Cohen announced his intention to resign his position as the Monitor for the Stipulation, while continuing his duties as the lead monitor in S.H. On November 23, 2009, the Parties amended the Stipulation to assigning monitoring duties for Scioto to the DOJ. Both Parties agreed that I, Dr. Kelly Dedel, would serve as the DOJ’s expert for protection from harm and special education issues.
This is my 2nd report on the special education program at Scioto. The DOJ opted for my assessment to be conducted remotely, and thus, while the State provided a large volume of useful information, I was limited in the extent to which I could verify the State’s data or delve further into certain issues. This report draws on the State’s self‐assessment materials submitted in late February 2011 and a series of follow‐up telephone calls and emails with various Scioto and DYS staff. For the sake of brevity, I have not reiterated information from previous reports that testified to the State’s compliance with each provision (e.g., discussions of policy and procedure; data analysis from previous monitoring periods; etc.). The reader is encouraged to read my 1st Compliance Report for a complete discussion of these issues.
In March, 2011, the Ohio Legislature indicated its intention to close the Ohio River Valley (ORV) facility. The closure of this facility and the subsequent transfer of youth to other facilities in the State will have a significant impact on Scioto’s ability to sustain its progress in making the required reforms. The transfer of youth must be carefully planned and managed so that the negative outcomes experienced during the closure of other DYS facilities may be avoided. The State is encouraged to share its plans for the transfer of youth to Scioto and how its previous experiences with facility closures will inform the upcoming reassignment of youth and redeployment of staff.
Section V.H of the Stipulation requires the Monitor/expert to provide the Parties with reports “describing the steps taken by the State to implement [the] Stipulation and to evaluate the extent to which the State has complied with each substantive provision of the Stipulation.” This is my second report on the 11 provisions related to the special education program at Scioto. The DOJ opted for my assessment to be conducted remotely, and thus, while the State provided a large volume of useful information, I was limited in the extent to which I could verify the data presented by the State or further delve into key issues. This report draws on the State’s self‐assessment materials submitted in late February 2011 and a series of follow‐up telephone calls to various DYS and Scioto staff. For the sake of brevity, I have not reiterated information from previous reports that testified to the State’s compliance with each provision (e.g., discussions of policy and procedure; analysis from previous monitoring periods, etc.). While I attempted to verify sustained compliance in areas which were found to be in good order during my last review, the most substantive discussions here are reserved for those areas in which I still have concerns.
This report describes the status of the facility with regard to the reforms required by the Stipulation. For each provision, the full text is provided, along with a detailed discussion of the State’s compliance as required by the Stipulation. The specific language from the Stipulation is presented in italics below, along with my interpretation of it.
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Case: 2:08-cv-00475-ALM-MRA Doc #: 79-3 Filed: 05/09/11 Page: 4 of 16 PAGEID #: 1682
 “The self‐assessment steps the facility undertook to assess compliance and the results thereof.” In response to a detailed document request I crafted to focus on specific performance measures for each provision, the State presented a large volume of information and data to demonstrate its progress in meeting the requirements of the Stipulation to date. This information is summarized.
 “[My own] steps taken to assess compliance.” Because I did not travel to Scioto, I did not take any independent actions to assess compliance, other than to ask clarifying questions about the State’s self‐assessment or to analyze the data contained in it.
 “Recommendations for facilitating or sustaining compliance.” These recommendations are generally outcome‐focused so as to reinforce the spirit of the provision itself, but also to permit the State sufficient flexibility to satisfy both this Stipulation and the requirements of S.H. The recommendations in this section are limited to those needed to demonstrate substantial compliance with the provision.
 “Sources of information that form the basis of [my] opinion.” The self‐assessment documents were organized by provision, and are referenced accordingly.
Given that the DOJ has been appointed as the Monitor in this case, I have not offered specific compliance ratings for each of the provisions. Instead, I endeavored to describe the current state of affairs in each area, along with my assessment of the steps needed for the State to meet the requirements of the provision.
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Provision 1. Provision of Special Education. The State shall, at all times, provide all youth confined at the facilities with adequate special education in compliance with the Individuals With Disabilities Education Act (IDEA), 20 U.S.C. § 1400‐1482, and regulations promulgate there under, and this Stipulation.

Self Assessment

One of the main concerns discussed in my 1st compliance report was the extent to which youth in the various forms of disciplinary isolation were permitted access to the education program. In its self‐assessment, the State reported that of the 10 youth who were held in isolation for more than 24 hours (on a school day) in November and December 2010 and January 2011, only one of them (10%) received access to instruction or educational materials. In a follow‐up conference call, the State reported that the other nine youth were in isolation for less than 10 days, and by ODYS policy, the State was not required to provide education services. The Court ruled on this matter in late March, 2011, requiring the State to develop policies and procedures for Alternative Education Opportunities (AEO) for youth in seclusion. While the details still need to be fleshed out, in general, the State is now required to provide education services to youth as soon as possible after the onset of seclusion (rather than the 10‐day threshold in use since June 2010). The AEO procedures flowing from the Court’s order and the implementation of those procedures require continued monitoring under the Stipulation to ensure the requirements of this provision are met.

The second concern addressed in my previous report was the extent to which teachers were skilled in behavior management techniques that could prevent excessive or unnecessary exclusions from the classroom. Since the previous compliance tour, Dr. Yurick, a DYS consultant, held two training sessions on the use of the Strength Based Behavior Management System (SBBMS) in the classroom. My review of documents suggested the training curriculum was high quality and that most of the Scioto education staff attended. Education administrators reported that teachers have begun to use the Character Coupons more consistently. Further, administrators’ reported that their classroom observations and reviews of lesson plans suggested that teachers were better engaging students throughout the class periods. The State also provided data on the use of its in‐school suspension program, the ABC Room. Over a three month period, 61 girls were sent to the ABC room and 90% of them were de‐escalated sufficiently to return to school during the following class period. Among the boys, 296 were sent to the ABC room and 91% returned to class. Thus, it appears that the teachers at Scioto are utilizing the variety of skills needed to manage student behavior constructively and to maximize the students’ engagement in the education program.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations

To meet the requirements of this provision, it is suggested that the State: 1. Provide regular, dependable access to class assignments and instruction by certified teachers to youth in the various forms of disciplinary isolation. 2. Reach substantial compliance with the remaining provisions in the special education section of the Stipulation.

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Evidentiary Basis

 Self‐Assessment materials for Provision 1, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and
Scioto Assistant Principal.  S.H. Order #249, filed March 28, 2011

Provision 2. Oversight. The State shall provide adequate oversight of special education at the facilities.

Self Assessment

Over the past three months, the Special Education Director reviewed a total of 19 special education files and provided guidance on formulating measurable annual goals and clarifying the types of services to be provided so that the documents were internally consistent. Further, the Director regularly communicated with Scioto education staff by telephone and email and held individual and group sessions with special education teachers on these same topics. Statewide meetings were held with the facility Special Education Administrators and the Special Education Secretaries.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

The oversight provided by the DYS Director of Special Education appears to meet the requirements of this provision.
 Self‐Assessment materials for Provision 2, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

5.

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Provision 3. Special Education Upon Intake. The State shall ensure that all students who qualify for special education services receive such services within a reasonable time following intake at the facilities.

Self Assessment

The State reported that all 215 students (100%) admitted to Scioto over the past three months received an education intake interview, records request, education program plan, and educational screening within 72 hours of their admission. The purpose of these activities is to ascertain the student’s performance level, appropriate grade placement and special education status. All students (100%) were enrolled in school on the 4th school day following their admission.

Of the 13 girls admitted over the past three months, three (23%) were identified as special education students upon entry. Of the 202 boys admitted, 83 (41%) were identified as special education students upon entry. The students’ schedules were constructed using the most recent data available at the time of admission. Once records from previous schools were collected, adjustments were made as necessary to ensure compatibility with the IEP. Given Scioto’s function as a reception center, the schedule construction process appears to be reasonable. With the planned closing of ORV, Scioto will likely receive additional students in its long‐term programs. Schedule development for these students is generally more straightforward, because the record retrieval and assessment processes are complete for these students. Further, the proportion of students who are identified as special education students reflects contemporary research that estimates that between 20 and 60 percent of incarcerated youth are eligible for special education.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

The State’s procedures and practices appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 3, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

6.

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Provision 4. Parent or Guardian Involvement. The State shall develop and implement policies, procedures and practices to appropriately notify and involve parents or guardians in the provision of special education services, whenever possible.

Self Assessment

The State reported that parent packets were mailed in a timely manner for two of the three special education students admitted to Scioto’s long‐term programs over the last three months. The other student was not initially identified as a special education student because of a data entry error, resulting in a delay in initiating the surrogate parent procedures needed for this youth. This is not a systemic problem. Parents regularly attend IEP meetings, usually by teleconference.

The State reported low rates of compliance across the last three IEP progress reporting periods. These concerns are addressed in Provision 7, Individual Education Plans.

Given the State’s track record of regularly informing parents of the steps to be taken to update their children’s IEPs and providing multiple opportunities for their participation, the procedures and practices in this area appear to conform to the requirements of this provision.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

The State’s procedures and practices appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 4, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

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Provision 5. Staffing. The State shall develop and implement an education staffing plan to ensure adequate staff to comply with the terms of this Stipulation.

Self Assessment

The staffing plan remains unchanged from my previous report and appears to be adequate to meet the needs of both short‐ and long‐term students at Scioto. If the facility receives a significant number of students as a result of ORV’s closure, the State will need to revisit its staffing plan, using a similar methodology as that used to create the original one.

As discussed in my previous report, there were two key vacancies in the education staff: a Transition Skills teacher and a Speech Language Pathologist (SLP). While the Transition Skills teacher has not yet been hired at the time of my teleconference in mid‐February 2011, Scioto administrators reported that final approvals had been received to hire the individual identified for this position, and should be imminent. After multiple unsuccessful efforts to attract a qualified SLP, DYS decided to provide these services via a contractor who provides SLP services at another DYS facility. The contract for these services has reportedly been signed and approved. For the past three months, Scioto has not housed any students requiring SLP services as part of their IEPs, and thus it is highly unlikely that the vacancy has negatively impacted the State’s ability to comply with the requirements of the Stipulation.

In January 2011, one of the facility’s English teachers resigned. Efforts to recruit for this position have begun. Students originally scheduled into this teacher’s class have been rescheduled into other English sessions. The small class sizes at Scioto allow for this redistribution without compromising the quality of services provided to students.

As stated in my previous report, all facilities experience some level of teacher turnover. At Scioto, turnover does not appear to be excessive and efforts to fill vacant positions are clear. The fact that Scioto has two Transition Skills teaching positions, one of which has been filled consistently throughout the past year, limits the negative impact of the one persistent vacancy. Nevertheless, given Scioto’s current number of students, and potential increase in number of student’s with ORV’s closure, the State is encouraged to fill this vacancy as soon as possible.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

The State’s staffing plan and its efforts to staff the facility accordingly appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 5, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

8.

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Provision 6. Screening for Special Education Needs. (a) The State shall provide prompt and adequate screening of youth for special education needs and shall identify youth who, upon admission to the Ohio Department of Youth Services, were receiving special education in their home school districts or who may be eligible to receive special education services but have not been so identified in the past. (b) The State shall ensure that those staff conducting the screening, assessment and evaluation processes are qualified to do so.

Self Assessment

A total of 215 students were admitted to Scioto over the past three months. Via the intake process described in Provision 3, above, 86 students (40%) were identified as special education students. Among the remaining regular education students, 96 students’ (85%) intake records revealed discrepancies between the students’ level of performance and grade levels. Because students are tested so quickly upon admission (when they may be anxious, disengaged or otherwise not performing at their best), the test scores often underestimate students’ true abilities. During the first few weeks the student is in class, teachers begin to implement various interventions in their own classrooms to better understand any performance deficits and to identify ways to address them. If the academic troubles are confirmed and the teacher cannot identify ways to address them, he or she may be referred to the IAT (Intervention Assistance Team). Two students were referred to the IAT in the past three months. One student was tested but determined not to be eligible for special education; he receives on‐going IAT support. The other student was transferred to another DYS facility, along with his IAT records.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

The State’s intake practices and IAT resources appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 6, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

9.

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Provision 7. Individual Education Plans. (a) The State shall develop and IEP as defined in 34 C.F.R. §300.320 for each youth who qualifies for an IEP. Following development of the IEP, the State shall implement the IEP as soon as possible. As part of satisfying this requirement, the State shall conduct required annual reviews of IEPs, adequately document the provision of special education services, and comply with requirements regarding participation by the professional staff, parents and student in the IEP process. The State shall, if necessary, develop, review or revise IEPs for qualified special education students. (b)In developing or modifying the IEP, the State shall ensure that: the IEP reflects the individualized educational needs of the youth and that services are provided accordingly; each IEP includes documentation of the team’s consideration of the youth’s need for related services and transition planning, and identifies the party responsible for providing such transition services; the student’s educational progress is monitored; teachers are trained on how to monitor progress toward IEP goals and objectives; and teachers understand and use functional behavioral assessment and behavior intervention programs in IEP planning and implementation.

Self Assessment

A total of 72 special education students were admitted to Scioto between November 2010 and February 2011. To date, only three of these were admitted to one of Scioto’s long‐term programs (others may ultimately be housed at Scioto, but their admissions were too recent to know as of the writing of this report). All three students’ eligibility documents (e.g. the Evaluation Team Report, ETR) were updated if needed and their IEPs were adopted, revised or updated in a timely manner.

Of the 11 long‐term Scioto students whose IEPs were updated in the past three months, all IEP meetings (100%) included the required participants. Although about 40% of the IEPs required some level of correction to ensure compliance with recently updated State guidelines, all but one or two were judged to be at least minimally compliant when reviewed by either the Special Education Director or Scioto Administrator. Historical problems with the articulation of clear, measurable IEP goals have persisted, but the facility’s process for reviewing draft IEP language before the IEP meeting ensures that well‐articulated goals are formalized at the IEP meeting.

The 23 special education students who were housed at Scioto on January 21, 2011 were served in a variety of ways—consultation between special and regular education teachers; provided with special education services while in the regular classroom; or provided with special education services within a special education classroom. Ten of the students received related services from an Occupational Therapist. Taken together, it appears that Scioto has the resources and flexibility to meet the diversity of students’ special education needs.

As discussed in Provision 4, above, the level of compliance with sending reports of students’ progress in meeting IEP goals to parents is not what it should be. The State reported compliance rates of only 22% in July 2010; 30% in October 2010; and 9% in January 2011. While teachers’ failure to place a copy of the mailed progress report in the students’ files may make the problem appear worse than it is, the large proportion of files that were not in compliance is of great concern. This finding triggered two corrective actions by DYS: 1) to require all progress

10.

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reports to be scanned into OPTIX, thereby eliminating the need for a paper copy to be placed in the file; 2) to require all teachers to submit drafts of student progress reports to Scioto’s Special Education Administrator in advance of the due date, who reviews them to ensure that the reports are completed and to assure that they include specific indicators of student progress (i.e., not simply “student making adequate progress”). Progress reports are due again in late March and late June 2011—hopefully these measures will result in higher rates of compliance.

The overall objective for crafting IEPs, articulating measurable goals and periodically measuring improvement is to ensure that students actually acquire the skills they need to make academic progress. The progress reports thus provide some measure of how well a given facility is accomplishing that objective. Success in meeting IEP goals was assessed for a sample of 10 students who had been housed at Scioto for at least 1 year (the term of an IEP) and whose IEPs had been written at Scioto or another DYS facility (to ensure consistent quality). Most of these students had multiple IEP goals. Across the 26 total goals, only 45% were rated as “met” during the students’ annual reviews. Given these results, it is suggested that Scioto review these 10 students in more depth to determine why they were unable to achieve the goals set out for them (i.e., something about the way the goal was written? Something about the type of instruction provided? An inability to engage the student in the program?). Only with this type of critical analysis can the overall quality of the education program at Scioto be improved.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

In order to meet the requirements of this provision, it is suggested that the State: 1. Increase teachers’ skills and compliance in monitoring and reporting student progress to ensure the extent to which the IEP actually resulted in improved student outcomes can be assessed.
 Self‐Assessment materials for Provision 4 and 7, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

11.

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Provision 8. Vocational Education. The State shall provide appropriate vocational services that are required transition services for disabled youth under the IDEA.

Self Assessment

The vocational services available to students at Scioto continue to be limited to a single career technology class, Administrative Office Technology (AOT). This course includes instruction in the Microsoft Office programs and is available to both girls and long‐term male residents who may earn of a certificate of course completion. On January 31, 2011, 16% of the long‐term boys were enrolled in AOT, along with 22% of the girls. Given that Scioto is likely to be many students’ final secondary school placement, providing access to a broader range of vocational options for students is essential.

The State’s proposal to bring short‐term vocational options to Scioto discussed in my previous report has been withdrawn due to personnel and logistical barriers. Instead, the DYS Superintendent proposes dividing the AOT program into specific modules so that certificates in each program can be earned; adding work‐study opportunities; and introducing job skills into certain academic classes. The specific opportunities and projected capacity for these programs is unknown at this time.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

In order to meet the requirements of this provision, it is suggested that the State: 1. Develop additional vocational opportunities for students that are realistic based on the short lengths of stay for most students and the employment opportunities likely to be available in their local communities.
 Self‐Assessment materials for Provision 8, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

12.

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Provision 9. Forwarding Screening and Assessment Information Upon Transfer. The State shall ensure that, when a youth is discharged from the facilities before the interventions required in Section III.E.6 above are complete, the facilities shall forward to the superintendent of the youth’s receiving school district all information regarding screening and evaluations completed to date, noting what evaluations are yet to be performed.

Self Assessment

The State reported that over the past three months, six students were referred for either initial testing to determine special education eligibility or reevaluations to confirm their continued eligibility but were released from Scioto prior to the testing process being completed. In all cases, the State reported their records were forwarded to the students’ receiving school districts.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

The State’s procedures and practices appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 9, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

13.

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Provision 10. Training and Quality Assurance. The State shall design and implement adequate annual training requirements for special education staff.

Self Assessment

The State provided data on the education staff’s attendance at various professional development sessions throughout 2010. Of the 31 total education staff, 30 (97%) received at least 15 days of professional development in the past year. Further, coaching by the DYS Special Education Director and Scioto Special Education Administrator provided additional skill‐building opportunities for teachers in IEP development and monitoring student progress.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

The State’s practices with regard to professional development appear to meet the requirements of this provision.
 Self‐Assessment materials for Provision 10, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

14.

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Provision 11. Transition Services. The State shall comply with any IDEA requirements for providing transition assistance. The State shall provide transition assistance to students by providing counseling and concrete information regarding appropriate community resources and how to pursue post‐ secondary options, re‐enroll in school or complete the GED.

Self Assessment

On January 31, 2011, 44 of Scioto’s 95 boys (46%) were participating in the Transition Skills program. Filling the second Transition Skills position (as discussed in Provision 5, above) will allow Scioto to enroll students in all of Scioto’s programs in this important transition course.

Over the past three months, 13 youth were released from Scioto’s long‐term programs. Of these, the State reported that the Transition Coordinator worked with 12 of them (92%). For some students, the Transition Coordinator facilitates re‐ enrollment in school upon release, while for other students, linkages are made with community resources that can facilitate job placement.

Discussion

As discussed in the Introduction to this report, I did not conduct any on‐site inquiries.

Recommendations Evidentiary Basis

In order to fully meet the requirements of this provision, it is suggested that the State:
1. Fill the vacant Transition Skills instructor position to ensure all students have access to this service.
 Self‐Assessment materials for Provision 11, prepared at my request  Follow‐up consultation via teleconference with DYS Superintendent,
Assistant Superintendent, Special Education Director, Scioto Principal, and Scioto Assistant Principal.

15.

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Attachment C

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 2 of 49 PAGEID #: 1696
United States of America v. The State of Ohio Case No. 2:08-cv-475
Review of the Scioto Juvenile Correctional Center Mental Health Services
Dr. Daphne Glindmeyer April 13, 2011

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-4 Filed: 05/09/11 Page: 3 of 49 PAGEID #: 1697
Dr. Daphne Glindmeyer is a board-certified psychiatrist with more than 14 years of experience treating youth and adults in correctional settings. She received her Medical Degree from the Louisiana State University Health Services Center in New Orleans and is board-certified as an adult psychiatrist, forensic psychiatrist and child and adolescent psychiatrist. Her clinical background includes extensive work with juvenile offenders. This includes her work as a clinical psychiatrist at the Bridge City Center for Youth, a secure juvenile facility in Louisiana, and past work with the Louisiana State University Health Sciences Center Juvenile Corrections Program, where she served as the Director of Psychiatry and the Director of Clinical Operations, and with the Jefferson Parish Juvenile Drug Court Program, where she served as the Medical Director. She has also provided compliance monitoring regarding mental health and rehabilitative services for several jurisdictions — including monitoring in Mississippi regarding its secure juvenile correctional facilities, in Los Angeles County regarding its secure juvenile correctional facilities, in Texas regarding five developmental centers in the state, and in Indiana regarding the South Bend Juvenile Correctional Center. Dr. Glindmeyer is a fellow of the American Psychiatric Association, the current president of the Louisiana Council of Child and Adolescent Psychiatry, and a past president of the Louisiana Psychiatric Medical Association.
1

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1. Discussion

Mental Health Screening: The State shall develop and implement policies, procedures, and practices to ensure that all youth admitted to the Facilities are comprehensively screened for mental disorders, including substance abuse, depression, and serious mental illness, within twenty-four hours of admission. This screening shall be performed by qualified personnel, aspart of the intake process, consistent with generally accepted professional standards of care.
Per facility policy and procedure entitled, “Mental Health Screenings”, a mental health screening is to be performed within 24 hours of admission by mental health trained or qualified mental health personnel to assess presence of current suicidal ideation, history of self injurious behavior, current prescription of psychotropic medication, current mental health issues, current treatment for mental health diagnoses, history of any type of mental health treatment and history of substance abuse.

Recommendations

Review of youth records available for off site review revealed variability in the documentation created as a result of the intake assessment process. This was an issue that will be discussed in several ensuing provisions. Per the facility verbal self-assessment, there were plans for a new Behavioral Health Appraisal document. This had not been implemented at the time of the tour, but was planned for testing the week following the tour, with plans to fully implement the format as of 3.15.11. It was reported by administrative staff that this document would provide improved case conceptualization and diagnostic clarification with recommendations for treatment. A review of documentation generated as a result of the full implementation of policy and procedure governing this entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation” will be requested in future record review.
. Full implementation of policy and procedure “Behavioral Health Assessment, Screening, Appraisal and Evaluation.”
. Begin quality assurance monitoring or clinical supervision regarding the reception assessment summary documents.

Evidentiary Basis

. Review of provided documents (e.g. policy and procedure, draft policy and procedure, youth records).
. Staff interview

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2. Discussion

Immediate Referral to a Qualified Mental Health Professional: If the mental health screen identifies an issue that places the youth’s safety at immediate risk, the youth shall be immediately referred to a qualified mental health professional for assessment, treatment, and any other appropriate action, such as transfer to another, more appropriate setting. The State shall ensure that, absent extraordinary circumstances, qualified mental health professionals are available for consultation within 12 hours of such referrals.
Per the facility verbal self-assessment and a review of policy and procedure, the Policy and Procedure entitled, “Referrals to Mental Health Services” delineates the referral process for youth to access mental health services, stating, “referral can take place in reception or on a programming unit, and is made via the psychology supervisor. When a youth has expressed suicidal or self-injurious thoughts, intent or plans, or when a unit staff member develops concerns for a youth’s functioning on the unit, referral for an assessment can be immediate by phone with the psychology staff assigned to the relevant living unit or by email... In the event that psychology staff are not available on grounds, Operations staff are notified and they call the psychology supervisor by phone and discuss the concerns.” Per staff interview, the psychology supervisor is on continuous call. A review of the psychology staff schedule revealed that psychology staff are assigned both evening and weekend hours to provide youth access to services. The extended hours allowed youth increased opportunities to access mental health staff, and were a positive finding during the tour.
Per discussion with facility administrative staff and a review of Ohio Rev. Code Sec. 4757.02(A)(5), civil servants in Ohio are exempted in that they do not have to have licensure to perform as a social worker, thus unlicensed staff would qualify as a QMHP in this system. The designation of unlicensed staff as a Q MRP was a novel situation for me, and bears consideration. The use of unlicensed staff is not consistent with generally accepted practices. R egardless, utilizing the current staffing model and QMRP designations, when combined for both disciplines, social work and psychology, there would be a QMRP on c ampus from 8 a m to 8 pm Monday through Friday, and from 9 am to 5 pm on weekends.
Review of provided documentation regarding the referral and ultimate assessment of a youth by mental health staff revealed that with regard to capacity assessments, 26 youth were assessed between 11.11.10 a nd 2.11.11. Of these all were done one the same date as the request except one, where the request was made 11.30.10 a nd the assessment was
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completed 12.2.10. There was documentation of four youth mental health requests (made per the youth themselves), all seen within four hours of request. There were 32 youth referred for risk assessment at intake, all documented as having been seen on the day of request, however, the time of the request and assessment was not noted, so it was not possible to determine if this was performed within the four hour time requirement.
These statistics do not take into account referrals for mental health intervention that are performed at the request of facility mental health staff. As stated during the facility verbal self-assessment, youth were not documented as making frequent requests for mental health services in writing. T herefore, the numbers of requests per other staff members, at the direction of the youth would be informative.
For all the examples above, actual referral documents were not included in the records, so it w as impossible to determine the elapsed time between the request for services and response to the request. Q uality assurance monitoring regarding the time elapsed would be useful to ensure that emergent and routine requests were addressed in a time period consistent with that outlined in policy and procedure. Additional concerns regarding the youth’s ability to independently access mental health services are included in the discussion regarding paragraph 9.

Recommendations

. Continue quality assurance monitoring regarding the elapsed time between requests for and provision of services.
. Monitor response to requests for mental health assessment made by staff members.

Evidentiary Basis

. Review of provided documents (policy and procedure, youth records, psychology staff schedules)
. Review of Ohio state statute . Staff interview

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3. Discussion

Identification of Previously Unidentified Youth with Mental Disorders: The Facilities shall implement policies, procedures, and practices consistent with generally accepted professional standards of care to identify and address potential manifestations of mental or behavioral disorder in youth who have not been previously identified as presenting mental health or behavioral needs requiring treatment.
Per the facility verbal self assessment, the Behavioral Health Review Panel designated in policy and procedure entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation” had begun to review assessments performed on Tuesdays, with plans to expand to a review of all intake assessments by 4.1.11.
Facility staff did report an example of a youth, who was admitted to general population, experienced a mental health decompensation and was referred to the mental health unit. R eview of the available records for youth 330 r evealed that on i ntake 5.21.10, di agnoses were assigned including: Bipolar Mood disorder, not otherwise specified; Conduct Disorder; Consider sexual abuse of a child-victim; Rule Out mood disorder secondary to a general medical condition; consider Posttraumatic Stress Disorder. T his youth reported a history of self-injurious behavior via cutting and burning herself. There “is also a report in the file that the youth made a suicide attempt in January 2010, although the youth denies it.” The mental status examination upon i ntake documented, “mood appears depressed…affect appears flat…being prescribed Risperdal.” The youth was initially placed on obs ervation status “to monitor adjustment” for one week, with no reported difficulties. The youth was recommended for placement in general population, however, she was maintained on the mental health caseload. The youth began to experience increased mental health symptoms 9.24.10 and a risk assessment was performed. A s a result, the youth was placed on obs ervation status. T he next documentation available for review was a risk assessment update dated 9.29.10. It was challenging to follow the trajectory of this youth’s mental health treatment, as there were multiple (approximately ten) late entry notes in the record all of which had an entry date of 11.1.10. T his late documentation would make it impossible for staff to follow a youth’s mental health treatment over time.
The goal of this provision was to ensure that youth who may not present with a history of mental illness and who are not identified at the time of initial assessment as being at risk for mental illness or behavioral challenges, are monitored over the course of their incarceration for exacerbations of symptoms and referred for mental health treatment.
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Administrative staff were aware of the need for ongoing and improved quality assurance to review documentation and the decision making process regarding youth mental health needs. As discussed in provision 4 below, multiple assessment documents were being generated, however, there was no case formulation to tie all the information obtained together in a c oherent package for the reader. This is an area that would be amenable to quality assurance, peer review process and clinical supervision.

Recommendations

. Complete implementation of draft policy entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation.”
. Quality assurance monitoring regarding re-evaluation of youth who experience an exacerbation of mental health symptoms or behavioral challenges.
. Ensure that youth mental health documentation is done regularly, as late documentation does not have the richness of that performed immediately following a mental health contact.
. Ensure the creation of a case conceptualization for each youth.

Evidentiary Basis

. Review of provided documents (e.g. Policy and Procedure, draft Policy and Procedure, youth records).
. Staff interview

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4. Discussion

Mental Health Assessment: The State shall implement policies, procedures, and practices to ensure that, as part of an overall assessment of the youth’s health, risks, strengths and needs, youth who are identified in screening as having possible mental health needs receive timely, comprehensive, and accurate assessments by qualified mental health professionals, consistent with generally accepted professional standards of care. Assessments shall be designed and implemented so as to identify youth with mental disorders in need of specific treatment and contribute to a full plan for managing the youth’s risk. A ssessments shall be updated as additional diagnostic and treatment information becomes available.
The policy provided “Behavioral Health Assessment, Screening, Appraisal and Evaluation” was partially implemented 1.1.11. Additional portions of this policy pending implementation included the review of all admission documentation for a specific youth via the Behavioral Health Review Panel slated for 3.1.11.
A review of youth records available for off site review revealed reception assessment summaries and mental health appraisals performed at the time of admission. While these documents provided useful information for the determination of placement and initial treatment planning, they were variable in quality. Per the facility verbal self-assessment, “ t here will likely not be a big change in the charts other than increased fidelity to the SOAP note format…and more in depth assessments…you might see youth with diagnostic criteria review and case conceptualization.” Administrative staff revealed that with the implementation of new policy and procedure, some quality assurance measures, specifically peer review, have begun. Documentation of peer review results was not included in the records available for off site review.
A review of the ten most recent admission assessments performed at the facility was limited by the low percentage of these youth having current mental health diagnoses or treatment (all were referred to general population following assessment). With regard to those where a mental health diagnosis was assigned, the inclusion of a statement of specific diagnostic criteria indicating what specific symptoms the youth was experiencing now or in the past that justified the diagnosis was not always included. F or example, documentation regarding youth 220 not ed in the Reception Assessment Summary included a review of a group of symptoms the youth was experiencing, however, the document did not review the signs or symptoms the youth was experiencing that led the examiner to make a specific diagnosis. The only nod to the current diagnosis was “he
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reports a history of ADHD…indicated that he has a problem with alcohol and drugs.” Based on t his documentation, the youth was diagnosed with ADHD; Alcohol Abuse; Conduct Disorder; Cannabis Abuse; Rule Out Polysubstance Dependence; Depressive Disorder, not otherwise specified. Further review of the Reception Screening document, Ohio Youth Assessment Summary, and Psychology Intake Interview did not reveal a diagnostic formulation or case conceptualization. Despite the generation of multiple assessment forms, there was no document to tie all the information obtained together in a coherent package for the reader. This is an area that would be amenable to quality assurance, peer review process and clinical supervision.

Recommendations

. Continue and expand quality assurance measures including a p eer review process and clinical supervision to ensure the development of a case conceptualization that ties together information gleaned in the assessment process.

Evidentiary Basis

. Review of policy and procedure . Review of youth records . Review of other provided documents . Staff interview

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5. Discussion

Adequate Mental Health Care and Treatment: The State shall implement policies, procedures, and practices to ensure that adequate mental health and substance abuse care and treatment services (including timely emergency services), and adequate rehabilitative services are provided to youth in the Facilities by qualified mental health professionals consistent with generally accepted professional standards of care.
Per the previous monitoring tour, the facility implemented the Strengths Based Behavior Management System as of May 2010. The facility was in the process of revamping the mental health treatment program with the intent of implementing the New Freedom Phoenix program as the overarching treatment program for all facility youth. Per the facility verbal self-assessment performed during this monitoring tour, this program was fully functional on one housing unit. S taff from other units have been trained, and it was the facility goal to have implemented this program in all units by April 1, 2011. Additional information regarding the progress of the implementation of this program will be requested in the next monitoring tour. Although the implementation of the New Freedom Phoenix program was not observed during this monitoring tour, a review of the curriculum revealed that the participation and integration of direct care staff is imperative to its success. As stated in other areas of this report, there were concerns regarding the overall integration of direct care staff into the treatment plan for the youth.
With regard to specific mental health treatment, the facility staff have completed the training regarding Trauma and Grief Component Therapy for Adolescents. The first of these groups were held on both the boys and girls mental health units during this monitoring tour 2.23.10. P ortions of both group interactions were observed. In both cases the group leader was effective and youth were engaged in the group process. It was apparent that group leaders had made the effort to review the group material in advance, and to develop strategies that appealed to the youth in an effort to engage them in the discussion of a difficult topic.
It was apparent that mental health staff were making efforts at cofacilitation of certain groups, a topic that was discussed in the previous monitoring report. Per the facility verbal self-assessment, psychology staff was taking the lead with regarding to trauma-based group therapies, while social work staff was taking the lead role with cognitive behavioral therapy (CBT) based group interactions. T he staff were then acting as the cofacilitator for each other’s primary group responsibility. While youth specialists were trained to facilitate CBT based groups, their investment and
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involvement in the group process was questionable. T his issue will be discussed further in provision 7.
A review of the group progress notes in the records available for off site review revealed some improvement in the documentation of group interaction. A review of the records of female youth revealed group notes that were appropriately written in SOAP format. T he difficulty with the notes reviewed was that they were boilerplate, in that for youth attending the group, assessment and planning documentation was identical for several consecutive sessions. Review of the mental health documentation for male youth revealed that the most recent mental health group notes available for off site review were authored in August 2010. T herefore, these were not utilized to formulate an opinion of group therapy documentation.
Per the facility verbal self-assessment, there were performance issues noted with social work and psychology staff with regard to documentation. The administrative staff estimated that three social workers were “not functional” and one psychology staff “lags behind.” A dministrators discussed plans to utilize available remedies with staff including the disciplinary process and performance evaluations in order to address documentation deficiencies.
Review of the youth records available for off site review revealed documentation of individual contact with youth via psychology services. Much of this documentation was in regard to crisis management or the difficulties that the youth was experiencing on that particular day. Review of the documentation did not allow the reader to discern the youth’s progress toward goals purported in the treatment plan, nor did they reference specific targeted interventions proposed in the youth’s treatment plan. Per the facility verbal self-assessment, in the recent months, staff have been diligently working to complete treatment plans for youth in the new integrated format. The administrative staff were aware of the need for youth progress notes to reflect goals specified in the treatment plan and the youths progress (or the lack thereof) toward a specific goal. This type of documentation was not noted in the records available for off site review. It is hoped that with the planned change to an Integrated Treatment Plan that this information will logically flow into the progress notes. Ongoing clinical supervision and quality assurance may be helpful for staff when adjusting to these new documentation requirements.
Given the above, it is apparent that while some treatment is occurring, improvements to the overall treatment program (already planned by the facility) and documentation of treatment provided will be necessary for the
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facility to meet the requirements of this provision. In the upcoming monitoring tour, additional information regarding the facilities mental health treatment program will be requested and reviewed.

Recommendations

. Implement planned mental health programming . Improve documentation of group therapeutic interaction . Improve documentation of individual therapeutic interaction . Ensure the provision of evidence based group therapeutic interactions . Expansion of the group curriculum available for male youth. . Continue the integration of treatment provider disciplines in order to
achieve an interdisciplinary model. . Engage and encourage direct care staff to participate in group modalities
and in the overall treatment program for the youth.

Evidentiary Basis

. Review of provided documents (e.g. group schedule, youth records, policy and procedure, description of treatment modalities)
. Observation of three group interactions . Youth interview . Staff interview

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6. Discussion

Treatment Planning: The State shall develop and implement policies, procedures and practices so that treatment service determinations, including ongoing treatment and discharge planning, are consistently made by an interdisciplinary team through integrated treatment planning and embodied in a single, integrated treatment plan.
Per staff interview and document review, the facility has implemented policy regarding the Interdisciplinary Treatment Team as well as a revised format/process for the documentation of treatment planning, via the creation of the Integrated Treatment Plan. It was reported that the facility adopted these policies 1.1.11, w ith the goal of completing the revised format for all youth as of 3.1.11. F or additional information regarding Treatment Planning, please see the discussion regarding the two following paragraphs (7 and 8).
Staff interviewed for the verbal facility self-assessment indicated the “need for lots of training for staff…especially social work staff…they will need help with the development of the treatment plans with the goal of looking forward to discharge.”

Recommendations

1. Completion of the Integrated Treatment Plan for all youth.
2. Begin Quality Assurance monitoring of the process and documentation included in the Integrated Treatment Plan. T his may include peer review and clinical supervision for those staff members who are new to this type of treatment documentation.

Evidentiary Basis

. Staff interview . Review of provided documents (e.g. Policy and Procedure, Integrated
Treatment Plans)

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7.

Treatment Teams: At a minimum, the interdisciplinary treatment team

for each youth in need of mental/behavioral health and/or substance

abuse treatment should: a. Be guided by a trained treatment

professional who shall provide clinical oversight and ensure the proper

functioning of treatment team meetings;b. Consist of a s table core of

members, including at least the youth, the social worker, a JCO, one of

the youth’s teachers, the Unit Manager, and as warranted by the needs

of the youth, the treating psychiatrist, the treating psychologist,

registered nurse, and, as appropriate, other staff;c. Ensure that needed

psychiatric evaluations are conducted on a youth before administering

psychotropic medications to the youth;d. Monitor as appropriate but at

least monthly, the efficacy and the side effects of psychotropic

medications, including consultation with the facility medical,

counseling, and other staff who are familiar with the youth; e. For

youth under a psychiatrist’s care: ensure the provision of individual

counseling and psychotherapy when needed, in coordination with

facility psychologists; ensure that all youth referred as possibly in need

of psychiatric services are evaluated and treated in a t imely manner;

and provide adequate documentation of treatment in the facility

medical records;f. Include, to the fullest extent practicable, proactive

efforts to obtain the participation of parents or guardians, unless their

participation would be inappropriate for some reason (e.g., the child

has been removed from the parent’s custody), in order to obtain

relevant information, understand family goals and concerns, and foster

ongoing engagement;g. Meet to assess the treatment plan’s efficacy at

least every 30 d ays, and more often as necessary; andh. Document

treatment team meetings and planning in the youth’s mental health

records.

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Discussion

Per a document review performed for the previous monitoring report, the policy and procedure implemented 1.1.11 entitled “Interdisciplinary Team” designated the staff who should be included in the Interdisciplinary Team, “a unit manager, Clinician(s), Provider(s), and staff from Mental Health Services, Psychiatry, Education, Psychology and Recreation. Other participating staff may be included, such as from medical services, religious services or administration.” Per policy, the team will meet regarding each youth “at least monthly” and meetings should include the youth and their parent or guardian.
At the time of the monitoring tour, there were functioning Interdisciplinary Teams (IDT) on t he designated mental health units for both male and female youth. A n IDT meeting was observed during the tour regarding youth 999 and youth 110. The psychiatrist was in attendance for these two meetings, additional team members present included the youth, psychology, occupational therapy, unit director, mental health nurse and the unit psychologist. The youth specialist (direct care staff) attended peripherally. The specialist was stating on the dais above the table where the staffing meeting was held. The specialist appeared to be listening to the conversation; however, telephone calls and other direct care staff coming up to the desk frequently interrupted this. As discussed during the monitoring tour, it will be necessary for the IDT to include the youth specialist as a full-fledged, functioning member of the team.
Interviews performed with the psychiatrist during this tour revealed that due to limited clinical resources, the psychiatric attendance at IDT was limited. A review of the documentation of attendance at IDT meetings during the period of 11.11.10 and 1.13.11 revealed no s ignatures of the psychiatric physician. Interviews with youth revealed variability with regard to this issue. S ome youth indicated that the psychiatrist “he comes to my team sometimes.” O ther youth reported that the psychiatrist had not attended their IDT meetings. Y outh acknowledged participating in their scheduled team meetings, but some youth opined that IDT should be more frequent. One youth reported that in their opinion, the development of treatment goals was rushed, rapid and left until the end of group, “the goals are last minute…and tacked on to the end of the meeting…this place is inconsistent.” This final comment was observed by the consultant, and will be discussed in the ensuing paragraphs.
For the two IDT meetings observed during this tour, staff appeared interested and knowledgeable regarding the youth. T he youth’s specific behavioral challenges as well as the hypothesis for these challenges were discussed. In light of the extensive discussions observed, a decision
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regarding management strategies or documentation of treatment planning interventions would be expected. Unfortunately, the translation of the rich discussion observed in treatment team into an intervention and practice regarding a specific youth was not observed. This was most evident in the IDT regarding youth 110.
Youth 110 ha d reportedly been confined to his room for four days at the time the IDT was observed. A review of the treatment modalities employed for this youth revealed that seclusion was the predominant treatment modality in effect since November 2010. T here were some individualized behavioral plans included in the documents, however, the plans provided nothing with regard to reward for positive behaviors with the target desired behavior per the plan dated 1.15.11 being that the youth would come out of his room.
More recently, the youth was reportedly experiencing increasing psychiatric symptoms including irritability, agitation, mood swings and psychotic thought processes. At the time of admission to the facility, this youth had experienced mental health symptoms inclusive of aggression and agitation. He had responded to treatment with depot neuroleptic medication, in that his symptoms resolved and for the period 7.25.10 t hrough 11.11.10 there were no reported incidents of agitation of aggression, “he was clear, logical, and on task.”
Per staff report and medical record review, this youth began to experience extrapyramidal side effects of the depot medication. Rather than a trial of anticholinergic medication or other medications commonly utilized to ameliorate side effects associated with neuroleptic medications, the medication was discontinued, resulting in the current psychiatric decompensation. It was likely that the lack of psychiatric resources contributed to this pharmacological mishap, as had more resources and attention been available to this youth, alternate modalities may have been trialed. Increased interventions per psychiatry could have included more frequent medication management appointments and psychiatric attendance at this youth’s treatment team meetings.
The youth was reportedly now refusing oral medications, and per report of the IDT, all the youth’s symptoms and treatment refusals were intensified by his inability to tolerate the stimulating environment of the unit, hence, he remained in his room for extended periods of time. Staff were aware that keeping this youth confined to his room was not appropriate, “it only seems to make him more psychotic.” S taff noted that the youth had begun to refuse to leave his room, refuse to bathe, refuse to comply with
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psychotropic medication, and demonstrate increased psychotic symptoms, however, as noted in the discussion above, they were experiencing difficulties with the development of a treatment plan and intervention to address the youth’s difficulties.
Ultimately, with some encouragement, staff were able to devise a workable treatment intervention pending response to a request for involuntary psychotropic medications and consideration for an alternate placement setting. While this was a good start, the IDT challenges with respect to the development of a written plan and training for youth specialists (direct care staff) were obvious, as the consultant observed the youth in his new programming environment 24 hour s after he was relocated with a revised individual behavioral management plan. U nfortunately, direct care staff had no w ritten instructions available to them at that time, and had reportedly not received any training regarding the management of this particularly challenging youth. P er verbal report of facility mental health staff, the goal of the plan was to reduce the level of stimulation the youth was exposed to, while ensuring him two on o ne interaction with staff. While the reduction in stimulation was achieved, without a plan in place 24 hours following the move, the youth was more isolated, as direct care staff were not aware of the planned interaction.
Documentation regarding IDT meetings was provided per the document request. T he documentation included meeting sign in sheets and meeting minutes. A review of the sign in sheets did not reveal any signatures of psychiatry indicating no documentation of psychiatry attendance.
The meeting minutes included general information regarding the unit and scheduling of activities as well as a listing of youth who were scheduled for a “progress review.” The quality of documentation was variable between the units. S ome units documented discussion regarding the youth goals, while others had briefer documentation. T he better documentation was noted in for those teams functioning on designated mental health treatment units. There was documentation located that indicated the IDT awareness of a need for improvement in collaboration and team functioning. Examples gleaned from a review of the IDT minutes are as follows:
11.9.10 – “staff need to watch talking in front of youth.” 11.23.10 - “still concerns that psychiatry not consulting with treatment team about youth meds.” 12.14.10 – “units have ‘heavily used the consequence of no f ree time’…early to bed is also being used too often”
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1.25.11 – “get the train back on track with the absence of the unit manager and irregular staff.”
Issues with team functioning were observed during the monitoring tour and discussed with facility staff. The challenges were multifactorial. Examples outlined in the discussion above, specifically the lack of integration of direct care staff in the IDT was apparent not only in the observation of IDT, but also in observation of direct care staff on the individual units.
For instance, during an observation of a group therapy on the girls mental health unit, there were frequent interruptions consisting of staff knocking on doors to enter the unit and youth being summoned to step out of group for brief periods to sign documents. T he most egregious event occurred when a girl was discussing a traumatic event that had occurred in her life (i.e. being gang raped) and four male direct care staff seated in the back of the room were talking amongst themselves and laughing. T his was disruptive, counter-therapeutic, insensitive and dismissive of the youth’s experiences. This issue was reported to administrative staff, and the location of the group interaction for the female youth was changed.
When the behavior of direct care staff during group was mentioned to mental health staff, they indicated it was a frequent occurrence, however, efforts to change staff behavior had been met with resistance. M ental health staff also mentioned concerns that if direct care staff were confronted or reported, that the physical safety of the mental health staff could be compromised. While mental health staff did not indicate that this had been an issue, the fact that it was stated at all was concerning. Throughout the tour the lack of collaboration between mental health staff and direct care staff was apparent. It is recognized that this concern on the part of mental heath staff may be a symptom of a larger issue.
It was interesting that the facility chose to relocate the group rather than deal with the staff. Interviews with youth conducted the next day revealed that youth were aware of the consultant’s discussion with administrative staff, and that direct care staff had vented frustration in front of the youth. Again, this inappropriate discussion in the presence of the youth is a sign of the direct care staff’s lack of personal involvement in the IDT.

Recommendations

. Ensure psychiatric resources are available to allow participation in Interdisciplinary Treatment Team meetings.
. Educate all staff regarding the sanctity of group therapeutic process

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Evidentiary Basis

. Ensure that direct care staff are included in and valued members of the IDT
. Begin Quality Assurance monitoring of treatment planning efforts and IDT meetings.
. Increase staff training/education regarding the timely formulation of a treatment plan and interventions developed as a result of, among other things, the rich discussion in IDT. These plans must then be implemented, first via training direct care staff.
. Staff Interview . Observation of Interdisciplinary Treatment Team meetings . Review of provided documents (e.g. IDT meeting minutes, review of youth
records). . Observation of group therapies . Youth interview

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8. Discussion

Integrated Treatment Plans: The State shall ensure that each youth in need of mental/behavioral health and/or substance abuse treatment shall have an appropriate, integrated, treatment plan, including an appropriate behavior management plan, that addresses such needs. The integrated treatment plan shall be driven by individualized risks and needs, be strengths-based (i.e., builds on an individual’s current strengths), account for the youth’s motivation for engaging in activities contributing to his/her wellness, and be reasonably calculated to lead to improvement in the individual’s mental/behavioral health and well being, consistent with generally accepted professional standards of care.
Interviews conducted during the monitoring tour revealed that the facility was in the process of collating the multiple treatment and case planning documents into one overarching document entitled Integrated Treatment Plan.
Per the recently implemented policy entitled “Behavioral Health Services” the Integrated Treatment Plan is “a formal strategy developed to address the habilitation, education, rehabilitation, social, mental health and psychiatric needs of a specific youth. The plan is developed by an assigned Clinician or Provider in collaboration with the youth and the Interdisciplinary Team (IDT), and is implemented by both the youth and all Behavioral Health Services staff who work with the youth.” P er interviews, the facility implemented the policy beginning 1.1.11. Facility staff gave different estimates as to the number of youth whose treatment plans had been rewritten to reflect the requirements of the above noted policy and procedure. D ocumentation regarding the names of those youth for whom this task had been completed was requested (this was a request made during the monitoring tour) however, was not included in the documents available for off site review. S taff interview revealed it w as their goal to complete this process by March 1, 2011.
A review of 10 Integrated Treatment Plans provided for review revealed variable quality of the documentation. For example:
Youth 888 – The goals purported via this youth’s plan included, “to reduce mental health symptoms and their impact on my daily life…I will address my sexual offense and learn to maintain health boundaries…I will recognize how my feelings of being abandoned influence my current relationship; I will work towards improving my social skills.” While these were admirable goals supported by documentation of the presenting issues,
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they were not measurable. There were objectives included with each goal, and some of these were measurable, some were not.
Similar issues were noted with the other Integrated Treatment Plans available for review. Acceptable Integrated Treatment Plans must include measurable goals and objectives, with available targeted interventions to address each goal. Progress notes authored regarding the youth’s treatment should refer to the youth’s treatment goals and document the response (or lack thereof) to the prescribed interventions. Mental health administrative staff interviewed during the facility verbal self-assessment revealed that progress notes specifically related to the youths Integrated Treatment Plans were in the beginning stages of implementation, “we may not have those…we are just getting started with that.” Integrated Treatment Plans should be reviewed at each Interdisciplinary Treatment Team meeting scheduled for the youth, and must be authored and reviewed with the participation of the youth and their parent or guardian (if appropriate).

Recommendations

. Complete Integrated Treatment Plans for all youth.
. Begin quality assurance monitoring of treatment plan documentation, and implementation.

Evidentiary Basis

. Staff interview . Review of provided documents (e.g. draft policy and procedure) . Review of youth records

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9. Discussion

Access to a Qualified Mental Health Professional: The State shall develop and implement policies, procedures, and practices to ensure that youth who seek access to a qualified mental health professional are provided appropriate access in a timely manner.
Per the review of policy and procedure entitled “Mental Health Referral, Evaluation and Disposition,” and the associated policy entitled “Referrals to Mental Health Services” performed for the previous monitoring report, these documents outline the process for any facility staff to refer a youth for an assessment to determine the need for mental health services. There are designated time limits for response to requests. Psychology must respond within five working days, psychiatry within ten working days and if the request is for additional evaluation, there is a fourteen working day response window. Per a r eview of mental health staff schedules, it appeared that mental health staff scheduling included both evening (until 8:00 p.m.) and weekend hours.
Per documentation provided via the document request, information regarding youth’s request for mental health services and the time lapse until a provider saw them was reviewed. There were four instances documented, in all four cases, the youth were reportedly seen the same day, within four hours of the request. Per additional documentation provided, “youth…and staff may request that psychology staff meet with a youth…psychology staff offices re located on the units, staff are accessed easily and formal requests are rare.”
Interviews with youth revealed variability in their perception of both their ability to request mental health services and the response to their request. Only one youth interviewed indicated that following completion of a form “that you put in the box over there” would result in a response from mental health. Another youth stated, “when it is after hours, you have to ask staff to call for you…there are forms…the staff has never told me no.”
Some youth indicated that they had to access mental health services via direct care staff, “and sometimes they don’t like you and don’t want to do it.” Another youth reported, “we don’t have to fill out the request because [psychology staff] is there…but if they aren’t, staff has to call…and sometimes they don’t want to do i t…your regular staff usually will, but others could care less.” This particular youth indicated that he/she did not know how to access mental health care in any other way. Finally, several youth indicated that while they were able to access mental health staff,
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“they really aren’t able to spend enough time with me…there is so much going on.”
As discussed with facility staff during this monitoring tour, the policies noted above do not indicate the method by which youth can independently access mental health services. Per these policies, access is limited to youth who are referred by other staff members. In the past, a review of the youth handbook revealed instructions for youth to access mental health services via direct care staff. A revised version of the youth handbook dated 10.29.10 was provided for review during this monitoring tour, per the revised handbook, youth who want to access mental health care can “complete a ‘Request for Services’ form, which is located on the unit.” The handbook does not instruct the youth what to do w ith the written request following completion. S taff interviews revealed that youth are “verbally instructed to put the request in the medical sick call box…and this is in their welcome letter.” This must be delineated, such that youth are instructed how to access mental health care and do not have to go through staff in order to access care. T here are situations where staff could unfortunately impede a youth’s access.

Recommendations

. Determination of method by which a youth can independently request mental health services which is clearly spelled out in the youth handbook and policy and procedure
. Quality assurance monitoring regarding the time elapsed between a request for services and clinical contact with the youth
. Ensure the youth’s open access to mental health services

Evidentiary Basis

. Facility verbal self-assessment . Review of provided documents . Youth interviews

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10. Discussion

Mental Health Involvement in Housing and Placement Decisions: The State shall develop and implement a system for ensuring that significantly mentally ill youth who do not have the adaptive functioning to manage the activities of daily living within the general population are provided appropriate housing and supports to assist them in managing within the institutional setting.
Per the policy and procedure entitled “Mental Health Referral, Evaluation, and Disposition” reviewed for the prior monitoring report, this policy “identifies the process for consideration and referral for mental health treatment, including placement on a mental health unit when determined to be necessary. Youth demonstrating serious mental health issues and/or who are determined to be unable to adequately manage the demands of living in the general population are referred for placement on a n alternative living unit.”
Policy and procedure implemented January 1, 2011 entitled “Behavioral Health-Special Services Living Units” includes “guidelines for the referral of youth identified through clinical assessment as needing specialized housing and programming for the stabilization of the symptoms of an identified mental illness and program modifications due to cognitive and/or developmental limitations.” T his policy guided the creation of the “Behavioral Health Review Panel” whose responsibility it is to “review information obtained in the reception process and determine the best options for each youth in regard to housing, programming…”
As of January 1, 2011, t he Behavioral Health Review Panel had begun to review reception assessment summary documents for youth who arrive on Tuesday of each week. During the verbal facility self-assessment, staff indicated plans to expand the Behavioral Health Review Panel to include all youth admitted by March 1, 2011. S taff further indicated that they have had no occasion where the recommendations regarding a housing unit made via either the reception assessment summary or the Behavioral Health Review Panel were not accommodated.
At the time of this monitoring tour, there were two mental health units on campus; one designated for female youth (Davey capacity 12 youth), the other for male youth (Buckeye capacity 18 youth).
Review of youth intake screenings and completed intake assessments for the ten most recently admitted youth revealed that 100% of these youth were recommended for placement in general population, with, in some
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cases, additional treatment modalities (e.g. substance abuse) recommended. It would be interesting to note if all of these youth were able to maintain in the general population. The facility could consider tracking youth who are initially recommended for general population, but ultimately require an increased level of care. This could prompt changes in the intake assessment process.

Recommendations

. Fully implement the Behavioral Health Review Panel . In the next monitoring period, provide minutes from the Behavioral Review
Panel . Consider quality assurance regarding youth who are initially recommended
for general population but ultimately require an enhanced level of care. Consider quality assurance measures to review the accuracy and completeness of the assessment

Evidentiary Basis

. Staff interview . Review of provided documents (e.g. Policy and Procedure, and ten sample
youth intake assessments) . Review of youth records

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11. Discussion

Staffing: The State shall staff, by contract or otherwise, the Facilities with adequate numbers of psychiatrists, psychologists, social workers, and other mental health professionals qualified through training and practical experience to meet the mental health needs of youth residents, as determined by the acuity of those needs. Mental health care shall be integrated with other medical and mental health services and shall comport with generally accepted practices. The State shall ensure that there are sufficient numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming.
Per staff interview during the monitoring tour, the facility verbal selfassessment, and a review of the provided documents, there were staff shortages at the Scioto facility, which were compromising youth mental health care. F or example, until September 30, 2010, t he facility had psychiatric physician coverage at one full time equivalent (FTE). A t the time of the current tour, the facility was stretched with regard to psychiatric resources, as they currently had a total of 0.42 FTE (a reduction from 0.7 FTE during the prior monitoring tour). Please see the discussion regarding provision 13 f or further information regarding the facilities recruitment attempts in the area of psychiatric services.
With regard to psychology, the facility verbal self-assessment reported a total of four psychologists and six psychology assistants on s taff. P er interviews conducted during the facility tour, there were a total of seven psychologists (three licensed) plus a psychology supervisor. There were two psychology assistants. Of the seven psychologists, five were assigned to the assessment units, the remainder to the program units.
Per interviews conducted during the tour, there were currently a total of 14 social workers budgeted at the facility. At the time of the tour, three staff were out for various reasons, leaving 11 s ocial work staff actually on site providing services.
Additional mental health staff included mental health nurses and occupational therapists. A t the time of the tour, there were two full time mental health nurses providing services at the facility as well as two full time occupational therapists.
Per observation and interview, the current mental health divisions were making renewed efforts to work together to integrate treatment for the facility youth. At the time of this monitoring tour, the facility was in the
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process of consolidating treatment planning documentation into one overarching document, the Integrated Treatment Plan. S taff interviewed revealed various estimates regarding the number of youth where this process had been completed.
Per the facility verbal self-assessment, training regarding the New Freedom Phoenix program, (a cognitive behavioral/aggression replacement therapy/problem solving based program) had been completed and this modality had been implemented across campus. A dditionally, trauma training had been provided to the girls units and the boys mental health units. The first trauma based treatment groups on bot h the boys and girls mental health units were held during this monitoring tour.

Recommendations

. Recruit and fill current vacancies . Determine the need for additional staff via workload indicators . Improve coordination between staff disciplines . Complete and implement the Integrated Treatment Plan . Begin quality assurance and clinical supervision regarding the Integrated
Treatment Plans.

Evidentiary Basis

. Staff interview . Review of provided documents

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12. Discussion

Medication Notice: Before renewing a psychoactive medication prescription from a community provider or commencing the administration of a psychoactive medication to a youth, the State shall ensure that the youth, and, to the fullest extent practicable and appropriate, his or her parent or caregiver, are provided with information regarding the goals, risks, benefits, and potential side effects of the medication and given an explanation of the potential consequences of not treating with the medication, and that the youth has an opportunity to consent to such medication. a. Involuntary administration of psychotropic medication(s) to juveniles shall comply with applicable federal and state laws and regulations. The DYS clinical director, in consultation with the DYS medical director, shall review any request with DYS Legal Services prior to the approval for involuntary administration.
Per the policy and procedure reviewed for the previous monitoring report entitled “Psychotropic Medication, Use and Management” education including “addressing the goals, risks, benefits, and potential side effects associated with any given medication is given to each youth and his or her parent or guardian… the prescribing physician provides an explanation of the potential consequences of not taking the medication and explains that the youth has an opportunity a consent or withhold consent to be treated…provides guidelines within which medical professionals may petition the court to authorize involuntary administration of psychotropic medication.”
Staff interview performed during this monitoring tour revealed that the current psychiatric practitioner was not performing informed consent for youth who enter the facility prescribed psychotropic medication where medications are continued. It was discussed with the provider during the tour that generally accepted practices as well as facility policy and procedure require documentation of informed consent for treatment with psychotropic medication, whether this was a new prescription or a continuation of care from another provider. T he psychiatric provider reported that he does attempt to contact the youth’s parent or guardian regarding new medication prescriptions.
Given that the psychiatrist was not performing appropriate informed consent regarding treatment with psychotropic medications when youth enter the facility prescribed a medication, documentation of informed consent was not located in the initial psychiatric evaluations of these youth. Further review of youth records regarding new medication starts instituted by the psychiatric provider did not reveal documentation of the appropriate
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elements of informed consent. G enerally accepted practices require documentation of a discussion with the patient of the risks, benefits, side effects, and alternatives to treatment with a particular medication. This was not noted in the facility progress notes.

Interviews with facility staff to complete the verbal self assessment revealed that staff were aware of the challenges and deficiencies in the area of informed consent for psychotropic medication, “we hope to see more consistency…but we are concerned due to the recent sporadic and scarce [psychiatry] coverage.” S taff further reported that documentation requirements were reviewed with the psychiatric physician, “the doctor is trying to increase contact with the parents of the youth…and we are in the process of developing information for the youth and their parents on s ide effects of the psychiatric medications.”

Interviews with youth performed during the monitoring tour revealed that youth were able to name some of the medications prescribed. T hey were also able to name some side effects of the medication.

There was no information located in the documents regarding petitions for authorizations to involuntary administer medications.

Recommendations

. Improve documentation regarding informed consent that is consistent with generally accepted practices and facility policy and procedure.
. Consider a peer review process for informed consent and other psychiatric documentation
. Consider the development of or use of commercially available information regarding side effects of psychotropic medication that is written such that an individual unfamiliar with medical jargon would understand the information.

Evidentiary Basis

. Youth record review . Review of provided documents . Youth interview . Staff interview

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13. Discussion

Mental Health Medications: The State shall develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, and consistent with generally accepted practices. The State shall provide regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy. The State shall issue and implement policies and procedures for the administration of appropriate tests (including, for example, blood tests, EKGs, and Abnormal Involuntary Movement Scale tests) to monitor the efficacy and any side effects of psychoactive medications in accordance with generally accepted professional standards. The State shall also: a.) Share medication compliance data with the psychiatrist and document the sharing of this information; and b.) Not withhold the provision of psychostimulants to youth when such treatment is clinically warranted.
Per the facility self-assessment and document review per formed during the prior monitoring period, the facility has policy and procedure in place entitled, “Psychotropic Medication, Use and Management.” This policy “provides the parameters for using medication for psychiatric purposes…education addressing the goals, risks, benefits, and potential side effects associated with any given medication.” T he Ohio Department of Youth Services also had a document entitled, “Recommended Laboratory Monitoring Frequency Guidelines.” This document was updated and approved by the current psychiatric provider as of 2.22.11.
Per the presentation provided at the outset of the tour as well as staff interviews, psychiatric resources at the facility were reduced over the prior monitoring tour. At the time of the current tour, there was one psychiatric provider, accounting for a total of 17 hour s of clinical services per week. Reportedly, this physician had interviewed for a potential full time position at the facility, and an offer of full time employment was extended to him on or about 2.24.11. A review of the physician’s curriculum vitae revealed that he completed a fellowship in child and adolescent psychiatry, and was board certified in adult psychiatry by the American Board of Psychiatry and Neurology. There was no documentation of board certification in child and adolescent psychiatry.
As one full time equivalent was a reduction in psychiatric resources over those available at the facility in August 2010, a dministrative staff had performed an analysis of resource requirements. T his document, entitled “Rationale for the Distribution of Psychiatry Hours” dated 2.22.11 m ade
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assumptions that approximately 50% of the youth committed to DYS will receive mental health services. It is opined that this is an underestimate of the number of youth who will require services. Per a r eview of the literature, “in a r eview of decades of research on psychiatric disorders in children…prevalence rates for current psychiatric disorders were estimated to be 16.5 pe rcent in adolescents…as many as 65 pe rcent of youth in the juvenile justice system have a diagnosable psychiatric or substance abuse disorder.” ( Desai R, Goulet J, et al. M ental Health Care in Juvenile Detention Facilities: A review. J Am Acad Psychiatry Law 2006; 34: 204214.)
The rationale further divided youth into minimum, moderate, and high levels regarding the level of mental health care they would require. It was opined in the rationale document that 60% of youth would require a minimum level of care, 27% of youth would require a moderate level of care, and 13% of youth would require a high level of care. Based on this, a calculation was derived inclusive of both direct and indirect clinical service requirements. This resulted in an estimation of yearly total hours at this facility at 2496 hours. Per the rationale document, one full time equivalent would be sufficient to cover this requirement. Interestingly, another facility, where a total of 1872 hours were estimated was also assigned one full time equivalent. It is recommended that as psychiatric services that are in keeping with generally accepted practice standards are implemented at the facility, that the facility re-evaluate the need for additional resources.
Further challenges with psychiatric services were reported, as the administrative psychiatry position via state office was also vacated in the intervening period between the two monitoring tours. Currently, even if the part time psychiatric provider accepted full time employment, there were no resources for coverage (e.g. vacation, sick time) or for peer review processes. Staff interviewed revealed active recruitment attempts to fill the administrative psychiatry position, which could allow for coverage. In the interim, in an effort to provide peer review and coverage, administrative staff were exploring the potential for a contract with a local hospital.
Given the limited psychiatric clinical resources, the psychiatry clinic at the Scioto facility was not fully functional at the time of the tour. T he psychiatrist was making efforts to perform initial psychiatric evaluations and ongoing medication management. The psychiatrist was also attending some interdisciplinary team meetings (one of these was observed during this monitoring tour). I nterviews with youth revealed variable reports regarding their satisfaction with psychiatric care. S ome youth were frustrated and indicated that they had to wait long periods to see the physician. This was observed during psychiatry clinic, where a youth was
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identified at admission as requiring a psychiatric evaluation, but due to limited resources, there was a s ix week interval between admission and evaluation. O ther youth reported that while they saw the physician at a reasonable interval, “he is just so busy…that he doesn’t listen…and sometimes I think he blows me off.” O ther youth had more positive reports, “the doctor comes to my treatment team.”
The psychiatrist reported good ability to obtain laboratory examinations following a physician order, and that abnormal lab results were communicated via a telephone call to the physician. T he psychiatrist reported taking after hours call for psychiatric emergencies at the facility, and per interviews with administrative staff, there were plans to add a requirement for after hours availability into the full time job description. There was, however, no formal process for informing the psychiatrist when a youth is placed on suicide watch or other restriction. This is an area in need of improvement; generally accepted practice is that the psychiatrist would be informed and aware that a youth on his or her caseload required enhanced supervision.
Psychiatry clinic was observed during the monitoring tour. The psychiatrist did a good job establishing rapport with the youth. H e queried the youth regarding signs and symptoms of mental illness inclusive of historical data. The physician reviewed the youth’s medical record inclusive of school and behavioral information.
Review of psychiatric documentation regarding the last ten youth admitted to the facility who were prescribed psychotropic medication revealed consistent deficiencies in documentation. For example:
Youth 444- This youth was admitted to the facility four days prior to the initial psychiatric evaluation dated 1.27.11. The youth was prescribed Abilify, an atypical antipsychotic medication, at the time of admission. This medication was continued following the initial evaluation, however, the evaluation makes no not e of a review of weight or vital signs, monitoring for abnormal involuntary movements, nor did it indicate laboratory examinations were ordered or reviewed.
This youth was diagnosed with Posttraumatic Stress Disorder, as well as two rule out diagnoses (mood disorder, not otherwise specified and conduct disorder). As there was no diagnostic formulation included in the dictation, it was unclear as to the specific symptoms that the youth was experiencing that led the physician to this particular diagnosis. Additionally, while per
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the document, the youth indicated the medication was prescribed to “keep…calm and...stabilize…mood,” there was no documentation by the physician regarding the indication or target symptoms associated with the prescription of this medication.
Youth 555 – This youth was admitted to the facility approximately one week prior to the initial psychiatric evaluation dated 1.27.11. This youth was prescribed Abilify, an atypical antipsychotic medication at the time of admission. T his medication was continued, however, the physician documented “I am not certain of the effectiveness.” The evaluation makes no note of a review of weight or vital signs, monitoring for abnormal involuntary movements, nor did it indicate laboratory examinations were ordered or reviewed.
The youth was diagnosed with “Likely” Posttraumatic Stress Disorder, as well as a rule out diagnosis of conduct disorder. As there was no diagnostic formulation included in the dictation, it was unclear as to the specific symptoms that the youth was experiencing that led the physician to this particular diagnosis. A dditionally, while per the document, the interview with the youth revealed the medication was prescribed to “help with mood swings and mood changes and irritability,” there was no documentation by the physician regarding the indication or target symptoms associated with the prescription of this medication. Youth 777 – This youth was admitted to the facility one day prior to the initial psychiatric evaluation dated 1.21.11. T his youth was prescribed the antidepressant medication Prozac, the anti-epileptic/mood stabilizing medication Lamictal and the atypical antipsychotic medication Risperdal upon admission. T he evaluation makes no not e of a review of weight or vital signs, monitoring for abnormal involuntary movements, nor did it indicate laboratory examinations were ordered or reviewed.
The youth was diagnosed with: Cannabis abuse; mood disorder, not otherwise specified, and a rule out diagnosis of conduct disorder. As there was no diagnostic formulation included in the dictation, it was unclear as to the specific symptoms that the youth was experiencing that led the physician to these particular diagnoses. Additionally, while per the document, the interview with the youth revealed that he was unclear as to the reason why medications were prescribed, medications were continued with out specific documentation by the physician regarding the indication or target symptoms associated with the prescription of these medications.
On a positive note, the evaluations reviewed were detailed with regard to
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the documentation of the youth’s historical information. It is possible that the documentation deficiencies are the result of diminished clinical resources, as interviews with youth revealed that as in the prior monitoring tour, youth interviewed had knowledge regarding their prescribed medication, they were able to discuss the symptoms that the medication was addressing, they indicated that laboratory examinations had been performed during their stay at the facility and they were able to discuss basic medication side effects.

At the time of the monitoring tour, there were 138 youth housed on campus. Of these, 33 were prescribed psychotropic medication. This indicates that 24% of the youth housed at the facility were prescribed psychotropic medication. Of the 33 youth prescribed psychotropic medication, nine were prescribed stimulant medications as a result of diagnoses including Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder or other Axis 1 mental health disorders.

Recommendations

. Recruit psychiatric physicians to fill available positions . Determine how vacation and sick time will be covered . Continually assess the number of FTE required to perform necessary
psychiatric duties (i.e. clinic, attendance at treatment team meetings). . Improve psychiatric documentation (consider quality assurance monitoring
or a peer review process).

Evidentiary Basis

. Staff interview . Clinic observation . Treatment Team observation . Youth record review . Review of provided documents (e.g. policy and procedure, lists of youth
prescribed medication, examples of initial psychiatric evaluations, and mental health caseload documentation) . Youth interview

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14. Discussion

Mental Health and Developmental Disability Training for Direct Care Staff: The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents in order to supervise them appropriately.
Per the facility verbal self-assessment performed during this monitoring tour, in the intervening period since the last visit, the facility has provided a three day mental health intensive training (for mental health staff), an update on the behavioral health policy and procedure (for all staff), trauma training (for staff assigned to the girls units and the boys mental health unit, and training regarding self injurious behavior (for staff assigned to the girls units and the boys mental health unit).
It was discussed that the three day mental health intensive training did not include direct care staff. M ental Health and administrative staff indicated that the purpose of this three day training was to assist staff with the treatment team process. D irect care staff are an important part of the youth’s treatment team, and unfortunately, they were excluded from this experience. There were several instances witnessed during this monitoring tour that provided evidence and gave credence to the fact that direct care staff generally do not consider themselves to be an integral part of the treatment program. This is an area that will require a cultural shift at the facility, inclusive of teamwork, integration and training.
Unfortunately, despite the document request requirements for a spreadsheet staff indicating all trainings attended and dates of completion, documentation of staff attendance at the trainings noted above was not included in the documents available for off site review. Per staff interview, they have “not had the time to address the requirements of provision 14 or 15 thoroughly.” For additional discussion and information regarding recommendations, please see the discussion regarding provision 15 below.
As stated in the previous report, the goal of this provision paragraph is to provide training to facility staff such that they have a working knowledge of the youth’s challenges (both from a mental health and developmental perspective) and to provide them with strategies to assist in their daily supervisory tasks with the youth. Training for direct care staff is important as in the correctional setting; they function as the de facto parents of the youth in their care. As direct care staff are an integral part of the youth’s treatment team, they should be aware that due to specific mental health
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diagnoses, youth may have special needs (i.e. a youth diagnosed with ADHD may not respond to you the first or even second time that you call his name because he is distracted by extraneous stimuli). They should also be aware of which youth are being treated with psychotropic medication and have a basic knowledge of the potential side effects of the medication so that they can monitor the youth in their care.

Recommendations Evidentiary Basis

. Continue development of Mental Health Unit training
. Create a s preadsheet that delineates staff attendance and completion of required training modules.
. Develop a mandatory training schedule for staff who provide care to youth on the mental health case load.
. Facility should make an appraisal of their staff training needs and develop curriculum to address these needs.
. Review of provided training module curriculum . Review of provided training documentation . Staff interview . Observation on the youth mental health units

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15. Discussion

Staff Mental Health Training: The Facilities shall train: a. All staff who directly interact with youth (e.g., JCOs, social workers, teachers, etc.) on: (i) basic mental health information (e.g., diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern) and recognition of signs and symptoms evidencing a response to trauma; and (ii) teenage development, strength-based treatment strategies, suicide, and, for staff who work with female youth, female development.
b. Clinical staff on the prevalence, signs, and symptoms of Post Traumatic Stress Disorder and other disorders associated with trauma.
The document request for this monitoring period included “spreadsheet of staff indicating training programs completed and dates of completion for the time period from 2.22.10 to 2.11.11.” I n response to this request, a listing of 11, presumably mental health staff, employees was provided, with documentation of their attendance at trainings including “youth advocate training, MIS self-study, medical risks of restraint, MYR policy review, MYR practice Q1, CPR/first aid, release authority, youth grievance training, SBBMS, emergency response training, mental health, MYR practice Q2, verbal strategies, planned intervention, report writing, structured programming, MYR practice Q3, annual policy review, standard precautions and TB prevention, MYR practice Q4, mechanical restraints, ethics, behavioral health, and cultural competency.”
Per the facility verbal self-assessment, they have provided training regarding the cognitive behavioral and trauma based treatment programs, however, documentation of these trainings was not included in the records provided for review. S taff indicated that, “we have not had the time to address the items in provision 15 thoroughly...we have some ideas and have plans to develop a curriculum, and a schedule.” S taff discussed plans to develop a quarterly training regarding specific mental health issues that could then be repeated on a quarterly basis. It was discussed during the tour that a thoughtful planned approach to staff training that addresses the requirements of this provision would be appropriate.
In the future, the facility should include data regarding training in the required mental health subject matter areas delineated in this paragraph. This data must include not only training for mental health staff, but training for all facility staff who interact with youth (e.g., direct care staff, teachers, etc.).
In the prior monitoring period, policy and procedure entitled “New
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Employee Orientation and Basic Academy Training” was reviewed. This document outlined specific pre-service training topics for new staff. These include: ba sic and fundamental mental health information: diagnosis, specific problem behaviors, psychiatric medication, recognition of signs and symptoms of mental illness and response to trauma, teenage development, strength-based treatment strategies, suicide, and others.

Specific training modules were provided for review in preparation for the prior monitoring report. T hese included: “Suicide Precautionary Equipment and Restraints”; “Understanding and Responding to SelfInflicted Injury”; “Training Module for Girls Programming”; “The interface between the Juvenile Justice and Mental Health Systems”; “Psychopharmacology”; “Staff Roles and Responsibilities”; Therapeutic Milieu”; “Verbal Strategies”; “Axis II Diagnoses”; and modules from the National Center for Mental Health and Juvenile Justice including “The Developmental Process”, “Mental Health Disorders”, “Treatment of Youth with Mental Health Disorders.” Unfortunately, while the document request provided for this monitoring period included a requirement for the production of a spreadsheet of staff attendance and training completion, this was not included in the documents reviewed. Attendance documents that were provided for review for the previous report included participation and attendance until December 2009. Given changes in programming and staff turnover, more recent training documentation is required.

Recommendations

. Continue development of Mental Health Unit training . Create a s preadsheet that delineates staff attendance and completion of
required training modules. This must be provided for all staff disciplines. . Develop a mandatory training schedule for staff that provide care for youth
on the mental health case load.

Evidentiary Basis

1. Review of provided training documentation. 2. Review of the previous monitoring report. 3. Staff interviews.

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16. Discussion

Suicide Prevention: The State shall review and, as appropriate, revise current suicide prevention practices to ensure that suicide preventions and interventions are implemented consistently and appropriately, consistent with generally accepted professional standards of care.
Per a meeting with key staff, where a verbal self-assessment was provided, mental health staff “review the precautionary status list weekly and monitor youth who are placed on s uicide status.” Staff noted anecdotally that the number of youth requiring precautionary status has decreased in recent weeks. The consultant discussed with key staff that per experts in the field of suicide prevention, a decrease in the number of youth identified is likely multifactorial. W hile it may be the result of improved treatment and intervention; or as facility staff hypothesized, the result of youth housed on mental health units settling into the facility milieu; it i mperative that the facility ensure that the this reduction is not the result of a lack of identification of youth at risk for self-injury.
Per a review of “Guiding Principles to Suicide Prevention in Correctional Facilities” by Lindsay M. Hayes published in the National Center on Institutions and Alternatives, 2007, “ A lack of inmates on s uicide precautions should not be interpreted as meaning that there are no currently suicidal inmates in the facility, nor a barometer of sound suicide prevention practices. We cannot make the argument that our correctional systems are increasingly housing more mentally ill a nd/or other high-risk individuals and then state there are not suicidal inmates in our facility today. Correctional facilities contain suicidal inmates every day; the challenge is to find them. The goal should not be ‘zero’ number of inmates on suicide precautions; rather the goal should be to identify, manage and stabilize suicidal inmates in our custody.”
A review of the names of all youth placed on suicide watch status between 11.11.10 and 2.11.10 r evealed 36 i nstances of precautionary status. O f these 36 instances, four youth required precautions a total of two times, two youth required precautions a total of three times, and one youth required precautions a total of four times. As such 16 instances were accounted for by six youth. This indicates that there is a subset of youth who may require additional mental health intervention and suicide precautions.
The provided policy and procedure entitled “Suicide Prevention and Response” was reviewed for the prior monitoring report. It appeared, however, per a review of the documents provided that this policy and procedure, number 404.03, was currently “pending” as noted in the listing
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of all mental health and behavioral health services related policies. The consultant was not clear regarding this policy status. Per the facility verbal self-assessment performed during this monitoring tour, the facility implemented revised policy entitled Behavioral Health Services as of January 2011, and it is questioned if this prompted a need to review and revise policy and procedure regarding suicide prevention.
One example of an audit tool and one example of a compliance summary regarding suicide prevention and response was provided for review as part of the request regarding quality assurance monitoring. The utility of these documents was limited as there was no date included on either document, so it was impossible to determine when the audit or the compliance summary was conducted. Regardless, the audit tool form form indicated that the sample size should be “10% of youth population and/or no less than 10 samples.” The document then indicated that “all CBT youth and females MH records” were audited. The form did not indicate the total number of records reviewed.
There was notation of 100% compliance across five areas related to suicide prevention including a review of the nursing intake form, receipt of a risk assessment for those youth identified as being at risk, assurance that risk assessments performed by staff other than psychology resulted in the youth’s placement on suicide watch, that all risk assessments are completed within four hours of the identification of suicide or self injury risk, and that youth shall be removed from precautionary status by psychology staff following a clinical assessment and document the revocation of precautionary status in the mental health data base. A comment included in one of the two audit tools provided stated, “multiple risk assessments and precautionary status documents for the girls…lacked a psychologist signature…Dr. Hamning contacted me…and stated this problem had been rectified in full.”
The second document, the compliance summary was also undated. It noted that contrary to the requirements for a 10% sample noted above, the sample size was three. This document reported 100% compliance in the five areas.

Recommendations

. Determine the status of policy and procedure regarding suicide prevention.
. Continue quality assurance efforts regarding suicide prevention. Quality assurance documents must be dated and include a representative sample of all youth.
. Ensure that youth requiring precautionary status are identified and

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Evidentiary Basis

monitored. . Determine the need for additional mental health intervention for that subset
of youth requiring frequent precautionary status.
1. Review of policy and procedure. 2. Review of provided quality assurance information 3. Review of the list of youth requiring suicide watch status. 4. Staff interview

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17. Discussion

Transition Planning: The State shall ensure that staff create transition plans for youth leaving the Facilities consistent with generally accepted professional standard of care.
Per a meeting with key facility staff regarding the facilities progress regarding the requirements of the agreement, the facility was reportedly; “in the infancy stages of transition planning…we need to work with social services staff regarding the development of a discharge plan and focus on establishing links with community providers.” Staff indicated a shift in their approach to transition planning, specifically, “we are trying to look at discharge planning from the date of admission.”
In response to a document request for transition plans for the last ten youth prescribed psychotropic medication discharged from the facility, the monitor was provided with medical release summary documents for the youth, as well as the psychological services summary form. W hen reviewing these documents, it was noted that there were some medical release summaries dated prior to the previous monitoring tour, these were not reviewed with regard to compliance. A review of more recent documentation revealed improvements in the documentation included in the medical release summaries. For example, the medical release summary of youth 111 revealed a listing of psychotropic medication, documentation of a 30-day supply of medication, and a listing of diagnoses. W hat was concerning, and indicative of other challenges in the mental health system at the facility, was despite a two year incarceration, the youth’s psychiatric diagnoses included two rule outs, signaling that a diagnostic assessment was not finalized. W ith regard to a follow up appointment, nursing indicated that the youth’s mother was “waiting on a call from the office.” Per the psychological services summary dated 1.25.11, t ransition planning included, “youth appears…to need a high level of wrap around services in the community. Follow up in the community will be necessary based on his history of medications…will require assistance in obtaining his…education…based on his lack of desire to participate while here…appearing to struggle toward the end of his stay and staff reported concerns about him just prior to his release…” Despite these concerns regarding this youth’s mental health status and history of significant mental health symptoms, no ot her documentation of mental health referrals or linkages to community supports was documented.
Per the medical release summary of youth 222, dated 10.26.10, a listing of medications and diagnoses was documented. There was no documentation regarding the amount of medication the youth was prescribed at discharge (either in actual medication or via prescription). The document did not note
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the requirement for psychiatric follow up after release from the facility. Per the psychological services summary form dated 10.27.10, “ she should continue to work with the psychiatrist…community psychiatrist have been [sic] contact to continue care upon r elease…mother indicated she would facilitate medication management while in the community…in her therapy…continue to address the thinking and choices that lead to aggressive and assaultive behavior…she should receive help to develop people in the community who can be a support for pro-social thinking and behavior…” Despite these recommendations, no notations regarding how the youth would link with these community services, or with whom or where her follow up ps ychiatric appointment or therapy was scheduled were noted.
These above examples are similar to those documented in the previous monitoring report, where recommendations were made, and the need for community linkages and appointments was clear, but there were no resources documented. Given the facility staff’s verbal self-assessment documented above, it was apparent that they were aware of the to develop transition planning services at the facility to include linkage with community resources.
Transition planning for all youth should include referral to appropriate community resources. For mentally ill youth this is especially important, and must include linkages to community mental health clinics and a scheduled appointment such that youth can access follow up care without an interruption in medication treatment.
Per the facility verbal self-assessment, the policy and procedure entitled “Behavioral Health Services” was finalized and implemented. A review of a subsection of this policy entitled “Discharge Planning” revealed a requirement that “for all youth placed on a mental health caseload, or who resided in a special services living center…a staffing shall be held to discuss clinical recommendations after a youth is released…based on the recommendations of the staffing team, a psychologist or assigned psychology assistant shall complete…discharge summary.” A review of the provided transition planning documentation revealed one example of the discharge summary documentation dated 1.12.11 regarding youth 333. It was noted that the diagnoses at the tie of discharge documented on the discharge summary were different from those noted on the medical release summary. This example was missing two critical pieces of information as the sections of the form entitled “continuity of care/referral information” and “after care options” were not included.
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Recommendations

. Development of community linkages and resources. . Ensure that all sections of the discharge summary form are included and
completed. . Continue to begin discharge planning at the time of admission. . Begin quality assurance monitoring regarding the documentation of
discharge information and the integration of this information with the medical release summary. . Ensure that all youth (not only those who are mentally ill) receive transition services and linkages to appropriate community services.

Evidentiary Basis

. Review of ten medical release summaries . Review of ten psychological service summaries used as part of transition
and discharge plan . Review of one discharge summary . Review of relevant policy and procedure . Staff interview

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18. Discussion

Oversight of Mental Health Services: The Facilities shall ensure that youth receive the care they need by developing and implementing an adequate mental health Quality Assurance/Improvement Program; annually assessing the overall efficacy of the staffing, treatments, and interventions used at the Facilities; and, as appropriate, revising such staffing, treatments and interventions.
Per a meeting with facility leadership during this monitoring review, policy and procedure regarding Quality Assurance and Clinical Supervision had been implemented. A review of these two policies revealed effective dates of January 1, 2011. As required by the newly implemented policy, the initial facility quality improvement meeting was held February 8, 2011. Unfortunately, minutes from this meeting were not included in the documents provided.
Included in the document request were quality assurance reviews regarding “Integrated Treatment and Service Delivery.” A review of this document revealed an eight-page report that was not dated, so it was impossible to determine the date or time period of review. There were multiple headings of subject matter reviews entitled: Individual Treatment Planning, Interdisciplinary Teams, Individual and Group Sessions, Suicide Prevention and Response, Substance Abuse Assessment and Service Delivery, Sex Offenders Assessment and Planning, Recreational Programming, Mental Health Screening and Appraisals, Mental Health Professional Guidelines, Mental Health Classification, Mental Health Referrals and Services, Mental Health Transfers from Reception and Facilities, Mental Health Treatment Plan, Transition, and Family Contact. Below each of these headings were a listing of standards, however, the document did not define what the standards were, nor was a copy of the guiding document defining the standards provided. As such, it was impossible to determine compliance with specific areas.
It was notable that despite knowledge of the requirements for the individual parameters, this document was informative. There were a majority of areas where compliance percentages as assigned by the facility reviewers were less than 70%. For example, regarding Individual Treatment Planning seven items were reviewed. Of these seven items, one was documented at 100%, the remaining six were rated at below 68%. Of those six, it should be noted that two items were rated at 0% and two items were rated at 12%. As it was impossible to determine the specific requirements for each individual rating, an average rating for each subject was calculated (percentages were not available for items entitled Mental Health Professional Guidelines, Mental Health Referrals and Services these were
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reported as compliant or non compliant). It was also noted that the document indicated eleven separate action plans would be generated. The areas were action plans were authored are noted with an asterisk:

Subject

Number of Items

Individual Treatment Planning*
Interdisciplinary Teams*
Individual and Group Sessions*
Suicide Prevention and Response
Substance Abuse Assessment and Service Delivery*
Sex Offenders Assessment and Planning
Recreational Programming
Mental Health Screening
Mental Health Classifications*
Mental Health Transfers from Reception and Facilities*
Mental Health Treatment*
Transition*
Family Contact*

Seven Seven Six Five Three
Two
Four Four Three Three
Six Three Six

Average Compliance Rating 35.4% 67.75% 65.8% 100% 82.6%
33%
100% 71.5% 93% 85.6%
76.8% 0% 44.2%

Additional information provided regarding quality assurance and clinical supervision revealed a performance review for one mental health provider dated 12.15.10. There was no documentation provided regarding regular clinical supervision of providers. Other information provided regarding
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quality assurance revealed social services weekly report. What was striking regarding this social work documentation (and discussed during the monitoring tour) was the apparent lack of commitment on the part of a small subset of staff, to the overall mental health treatment program. There was documentation of multiple missed group therapy sessions, and although a percentage of these were rescheduled and “made up” there was cause for concern regarding a lack of investment by treatment staff. Per the weekly report for the week ending January 10, 2011 it was noted that a specific provider did not have any documentation of individual sessions with youth documented in the case notes for the previous month. For the week ending December 20, 2010, it was reported that there were no individual sessions regarding youth 111 for the previous week. This is especially concerning given this youth’s serious mental health issues which as stated above in this monitoring report led the treatment team to place him in isolation without time out of his room for a period of four days.
During this monitoring tour, it was evident that staff were working diligently to implement treatment modalities in an effort to both provide necessary services to the youth and to satisfy the requirements of the settlement agreement. There were areas, however, where implementation was just beginning. For example, the Behavioral Health Review Panel had been piloted, beginning with those youth admitted on Tuesdays. There were plans to expand this review panel to include all admissions beginning 4.1.11. During this monitoring tour, the first trauma groups were held on the mental health units (both male and female units). Training was in process for staff regarding cognitive behavioral therapy (CBT). The facility staff indicated 4.1.11 as the date for the full implementation of CBT across campus.
Given this recent surge in mental health treatment (i.e. development of a framework) and actual service provision, quality improvement monitoring may be slightly premature. Staff interviewed revealed that they are “keeping lots of statistics, but there is no system to accurately manage data…and the analysis of the data will come later.” Staff indicated that they have created a database for quality assurance information, and have hired a data manager.
With regard to the current mental health policies and procedures in effect, it was difficult to determine the adequacy of these documents based on only partial implementation. Policy and procedure must be reviewed and revised on a periodic (e.g. annual or more frequently as needed) basis in order to ensure that the written document adequately reflects actual facility practice and vice versa. In addition, quality assurance measures regarding outcomes based on policy implementation will be beneficial in determining adequacy
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of the current procedures. The quality assurance documentation reviewed in preparation for this monitoring report was below par, in that as stated above, it was not dated; it was impossible to determine the requirements for each individual parameter; and per interviews with facility staff as well as observation of practices, policy and procedure had not been fully implemented.

Recommendations

. Complete staff training and implement planned mental health administrative structure, meetings and treatment modalities.
. Following the full implementation of these programs, begin quality assurance monitoring to assess the efficacy of staffing, treatment and interventions.
. When providing quality assessment results, date the document and describe the standard being monitored in the document.

Evidentiary Basis . Staff Interview . Review of the provided documents.

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Attachment D

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United States of America v. The State of Ohio Case No. 2:08-cv-475
Review of the Scioto Juvenile Correctional Center Medical Care
Dr. Michelle Staples-Horne April 05, 2011

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Dr. Michelle Staples-Horne has been the Medical Director of the Georgia Department of Juvenile Justice since 1994 and is responsible for the provision of medical services to over 1900 youth each day in 28 facilities served by the Department. She received her Medical Degree from the Morehouse School of Medicine and her Master of Public Health in Health Policy and Management from Emory University in Atlanta. She holds both a Bachelor of Science Degree and a Master of Science Degree in Biology from Clark Atlanta University with research experience in Biochemistry and Microbiology. She also is a Certified Correctional Health Care Professional (CCHP) by the National Commission on Correctional Health Care. Her clinical experience includes training in Pediatrics at Columbia University’s Babies Hospital in New York and Preventive Medicine at Morehouse School of Medicine. She has provided clinical services on a part time basis as an adolescent health physician for the Fulton County Department of Health and Wellness for the past 18 years
Dr. Staples-Horne is a current member of the Health Care Committee of the American Correctional Association (ACA) and the Juvenile Health Committee of the National Commission on Correctional Health Care (NCCHC). She is Past President of the Society of Correctional Physicians. She has provided correctional health care consultation and training in several states as well as for the National Institute of Corrections and the Centers for Disease Control and Prevention. Dr. StaplesHorne assisted the Arizona Department of Juvenile Corrections in development of an electronic medical record and policy development. She consulted with the American Correctional Association on an assessment of the Texas Youth Commission. She has conducted several compliance audits for the NCCHC and has served as an expert witness for the plaintiff in two legal cases.
Dr. Staples-Horne is also the author of several standards, guidelines, articles and book chapters relating to correctional health care. She participated in the CDC/HRSA funded Demonstration Project to provide GC and CT screening and education to thousands of DJJ youth admitted to the Metro Regional Detention Center. She is currently involved with a National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant (Project RHAPS) to conduct an alcohol and drug related HIV risk reduction intervention for male adolescent detainees (MADS) within the Georgia Department of Juvenile Justice. Dr. Staples-Horne is also a participant in the Adapting SiHLE for Recently Detained African American Adolescent Females (METRO Study). This study will adapt an effective intervention (SiHLE), which is designed to promote HIV preventive sexual behaviors among African American adolescent females recently discharged from youth detention centers. Dr. Staples-Horne has provided training to students and health professionals through teaching and presentations at numerous health care and correctional conferences.
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Ohio Department of Youth Services Scioto Facility Follow Up Report Submitted by Dr. Michelle Staples-Horne April 4, 2011
I. GENERAL MEDICAL CARE
C.1 GENERALLY
The Facilities shall ensure that the individuals they serve receive routine, preventive, and emergency medical and dental care consistent with current, generally accepted professional standards. The Facilities shall ensure that individuals with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care.
A request was made in January, 2011 for additional documentation for review by this subject matter expert in order to assess continuing compliance with the U.S. Department of Justice requirements. Specific documents were requested this time to address concerns or questions established during the last health record review reported on January 8, 2011. Twelve health records were provided by the Ohio Department of Youth Services for review off site, as well as staff training records, and status updates on the electronic health record and health policies as requested.
No health care policies have been added or updated since the last review. Ohio Department of Youth Services reported that two thirds of their current health care policies were approved and implemented on 3/31/2010 and were currently in the annual review process. Approximately one third of the health policies including quality assurance were reported to be awaiting final approval.
Since staffing often dictates the level of care youth receive, a list of total health care positions at the facility by FTE count was requested to include RNs, LPNs, physicians, mid-level staff and all dental staff, including the dentist. The following response was submitted:
One (1) HEALTH SERVICES ADMINISTRATOR One (1) ADMINISTRATIVE ASSISTANT 2 Two (2) MENTAL HEALTH REGISTERED NURSES One (1) HEALTH INFORMATION TECH/PHLEBOTOMIST Eleven (11) REGISTERED NURSES STAFFING THE CLINIC One (1) REGISTERED NURSE FOR RECEPTION One (1) LICENSED PRACTICAL NURSE FOR RECEPTION One (1) LICENSED PRACTICAL NURSE STAFFING THE CLINIC
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For Scioto Juvenile Correctional Facility this totals fourteen (14) Registered Nurses and two (2) Licensed Practical Nurses. The Health Services Administrator is also a Registered Nurse. This staffing pattern could provide coverage with at least 3 registered nurses on the first and second shift and 2 nurses on the third shift, 7 days a week, without including the Health Services Administrator in any direct patient care responsibilities.
In addition to the nursing staff, clinical staff included: One (1) PHYSICIAN SERVING THE MALE POPULATION One (1) PHYSICIAN SERVING THE FEMALE POPULATION FOR GENERAL MEDICAL CARE. One (1) DENTIST One (1) DENTAL HYGIENIST One (1) DENTAL ASSISTANT Two (2) OB/GYN M.D.’S Two (2) OB/GYN D.O.’S One (1) CERTIFIED MIDWIFE One (1) OPTOMETRIST One (1) PSYCHIATRIST
The schedule for the above clinical staff was also submitted for review. The two primary care physicians provided coverage each day of the week, except Wednesday and Sunday, for a combined total of approximately 1 FTE. The psychiatrist saw youth 7 hours each on Tuesday, Thursday and Friday. OB\GYN services were provided 3 hours a week by 5 rotating providers. The Optometrist saw youth the second and third Friday of each month. It appears from review of the health record that these hours provide adequate clinic coverage and access to care and treatment of youth. Dental staffing is addressed in section C7 Dental Care.
At the last documents review reported in January 2011, the training curriculum was appropriate and adequate to address the general care of juvenile detainees at Scioto, but few were specific to medical staff training. No documentation of health care provider continuing education was submitted for review. I requested training records specific to health staff for this review. Training records were submitted for 14 nurses and one phlebotomist. Although the training documentation was exhaustive, it still primarily consisted of courses relevant to the general correctional staff. Examples included Managing Youth Resistance, Information Technology, Cultural Competency, Planned Intervention, etc. No evidence of continuing education training specific for health care professionals was submitted.
Intake screenings upon admission were completed in 100% of the charts reviewed. Physical examinations were completed by the facility Pediatrician and gynecological examinations by the facility Gynecologist in all cases. Females received gender specific health services such as pelvic examinations, family planning and pregnancy related services.
Sick call requests were appropriately addressed and documented in the health records reviewed. There was a concern expressed by youth during the last site visit that some requests were not being addressed. This concern is addressed more thoroughly in section C5. Access to Health Services. Injury assessments
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are being completed in a timely manner. There was one emergency response documented that occurred on site at the facility included in one of the health records
Youth with chronic medical conditions were provided excellent care (see C8 for details). Youth continued to receive appropriate diagnostic services such as laboratory and radiology in a timely manner. Preventative services continue to be reflected by immunization administration updates, including influenza vaccination and dental prophylaxis. There was documentation of health education provided to youth in their health records including dental hygiene education.
ODYS policy 403.08, Section VI Monitoring requires that ongoing reviews shall be conducted by the designated Interdisciplinary Team on a quarterly basis as a part of the Department’s Continuous Quality Improvement (CQI) process. No additional evidence was sent to me that CQI is occurring, other that a roster of medical staff receiving Quality Improvement training on 5/21/2010 that was provided during the last review. Although a quality assurance component was not specifically included in the DOJ requirements, it is an essential part of any medical program that aims for continuous quality improvement. Doing such through a structured format will keep the medical program compliant with national standards.
As evidenced by the twelve scanned health records reviewed, medical care received by youth at Scioto is adequately being provided consistent with current professional standards to include routine, preventative and emergency care. Youth health records reflect routine care through a thorough and consistent intake screening process including initial medical, dental, and mental health assessments.
Status: Maintained staffing levels, but no improvement in staff training. Other requirements of this provision were maintained at the previous level.
C.2 HEALTH RECORDS
The State shall develop and implement policies, procedures, and practices to ensure that, consistent with state and Federal law, at a minimum, the juvenile courts in the State, all juvenile detention facilities, and all placement settings from which youth are committed shall timely forward to Scioto, or to the facility of placement (if the records arrive after the youth has been placed), all pertinent youth records regarding medical and mental health care. The Facilities shall develop and implement policies, procedures, and practices to ensure that health care staff, including mental health care staff, have access to documents that are relevant to the care and treatment of the youth.
Policies and Procedures were updated March 31, 2010 identifying required components of the medical record, and addressing the requirement of records confidentiality and transfer adequately. No further policy updates were submitted for review. Health records continued to be formatted according to policy. Allergies were consistently noted within the health record.
Scioto still does not currently combine mental health psychological and medical records into one health record, such as was the case during the last review. Psychiatric evaluations and chronological psychiatric progress notes were included, but no psychological records such as case notes were included in the
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health record. Progress notes indicated that youth were participating in groups, but did not include details within the health record. These are most likely still being documented in a separate psychological record. Merging documentation of the two records creates a large health record, which could involve several volumes. The best solution is to implement the electronic health record, so that all documentation exists in one record without the bulk of a physical record. The electronic health record has not been implemented. The Ohio Department of Youth Services reports collaborating with Ohio State University to explore the EPIC electronic health record program that is currently being used by the Ohio Department of Rehabilitation and Corrections.
During this review, problem lists were documented in each health record that included both medical and mental health diagnoses. There was adequate documentation on t he transfer of medical information included in the review of the health records. The nurses did an excellent job of documenting communication regarding transferring care of youth to outside health providers and notifying parents and probation officers of the need for follow up care in the community.
Status: Maintained without further progress in development of health policies, electronic health record, or combination of psychological records into the youth health record.
C.3 CONFIDENTIAL HEALTH CARE
No expansion of current Policy 403.04, Medical Facilities, Equipment and Supplies was made to include the language in the provision requiring placing of non-medical staff out of the line of sight and hearing of the health assessment, except in circumstances where documented safety considerations posed by a particular youth require enhanced, non-medical supervision. During the recent DOJ site visit youth did not express concern over confidentiality of health care.
Status: Maintained practice but no policy development.
C.4 INITIAL HEALTH ASSESSMENT
The Facilities shall ensure that initial health assessments are complete and include: use of growth and weight charts; laboratory test results placed in the youth’s health records before the youth is transferred out of reception; results of all laboratory tests, to be provided for each test within 20 days of its performance; testing of all youth for sexually transmitted diseases; and a problem list and a plan of care for each problem identified at reception.
Each of the 12 health records reviewed included an initial health assessment, physical examination, and growth chart. Timely laboratory results, including sexually transmitted diseases were documented in all the health records. All lab tests results were on the chart usually within 10 days of its performance. Tuberculosis, vision and hearing screening results were consistently documented. Each record included STD testing results. Problems identified on the initial health assessment were followed up by health care staff. Improvement has been made on making the problem list more inclusive of all diagnoses. The
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health records consistently included the mental health diagnoses in this review compared to the previous review. Only one outlier chart missed listing one major medical diagnosis on the problem list.
Status: Improved
C.5 ACCESS TO HEALTH SERVICES
The Facilities shall ensure that youth can request to be seen by medical staff confidentially and independent from JCOs and custodial staff.
Sick Call Policies and Procedures were reviewed and updated by ODYS in March of 2010. Prior to that time, policies were last updated in 2006 and 2007. Policies and Procedures should be reviewed at least annually and updated as needed. This policy should have been due for review in March 2011.
During the DOJ compliance tour of February 22-24, 2011, numerous youth alleged that they were waiting three or more days to be seen for sick call. One youth alleged their sick call complaint was never answered and one youth complained of a 2 complaints not answered timely. These complaints were documented in the US V Ohio Post Tour letter of March 11, 2011. It is difficult to assess whether or not these allegations are true based on the documentation in the twelve health records reviewed. There were relatively few sick call request forms completed by youth in their medical record compared to the number of assessments completed for medical complaints documented in the progress notes. Of the twelve health records reviewed, two did not contain any sick call request forms and one record had only one hand written request. Youth may not be submitting many sick call requests or the sick call request forms are not being placed in the health record. Another explanation may be due to nurses being approached by youth directly with medical complaints, such as while they are passing medications on the units and a sick call form is not completed. There was one such case documented in the progress notes of one youth that complained of a toe injury while the nurse was on the unit. She was evaluated by the RN on the unit, later that day brought to the clinic for further evaluation and followed up in clinic the next day. Youth are being seen in a timely manner according to the date on the sick call request form, usually the following day. Youth are frequently referred when appropriate from the nursing staff to the physician. The physicians saw youth and documented on all the records reviewed. A minor surgical procedure was completed by the physician to incise and drain a boil in one case. One youth complained of ear pain one day, was seen by the nurse the next day, given Tylenol for pain and referred to the physician. Youth was seen the following day by the physician, diagnosed and treated. In all cases, according to the health records, more youth medical complaints were being addressed than the number requested through sick call requests.
Status: Maintained according to review of health records, however during site visit some youth had expressed some decrease in access to sick call.
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C.6 MEDICATION MANAGEMENT
The Facilities shall not discontinue a chronically ill youth’s usual medication for non-medical reasons, including that the medication is not on the Facilities’ formulary.
Medications were continued for youth with chronic medical conditions. Medication administration records were documented thoroughly that youth were receiving their medications. Progress notes documented treatment refusals made by youth. Chronically ill youth that arrive with medications at the facility are continued as ordered upon timely review by the facility physician. Prescriber’s orders for medications and medication administration records are complete and in all the youth health records. Medications are being administered and documented by nurses as ordered. Consents for psychotropic medications are present in the youth record where applicable. Hot weather precautions were included for youth on certain medications predisposing them to heat sensitivity. Abnormal Involuntary Movement Scale (AIMS) were also documented for youth on psychotropic medication.
Status: Maintained
C.7 DENTAL CARE
The Facilities shall ensure that: Dental restorative needs are listed on a dental treatment plan for the youth, tracked by the dental program, and treated on a timely basis consistent with generally accepted professional standards of care; b. Prosthetic dental services are provided based on need, as determined by the treating dentist, with appropriate consideration for the replacement or repair of missing front teeth, according to generally accepted professional standards of care; c. Youth experiencing dental pain are not denied adequate pain medication; d. Health records contain adequate documentation of all outside dental consults, including the clinical examination, treatment plan, procedures performed, orders for management after the procedures, and any follow-up appointment or plan; and e. Dental staffing is adequate to meet the restorative dental needs of the Facilities’ populations.
Statistical data for dental services was provided for review. The dental hygienist works up to 16 hours/week and averaged 1-2 dental prophylaxis/hour. The dentist and dental assistant work up to 30 hours/week and completed an average of 97 examinations and 34 restorations per month. Dental staffing appears to be adequate; however, there was a downward trend in the number of youth examined between September and December 2010 compared to the previous months of the year. Each youth examined received 3-4 dental x-rays each. Appropriately, far more restorations were completed than extractions. There was documentation in the health record that youth were receiving sealants, appropriate dental referrals were being made and dental prostheses (night guards) were being provided. Youth experiencing dental pain were seen by the nurse and given pain medication until seen by the dentist, usually the
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 10 of 11 PAGEID #: 1753
following day. One youth, NH, had more than one sick call request complaining of dental pain. The nurse documented in the progress note that the youth had admitted that she had seen the dentist, but refused to get fillings because she was afraid of needles.
Status: Improved
C.8 MANAGEMENT OF CHRONIC ILLNESSES
The Facilities shall ensure that: a. Chronic disease policies, protocols, and practices are appropriate for chronically ill adolescents; b. Youth with chronic asthma are continued on their established medicines on admission unless the youth’s condition warrants a change in treatment; and c. Youth who frequently use rescue inhalers are appropriately monitored and treated by physicians to minimize preventable asthma hospitalization resulting from acute respiratory crisis that follows an inadequately treated exacerbation of chronic asthma.
Cases of youth were identified and treated appropriately for hypertension, seizure disorder, hypothyroidism, renal disease, asthma, hepatitis C, latent tuberculosis, and a cardiac condition. Health records were also reviewed for the care and treatment of two pregnant females. One pregnant girl’s care was particularly a challenge due to additional diagnoses of hypertension, renal disease and asthma. Prenatal care was provided using the community standard of care (ACOG). The youth with hepatitis C received extensive education on her disease, liver ultrasound studies, appropriate laboratory tests and immunizations. There were four youth whose records indicated a history of Asthma. Three of the cases were mild and only required use of an inhaler as needed. However, one of these youth did experience an exercise induced asthma attack and required use of the inhaler imminently. KS’s medication order was changed to allow use of the inhaler prior to exercise. The other youth had severe persistent asthma with numerous past hospitalizations requiring multiple medications. This youth was well managed by the health care staff including continuing outside allergist consultation visits for Xolair medication injections. Excellent continuity of care occurred for youth with chronic diseases. Medical records from community providers were included in the health record as well as care plans documented for when youth were to be released back into the community.
Status: Maintained
C.9 ACCESS TO SPECIALTY CARE
Absent clinically justified rationale, the Facilities shall not withhold access to specialist services recommended by a treating physician and shall ensure that: prior approval of specialty medical consultations is made by a physician trained and qualified in pediatrics and adolescent medicine; and assessment
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 79-5 Filed: 05/09/11 Page: 11 of 11 PAGEID #: 1754
criteria for the necessity of specialty consultations are based on pediatric and adolescent medicine. Upon review of the heath record, youth continued to have access to specialty care. Referrals are being made appropriately by the facility pediatrician and family practice physician. Optometry care was provided and glasses purchased routinely when youth failed the vision screening. Youth received appropriate outside consultations with Nephrology, Cardiology, Neurology and Obstetrics specialists in the health records reviewed. Other diagnostic studies such as x-rays, ultrasounds, EKGs, and other studies were provided as appropriate. Status: Maintained
C.10 IMMUNIZATIONS The State shall make reasonable efforts to obtain immunization records for all youth who are detained at the facilities for more than one (1) month. The State shall ensure that medical staff update immunizations for such youth in accordance with nationally recognized guidelines and state school admission requirements. The physicians who determine that the vaccination of a youth is medically inappropriate shall properly record such determination in the youth’s medical record.
As in the previous health record review, youth in general were receiving appropriate immunizations including HPV and influenza vaccine. Immunization records were included in all 12 health records except one, where the youth had only recently been admitted to the facility. Only one youth, SM, was not brought current on her immunizations although her previous immunization records were in the health record. Immunization policies have not been updated. Status: Maintained in 11 of 12 health records
9

 Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 1 of 104 PAGEID #: 1864

	
   	
   	
   	
   	
   	
   	
  

U.S.	
  Department	
  of	
  Justice	
  v.	
  The	
  State	
  of	
  Ohio	
  

Civil	
  Action	
  No:	
  2:08-­‐cv-­‐475	
  

Monitor’s	
  First	
  Report	
  on	
  the	
  Amended	
  Stipulation	
  dated	
  June	
  28,	
  2011	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

Kelly	
  Dedel,	
  Ph.D.,	
  Lead	
  Monitor	
  

Daphne	
  Glindmeyer,	
  M.D.,	
  Subject	
  Matter	
  Expert	
  

Michelle	
  Staples-­‐Horne,	
  M.D.,	
  Subject	
  Matter	
  Expert	
  

	
  

One	
  in	
  37	
  Research,	
  Inc.	
  

1608	
  NW	
  Riverscape	
  Street	
  

Portland,	
  OR	
  	
  97209	
  

(503)799-­‐0915	
  

kdedel@comcast.net	
  

	
  

	
  

	
  

Draft	
  Submitted	
  December	
  2,	
  2011	
  

Final	
  Submitted	
  January	
  23,	
  2012	
  

	
  

	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 2 of 104 PAGEID #: 1865

TABLE	
  OF	
  CONTENTS	
  
	
   Introduction	.
  ......................................................................................................................	3
   	
   Executive	
  Summary	.
  ...........................................................................................................	4
   	
  
Protection	
  from	
  Harm	
  ..............................................................................................................	
  9	
   General	
  Protection	
  From	
  Harm	
 .  ...........................................................................................	
  9	
   Seclusion	.
  ............................................................................................................................	
 1  4	
   Investigation	
  of	
  Serious	
  Incidents	
  ......................................................................................	
 1  9	
   Grievances	
 .  .........................................................................................................................	
 2  3	
   Grievances	
  Explained	
  to	
  Youth	
.  ..........................................................................................	
 2  5	
   Structured	
  Programming	
.   ...................................................................................................	
 2  6	
   Orientation	
 .  ........................................................................................................................	
 3  0	
  
	
   Mental	
  Health	
  Services	.
  .........................................................................................................	
 3  3	
  
Mental	
  Health	
  Screening	
  ...................................................................................................	
 3  3	
   Immediate	
  Referral	
  to	
  QMHP	
 .  ...........................................................................................	
 3  5	
   Identification	
  of	
  Previously	
  Unidentified	
  Youth	.
  ................................................................	
 3  7	
   Mental	
  Health	
  Assessment	
 .  ...............................................................................................	
 3  9	
   Adequate	
  Care	
  and	
  Treatment	
 .  .........................................................................................	
 4  3	
   Treatment	
  Planning	
  ...........................................................................................................	
 4  9	
   Treatment	
  Teams	.
  ..............................................................................................................	
 5  0	
   Integrated	
  Treatment	
  Plans	
.   ..............................................................................................	
 5  4	
   Access	
  to	
  QMHP	.
  ................................................................................................................	
 5  7	
   Mental	
  Health	
  Involvement	
  in	
  Housing	
  and	
  Placement	
 .  ...................................................	
 5  9	
   Staffing	.
  ..............................................................................................................................	
 6  2	
   Medication	
  Notice	
  .............................................................................................................	
 6  5	
   Mental	
  Health	
  Medications	
 .  ..............................................................................................	
 6  7	
   MH/DD	
  Training	
  for	
  Direct	
  Care	
  Staff	
 .  ...............................................................................	
 7  2	
   Staff	
  Mental	
  Health	
  Training	.
  .............................................................................................	
 7  4	
   Suicide	
  Prevention	
 .  ............................................................................................................	
 7  7	
   Transition	
  Planning	
 .  ...........................................................................................................	
 8  1	
   Oversight	
  of	
  Mental	
  Health	
  ...............................................................................................	
 8  6	
   Documentation	
 .  .....................................................................................................................	
 8  9	
   Progress	
  Notes	
.   ..................................................................................................................	
 8  9	
   Accessibility	
  of	
  Information	
 .  ..............................................................................................	
 9  0	
   	
   Medical	
  Services	
  ....................................................................................................................	
 9  1	
   General	
  Medical	
  Care	
  ........................................................................................................	
 9  1	
   Health	
  Records	.
  ..................................................................................................................	
 9  4	
   Access	
  to	
  Health	
  Systems	
  ..................................................................................................	
 9  7	
   	
   Special	
  Education	
  Services	.
  ....................................................................................................	
 9  9	
   Provision	
  of	
  Special	
  Education	
.   ..........................................................................................	
 9  9	
   Individual	
  Education	
  Plans	
.   ..............................................................................................	
 1  02	
   Vocational	
  Education	
.   ......................................................................................................	
 1  04	
  

	
  

2	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 3 of 104 PAGEID #: 1866

	
  
INTRODUCTION	
   	
  

On	
  June	
  4,	
  2008,	
  The	
  United	
  States	
  Department	
  of	
  Justice	
  (DOJ)	
  and	
  the	
  State	
  of	
  Ohio	
  (the	
  

State)	
  signed	
  a	
  stipulation	
  for	
  injunctive	
  relief	
  (the	
  Stipulation)	
  concerning	
  conditions	
  at	
  the	
  

Scioto	
  Juvenile	
  Correctional	
  Facility	
  (Scioto)	
  and	
  the	
  Marion	
  Juvenile	
  Correctional	
  Facility	
  

(Marion;	
  which	
  was	
  closed	
  shortly	
  after	
  the	
  Stipulation	
  was	
  signed).	
  Fred	
  Cohen,	
  the	
  Lead	
  

Monitor	
  of	
  the	
  concurrent	
  conditions	
  of	
  confinement	
  lawsuit,	
  S.H.	
  v	
  Stickrath	
  et	
  al.,	
  served	
  

as	
  the	
  monitor	
  for	
  the	
  Stipulation	
  until	
  late	
  2009.	
  At	
  that	
  point,	
  Mr.	
  Cohen	
  resigned	
  and	
  the	
  

DOJ	
  assumed	
  the	
  role	
  of	
  Monitor,	
  with	
  Dr.	
  Kelly	
  Dedel,	
  Dr.	
  Daphne	
  Glindmeyer,	
  and	
  Dr.	
  

Michelle	
  Staples-­‐Horne	
  serving	
  as	
  subject	
  matter	
  experts.	
  	
  

	
  

As	
  the	
  original	
  stipulation	
  expired,	
  the	
  Parties	
  recognized	
  that	
  the	
  State	
  had	
  not	
  yet	
  reached	
  

substantial	
  compliance	
  with	
  several	
  key	
  portions	
  of	
  the	
  Stipulation.	
  Thus,	
  the	
  Stipulation	
  

was	
  renegotiated	
  to	
  include	
  a	
  subset	
  of	
  the	
  original	
  provisions.	
  The	
  Amended	
  Stipulation	
  

terminates	
  when	
  the	
  State	
  has	
  achieved	
  substantial	
  compliance	
  with	
  each	
  provision	
  and	
  has	
  

maintained	
  substantial	
  compliance	
  for	
  two	
  reporting	
  periods	
  (i.e.,	
  12	
  months).	
  The	
  Parties	
  

also	
  agreed	
  that	
  the	
  Amended	
  Stipulation	
  is	
  subject	
  to	
  the	
  termination	
  provisions	
  of	
  the	
  

Prison	
  Litigation	
  Reform	
  Act.	
  	
  

	
  

The	
  Monitor	
  for	
  the	
  Amended	
  Stipulation	
  is	
  Dr.	
  Kelly	
  Dedel,	
  who	
  evaluates	
  the	
  State’s	
  

progress	
  in	
  the	
  areas	
  of	
  Protection	
  From	
  Harm,	
  Grievances,	
  Programming	
  and	
  Special	
  

Education.	
  She	
  is	
  assisted	
  by	
  two	
  Subject	
  Matter	
  Experts,	
  Dr.	
  Daphne	
  Glindmeyer,	
  who	
  

evaluates	
  the	
  State’s	
  progress	
  on	
  provisions	
  related	
  to	
  Mental	
  Health	
  Services,	
  and	
  Dr.	
  

Michelle	
  Staples-­‐Horne,	
  who	
  evaluates	
  the	
  State’s	
  progress	
  on	
  provisions	
  related	
  to	
  Medical	
  

Care.	
  	
  

	
  

As	
  the	
  Monitor,	
  Dr.	
  Dedel	
  is	
  the	
  primary	
  liaison	
  between	
  the	
  Monitoring	
  Team	
  and	
  the	
  

Parties	
  and	
  she	
  compiles	
  the	
  Monitor’s	
  Report.	
  To	
  do	
  so,	
  she	
  combines	
  Drs.	
  Glindmeyer’s	
  

and	
  Staples-­‐Horne’s	
  reports	
  with	
  her	
  own	
  to	
  form	
  a	
  coherent	
  whole,	
  but	
  does	
  not	
  change	
  

the	
  substance	
  of	
  the	
  reports	
  by	
  either	
  of	
  the	
  Subject	
  Matter	
  Experts,	
  who	
  are	
  responsible	
  

for	
  forming	
  their	
  own	
  opinions	
  about	
  the	
  level	
  of	
  compliance	
  for	
  each	
  provision	
  in	
  their	
  

areas	
  of	
  expertise.	
  	
  

	
  

This	
  is	
  the	
  Monitor’s	
  first	
  report	
  on	
  the	
  State’s	
  progress	
  toward	
  the	
  reforms	
  required	
  by	
  the	
  

Amended	
  Stipulation.	
  The	
  monitoring	
  period	
  is	
  June	
  4,	
  2011	
  through	
  October	
  31,	
  2011.	
  

Progress	
  reports	
  will	
  be	
  issued	
  approximately	
  every	
  six	
  months	
  hereafter.	
  	
  

	
  

	
  

	
  

	
  

3	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 4 of 104 PAGEID #: 1867

EXECUTIVE	
  SUMMARY	
  
	
   The	
  Amended	
  Stipulation	
  includes	
  33	
  provisions	
  related	
  to	
  Protection	
  From	
  Harm	
  (n=3);	
   Grievances	
  (n=2);	
  Programming	
  (n=2);	
  Mental	
  Health	
  Care	
  (n=18)	
  and	
  Documentation	
  (n=2);	
   Medical	
  Care	
  (n=3);	
  and	
  Special	
  Education	
  (n=3).	
  Each	
  provision	
  is	
  listed	
  in	
  the	
  table	
  below,	
   along	
  with	
  the	
  Monitor’s	
  or	
  Subject	
  Matter	
  Expert’s	
  compliance	
  rating.	
  	
   	
   The	
  following	
  compliance	
  ratings	
  are	
  used	
  throughout	
  this	
  report:	
   	
  
• Substantial	
  Compliance	
  means	
  that	
  the	
  facility	
  has	
  drafted	
  relevant	
  policies	
  and	
   procedures;	
  has	
  trained	
  the	
  staff	
  responsible	
  for	
  implementation;	
  has	
  sufficient	
  staff	
   to	
  implement	
  the	
  required	
  reform;	
  has	
  demonstrated	
  the	
  ability	
  to	
  properly	
   implement	
  the	
  procedures	
  during	
  the	
  majority	
  of	
  the	
  monitoring	
  period;	
  and	
  has	
   ascertained	
  that	
  the	
  procedures	
  accomplish	
  the	
  outcome	
  envisioned	
  by	
  the	
   provision.	
  Non-­‐compliance	
  with	
  mere	
  technicalities	
  or	
  a	
  temporary	
  failure	
  to	
  comply	
   (due	
  to	
  staff	
  vacancy	
  or	
  illness,	
  facility	
  disruptions,	
  or	
  other	
  short-­‐term	
  events)	
   during	
  an	
  otherwise	
  sustained	
  period	
  of	
  compliance	
  do	
  not	
  constitute	
  a	
  failure	
  to	
   achieve	
  or	
  maintain	
  substantial	
  compliance.	
  Conversely,	
  temporary	
  compliance	
   during	
  a	
  period	
  of	
  sustained	
  non-­‐compliance	
  does	
  not	
  constitute	
  substantial	
   compliance.	
   	
  
• Non-­‐Compliance	
  means	
  that	
  the	
  facility	
  has	
  not	
  drafted	
  relevant	
  policies	
  and	
   procedures;	
  and/or	
  has	
  not	
  trained	
  the	
  staff	
  responsible	
  for	
  implementation;	
  and/or	
   does	
  not	
  have	
  sufficient	
  staff	
  to	
  implement	
  the	
  required	
  reform;	
  and/or	
  has	
  not	
   implemented	
  the	
  procedures	
  over	
  a	
  significant	
  period	
  of	
  time;	
  and/or	
  has	
  not	
  yet	
   ascertained	
  whether	
  the	
  procedures	
  accomplish	
  the	
  outcome	
  envisioned	
  by	
  the	
   provision.	
  
	
   	
   	
   	
  
Table	
  1.	
  Compliance	
  Ratings	
  for	
  Each	
  Provision	
  

No	
  

Provision	
  

Rating	
  

Protection	
  From	
  Harm	
  

III.A.	
  1	
   General	
  Protection	
  From	
  Harm	
  

NC	
  

III.A.3	
  

Seclusion	
  

NC	
  

III.A.5	
  

Investigation	
  of	
  Serious	
  Incidents	
  

SC	
  

III.D.1	
  

Grievances	
  

NC	
  

III.D.2	
  

Grievances	
  Explained	
  to	
  Youth	
  

NC	
  

III.F.1	
  

Structured	
  Programming	
  

NC	
  

III.F.2	
  

Orientation	
  

NC	
  

	
  

4	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 5 of 104 PAGEID #: 1868

Mental	
  Health	
  Services	
  

III.B.1	
  

Mental	
  Health	
  Screening	
  

NC	
  

III.B.2	
  

Immediate	
  Referral	
  to	
  QMHP	
  

NC	
  

III.B.3	
  

Identification	
  of	
  Previously	
  Unidentified	
  Youth	
  	
  

NC	
  

III.B.4	
  

Mental	
  Health	
  Assessment	
  

NC	
  

III.B.5	
  

Adequate	
  Care	
  and	
  Treatment	
  

NC	
  

III.B.6	
  

Treatment	
  Planning	
  

NC	
  

III.B.7	
  

Treatment	
  Teams	
  

NC	
  

III.B.8	
  

Integrated	
  Treatment	
  Plans	
  

NC	
  

III.B.9	
  

Access	
  to	
  QMHP	
  

NC	
  

III.B.10	
   Mental	
  Health	
  Involvement	
  in	
  Housing	
  and	
  Plcmt	
  

NC	
  

III.B.11	
   Staffing	
  

NC	
  

III.B.12	
   Medication	
  Notice	
  

NC	
  

III.B.13	
   Mental	
  Health	
  Medications	
  

NC	
  

III.B.14	
   MH/DD	
  Training	
  for	
  Direct	
  Care	
  Staff	
  

NC	
  

III.B.15	
   Staff	
  Mental	
  Health	
  Training	
  

NC	
  

III.B.16	
   Suicide	
  Prevention	
  

NC	
  

III.B.17	
   Transition	
  Planning	
  

NC	
  

III.B.18	
   Oversight	
  of	
  Mental	
  Health	
  

NC	
  

III.G.1	
  

Progress	
  Notes	
  

NC	
  

III.G.2	
  

Accessibility	
  of	
  Information	
  

NC	
  

Medical	
  Services	
  

III.C.1	
  

General	
  Medical	
  Care	
  

SC	
  

III.C.2	
  

Health	
  Records	
  

SC	
  

III.C.5	
  

Access	
  to	
  Health	
  Services	
  

SC	
  

Special	
  Education	
  Services	
  

III.E.1	
  

Provision	
  of	
  Special	
  Education	
  

NC	
  

III.E.7	
  

Individual	
  Education	
  Plans	
  

NC	
  

III.E.8	
  

Vocational	
  Education	
  

NC	
  

	
   	
   Overall,	
  the	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  4	
  of	
  the	
  33	
  provisions	
  (15%).	
  Compliance	
   ratings	
  for	
  each	
  section	
  and	
  key	
  issues	
  to	
  be	
  addressed	
  are	
  highlighted	
  below.	
  	
  

	
  

5	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 6 of 104 PAGEID #: 1869
	
   Protection	
  from	
  Harm	
  (includes	
  Grievances	
  and	
  Programming)	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  1	
  of	
  the	
  7	
  provisions	
  (14%)	
  related	
  to	
  protecting	
   youth	
  from	
  harm.	
  Two	
  provisions,	
  those	
  related	
  to	
  the	
  Grievance	
  process,	
  require	
  only	
  very	
   minor	
  actions	
  to	
  reach	
  substantial	
  compliance.	
  More	
  significant	
  concerns	
  plague	
  the	
  other	
   provisions	
  and	
  the	
  following	
  actions	
  should	
  be	
  prioritized:	
   	
  
• Determine	
  the	
  underlying	
  causes	
  of	
  youth	
  violence	
  and	
  enact	
  targeted	
  violence	
   prevention	
  strategies	
  to	
  reduce	
  youth-­‐on-­‐youth	
  and	
  youth-­‐on-­‐staff	
  assaults.	
  	
  
• Address	
  the	
  pattern	
  of	
  perceptions	
  by	
  female	
  residents	
  that	
  some	
  staff	
  speak	
  or	
   behave	
  in	
  sexually	
  inappropriate	
  ways.	
  Expand	
  the	
  dialog	
  among	
  administrators,	
   girls	
  and	
  staff	
  about	
  this	
  issue	
  to	
  ensure	
  that	
  the	
  facility	
  is	
  aware	
  of	
  and	
  addresses	
  all	
   such	
  perceptions.	
  	
  
• Decrease	
  the	
  reliance	
  on	
  regular	
  seclusion	
  to	
  respond	
  to	
  mid-­‐level,	
  non-­‐violent	
   misconduct.	
  	
  
• Address	
  staff	
  shortages	
  to	
  ensure	
  sufficient	
  personnel	
  are	
  available	
  to	
  provide	
  youth	
   with	
  safe	
  access	
  to	
  a	
  full	
  range	
  of	
  programming.	
  	
  
• Improve	
  the	
  quality	
  of	
  internal	
  investigations.	
  	
   • Expand	
  the	
  PROGRESS	
  Unit’s	
  program	
  design	
  to	
  ensure	
  treatment	
  plans	
  and	
  
treatment	
  team	
  meetings	
  are	
  focused	
  around	
  realistic,	
  measurable	
  goals	
  and	
  that	
   data	
  are	
  routinely	
  captured	
  to	
  assess	
  youth	
  progress	
  and	
  readiness	
  to	
  transition	
  to	
   the	
  general	
  population.	
  	
   • Ensure	
  that	
  youth	
  admitted	
  to	
  the	
  PROGRESS	
  Unit	
  receive	
  a	
  timely,	
  comprehensive	
   Orientation.	
  	
   • Ensure	
  youth	
  have	
  access	
  to	
  a	
  full	
  range	
  of	
  structured	
  programming	
  so	
  that	
  idle	
  time	
   is	
  kept	
  to	
  a	
  minimum,	
  particularly	
  among	
  youth	
  who	
  have	
  graduated	
  from	
  high	
   school	
  or	
  obtained	
  a	
  GED.	
  	
   	
   	
   Mental	
  Health	
  Services	
   	
   The	
  facility	
  is	
  not	
  in	
  substantial	
  compliance	
  with	
  any	
  (0%)	
  of	
  the	
  18	
  provisions	
  related	
  to	
   mental	
  health	
  services.	
  The	
  following	
  actions	
  are	
  required:	
   • Review	
  and	
  revise	
  policies	
  and	
  procedures,	
  as	
  needed,	
  to	
  ensure	
  they	
  are	
   compatible	
  with	
  the	
  facility’s	
  new	
  mission	
  as	
  a	
  long-­‐term	
  placement.	
   • Adequately	
  staff	
  the	
  facility	
  with	
  qualified	
  social	
  workers,	
  clinicians,	
  psychiatrists	
   and	
  psychiatric	
  nurses	
  so	
  that	
  mental	
  health	
  treatment	
  can	
  be	
  implemented	
  to	
  meet	
   the	
  needs	
  of	
  all	
  youth.	
  Increase	
  psychiatry	
  clinical	
  resources.	
  	
   • Develop	
  an	
  organized	
  training	
  schedule	
  for	
  mental	
  health	
  staff.	
  	
   • Train	
  direct	
  care	
  staff	
  and	
  mental	
  health	
  staff	
  to	
  understand	
  the	
  behavior	
  and	
  needs	
   of	
  youth	
  with	
  mental	
  illnesses	
  and	
  developmental	
  disabilities	
  and	
  recognize	
  and	
   respond	
  to	
  signs	
  and	
  symptoms	
  of	
  serious	
  mental	
  illness.	
  	
  

	
  

6	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 7 of 104 PAGEID #: 1870

• Train	
  mental	
  health	
  staff	
  to	
  develop	
  high-­‐quality	
  case	
  conceptualizations	
  that	
   integrate	
  the	
  information	
  generated	
  by	
  the	
  multiple	
  assessments	
  administered	
  to	
   youth	
  upon	
  admission.	
  	
  
• Train,	
  coach	
  and	
  adequately	
  supervise	
  direct	
  care	
  staff	
  and	
  mental	
  health	
  staff	
  to	
   implement	
  the	
  Phoenix	
  New	
  Freedom	
  curriculum,	
  particularly	
  in	
  skills	
  for	
  leading	
   group	
  therapy	
  sessions	
  to	
  ensure	
  the	
  interactions	
  and	
  documentation	
  reflect	
   generally	
  accepted	
  practices	
  for	
  mental	
  health	
  care.	
  	
  
• Ensure	
  all	
  screenings	
  are	
  completed	
  within	
  24	
  hours	
  of	
  the	
  youth’s	
  admission.	
   • Provide	
  a	
  written	
  rationale	
  for	
  all	
  placement	
  decisions	
  by	
  the	
  Behavior	
  Review	
  
Panel.	
  	
   • Develop	
  procedures	
  to	
  ensure,	
  and	
  to	
  document,	
  that	
  youth	
  are	
  assessed	
  by	
  a	
  
qualified	
  mental	
  health	
  professional	
  within	
  12	
  hours	
  when	
  a	
  serious	
  risk	
  to	
  the	
   youth’s	
  safety	
  is	
  identified.	
  	
   • Ensure	
  mental	
  health	
  staff	
  assesses	
  youth	
  on	
  suicide	
  precautions,	
  those	
  in	
  seclusion,	
   and	
  those	
  on	
  the	
  Progress	
  Units	
  every	
  24	
  hours.	
  	
   • Ensure	
  youth	
  with	
  acute	
  mental	
  illnesses	
  requiring	
  extensive	
  mental	
  health	
   treatment	
  have	
  access	
  to	
  more	
  appropriate	
  placements.	
   • Ensure	
  treatment	
  plans	
  are	
  individualized	
  including	
  measurable	
  goals	
  and	
  targeted	
   interventions	
  to	
  address	
  the	
  goals.	
  Update	
  treatment	
  plans	
  regularly	
  and	
  monitor	
   youth’s	
  progress	
  toward	
  achieving	
  treatment	
  goals.	
  Adapt	
  treatment	
  plans	
  for	
  youth	
   who	
  are	
  not	
  progressing.	
   • Ensure	
  Interdisciplinary	
  Treatment	
  Team	
  meetings	
  include	
  representatives	
  from	
  the	
   major	
  sectors	
  of	
  the	
  facility	
  including	
  social	
  workers,	
  direct	
  care	
  staff	
  and	
   psychiatrists	
  and	
  that	
  Treatment	
  Teams	
  are	
  focused	
  on	
  treatment	
  issues	
  and	
  the	
   youth’s	
  progress	
  toward	
  treatment	
  goals.	
   • Ensure	
  youth	
  on	
  the	
  Progress	
  Units	
  are	
  appropriate	
  for	
  the	
  secure	
  setting	
  and	
   receive	
  appropriate	
  treatment.	
  Conduct	
  thorough	
  assessments	
  of	
  all	
  youth	
  currently	
   housed	
  on	
  the	
  Progress	
  Units	
  and	
  those	
  proposed	
  for	
  placement	
  in	
  the	
  future.	
  	
   • Ensure	
  youth	
  receive	
  proper	
  laboratory	
  examinations	
  and	
  side-­‐effect	
  monitoring	
   commensurate	
  with	
  the	
  psychotropic	
  medications	
  prescribed	
  and	
  reflecting	
   generally	
  accepted	
  practices.	
  	
   • Beginning	
  at	
  admission,	
  hold	
  structured	
  discussions	
  in	
  Treatment	
  Team	
  meetings	
   about	
  discharge	
  needs	
  and	
  appropriate	
  community	
  services.	
  Ensure	
  aftercare	
   appointments	
  and	
  linkages	
  are	
  set	
  up	
  prior	
  to	
  youths’	
  release	
  from	
  Scioto.	
  	
   • Develop	
  a	
  coherent,	
  coordinated	
  quality	
  assurance	
  process	
  that	
  provides	
  a	
  cogent	
   review	
  of	
  social	
  work,	
  psychological	
  and	
  psychiatric	
  services	
  at	
  the	
  facility.	
  	
   	
   	
   Medical	
  Services	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  all	
  3	
  (100%)	
  of	
  the	
  provisions	
  related	
  to	
  medical	
   services.	
  The	
  following	
  suggestions	
  are	
  offered	
  in	
  the	
  spirit	
  of	
  continually	
  improving	
  those	
   services,	
  and	
  are	
  discussed	
  in	
  greater	
  detail	
  under	
  the	
  relevant	
  provision:	
   • Expand	
  the	
  immunization	
  program	
  to	
  Include	
  Hepatitis	
  A	
  and	
  HPV	
  vaccinations	
  of	
   youth.	
  	
  

	
  

7	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 8 of 104 PAGEID #: 1871

• Develop	
  protocols	
  for	
  decontamination	
  and	
  medical	
  assessment	
  of	
  youth	
  after	
   exposure	
  to	
  OC	
  spray.	
  	
  
• Provide	
  AEDs	
  (Automated	
  External	
  Defibrillators)	
  on	
  site,	
  train	
  staff	
  in	
  its	
  use	
  and	
   include	
  them	
  in	
  the	
  Emergency	
  Medical	
  Response	
  and	
  Services	
  Policy.	
  
• Improve	
  completeness	
  of	
  youth	
  Problem	
  List	
  in	
  health	
  record	
  to	
  include	
  all	
  chronic	
   diagnoses,	
  including	
  mental	
  health,	
  substance	
  abuse	
  and	
  acute	
  diagnoses	
  such	
  as	
   headache,	
  shoulder	
  pain,	
  etc.	
  
• Improve	
  Quality	
  Assurance	
  (QA)	
  activities	
  by	
  considering	
  a	
  review	
  at	
  least	
  annually	
   by	
  a	
  source	
  external	
  to	
  ODYS	
  Health	
  Services.	
  ODYS	
  should	
  also	
  consider	
  expansion	
   of	
  the	
  QA	
  process	
  to	
  include	
  some	
  additional	
  quality	
  indicators.	
  
• Continue	
  to	
  improve	
  process	
  for	
  sharing	
  of	
  health	
  information	
  between	
  medical	
  and	
   mental	
  health	
  to	
  include	
  psychologists.	
  Consider	
  implementation	
  of	
  electronic	
   health	
  record	
  or	
  if	
  not	
  possible	
  now,	
  allow	
  medical	
  staff	
  to	
  access	
  to	
  the	
  Mental	
   Health	
  database.	
  
• Continue	
  to	
  review	
  and	
  update	
  policies	
  and	
  procedures	
  annually.	
  Reduce	
  length	
  of	
   policies	
  and	
  procedures	
  and	
  attempt	
  to	
  consolidate	
  some.	
  	
  	
  
• Encourage	
  youth	
  to	
  complete	
  Health	
  Call	
  forms	
  in	
  non-­‐emergency	
  situations	
  in	
   order	
  to	
  fully	
  document	
  medical	
  responses	
  to	
  youth	
  requests.	
  	
  
	
   	
   Special	
  Education	
   	
   The	
  facility	
  is	
  not	
  in	
  substantial	
  compliance	
  with	
  any	
  of	
  the	
  3	
  education-­‐related	
  provisions	
   (0%).	
  The	
  following	
  actions	
  should	
  be	
  prioritized:	
  
• Improve	
  the	
  documentation	
  of	
  Unit	
  Instruction	
  and	
  ascertain	
  whether	
  youth	
  receive	
   the	
  required	
  education	
  services	
  while	
  serving	
  time	
  in	
  disciplinary	
  seclusion.	
  	
  
• Increase	
  attendance	
  rates	
  among	
  youth	
  on	
  the	
  PROGRESS	
  units.	
  	
   • Improve	
  the	
  quality	
  of	
  IEP	
  progress	
  reporting	
  to	
  ensure	
  reports	
  are	
  grounded	
  in	
  data	
  
that	
  are	
  responsive	
  to	
  a	
  set	
  of	
  realistic,	
  measurable	
  IEP	
  goals.	
   • Develop	
  sufficient	
  vocational	
  opportunities	
  to	
  meet	
  the	
  needs	
  of	
  the	
  population	
  of	
  
Scioto	
  students	
  and	
  graduates.	
  	
   	
   	
   	
   The	
  facility	
  has	
  undergone	
  a	
  massive	
  transformation	
  since	
  the	
  Stipulation	
  was	
  amended.	
   Originally,	
  Scioto	
  was	
  the	
  central	
  reception	
  facility	
  for	
  all	
  DYS	
  facilities.	
  In	
  the	
  summer	
  of	
   2011,	
  DYS	
  began	
  to	
  de-­‐centralize	
  its	
  reception	
  process	
  to	
  convert	
  Scioto	
  to	
  a	
  long-­‐term	
   facility	
  that	
  houses	
  medium	
  and	
  close	
  custody	
  boys.	
  Scioto	
  remains	
  the	
  reception	
  center	
  for	
   girls	
  and	
  also	
  operates	
  a	
  long-­‐term	
  girls’	
  program	
  and	
  a	
  mental	
  health	
  unit	
  for	
  girls.	
  The	
   facility	
  has	
  struggled	
  mightily	
  with	
  these	
  changes	
  which	
  is	
  disheartening	
  given	
  the	
  significant	
   progress	
  toward	
  compliance	
  with	
  the	
  Stipulation	
  Scioto	
  had	
  made	
  as	
  a	
  reception	
  center.	
   With	
  the	
  change	
  in	
  target	
  population	
  came	
  a	
  set	
  of	
  new	
  problems,	
  with	
  different	
  dynamics,	
   and	
  different	
  solutions	
  than	
  the	
  challenges	
  that	
  had	
  been	
  conquered	
  in	
  the	
  past.	
  Facility	
   administrators	
  and	
  staff	
  are	
  commended	
  for	
  their	
  adaptability	
  and	
  encouraged	
  to	
  apply	
  the	
   same	
  level	
  of	
  problem	
  solving	
  and	
  commitment	
  to	
  the	
  new	
  challenges	
  they	
  face.	
  	
  

	
  

8	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 9 of 104 PAGEID #: 1872

PROTECTION	
  FROM	
  HARM	
  	
  
	
   	
  
III.A.1	
  General	
  Protection	
  From	
  Harm.	
  The	
  State	
  shall,	
  at	
  all	
  times,	
  provide	
  youth	
  in	
  the	
   facilities	
  with	
  safe	
  living	
  conditions.	
  As	
  part	
  of	
  this	
  requirement,	
  the	
  State	
  shall	
  take	
   appropriate	
  measures	
  to	
  ensure	
  that	
  youth	
  are	
  protected	
  from	
  abuse	
  and	
  neglect,	
  use	
  of	
   excessive	
  force,	
  undue	
  seclusion,	
  undue	
  restraint,	
  and	
  over-­‐familiarization.	
  	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

The	
  State	
  provided	
  an	
  array	
  of	
  data	
  to	
  illustrate	
  the	
  trends	
  in	
  youth	
   violence,	
  restraints,	
  seclusion,	
  and	
  allegations	
  of	
  employee	
   misconduct,	
  along	
  with	
  an	
  interpretation	
  of	
  the	
  trends	
  and	
  the	
   underlying	
  causes	
  of	
  recent	
  increases.	
  While	
  the	
  interpretation	
  of	
   these	
  data	
  leads	
  to	
  significant	
  concern	
  for	
  the	
  safety	
  of	
  youth	
  and	
   staff	
  at	
  Scioto,	
  the	
  fact	
  that	
  the	
  facility	
  continues	
  to	
  be	
  able	
  to	
  collect	
   and	
  analyze	
  an	
  array	
  of	
  data	
  related	
  to	
  key	
  indicators	
  of	
  youth	
  safety	
   is	
  very	
  positive.	
  Without	
  this	
  capacity,	
  the	
  facility	
  would	
  be	
  unable	
  to	
   craft	
  new	
  violence	
  prevention	
  initiatives	
  to	
  address	
  the	
  underlying	
   causes	
  of	
  the	
  youths’	
  behavior.	
  When	
  the	
  facility’s	
  target	
  population	
   changed,	
  so	
  did	
  the	
  factors	
  that	
  contribute	
  to	
  youth	
  violence.	
  In	
  the	
   past,	
  the	
  facility	
  clearly	
  demonstrated	
  its	
  ability	
  to	
  analyze	
  and	
   respond	
  to	
  youth	
  violence	
  in	
  its	
  reception	
  population.	
  It	
  must	
  employ	
   these	
  same	
  skills	
  to	
  its	
  new	
  population	
  of	
  long-­‐term	
  residents.	
  	
  	
   	
   Trends	
  in	
  youth	
  violence,	
  restraints,	
  and	
  allegations	
  of	
  over-­‐ familiarization	
  are	
  discussed	
  here,	
  while	
  detailed	
  discussions	
  about	
   the	
  use	
  of	
  seclusion	
  and	
  staff	
  misconduct	
  can	
  be	
  found	
  in	
  III.A.3	
  and	
   III.A.5	
  respectively.	
  	
   	
   Youth	
  Violence	
   Early	
  in	
  the	
  monitoring	
  period,	
  youth	
  violence	
  was	
  concentrated	
  in	
   two	
  units:	
  Jefferson	
  (younger	
  boys’	
  reception)	
  and	
  Buckeye	
  (boys’	
   intensive	
  mental	
  health	
  program).	
  	
  The	
  State	
  enacted	
  a	
  variety	
  of	
   violence	
  prevention	
  strategies	
  and	
  achieved	
  significant	
  reductions	
  in	
   the	
  rates	
  of	
  youth	
  violence	
  by	
  July	
  2011.	
  	
   	
   As	
  noted	
  in	
  the	
  Introduction,	
  in	
  late	
  Summer	
  2011,	
  Scioto	
  converted	
   from	
  a	
  reception	
  center	
  and	
  boys’	
  mental	
  health	
  unit	
  to	
  a	
  long-­‐term	
   program.	
  Scioto’s	
  boys’	
  program	
  now	
  includes	
  general	
  population	
   housing	
  for	
  medium	
  and	
  close	
  custody	
  boys	
  and	
  a	
  maximum-­‐security	
   segregation	
  unit.	
  Scioto’s	
  girls’	
  program	
  continues	
  to	
  include	
   reception,	
  general	
  population	
  and	
  an	
  intensive	
  mental	
  health	
   program.	
  With	
  this	
  conversion	
  came	
  rather	
  immediate	
  and	
  significant	
   increases	
  in	
  the	
  rates	
  of	
  youth	
  violence.	
  In	
  contrast	
  to	
  the	
  previous	
   eight	
  months	
  where	
  the	
  average	
  rate	
  of	
  youth	
  violence	
  was	
  .34,	
  the	
  

	
  

9	
  

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rate	
  of	
  youth	
  violence	
  in	
  September	
  2011	
  increased	
  60%	
  to	
  .54.	
  	
   Nearly	
  all	
  of	
  this	
  increase	
  can	
  be	
  attributed	
  to	
  a	
  increase	
  in	
  gang	
   recruitment	
  activity,	
  in	
  which	
  initiation	
  rites	
  required	
  youth	
  to	
  assault	
   staff.	
  In	
  contrast	
  to	
  the	
  previous	
  eight	
  months	
  where	
  the	
  average	
   number	
  of	
  assaults	
  on	
  staff	
  was	
  12,	
  in	
  September	
  2011,	
  the	
  number	
   increased	
  nearly	
  400%	
  to	
  45	
  assaults	
  on	
  staff.	
  	
   	
   Restraints	
   Compared	
  to	
  the	
  previous	
  eight	
  months,	
  the	
  rates	
  of	
  physical	
   restraint	
  and	
  use	
  of	
  handcuffs	
  more	
  than	
  doubled	
  in	
  September	
  2011.	
   These	
  increases	
  are	
  commensurate	
  with	
  the	
  increases	
  in	
  acts	
  of	
   violence,	
  discussed	
  above.	
  	
   	
   Over	
  the	
  past	
  six	
  months,	
  Scioto	
  investigated	
  17	
  allegations	
  of	
   excessive	
  or	
  inappropriate	
  uses	
  of	
  force.	
  Six	
  of	
  these	
  (35%)	
  were	
   substantiated.	
  As	
  discussed	
  in	
  more	
  detail	
  in	
  Provision	
  III.A.5,	
  most	
  of	
   the	
  substantiated	
  cases	
  were	
  for	
  relatively	
  minor	
  violations	
  of	
  the	
  use	
   of	
  force	
  policy.	
  Further,	
  while	
  the	
  number	
  of	
  excessive	
  use	
  of	
  force	
   allegations	
  seems	
  high	
  in	
  comparison	
  to	
  other	
  facilities	
  of	
  a	
  similar	
   size,	
  the	
  facility’s	
  well-­‐developed	
  use	
  of	
  force	
  review	
  and	
  its	
  vigilance	
   surrounding	
  adherence	
  to	
  policy	
  and	
  procedure	
  may	
  translate	
  to	
  a	
   higher	
  number	
  of	
  referrals,	
  but	
  also	
  to	
  greater	
  protection	
  from	
  harm	
   by	
  staff.	
  	
   	
   Thus,	
  with	
  the	
  change	
  in	
  the	
  facility’s	
  mission	
  came	
  a	
  rather	
   immediate	
  spike	
  in	
  youth	
  violence	
  and	
  restraints.	
  The	
  extent	
  to	
  which	
   these	
  increases	
  will	
  be	
  short-­‐lived	
  or	
  will	
  persist	
  over	
  time	
  will	
  depend	
   on	
  the	
  State’s	
  success	
  in	
  identifying	
  the	
  underlying	
  causes	
  (e.g.,	
  gang	
   activity)	
  and	
  to	
  enact	
  evidence-­‐based	
  solutions	
  that	
  respond	
  to	
  these	
   dynamics.	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

In	
  addition	
  to	
  reviewing	
  the	
  data	
  presented	
  by	
  the	
  State	
  in	
  its	
  self-­‐ assessment,	
  the	
  Monitor	
  also	
  reviewed	
  information	
  gathered	
  by	
  the	
   DOJ	
  related	
  to	
  allegations	
  of	
  over-­‐familiarization	
  by	
  staff	
  and	
  the	
   circumstances	
  surrounding	
  a	
  major	
  tactical	
  operation	
  that	
  occurred	
  in	
   September	
  2011.	
  	
   	
   Over-­‐Familiarization	
   While	
  on	
  site	
  in	
  October	
  2011,	
  the	
  DOJ	
  interviewed	
  several	
  female	
   youth	
  who	
  alleged	
  that	
  some	
  staff	
  speak	
  to	
  them	
  and	
  behave	
  in	
   sexually	
  inappropriate	
  ways.	
  The	
  allegations	
  included	
  inappropriate	
   touching	
  on	
  the	
  buttocks,	
  sexual	
  propositions	
  and	
  language,	
   comments	
  about	
  the	
  girls’	
  bodies,	
  and	
  sexual	
  relationships	
  between	
   staff	
  and	
  youth.	
  The	
  DOJ	
  has	
  received	
  similar	
  allegations	
  during	
  each	
   of	
  its	
  prior	
  visits	
  to	
  the	
  facility	
  and	
  has	
  made	
  the	
  facility	
  aware	
  of	
   some	
  of	
  the	
  details	
  of	
  each	
  allegation.	
  However,	
  wanting	
  their	
  

	
  

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conversations	
  with	
  youth	
  to	
  remain	
  confidential,	
  the	
  DOJ	
  has	
  chosen	
   not	
  to	
  reveal	
  the	
  names	
  of	
  the	
  youth	
  making	
  the	
  allegations.	
  Further,	
   in	
  some	
  cases,	
  the	
  alleged	
  victims	
  did	
  not	
  know	
  or	
  want	
  to	
  report	
  the	
   name	
  of	
  the	
  staff	
  member	
  who	
  was	
  alleged	
  to	
  have	
  been	
   inappropriate	
  with	
  them.	
  DOJ	
  reported	
  the	
  most	
  recent	
  allegations	
  to	
   the	
  State	
  in	
  a	
  letter	
  dated	
  November	
  2,	
  2011.	
  The	
  State	
  responded	
   with	
  a	
  letter	
  of	
  its	
  own,	
  dated	
  November	
  30,	
  2011,	
  contesting	
  that	
   the	
  lack	
  of	
  detail	
  provided	
  by	
  the	
  DOJ	
  was	
  not	
  conducive	
  to	
   reasonable	
  and	
  effective	
  investigations.	
  	
   	
   While	
  the	
  Monitor	
  agrees	
  that	
  without	
  knowing	
  the	
  identity	
  of	
  the	
   alleged	
  victim,	
  the	
  State’s	
  ability	
  to	
  investigate	
  the	
  specific	
  allegations	
   heard	
  by	
  DOJ	
  is	
  very	
  limited.	
  However,	
  given	
  that	
  the	
  DOJ	
  hears	
  such	
   allegations	
  every	
  time	
  it	
  interviews	
  youth	
  at	
  Scioto,	
  the	
  persistence	
  of	
   the	
  youth’s	
  perceptions	
  that	
  some	
  staff	
  are	
  sexually	
  inappropriate	
  is	
   concerning	
  and	
  needs	
  to	
  be	
  addressed.	
  While	
  the	
  State	
  receives	
  a	
  few	
   similar	
  allegations	
  through	
  its	
  grievance	
  process,	
  the	
  frequency	
  and	
   seriousness	
  of	
  the	
  allegations	
  does	
  not	
  mirror	
  those	
  noted	
  by	
  the	
   DOJ.	
  In	
  an	
  effort	
  to	
  reconcile	
  the	
  two	
  positions,	
  the	
  Monitor	
   recommends	
  that	
  the	
  State	
  launch	
  a	
  proactive	
  initiative	
  to	
  expand	
  the	
   discussion	
  about	
  this	
  topic	
  with	
  both	
  youth	
  and	
  staff.	
  The	
  youth	
   initiative	
  could	
  include	
  an	
  Ombudsman	
  (or	
  another	
  individual	
  who	
  is	
   trusted	
  by	
  youth	
  and	
  is	
  skilled	
  at	
  talking	
  with	
  youth	
  about	
  sensitive	
   issues)	
  who	
  holds	
  on-­‐going	
  group	
  and	
  individual	
  meetings	
  with	
  girls	
  to	
   hear	
  their	
  complaints	
  or	
  concerns	
  about	
  sexually	
  inappropriate	
   behavior	
  or	
  language	
  from	
  staff.	
  The	
  staff	
  part	
  of	
  the	
  initiative	
  could	
   include	
  training	
  (e.g.,	
  short	
  sessions	
  during	
  shift	
  briefing	
  or	
  at	
  all-­‐staff	
   meetings)	
  discussing	
  the	
  prohibitions	
  on	
  sexualized	
  language	
  and	
   behavior	
  with	
  youth	
  and	
  also	
  how	
  to	
  recognize	
  and	
  respond	
  to	
  over-­‐ familiarization	
  issues	
  when	
  working	
  with	
  youth.	
  Again,	
  the	
  State	
  is	
   indeed	
  limited	
  in	
  its	
  ability	
  to	
  investigate	
  specific	
  allegations	
  absent	
   identifying	
  information;	
  however,	
  given	
  the	
  pattern	
  of	
  such	
   allegations	
  received	
  by	
  the	
  DOJ,	
  the	
  State	
  needs	
  to	
  be	
  proactive	
  in	
  its	
   efforts	
  to	
  expand	
  the	
  conversation	
  around	
  this	
  issue	
  with	
  both	
  youth	
   and	
  staff.	
  	
   	
   Operation	
  Safety	
  First	
   In	
  response	
  to	
  the	
  increasing	
  violence	
  at	
  Scioto	
  and	
  also	
  at	
  DYS’	
   Circleville	
  facility,	
  the	
  Department	
  launched	
  Operation	
  Safety	
  First.	
   This	
  operation	
  targeted	
  a	
  set	
  of	
  highly	
  aggressive	
  youth	
  and	
   entrenched	
  gang	
  leaders	
  for	
  transfer	
  to	
  a	
  maximum-­‐security	
   segregation	
  unit	
  at	
  Scioto.	
  The	
  heightened	
  security	
  features	
  of	
  the	
   unit	
  were	
  designed	
  to	
  decrease	
  the	
  youth’s	
  access	
  to	
  potential	
   victims.	
  The	
  DYS	
  utilized	
  a	
  tactical	
  team	
  from	
  Ohio’s	
  adult	
  prison	
   system	
  (the	
  DRC’s	
  STAR	
  team)	
  to	
  effect	
  the	
  transfer	
  of	
  youth.	
  	
  

	
  

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   Although	
  by	
  policy	
  DYS	
  staff	
  are	
  not	
  permitted	
  to	
  use	
  Oleoresin	
   Capsicum	
  (OC)	
  spray,	
  the	
  DYS’	
  agreement	
  with	
  the	
  DRC	
  permitted	
  the	
   STAR	
  team	
  to	
  use	
  the	
  spray	
  when	
  deemed	
  necessary.	
  During	
  the	
   transfer,	
  one	
  youth	
  was	
  sprayed	
  for	
  resisting	
  transport.	
  Three	
  other	
   Scioto	
  youth	
  who	
  were	
  not	
  part	
  of	
  the	
  transfer	
  were	
  also	
  OC	
  sprayed	
   in	
  response	
  to	
  disruptive	
  behavior.	
  A	
  review	
  of	
  incident	
  reports	
   related	
  to	
  the	
  events	
  and	
  interviews	
  with	
  each	
  of	
  the	
  four	
  Scioto	
   youth	
  who	
  were	
  sprayed	
  suggest	
  that	
  OC	
  spray	
  was	
  used	
  in	
  situations	
   when	
  the	
  youth	
  did	
  not	
  present	
  an	
  immediate	
  threat	
  of	
  serious	
  bodily	
   harm	
  to	
  staff	
  or	
  other	
  youth.	
  	
   	
   Although	
  the	
  youth	
  involved	
  had	
  a	
  history	
  of	
  assaultive	
  behavior,	
   their	
  refusal	
  to	
  follow	
  staff	
  instructions	
  and	
  the	
  level	
  disruption	
  to	
  the	
   operation	
  of	
  the	
  facility	
  was	
  not	
  overly	
  aggressive	
  nor	
  did	
  it	
  present	
   an	
  immediate	
  risk	
  of	
  serious	
  harm	
  to	
  other	
  youth	
  or	
  staff.	
  In	
  fact,	
  one	
   youth	
  was	
  sprayed	
  while	
  he	
  was	
  in	
  handcuffs	
  and	
  several	
  other	
  youth	
   were	
  sprayed	
  through	
  the	
  cuff	
  ports	
  of	
  their	
  cell	
  doors	
  when	
  they	
   posed	
  no	
  danger	
  at	
  all	
  to	
  staff	
  or	
  youth.	
  If	
  they	
  are	
  to	
  be	
  used,	
   generally	
  accepted	
  practices	
  for	
  juvenile	
  correctional	
  facilities	
  limit	
   the	
  use	
  of	
  chemical	
  restraints	
  to	
  only	
  those	
  situations	
  in	
  which	
  less	
   restrictive	
  measures	
  have	
  failed	
  and	
  only	
  when	
  an	
  immediate	
  risk	
  of	
   harm	
  is	
  present.	
  The	
  use	
  of	
  OC	
  spray	
  during	
  Operation	
  Safety	
  First	
   appears	
  to	
  have	
  been	
  unnecessary	
  to	
  maintain	
  control	
  of	
  the	
  youth	
   involved	
  and	
  therefore	
  is	
  of	
  concern	
  to	
  the	
  Monitor.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Continue	
  to	
  utilize	
  aggregate	
  data	
  on	
  youth	
  violence,	
   restraints	
  and	
  seclusion	
  to	
  identify	
  trends	
  that	
  threaten	
  youth	
   and	
  staff	
  safety.	
  	
  
2. Identify	
  the	
  underlying	
  causes	
  of	
  the	
  increases	
  in	
  youth	
   violence	
  and	
  develop	
  targeted	
  violence	
  prevention	
  strategies	
   to	
  address	
  the	
  factors	
  that	
  contribute	
  to	
  assaultive	
  behavior	
   among	
  youth.	
  	
  
3. Launch	
  a	
  proactive	
  initiative	
  to	
  expand	
  the	
  conversation	
   surrounding	
  the	
  perception	
  of	
  female	
  residents	
  that	
  some	
   staff	
  engage	
  in	
  sexually	
  inappropriate	
  talk	
  and	
  behavior.	
   Reinforce	
  the	
  prohibition	
  against	
  this	
  type	
  of	
  behavior	
  with	
   staff	
  and	
  ensure	
  staff	
  know	
  how	
  to	
  recognize	
  and	
  respond	
  to	
   such	
  behavior.	
  	
  
4. Ensure	
  that	
  all	
  restraint	
  practices	
  are	
  aligned	
  with	
  DYS	
  policy,	
   limiting	
  the	
  use	
  of	
  force	
  to	
  only	
  what	
  is	
  necessary	
  to	
  control	
   the	
  immediate	
  risk	
  posed	
  by	
  youth.	
  	
  

Sources	
  of	
  

• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  

	
  

12	
  

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Information	
  
	
   	
   	
  

interpretation	
  for	
  III.A.1,	
  prepared	
  at	
  my	
  request	
   • Incident	
  reports	
  and	
  youth	
  interviews	
  regarding	
  Operation	
  
Safety	
  First,	
  conducted	
  in	
  early	
  October	
  2011	
   • Interviews	
  with	
  n=29	
  youth	
  housed	
  on	
  the	
  PROGRESS	
  units,	
  
conducted	
  by	
  the	
  Monitor	
  and	
  the	
  DOJ	
  attorney	
  during	
  two	
   site	
  visits	
  in	
  October	
  2011	
  
	
  

	
  

13	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 14 of 104 PAGEID #: 1877

III.A.3	
  Seclusion.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
  practices	
   so	
  that	
  staff	
  use	
  seclusion	
  only	
  in	
  accordance	
  with	
  policy	
  and	
  in	
  an	
  appropriate	
  manner	
  and	
   so	
  that	
  staff	
  document	
  fully	
  the	
  use	
  and	
  administrative	
  review	
  of	
  any	
  imposition	
  of	
   seclusion,	
  including	
  the	
  placing	
  of	
  youth	
  in	
  their	
  rooms	
  outside	
  normal	
  sleeping	
  hours.	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

The	
  State	
  presented	
  data	
  on	
  the	
  use	
  of	
  seclusion	
  across	
  the	
  previous	
   nine	
  months.	
  	
   	
   Regular	
  Seclusion	
   Data	
  on	
  the	
  use	
  of	
  regular	
  seclusion	
  (a	
  period	
  of	
  isolation	
  imposed	
  by	
   direct	
  care	
  staff	
  in	
  response	
  to	
  mid-­‐level,	
  non-­‐violent	
  misconduct)	
   showed	
  significant	
  increases	
  in	
  both	
  its	
  use	
  and	
  duration	
  beginning	
  in	
   August	
  2011.	
  The	
  average	
  number	
  of	
  seclusions	
  from	
  January	
  to	
  July	
   was	
  71.	
  In	
  August,	
  the	
  number	
  of	
  seclusions	
  tripled	
  to	
  205,	
  and	
  then	
   doubled	
  again	
  to	
  430	
  in	
  September	
  2011.	
  These	
  data	
  reflect	
  the	
  high	
   level	
  of	
  non-­‐violent	
  (yet	
  still	
  concerning)	
  behavior	
  that	
  accompanied	
   the	
  influx	
  of	
  long-­‐term,	
  medium	
  and	
  close	
  custody	
  boys.	
  Further,	
  the	
   duration	
  of	
  seclusion	
  increased	
  significantly.	
  In	
  the	
  first	
  seven	
  months	
   of	
  2011,	
  approximately	
  85%	
  of	
  seclusions	
  were	
  4	
  hours	
  or	
  less.	
  In	
   August	
  and	
  September,	
  only	
  about	
  half	
  were	
  4	
  hours	
  or	
  less,	
  with	
  the	
   remainder	
  anywhere	
  between	
  4	
  and	
  72	
  hours.	
  	
   	
   Pre-­‐Hearing	
  Seclusion	
   Data	
  on	
  the	
  use	
  of	
  pre-­‐hearing	
  seclusion	
  (PHS;	
  a	
  period	
  of	
  isolation	
   imposed	
  following	
  an	
  act	
  of	
  violence,	
  pending	
  a	
  disciplinary	
  hearing)	
   showed	
  significant	
  increases	
  in	
  the	
  use	
  of	
  PHS	
  in	
  September	
  2011,	
   concurrent	
  with	
  the	
  increase	
  in	
  youth-­‐on-­‐staff	
  assaults	
  discussed	
  in	
   III.A.1.	
  Whereas	
  the	
  average	
  number	
  of	
  PHSs	
  in	
  the	
  preceding	
  eight	
   months	
  was	
  55,	
  there	
  were	
  91	
  PHSs	
  in	
  September	
  2011.	
  Over	
  one-­‐ third	
  of	
  these	
  lasted	
  56	
  hours	
  or	
  more	
  (which	
  makes	
  sense	
  given	
  the	
   high	
  proportion	
  of	
  staff	
  assaults	
  after	
  which,	
  according	
  to	
  the	
  IRAV	
   policy,	
  youth	
  are	
  not	
  eligible	
  for	
  release	
  from	
  PHS	
  pending	
  the	
   disciplinary	
  hearing).	
  In	
  prior	
  months,	
  only	
  about	
  15%	
  of	
  youth	
  who	
   committed	
  an	
  act	
  of	
  violence	
  were	
  in	
  PHS	
  longer	
  than	
  56	
  hours.	
  	
   	
   Intervention	
  Seclusion	
   Intervention	
  hearings	
  are	
  held	
  to	
  determine	
  whether	
  youth	
  are	
   culpable	
  for	
  serious	
  misconduct	
  and	
  whether	
  additional	
  time	
  in	
   seclusion	
  is	
  warranted.	
  Sometimes,	
  youth	
  are	
  suspected	
  of	
  taking	
  part	
   in	
  an	
  act	
  of	
  group	
  violence,	
  but	
  the	
  subsequent	
  investigation	
  shows	
   they	
  were	
  not	
  involved.	
  The	
  hearing	
  officer	
  may	
  also	
  decide	
  that	
  a	
   treatment-­‐related	
  sanction,	
  combined	
  with	
  the	
  time	
  already	
  spent	
  in	
   PHS,	
  is	
  sufficient	
  to	
  address	
  the	
  youth’s	
  behavior.	
  In	
  these	
  cases,	
   intervention	
  seclusion	
  is	
  not	
  used.	
  The	
  self-­‐assessment	
  showed	
  that	
  

	
  

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the	
  proportion	
  of	
  youth	
  receiving	
  intervention	
  seclusion	
  is	
  lower	
  than	
   that	
  witnessed	
  in	
  previous	
  months.	
  In	
  August	
  and	
  September,	
  an	
   average	
  of	
  35%	
  of	
  youth	
  in	
  PHS	
  received	
  intervention	
  seclusion,	
   compared	
  to	
  an	
  average	
  of	
  57%	
  in	
  the	
  previous	
  seven	
  months.	
  This	
   decrease	
  reflects	
  the	
  dynamics	
  of	
  the	
  disciplinary	
  process,	
  particularly	
   for	
  a	
  group	
  of	
  youth	
  who	
  are	
  relatively	
  unfamiliar	
  to	
  staff.	
  	
   	
   Overall,	
  the	
  total	
  number	
  of	
  hours	
  of	
  seclusion	
  utilized	
  in	
  the	
  day-­‐to-­‐ day	
  operation	
  of	
  the	
  facility	
  has	
  increased	
  significantly	
  in	
  recent	
   months.	
  In	
  contrast	
  to	
  June	
  and	
  July	
  2011,	
  when	
  the	
  facility	
  had	
   begun	
  to	
  get	
  a	
  handle	
  on	
  the	
  violent	
  behavior	
  of	
  youth	
  in	
  the	
   reception	
  units,	
  the	
  total	
  number	
  of	
  seclusion	
  hours	
  nearly	
  doubled	
  in	
   August	
  and	
  September	
  2011	
  (5,428	
  total	
  hours	
  in	
  June	
  and	
  July	
  versus	
   10,074	
  total	
  hours	
  in	
  August	
  and	
  September).	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

The	
  data	
  presented	
  for	
  the	
  self-­‐assessment	
  suggest	
  that	
  the	
  use	
  of	
   seclusion	
  has	
  become	
  a	
  more	
  central	
  feature	
  in	
  the	
  facility’s	
  response	
   to	
  youth	
  misconduct.	
  The	
  use	
  of	
  regular,	
  pre-­‐hearing	
  and	
  intervention	
   seclusion	
  all	
  increased	
  significantly	
  at	
  the	
  end	
  of	
  the	
  monitoring	
   period.	
  In	
  large	
  part,	
  these	
  increases	
  reflect	
  the	
  increase	
  in	
  youth	
   violence	
  at	
  the	
  facility	
  and	
  may	
  have	
  been	
  an	
  appropriate	
  response	
  in	
   a	
  crisis	
  situation.	
  Moving	
  forward,	
  as	
  the	
  staff	
  become	
  more	
  familiar	
   with	
  the	
  youth	
  involved	
  and	
  the	
  dynamics	
  among	
  groups	
  of	
  youth,	
   staff	
  should	
  become	
  able	
  to	
  respond	
  to	
  misconduct	
  in	
  a	
  more	
   productive,	
  less	
  punitive	
  manner.	
  	
   	
   In	
  the	
  past,	
  a	
  major	
  concern	
  related	
  to	
  the	
  use	
  of	
  seclusion	
  was	
  the	
   extent	
  to	
  which	
  staff	
  followed	
  required	
  procedures	
  to	
  mitigate	
  the	
   risk	
  of	
  self-­‐harm	
  posed	
  by	
  youth	
  confined	
  to	
  their	
  rooms	
  for	
   disciplinary	
  reasons.	
  For	
  several	
  years,	
  the	
  administrative	
  team	
  has	
   conducted	
  random	
  reviews	
  of	
  videotape	
  footage	
  to	
  ensure	
  that	
  staff	
   conduct	
  the	
  required	
  safety	
  and	
  welfare	
  checks.	
  Over	
  the	
  past	
  seven	
   months,	
  45	
  reviews	
  were	
  conducted	
  (about	
  6	
  per	
  month).	
  In	
  about	
   20%	
  of	
  these	
  reviews,	
  staff	
  were	
  cited	
  for	
  their	
  failure	
  to	
  follow	
  some	
   aspect	
  of	
  the	
  policy.	
  In	
  contrast	
  to	
  previous	
  reviews,	
  the	
  severity	
  of	
   these	
  policy	
  violations	
  has	
  decreased	
  with	
  staff	
  missing	
  a	
  very	
  small	
   number	
  of	
  checks	
  during	
  a	
  shift,	
  rather	
  than	
  failing	
  to	
  conduct	
  safety	
   checks	
  during	
  an	
  entire	
  shift.	
  The	
  facility’s	
  continued	
  vigilance	
  and	
   quality	
  assurance	
  efforts	
  in	
  this	
  area	
  offer	
  a	
  solid	
  mechanism	
  for	
   protecting	
  youth	
  from	
  self-­‐harm.	
  	
   	
   However,	
  compared	
  to	
  previous	
  visits	
  to	
  Scioto,	
  two	
  recent	
  situations	
   have	
  caused	
  youth	
  to	
  spend	
  more	
  time	
  in	
  isolation	
  behind	
  their	
   locked	
  doors.	
  First,	
  Scioto	
  has	
  experienced	
  significant	
  staff	
  shortages	
   in	
  the	
  past	
  few	
  months.	
  Of	
  the	
  170	
  Youth	
  Specialists,	
  27	
  staff	
  (16%)	
   were	
  on	
  extended	
  leave	
  due	
  to	
  work-­‐related	
  injury	
  or	
  FMLA	
  and	
  8	
  

	
  

15	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 16 of 104 PAGEID #: 1879

positions	
  are	
  vacant	
  (5%).	
  Staff	
  and	
  youth	
  reported	
  and	
  unit	
  logbooks	
   confirmed	
  that	
  over	
  the	
  past	
  couple	
  months,	
  several	
  units	
  were	
   locked	
  down,	
  mostly	
  during	
  1st	
  shift,	
  because	
  sufficient	
  staff	
  were	
  not	
   available	
  to	
  operate	
  the	
  program	
  safely.	
  When	
  confined	
  to	
  their	
  cells,	
   youth	
  are	
  denied	
  access	
  to	
  the	
  normal	
  range	
  of	
  programming	
  and	
   their	
  risk	
  of	
  becoming	
  frustrated,	
  anxious	
  and	
  self-­‐injurious	
  increases	
   accordingly.	
  	
   	
   Second,	
  some	
  of	
  the	
  youth	
  confined	
  in	
  the	
  maximum-­‐security	
   segregation	
  units	
  	
  (i.e.,	
  Cedar	
  and	
  Sycamore;	
  the	
  PROGRESS	
  Units)	
   appear	
  to	
  be	
  spending	
  excessive	
  amounts	
  of	
  time	
  locked	
  in	
  their	
   rooms.	
  The	
  program	
  design	
  includes	
  two	
  phases	
  (Phase	
  I	
  and	
  II)	
  with	
   different	
  levels	
  of	
  restrictiveness.	
  Phase	
  I	
  youth	
  are	
  permitted	
  out	
  of	
   their	
  cells	
  for	
  school,	
  one	
  hour	
  of	
  large	
  muscle	
  activity,	
  treatment,	
   and	
  showers.	
  Meals	
  and	
  leisure	
  time	
  are	
  spent	
  in-­‐cell.	
  Once	
  promoted	
   to	
  Phase	
  II,	
  youth	
  may	
  also	
  spend	
  their	
  leisure	
  time	
  out-­‐of-­‐cell.	
  While	
   youth	
  in	
  both	
  Phases	
  should	
  be	
  out	
  of	
  their	
  rooms	
  during	
  the	
  school	
   day,	
  during	
  Intersession,	
  PROGRESS	
  youth	
  were	
  in	
  their	
  rooms	
   throughout	
  most	
  of	
  the	
  day	
  because	
  Intersession	
  activities	
  had	
  not	
   been	
  planned	
  for	
  them.	
  Even	
  once	
  school	
  was	
  back	
  in	
  session	
  in	
  mid-­‐ October	
  2011,	
  attendance	
  records	
  revealed	
  high	
  levels	
  of	
  chronic	
   absenteeism.	
  If	
  not	
  attending	
  school,	
  or	
  if	
  they	
  have	
  graduated,	
  youth	
   on	
  the	
  PROGRESS	
  units	
  spend	
  most	
  of	
  their	
  day	
  locked	
  in	
  their	
  cells.	
   The	
  facility’s	
  ability	
  to	
  identify	
  and	
  address	
  this	
  problem	
  is	
  hampered	
   by	
  the	
  lack	
  of	
  valid	
  data.	
  The	
  PROGRESS	
  Unit’s	
  logbooks	
  have	
  a	
  form	
   for	
  recording	
  the	
  location	
  of	
  each	
  youth,	
  each	
  hour	
  of	
  the	
  day.	
  If	
  filled	
   in	
  properly,	
  the	
  facility	
  would	
  have	
  a	
  record	
  of	
  precisely	
  how	
  much	
   time	
  each	
  PROGRESS	
  youth	
  spends	
  in	
  his	
  cell.	
  However,	
  staff	
  do	
  not	
   exercise	
  adequate	
  care	
  in	
  completing	
  this	
  form.	
  Most	
  often,	
  they	
   simply	
  place	
  an	
  “X”	
  in	
  each	
  box,	
  indicating	
  that	
  the	
  youth	
  is	
  on	
  the	
   unit,	
  but	
  without	
  distinguishing	
  whether	
  the	
  youth	
  is	
  in	
  his	
  room,	
  the	
   dayroom,	
  the	
  group	
  room,	
  etc.	
  These	
  records	
  should	
  be	
  maintained	
   more	
  conscientiously.	
  	
   	
   Further,	
  the	
  PROGRESS	
  units	
  have	
  only	
  been	
  operating	
  for	
  a	
  couple	
   months,	
  and	
  the	
  program	
  design	
  has	
  not	
  been	
  fully	
  developed.	
  In	
   particular,	
  the	
  requirements	
  around	
  treatment	
  planning,	
  articulating	
   treatment	
  goals,	
  and	
  conducting	
  treatment	
  teams	
  have	
  not	
  been	
  fully	
   explicated.	
  A	
  review	
  of	
  treatment	
  team	
  notes	
  for	
  nine	
  PROGRESS	
   youth	
  indicated	
  pervasive	
  problems	
  conceptualizing	
  specific,	
   measurable	
  goals	
  for	
  the	
  youth	
  on	
  these	
  units.	
  Even	
  when	
  youth	
  have	
   goals	
  that	
  could	
  be	
  measured,	
  updates	
  on	
  the	
  youth’s	
  progress	
  at	
   weekly	
  interdisciplinary	
  team	
  meetings	
  (IDT	
  meetings)	
  do	
  not	
  include	
   data	
  that	
  reflect	
  youth	
  progress	
  on	
  their	
  goals.	
  Most	
  often	
  the	
   “Outcomes”	
  section	
  of	
  the	
  IDT	
  report	
  is	
  completely	
  blank.	
  As	
  a	
  result,	
  

	
  

16	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 17 of 104 PAGEID #: 1880

youth	
  are	
  not	
  moving	
  through	
  Phase	
  I,	
  to	
  Phase	
  II,	
  to	
  Transition	
  as	
   quickly	
  as	
  they	
  would	
  if	
  the	
  program	
  were	
  better	
  orchestrated.	
  As	
  a	
   result,	
  youth	
  are	
  held	
  in	
  highly	
  restrictive	
  settings	
  without	
  a	
  clear	
   pathway	
  for	
  a	
  return	
  to	
  the	
  general	
  population.	
  	
   	
   In	
  addition,	
  facility	
  staff	
  were	
  confused	
  about	
  the	
  process	
  for	
  phase	
   promotion	
  and	
  demotion	
  on	
  the	
  PROGRESS	
  Units.	
  As	
  noted	
  above,	
  by	
   design,	
  the	
  PROGRESS	
  Unit	
  behavior	
  management	
  program	
  has	
  two	
   phases.	
  Once	
  youth	
  complete	
  goals	
  for	
  Phase	
  I,	
  they	
  should	
  be	
   promoted	
  to	
  Phase	
  II.	
  If	
  a	
  Phase	
  II	
  youth	
  engages	
  in	
  an	
  act	
  of	
  violence,	
   he	
  should	
  be	
  demoted	
  to	
  Phase	
  I.	
  However,	
  in	
  practice,	
  this	
  process	
   became	
  blurred	
  with	
  the	
  SBBMS,	
  where	
  youth	
  were	
  not	
  demoted	
  but	
   their	
  Phase	
  was	
  “frozen”	
  for	
  a	
  period	
  of	
  time.	
  	
  While	
  the	
  end	
  result	
   may	
  have	
  been	
  the	
  same	
  (youth	
  lose	
  status	
  and	
  thus	
  spend	
  more	
   time	
  in	
  their	
  room	
  than	
  a	
  Phase	
  II	
  youth),	
  the	
  reason	
  for	
  demotion	
   and	
  the	
  consequent	
  seclusion	
  must	
  be	
  accurately	
  described	
  and	
   implemented	
  so	
  that	
  the	
  youth	
  understand	
  the	
  workings	
  of	
  the	
   system.	
  	
   	
   In	
  summary,	
  the	
  increased	
  levels	
  of	
  misconduct	
  and	
  violence	
  among	
   youth	
  who	
  were	
  not	
  well	
  known	
  to	
  staff,	
  staffing	
  shortages,	
  and	
  early	
   implementation	
  issues	
  on	
  the	
  PROGRESS	
  units	
  have	
  resulted	
  in	
  the	
   increased	
  use	
  and	
  duration	
  of	
  seclusion	
  at	
  Scioto.	
  Not	
  only	
  is	
   seclusion	
  one	
  of	
  the	
  least	
  effective	
  tools	
  for	
  managing	
  youth	
   behavior,	
  it	
  also	
  decreases	
  youth’s	
  access	
  to	
  needed	
  treatment	
   programs	
  and	
  increases	
  their	
  risk	
  of	
  self-­‐harm.	
  As	
  a	
  result,	
  its	
  use	
   should	
  be	
  minimized.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Continue	
  to	
  track	
  data	
  on	
  the	
  use	
  of	
  seclusion	
  to	
  ensure	
  that	
   it	
  is	
  used	
  only	
  in	
  response	
  to	
  the	
  most	
  serious	
  misconduct	
  and	
   is	
  only	
  of	
  the	
  duration	
  necessary	
  to	
  ensure	
  the	
  safety	
  of	
  the	
   facility.	
  Continue	
  to	
  review	
  videotaped	
  footage	
  to	
  ensure	
  that	
   staff	
  conduct	
  required	
  safety	
  checks	
  when	
  youth	
  are	
  confined	
   to	
  their	
  rooms.	
  	
  
2. Address	
  the	
  underlying	
  causes	
  of	
  mid-­‐level	
  misconduct	
   resulting	
  in	
  regular	
  seclusion	
  and	
  expand	
  the	
  use	
  of	
   alternative	
  sanctions	
  (i.e.,	
  non-­‐seclusion)	
  for	
  these	
  behaviors.	
  	
  
3. Address	
  staff	
  shortages	
  to	
  ensure	
  that	
  sufficient	
  staff	
  are	
   available	
  to	
  operate	
  the	
  program	
  without	
  confining	
  youth	
  to	
   their	
  rooms	
  during	
  non-­‐sleeping	
  hours.	
  [The	
  remedy	
  to	
  this	
   problem	
  involves	
  systemic	
  reforms	
  that	
  are	
  currently	
  being	
   undertaken	
  by	
  the	
  S.H.	
  Monitoring	
  Team.]	
  
4. Improve	
  the	
  quality	
  of	
  record	
  keeping	
  on	
  the	
  PROGRESS	
  units	
   so	
  that	
  the	
  precise	
  number	
  of	
  hours	
  youth	
  spend	
  locked	
  inside	
  

	
  

17	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 18 of 104 PAGEID #: 1881

Sources	
  of	
   Information	
  
	
   	
  

their	
  rooms	
  can	
  be	
  ascertained.	
  	
   5. Expand	
  the	
  development	
  of	
  the	
  PROGRESS	
  Unit	
  program	
  
design	
  to	
  address	
  the	
  issues	
  of	
  treatment	
  planning,	
   articulating	
  treatment	
  goals	
  and	
  conducting	
  treatment	
  teams	
   to	
  facilitate	
  the	
  youth’s	
  transition	
  to	
  the	
  general	
  population	
  as	
   quickly	
  as	
  possible.	
  Ensure	
  that	
  PROGRESS	
  Unit	
  youth	
  are	
  not	
   confined	
  to	
  their	
  rooms,	
  except	
  as	
  articulated	
  in	
  the	
  original	
   program	
  design	
  (e.g.,	
  all	
  youth	
  are	
  out	
  of	
  their	
  rooms	
  for	
   school,	
  recreation,	
  treatment	
  and	
  showers;	
  Phase	
  II	
  youth	
  are	
   also	
  out	
  of	
  their	
  rooms	
  for	
  leisure	
  time).	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
   interpretation	
  for	
  III.A.3,	
  prepared	
  at	
  my	
  request	
  
• Interviews	
  with	
  29	
  youth	
  on	
  the	
  PROGRESS	
  Units	
  conducted	
   by	
  the	
  Monitor	
  and	
  DOJ	
  attorney	
  in	
  October	
  2011,	
  plus	
   information	
  from	
  interviews	
  with	
  20	
  general	
  population	
  youth	
   conducted	
  by	
  the	
  DOJ	
  attorney	
  in	
  late	
  October	
  2011	
  
• SOP	
  303.01.07	
  “PROGRESS	
  Unit”,	
  draft	
  dated	
  10/20/11	
   • Draft	
  “PROGRESS	
  Unit	
  Handbook”	
  and	
  “Transition	
  Unit	
  
Manual”,	
  received	
  October	
  26,	
  2011	
   • “Unit	
  PROGRESS	
  and	
  Transition	
  Training,”	
  PowerPoint	
  
presentation	
  slides,	
  received	
  October	
  26,	
  2011	
   • Treatment	
  plans	
  and	
  IDT	
  minutes	
  for	
  n=9	
  youth	
  from	
  the	
  
Cedar	
  and	
  Sycamore	
  units	
   • Attendance	
  records	
  for	
  the	
  Cedar	
  and	
  Sycamore	
  units,	
  
October	
  18-­‐31,	
  2011	
   • Unit	
  logbooks	
  for	
  the	
  Cedar	
  and	
  Sycamore	
  units,	
  October	
  
2011	
  
	
  

	
  

18	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 19 of 104 PAGEID #: 1882

	
  
III.A.5	
  Investigation	
  of	
  Serious	
  Incidents.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  so	
  that	
  appropriate	
  investigations	
  are	
  conducted	
  of	
  all	
  incidents	
   of:	
  use	
  of	
  force;	
  staff-­‐on-­‐youth	
  violence;	
  serious	
  youth-­‐on-­‐youth	
  violence;	
  inappropriate	
   relationships	
  with	
  youth;	
  sexual	
  misconduct	
  between	
  youth;	
  and	
  abusive	
  institutional	
   practices.	
  Investigations	
  shall	
  be	
  conducted	
  by	
  persons	
  who	
  do	
  not	
  have	
  direct	
  or	
   immediate	
  indirect	
  responsibility	
  for	
  the	
  employee	
  being	
  investigated.	
  	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  State	
  submitted	
  a	
  log	
  of	
  all	
  investigations	
  related	
  to	
  excessive	
   uses	
  of	
  force,	
  allegations	
  of	
  abuse,	
  allegations	
  of	
  verbal	
  abuse,	
  and	
   inappropriate	
  relationships.	
  More	
  serious	
  allegations	
  (n=22)	
  were	
   investigated	
  by	
  the	
  Chief	
  Inspector’s	
  Office	
  (CIO),	
  while	
  less	
  serious	
   allegations	
  (n=29)	
  were	
  investigated	
  by	
  facility-­‐based	
  investigators.	
   Training	
  for	
  facility-­‐based	
  investigators	
  by	
  the	
  CIO	
  is	
  planned	
  for	
   November	
  2011.	
  	
   	
   Between	
  January	
  and	
  August	
  2011,	
  the	
  facility	
  completed	
  51	
   investigations	
  related	
  to	
  the	
  topics	
  covered	
  by	
  this	
  provision.	
  [The	
   facility	
  also	
  conducted	
  approximately	
  60	
  investigations	
  of	
  time	
  and	
   attendance	
  issues	
  during	
  this	
  same	
  time	
  period.]	
  Across	
  the	
  51	
   investigations,	
  20	
  were	
  substantiated	
  (39%),	
  the	
  vast	
  majority	
  for	
   violating	
  the	
  use	
  of	
  force	
  policy.	
  	
   	
   The	
  CIO	
  conducts	
  quarterly	
  audits	
  of	
  the	
  investigations	
  to	
  ensure	
  they	
   are	
  high	
  quality	
  and	
  completed	
  within	
  required	
  timelines.	
  A	
  number	
   of	
  deficits	
  in	
  investigative	
  technique	
  were	
  noted	
  in	
  the	
  Q1	
  audit,	
  and	
   most	
  of	
  these	
  had	
  been	
  rectified	
  by	
  the	
  Q2	
  audit.	
  The	
  facility’s	
   Administrative	
  Reviews	
  of	
  all	
  investigations	
  likely	
  contributed	
  to	
  these	
   improvements.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Rate	
  of	
  Substantiated	
  Allegations	
   Of	
  the	
  51	
  investigations	
  completed,	
  20	
  allegations	
  were	
  substantiated	
   (39%).	
  Approximately	
  12	
  of	
  these	
  were	
  for	
  improper	
  uses	
  of	
  force.	
   More	
  specifically:	
  
• failing	
  to	
  submit	
  an	
  incident	
  report	
  or	
  witness	
  statement	
  (5	
  of	
   20);	
  
• using	
  an	
  unauthorized	
  restraint	
  technique	
  (e.g.,	
  headlock,	
  arm	
   lock,	
  grabbing	
  a	
  youth’s	
  collar;	
  4	
  of	
  20);	
  
• pushing	
  a	
  youth	
  (3	
  of	
  20);	
   • excessive	
  force	
  (e.g.,	
  lifting	
  a	
  youth	
  off	
  the	
  ground	
  and	
  
slamming	
  him	
  to	
  the	
  ground;	
  throwing	
  a	
  punch	
  at	
  a	
  youth;	
   pinning	
  a	
  youth’s	
  arms	
  to	
  his	
  side	
  and	
  taking	
  him	
  to	
  the	
  floor;	
   3	
  of	
  20);	
   • restraining	
  a	
  youth	
  who	
  did	
  not	
  pose	
  an	
  immediate	
  threat	
  (2	
   of	
  20);	
  	
  

	
  

19	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 20 of 104 PAGEID #: 1883

• inappropriate	
  relationships	
  with	
  youth	
  via	
  FaceBook	
  (2	
  of	
  20);	
   and	
  	
  
• verbal	
  abuse	
  (1	
  of	
  20).	
  	
   	
   For	
  the	
  most	
  part,	
  these	
  data	
  mirror	
  the	
  youth’s	
  perceptions	
  of	
  their	
   treatment	
  by	
  staff.	
  The	
  12	
  substantiated	
  allegations	
  were	
  among	
   approximately	
  1,150	
  physical	
  restraints	
  during	
  that	
  time	
  period	
  (or,	
   approximately	
  1%).	
  By	
  and	
  large,	
  youth	
  reported	
  that	
  staff	
  do	
  not	
   physically	
  abuse	
  them	
  or	
  treat	
  them	
  heavy-­‐handedly	
  during	
   restraints.	
   	
   As	
  discussed	
  in	
  Provision	
  I.A.1,	
  above,	
  the	
  DOJ	
  has	
  consistently	
   received	
  a	
  larger	
  number	
  of	
  allegations	
  of	
  inappropriate	
  comments,	
   touching	
  and	
  sexual/inappropriate	
  relationships	
  when	
  interviewing	
   youth	
  than	
  is	
  reflected	
  in	
  the	
  facility’s	
  investigation	
  log.	
  The	
  reasons	
   for	
  this	
  disparity	
  are	
  unknown,	
  but	
  the	
  State	
  is	
  encouraged	
  to	
   broaden	
  its	
  inquiry	
  about	
  these	
  types	
  of	
  concerns	
  among	
  the	
  girls	
  to	
   determine	
  whether	
  the	
  difference	
  in	
  frequency	
  can	
  be	
  attributed	
  the	
   DOJ’s	
  proactive	
  inquiry	
  (see	
  I.A.1	
  for	
  a	
  more	
  detailed	
  discussion	
  of	
   this	
  issue).	
  	
   	
   Quality	
  of	
  Investigations	
   A	
  random	
  sample	
  of	
  15	
  investigations	
  of	
  alleged	
  physical	
  abuse	
  or	
   excessive	
  uses	
  of	
  force	
  were	
  selected	
  for	
  in-­‐depth	
  review.	
  These	
   investigations	
  were	
  completed	
  by	
  the	
  CIO	
  and	
  were	
  particularly	
  well	
   done.	
  They	
  featured	
  comprehensive	
  interviews	
  with	
  all	
  key	
  witnesses,	
   and	
  pursued	
  tangential	
  issues	
  that	
  emerged	
  during	
  the	
  course	
  of	
  the	
   initial	
  inquiry.	
  Across	
  the	
  sample,	
  the	
  findings	
  appeared	
  to	
  be	
   reasonable	
  and	
  the	
  basis	
  for	
  the	
  conclusion	
  was	
  clearly	
  identified	
   among	
  the	
  evidence.	
  	
   	
   In	
  order	
  to	
  examine	
  the	
  State’s	
  response	
  to	
  allegations	
  of	
  verbal	
   mistreatment,	
  all	
  14	
  investigations	
  of	
  this	
  type	
  were	
  selected	
  for	
   review.	
  [Only	
  11	
  of	
  the	
  14	
  investigations	
  could	
  be	
  reviewed	
  because	
   three	
  of	
  the	
  electronic	
  files	
  were	
  mismarked.]	
  Scioto	
  supervisory	
  staff	
   conduct	
  investigations	
  of	
  alleged	
  verbal	
  abuse.	
  While	
  most	
  of	
  the	
   internal	
  investigations	
  were	
  at	
  least	
  adequate,	
  a	
  small	
  number	
  (36%;	
   4	
  of	
  the	
  11)	
  were	
  poorly	
  done:	
  	
  
• 5501110021	
  failed	
  to	
  substantiate	
  the	
  alleged	
  inappropriate	
   conduct,	
  even	
  though	
  the	
  subject	
  of	
  the	
  investigation	
   admitted	
  that	
  she	
  made	
  the	
  statement	
  alleged	
  by	
  the	
  youth.	
   The	
  reason	
  that	
  the	
  comment	
  was	
  judged	
  by	
  the	
  investigator	
   to	
  be	
  appropriate	
  was	
  not	
  explained;	
  	
  	
  
• 550110025	
  is	
  very	
  convoluted	
  in	
  its	
  presentation	
  of	
  the	
  facts.	
   It	
  is	
  not	
  clear	
  how	
  the	
  facility	
  became	
  aware	
  of	
  the	
  incident	
  or	
  

	
  

20	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 21 of 104 PAGEID #: 1884

why	
  it	
  took	
  over	
  one	
  month	
  to	
  assign	
  the	
  investigation.	
   Further,	
  the	
  investigator	
  did	
  not	
  interview	
  the	
  alleged	
  victim	
   until	
  two	
  months	
  after	
  the	
  incident	
  occurred.	
  Finally,	
  a	
  youth	
   witness	
  corroborated	
  the	
  youth’s	
  allegation,	
  and	
  the	
  reason	
   for	
  discounting	
  this	
  evidence	
  was	
  not	
  explained;	
   • 5500110070	
  noted	
  that	
  4	
  youth	
  witnesses	
  corroborated	
  the	
   youth’s	
  allegation	
  but	
  did	
  not	
  explain	
  why	
  this	
  evidence	
  was	
   discounted.	
  	
   • 5500110085	
  does	
  not	
  pursue	
  a	
  full	
  investigation,	
  apparently	
   because	
  the	
  youth	
  indicated	
  that	
  he	
  did	
  not	
  want	
  to	
  pursue	
   the	
  allegation.	
  The	
  summary	
  of	
  the	
  interview	
  with	
  the	
   accused	
  staff	
  said	
  only	
  that	
  the	
  staff	
  “denied”	
  making	
  the	
   comments	
  and	
  “said	
  there	
  were	
  no	
  witnesses.”	
  The	
   investigator	
  never	
  describes	
  the	
  situation	
  in	
  which	
  the	
   comments	
  were	
  alleged	
  to	
  have	
  occurred	
  and	
  the	
  paucity	
  of	
   this	
  contextual	
  information	
  makes	
  it	
  appear	
  that	
  the	
  inquiry	
   was	
  dropped	
  simply	
  because	
  the	
  youth	
  did	
  not	
  want	
  to	
   pursue	
  it.	
  	
  	
   	
   Unfortunately,	
  these	
  shoddy	
  investigations	
  cluster	
  around	
  an	
  issue	
  of	
   significant	
  concern—inappropriate	
  comments	
  or	
  antagonizing	
   language	
  by	
  staff.	
  While	
  not	
  the	
  overwhelming	
  sentiment	
  across	
   youth,	
  a	
  significant	
  minority	
  of	
  youth	
  reported	
  that	
  some	
  staff	
  treat	
   them	
  disrespectfully	
  and	
  the	
  youth	
  believe	
  that	
  these	
  staff	
  are	
  not	
   held	
  accountable	
  for	
  their	
  behavior.	
  As	
  discussed	
  in	
  Provision	
  III.D.1,	
   the	
  State	
  has	
  not	
  yet	
  developed	
  procedures	
  to	
  inform	
  youth	
  of	
  the	
   outcome	
  of	
  grievances	
  that	
  are	
  referred	
  for	
  investigation.	
  The	
  shoddy	
   quality	
  of	
  some	
  of	
  these	
  investigations	
  may	
  contribute	
  to	
  the	
   perception	
  that	
  staff	
  are	
  not	
  held	
  accountable	
  for	
  their	
  verbal	
   mistreatment	
  of	
  youth.	
   	
   Timeliness	
  of	
  Investigations	
   Across	
  the	
  51	
  investigations	
  submitted	
  for	
  review,	
  a	
  significant	
   proportion	
  (42%)	
  were	
  not	
  completed	
  before	
  their	
  due	
  dates.	
  Often,	
   the	
  assigned	
  investigator	
  experienced	
  a	
  delay	
  of	
  between	
  4	
  and	
  7	
   days	
  while	
  awaiting	
  approval	
  from	
  the	
  Ohio	
  State	
  Patrol	
  (the	
  law	
   enforcement	
  agency	
  with	
  jurisdiction	
  to	
  bring	
  criminal	
  charges)	
  to	
   pursue	
  the	
  internal	
  investigation.	
  Compared	
  to	
  other	
  jurisdictions,	
  the	
   investigation	
  timelines	
  in	
  Ohio	
  are	
  relatively	
  short	
  (particularly	
  the	
  14	
   days	
  allocated	
  for	
  use	
  of	
  force	
  investigations).	
  The	
  DYS	
  may	
  want	
  to	
   reconsider	
  the	
  timelines	
  required	
  by	
  policy	
  so	
  that	
  they	
  remain	
  both	
   speedy	
  and	
  reasonable,	
  but	
  so	
  that	
  the	
  vast	
  majority	
  of	
  investigations	
   could	
  be	
  completed	
  on	
  time.	
  This	
  would	
  highlight	
  those	
  investigations	
   experiencing	
  unusual	
  delays.	
  	
  	
  
Recommendations	
   The	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  However,	
  in	
  

	
  

21	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 22 of 104 PAGEID #: 1885

Sources	
  of	
   Information	
  
	
   	
  

order	
  to	
  maintain	
  substantial	
  compliance,	
  the	
  State	
  must	
  improve	
  the	
   quality	
  of	
  its	
  internal	
  investigations	
  to	
  ensure	
  they	
  are	
  promptly	
   assigned,	
  thoroughly	
  and	
  properly	
  investigated.	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
   interpretation	
  for	
  III.A.5,	
  prepared	
  at	
  my	
  request	
  	
  
• Log,	
  “Investigations	
  of	
  Serious	
  Incidents,	
  January-­‐August,	
   2011”	
  
• Random	
  sample	
  of	
  n=15	
  CIO	
  investigations	
  completed	
  since	
   February	
  2011	
  
• Review	
  of	
  n=11	
  internal	
  investigations	
  of	
  alleged	
  verbal	
  abuse	
   completed	
  since	
  February	
  2011	
  
• Communication	
  with	
  DOJ	
  attorney	
  regarding	
  the	
  allegations	
   of	
  verbal	
  mistreatment	
  made	
  by	
  youth	
  on	
  the	
  girls’	
  units,	
   October	
  2011	
  
	
  

	
  

22	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 23 of 104 PAGEID #: 1886

III.D.1	
  Grievances.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
  practices	
   to	
  ensure	
  that	
  the	
  facility	
  has	
  an	
  adequate	
  grievance	
  system	
  including:	
  no	
  formal	
  or	
   informal	
  preconditions	
  to	
  the	
  completion	
  and	
  submission	
  of	
  a	
  grievance;	
  review	
  of	
   grievances	
  by	
  the	
  Chief	
  Inspector;	
  timely	
  initiation	
  and	
  resolution	
  of	
  grievances;	
  appropriate	
   corrective	
  action;	
  and	
  written	
  notification	
  provided	
  to	
  the	
  youth	
  of	
  the	
  final	
  resolution	
  of	
   the	
  grievance.	
  	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

The	
  Grievance	
  Officer	
  reported	
  that	
  the	
  process	
  is	
  unchanged	
  from	
   previous	
  visits	
  and	
  continues	
  to	
  meet	
  the	
  requirements	
  of	
  this	
   provision:	
  no	
  preconditions;	
  review	
  by	
  Chief	
  Inspector;	
  timely	
   initiation	
  and	
  resolution;	
  appropriate	
  corrective	
  action;	
  and	
  written	
   notification	
  to	
  youth	
  of	
  the	
  final	
  resolution	
  of	
  the	
  grievance.	
  	
   	
   Between	
  February	
  and	
  September	
  2011,	
  Scioto	
  youth	
  filed	
  over	
  300	
   grievances.	
  The	
  Chief	
  Inspector’s	
  Office’s	
  Q1	
  and	
  Q2	
  audits	
  found	
  that	
   all	
  grievances	
  were	
  resolved	
  in	
  a	
  timely	
  manner.	
  Scioto	
  also	
  had	
  a	
   lower	
  rate	
  of	
  grievances	
  per	
  youth	
  than	
  the	
  other	
  DYS	
  facilities.	
  	
   	
   Each	
  month,	
  the	
  Grievance	
  Officer	
  drafts	
  a	
  monthly	
  report	
  showing	
   the	
  number	
  and	
  type	
  of	
  grievances	
  coming	
  from	
  each	
  housing	
  unit.	
   The	
  report	
  also	
  describes	
  the	
  major	
  dynamics	
  in	
  the	
  facility.	
  Reading	
   the	
  past	
  nine	
  months’	
  summaries	
  in	
  succession	
  illuminates	
  the	
   challenges	
  that	
  have	
  faced	
  the	
  facility	
  during	
  its	
  conversion	
  to	
  a	
  long-­‐ term	
  program.	
  	
   	
   Staff	
  training	
  in	
  this	
  area	
  admonishes	
  staff	
  not	
  to	
  impede	
  the	
   grievance	
  process	
  in	
  any	
  way,	
  e.g.,	
  by	
  refusing	
  access	
  to	
  necessary	
   supplies	
  or	
  by	
  threatening	
  or	
  intimidating	
  youth	
  who	
  choose	
  to	
  file	
  a	
   grievance.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Between	
  February	
  and	
  September	
  2011,	
  a	
  total	
  of	
  321	
  grievances	
   were	
  submitted.	
  The	
  most	
  frequent	
  types	
  of	
  concerns	
  were	
   complaints	
  about	
  unfair	
  treatment	
  by	
  staff	
  (32%);	
  living	
  conditions	
   (9%);	
  medical	
  care	
  (7%)	
  and	
  verbal	
  abuse	
  by	
  staff	
  (4%).	
  Together,	
   these	
  four	
  categories	
  accounted	
  for	
  over	
  half	
  (52%)	
  of	
  all	
  grievances.	
   Of	
  the	
  321	
  grievances	
  received,	
  24	
  (7%)	
  were	
  closed	
  and	
  forwarded	
   for	
  investigation.	
  [Although	
  the	
  data	
  were	
  not	
  presented	
  this	
  way,	
  the	
   Monitor	
  suspects	
  these	
  24	
  referrals	
  included	
  the	
  complaints	
  about	
   verbal	
  abuse	
  (n=13)	
  and	
  physical	
  abuse/excessive	
  force	
  (n=10).]	
  	
   	
   As	
  the	
  facility	
  converted	
  from	
  a	
  reception	
  to	
  a	
  long-­‐term	
  program,	
  the	
   number	
  and	
  content	
  of	
  grievances	
  changed	
  noticeably.	
  During	
  the	
   first	
  half	
  of	
  2011,	
  the	
  facility	
  averaged	
  about	
  35	
  grievances	
  per	
   month.	
  In	
  September,	
  once	
  the	
  facility	
  had	
  completely	
  switched	
  over	
   to	
  a	
  long-­‐term	
  program,	
  70	
  grievances	
  were	
  submitted.	
  Many	
  of	
  

	
  

23	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 24 of 104 PAGEID #: 1887

these	
  reflected	
  youth’s	
  attempts	
  to	
  become	
  familiar	
  with	
  a	
  new	
   facility	
  with	
  slightly	
  different	
  rules	
  and	
  to	
  ensure	
  that	
  possessions	
  and	
   privileges	
  from	
  their	
  previous	
  facility	
  were	
  transferred	
  to	
  Scioto.	
   Some	
  of	
  the	
  grievances	
  also	
  highlighted	
  staff’s	
  lack	
  of	
  familiarity	
  with	
   procedures	
  for	
  the	
  long-­‐term	
  program	
  (e.g.,	
  certain	
  features	
  of	
  the	
   SBBMS;	
  Phase	
  Freeze;	
  commissary).	
  	
   	
   The	
  Grievance	
  Officer	
  has	
  exhibited	
  tremendous	
  compassion	
  towards	
   both	
  youth	
  and	
  staff	
  as	
  they	
  attempt	
  to	
  adapt	
  to	
  the	
  transition.	
  Youth	
   at	
  Scioto	
  continue	
  to	
  have	
  dependable	
  access	
  to	
  a	
  grievance	
  process	
   that	
  is	
  timely,	
  thorough	
  and	
  responsive	
  to	
  their	
  concerns.	
  When	
   interviewed,	
  youth	
  continue	
  to	
  have	
  positive	
  reviews	
  of	
  the	
  Grievance	
   Officer	
  and	
  the	
  process	
  for	
  handling	
  most	
  of	
  their	
  concerns.	
  	
  	
   	
   However,	
  as	
  discussed	
  in	
  previous	
  reports,	
  the	
  Grievance	
  Process	
  has	
   not	
  yet	
  been	
  adapted	
  to	
  provide	
  sufficient	
  feedback	
  to	
  youth	
   regarding	
  their	
  allegations	
  of	
  staff	
  misconduct	
  that	
  are	
  forwarded	
  for	
   investigation.	
  Youth	
  are	
  told	
  that	
  their	
  complaint	
  was	
  referred	
  for	
   investigation	
  and	
  the	
  grievance	
  response	
  includes	
  the	
  assigned	
   investigation	
  number;	
  however,	
  youth	
  are	
  not	
  informed	
  when	
  the	
   investigation	
  has	
  been	
  concluded	
  and	
  whether	
  the	
  allegation	
  was	
   substantiated.	
  For	
  this	
  reason,	
  youth	
  tend	
  to	
  believe	
  that	
  the	
  issue	
   was	
  dropped	
  and	
  that	
  staff	
  are	
  never	
  held	
  accountable.	
  The	
   Grievance	
  Officer	
  reported	
  that	
  policy	
  revisions	
  toward	
  this	
  end	
  are	
   underway.	
  The	
  Monitor	
  would	
  like	
  to	
  review	
  the	
  policy	
  revisions	
  prior	
   to	
  the	
  policy	
  being	
  finalized.	
  	
  When	
  the	
  process	
  is	
  fully	
  implemented	
   and	
  youth	
  are	
  informed	
  of	
  the	
  outcomes	
  of	
  investigations	
  of	
  their	
   allegations,	
  the	
  facility	
  will	
  be	
  in	
  substantial	
  compliance	
  with	
  this	
   provision.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Develop	
  procedures	
  and	
  practices	
  to	
  inform	
  youth	
  that	
   investigations	
  of	
  staff	
  misconduct	
  have	
  been	
  completed	
  and	
   whether	
  the	
  allegation	
  was	
  substantiated	
  or	
  not.	
  	
  

Sources	
  of	
   Information	
  
	
  

• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
   interpretation	
  for	
  III.D.1,	
  prepared	
  at	
  my	
  request	
  
• Grievance	
  Monthly	
  Reports,	
  February	
  through	
  September	
   2011	
  
• Q1	
  and	
  Q2	
  Grievance	
  Audits	
  by	
  the	
  Chief	
  Inspector’s	
  Office	
   • Youth	
  Grievances	
  from	
  March,	
  June,	
  August	
  and	
  September	
  
2011	
   • Interviews	
  with	
  n=20	
  youth	
  in	
  the	
  general	
  population,	
  
conducted	
  by	
  the	
  DOJ	
  attorney	
  in	
  late	
  October	
  2011	
  

	
  

24	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 25 of 104 PAGEID #: 1888

	
  
III.D.2	
  Grievances	
  Explained	
  to	
  Youth.	
  A	
  clear	
  explanation	
  of	
  the	
  grievance	
  process	
  shall	
  be	
   provided	
  to	
  each	
  youth	
  upon	
  admission	
  to	
  the	
  facilities	
  during	
  orientation	
  and	
  to	
  their	
   parents	
  or	
  guardians,	
  and	
  the	
  youth’s	
  understanding	
  of	
  the	
  process	
  shall	
  be	
  at	
  least	
  verbally	
   verified.	
  	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

The	
  Grievance	
  Officer	
  held	
  “Grievance	
  Clinics”	
  during	
  the	
  most	
  recent	
   Intersession.	
  These	
  clinics	
  discussed	
  the	
  mechanics	
  of	
  the	
  grievance	
   process	
  and	
  what	
  youth	
  should	
  expect.	
  A	
  learning	
  activity	
  asked	
   youth	
  to	
  critique	
  sample	
  grievances	
  as	
  to	
  whether	
  1)	
  the	
  issue	
  was	
   grieveable	
  and	
  2)	
  all	
  necessary	
  information	
  had	
  been	
  included.	
  	
  Youth	
   reported	
  an	
  improved	
  understanding	
  of	
  the	
  process	
  after	
  attending	
   the	
  clinics.	
  Given	
  that	
  many	
  of	
  the	
  youth	
  involved	
  have	
  been	
  released	
   from	
  the	
  facility,	
  the	
  Clinics	
  will	
  be	
  offered	
  again	
  in	
  December	
  2011.	
  	
   	
   The	
  facility	
  continues	
  to	
  audit	
  a	
  random	
  10%	
  sample	
  of	
  admissions	
   files	
  every	
  month	
  to	
  ensure	
  compliance	
  with	
  policy	
  and	
  procedure.	
   Each	
  month,	
  February	
  through	
  September	
  2011,	
  100%	
  of	
  the	
  youth	
   sampled	
  received	
  a	
  complete	
  orientation	
  to	
  the	
  facility,	
  which	
   included	
  information	
  on	
  how	
  to	
  access	
  the	
  grievance	
  system.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

I	
  did	
  not	
  need	
  to	
  conduct	
  any	
  additional	
  inquiry	
  to	
  assess	
  compliance.	
   As	
  noted	
  in	
  III.D.1,	
  the	
  orientation	
  process	
  has	
  not	
  yet	
  been	
  adapted	
   to	
  inform	
  youth	
  that	
  they	
  will	
  be	
  advised	
  when	
  grievances	
  that	
  are	
   referred	
  for	
  investigation	
  are	
  concluded	
  and	
  whether	
  the	
  allegation	
   was	
  substantiated.	
  Policy	
  revisions	
  are	
  reportedly	
  underway.	
  The	
   Monitor	
  would	
  like	
  to	
  review	
  the	
  revisions	
  prior	
  to	
  the	
  policy	
  being	
   finalized.	
  When	
  this	
  process	
  is	
  explained	
  to	
  youth	
  during	
  Orientation,	
   the	
  facility	
  will	
  be	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Adapt	
  the	
  orientation	
  process	
  to	
  explain	
  how	
  grievances	
   alleging	
  staff	
  misconduct	
  will	
  be	
  handled	
  and	
  that	
  youth	
  will	
   be	
  informed	
  that	
  the	
  investigation	
  is	
  concluded	
  and	
  whether	
   the	
  allegation	
  was	
  substantiated.	
  	
  

Sources	
  of	
   Information	
  
	
   	
   	
  

• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
   interpretation	
  for	
  III.D.2,	
  prepared	
  at	
  my	
  request	
  
• Intake	
  Audit	
  Report,	
  February	
  through	
  September,	
  2011	
  
	
  

	
  

25	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 26 of 104 PAGEID #: 1889

III.F.1	
  Structured	
  Programming.	
  The	
  State	
  shall	
  provide	
  adequate	
  structured	
  rehabilitative	
   services,	
  including	
  an	
  appropriate	
  mix	
  of	
  physical,	
  recreational	
  or	
  leisure	
  activities	
  during	
   non-­‐school	
  hours	
  and	
  days.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  structured	
  programming	
   from	
  the	
  end	
  of	
  the	
  school	
  day	
  until	
  youth	
  go	
  to	
  bed,	
  and	
  on	
  weekends.	
  For	
  youth	
  housed	
  in	
   closed-­‐cell	
  environments,	
  programming	
  shall	
  be	
  designed	
  to	
  ensure	
  that	
  youth	
  are	
  not	
   confined	
  in	
  locked	
  cells	
  except:	
  a)	
  from	
  after	
  programming	
  to	
  wake	
  up;	
  b)	
  as	
  necessary	
   where	
  youth	
  pose	
  an	
  immediate	
  risk	
  of	
  harm	
  to	
  self	
  or	
  others;	
  c)	
  following	
  an	
  adequate	
   disciplinary	
  hearing,	
  pursuant	
  to	
  an	
  appropriate	
  disciplinary	
  sanctions.	
  The	
  programming	
   shall	
  be	
  designed	
  to	
  modify	
  behaviors,	
  provide	
  rehabilitation	
  to	
  the	
  types	
  of	
  youth	
   committed	
  at	
  the	
  facility,	
  address	
  general	
  health	
  and	
  mental	
  health	
  needs,	
  and	
  be	
   coordinated	
  with	
  the	
  youth’s	
  individual	
  behavioral	
  and	
  treatment	
  plans.	
  The	
  State	
  shall	
  use	
   teachers,	
  school	
  administrators,	
  correctional	
  officers,	
  caseworkers,	
  school	
  counselors,	
   cottage	
  staff,	
  and	
  any	
  other	
  qualified	
  assistance	
  to	
  develop	
  and	
  implement	
  structured	
   programming.	
  The	
  State	
  shall	
  provide	
  youth	
  with	
  access	
  to	
  programming	
  activities	
  that	
  are	
   required	
  for	
  parole	
  eligibility.	
  	
  	
  

Compliance	
  Rating	
   Non-­‐compliance	
  

Self	
  Assessment	
  

Structured	
  Programming	
   The	
  facility’s	
  Youth	
  Activity	
  Tracking	
  System	
  (YATS)	
  is	
  now	
  operational	
   and	
  is	
  used	
  to	
  track	
  youth	
  participation	
  in	
  the	
  variety	
  of	
  programs	
   available	
  to	
  them.	
  These	
  include	
  recreation,	
  religious	
  programming,	
   programs	
  delivered	
  by	
  volunteers	
  and	
  those	
  facilitated	
  by	
  direct	
  care	
   staff.	
  	
   	
   Data	
  from	
  the	
  YATS’s	
  first	
  month	
  of	
  implementation	
  (September	
   2011)	
  were	
  not	
  particularly	
  promising.	
  A	
  one-­‐weekday	
  snapshot	
   showed	
  that	
  youth	
  were	
  involved	
  in	
  an	
  average	
  of	
  only	
  1.2	
  hours	
  of	
   structured	
  programming	
  that	
  day.	
  A	
  one-­‐weekend-­‐day	
  snapshot	
   showed	
  that	
  youth	
  were	
  involved	
  in	
  an	
  average	
  of	
  only	
  1.5	
  hours	
  of	
   structured	
  programming	
  that	
  day.	
  Further	
  investigation	
  into	
  these	
   trends	
  revealed	
  problems	
  with	
  data	
  collection	
  (Unit	
  Managers	
  were	
   not	
  completing	
  youth	
  sign-­‐in	
  sheets,	
  collecting	
  them	
  or	
  delivering	
   them	
  for	
  data	
  entry).	
  Two	
  interventions	
  were	
  designed	
  to	
  target	
  this	
   problem:	
  1)	
  using	
  a	
  student	
  clerk	
  to	
  prepare	
  attendance	
  sheets	
  for	
   each	
  day’s	
  activities	
  and	
  to	
  ensure	
  they	
  are	
  collected	
  and	
  submitted;	
   and	
  2)	
  requiring	
  youth	
  to	
  sign	
  the	
  attendance	
  sheets	
  before	
  the	
   activity	
  begins,	
  rather	
  than	
  after.	
  These	
  measures	
  should	
  improve	
  the	
   quality	
  of	
  the	
  data	
  so	
  that	
  in	
  subsequent	
  months,	
  the	
  extent	
  to	
  which	
   staff	
  are	
  actually	
  providing	
  access	
  and	
  delivering	
  programs	
  as	
   required	
  can	
  be	
  discerned.	
  	
   	
   SBBMS	
   With	
  Scioto’s	
  conversion	
  to	
  a	
  long-­‐term	
  program,	
  staff	
  are	
  now	
   required	
  to	
  deliver	
  the	
  fully-­‐loaded	
  SBBMS	
  rather	
  than	
  the	
  SBBMS-­‐lite	
   program	
  that	
  operated	
  in	
  the	
  reception	
  units.	
  Since	
  the	
  long-­‐term	
  

	
  

26	
  

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population	
  arrived	
  at	
  Scioto,	
  the	
  Grievance	
  Officer	
  has	
  received	
  a	
   significant	
  number	
  of	
  informal	
  complaints	
  and	
  formal	
  grievances	
   indicating	
  that	
  some	
  staff	
  have	
  not	
  properly	
  implemented	
  the	
  fully-­‐ loaded	
  SBBMS.	
  Youth	
  complained	
  that	
  staff	
  did	
  not	
  provide	
  access	
  to	
   earned	
  incentives,	
  reported	
  that	
  commissary	
  orders	
  were	
  not	
   delivered,	
  and	
  were	
  confused	
  about	
  Phase	
  Freeze.	
  Staff	
  errors	
  may	
  be	
   training-­‐related—approximately	
  65	
  direct	
  care	
  staff	
  have	
  not	
  yet	
   completed	
  training	
  on	
  the	
  fully-­‐loaded	
  SBBMS	
  used	
  in	
  the	
  long-­‐term	
   program.	
  	
  Facility	
  administrators	
  continue	
  to	
  oversee	
  the	
  program’s	
   implementation	
  carefully,	
  through	
  the	
  monthly	
  meetings	
  in	
  which	
   staff	
  practices	
  around	
  the	
  use	
  of	
  Character	
  Coupons	
  and	
  other	
   features	
  of	
  the	
  system	
  are	
  tracked.	
  The	
  SBBMS	
  has	
  a	
  solid	
  program	
   design;	
  in	
  the	
  past,	
  when	
  properly	
  implemented,	
  the	
  SBBMS	
  was	
   compelling	
  to	
  youth	
  and	
  contributed	
  to	
  the	
  effective	
  management	
  of	
   aggressive	
  behavior.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

The	
  YATS	
  data	
  reported	
  in	
  the	
  State’s	
  self-­‐assessment	
  mirror	
  the	
   youth’s	
  comments	
  about	
  the	
  programming	
  available	
  to	
  them.	
  Youth	
   reported	
  excessive	
  idle	
  time	
  in	
  the	
  afternoons	
  and	
  particularly	
  on	
  the	
   weekends.	
  Many	
  youth	
  at	
  Scioto	
  have	
  graduated	
  from	
  high	
  school	
  or	
   have	
  obtained	
  their	
  GED.	
  These	
  students	
  complained	
  that	
  there	
  were	
   too	
  few	
  work	
  assignments	
  and	
  post-­‐secondary	
  options	
  available	
  to	
   them	
  and	
  that	
  they	
  spent	
  the	
  majority	
  of	
  the	
  weekdays	
  on	
  the	
  units	
   with	
  nothing	
  to	
  occupy	
  their	
  time.	
  Education	
  staff	
  reported	
  that	
  the	
   Career-­‐Based	
  Intervention	
  program	
  has	
  identified	
  approximately	
  60	
   jobs	
  on	
  campus,	
  but	
  has	
  yet	
  to	
  be	
  implemented.	
  Once	
  implemented,	
   the	
  State	
  will	
  need	
  to	
  devise	
  additional	
  self-­‐assessment	
  mechanisms	
   to	
  capture	
  these	
  data.	
  Technical	
  assistance	
  toward	
  this	
  end	
  is	
   available	
  upon	
  request.	
  	
   	
   At	
  one	
  time,	
  the	
  facility	
  had	
  achieved	
  notable	
  success	
  in	
  requiring	
   direct	
  care	
  staff	
  to	
  provide	
  structured	
  programming	
  during	
  non-­‐ school	
  hours,	
  but	
  it	
  appears	
  staff	
  compliance	
  with	
  the	
  unit	
  schedules	
   has	
  waned.	
  These	
  programs	
  served	
  an	
  essential	
  role	
  in	
  reducing	
  youth	
   idle	
  time,	
  developing	
  rapport	
  between	
  staff	
  and	
  youth,	
  and	
  building	
   the	
  skills	
  necessary	
  for	
  effective	
  youth	
  rehabilitation.	
  	
   	
   The	
  lack	
  of	
  programming	
  is	
  caused	
  by	
  staff	
  shortages	
  of	
  two	
  types.	
   The	
  shortages	
  of	
  direct	
  care	
  staff	
  noted	
  in	
  III.A.3,	
  above,	
  have	
  caused	
   multiple	
  institution-­‐wide	
  lockdowns	
  over	
  the	
  past	
  several	
  months.	
   Not	
  only	
  do	
  these	
  shortages	
  result	
  in	
  an	
  increased	
  reliance	
  on	
   isolation	
  to	
  ensure	
  the	
  safety	
  of	
  the	
  youth,	
  but	
  they	
  also	
  deny	
  these	
   same	
  youth	
  access	
  to	
  the	
  education,	
  treatment	
  and	
  recreational	
   programming	
  to	
  which	
  they	
  are	
  legally	
  entitled.	
  In	
  addition,	
  9	
  of	
  the	
   facility’s	
  18	
  social	
  worker	
  positions	
  are	
  unfilled	
  (7	
  are	
  vacant,	
  2	
  are	
  on	
   FMLA)	
  which	
  compromises	
  the	
  ability	
  to	
  run	
  CBT	
  groups	
  and	
  other	
  

	
  

27	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 28 of 104 PAGEID #: 1891

treatment	
  programs.	
  	
   	
   The	
  language	
  of	
  this	
  provision	
  also	
  addresses	
  programming	
  for	
  youth	
   in	
  closed-­‐cell	
  environments	
  to	
  ensure	
  they	
  are	
  not	
  confined	
  to	
  their	
   cells	
  unnecessarily	
  and	
  that	
  they	
  have	
  access	
  to	
  rehabilitative	
  services	
   that	
  meet	
  their	
  needs.	
  The	
  facility	
  now	
  operates	
  the	
  PROGRESS	
  unit,	
   which	
  is	
  a	
  closed-­‐cell	
  program.	
  Concerns	
  about	
  the	
  amount	
  of	
  time	
   these	
  youth	
  spend	
  in	
  their	
  rooms	
  due	
  to	
  staff	
  shortages	
  and	
  “Phase	
   Freeze”	
  were	
  discussed	
  in	
  III.A.3,	
  Seclusion.	
  The	
  PROGRESS	
  unit	
  is	
   newly	
  implemented	
  and	
  additional	
  program	
  planning	
  is	
  needed	
  to	
   address	
  the	
  following	
  problems:	
  	
  
• Orientation	
  is	
  relatively	
  unstructured	
  and	
  often	
  does	
  not	
   occur	
  until	
  several	
  days	
  after	
  the	
  youth	
  has	
  been	
  assigned	
  to	
   the	
  unit;	
  
• Treatment	
  plans	
  lack	
  specific	
  goals	
  with	
  discrete	
  behavioral	
   objectives	
  and	
  a	
  specific	
  timeline	
  for	
  movement	
  to	
  the	
  next	
   phase;	
  
• Treatment	
  Teams	
  do	
  not	
  appear	
  to	
  assess	
  youth’s	
  progress	
   toward	
  these	
  goals	
  systematically	
  nor	
  facilitate	
  youth	
   movement	
  to	
  a	
  less	
  restrictive	
  environment	
  in	
  a	
  consistent	
   manner;	
  
• Contact	
  standards	
  for	
  individual	
  sessions	
  with	
  social	
  workers	
   and	
  mental	
  health	
  staff	
  have	
  not	
  been	
  clearly	
  articulated;	
  and	
  
• Performance	
  measures	
  to	
  determine	
  program	
  effectiveness	
   have	
  not	
  been	
  established.	
  	
  
Fully	
  developing	
  and	
  implementing	
  the	
  PROGRESS	
  program	
  design	
  is	
   required	
  to	
  meet	
  the	
  requirements	
  of	
  this	
  provision.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Provide	
  structured	
  programming	
  to	
  general	
  population	
  youth	
   during	
  non-­‐school	
  hours	
  and	
  on	
  weekends	
  to	
  minimize	
  the	
   amount	
  of	
  idle	
  time.	
  	
  
2. Ensure	
  all	
  direct	
  care	
  staff	
  are	
  trained	
  and	
  properly	
  implement	
   the	
  SBBMS.	
  Continue	
  to	
  utilize	
  the	
  grievance	
  system	
  and	
   monthly	
  administrative	
  meetings	
  to	
  identify	
  emerging	
   problems	
  with	
  the	
  SBBMS.	
  	
  
3. Develop	
  structured	
  activities	
  for	
  youth	
  who	
  have	
  graduated	
   from	
  high	
  school	
  or	
  obtained	
  their	
  GED	
  so	
  that	
  they	
  are	
   engaged	
  in	
  meaningful	
  activities	
  throughout	
  the	
  day.	
  	
  
4. Address	
  direct	
  care	
  staff	
  and	
  social	
  worker	
  shortages	
  to	
   ensure	
  that	
  all	
  youth	
  have	
  access	
  to	
  structured	
  activities	
  and	
   rehabilitative	
  programming	
  throughout	
  the	
  day.	
  	
  
5. Fully	
  develop	
  the	
  PROGRESS	
  unit’s	
  program	
  features	
  (e.g.,	
   treatment	
  plans,	
  treatment	
  teams,	
  individual	
  sessions,	
  etc.)	
  to	
   ensure	
  youth	
  have	
  maximal	
  access	
  to	
  structured	
  

	
  

28	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 29 of 104 PAGEID #: 1892

Sources	
  of	
   Information	
  
	
   	
  

programming,	
  given	
  their	
  legitimate	
  safety	
  concerns.	
  	
   	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
   interpretation	
  for	
  III.F.1,	
  prepared	
  at	
  my	
  request	
  
• Interviews	
  with	
  n=20	
  general	
  population	
  youth	
  conducted	
  by	
   the	
  DOJ	
  attorney	
  in	
  late	
  October	
  2011;	
  interviews	
  with	
  n=29	
   youth	
  on	
  PROGRESS	
  units	
  conducted	
  by	
  the	
  Monitor	
  and	
  DOJ	
   attorney	
  in	
  October	
  2011	
  
• SOP	
  303.01.07	
  “PROGRESS	
  Unit”,	
  draft	
  dated	
  10/20/11	
   • Draft	
  “PROGRESS	
  Unit	
  Handbook”	
  and	
  “Transition	
  Unit	
  
Manual”,	
  received	
  October	
  26,	
  2011	
   • “Unit	
  PROGRESS	
  and	
  Transition	
  Training,”	
  PowerPoint	
  
presentation	
  slides,	
  received	
  October	
  26,	
  2011	
  
	
  

	
  

29	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 30 of 104 PAGEID #: 1893

	
  
III.F.2	
  Orientation.	
  	
   a) Admissions	
  Intake	
  and	
  Orientation.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  establish	
  a	
  consistent,	
  orderly	
  admissions	
  intake	
   system,	
  conducive	
  to	
  gathering	
  necessary	
  information	
  about	
  youth,	
  disseminating	
   information	
  to	
  staff	
  providing	
  services	
  and	
  care	
  for	
  youth,	
  and	
  maintaining	
  youth	
   safety.	
  The	
  orientation	
  shall	
  also	
  clearly	
  set	
  forth	
  the	
  rules	
  youth	
  must	
  follow	
  at	
  the	
   facility,	
  explain	
  how	
  to	
  access	
  medical	
  and	
  mental	
  health	
  care	
  and	
  the	
  grievance	
   system,	
  and	
  provide	
  other	
  information	
  pertinent	
  to	
  the	
  youth’s	
  participation	
  in	
   facility	
  programs.	
   b) Notice	
  to	
  Youth	
  of	
  Facility	
  Rules	
  and	
  Incentives/Consequences	
  for	
  Compliance.	
  The	
   State	
  shall	
  explain	
  the	
  structured	
  programming	
  to	
  all	
  youth	
  during	
  an	
  orientation	
   session	
  that	
  shall	
  set	
  forth	
  the	
  facility	
  rules,	
  the	
  positive	
  incentives	
  for	
  compliance	
   and	
  good	
  behavior	
  and	
  the	
  sanctions	
  for	
  rule	
  violations.	
  The	
  State	
  shall	
  provide	
  the	
   facility	
  rules	
  in	
  writing.	
  	
  	
   c) Introductory	
  Handbook,	
  Orientation	
  and	
  Reporting	
  Abuse.	
  Each	
  youth	
  entering	
  the	
   facilities	
  shall	
  be	
  given	
  an	
  orientation	
  that	
  shall	
  include	
  simple	
  directions	
  for	
   reporting	
  abuse	
  and	
  assuring	
  youth	
  of	
  his/her	
  right	
  to	
  be	
  protected	
  from	
  retaliation	
   for	
  reporting	
  allegations	
  of	
  abuse.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

During	
  the	
  current	
  monitoring	
  period,	
  the	
  DYS	
  changed	
  from	
  a	
   centralized	
  reception	
  process	
  at	
  Scioto	
  to	
  a	
  decentralized	
  intake	
   process	
  at	
  each	
  facility.	
  The	
  intake	
  process	
  at	
  Scioto	
  is	
  now	
  only	
  4-­‐ days	
  long.	
  The	
  facility	
  continues	
  to	
  audit	
  a	
  random	
  10%	
  sample	
  of	
   admissions	
  files	
  every	
  month	
  to	
  ensure	
  compliance	
  with	
  policy	
  and	
   procedure.	
  Each	
  month,	
  February	
  through	
  September,	
  100%	
  of	
  the	
   youth	
  sampled	
  received	
  a	
  complete	
  orientation	
  to	
  the	
  facility	
  which	
   included,	
  among	
  other	
  things:	
  
• Youth	
  Handbook	
   • Orientation	
  Video	
   • Facility	
  rules	
  and	
  consequences	
  (IRAV)	
   • Strength	
  Based	
  Behavior	
  Management	
  System	
  (SBBMS)	
   • Obtaining	
  legal	
  assistance	
   • Accessing	
  medical	
  and	
  mental	
  health	
  care	
   • Sexual	
  abuse	
  and	
  sexual	
  assault	
  information	
   • Grievance	
  system	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Religious	
  Accommodations	
   Given	
  the	
  audit	
  results	
  above,	
  the	
  Orientation	
  program	
  for	
  youth	
  in	
   the	
  general	
  population	
  at	
  Scioto	
  nearly	
  meets	
  the	
  requirements	
  of	
   this	
  provision.	
  However,	
  this	
  provision	
  also	
  requires	
  the	
  State	
  to	
   provide	
  youth	
  with	
  “information	
  pertinent	
  to	
  the	
  youth’s	
   participation	
  in	
  facility	
  programs,”	
  which	
  includes	
  participation	
  in	
   religious	
  programming.	
  As	
  discussed	
  in	
  DOJ’s	
  compliance	
  letter	
  issued	
  

	
  

30	
  

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at	
  the	
  end	
  of	
  the	
  term	
  for	
  the	
  original	
  Stipulation,	
  the	
  facility’s	
  Youth	
   Handbook	
  still	
  needs	
  to	
  be	
  adapted	
  to	
  describe	
  the	
  youth’s	
  rights	
   related	
  to	
  practicing	
  their	
  religion	
  of	
  choice,	
  in	
  particular,	
  how	
  they	
   may	
  seek	
  accommodations	
  for	
  religious	
  beliefs,	
  practices	
  or	
   observance	
  as	
  described	
  in	
  SOP	
  #507.02.06.	
  	
  A	
  draft	
  of	
  the	
  revised	
   Handbook	
  was	
  reviewed	
  while	
  on	
  site	
  in	
  October	
  2011	
  and	
   suggestions	
  for	
  stating	
  the	
  youth’s	
  rights	
  more	
  clearly	
  were	
  offered	
  at	
   the	
  time.	
  Just	
  prior	
  to	
  the	
  final	
  report	
  being	
  issued,	
  the	
  State	
  reported	
   that	
  the	
  Youth	
  Handbook	
  had	
  been	
  revised	
  to	
  include	
  better	
   information	
  on	
  the	
  youth’s	
  right	
  to	
  practice	
  their	
  religion	
  of	
  choice.	
   The	
  Handbook	
  now	
  informs	
  youth	
  that	
  they	
  have	
  a	
  right	
  to	
  the	
   resources	
  to	
  practice	
  their	
  religion	
  of	
  choice	
  providing	
  it	
  does	
  not	
   interfered	
  with	
  the	
  safety	
  and	
  security	
  of	
  the	
  institution.	
  The	
  revised	
   Handbook	
  was	
  put	
  into	
  use	
  on	
  January	
  12,	
  2012.	
  Although	
  this	
   revision	
  was	
  not	
  put	
  into	
  practice	
  during	
  the	
  Monitoring	
  period,	
  as	
   long	
  as	
  youth’s	
  religious	
  beliefs	
  are	
  adequately	
  accommodated,	
  the	
   State	
  will	
  remain	
  in	
  substantial	
  compliance.	
  Note	
  that	
  the	
  State	
  must	
   seek	
  alternative	
  ways	
  for	
  the	
  youth	
  to	
  practice	
  his/her	
  religion,	
  even	
   when	
  a	
  legitimate	
  safety	
  concerns	
  exists.	
  	
   	
   PROGRESS	
  Unit	
  Orientation	
   While	
  most	
  of	
  the	
  youth	
  at	
  Scioto	
  undergo	
  an	
  Orientation	
  to	
  the	
   general	
  Scioto	
  population,	
  youth	
  can	
  also	
  be	
  admitted	
  directly	
  to	
  the	
   PROGRESS	
  Unit,	
  and	
  thus	
  the	
  Orientation	
  for	
  that	
  program	
  is	
  relevant	
   to	
  this	
  provision.	
  Draft	
  SOP	
  303.01.07	
  “Progress	
  Unit”	
  requires	
  the	
   Unit	
  Manager	
  to	
  ensure	
  that	
  the	
  PROGRESS	
  Youth	
  Handbook	
  is	
   available	
  to	
  all	
  youth	
  and	
  that	
  a	
  staff	
  member	
  provides	
  a	
  thorough	
   orientation	
  to	
  youth	
  upon	
  their	
  admission	
  to	
  the	
  Unit.	
  Youth	
  must	
   sign	
  the	
  Handbook’s	
  signature	
  page	
  to	
  acknowledge	
  receipt	
  of	
  the	
   information.	
  The	
  most	
  recent	
  version	
  of	
  the	
  Handbook	
  is	
  dated	
   January	
  10,	
  2012	
  and	
  remains	
  in	
  draft	
  form.	
  It	
  includes	
  information	
  on	
   the	
  Unit’s	
  rules	
  and	
  expectations;	
  phases,	
  treatment	
  planning	
  and	
   treatment	
  team	
  meetings;	
  programs	
  (education,	
  mental	
  health,	
   recreation,	
  religion);	
  telephone	
  use,	
  mail	
  and	
  visitation;	
  grievance	
   procedures;	
  and	
  access	
  to	
  legal	
  services.	
  	
  	
   	
   The	
  signature	
  pages	
  for	
  the	
  youth	
  admitted	
  to	
  the	
  Progress	
  Unit	
  were	
   requested	
  for	
  review.	
  A	
  total	
  of	
  51	
  youth	
  were	
  admitted	
  between	
   September	
  1,	
  2011	
  and	
  January	
  7,	
  2010.	
  Of	
  these,	
  no	
  documentation	
   was	
  provided	
  for	
  13	
  youth	
  (25%).	
  Among	
  the	
  remaining	
  youth,	
  nearly	
   all	
  received	
  the	
  Orientation	
  between	
  1	
  and	
  4	
  months	
  AFTER	
  their	
   admission	
  to	
  the	
  Unit.	
  A	
  timely	
  orientation	
  to	
  the	
  unit	
  is	
  essential	
  to	
   ensure	
  that	
  youth	
  are	
  aware	
  of	
  the	
  Unit’s	
  rules	
  and	
  the	
  consequences	
   for	
  breaking	
  them,	
  understand	
  how	
  to	
  progress	
  to	
  the	
  transition	
   phase	
  and	
  back	
  to	
  the	
  general	
  population,	
  and	
  how	
  to	
  access	
  services	
  

	
  

31	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 32 of 104 PAGEID #: 1895

while	
  on	
  the	
  Unit.	
  The	
  lack	
  of	
  a	
  timely,	
  structured	
  orientation	
  to	
  the	
   Unit	
  likely	
  contributed	
  to	
  the	
  frustration	
  that	
  many	
  youth	
  expressed	
   about	
  their	
  placement	
  and	
  their	
  lack	
  of	
  progress	
  moving	
  through	
  the	
   Unit’s	
  phases.	
  	
  

Recommendations	
  

In	
  order	
  to	
  achieve	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
   State	
  must:	
  
1. Finalize	
  SOP	
  303.01.07	
  and	
  the	
  PROGRESS	
  Unit	
  Student	
   Handbook.	
  	
  
2. Provide	
  a	
  comprehensive	
  and	
  timely	
  Orientation	
  to	
  all	
  youth	
   admitted	
  to	
  the	
  Progress	
  Unit	
  to	
  ensure	
  that	
  youth	
   understand	
  the	
  rules,	
  expectations	
  and	
  how	
  to	
  access	
   services.	
  	
  

Sources	
  of	
   Information	
  
	
   	
   	
  

• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
   interpretation	
  for	
  III.F.2,	
  prepared	
  at	
  my	
  request	
  
• Intake	
  Audit	
  Report,	
  February	
  through	
  September,	
  2011	
   • Scioto	
  Youth	
  Handbook,	
  dated	
  January	
  10,	
  2012	
   • Draft	
  SOP	
  303.01.07	
  “Progress	
  Unit,”	
  dated	
  October	
  20,	
  2010	
   • Draft	
  PROGRESS	
  Unit	
  Youth	
  Handbook,	
  dated	
  January	
  10,	
  
2012	
   • Orientation	
  records	
  for	
  youth	
  admitted	
  to	
  the	
  PROGRESS	
  Unit	
  
between	
  September	
  1,	
  2010	
  and	
  January	
  7,	
  2012.	
  	
  
	
  

	
  

32	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 33 of 104 PAGEID #: 1896

MENTAL	
  HEALTH	
  SERVICES	
  
	
  
III.B.	
  1	
  	
  Mental	
  Health	
  Screening.	
  	
  The	
  State	
  shall	
  implement	
  policies,	
  procedures	
  and	
   practices	
  to	
  ensure	
  that	
  all	
  youth	
  admitted	
  to	
  the	
  facilities	
  are	
  comprehensively	
  screened	
   for	
  mental	
  disorders,	
  including	
  substance	
  abuse,	
  depression,	
  and	
  serious	
  mental	
  illness,	
   within	
  twenty-­‐four	
  hours	
  of	
  admission.	
  This	
  screening	
  shall	
  be	
  performed	
  by	
  qualified	
   personnel,	
  as	
  part	
  of	
  the	
  intake	
  process,	
  consistent	
  with	
  generally	
  accepted	
  professional	
   standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  SJCF	
  self-­‐assessment,	
  the	
  facility	
  continued	
  to	
  function	
  as	
  the	
   intake	
  facility	
  for	
  all	
  youth	
  admitted	
  to	
  ODYS.	
  According	
  to	
  the	
  self-­‐ assessment,	
  “the	
  recently	
  developed	
  policy	
  and	
  procedure	
   ‘Behavioral	
  Health	
  Assessment,	
  Screening,	
  Appraisal	
  and	
  Evaluation’	
   has	
  been	
  implemented	
  and	
  quality	
  assurance	
  monitoring	
  and	
  clinical	
   supervision	
  is	
  being	
  documented	
  in	
  the	
  format	
  provided	
  in	
  policy.”	
  
	
  
Per	
  the	
  documents	
  reviewed,	
  it	
  was	
  evident	
  that	
  there	
  was	
  a	
  process	
   in	
  place	
  to	
  screen	
  youth	
  admitted	
  to	
  the	
  facility	
  for	
  mental	
  health	
   and	
  substance	
  abuse	
  disorders.	
  Ten	
  recent	
  intake	
  packets	
  were	
   reviewed;	
  six	
  of	
  these	
  youth	
  were	
  identified	
  as	
  needing	
  mental	
   health	
  follow-­‐up.	
  In	
  reviewing	
  policy	
  404.01:	
  “Behavioral	
  Health	
   Services,”	
  it	
  stated	
  “all	
  youth	
  committed	
  to	
  ODYS	
  shall	
  receive	
  a	
   Behavioral	
  Health	
  screening	
  within	
  one	
  hour	
  of	
  admission	
  into	
   reception,	
  in	
  accordance	
  with	
  ODYS	
  Policy	
  403.10…The	
  screening	
   shall	
  identify	
  risk/need	
  areas	
  and	
  assist	
  in	
  the	
  classification	
  and	
   future	
  case	
  planning	
  processes,	
  in	
  accordance	
  with	
  ODYS	
  Policy	
   404.01.01…”	
  In	
  reviewing	
  the	
  admission	
  date	
  and	
  administration	
  of	
   the	
  Reception	
  Assessment	
  Summary,	
  which	
  includes	
  the	
  initial	
   mental	
  health	
  screening,	
  nine	
  of	
  the	
  ten	
  youth	
  appear	
  to	
  have	
  been	
   screened	
  within	
  24	
  hours	
  of	
  arrival	
  at	
  the	
  facility.	
  	
  
	
  
With	
  regard	
  to	
  the	
  nursing	
  intake	
  screening/assessment,	
  all	
  youth	
   records	
  provided	
  for	
  review	
  revealed	
  that	
  this	
  assessment	
  was	
   performed	
  on	
  the	
  date	
  of	
  admission.	
  	
  It	
  was	
  not	
  possible	
  to	
   determine	
  if	
  this	
  was	
  performed	
  within	
  one	
  hour	
  of	
  admission,	
  as	
   although	
  the	
  time	
  the	
  instrument	
  was	
  administered	
  was	
   documented	
  on	
  the	
  form,	
  data	
  regarding	
  the	
  time	
  the	
  youth	
  entered	
   the	
  facility	
  was	
  not	
  included	
  in	
  the	
  documentation.	
  
	
  
Most	
  of	
  the	
  assessment	
  packets	
  provided	
  included	
  the	
  ODYS	
   Behavioral	
  Health	
  Appraisal.	
  The	
  timing	
  of	
  the	
  administration	
  of	
  this	
  

	
  

33	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 34 of 104 PAGEID #: 1897

tool	
  varied	
  from	
  one	
  day	
  after	
  admission	
  to	
  two	
  weeks	
  after	
   admission.	
  This	
  tool	
  provided	
  a	
  detailed	
  exploration	
  of	
  symptoms	
   that	
  youth	
  could	
  be	
  experiencing.	
  It	
  was	
  reported	
  during	
  the	
   previous	
  monitoring	
  tour	
  that	
  this	
  document	
  would	
  provide	
   information	
  required	
  for	
  improved	
  case	
  conceptualization	
  and	
   diagnostic	
  clarifications	
  with	
  recommendations	
  for	
  treatment.	
   However,	
  it	
  was	
  unclear	
  at	
  this	
  time	
  how	
  this	
  tool	
  is	
  utilized	
  to	
   formulate	
  diagnoses	
  and	
  case	
  conceptualizations.	
  Again,	
  the	
  clinical	
   summaries	
  were	
  minimal	
  and	
  did	
  not	
  identify	
  specific	
  diagnostic	
   criteria.	
  Additionally,	
  the	
  use	
  of	
  this	
  document	
  as	
  a	
  means	
  to	
   identifying	
  recommendations	
  appears	
  basic.	
  The	
  identification	
  of	
   mental	
  health	
  symptoms	
  and	
  case	
  conceptualizations	
  are	
  further	
   discussed	
  in	
  provision	
  4	
  below.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Full	
  implementation	
  of	
  policy	
  and	
  procedure	
  “Behavioral	
   Health	
  Assessment,	
  Screening,	
  Appraisal	
  and	
  Evaluation.”	
  	
   Given	
  the	
  change	
  in	
  facility	
  mission,	
  review	
  and	
  revise	
  this	
   policy	
  as	
  necessary.	
  
2. Begin	
  quality	
  assurance	
  monitoring	
  or	
  clinical	
  supervision	
   regarding	
  the	
  reception	
  assessment	
  summary	
  documents.	
  
3. Begin	
  quality	
  assurance	
  monitoring	
  to	
  ensure	
  that	
  timelines	
   required	
  by	
  policy	
  and	
  procedure	
  are	
  adhered	
  to.	
  

Sources	
  of	
   Information	
  
	
   	
  

• Review	
  of	
  provided	
  documents	
  	
   • Staff	
  interview	
  
	
  

	
  

34	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 35 of 104 PAGEID #: 1898

	
  
III.B.2	
  	
  Immediate	
  Referral.	
  If	
  the	
  mental	
  health	
  screen	
  identifies	
  an	
  issue	
  that	
  places	
  the	
   youth’s	
  safety	
  at	
  immediate	
  risk,	
  the	
  youth	
  shall	
  be	
  immediately	
  referred	
  to	
  a	
  qualified	
   mental	
  health	
  professional	
  for	
  assessment,	
  treatment	
  and	
  any	
  other	
  appropriate	
  action,	
   such	
  as	
  transfer	
  to	
  another,	
  more	
  appropriate	
  setting.	
  The	
  State	
  shall	
  ensure	
  that,	
  absent	
   extraordinary	
  circumstances,	
  qualified	
  mental	
  health	
  professionals	
  are	
  available	
  for	
   consultation	
  within	
  12	
  hours	
  of	
  such	
  referrals.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  facility	
  self-­‐assessment,	
  several	
  changes	
  were	
  implemented	
   in	
  order	
  “to	
  ensure	
  that	
  qualified	
  staff	
  are	
  available	
  for	
  consultation	
   within	
  24	
  hours	
  of	
  an	
  emergent	
  need.”	
  This	
  included	
  extended	
  work	
   hours	
  for	
  social	
  work	
  and	
  psychology	
  staff,	
  placement	
  of	
  psychology	
   offices	
  on	
  the	
  living	
  units,	
  and	
  installation	
  of	
  secure	
  boxes	
  on	
  each	
   unit.	
  Per	
  the	
  self-­‐assessment,	
  mental	
  health	
  staff	
  were	
  scheduled	
  to	
   be	
  at	
  the	
  facility	
  until	
  8pm	
  on	
  weeknights	
  and	
  from	
  8am	
  to	
  4:30pm	
   on	
  weekends.	
  This	
  was	
  echoed	
  by	
  the	
  review	
  of	
  staff	
  schedules	
   provided	
  via	
  the	
  document	
  request.	
  	
  
	
  
The	
  self-­‐assessment	
  admitted	
  that	
  historically,	
  the	
  documentation	
  of	
   response	
  times	
  to	
  requests	
  for	
  services	
  was	
  not	
  a	
  priority.	
  “In	
   addition	
  to	
  the	
  new	
  formal	
  process	
  for	
  requesting	
  services	
   represented	
  by	
  the	
  secure	
  boxes	
  on	
  units,	
  we	
  have	
  begun	
  to	
  include	
   not	
  only	
  the	
  time	
  of	
  the	
  visits	
  in	
  case	
  notes,	
  but	
  also	
  the	
  time	
  a	
   verbal	
  request	
  was	
  made.”	
  Please	
  see	
  the	
  discussion	
  documented	
   regarding	
  provision	
  9	
  below	
  for	
  further	
  information	
  regarding	
  this	
   topic.	
  	
  
	
  
Given	
  that	
  facility	
  administrative	
  and	
  behavioral	
  health	
  staff	
  as	
  well	
   as	
  DYS	
  administrative	
  staff	
  verbalized	
  the	
  need	
  to	
  revise	
  behavioral	
   health	
  policy	
  and	
  procedure,	
  this	
  process	
  must	
  be	
  formalized	
  in	
   policy	
  and	
  procedure.	
  	
  Following	
  the	
  development	
  and	
   implementation	
  of	
  policy	
  and	
  procedure	
  to	
  guide	
  this	
  process,	
  data	
   regarding	
  the	
  time	
  interval	
  between	
  identification	
  of	
  an	
  issue	
  that	
   places	
  the	
  youth’s	
  safety	
  at	
  risk	
  and	
  when	
  he	
  or	
  she	
  is	
  actually	
   assessed	
  by	
  a	
  mental	
  health	
  professional	
  must	
  be	
  collated	
  and	
   reviewed	
  via	
  a	
  quality	
  assurance	
  process.	
  
	
  
This	
  provision	
  includes	
  a	
  requirement	
  for	
  staff	
  ability	
  to	
  access	
   transfer	
  of	
  a	
  youth	
  to	
  “another,	
  more	
  appropriate	
  setting.”	
  	
  During	
   the	
  last	
  two	
  monitoring	
  tours,	
  youth	
  with	
  exacerbated	
  mental	
  illness	
   requiring	
  intensive	
  mental	
  health	
  treatment	
  were	
  discovered	
  at	
  SJCF.	
  	
   As	
  discussed	
  in	
  provision	
  16	
  below,	
  it	
  was	
  concerning	
  that	
  during	
  

	
  

35	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 36 of 104 PAGEID #: 1899

both	
  of	
  these	
  tours,	
  facility	
  mental	
  health	
  staff	
  were	
  unable	
  to	
  access	
   more	
  appropriate	
  placements.	
  	
  During	
  upcoming	
  monitoring	
  tours,	
   this	
  will	
  be	
  a	
  focus	
  of	
  attention.	
  	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Revise	
  policy	
  and	
  procedure	
  to	
  address	
  the	
  newly	
  instituted	
   process	
  regarding	
  immediate	
  referral	
  to	
  a	
  qualified	
  mental	
   health	
  professional.	
  
2. Collect	
  data	
  regarding	
  the	
  time	
  lapse	
  between	
  referral	
  and	
   actual	
  evaluation	
  or	
  assessment	
  for	
  quality	
  assurance	
   monitoring.	
  
3. Ensure	
  that	
  staff	
  are	
  aware	
  of	
  the	
  process	
  by	
  which	
  a	
  youth	
   may	
  access	
  other	
  appropriate	
  mental	
  health	
  services	
  (e.g.	
  a	
   facility	
  based	
  mental	
  health	
  unit	
  or	
  an	
  inpatient	
  psychiatric	
   facility).	
  	
  This	
  may	
  be	
  accomplished	
  via	
  policy	
  and	
  procedure	
   development,	
  staff	
  training,	
  and	
  staff	
  supervision.	
  

Sources	
  of	
   Information	
  
	
   	
  

• Review	
  of	
  provided	
  documents	
  	
   • Observation	
   • Staff	
  interview	
  
	
  

	
  

36	
  

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III.B.3	
  	
  	
  Identification	
  of	
  Previously	
  Unidentified	
  Youth.	
  The	
  facilities	
  shall	
  implement	
   policies,	
  procedures	
  and	
  practices	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
   of	
  care	
  to	
  identify	
  and	
  address	
  potential	
  manifestations	
  of	
  mental	
  or	
  behavioral	
  disorder	
  in	
   youth	
  who	
  have	
  not	
  been	
  previously	
  identified	
  as	
  presenting	
  mental	
  health	
  or	
  behavioral	
   needs	
  requiring	
  treatment.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  facility	
  self-­‐assessment,	
  “under	
  our	
  current	
  mission,	
  we	
  are	
   anticipating	
  that	
  this	
  will	
  be	
  a	
  more	
  common	
  occurrence.”	
  	
  The	
  self-­‐ assessment	
  identified	
  numerous	
  steps	
  that	
  the	
  facility	
  had	
  identified	
   in	
  order	
  to	
  ensure	
  that	
  youth	
  with	
  mental	
  health	
  disorders	
  were	
   identified.	
  	
  These	
  included:	
  “the	
  new	
  Behavioral	
  Health	
   Appraisal…includes	
  an	
  enhanced…MSE	
  [mental	
  status	
   exam]…psychology	
  staff	
  meet	
  on	
  a	
  weekly	
  basis…standard	
   component	
  of…meetings	
  a….discussion	
  of	
  ‘red-­‐flag’	
  youth.”	
  
	
  
Per	
  the	
  facility	
  assessment	
  and	
  staff	
  interviews,	
  given	
  the	
  change	
  in	
   facility	
  mission,	
  with	
  more	
  male	
  youth	
  residing	
  at	
  the	
  facility	
  as	
  their	
   primary	
  site,	
  this	
  was	
  opined	
  to	
  become	
  more	
  of	
  an	
  issue.	
  	
  In	
  the	
   past,	
  the	
  facility	
  housed	
  greater	
  numbers	
  of	
  female	
  youth,	
  the	
   majority	
  of	
  who	
  were	
  added	
  to	
  the	
  mental	
  health	
  caseload	
  upon	
   admission.	
  	
  Currently	
  with	
  an	
  increased	
  census	
  of	
  long	
  term	
  male	
   youth,	
  many	
  of	
  whom	
  were	
  not	
  initially	
  identified	
  as	
  requiring	
   mental	
  health	
  services,	
  this	
  was	
  likely	
  to	
  become	
  a	
  significant	
  issue.	
  
	
  
Per	
  the	
  most	
  recent	
  monitoring	
  tour,	
  there	
  were	
  concerns	
  that	
   facility	
  mental	
  health	
  staff	
  were	
  experiencing	
  difficulty	
  with	
   recognizing	
  and	
  responding	
  to	
  signs	
  and	
  symptoms	
  of	
  serious	
  mental	
   illness.	
  Deficiencies	
  of	
  this	
  type	
  were	
  discussed	
  in	
  the	
  previous	
   monitoring	
  report	
  regarding	
  Youth	
  060.	
  	
  	
  
	
  
Youth	
  060	
  was	
  experiencing	
  the	
  signs	
  and	
  symptoms	
  of	
  a	
  serious	
   mental	
  illness	
  including	
  but	
  not	
  limited	
  to,	
  experiencing	
  auditory	
   hallucinations,	
  engaging	
  in	
  bizarre	
  behavior,	
  refusing	
  to	
  leave	
  his	
  cell,	
   and	
  refusing	
  to	
  engage	
  in	
  mental	
  health	
  treatment.	
  	
  While	
  staff	
  had	
   identified	
  him	
  as	
  mentally	
  ill,	
  they	
  were	
  having	
  difficulty	
  with	
  the	
   development	
  of	
  a	
  treatment	
  plan,	
  and	
  with	
  making	
  the	
   determination	
  regarding	
  his	
  appropriateness	
  for	
  placement	
  at	
  SJCF.	
  	
   Ultimately,	
  following	
  prompting	
  from	
  the	
  monitor,	
  this	
  youth	
  was	
   transferred	
  from	
  SJCF	
  into	
  a	
  treatment	
  facility.	
  
	
  
A	
  similar	
  issue	
  occurred	
  during	
  the	
  most	
  recent	
  monitoring	
  tour.	
  

	
  

37	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 38 of 104 PAGEID #: 1901

Youth	
  040	
  was	
  reportedly	
  declining	
  to	
  engage	
  in	
  mental	
  health	
   treatment	
  and	
  programming.	
  	
  Upon	
  the	
  request	
  of	
  the	
  monitor,	
  this	
   youth	
  was	
  interviewed	
  by	
  the	
  facility	
  psychiatrist	
  and	
  was	
  noted	
  to	
   exhibit	
  signs	
  and	
  symptoms	
  of	
  psychosis	
  requiring	
  his	
  transfer	
  to	
   another	
  facility	
  so	
  that	
  he	
  could	
  receive	
  mental	
  health	
  treatment.	
  	
  It	
   was	
  concerning	
  that	
  while	
  behavioral	
  health	
  staff	
  had	
  questioned	
  the	
   existence	
  of	
  psychiatric	
  illness;	
  they	
  had	
  not	
  taken	
  steps	
  to	
  ensure	
   that	
  he	
  received	
  a	
  further	
  assessment	
  or	
  necessary	
  treatment.	
  	
  	
  
	
  
Observation	
  of	
  and	
  interaction	
  with	
  several	
  of	
  the	
  male	
  youth	
   currently	
  housed	
  on	
  the	
  Progress	
  Unit	
  at	
  SJCF	
  raised	
  concerns	
   regarding	
  their	
  mental	
  health	
  needs.	
  The	
  need	
  for	
  comprehensive	
   assessments	
  of	
  these	
  youth	
  is	
  discussed	
  in	
  the	
  ensuing	
  provisions	
   (see	
  the	
  discussion	
  regarding	
  provision	
  10	
  below).	
  
	
  
The	
  goal	
  of	
  this	
  provision	
  was	
  to	
  ensure	
  that	
  youth	
  who	
  may	
  not	
   present	
  with	
  a	
  history	
  of	
  mental	
  illness	
  and	
  who	
  are	
  not	
  identified	
  at	
   the	
  time	
  of	
  initial	
  assessment	
  as	
  being	
  at	
  risk	
  for	
  mental	
  illness	
  or	
   behavioral	
  challenges,	
  are	
  monitored	
  over	
  the	
  course	
  of	
  their	
   incarceration	
  for	
  exacerbations	
  of	
  symptoms	
  and	
  referred	
  for	
  mental	
   health	
  treatment.	
  Administrative	
  staff	
  were	
  aware	
  of	
  the	
  need	
  for	
   ongoing	
  and	
  improved	
  quality	
  assurance	
  to	
  review	
  documentation	
   and	
  the	
  decision-­‐making	
  process	
  regarding	
  youth	
  mental	
  health	
   needs.	
  	
  As	
  discussed	
  in	
  provision	
  4	
  below,	
  multiple	
  assessment	
   documents	
  were	
  being	
  generated,	
  however,	
  there	
  were	
  no	
   acceptable	
  case	
  formulations	
  reviewed	
  in	
  the	
  documents	
  that	
  tied	
  all	
   the	
  information	
  obtained	
  together	
  in	
  a	
  coherent	
  package	
  for	
  the	
   reader.	
  	
  This	
  was	
  an	
  area	
  that	
  would	
  be	
  amenable	
  to	
  quality	
   assurance,	
  peer	
  review	
  process	
  and	
  clinical	
  supervision.	
  	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Develop	
  quality	
  assurance	
  monitoring	
  regarding	
  re-­‐ evaluation	
  of	
  youth	
  who	
  experience	
  an	
  exacerbation	
  of	
   mental	
  health	
  symptoms	
  or	
  behavioral	
  challenges.	
  
2. Ensure	
  the	
  creation	
  of	
  a	
  case	
  conceptualization	
  for	
  each	
   youth.	
  
3. Ensure	
  that	
  direct	
  care	
  staff	
  and	
  behavioral	
  health	
  staff	
  are	
   trained	
  to	
  recognize	
  and	
  respond	
  to	
  signs	
  and	
  symptoms	
  of	
   serious	
  mental	
  illness.	
  

Sources	
  of	
   Information	
  
	
  

• Review	
  of	
  provided	
  documents	
  (e.g.	
  Policy	
  and	
  Procedure,	
   draft	
  Policy	
  and	
  Procedure,	
  youth	
  records).	
  
• Staff	
  interview	
  
	
  

	
  

38	
  

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III.B.4	
  	
  Mental	
  Health	
  Assessment.	
  The	
  State	
  shall	
  implement	
  policies,	
  procedures	
  and	
   practices	
  to	
  ensure	
  that,	
  as	
  part	
  of	
  an	
  overall	
  assessment	
  of	
  the	
  youth’s	
  health,	
  risks,	
   strengths	
  and	
  needs,	
  youth	
  who	
  are	
  identified	
  in	
  screening	
  as	
  having	
  possible	
  mental	
  health	
   needs	
  receive	
  timely,	
  comprehensive	
  and	
  accurate	
  assessments	
  by	
  qualified	
  mental	
  health	
   professionals,	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
   Assessments	
  shall	
  be	
  designed	
  and	
  implemented	
  so	
  as	
  to	
  identify	
  youth	
  with	
  mental	
   disorders	
  in	
  need	
  of	
  specific	
  treatment	
  and	
  contribute	
  to	
  a	
  full	
  plan	
  for	
  managing	
  the	
   youth’s	
  risk.	
  Assessments	
  shall	
  be	
  updated	
  as	
  additional	
  diagnostic	
  and	
  treatment	
   information	
  becomes	
  available.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  previous	
  monitoring	
  report,	
  policy	
  and	
  procedure	
  entitled	
   “Behavioral	
  Health	
  Assessment,	
  Screening,	
  Appraisal	
  and	
  Evaluation”	
   was	
  scheduled	
  for	
  full	
  implementation	
  3.1.11.	
  	
  Per	
  interviews	
  with	
   facility	
  administrative	
  and	
  mental	
  health	
  staff	
  as	
  well	
  as	
  DYS	
   administration,	
  there	
  were	
  plans	
  to	
  review	
  and	
  revise	
  current	
  policy	
   and	
  procedure	
  regarding	
  behavioral	
  health.	
  	
  This	
  was	
  necessary	
  not	
   only	
  due	
  to	
  omissions	
  in	
  the	
  previously	
  authored	
  documents,	
  but	
  due	
   to	
  the	
  recent	
  change	
  in	
  mission	
  incurred	
  at	
  SJCF.	
  
	
  
Per	
  the	
  facility	
  self	
  assessment,	
  “we	
  have	
  implemented	
  all	
   recommendations	
  including…peer	
  review	
   (quarterly)…documentation	
  of	
  clinical	
  supervision…the	
  psychology	
   department	
  meets	
  weekly	
  for	
  group	
  discussion	
  and	
  supervision,	
  and	
   includes	
  a	
  round	
  table	
  discussion	
  of	
  ‘red	
  flag’	
  youth,	
  as	
  well	
  as	
   seriously	
  mentally	
  ill	
  youth	
  in	
  the	
  facility.”	
  	
  This	
  self-­‐assessment	
   statement	
  was	
  referring	
  to	
  recommendations	
  included	
  in	
  previous	
   monitoring	
  reports.	
  	
  	
  The	
  following	
  information	
  will	
  note	
  the	
  status	
   of	
  the	
  implementation	
  of	
  these	
  recommendations	
  per	
  the	
  monitor’s	
   review.	
  
	
  
Documentation	
  regarding	
  quarterly	
  peer	
  review	
  provided	
  as	
  part	
  of	
   the	
  document	
  request	
  revealed	
  one	
  peer	
  review	
  performed	
  3.14.11.	
  	
   It	
  was	
  apparent	
  that	
  the	
  treatment	
  provider	
  under	
  review	
  provided	
   copies	
  of	
  the	
  case	
  summary	
  and	
  treatment	
  plan,	
  then	
  presented	
  the	
   information	
  to	
  a	
  panel	
  of	
  peers	
  who	
  then	
  completed	
  rating	
  forms	
   and	
  made	
  commentary	
  regarding	
  the	
  documentation	
  and	
   presentation.	
  	
  A	
  review	
  of	
  the	
  case	
  summary	
  and	
  treatment	
  plan	
   regarding	
  Youth	
  070	
  revealed	
  that	
  there	
  was	
  no	
  case	
   conceptualization	
  documented.	
  	
  The	
  document	
  contained	
  a	
  review	
   of	
  the	
  youth’s	
  history.	
  	
  There	
  was	
  little	
  documentation	
  regarding	
   specific	
  mental	
  health	
  symptoms	
  that	
  the	
  youth	
  was	
  experiencing	
  

	
  

39	
  

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that	
  qualified	
  for	
  diagnoses	
  including:	
  	
  Major	
  Depressive	
  Disorder	
   with	
  possible	
  Psychosis;	
  Conduct	
  Disorder;	
  Posttraumatic	
  Stress	
   Disorder;	
  Polysubstance	
  Abuse;	
  Rule	
  Out	
  Bipolar	
  Disorder.”	
  	
  The	
  list	
   of	
  symptoms,	
  characterized	
  as	
  current	
  behaviors	
  included:	
  	
  “periods	
   of	
  not	
  eating;	
  self	
  isolates;	
  bites	
  wrist/left	
  forearm	
  when	
  upset;	
  gets	
   himself	
  restrained	
  to	
  relieve	
  tension;	
  and	
  noted	
  periods	
  of	
  manic	
  like	
   behavior-­‐can	
  see	
  building	
  up	
  before	
  acts	
  out.”	
  	
  This	
  list	
  of	
  symptoms	
   did	
  not	
  indicate	
  that	
  this	
  youth	
  met	
  diagnostic	
  criteria	
  for	
  any	
  of	
  the	
   reported	
  diagnoses.	
  	
  Additionally,	
  following	
  a	
  review	
  of	
  this	
   document,	
  it	
  was	
  unclear	
  what	
  treatment	
  modalities	
  would	
  be	
   beneficial	
  to	
  address	
  the	
  youth’s	
  specific	
  risk	
  factors.	
  
	
  
A	
  review	
  of	
  the	
  integrated	
  treatment	
  plan	
  provided	
  in	
  this	
  case	
   revealed	
  no	
  measurable	
  goals	
  or	
  objectives	
  other	
  than	
  a	
  requirement	
   that	
  the	
  youth	
  attend	
  trauma	
  group	
  twice	
  weekly,	
  and	
  that	
  the	
  youth	
   remain	
  100%	
  compliant	
  with	
  prescribed	
  medications.	
  	
  Other	
   interventions	
  were	
  vague,	
  for	
  example,	
  “begin	
  to	
  address	
  underlying	
   triggers	
  driving	
  current	
  symptoms	
  and	
  behaviors...	
  I	
  will	
  tell	
  a	
  staff	
   member	
  when	
  I	
  want	
  to	
  hit	
  something.”	
  	
  Given	
  the	
  positive	
  results	
  of	
   the	
  review	
  and	
  the	
  positive	
  commentary	
  provided,	
  it	
  was	
  apparent	
   that	
  members	
  of	
  the	
  peer	
  review	
  committee	
  did	
  not	
  appreciate	
  the	
   absence	
  of	
  the	
  case	
  conceptualization,	
  which	
  would	
  have	
  been	
   necessary	
  for	
  the	
  development	
  of	
  the	
  treatment	
  plan.	
  	
  Additionally,	
   the	
  lack	
  of	
  measurable	
  goals	
  and	
  objectives	
  along	
  with	
  targeted	
   quantified	
  interventions	
  in	
  the	
  treatment	
  plan	
  was	
  also	
  an	
  issue.	
  
	
  
A	
  necessary	
  part	
  of	
  any	
  mental	
  health	
  assessment	
  is	
  the	
  case	
   conceptualization	
  or	
  diagnostic	
  formulation.	
  	
  This	
  information	
  is	
   intended	
  to	
  review	
  specific	
  symptoms	
  experienced	
  by	
  the	
  youth	
  in	
   order	
  to	
  justify	
  a	
  specific	
  diagnosis.	
  	
  In	
  addition,	
  the	
  diagnostic	
   formulation	
  or	
  case	
  conceptualization	
  must	
  integrate	
  relevant	
   factors	
  impacting	
  a	
  youth’s	
  development/behavior/mental	
  status,	
   including	
  biological,	
  psychological,	
  social,	
  and	
  cultural	
  perspectives	
   that	
  can	
  be	
  utilized	
  by	
  the	
  clinician	
  to	
  identify	
  specific	
  risk	
  factors	
  or	
   targets	
  for	
  ongoing	
  behavioral	
  and	
  mental	
  health	
  therapies.	
  	
  From	
   this	
  information,	
  an	
  individualized	
  and	
  integrated	
  treatment	
  plan	
   could	
  be	
  derived.	
  	
  
	
  
A	
  review	
  of	
  ten	
  assessment	
  packets	
  provided	
  as	
  part	
  of	
  the	
   document	
  request	
  revealed	
  that	
  a	
  variety	
  of	
  tools	
  were	
  utilized	
  in	
  the	
   assessment	
  process.	
  These	
  included:	
  Reception	
  Assessment	
   Summary,	
  ODYS	
  Behavioral	
  Health	
  Appraisal,	
  Juvenile	
  Automated	
   Substance	
  Abuse	
  Evaluation	
  and	
  Staffing	
  Form,	
  Nursing	
  Intake	
   Screening/Assessment,	
  MAYSI-­‐2,	
  Reception	
  Risk	
  Assessment	
  

	
  

40	
  

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Interview,	
  and	
  PREA	
  Flier.	
  As	
  stated	
  above	
  there	
  was	
  a	
  lack	
  of	
   utilization	
  of	
  these	
  tools	
  in	
  the	
  development	
  of	
  comprehensive	
  case	
   conceptualizations.	
  	
  	
  
	
  
It	
  was	
  reported	
  during	
  the	
  monitoring	
  tour	
  that	
  staff	
  have	
  begun	
  to	
   develop	
  case	
  conceptualizations.	
  Provided	
  as	
  part	
  of	
  the	
  document	
   request	
  were	
  ten	
  case	
  conceptualization	
  examples,	
  which	
  served	
  to	
   further	
  demonstrate	
  the	
  need	
  to	
  evaluate	
  and	
  train	
  staff	
  on	
  case	
   conceptualizations.	
  	
  For	
  example:	
  
	
  
Youth	
  090	
  was	
  admitted	
  8.26.11	
  and	
  his	
  case	
  conceptualization	
  was	
   completed	
  9.7.11.	
  There	
  were	
  no	
  diagnostic	
  criteria	
  or	
  clear	
   symptom	
  picture	
  documented.	
  His	
  diagnoses	
  at	
  the	
  time	
  of	
  the	
   report	
  were:	
  History	
  of	
  Bipolar	
  Disorder,	
  history	
  of	
  ADHD,	
  history	
  of	
   Learning	
  Disorder.	
  	
  
	
  
Youth	
  210	
  had	
  been	
  at	
  the	
  facility	
  since	
  at	
  least	
  October	
  2010	
  (an	
   exact	
  date	
  was	
  unclear	
  from	
  the	
  assessment)	
  and	
  the	
  case	
   conceptualization	
  was	
  completed	
  on	
  the	
  psychological	
  services	
   summary	
  form	
  on	
  7.5.11.	
  The	
  writer	
  expanded	
  on	
  this	
  youth’s	
  history	
   and	
  summary	
  of	
  services,	
  as	
  well	
  as	
  explaining	
  testing	
  results.	
   However,	
  the	
  diagnostic	
  picture	
  was	
  unclear,	
  despite	
  a	
  long	
   incarceration.	
  Diagnoses	
  at	
  the	
  time	
  of	
  the	
  report	
  were:	
  Mood	
   Disorder,	
  NOS;	
  Schizoaffective	
  Disorder;	
  R/O	
  Bipolar	
  Disorder;	
   Conduct	
  Disorder;	
  and	
  Polysubstance	
  Abuse,	
  by	
  history.	
  
	
  
Per	
  a	
  review	
  of	
  the	
  10	
  reception/assessment	
  summaries	
  provided	
   per	
  the	
  document	
  request,	
  six	
  youth	
  were	
  identified	
  at	
  intake	
  as	
   requiring	
  mental	
  health	
  follow-­‐up.	
  	
  Four	
  of	
  these	
  were	
  diagnosed	
   with	
  Mood	
  Disorder,	
  NOS.	
  The	
  fifth	
  was	
  diagnosed	
  with	
  Depressive	
   Disorder,	
  NOS.	
  The	
  sixth	
  youth	
  reported	
  auditory	
  and	
  visual	
   hallucinations	
  and	
  was	
  also	
  placed	
  on	
  the	
  mental	
  health	
  caseload;	
   however,	
  no	
  mental	
  health	
  diagnosis	
  was	
  given	
  during	
  the	
  intake	
   process.	
  Three	
  of	
  the	
  youth	
  were	
  also	
  diagnosed	
  a	
  disorder	
  in	
  the	
   spectrum	
  of	
  attention	
  deficit	
  hyperactivity	
  disorder.	
  	
  In	
  no	
  case	
  were	
   diagnostic	
  criteria	
  expounded	
  upon,	
  making	
  it	
  difficult	
  to	
  ascertain	
   the	
  reason	
  behind	
  the	
  clinical	
  impressions.	
  It	
  is	
  necessary	
  to	
  identify	
   the	
  specific	
  symptoms	
  a	
  youth	
  identifies,	
  in	
  addition	
  to	
  utilizing	
   collateral	
  information	
  from	
  parents	
  or	
  guardians	
  and	
  treatment	
   providers,	
  in	
  order	
  to	
  develop	
  a	
  comprehensive	
  mental	
  health	
   assessment.	
  	
  
	
  
As	
  indicated	
  in	
  the	
  previous	
  monitoring	
  report,	
  despite	
  the	
  generation	
   of	
  multiple	
  assessment	
  forms,	
  there	
  was	
  no	
  document	
  to	
  tie	
  all	
  the	
  

	
  

41	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 42 of 104 PAGEID #: 1905

information	
  obtained	
  together	
  in	
  a	
  coherent	
  package	
  for	
  the	
  reader,	
   treatment	
  team,	
  or	
  future	
  treatment	
  provider	
  inclusive	
  of	
  a	
  diagnostic	
   formulation	
  or	
  case	
  conceptualization.	
  	
  This	
  is	
  an	
  area	
  that	
  would	
  be	
   amenable	
  to	
  quality	
  assurance,	
  peer	
  review	
  process	
  and	
  clinical	
   supervision.	
  	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Continue	
  and	
  expand	
  quality	
  assurance	
  measures	
  including	
  a	
   peer	
  review	
  process	
  and	
  clinical	
  supervision	
  to	
  ensure	
  the	
   development	
  of	
  a	
  case	
  conceptualization	
  that	
  ties	
  together	
   information	
  gleaned	
  in	
  the	
  assessment	
  process.	
  	
  In	
  order	
  for	
   quality	
  assurance	
  to	
  be	
  meaningful,	
  a	
  subset	
  of	
  case	
  records	
   must	
  be	
  reviewed,	
  one	
  case	
  review	
  does	
  not	
  suffice	
  as	
  quality	
   assurance.	
  
2. Consider	
  individual	
  clinical	
  supervision	
  regarding	
  the	
   assessment	
  process	
  and	
  development	
  of	
  the	
  case	
   formulation.	
  
3. Ensure	
  that	
  behavioral	
  health	
  staff	
  are	
  aware	
  of	
  the	
   necessary	
  components	
  of	
  a	
  quality	
  case	
  formulation.	
  
4. Review	
  and	
  revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  the	
   requirements	
  of	
  this	
  provision	
  and	
  the	
  new	
  facility	
  mission.	
  

Sources	
  of	
   Information	
  
	
   	
  

• Review	
  of	
  policy	
  and	
  procedure	
   • Review	
  of	
  youth	
  records	
   • Review	
  of	
  other	
  provided	
  documents	
   • Staff	
  interview	
  
	
  

	
  

42	
  

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III.B.5	
  	
  	
  Adequate	
  Mental	
  Health	
  Care	
  and	
  Treatment.	
  	
  The	
  State	
  shall	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  ensure	
  that	
  adequate	
  mental	
  health	
  and	
  substance	
  abuse	
  care	
   and	
  treatment	
  services	
  (including	
  timely	
  emergency	
  services),	
  and	
  adequate	
  rehabilitative	
   services	
  are	
  provided	
  to	
  youth	
  in	
  the	
  facilities	
  by	
  qualified	
  mental	
  health	
  professionals	
   consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  facility	
  self-­‐assessment,	
  the	
  Freedom	
  New	
  Phoenix	
  Cognitive	
   Behavioral	
  Health	
  Program	
  (NFP)	
  was	
  implemented	
  on	
  all	
  units.	
  	
  This	
   program	
  was	
  reportedly	
  a	
  component	
  of	
  the	
  “Ohio	
  Model…a	
   comprehensive	
  program	
  that	
  includes	
  evidence-­‐based	
  concepts	
  of	
   cognitive-­‐behavioral	
  therapy	
  (CBT),	
  motivational	
  enhancement	
   (MET),	
  motivational	
  interviewing	
  (MI),	
  and	
  social	
  learning.”	
  	
  
	
  
	
  Per	
  the	
  facility	
  self-­‐assessment,	
  NFP	
  was	
  implemented	
  “after	
   training	
  all	
  staff	
  including	
  Youth	
  Specialists	
  on	
  how	
  to	
  conduct	
  the	
   Managing	
  Anger	
  and	
  Violence	
  groups.	
  	
  Social	
  Workers	
  were	
  trained	
   on	
  Core	
  A	
  which	
  is	
  the	
  Social	
  Worker	
  component	
  and	
  Social	
  Workers	
   and	
  Psychology	
  staff	
  were	
  trained	
  on	
  the	
  overlay	
  components	
  of	
  the	
   program.”	
  	
  Following	
  the	
  training,	
  the	
  self-­‐assessment	
  described	
   coaching	
  by	
  administrative	
  staff	
  as	
  well	
  as	
  the	
  formation	
  of	
  a	
   Cognitive	
  Behavior	
  Therapy	
  Oversight	
  Committee	
  (CBTOC).	
  The	
   reported	
  purpose	
  of	
  coaching	
  was	
  to	
  assist	
  staff	
  with	
  “understanding	
   the	
  curriculum,	
  how	
  to	
  run	
  groups,	
  how	
  to	
  complete	
  documentation,	
   etc.”	
  
	
  
Following	
  the	
  change	
  of	
  mission	
  and	
  focus	
  of	
  the	
  SJCF,	
  personnel	
   changes	
  necessitated	
  by	
  the	
  “pick-­‐a-­‐post”	
  resulted	
  in	
  staff	
  unfamiliar	
   with	
  the	
  CBT	
  processes	
  in	
  place	
  at	
  SJCF.	
  “Pick-­‐a-­‐post”	
  allows	
  direct	
   care	
  staff	
  to	
  choose,	
  according	
  to	
  seniority,	
  where	
  they	
  will	
  work.	
   With	
  this	
  process	
  in	
  place,	
  staff	
  who	
  have	
  not	
  been	
  properly	
  trained	
   in	
  a	
  specific	
  modality	
  (e.g.,	
  CBT),	
  can	
  request	
  work	
  on	
  a	
  particular	
   unit	
  in	
  the	
  absence	
  of	
  training.	
  Per	
  the	
  self-­‐	
  assessment,	
  “we	
  then	
   began	
  a	
  QA/QI	
  process	
  to	
  implement	
  a	
  new	
  coaching	
  project	
  for	
   each	
  of	
  the	
  teams	
  so	
  that	
  we	
  could	
  provide	
  technical	
  support	
  and	
   assistance	
  to	
  the	
  teams	
  as	
  they	
  began	
  their	
  new	
  missions.	
  	
  This	
   process	
  is	
  in	
  the	
  beginning	
  stage.”	
  
	
  
In	
  reviewing	
  the	
  Freedom	
  New	
  Phoenix	
  Cognitive	
  Behavioral	
  Health	
   program	
  curriculum,	
  the	
  inclusion	
  of	
  direct	
  care	
  staff	
  is	
  vital	
  to	
  the	
   success	
  of	
  the	
  program.	
  Per	
  the	
  documents	
  provided	
  and	
  the	
  self-­‐ assessment,	
  it	
  was	
  reported	
  that	
  youth	
  specialists	
  are	
  being	
  

	
  

43	
  

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integrated	
  into	
  treatment	
  team	
  meetings	
  to	
  further	
  involve	
  them	
  in	
   group	
  process	
  and	
  gather	
  information	
  regarding	
  their	
  observations	
  of	
   youth.	
  	
  
	
  
Youth	
  specialists	
  facilitate	
  CBT	
  groups	
  on	
  the	
  units.	
  It	
  appeared	
  from	
   the	
  two	
  youth	
  specialist	
  run	
  groups	
  observed	
  during	
  the	
  monitoring	
   tour	
  that	
  additional	
  training,	
  coaching,	
  modeling	
  was	
  required.	
  	
  Basic	
   tenets	
  of	
  effective	
  group	
  facilitation	
  were	
  not	
  utilized,	
  these	
  included	
   environment,	
  review	
  of	
  group	
  rules,	
  direction	
  of	
  group	
  topic,	
  and	
   engagement	
  of	
  the	
  youth.	
  	
  	
  
	
  
In	
  one	
  group	
  observed,	
  youth	
  were	
  spread	
  about	
  a	
  large	
  room,	
   seated	
  in	
  groups	
  at	
  tables.	
  	
  Youth	
  were	
  not	
  engaged	
  in	
  the	
  group	
   process,	
  rather	
  talking	
  amongst	
  themselves	
  or	
  playing	
  cards.	
  	
  The	
   facilitator	
  did	
  not	
  attempt	
  to	
  engage	
  the	
  youth,	
  but	
  continued	
  to	
   read	
  directly	
  from	
  a	
  prepared	
  document	
  regarding	
  the	
  scheduled	
   group	
  topic	
  for	
  that	
  day.	
  	
  When	
  youth	
  continued	
  to	
  avoid	
   engagement	
  in	
  the	
  group	
  process,	
  another	
  youth	
  specialist,	
  not	
  the	
   group	
  facilitator,	
  began	
  to	
  shout	
  at	
  the	
  youth,	
  threatening,	
  “if	
  you	
   aren’t	
  going	
  to	
  participate,	
  you	
  can	
  go	
  to	
  your	
  rooms.”	
  	
  As	
  the	
  group	
   progressed,	
  the	
  youth	
  facilitator	
  became	
  understandably	
  frustrated.	
  	
   It	
  was	
  noted	
  by	
  the	
  monitor	
  that	
  the	
  facilitator	
  was	
  attempting	
  to	
   lead	
  the	
  group,	
  but	
  was	
  ill	
  equipped	
  for	
  the	
  task.	
  	
  This	
  was	
  an	
   untenable	
  situation	
  for	
  both	
  the	
  youth	
  specialist	
  and	
  the	
  youth	
   participants.	
  	
  	
  
	
  
It	
  was	
  pertinent	
  to	
  note	
  that	
  concurrently,	
  mental	
  health	
  staff	
   assigned	
  to	
  this	
  unit	
  was	
  conducting	
  a	
  group.	
  	
  There	
  were	
  two	
  youth	
   in	
  the	
  mental	
  health	
  group	
  and	
  approximately	
  twenty	
  youth	
  in	
  the	
   group	
  facilitated	
  by	
  the	
  youth	
  specialist.	
  	
  This	
  was	
  another	
  factor	
   contributing	
  to	
  the	
  youth	
  specialist’s	
  inability	
  to	
  engage	
  the	
  youth.	
  	
   Effective	
  groups	
  should	
  have	
  no	
  more	
  than	
  eight	
  to	
  ten	
  youth	
   participants.	
  
	
  
A	
  second	
  group	
  facilitated	
  by	
  a	
  youth	
  specialist	
  was	
  observed.	
  	
  	
  This	
   group	
  was	
  comprised	
  of	
  seven	
  female	
  youth.	
  	
  These	
  youth	
  were	
   initially	
  engaged	
  in	
  the	
  group	
  process.	
  	
  There	
  were	
  periods	
  of	
  good	
   interaction	
  between	
  the	
  youth	
  and	
  the	
  facilitator,	
  however,	
  the	
   topics	
  discussed	
  ran	
  the	
  gamut,	
  and	
  the	
  monitor	
  was	
  unclear	
  with	
   regard	
  to	
  the	
  CBT	
  topic	
  being	
  addressed.	
  	
  Maintaining	
  order	
  was	
  a	
   challenge,	
  as	
  in	
  middle	
  of	
  group,	
  three	
  youth	
  stood	
  and	
  walked	
  away	
   from	
  the	
  discussion,	
  while	
  another	
  began	
  to	
  talk	
  loudly	
  with	
  no	
   redirection	
  from	
  the	
  group	
  facilitator.	
  	
  Again,	
  it	
  was	
  opined	
  that	
  the	
   youth	
  specialist	
  was	
  attempting	
  to	
  lead	
  the	
  group,	
  but	
  was	
  ill	
  

	
  

44	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 45 of 104 PAGEID #: 1908

equipped	
  for	
  the	
  task.	
  
	
  
Both	
  of	
  these	
  examples	
  indicate	
  that	
  additional	
  modeling	
  and	
   coaching	
  are	
  necessary.	
  	
  Also,	
  administration	
  needs	
  to	
  review	
  group	
   structure	
  in	
  order	
  to	
  ensure	
  that	
  appropriate	
  numbers	
  of	
  youth	
  are	
   assigned	
  to	
  a	
  specific	
  group	
  interaction.	
  	
  	
  
	
  
With	
  regard	
  to	
  treatment	
  provided	
  by	
  mental	
  health	
  staff,	
  two	
  group	
   interactions	
  were	
  observed.	
  	
  One	
  of	
  these	
  groups	
  held	
  on	
  the	
  girls	
   mental	
  health	
  unit	
  was	
  well	
  run.	
  	
  The	
  group	
  leader	
  engaged	
  the	
  six	
   youth	
  participants.	
  	
  Appropriate	
  topics	
  were	
  introduced	
  and	
   supported	
  with	
  toys	
  and	
  other	
  visual	
  aides	
  to	
  ensure	
  that	
  youth	
  “got	
   the	
  message.”	
  	
  This	
  was	
  a	
  trauma	
  -­‐focused	
  group,	
  and	
  toward	
  the	
   end,	
  one	
  youth	
  became	
  visibly	
  distressed.	
  	
  The	
  mental	
  health	
  staff	
   appropriately	
  addressed	
  this	
  youth’s	
  issues,	
  but	
  other	
  youth	
  became	
   distressed	
  as	
  a	
  result.	
  	
  The	
  unit	
  social	
  worker,	
  unit	
  manger	
  and	
  youth	
   specialists	
  did	
  a	
  good	
  job	
  of	
  ensuring	
  the	
  safety	
  of	
  all	
  youth	
   participating	
  in	
  group	
  and	
  of	
  addressing	
  the	
  distress	
  of	
  all	
  youth	
   participants.	
  
	
  
A	
  second	
  trauma	
  focused	
  mental	
  health	
  facilitated	
  group	
  was	
   observed	
  on	
  Cedar	
  unit.	
  	
  This	
  group	
  was	
  attended	
  by	
  six	
  youth.	
  	
   Unlike	
  the	
  group	
  observed	
  with	
  the	
  female	
  youth	
  where	
  the	
  unit	
   social	
  worker	
  was	
  in	
  attendance,	
  this	
  group	
  had	
  no	
  other	
  mental	
   health	
  staff	
  in	
  attendance.	
  	
  The	
  mental	
  health	
  facilitator	
  had	
   prepared	
  documents	
  for	
  the	
  youth	
  to	
  read	
  and	
  review.	
  	
  The	
   facilitator	
  attempted	
  to	
  engage	
  the	
  youth;	
  however,	
  these	
  attempts	
   became	
  futile	
  following	
  her	
  disclosure	
  of	
  confidential	
  information	
   that	
  three	
  separate	
  youth	
  had	
  disclosed	
  to	
  her	
  during	
  individual	
   sessions	
  (e.g.,	
  statements	
  from	
  the	
  mental	
  health	
  professional	
  such	
   as	
  “you	
  know	
  about	
  that	
  [insert	
  youth	
  name]…you	
  told	
  me	
  about	
   that	
  in	
  therapy.”)	
  	
  Following	
  this,	
  youth	
  became	
  frustrated	
  and	
  the	
   facilitator	
  lost	
  credibility.	
  	
  Youth	
  were	
  noted	
  to	
  mumble	
  under	
  their	
   breath,	
  looking	
  at	
  peers	
  across	
  the	
  room,	
  stating	
  audibly,	
  “I	
  didn’t	
  say	
   that	
  …she	
  don’t	
  know	
  what	
  she	
  is	
  saying.”	
  	
  Concerns	
  regarding	
  this	
   inappropriate	
  disclosure	
  of	
  confidential	
  information	
  were	
  discussed	
   with	
  administrative	
  mental	
  health	
  staff	
  during	
  the	
  monitoring	
  tour.	
  	
   Subsequent	
  documentation	
  received	
  from	
  the	
  facility	
  indicated	
  that	
   it	
  was	
  being	
  addressed	
  via	
  supervision.	
  
	
  
Per	
  the	
  requested	
  documents,	
  sign-­‐in	
  sheets	
  for	
  groups	
  completed	
   during	
  the	
  90	
  days	
  prior	
  to	
  the	
  monitoring	
  visit	
  were	
  provided.	
   According	
  to	
  these	
  sign-­‐in	
  sheets,	
  attendance	
  and	
  participation	
  in	
   each	
  group	
  varied.	
  Documentation	
  indicated	
  anywhere	
  from	
  one	
  to	
  

	
  

45	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 46 of 104 PAGEID #: 1909

18	
  youth	
  in	
  attendance	
  at	
  group	
  sessions.	
  As	
  stated	
  above,	
  the	
   facility	
  must	
  address	
  the	
  issue	
  of	
  too	
  many	
  youth	
  assigned	
  to	
  one	
   group	
  therapy	
  interaction.	
  	
  Additionally,	
  one	
  youth	
  in	
  attendance	
   does	
  not	
  qualify	
  as	
  a	
  group	
  therapeutic	
  interaction.	
  
	
  
Additionally,	
  per	
  the	
  documentation	
  provided,	
  there	
  were	
  groups	
   cancelled	
  due	
  to	
  mental	
  health	
  staff	
  being	
  unavailable.	
  	
  This	
  issue	
   was	
  further	
  discussed	
  with	
  regard	
  to	
  staffing	
  patterns	
  in	
  the	
   discussion	
  of	
  provision	
  11.	
  When	
  fully	
  staffed,	
  there	
  must	
  be	
   provisions	
  to	
  provide	
  services	
  in	
  the	
  absence	
  of	
  primary	
  staff.	
  	
  
	
  
Review	
  of	
  progress	
  notes	
  regarding	
  individual	
  therapy	
  sessions	
   revealed	
  marked	
  variability	
  in	
  the	
  quality	
  of	
  the	
  documentation,	
  the	
   duration	
  of	
  the	
  therapeutic	
  interactions	
  and	
  the	
  frequency	
  of	
  the	
   therapeutic	
  interactions.	
  	
  Some	
  mental	
  health	
  providers	
  were	
  noted	
   to	
  meet	
  frequently	
  with	
  youth	
  for	
  brief	
  periods	
  of	
  time	
  (15	
  minutes	
   to	
  30	
  minutes),	
  where	
  others	
  met	
  less	
  frequently	
  for	
  longer	
  periods	
   (45	
  minutes).	
  	
  A	
  review	
  of	
  treatment	
  planning	
  documents	
  did	
  not	
   reveal	
  documentation	
  regarding	
  the	
  level	
  of	
  care	
  or	
  frequency	
  of	
   interaction	
  prescribed	
  for	
  each	
  individual	
  youth.	
  	
  Therefore,	
  it	
  was	
   not	
  possible	
  to	
  determine	
  if	
  the	
  frequency	
  noted	
  via	
  record	
  review	
   was	
  appropriate	
  for	
  a	
  particular	
  youth.	
  	
  On	
  a	
  positive	
  note,	
   documentation	
  and	
  observed	
  interaction	
  between	
  occupational	
   therapy	
  staff	
  and	
  youth	
  was	
  superior.	
  
	
  
Given	
  the	
  above,	
  it	
  was	
  apparent	
  that	
  while	
  some	
  treatment	
  was	
   occurring,	
  improvements	
  to	
  the	
  overall	
  treatment	
  program	
  and	
   documentation	
  of	
  treatment	
  planned	
  and	
  provided	
  will	
  be	
  necessary	
   for	
  the	
  facility	
  to	
  meet	
  the	
  requirements	
  of	
  this	
  provision.	
  	
  In	
  the	
   upcoming	
  monitoring	
  tour,	
  additional	
  information	
  regarding	
  the	
   facilities	
  mental	
  health	
  treatment	
  program	
  will	
  be	
  requested	
  and	
   reviewed.	
  
	
  
Specific	
  concerns	
  were	
  noted	
  regarding	
  the	
  treatment	
  program	
  for	
   youth	
  housed	
  in	
  the	
  Progress	
  unit.	
  	
  It	
  was	
  concerning	
  that	
  this	
   particular	
  unit	
  relied	
  on	
  room	
  confinement	
  with	
  a	
  paucity	
  of	
  mental	
   health	
  treatment	
  for	
  youth,	
  some	
  whom,	
  were	
  identified	
  as	
  having	
   serious	
  mental	
  health	
  issues.	
  	
  As	
  discussed	
  with	
  the	
  facility	
   administration,	
  facility	
  mental	
  health	
  staff	
  and	
  DYS	
  administration,	
   the	
  programming	
  on	
  this	
  unit	
  must	
  be	
  a	
  priority	
  and	
  will	
  be	
  the	
  focus	
   of	
  future	
  monitoring	
  visits.	
  	
  In	
  the	
  meantime,	
  it	
  is	
  strongly	
   recommended	
  and	
  discussed	
  via	
  this	
  monitoring	
  report	
  that	
  the	
   facility	
  begin	
  to	
  reevaluate	
  all	
  the	
  youth	
  housed	
  in	
  this	
  program	
  with	
   respect	
  to	
  their	
  mental	
  health	
  and	
  intellectual	
  functioning	
  in	
  order	
  to	
  

	
  

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determine	
  if	
  they	
  are	
  appropriate	
  for	
  this	
  type	
  of	
  setting.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Continue	
  the	
  implementation	
  of	
  mental	
  health	
  programming.	
   2. Ensure	
  that	
  all	
  staff	
  (i.e.,	
  direct	
  care	
  staff)	
  have	
  received	
  
appropriate	
  training	
  to	
  participate	
  in	
  the	
  required	
  mental	
   health	
  and	
  rehabilitative	
  programming	
  activities	
  on	
  each	
  unit.	
   3. Improve	
  documentation	
  of	
  group	
  therapeutic	
  interaction.	
   4. Improve	
  documentation	
  of	
  individual	
  therapeutic	
  interaction.	
   5. Ensure	
  the	
  provision	
  of	
  evidence	
  based	
  group	
  therapeutic	
   interactions.	
  	
   6. Increase	
  modeling	
  and	
  coaching	
  for	
  youth	
  specialists	
   responsible	
  for	
  group	
  therapeutic	
  interactions.	
   7. Determine	
  and	
  ensure	
  that	
  appropriate	
  numbers	
  of	
  youth	
   are	
  assigned	
  to	
  specific	
  group	
  therapy	
  sessions.	
   8. Continue	
  the	
  integration	
  of	
  treatment	
  provider	
  disciplines	
  in	
   order	
  to	
  achieve	
  an	
  interdisciplinary	
  model.	
   9. Continue	
  to	
  engage	
  and	
  encourage	
  direct	
  care	
  staff	
  to	
   participate	
  in	
  group	
  modalities	
  and	
  in	
  the	
  overall	
  treatment	
   program	
  for	
  the	
  youth.	
   10. Ensure	
  available	
  mental	
  health	
  staff	
  to	
  provide	
  scheduled	
   treatment.	
  	
  If	
  a	
  particular	
  mental	
  health	
  staff	
  is	
  unavailable	
   (e.g.	
  on	
  vacation,	
  ill),	
  ensure	
  clinical	
  coverage	
  such	
  that	
  the	
   youth’s	
  treatment	
  program	
  is	
  not	
  impeded.	
   11. Begin	
  quality	
  assurance	
  monitoring	
  regarding	
  the	
  mental	
   health	
  treatment	
  program	
  that	
  addresses	
  both	
  adherence	
  to	
   the	
  required	
  procedural	
  elements	
  but	
  also	
  measures	
  youth	
   outcomes	
  related	
  to	
  the	
  treatment	
  modality	
  (e.g.	
  reduction	
   in	
  SHU	
  referrals,	
  reduction	
  in	
  facility	
  violence).	
   12. Review	
  the	
  Progress	
  program,	
  and	
  ensure	
  that	
  youth	
  are	
   receiving	
  appropriate	
  mental	
  health	
  treatment	
  via	
  this	
   program.	
   13. Utilize	
  clinical	
  supervision	
  to	
  address	
  confidentially	
  and	
  other	
   pertinent	
  topics	
  with	
  mental	
  health	
  staff.	
  	
  This	
  supervision	
   must	
  be	
  documented.	
   14. Reevaluate	
  all	
  youth	
  housed	
  in	
  the	
  Progress	
  unit	
  to	
   determine	
  if	
  they	
  are	
  appropriate	
  for	
  this	
  type	
  of	
  placement	
   given	
  potential	
  mental	
  health	
  disorders	
  or	
   intellectual/developmental	
  disabilities.	
  

Sources	
  of	
   Information	
  

• Review	
  of	
  provided	
  documents	
  (e.g.	
  group	
  schedule,	
  youth	
   records,	
  policy	
  and	
  procedure,	
  description	
  of	
  treatment	
   modalities)	
  
• Observation	
  of	
  three	
  group	
  interactions	
   • Youth	
  interview	
  

	
  

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• Staff	
  interview	
  

	
  

	
  

	
  

	
  

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III.B.6	
  	
  	
  Treatment	
  Planning.	
  	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
   and	
  practices	
  so	
  hat	
  treatment	
  service	
  determinations,	
  including	
  ongoing	
  treatment	
  and	
   discharge	
  planning,	
  are	
  consistently	
  made	
  by	
  an	
  interdisciplinary	
  team	
  through	
  integrated	
   treatment	
  planning	
  and	
  embodied	
  in	
  a	
  single,	
  integrated	
  treatment	
  plan.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  facility	
  self	
  assessment,	
  “with	
  the	
  identification	
  that	
   Integrated	
  Treatment	
  Plans	
  needed	
  improved	
  [sic],	
  the	
  Psychology	
   Supervisor	
  and	
  Social	
  Worker	
  Supervisors…had	
  planned	
  to	
  provide	
   case	
  note	
  documentation,	
  as	
  well	
  as	
  Integrated	
  Treatment	
  Planning	
   Training	
  for	
  all	
  of	
  the	
  Behavioral	
  Health	
  Services	
  staff…a	
  meeting	
  to	
   review	
  and	
  critique	
  a	
  sample	
  of	
  ITP’s	
  written	
  by	
  SJCF	
  Behavioral	
   Health	
  Staff	
  was	
  held	
  on	
  9.22.11…training	
  for	
  all	
  Behavioral	
  Health	
   Services	
  staff	
  on	
  ITP	
  development	
  will	
  be	
  scheduled	
  immediately	
   upon	
  implementation	
  of	
  the	
  ITP	
  policy	
  which	
  is	
  expected	
  by	
  the	
  end	
   of	
  2011.”	
  	
  For	
  additional	
  discussion	
  regarding	
  Treatment	
  Planning	
  and	
   IDT	
  meetings,	
  please	
  see	
  the	
  discussion	
  regarding	
  the	
  provisions	
   below	
  (7	
  and	
  8).	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Review,	
  revise,	
  and	
  implement	
  policy	
  and	
  procedure	
   regarding	
  treatment	
  planning	
  and	
  the	
  IDT	
  process.	
  
2. Address	
  recommendations	
  provided	
  regarding	
  provisions	
   7	
  and	
  8	
  below.	
  

Sources	
  of	
   Information	
  
	
   	
  

• Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  (e.g.	
  Policy	
  and	
  Procedure,	
  
Integrated	
  Treatment	
  Plans)	
  
	
  

	
  

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III.B.7	
  	
  Treatment	
  Teams.	
  	
  	
  At	
  a	
  minimum,	
  the	
  interdisciplinary	
  treatment	
  team	
  for	
  each	
   youth	
  in	
  need	
  of	
  mental/behavioral	
  health	
  and/or	
  substance	
  abuse	
  treatment	
  should:	
  a)	
  be	
   guided	
  by	
  a	
  trained	
  treatment	
  professional	
  who	
  shall	
  provide	
  clinical	
  oversight	
  and	
  ensure	
   the	
  proper	
  functioning	
  of	
  treatment	
  team	
  meetings;	
  b)	
  consist	
  of	
  a	
  stable	
  core	
  of	
  members,	
   including	
  at	
  least	
  the	
  youth,	
  the	
  social	
  worker,	
  a	
  JCO,	
  one	
  of	
  the	
  youth’s	
  teachers,	
  the	
  Unit	
   Manager,	
  and	
  as	
  warranted	
  by	
  the	
  needs	
  of	
  the	
  youth,	
  the	
  treating	
  psychiatrist,	
  the	
  treating	
   psychologist,	
  registered	
  nurse,	
  and,	
  as	
  appropriate,	
  other	
  staff;	
  c)	
  ensure	
  that	
  needed	
   psychiatric	
  evaluations	
  are	
  conducted	
  on	
  a	
  youth	
  before	
  administering	
  psychotropic	
   medications	
  to	
  the	
  youth;	
  d)	
  monitor	
  as	
  appropriate	
  but	
  at	
  least	
  monthly,	
  the	
  efficacy	
  and	
   the	
  side	
  effects	
  of	
  psychotropic	
  medications,	
  including	
  consultation	
  with	
  family	
  medical,	
   counseling	
  and	
  other	
  staff	
  who	
  are	
  familiar	
  with	
  the	
  youth;	
  e)	
  for	
  youth	
  under	
  a	
   psychiatrist’s	
  care:	
  ensure	
  the	
  provision	
  of	
  individual	
  counseling	
  and	
  psychotherapy	
  when	
   needed,	
  in	
  coordination	
  with	
  facility	
  psychologists;	
  ensure	
  that	
  all	
  youth	
  referred	
  as	
  possibly	
   in	
  need	
  of	
  psychiatric	
  services	
  are	
  evaluated	
  and	
  treated	
  in	
  a	
  timely	
  manner;	
  and	
  provide	
   adequate	
  documentation	
  of	
  treatment	
  in	
  the	
  facility	
  medical	
  records;	
  f)	
  include	
  to	
  the	
   fullest	
  extent	
  practicable,	
  proactive	
  efforts	
  to	
  obtain	
  the	
  participation	
  of	
  parents	
  or	
   guardians,	
  unless	
  their	
  participation	
  would	
  be	
  inappropriate	
  for	
  some	
  reason	
  (e.g.,	
  the	
  child	
   has	
  been	
  removed	
  from	
  the	
  parent’s	
  custody),	
  in	
  order	
  to	
  obtain	
  relevant	
  information,	
   understand	
  family	
  goals	
  and	
  concerns,	
  and	
  foster	
  ongoing	
  engagement;	
  g)	
  meet	
  to	
  assess	
   the	
  treatment	
  plan’s	
  efficacy	
  at	
  least	
  every	
  30	
  days	
  and	
  more	
  often	
  as	
  necessary;	
  and	
  h)	
   document	
  treatment	
  team	
  meetings	
  and	
  planning	
  in	
  the	
  youth’s	
  mental	
  health	
  records.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  policy	
  and	
  procedure	
  entitled	
  “Behavioral	
  Health	
  Services”,	
   Interdisciplinary	
  Team	
  Meetings	
  are	
  “a	
  structured	
  meeting	
  of	
  the	
  IDT	
   for	
  youth	
  and	
  staff	
  to	
  discuss,	
  at	
  least	
  monthly,	
  progress	
  related	
  to	
   ITP.	
  This	
  meeting	
  can	
  also	
  address	
  problem	
  solving,	
  implementing	
  and	
   evaluating	
  operational	
  functions	
  within	
  each	
  unit	
  of	
  the	
  facility.”	
  	
  It	
   was	
  evident	
  via	
  both	
  a	
  review	
  of	
  documents	
  provided	
  and	
   observations	
  conducted	
  during	
  the	
  monitoring	
  visit	
  that	
  IDT	
  meetings	
   were	
  a	
  combination	
  of	
  staff	
  meeting	
  and	
  youth	
  treatment	
  team.	
   Similar	
  announcements	
  were	
  documented	
  in	
  team	
  minutes	
  across	
   units,	
  demonstrating	
  continuity	
  in	
  the	
  delivery	
  of	
  information	
  from	
   the	
  facility	
  administration.	
  	
  	
   	
   Generally,	
  IDT	
  minutes	
  reflected	
  significant	
  time	
  spent	
  in	
  the	
   discussion	
  of	
  	
  “housekeeping”	
  issues	
  such	
  as	
  the	
  unit	
  schedule	
  and	
   youth	
  rules.	
  With	
  the	
  exception	
  of	
  the	
  girls	
  mental	
  health	
  unit	
  (where	
   documentation	
  of	
  IDT	
  addressed	
  youth	
  mental	
  health	
  issues)	
   documented	
  discussions,	
  particularly	
  regarding	
  mental	
  health	
   treatment	
  issues	
  appeared	
  to	
  be	
  minimal.	
  	
   	
   One	
  of	
  the	
  recommendations	
  from	
  the	
  March	
  2011	
  report	
  was	
  to	
  

	
  

50	
  

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integrate	
  youth	
  specialists	
  into	
  weekly	
  IDT	
  meetings.	
  The	
  self-­‐ assessment	
  reported	
  “a	
  QI	
  process	
  was	
  implemented	
  regarding	
  the	
   integration	
  of	
  direct	
  care	
  staff…there	
  has	
  been	
  an	
  increase	
  in	
  Youth	
   Specialist	
  presence	
  and	
  involvement	
  in	
  all	
  Interdisciplinary	
  Teams.”	
   During	
  the	
  observed	
  IDT	
  meeting,	
  two	
  officers	
  were	
  present,	
   indicating	
  an	
  effort	
  to	
  include	
  all	
  disciplines	
  in	
  review	
  and	
  planning	
  of	
   youth	
  treatment.	
  Reportedly	
  due	
  to	
  a	
  paucity	
  of	
  psychiatric	
   resources,	
  the	
  psychiatrist	
  was	
  not	
  a	
  consistent	
  participant	
  in	
  IDT	
   meetings	
  other	
  than	
  the	
  girls	
  mental	
  health	
  unit.	
  	
  This	
  was	
  not	
   acceptable	
  as	
  there	
  were	
  mentally	
  ill	
  youth	
  housed	
  on	
  units	
  other	
   than	
  Davey	
  who	
  required	
  the	
  presence	
  of	
  their	
  treating	
  psychiatrist	
  at	
   their	
  IDT	
  meeting.	
  	
   	
   The	
  monitor	
  noted	
  the	
  focus	
  on	
  security	
  rather	
  than	
  treatment	
  issues	
   during	
  the	
  IDT	
  meeting	
  observed	
  in	
  the	
  Progress	
  Unit	
  (Cedar)	
  as	
  part	
   of	
  the	
  monitoring	
  visit.	
  At	
  this	
  meeting,	
  announcements	
  were	
  made	
   and	
  phases	
  were	
  reviewed.	
  There	
  was	
  no	
  discussion	
  regarding	
  the	
   youth	
  or	
  their	
  specific	
  phases,	
  nor	
  was	
  there	
  discussion	
  regarding	
   what	
  each	
  youth	
  needed	
  to	
  accomplish	
  in	
  order	
  to	
  progress	
  to	
  the	
   next	
  phase	
  of	
  the	
  program.	
  	
  Both	
  youth	
  and	
  staff	
  were	
  unclear	
   regarding	
  movement	
  between	
  specific	
  phases,	
  the	
  ability	
  to	
  freeze	
   phases,	
  and	
  the	
  ability	
  for	
  youth	
  to	
  transition	
  out	
  of	
  the	
  Progress	
  unit	
   (due	
  to	
  concerns	
  regarding	
  space	
  on	
  the	
  identified	
  transition	
  unit).	
  	
   These	
  concerns	
  were	
  addressed	
  with	
  facility	
  and	
  statewide	
   administration.	
  	
  Per	
  the	
  monitor,	
  the	
  facility	
  administration	
  and	
  staff	
   must	
  focus	
  on	
  the	
  Progress	
  unit	
  in	
  order	
  to	
  ensure	
  that	
  not	
  only	
  are	
   appropriate	
  youth	
  assigned	
  to	
  this	
  program,	
  but	
  that	
  the	
  program	
  is	
   implemented	
  correctly.	
   	
   Additional	
  issues	
  identified	
  during	
  this	
  IDT	
  observation	
  were	
  the	
  lack	
   of	
  focus	
  and	
  decision-­‐making	
  regarding	
  mental	
  health	
  issues.	
  Staff	
   spent	
  approximately	
  one	
  hour	
  discussing	
  unit	
  issues,	
  then	
  reviewed	
   each	
  youth	
  briefly	
  prior	
  to	
  the	
  youth	
  entering	
  the	
  IDT.	
  	
  In	
  general,	
   youth	
  were	
  presented	
  in	
  IDT	
  for	
  less	
  than	
  ten	
  minutes.	
  	
  There	
  was	
   one	
  exception,	
  Youth	
  444.	
  	
  Reportedly,	
  this	
  youth	
  was	
  experiencing	
   difficulties	
  with	
  respect	
  to	
  “self	
  secluding”	
  in	
  his	
  cell,	
  refusing	
  to	
   interact	
  with	
  staff,	
  and	
  refusing	
  treatment	
  with	
  psychotropic	
   medication.	
  	
  Staff	
  met	
  with	
  him	
  for	
  approximately	
  20	
  minutes	
  until	
   the	
  unit	
  psychologist	
  signaled	
  to	
  discontinue	
  the	
  conversation	
  with	
   him.	
  	
  During	
  the	
  youth’s	
  interaction	
  with	
  the	
  team	
  and	
  following	
  his	
   departure,	
  no	
  clear	
  mental	
  health	
  interventions	
  or	
  goals	
  were	
   identified	
  or	
  planned.	
  	
   	
   This	
  lack	
  of	
  decision-­‐making	
  and	
  formal	
  planning	
  with	
  respect	
  to	
  IDT	
   team	
  meetings	
  was	
  consistent	
  with	
  observations	
  made	
  during	
  the	
  

	
  

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previous	
  monitoring	
  period.	
  	
  Per	
  the	
  facility	
  self-­‐assessment,	
  “coaches	
   have	
  been	
  assigned	
  to	
  every	
  IDT…a	
  kick	
  off	
  meeting	
  is	
  scheduled	
  for	
   11/15/11	
  to	
  clarify	
  the	
  role	
  of	
  each	
  coach…[to]	
  increase	
  participation	
   in	
  the	
  meeting	
  from	
  all	
  members;	
  work	
  with	
  the	
  team	
  in	
  developing	
   and	
  monitoring	
  measurable	
  goals	
  and	
  objectives	
  related	
  for	
  each	
   youth;	
  conduct	
  on	
  the	
  spot	
  feedback	
  to	
  allow	
  for	
  a	
  more	
  improved	
   process	
  and	
  clarification	
  of	
  goals	
  for	
  each	
  youth;	
  [and]	
  coaches	
  are	
  to	
   attend	
  all	
  meetings	
  whenever	
  possible.”	
  	
   	
   Full	
  implementation	
  of	
  the	
  coaching	
  plan	
  may	
  improve	
   communication	
  and	
  treatment	
  planning	
  within	
  the	
  IDT.	
  	
   Unfortunately,	
  the	
  facility	
  had	
  not	
  begun	
  the	
  QA	
  process	
  for	
  IDT	
   meetings.	
  	
  A	
  review	
  of	
  two	
  quality	
  assurance	
  reports	
  dated	
  9.13.11	
   (covering	
  months	
  January,	
  February,	
  and	
  March	
  2011)	
  and	
   9.14.11(covering	
  months	
  April,	
  May,	
  and	
  June	
  2011)	
  revealed	
  no	
  QA	
   data	
  for	
  IDT	
  meetings.	
  	
   	
   Per	
  the	
  documentation	
  9.13.11,	
  “Supervisor	
  attended	
  treatment	
   team	
  on	
  the	
  boys	
  mental	
  health	
  unit,	
  but	
  did	
  not	
  document	
  the	
   reviews	
  for	
  1st	
  quarter…Supervisor	
  needs	
  to	
  be	
  given	
  more	
  time	
  to	
   conduct	
  IDT	
  reviews	
  and	
  to	
  make	
  sure	
  that	
  he	
  documents	
  the	
  ones	
   that	
  he	
  is	
  able	
  to	
  review…Psychology	
  supervisor	
  does	
  not	
  have	
  time	
   to	
  attend	
  IDT	
  meetings	
  due	
  to	
  his	
  host	
  of	
  other	
  duties.”	
  	
  	
   	
   Per	
  the	
  documentation	
  9.14.11,	
  “Supervisor	
  did	
  not	
  conduct	
  IDT	
   reviews	
  this	
  quarter.	
  	
  The	
  Supervisor	
  should	
  be	
  given	
  time	
  to	
  sit	
  in	
  on	
   these	
  meetings	
  once	
  per	
  month.	
  Current	
  workload	
  does	
  not	
  permit	
   this…Supervisors	
  time	
  is	
  so	
  consumed	
  that	
  he	
  does	
  not	
  have	
  the	
   opportunity	
  to	
  sit	
  in	
  on	
  the	
  IDT	
  meetings.”	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Ensure	
  psychiatric	
  resources	
  are	
  available	
  to	
  allow	
   participation	
  in	
  Interdisciplinary	
  Treatment	
  Team	
  meetings.	
  
2. Ensure	
  that	
  direct	
  care	
  staff	
  are	
  included	
  in	
  and	
  valued	
   members	
  of	
  the	
  IDT.	
  
3. Begin	
  Quality	
  Assurance	
  monitoring	
  of	
  treatment	
  planning	
   efforts	
  and	
  IDT	
  meetings.	
  
4. Increase	
  staff	
  training/education	
  regarding	
  the	
  timely	
   formulation	
  of	
  a	
  treatment	
  plan	
  and	
  interventions	
   developed	
  as	
  a	
  result	
  of,	
  among	
  other	
  things,	
  the	
  discussion	
   in	
  IDT.	
  	
  These	
  plans	
  must	
  then	
  be	
  implemented,	
  first	
  via	
   training	
  direct	
  care	
  staff.	
  
5. Review	
  the	
  psychology	
  supervisor	
  duties	
  and	
  schedule	
  to	
   determine	
  the	
  need	
  for	
  additional	
  resources	
  such	
  that	
  this	
  

	
  

52	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 53 of 104 PAGEID #: 1916

Sources	
  of	
   Information	
  
	
   	
  

staff	
  member	
  can	
  complete	
  the	
  current	
  assigned	
  tasks.	
  
• Staff	
  Interview	
   • Observation	
  of	
  Interdisciplinary	
  Treatment	
  Team	
  meeting	
   • Review	
  of	
  provided	
  documents	
  	
   • Youth	
  interview	
  
	
  

	
  

53	
  

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III.B.8	
  	
  Integrated	
  Treatment	
  Plans.	
  The	
  State	
  shall	
  ensure	
  that	
  each	
  youth	
  in	
  need	
  of	
   mental/behavioral	
  health	
  and/or	
  substance	
  abuse	
  treatment	
  shall	
  have	
  an	
  appropriate,	
   integrated	
  treatment	
  plan,	
  including	
  an	
  appropriate	
  behavior	
  management	
  plan	
  that	
   addresses	
  such	
  needs.	
  The	
  integrated	
  treatment	
  plan	
  shall	
  be	
  driven	
  by	
  individualized	
  risks	
   and	
  needs,	
  be	
  strengths-­‐based	
  (i.e.,	
  builds	
  on	
  an	
  individual’s	
  current	
  strengths),	
  account	
  for	
   the	
  youth’s	
  motivation	
  for	
  engaging	
  in	
  activities	
  contributing	
  to	
  his/her	
  wellness,	
  and	
  be	
   reasonably	
  calculated	
  to	
  lead	
  to	
  improvement	
  in	
  the	
  individual’s	
  mental/behavioral	
  health	
   and	
  well	
  being,	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  facility	
  self-­‐assessment,	
  Integrated	
  Treatment	
  Planning	
  (ITP)	
   remains	
  an	
  area	
  in	
  need	
  of	
  improvement.	
  	
  Per	
  the	
  self-­‐assessment,	
   “training	
  for	
  all	
  Behavioral	
  Health	
  Service	
  staff	
  will	
  be	
  scheduled	
   immediately	
  upon	
  implementation	
  of	
  the	
  ITP	
  policy	
  which	
  is	
   expected	
  by	
  the	
  end	
  of	
  2011.”	
  	
  	
  
	
  
This	
  statement	
  was	
  somewhat	
  confusing,	
  as	
  it	
  was	
  previously	
   understood	
  by	
  the	
  monitor	
  that	
  policy	
  and	
  procedure	
  entitled	
   “Behavioral	
  Health	
  Integrated	
  Treatment	
  Plan”	
  was	
  approved	
  and	
   implemented	
  as	
  of	
  1.1.11.	
  Discussions	
  with	
  facility	
  and	
  DYS	
  staff	
   during	
  the	
  monitoring	
  tour	
  revealed	
  plans	
  to	
  review	
  and	
  revise	
   multiple	
  policy	
  and	
  procedure	
  documents	
  governing	
  Behavioral	
   Health	
  Services	
  at	
  DYS	
  facilities.	
  	
  	
  
	
  
As	
  such,	
  given	
  the	
  lack	
  of	
  policy	
  and	
  procedure,	
  the	
  lack	
  of	
  training	
   regarding	
  integrated	
  treatment	
  plans,	
  and	
  document	
  review	
  that	
   revealed	
  no	
  change	
  in	
  the	
  quality	
  of	
  documentation	
  in	
  the	
   intervening	
  period	
  since	
  the	
  prior	
  monitoring	
  tour,	
  the	
  issues	
   outlined	
  in	
  the	
  previous	
  monitoring	
  report	
  remain.	
  For	
  example,	
   most	
  treatment	
  plans	
  were	
  not	
  individualized,	
  did	
  not	
  include	
   measurable	
  goals,	
  and	
  did	
  not	
  give	
  examples	
  of	
  appropriate/desired	
   behaviors	
  or	
  skills	
  the	
  youth	
  should	
  focus	
  on	
  developing.	
  
	
  
As	
  indicated	
  elsewhere	
  in	
  this	
  monitoring	
  report,	
  this	
  facility	
  was	
  in	
  a	
   state	
  of	
  chaos	
  as	
  a	
  result	
  of	
  massive	
  institutional	
  changes	
  (change	
  of	
   mission,	
  change	
  of	
  facility	
  population,	
  change	
  of	
  programming)	
  and	
   was	
  in	
  dire	
  need	
  of	
  an	
  organized	
  planned	
  approach	
  to	
  Behavioral	
   Health	
  program	
  development	
  and	
  implementation.	
  	
  Training	
  needs	
   aside,	
  this	
  facility	
  required	
  stability	
  with	
  regard	
  to	
  the	
  system	
  and	
   program,	
  a	
  full	
  complement	
  of	
  staff,	
  and	
  a	
  cogent	
  action	
  plan	
  for	
  the	
   future	
  	
  	
  	
  
Given	
  the	
  lack	
  of	
  progress	
  with	
  regard	
  to	
  this	
  provision	
  indicated	
  via	
  

	
  

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the	
  facility	
  self-­‐assessment	
  and	
  review	
  of	
  the	
  provided	
  documents,	
   information	
  included	
  in	
  the	
  previous	
  monitoring	
  report	
  will	
  be	
   italicized	
  below	
  for	
  review:	
  
	
  
“Per	
  the	
  recently	
  implemented	
  policy	
  entitled	
  “Behavioral	
  Health	
   Services”	
  the	
  Integrated	
  Treatment	
  Plan	
  is	
  “a	
  formal	
  strategy	
   developed	
  to	
  address	
  the	
  habilitation,	
  education,	
  rehabilitation,	
   social,	
  mental	
  health	
  and	
  psychiatric	
  needs	
  of	
  a	
  specific	
  youth.	
  	
  The	
   plan	
  is	
  developed	
  by	
  an	
  assigned	
  Clinician	
  or	
  Provider	
  in	
  collaboration	
   with	
  the	
  youth	
  and	
  the	
  Interdisciplinary	
  Team	
  (IDT),	
  and	
  is	
   implemented	
  by	
  both	
  the	
  youth	
  and	
  all	
  Behavioral	
  Health	
  Services	
   staff	
  who	
  work	
  with	
  the	
  youth...Acceptable	
  Integrated	
  Treatment	
   Plans	
  must	
  include	
  measurable	
  goals	
  and	
  objectives,	
  with	
  available	
   targeted	
  interventions	
  to	
  address	
  each	
  goal.	
  	
  Progress	
  notes	
  authored	
   regarding	
  the	
  youth’s	
  treatment	
  should	
  refer	
  to	
  the	
  youth’s	
  treatment	
   goals	
  and	
  document	
  the	
  response	
  (or	
  lack	
  thereof)	
  to	
  the	
  prescribed	
   interventions…Integrated	
  Treatment	
  Plans	
  should	
  be	
  reviewed	
  at	
  each	
   Interdisciplinary	
  Treatment	
  Team	
  meeting	
  scheduled	
  for	
  the	
  youth,	
   and	
  must	
  be	
  authored	
  and	
  reviewed	
  with	
  the	
  participation	
  of	
  the	
   youth	
  and	
  their	
  parent	
  or	
  guardian	
  (if	
  appropriate).”	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Finalize	
  and	
  implement	
  policy	
  and	
  procedure	
  regarding	
   Integrated	
  Treatment	
  Plans.	
  
2. Train	
  Behavioral	
  Health	
  Staff	
  regarding	
  development	
  of	
   Integrated	
  Treatment	
  Plans.	
  
3. Ensure	
  that	
  Integrated	
  Treatment	
  Teams	
  utilize	
  the	
   Integrated	
  Treatment	
  Plans	
  as	
  a	
  road	
  map	
  for	
  youth	
   treatment	
  and	
  progress,	
  and	
  that	
  the	
  Integrated	
  Treatment	
   Plans	
  are	
  updated	
  regularly	
  as	
  per	
  policy	
  and	
  procedure	
   pending	
  implementation.	
  
4. Develop	
  quality	
  assurance	
  monitoring	
  tools	
  that	
  are	
  both	
   process	
  (e.g.	
  were	
  the	
  targeted	
  interventions	
  appropriate	
  for	
   a	
  particular	
  youth;	
  were	
  measurable	
  goals	
  and	
  objectives	
   identified;	
  per	
  a	
  review	
  of	
  the	
  youth’s	
  progress	
  notes,	
  did	
   treatment	
  provided	
  to	
  the	
  youth	
  follow	
  the	
  outline	
  of	
  the	
   Integrated	
  Treatment	
  Plan)	
  and	
  outcome	
  oriented	
  (e.g.	
  did	
   the	
  youth	
  improve	
  over	
  the	
  course	
  of	
  treatment	
  per	
  the	
   Integrated	
  Treatment	
  Plan).	
  

Sources	
  of	
   Information	
  

• Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  (e.g.	
  draft	
  policy	
  and	
  
procedure)	
   • Review	
  of	
  youth	
  records	
  

	
  

55	
  

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III.B.9	
  	
  Access	
  to	
  a	
  QMHP.	
  	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
   practices	
  to	
  ensure	
  that	
  youth	
  who	
  seek	
  access	
  to	
  a	
  qualified	
  mental	
  health	
  professional	
  are	
   provided	
  appropriate	
  access	
  in	
  a	
  timely	
  manner.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  review	
  of	
  policy	
  and	
  procedure	
  entitled	
  “Mental	
  Health	
   Referral,	
  Evaluation	
  and	
  Disposition,”	
  and	
  the	
  associated	
  policy	
   entitled	
  “Referrals	
  to	
  Mental	
  Health	
  Services”	
  performed	
  for	
  the	
   previous	
  monitoring	
  report,	
  these	
  documents	
  outline	
  the	
  process	
  for	
   any	
  facility	
  staff	
  to	
  refer	
  a	
  youth	
  for	
  an	
  assessment	
  to	
  determine	
  the	
   need	
  for	
  mental	
  health	
  services.	
  	
  There	
  are	
  designated	
  time	
  limits	
  for	
   response	
  to	
  requests.	
  	
  Psychology	
  must	
  respond	
  within	
  five	
  working	
   days,	
  psychiatry	
  within	
  ten	
  working	
  days	
  and	
  if	
  the	
  request	
  is	
  for	
   additional	
  evaluation,	
  there	
  is	
  a	
  fourteen	
  working	
  day	
  response	
   window.	
  	
  	
  
	
  
Per	
  the	
  documents	
  provided	
  and	
  observations	
  made	
  during	
  the	
  most	
   recent	
  monitoring	
  visit,	
  psychology	
  staff	
  offices	
  were	
  located	
  on	
  the	
   housing	
  units,	
  providing	
  access	
  to	
  mental	
  health	
  professionals.	
  Per	
   the	
  documents	
  received	
  regarding	
  this	
  provision,	
  it	
  was	
  noted,	
   “…youth	
  typically	
  ask	
  to	
  be	
  seen	
  directly	
  and	
  face	
  to	
  face,	
  and	
  when	
   their	
  psychology	
  staff	
  is	
  not	
  available,	
  they	
  typically	
  wait	
  until	
  he	
  or	
   she	
  is	
  available.”	
  It	
  was	
  further	
  noted	
  that	
  “when	
  a	
  youth…needs	
  to	
   see	
  psychology	
  staff	
  urgently,	
  unit	
  staff	
  will	
  call…all	
  urgent	
  requests	
   are	
  seen	
  within	
  24	
  hours…notification	
  of	
  these	
  needs	
  typically	
  is	
   done	
  by	
  phone	
  without	
  the	
  intermediate	
  step	
  of	
  form	
   completion…completion	
  of	
  forms…would	
  be	
  more	
  likely	
  to	
  slow	
   down	
  the	
  process	
  of	
  accessing	
  psychology	
  services.”	
  
	
  
A	
  review	
  of	
  sample	
  documentation	
  regarding	
  psychology	
  response	
   time	
  to	
  urgent	
  mental	
  health	
  requests	
  revealed	
  six	
  examples.	
  	
  Of	
   these,	
  two	
  youth	
  were	
  seen	
  immediately	
  following	
  their	
  request,	
  one	
   was	
  seen	
  1.5	
  hours	
  following	
  their	
  request,	
  and	
  one	
  was	
  seen	
  ten	
   minutes	
  following	
  their	
  request.	
  	
  Request	
  times	
  were	
  not	
   documented	
  on	
  the	
  other	
  two	
  examples	
  provided.	
  	
  	
  
	
  
Per	
  the	
  self-­‐assessment,	
  secure	
  mailboxes	
  have	
  been	
  provided	
  on	
   the	
  units	
  for	
  youth	
  to	
  request	
  services	
  without	
  reliance	
  upon	
  direct	
   care	
  staff	
  to	
  communicate	
  their	
  request.	
  Psychology	
  or	
  social	
  work	
   staff	
  check	
  these	
  boxes	
  daily.	
  Youth	
  interviewed	
  during	
  this	
   monitoring	
  tour	
  were	
  able	
  to	
  show	
  the	
  monitor	
  the	
  box	
  within	
  which	
   to	
  place	
  their	
  requests	
  for	
  services	
  on	
  their	
  individual	
  units.	
  	
  It	
  is	
   imperative	
  that	
  youth	
  are	
  able	
  to	
  independently	
  access	
  mentalhealth	
  

	
  

57	
  

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care;	
  as	
  unfortunately,	
  there	
  may	
  be	
  situations	
  where	
  direct	
  care	
   staff	
  could	
  unintentionally	
  or	
  purposefully	
  impede	
  the	
  youth’s	
  access	
   to	
  necessary	
  mental	
  health	
  treatment	
  with	
  resultant	
  negative	
   outcomes.	
  
	
  
One	
  concern	
  noted	
  and	
  communicated	
  during	
  the	
  monitoring	
  tour	
   was	
  access	
  to	
  mental	
  health	
  services	
  for	
  youth	
  housed	
  on	
  the	
   Progress	
  unit.	
  	
  These	
  youth	
  were	
  assigned	
  to	
  single	
  cells	
  where	
  they	
   remained	
  the	
  majority	
  of	
  the	
  day.	
  	
  Youth	
  on	
  phase	
  one	
  of	
  the	
   program	
  are	
  in	
  ambulatory	
  restraints	
  (“gators”)	
  when	
  they	
  are	
   outside	
  of	
  their	
  cells.	
  	
  Youth	
  and	
  psychology	
  staff	
  interviewed	
   revealed	
  that	
  these	
  youth	
  were	
  not	
  assessed	
  by	
  mental	
  health	
  staff	
   on	
  a	
  daily	
  basis,	
  they	
  were	
  reportedly	
  being	
  checked	
  three	
  times	
   weekly.	
  	
  These	
  youth	
  are	
  at	
  high	
  risk	
  for	
  self-­‐injury	
  and	
  for	
  the	
   exacerbation	
  of	
  mental	
  health	
  symptoms.	
  	
  As	
  such,	
  they	
  must	
  be	
   assessed	
  on	
  a	
  daily	
  basis	
  by	
  mental	
  health	
  staff.	
  	
  Following	
   recommendations	
  made	
  by	
  the	
  monitor	
  during	
  the	
  monitoring	
  tour	
   the	
  facility	
  self-­‐assessment	
  revealed	
  that	
  now	
  “Behavioral	
  Health	
   staff	
  assigned	
  to	
  Progress	
  programs	
  will	
  make	
  rounds	
  daily	
  as	
  a	
  check	
   in	
  with	
  all	
  youth.	
  They	
  are	
  required	
  to	
  speak	
  with	
  all	
  youth	
  and	
   follow	
  up	
  where	
  needed.”	
  	
  
	
  
Per	
  a	
  review	
  of	
  mental	
  health	
  staff	
  schedules	
  provided,	
  mental	
   health	
  staff	
  scheduling	
  included	
  both	
  evening	
  (until	
  8:00	
  p.m.)	
  and	
   weekend	
  hours,	
  allowing	
  for	
  better	
  daily	
  coverage	
  of	
  youth	
  mental	
   health	
  needs.	
  However,	
  of	
  the	
  mental	
  health	
  staff,	
  only	
  the	
   psychology	
  supervisor	
  was	
  on-­‐call	
  24	
  hours	
  per	
  day.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  requirements	
  for	
  daily	
   mental	
  health	
  assessments	
  for	
  those	
  youth	
  housed	
  on	
  the	
   Progress	
  unit.	
  
2. Develop	
  quality	
  assurance	
  monitoring	
  to	
  audit	
  requests	
  for	
   mental	
  health	
  services	
  inclusive	
  of	
  staff	
  response	
  time	
  as	
  well	
   as	
  timelines	
  for	
  completion	
  of	
  other	
  mental	
  health	
  services	
  as	
   outlined	
  by	
  facility	
  policy	
  and	
  procedure.	
  
3. Ensure	
  the	
  youth’s	
  open	
  access	
  to	
  mental	
  health	
  services	
  

Sources	
  of	
   Information	
  
	
   	
  

• Facility	
  self-­‐assessment	
   • Review	
  of	
  provided	
  documents	
   • Youth	
  interviews	
   • Staff	
  interviews	
  

	
  

58	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 59 of 104 PAGEID #: 1922

III.B.10	
  	
  Mental	
  Health	
  Involvement	
  in	
  Housing	
  and	
  Placement	
  Decisions.	
  	
  The	
  State	
  shall	
   develop	
  and	
  implement	
  a	
  system	
  for	
  ensuring	
  that	
  significantly	
  mentally	
  ill	
  youth	
  who	
  do	
   not	
  have	
  the	
  adaptive	
  functioning	
  to	
  manage	
  the	
  activities	
  of	
  daily	
  living	
  within	
  the	
  general	
   population	
  are	
  provided	
  appropriate	
  housing	
  and	
  supports	
  to	
  assist	
  them	
  in	
  managing	
   within	
  the	
  institutional	
  setting.	
  	
  

Compliance	
  Rating	
   Non	
  compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  policy	
  and	
  procedure	
  entitled	
  “Mental	
  Health	
  Referral,	
   Evaluation,	
  and	
  Disposition”	
  reviewed	
  for	
  the	
  prior	
  monitoring	
   report,	
  this	
  policy	
  “identifies	
  the	
  process	
  for	
  consideration	
  and	
   referral	
  for	
  mental	
  health	
  treatment,	
  including	
  placement	
  on	
  a	
   mental	
  health	
  unit	
  when	
  determined	
  to	
  be	
  necessary.	
  Youth	
   demonstrating	
  serious	
  mental	
  health	
  issues	
  and/or	
  who	
  are	
   determined	
  to	
  be	
  unable	
  to	
  adequately	
  manage	
  the	
  demands	
  of	
   living	
  in	
  the	
  general	
  population	
  are	
  referred	
  for	
  placement	
  on	
  an	
   alternative	
  living	
  unit.”	
  
	
  
Policy	
  and	
  procedure	
  implemented	
  January	
  1,	
  2011	
  entitled	
   “Behavioral	
  Health-­‐Special	
  Services	
  Living	
  Units”	
  included	
  “guidelines	
   for	
  the	
  referral	
  of	
  youth	
  identified	
  through	
  clinical	
  assessment	
  as	
   needing	
  specialized	
  housing	
  and	
  programming	
  for	
  the	
  stabilization	
  of	
   the	
  symptoms	
  of	
  an	
  identified	
  mental	
  illness	
  and	
  program	
   modifications	
  due	
  to	
  cognitive	
  and/or	
  developmental	
  limitations.”	
  	
   This	
  policy	
  guided	
  the	
  creation	
  of	
  the	
  “Behavioral	
  Health	
  Review	
   Panel”	
  whose	
  responsibility	
  it	
  was	
  to	
  “review	
  information	
  obtained	
  in	
   the	
  reception	
  process	
  and	
  determine	
  the	
  best	
  options	
  for	
  each	
  youth	
   in	
  regard	
  to	
  housing,	
  programming…”	
  	
  
	
  
In	
  the	
  intervening	
  period	
  since	
  the	
  last	
  monitoring	
  visit,	
  the	
  facility	
   has	
  undergone	
  a	
  change	
  in	
  mission.	
  	
  Per	
  a	
  memorandum	
  dated	
  8.4.11	
   authored	
  by	
  legal	
  counsel	
  from	
  DYS,	
  “SJCF	
  will	
  serve	
  all	
  security	
   classifications	
  as	
  a	
  permanent	
  facility	
  for	
  both	
  male	
  and	
  female	
  youth.	
  	
   It	
  will	
  include	
  initial	
  intake	
  for	
  youth	
  from	
  all	
  88	
  counties	
  with	
  referral	
   and	
  transfer	
  to	
  other	
  sites	
  within	
  4	
  days.	
  	
  SJCF	
  will	
  continue	
  to	
  have	
   Central	
  Medical	
  Facility	
  and	
  will	
  now	
  house	
  behaviorally	
  challenged	
   boys	
  on	
  a	
  specialized	
  unit	
  named	
  PROGRESS	
  (Programming	
  for	
  Real	
   Opportunity	
  through	
  Growth,	
  Respect,	
  Education,	
  Safety,	
  and	
   Success)	
  that	
  will	
  include	
  a	
  transition	
  program.	
  	
  The	
  male	
  mental	
   health	
  unit	
  has	
  been	
  transferred	
  to	
  Indian	
  River	
  Juvenile	
  Correctional	
   Facility	
  (IRJCF)…Reception	
  is	
  Condensed	
  to	
  a	
  Four	
  Day	
  Process	
  at	
  SJCF	
   and	
  Continues	
  at	
  the	
  Youth’s	
  Parent	
  Facility…Day	
  Twenty-­‐five:	
   Behavioral	
  Health	
  Review	
  Panel	
  meets,	
  Reception	
  Assessment	
   Summary	
  completed…”	
  Per	
  interviews	
  with	
  facility	
  and	
  statewide	
  

	
  

59	
  

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mental	
  health	
  administration,	
  policy	
  and	
  procedure	
  revisions	
  required	
   by	
  the	
  aforementioned	
  change	
  in	
  mission	
  remained	
  pending	
  at	
  the	
   time	
  of	
  the	
  most	
  recent	
  monitoring	
  visit.	
  	
  This	
  is	
  concerning	
  as	
  there	
   has	
  been	
  a	
  significant	
  lapse	
  in	
  time	
  between	
  the	
  change	
  in	
  mission	
   and	
  adjustment	
  of	
  facility	
  policy	
  and	
  procedure	
  to	
  govern	
  processes.	
   	
  
Per	
  a	
  review	
  of	
  provided	
  documents,	
  the	
  behavioral	
  review	
  panel	
  at	
   SJCF	
  had	
  met	
  on	
  a	
  weekly	
  basis.	
  	
  The	
  review	
  of	
  the	
  panel’s	
  meeting	
   agenda	
  and	
  recommendations	
  was	
  limited	
  by	
  the	
  documents	
   provided.	
  	
  Minutes	
  of	
  the	
  meeting	
  consisted	
  of	
  a	
  listing	
  of	
  youth	
   reviewed	
  that	
  day.	
  	
  Additional	
  documentation	
  was	
  not	
  provided	
  for	
   review.	
  
	
  
A	
  review	
  of	
  other	
  provided	
  documentation	
  revealed	
  concerns	
  with	
   the	
  outcome	
  of	
  the	
  intake	
  assessment	
  and	
  housing	
  unit	
  assignments.	
  	
   For	
  example,	
  there	
  were	
  six	
  female	
  youth	
  identified	
  per	
  the	
   document	
  request	
  who	
  were	
  initially	
  approved	
  for	
  placement	
  in	
  the	
   general	
  population.	
  	
  These	
  youth,	
  however,	
  ultimately	
  required	
   enhanced	
  services	
  and	
  required	
  referral	
  to	
  the	
  mental	
  health	
  unit.	
  	
  It	
   should	
  be	
  noted	
  that	
  all	
  six	
  of	
  these	
  youth	
  were	
  appropriately	
   assigned	
  to	
  the	
  mental	
  health	
  caseload	
  upon	
  admission.	
  	
  It	
  may	
  be	
   useful	
  to	
  complete	
  retrospective	
  record	
  reviews	
  for	
  these	
  youth	
  to	
   determine	
  if	
  there	
  were	
  any	
  patterns	
  or	
  warning	
  signs	
  that	
  may	
  aid	
   in	
  formulating	
  recommendations	
  for	
  youth	
  in	
  the	
  future.	
  	
  	
  
	
  
Additional	
  concerns	
  regarding	
  this	
  particular	
  provision	
  include	
  youth	
   identified	
  as	
  appropriate	
  for	
  assignment	
  to	
  the	
  Progress	
  Unit.	
  	
  A	
   review	
  of	
  the	
  youth	
  reviewed	
  by	
  the	
  Behavioral	
  Health	
  Review	
  Panel	
   did	
  not	
  reveal	
  reviews	
  of	
  these	
  youth	
  for	
  appropriateness	
  of	
   placement.	
  During	
  the	
  monitor’s	
  most	
  recent	
  monitoring	
  tour,	
  there	
   were	
  concerns	
  brought	
  to	
  the	
  attention	
  of	
  both	
  facility	
  and	
  statewide	
   mental	
  health	
  staff	
  regarding	
  the	
  appropriateness	
  of	
  youth	
  currently	
   assigned	
  to	
  the	
  Progress	
  unit.	
  	
  One	
  youth	
  was	
  determined	
  to	
  be	
   experiencing	
  psychotic	
  symptoms	
  (e.g.,	
  mumbling,	
  unable	
  to	
  engage	
   in	
  conversation,	
  staring	
  without	
  blinking	
  for	
  periods	
  as	
  long	
  as	
  90	
   seconds,	
  appearing	
  to	
  respond	
  to	
  internal	
  stimuli)	
  requiring	
   treatment	
  in	
  another	
  more	
  appropriate	
  setting.	
  	
  Other	
  youth	
  were	
   identified	
  as	
  having	
  mental	
  health	
  disorders.	
  	
  	
  
	
  
Given	
  the	
  restrictive	
  nature	
  of	
  this	
  unit	
  and	
  the	
  unique	
  behavioral	
   and	
  mental	
  health	
  challenges	
  of	
  youth	
  assigned	
  to	
  this	
  unit,	
  a	
   thorough	
  evaluation	
  of	
  each	
  youth	
  currently	
  residing	
  on	
  this	
  unit	
  and	
   of	
  youth	
  proposed	
  for	
  placement	
  on	
  this	
  unit	
  must	
  be	
  performed.	
  	
   This	
  process	
  must	
  be	
  completed	
  for	
  all	
  youth	
  considered	
  for	
  

	
  

60	
  

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placement	
  on	
  the	
  Progress	
  unit.	
  	
  For	
  those	
  youth	
  who	
  are	
  deemed	
   appropriate	
  for	
  participation	
  in	
  the	
  Progress	
  unit	
  program,	
  but	
  are	
   not	
  successfully	
  navigating	
  the	
  program,	
  a	
  review	
  of	
  their	
   individualized	
  treatment	
  plan	
  must	
  ensue	
  in	
  order	
  to	
  determine	
   alternative	
  interventions	
  they	
  may	
  require	
  in	
  order	
  for	
  them	
  to	
   succeed.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Review	
  and	
  revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  the	
  change	
   in	
  facility	
  mission.	
  
2. Improve	
  documentation	
  promulgated	
  by	
  the	
  Behavioral	
   Review	
  Panel	
  to	
  include	
  rationale	
  for	
  specific	
  placement	
   recommendations.	
  
3. For	
  those	
  youth	
  who	
  require	
  enhanced	
  treatment	
  following	
   the	
  initial	
  placement	
  determination,	
  consider	
  performing	
   retrospective	
  record	
  review	
  (e.g.	
  QA)	
  in	
  order	
  to	
  improve	
  the	
   function	
  of	
  the	
  panel.	
  
4. Perform	
  a	
  thorough	
  evaluation	
  of	
  all	
  youth	
  currently	
  housed	
   or	
  proposed	
  for	
  placement	
  in	
  the	
  Progress	
  unit	
  to	
  determine	
   the	
  appropriateness	
  of	
  their	
  participation	
  in	
  this	
  type	
  of	
   restrictive	
  program.	
  	
  	
  This	
  evaluation	
  must	
  include	
  specific	
   recommendations	
  for	
  other	
  more	
  appropriate	
  settings	
  per	
   the	
  youth’s	
  individual	
  needs.	
  
5. For	
  youth	
  housed	
  on	
  the	
  Progress	
  unit	
  who	
  are	
  not	
   progressing	
  through	
  the	
  program,	
  a	
  review	
  of	
  their	
  current	
   status	
  and	
  treatment	
  plan	
  must	
  ensue	
  in	
  order	
  to	
  determine	
   specific	
  individualized	
  treatment	
  or	
  interventions	
  that	
  may	
   assist	
  them	
  with	
  their	
  progress.	
  

Sources	
  of	
   Information	
  
	
   	
  

• Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  	
   • Review	
  of	
  youth	
  records	
   • Youth	
  interview	
  and	
  observation	
  
	
  

	
  

61	
  

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III.B.11	
  	
  	
  Staffing.	
  	
  The	
  State	
  shall	
  staff,	
  by	
  contract	
  or	
  otherwise,	
  the	
  facilities	
  with	
  adequate	
   numbers	
  of	
  psychiatrists,	
  psychologists,	
  social	
  workers,	
  and	
  other	
  mental	
  health	
   professionals	
  qualified	
  through	
  training	
  and	
  practical	
  experience	
  to	
  meet	
  the	
  mental	
  health	
   needs	
  of	
  youth	
  residents,	
  as	
  determined	
  by	
  the	
  acuity	
  of	
  those	
  needs.	
  Mental	
  health	
  care	
   shall	
  be	
  integrated	
  with	
  other	
  medical	
  and	
  mental	
  health	
  services	
  and	
  shall	
  comport	
  with	
   generally	
  accepted	
  practices.	
  The	
  State	
  shall	
  ensure	
  that	
  there	
  are	
  sufficient	
  numbers	
  of	
   adequately	
  trained	
  direct	
  care	
  and	
  supervisory	
  staff	
  to	
  allow	
  youth	
  reasonable	
  access	
  to	
   structured	
  programming.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  staff	
  interviews,	
  the	
  facility	
  self-­‐assessment,	
  and	
  a	
  review	
  of	
   provided	
  documents,	
  it	
  was	
  clear	
  that	
  there	
  continued	
  to	
  be	
  staff	
   shortages	
  at	
  the	
  Scioto	
  facility.	
  Currently,	
  the	
  psychiatrist	
  contract	
  is	
   for	
  20	
  hours	
  per	
  week.	
  Please	
  see	
  the	
  discussion	
  in	
  provision	
  13	
  for	
   further	
  information	
  regarding	
  psychiatric	
  staffing	
  issues.	
  
	
  
The	
  self-­‐assessment	
  reported	
  that	
  all	
  psychology	
  positions	
  were	
   filled.	
  Based	
  on	
  the	
  spreadsheet	
  of	
  mental	
  health	
  positions	
  provided,	
   psychology	
  staff	
  was	
  comprised	
  of	
  six	
  psychology	
  assistants,	
  three	
   psychologists,	
  one	
  psychiatric	
  nurse,	
  and	
  one	
  psychology	
  supervisor.	
   Both	
  staff	
  interviews	
  and	
  the	
  self-­‐report	
  indicated	
  that	
  the	
  workload	
   for	
  psychology	
  staff	
  had	
  increased	
  due	
  to	
  vacancies	
  in	
  social	
  work	
   staff	
  positions.	
  Once	
  social	
  work	
  positions	
  are	
  filled,	
  it	
  will	
  be	
   necessary	
  to	
  examine	
  the	
  current	
  psychology	
  staffing	
  pattern	
  to	
   determine	
  the	
  need	
  for	
  additional	
  staff.	
  	
  In	
  order	
  to	
  accomplish	
  this,	
   the	
  facility	
  administration	
  and	
  mental	
  health	
  leadership	
  should	
   consider	
  the	
  development	
  of	
  workload	
  indicators	
  to	
  objectively	
   determine	
  the	
  need	
  for	
  additional	
  staff.	
  	
  These	
  indicators	
  must	
  be	
   based	
  on	
  the	
  mental	
  health	
  treatment	
  program	
  planned	
  for	
  this	
   facility.	
  	
  Unfortunately,	
  to	
  assess	
  this	
  at	
  the	
  present	
  time	
  would	
  be	
  a	
   wasted	
  effort,	
  as	
  this	
  facility	
  was	
  in	
  a	
  state	
  of	
  flux,	
  with	
  little	
   direction	
  or	
  course	
  with	
  regard	
  to	
  the	
  mental	
  health	
  programming.	
  	
   The	
  only	
  exception	
  to	
  this	
  criticism	
  was	
  programming	
  currently	
   provided	
  on	
  the	
  female	
  mental	
  health	
  unit.	
  
	
  
As	
  stated	
  above,	
  deficiencies	
  in	
  social	
  work	
  staffing	
  continued	
  in	
  the	
   intervening	
  period	
  since	
  the	
  last	
  monitoring	
  report.	
  In	
  fact,	
  the	
  self-­‐ assessment	
  and	
  spreadsheet	
  of	
  mental	
  health	
  positions	
  reported	
   seven	
  current	
  vacancies.	
  These	
  positions	
  have	
  been	
  vacant	
  since:	
   5.9.10,	
  9.25.10,	
  10.25.10,	
  4.15.11,	
  7.30.11,	
  and	
  7.31.11	
  (two).	
  Three	
   positions	
  have	
  been	
  vacant	
  for	
  over	
  a	
  year.	
  It	
  was	
  reported	
  that	
   more	
  recently,	
  six	
  licensed	
  social	
  workers	
  have	
  been	
  hired;	
  however,	
  

	
  

62	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 63 of 104 PAGEID #: 1926

they	
  had	
  not	
  begun	
  work	
  at	
  the	
  facility	
  at	
  the	
  time	
  of	
  this	
  monitoring	
   tour,	
  as	
  all	
  were	
  required	
  to	
  attend	
  pre-­‐service	
  training.	
  
	
  
Per	
  staff	
  interviews	
  and	
  documentation	
  provided	
  regarding	
  support	
   staff	
  for	
  psychiatry,	
  the	
  psychiatric	
  nurse	
  was	
  carrying	
  a	
  large	
   workload.	
  According	
  to	
  the	
  documents	
  reviewed,	
  the	
  nurse	
  provided	
   the	
  following	
  support	
  services	
  to	
  psychiatry:	
  scheduling	
  new	
  and	
   follow-­‐up	
  appointments;	
  preparing	
  medical	
  records	
  for	
  review;	
   providing	
  dictated	
  reports	
  for	
  review;	
  updating	
  the	
  mental	
  health	
   database;	
  attending	
  team	
  meetings	
  and	
  providing	
  updates	
  to	
  the	
   psychiatrist	
  when	
  he	
  was	
  unavailable	
  to	
  attend;	
  responding	
  to	
  staff	
   concerns	
  and	
  preparing	
  assessment	
  information	
  for	
  psychiatry;	
   assisting	
  with	
  the	
  notification	
  of	
  parents/guardians	
  of	
  any	
  changes	
  in	
   the	
  youth’s	
  mental	
  health	
  status	
  or	
  treatment;	
  providing	
  updates,	
   changes,	
  and	
  concerns	
  regarding	
  youth	
  to	
  psychiatry;	
  assisting	
  in	
   education	
  of	
  youth	
  regarding	
  mental	
  health	
  issues;	
  monitoring,	
   counseling,	
  and	
  reporting	
  regarding	
  medication	
  compliance;	
  and	
   communicating	
  day	
  to	
  day	
  issues	
  regarding	
  psychiatric	
  care	
  to	
  the	
   health	
  services	
  administrator.	
  	
  	
  
	
  
This	
  list	
  of	
  tasks	
  was	
  daunting,	
  and	
  physically	
  impossible	
  for	
  one	
   individual	
  to	
  complete,	
  although	
  the	
  individual	
  currently	
  in	
  this	
   position	
  was	
  doing	
  her	
  best	
  to	
  manage	
  the	
  workload	
  and	
  did	
  not	
   complain.	
  During	
  the	
  previous	
  monitoring	
  tour,	
  there	
  were	
  two	
   mental	
  health	
  nurse	
  positions	
  at	
  the	
  facility.	
  It	
  was	
  explained	
  to	
  the	
   monitor	
  that	
  due	
  to	
  budgetary	
  issues,	
  and	
  the	
  transition	
  of	
  the	
  male	
   mental	
  health	
  unit	
  to	
  another	
  DYS	
  facility,	
  that	
  this	
  position	
  was	
   eliminated.	
  	
  It	
  was	
  evident,	
  however,	
  that	
  the	
  nursing	
  duties	
  had	
  not	
   only	
  expanded,	
  but	
  the	
  number	
  of	
  youth	
  requiring	
  mental	
  health	
   treatment	
  and	
  treated	
  with	
  psychotropic	
  medication	
  at	
  the	
  facility	
   had	
  doubled	
  in	
  the	
  intervening	
  period	
  since	
  the	
  last	
  monitoring	
  tour.	
  	
   As	
  such,	
  the	
  need	
  for	
  additional	
  staff	
  coverage	
  in	
  this	
  area	
  was	
   obvious.	
  
	
  
There	
  were	
  several	
  examples	
  in	
  the	
  provided	
  documentation	
  of	
  the	
   compromise	
  of	
  clinical	
  services	
  as	
  a	
  result	
  of	
  inadequate	
  mental	
   health	
  staff.	
  	
  There	
  were	
  multiple	
  documents	
  indicating	
  that	
  CBT	
   group	
  was	
  cancelled	
  when	
  the	
  social	
  worker	
  responsible	
  was	
  on	
   leave	
  or	
  otherwise	
  detained.	
  Additionally,	
  in	
  the	
  quality	
  assurance	
   documents	
  provided,	
  other	
  staffing	
  deficiencies	
  were	
  identified.	
  A	
   staff	
  member	
  was	
  placed	
  on	
  a	
  performance	
  improvement	
  plan	
  due	
   to	
  failure	
  to	
  document	
  individual	
  counseling	
  sessions.	
  	
  Per	
  the	
  quality	
   assurance	
  chart	
  review,	
  “the	
  clinician	
  explained	
  to	
  the	
  supervisor	
   that	
  she	
  was	
  spending	
  too	
  much	
  time	
  out	
  of	
  the	
  facility	
  doing	
  CBT	
  

	
  

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training/coaching	
  at	
  other	
  sites.	
  The	
  clinician	
  was	
  pulled	
  out	
  of	
  the	
   CBT	
  training/coaching	
  so	
  that	
  she	
  could	
  provide	
  services	
  to	
  the	
  youth	
   on	
  her	
  caseload.”	
  It	
  is	
  necessary	
  to	
  have	
  sufficient	
  coverage	
  in	
  order	
   for	
  staff	
  to	
  complete	
  training	
  and	
  continue	
  to	
  provide	
  adequate	
   services.	
  This	
  topic	
  was	
  reviewed	
  in	
  detail	
  in	
  the	
  discussion	
  regarding	
   provisions	
  14	
  and	
  15	
  below.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Recruit	
  and	
  fill	
  current	
  vacancies	
   2. Determine	
  the	
  need	
  for	
  additional	
  staff	
  via	
  workload	
  indicators	
   3. Improve	
  coordination	
  between	
  staff	
  disciplines.	
   4. Ensure	
  coverage	
  for	
  staff	
  during	
  required	
  trainings	
  and	
  other	
  
absences.	
   5. Review	
  the	
  mental	
  health	
  nurse	
  position	
  and	
  consider	
  
additional	
  staff.	
   6. Per	
  the	
  discussion	
  included	
  in	
  provision	
  13	
  below,	
  address	
  the	
  
need	
  for	
  additional	
  psychiatric	
  clinical	
  resources	
  at	
  the	
  facility.	
  

Sources	
  of	
   Information	
  
	
   	
  

• Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  
	
  

	
  

64	
  

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III.B.12	
  	
  Medication	
  Notice.	
  	
  	
  Before	
  renewing	
  a	
  psychoactive	
  medication	
  prescription	
  from	
  a	
   community	
  provider	
  or	
  commencing	
  the	
  administration	
  of	
  a	
  psychoactive	
  medication	
  to	
  a	
   youth,	
  the	
  State	
  shall	
  ensure	
  that	
  the	
  youth	
  and	
  to	
  the	
  fullest	
  extent	
  practicable	
  and	
   appropriate,	
  his	
  or	
  her	
  parent	
  or	
  caregiver,	
  are	
  provided	
  with	
  information	
  regarding	
  the	
   goals,	
  risks,	
  benefits	
  and	
  the	
  potential	
  side	
  effects	
  of	
  the	
  medication	
  and	
  given	
  an	
   explanation	
  of	
  the	
  potential	
  consequences	
  of	
  not	
  treating	
  with	
  the	
  medication,	
  and	
  that	
  the	
   youth	
  has	
  an	
  opportunity	
  to	
  consent	
  to	
  such	
  medication.	
  	
  A)	
  Involuntary	
  administration	
  of	
   psychotropic	
  medications	
  to	
  juveniles	
  shall	
  comply	
  with	
  applicable	
  federal	
  and	
  state	
  laws	
   and	
  regulations.	
  The	
  DYS	
  clinical	
  director,	
  in	
  consultation	
  with	
  the	
  DYS	
  medical	
  director,	
   shall	
  review	
  and	
  request	
  with	
  DYS	
  Legal	
  Services	
  prior	
  to	
  the	
  approval	
  for	
  involuntary	
   administration.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  draft	
  policy	
  and	
  procedure	
  reviewed	
  for	
  this	
  monitoring	
   report	
  entitled	
  “Psychotropic	
  Medication,	
  Use	
  and	
  Management”	
   education	
  including	
  “addressing	
  the	
  goals,	
  risks,	
  benefits,	
  and	
   potential	
  side	
  effects	
  associated	
  with	
  any	
  given	
  medication	
  is	
  given	
   to	
  each	
  youth	
  and	
  his	
  or	
  her	
  parent	
  or	
  guardian…	
  the	
  prescribing	
   physician	
  provides	
  an	
  explanation	
  of	
  the	
  potential	
  consequences	
  of	
   not	
  taking	
  the	
  medication	
  and	
  explains	
  that	
  the	
  youth	
  has	
  an	
   opportunity	
  a	
  consent	
  or	
  withhold	
  consent	
  to	
  be	
  treated…provides	
   guidelines	
  within	
  which	
  medical	
  professionals	
  may	
  petition	
  the	
  court	
   to	
  authorize	
  involuntary	
  administration	
  of	
  psychotropic	
  medication.”	
  
	
  
During	
  the	
  previous	
  monitoring	
  visit,	
  it	
  was	
  identified	
  that	
  the	
   psychiatric	
  practitioner	
  was	
  not	
  performing	
  appropriate	
  informed	
   consent.	
  In	
  reviewing	
  the	
  15	
  medical	
  charts	
  provided	
  as	
  part	
  of	
  the	
   documentation	
  request,	
  it	
  was	
  noted	
  that	
  informed	
  consent	
   documentation	
  was	
  not	
  included.	
  	
  As	
  stated	
  in	
  provision	
  13	
  below,	
  it	
   was	
  considered	
  that	
  perhaps	
  documentation	
  did	
  exist,	
  however,	
  it	
   was	
  not	
  included	
  in	
  the	
  part	
  of	
  the	
  medical	
  record	
  copied	
  for	
  off	
  site	
   review.	
  
	
  
Ten	
  examples	
  of	
  informed	
  consent	
  documentation	
  were	
  provided	
  via	
   the	
  document	
  request.	
  	
  These	
  examples	
  included	
  a	
  form	
  entitled	
   “Information	
  about	
  and	
  consent	
  for	
  medications	
  for	
  youth	
  with	
   mental	
  health	
  diagnoses.”	
  	
  These	
  forms,	
  competed	
  by	
  the	
  youth,	
   outlined	
  what	
  information	
  the	
  youth	
  retained	
  following	
  their	
   discussion	
  with	
  the	
  psychiatrist	
  regarding	
  the	
  prescribed	
  medication.	
  	
   The	
  form	
  also	
  allows	
  for	
  documentation	
  by	
  the	
  psychiatrist	
  of	
   attempts	
  to	
  or	
  successful	
  contact	
  with	
  the	
  youth’s	
  parent	
  or	
  guardian	
   in	
  order	
  to	
  review	
  potential	
  psychotropic	
  medications	
  and	
  obtain	
   parental	
  consent.	
  	
  Additional	
  information	
  (i.e.	
  medication	
  

	
  

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Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 66 of 104 PAGEID #: 1929

information	
  sheets)	
  should	
  be	
  provided	
  to	
  the	
  youth	
  and	
  their	
   parents	
  for	
  their	
  review	
  such	
  that	
  full	
  disclosure	
  of	
  potential	
   medication	
  side	
  effects	
  is	
  provided.	
  
	
  
Interviews	
  with	
  youth	
  at	
  the	
  facility	
  revealed	
  that	
  in	
  general,	
  youth	
   were	
  able	
  to	
  name	
  their	
  prescribed	
  medication.	
  	
  Youth	
  also	
  had	
   some	
  knowledge	
  regarding	
  the	
  potential	
  side	
  effects	
  associated	
  with	
   their	
  prescribed	
  medication.	
  	
  This	
  indicated	
  that	
  informed	
  consent	
   practices	
  were	
  occurring	
  with	
  respect	
  to	
  treatment	
  with	
   psychotropic	
  medications.	
  	
  
	
  
Per	
  the	
  document	
  request,	
  there	
  were	
  no	
  court	
  petitions	
  for	
   involuntary	
  administration	
  of	
  psychotropic	
  medications	
  in	
  the	
  90	
   days	
  prior	
  to	
  this	
  monitoring	
  visit.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Continue	
  documentation	
  regarding	
  informed	
  consent	
  that	
  is	
   consistent	
  with	
  generally	
  accepted	
  practices	
  and	
  facility	
   policy	
  and	
  procedure.	
  
2. Finalize	
  policy	
  and	
  procedure	
  regarding	
  informed	
  consent.	
   3. Consider	
  a	
  peer	
  review	
  or	
  quality	
  assurance	
  process	
  for	
  
informed	
  consent	
  and	
  other	
  psychiatric	
  documentation.	
   4. Consider	
  the	
  development	
  of	
  or	
  use	
  of	
  commercially	
  
available	
  information	
  regarding	
  side	
  effects	
  of	
  psychotropic	
   medication	
  that	
  is	
  written	
  such	
  that	
  an	
  individual	
  unfamiliar	
   with	
  medical	
  jargon	
  would	
  understand	
  the	
  information.	
  	
  This	
   information	
  should	
  be	
  provided	
  to	
  the	
  youth	
  and	
  sent	
  via	
   mail	
  to	
  their	
  parent	
  or	
  guardian.	
  

Sources	
  of	
   Information	
  
	
   	
   	
  

• Youth	
  record	
  review	
   • Review	
  of	
  provided	
  documents	
  	
   • Youth	
  interview	
   • Staff	
  interview	
  
	
  

	
  

66	
  

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III.B.13	
  	
  	
  Mental	
  Health	
  Medications.	
  	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  ensure	
  that	
  psychoactive	
  medications	
  are	
  prescribed,	
   distributed	
  and	
  monitored	
  properly	
  and	
  safely,	
  and	
  consistent	
  with	
  generally	
  accepted	
   practices.	
  The	
  State	
  shall	
  provide	
  regular	
  training	
  to	
  all	
  health	
  and	
  mental	
  health	
  staff	
  on	
   current	
  issues	
  in	
  psychopharmacological	
  treatment,	
  including	
  information	
  necessary	
  to	
   monitor	
  for	
  side	
  effects	
  and	
  efficacy.	
  The	
  State	
  shall	
  issue	
  and	
  implement	
  policies	
  and	
   procedures	
  for	
  the	
  administration	
  of	
  appropriate	
  tests	
  (including,	
  for	
  example,	
  blood	
  tests,	
   EKGs,	
  and	
  Abnormal	
  Involuntary	
  Movement	
  Scale	
  tests)	
  to	
  monitor	
  the	
  efficacy	
  and	
  any	
  side	
   effects	
  of	
  psychoactive	
  medications	
  in	
  accordance	
  with	
  generally	
  accepted	
  professional	
   standards.	
  The	
  State	
  shall	
  also:	
  a)	
  share	
  medication	
  compliance	
  data	
  with	
  the	
  psychiatrist	
   and	
  document	
  the	
  sharing	
  of	
  this	
  information;	
  b)	
  not	
  withhold	
  the	
  provision	
  of	
   psychostimulants	
  to	
  youth	
  when	
  such	
  treatment	
  is	
  clinically	
  warranted.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Currently,	
  Policy	
  403.18.03,	
  entitled	
  “Psychotropic	
  Medication,	
  Use	
   and	
  Management	
  Of,”	
  dated	
  as	
  being	
  in	
  effect	
  7/1/02;	
  remains	
  in	
  the	
   pending	
  policy/draft	
  section.	
  	
  Per	
  staff	
  interviews	
  performed	
  during	
   the	
  most	
  recent	
  monitoring	
  tour,	
  there	
  were	
  plans	
  to	
  review	
  and	
   revise	
  the	
  facility	
  behavioral	
  health	
  policies.	
  	
  This	
  should	
  include	
  a	
   review	
  and	
  finalization	
  of	
  the	
  policy	
  and	
  procedure	
  regarding	
   psychiatric	
  treatment.	
  
	
  
From	
  the	
  records	
  provided,	
  it	
  was	
  determined	
  via	
  a	
  review	
  of	
  the	
   “Youth	
  on	
  MH	
  Caseload	
  with	
  Recent	
  Meds	
  and	
  Chronic	
  Conditions”	
   that	
  74	
  youth	
  were	
  prescribed	
  medication	
  by	
  the	
  psychiatrist.	
  This	
   was	
  an	
  increase	
  over	
  the	
  previous	
  monitoring	
  period	
  where	
  33	
  youth	
   were	
  prescribed	
  psychotropic	
  medication.	
  	
  	
  As	
  such,	
  despite	
  greater	
   than	
  100%	
  increase	
  in	
  the	
  number	
  of	
  youth	
  requiring	
  psychiatric	
   services	
  at	
  the	
  facility,	
  there	
  has,	
  of	
  yet,	
  been	
  no	
  increase	
  in	
   psychiatric	
  clinical	
  resources.	
  
	
  
It	
  was	
  recognized,	
  however,	
  that	
  there	
  might	
  be	
  inaccuracies	
  in	
  the	
   “Youth	
  on	
  the	
  MH	
  Caseload	
  with	
  Recent	
  Meds	
  and	
  Chronic	
   Conditions”	
  provided	
  via	
  the	
  document	
  request.	
  This	
  made	
  it	
  difficult	
   to	
  ascertain	
  the	
  exact	
  make	
  up	
  of	
  the	
  psychiatric	
  caseload	
  at	
  this	
   time.	
  For	
  example,	
  63	
  youth	
  entries	
  included	
  in	
  this	
  document	
  had	
   no	
  information	
  of	
  why	
  they	
  were	
  included.	
  	
  The	
  pages	
  below	
  their	
   names	
  were	
  essentially	
  blank	
  forms.	
  Additionally,	
  there	
  were	
   multiple	
  youth	
  included	
  in	
  that	
  list	
  who	
  were	
  discharged	
  (these	
   youth	
  were	
  not	
  included	
  in	
  the	
  calculations	
  above).	
  Medication	
   orders	
  do	
  not	
  appear	
  to	
  be	
  updated	
  consistently	
  in	
  the	
  system	
   tracking,	
  as	
  many	
  prescriptions	
  appeared	
  outdated.	
  The	
  written	
  

	
  

67	
  

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report	
  of	
  medication	
  adjustments	
  did	
  not	
  consistently	
  match	
  the	
   medication	
  log.	
  	
  This	
  was	
  an	
  area	
  in	
  need	
  of	
  improvement.	
  	
   Maintenance	
  of	
  a	
  regularly	
  updated	
  listing	
  of	
  all	
  youth	
  assigned	
  to	
   the	
  mental	
  health	
  caseload	
  along	
  with	
  their	
  most	
  recent	
  evaluation	
   dates	
  and	
  prescribed	
  psychotropic	
  medication	
  would	
  be	
  useful	
  to	
  all	
   treatment	
  providers.	
  
	
  
Per	
  staff	
  interview	
  and	
  document	
  review,	
  there	
  had	
  recently	
  been	
   difficulties	
  with	
  regard	
  to	
  psychiatric	
  availability.	
  	
  Due	
  to	
   circumstances	
  beyond	
  his	
  control,	
  the	
  current	
  psychiatrist	
  required	
   time	
  away	
  from	
  the	
  facility	
  and	
  a	
  temporary	
  reduction	
  in	
  his	
  clinical	
   availability.	
  	
  Given	
  current	
  contracts	
  and	
  the	
  paucity	
  of	
  available	
   psychiatric	
  treatment	
  providers,	
  there	
  was	
  no	
  clinician	
  available	
  to	
   cover	
  for	
  him	
  in	
  his	
  absence.	
  	
  While	
  per	
  interview	
  and	
  review	
  of	
  the	
   self-­‐assessment	
  it	
  was	
  stated	
  that	
  a	
  psychiatrist	
  from	
  another	
  DYS	
   facility	
  was	
  available	
  to	
  cover	
  psychiatric	
  clinic,	
  there	
  was	
  no	
   documentation	
  that	
  another	
  psychiatrist	
  ever	
  performed	
  clinical	
   consultation	
  at	
  Scioto.	
  	
  As	
  a	
  result	
  of	
  this,	
  psychiatric	
  treatment	
  of	
   some	
  youth	
  was	
  delayed.	
  	
  	
  
	
  
According	
  to	
  the	
  documentation	
  reviewed	
  via	
  the	
  “Youth	
  on	
  MH	
   Caseload	
  with	
  Recent	
  Meds	
  and	
  Chronic	
  Conditions,”	
  there	
  were	
  six	
   youth	
  referred	
  for	
  initial	
  psychiatric	
  evaluations	
  who	
  were	
  not	
   evaluated	
  for	
  over	
  three	
  weeks	
  after	
  referral	
  for	
  an	
  initial	
  evaluation.	
  	
   Four	
  out	
  of	
  these	
  six	
  youth	
  were	
  referred	
  in	
  the	
  month	
  of	
  September	
   2011.	
  	
  Per	
  review	
  of	
  the	
  draft	
  policy	
  and	
  procedure	
  noted	
  above,	
   youth	
  referred	
  for	
  psychiatric	
  evaluation	
  that	
  entered	
  the	
  facility	
   with	
  prescribed	
  medication	
  must	
  be	
  evaluated	
  within	
  two	
  weeks	
  of	
   referral.	
  	
  There	
  was	
  no	
  timeline	
  indicated	
  in	
  policy	
  and	
  procedure	
   within	
  which	
  the	
  psychiatrist	
  must	
  complete	
  a	
  routine	
  evaluation.	
  
	
  
There	
  were	
  33	
  youth	
  treated	
  with	
  psychotropic	
  medications	
  that	
   were	
  not	
  assessed	
  by	
  the	
  psychiatrist	
  during	
  the	
  month	
  of	
   September	
  2011.	
  	
  Generally	
  accepted	
  practices	
  and	
  draft	
  facility	
   policy	
  and	
  procedure	
  require	
  that	
  youth	
  treated	
  with	
  psychotropic	
   medications	
  are	
  assessed	
  by	
  the	
  psychiatrist	
  a	
  minimum	
  of	
  monthly.	
  	
   This	
  was	
  an	
  untenable	
  situation	
  for	
  the	
  current	
  treating	
  psychiatrist,	
   as	
  he	
  has	
  no	
  reliable	
  back	
  up	
  coverage	
  should	
  he	
  require	
  time	
  away	
   from	
  the	
  facility.	
  	
  Per	
  staff	
  interview,	
  DYS	
  has	
  recently	
  recruited	
  and	
   hired	
  an	
  administrative	
  psychiatrist	
  who	
  will	
  be	
  addressing	
  clinical	
   coverage	
  requirements.	
  	
  	
  
	
  
Once	
  coverage	
  needs	
  are	
  addressed,	
  the	
  facility	
  will	
  still	
  require	
   additional	
  clinical	
  resources,	
  as	
  the	
  current	
  contract	
  for	
  20	
  hours	
  of	
  

	
  

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psychiatric	
  time	
  per	
  week	
  was	
  inadequate	
  to	
  provide	
  clinical	
   services,	
  participate	
  in	
  treatment	
  team	
  meetings,	
  for	
  response	
  to	
   crisis	
  situations,	
  for	
  provision	
  of	
  on-­‐call/after	
  hours	
  consultations;	
   and	
  for	
  the	
  psychiatrist	
  to	
  function	
  as	
  an	
  integral	
  member	
  of	
  the	
   treatment	
  team.	
  	
  As	
  such,	
  the	
  facility	
  must	
  investigate	
  other	
  avenues	
   in	
  order	
  to	
  address	
  the	
  paucity	
  of	
  psychiatric	
  clinical	
  services.	
  	
  These	
   could	
  include	
  telemedicine;	
  developing	
  an	
  association	
  with	
  a	
   residency	
  training	
  program	
  where	
  residents	
  or	
  fellows	
  (with	
   appropriate	
  clinical	
  supervision)	
  could	
  provide	
  services;	
  or	
  if	
  they	
   remain	
  unable	
  to	
  recruit	
  a	
  child	
  and	
  adolescent	
  psychiatrist,	
   contracting	
  with	
  an	
  adult	
  psychiatrist	
  to	
  provide	
  services.	
  	
  In	
  the	
   latter	
  case,	
  the	
  adult	
  psychiatrist	
  could	
  appropriately	
  evaluate	
  and	
   treat	
  youth	
  aged	
  sixteen	
  years	
  and	
  older.	
  	
  For	
  younger	
  youth,	
  clinical	
   supervision	
  for	
  a	
  treating	
  adult	
  psychiatrist	
  with	
  a	
  child	
  and	
   adolescent	
  psychiatrist	
  could	
  be	
  considered.	
  
	
  
Per	
  the	
  document	
  request,	
  15	
  youth	
  medical	
  charts	
  were	
  provided	
   for	
  review.	
  Of	
  these,	
  13	
  youth	
  were	
  prescribed	
  psychotropic	
   medication.	
  Review	
  of	
  the	
  records	
  did	
  not	
  reveal	
  appropriate	
   laboratory	
  examinations	
  for	
  treatment	
  with	
  specific	
  medications.	
  	
   For	
  example:	
  
	
  
Youth	
  020	
  was	
  prescribed	
  psychotropic	
  medication	
  including	
  the	
   antipsychotic	
  medication	
  Geodon	
  and	
  the	
  mood	
  stabilizing	
   medication	
  Depakote.	
  	
  A	
  review	
  of	
  this	
  youth’s	
  medical	
  record	
   revealed	
  no	
  mention	
  of	
  assessment	
  for	
  abnormal	
  involuntary	
   movements.	
  	
  	
  Additionally,	
  while	
  a	
  Depakote	
  level	
  was	
  obtained,	
   other	
  ancillary	
  laboratory	
  examinations	
  (e.g.	
  complete	
  blood	
  count	
   and	
  liver	
  functions)	
  were	
  not	
  ordered	
  or	
  discussed	
  in	
  the	
  progress	
   notes.	
  
	
  
Youth	
  010	
  was	
  prescribed	
  psychotropic	
  medication	
  including	
  the	
   antipsychotic	
  medication	
  Abilify,	
  the	
  mood	
  stabilizing	
  medication	
   Depakote	
  and	
  the	
  anticholinergic	
  medication	
  Cogentin.	
  	
  A	
  review	
  of	
   this	
  youth’s	
  medical	
  record	
  did	
  not	
  reveal	
  requests	
  for	
  laboratory	
   examinations,	
  nor	
  did	
  it	
  reveal	
  abnormal	
  involuntary	
  movement	
   monitoring.	
  
	
  
Youth	
  050	
  was	
  prescribed	
  psychotropic	
  medication	
  including	
  the	
   antipsychotic	
  medication	
  Abilify,	
  the	
  mood	
  stabilizing	
  medication	
   Depakote,	
  the	
  stimulant	
  medication	
  Concerta,	
  and	
  the	
   antihypertensive	
  medication	
  Tenex.	
  	
  A	
  review	
  of	
  this	
  youth’s	
  medical	
   record	
  did	
  not	
  reveal	
  laboratory	
  examinations,	
  abnormal	
  involuntary	
   movement	
  monitoring,	
  or	
  vital	
  sign	
  monitoring.	
  

	
  

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It	
  should	
  be	
  noted	
  that	
  the	
  above	
  medical	
  record	
  reviews	
  were	
   performed	
  off	
  site,	
  with	
  documentation	
  provided	
  by	
  the	
  facility.	
  	
  It	
   was	
  recognized	
  that	
  the	
  required	
  laboratory	
  or	
  monitoring	
  items	
   may	
  be	
  in	
  the	
  youth’s	
  total	
  medical	
  record,	
  however,	
  they	
  were	
  not	
   provided	
  for	
  off	
  site	
  review.	
  	
  This	
  is	
  important	
  to	
  note,	
  as	
  there	
  were	
   examples	
  of	
  medical	
  records	
  that	
  did	
  evidence	
  appropriate	
   laboratory	
  monitoring	
  (four	
  out	
  of	
  13	
  records	
  reviewed).	
  
	
  
Observations	
  of	
  the	
  facility	
  psychiatrist	
  with	
  youth	
  in	
  clinic	
  revealed	
   that	
  he	
  was	
  knowledgeable,	
  caring,	
  and	
  invested	
  in	
  the	
  mental	
   health	
  treatment	
  of	
  the	
  youth.	
  	
  Documentation	
  regarding	
  the	
  youth’s	
   history	
  of	
  mental	
  health	
  issues,	
  diagnoses,	
  and	
  psychiatric	
  treatment	
   plans	
  varied	
  with	
  regard	
  to	
  detail.	
  	
  It	
  was	
  apparent	
  that	
  there	
  were	
   not	
  enough	
  clinical	
  resources	
  allocated	
  for	
  the	
  physician	
  to	
  perform	
   his	
  duties	
  adequately.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Update	
  policy	
  and	
  procedure	
  regarding	
  behavioral	
  health	
  to	
   include	
  timelines	
  for	
  psychiatric	
  services.	
  
2. Investigate	
  other	
  avenues	
  to	
  increase	
  psychiatry	
  clinical	
   resources	
  at	
  the	
  facility	
  (e.g.	
  telemedicine,	
  association	
  with	
   academic	
  institutions,	
  use	
  of	
  residents	
  or	
  fellows	
  with	
   appropriate	
  supervision).	
  
3. In	
  order	
  to	
  determine	
  the	
  appropriate	
  number	
  of	
  full	
  time	
   equivalent	
  psychiatric	
  clinicians	
  required	
  by	
  the	
  facility,	
   consider	
  workload	
  indicators	
  inclusive	
  of	
  all	
  clinical	
   responsibilities	
  required	
  of	
  the	
  physician	
  (e.g.	
  clinic,	
   documentation,	
  treatment	
  team	
  meetings,	
  crisis	
  response).	
  
4. Ensure	
  clinical	
  coverage	
  for	
  the	
  current	
  psychiatric	
  treatment	
   provider.	
  
5. Update	
  and	
  maintain	
  the	
  document	
  regarding	
  the	
  current	
   mental	
  health	
  caseload.	
  
6. Ensure	
  that	
  youth	
  are	
  receiving	
  proper	
  laboratory	
   examinations	
  and	
  side	
  effect	
  monitoring	
  commensurate	
  with	
   the	
  psychotropic	
  medication	
  they	
  are	
  prescribed.	
  

Sources	
  of	
   Information	
  

• Staff	
  interview	
   • Clinic	
  observation	
   • Treatment	
  Team	
  observation	
   • Youth	
  record	
  review	
  

	
  

70	
  

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• Review	
  of	
  provided	
  documents	
  	
   • Youth	
  interview	
  

	
  

	
  

	
  

	
  

71	
  

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III.B.14	
  	
  Mental	
  Health	
  and	
  Developmental	
  Disability	
  Training	
  for	
  Direct	
  Care	
  Staff.	
  	
  The	
   State	
  shall	
  develop	
  and	
  implement	
  strategies	
  for	
  providing	
  direct	
  care	
  and	
  other	
   appropriate	
  staff	
  with	
  training	
  on	
  mental	
  health	
  and	
  developmental	
  disabilities	
  sufficient	
  for	
   staff	
  to	
  understand	
  the	
  behaviors	
  and	
  needs	
  of	
  youth	
  residents	
  in	
  order	
  to	
  supervise	
  them	
   appropriately.	
  	
  

Compliance	
  Rating	
   Non	
  compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  facility	
  self-­‐assessment,	
  staff	
  interviews	
  performed	
  during	
   the	
  most	
  recent	
  monitoring	
  tour,	
  and	
  the	
  review	
  of	
  provided	
   documents	
  (outlined	
  in	
  the	
  discussion	
  regarding	
  provision	
  15	
  below),	
   specific	
  training	
  regarding	
  mental	
  health	
  and	
  developmental	
   disabilities	
  as	
  required	
  by	
  this	
  provision	
  has	
  not	
  begun.	
  	
  Facility	
  staff	
   reported,	
  “we	
  have	
  not	
  done	
  this	
  yet…we	
  have	
  had	
  so	
  many	
  other	
   trainings…do	
  a	
  lot	
  of	
  training.”	
  Per	
  the	
  facility	
  self-­‐assessment,	
  “due	
   to	
  the	
  many	
  training	
  demands	
  over	
  the	
  past	
  six	
  months,	
  additional	
   mental	
  health	
  training	
  have	
  not	
  been	
  developed	
  or	
  offered	
  to	
  direct	
   care	
  staff.”	
  	
  	
  
	
  
As	
  stated	
  in	
  the	
  previous	
  report,	
  the	
  goal	
  of	
  this	
  provision	
  paragraph	
   is	
  to	
  provide	
  training	
  to	
  facility	
  staff	
  such	
  that	
  they	
  have	
  a	
  working	
   knowledge	
  of	
  the	
  youth’s	
  challenges	
  (both	
  from	
  a	
  mental	
  health	
  and	
   developmental	
  perspective)	
  and	
  to	
  provide	
  them	
  with	
  strategies	
  to	
   assist	
  in	
  their	
  daily	
  supervisory	
  tasks	
  with	
  the	
  youth.	
  	
  	
  Training	
  for	
   direct	
  care	
  staff	
  is	
  important	
  as	
  in	
  the	
  correctional	
  setting;	
  they	
   function	
  as	
  the	
  de	
  facto	
  parents	
  of	
  the	
  youth	
  in	
  their	
  care.	
  As	
  direct	
   care	
  staff	
  are	
  an	
  integral	
  part	
  of	
  the	
  youth’s	
  treatment	
  team,	
  they	
   should	
  be	
  aware	
  that	
  due	
  to	
  specific	
  mental	
  health	
  diagnoses,	
  youth	
   may	
  have	
  special	
  needs	
  (i.e.	
  a	
  youth	
  diagnosed	
  with	
  ADHD	
  may	
  not	
   respond	
  to	
  you	
  the	
  first	
  or	
  even	
  second	
  time	
  that	
  you	
  call	
  his	
  name	
   because	
  he	
  is	
  distracted	
  by	
  extraneous	
  stimuli).	
  They	
  should	
  also	
  be	
   aware	
  of	
  which	
  youth	
  are	
  being	
  treated	
  with	
  psychotropic	
  medication	
   and	
  have	
  a	
  basic	
  knowledge	
  of	
  the	
  potential	
  side	
  effects	
  of	
  the	
   medication	
  so	
  that	
  they	
  can	
  monitor	
  the	
  youth	
  in	
  their	
  care.	
  	
   	
  
As	
  discussed	
  in	
  detail	
  in	
  provision	
  15	
  below,	
  there	
  is	
  a	
  need	
  for	
  an	
   organized	
  response	
  to	
  facility	
  training	
  needs.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Develop	
  an	
  organized	
  training	
  schedule	
  and	
  training	
  curriculum	
  
for	
  facility	
  staff	
  that	
  addresses	
  the	
  requirements	
  of	
  this	
  provision	
   and	
  addresses	
  the	
  facility	
  mental	
  health	
  programming	
  initiatives.	
  	
  	
  

	
  

72	
  

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Sources	
  of	
   Information	
  
	
   	
  

2. This	
  training	
  must	
  be	
  based	
  on	
  facility	
  policy	
  and	
  procedure	
  that	
   given	
  the	
  facility	
  mission	
  change	
  must	
  be	
  revised.	
  
3. Continue	
  to	
  track	
  staff	
  compliance	
  with	
  training	
  requirements.	
  
• Review	
  of	
  provided	
  documents	
  	
   • Staff	
  interview	
  
	
  

	
  

73	
  

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III.B.15	
  	
  Staff	
  Mental	
  Health	
  Training.	
  The	
  facilities	
  shall	
  train:	
  a)	
  all	
  staff	
  who	
  directly	
   interact	
  with	
  youth	
  (e.g.,	
  JCOs	
  ,	
  social	
  workers,	
  teachers,	
  etc.)	
  on:	
  (i)	
  basic	
  mental	
  health	
   information	
  (e.g.,	
  diagnosis,	
  specific	
  problematic	
  behaviors,	
  psychiatric	
  medication,	
   additional	
  areas	
  of	
  concern)	
  and	
  recognition	
  of	
  signs	
  and	
  symptoms	
  evidencing	
  a	
  response	
   to	
  trauma;	
  and	
  (ii)	
  teenage	
  development,	
  strength-­‐based	
  treatment	
  strategies,	
  suicide,	
  and	
   for	
  staff	
  who	
  work	
  with	
  female	
  youth,	
  female	
  development;	
  b)	
  clinical	
  staff	
  on	
  the	
   prevalence,	
  signs	
  and	
  symptoms	
  of	
  Post	
  Traumatic	
  Stress	
  Disorder	
  and	
  other	
  disorders	
   associated	
  with	
  trauma.	
  	
  

Compliance	
  Rating	
   Non	
  compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  SJCF	
  Self-­‐Assessment	
  dated	
  11/7/11,	
  there	
  are	
  further	
  steps	
   that	
  need	
  to	
  be	
  taken	
  to	
  ensure	
  appropriate	
  training	
  is	
  being	
   provided	
  to	
  all	
  staff	
  providing	
  direct	
  care.	
  The	
  self-­‐assessment	
   indicated,	
  “due	
  to	
  the	
  many	
  training	
  demands	
  over	
  the	
  past	
  six	
   months	
  additional	
  mental	
  health	
  trainings	
  have	
  not	
  been	
   developed.”	
  It	
  also	
  reported	
  a	
  plan	
  for	
  the	
  Central	
  Office	
  of	
   Behavioral	
  Health	
  to	
  develop	
  an	
  “organized,	
  mandatory	
  training	
   schedule.”	
  	
  
	
  
The	
  development	
  of	
  an	
  organized,	
  mandatory	
  training	
  schedule	
  was	
   a	
  recommendation	
  from	
  the	
  previous	
  monitoring	
  visit.	
  Given	
  the	
   issues	
  noted	
  during	
  this	
  monitoring	
  tour,	
  it	
  is	
  absolutely	
  necessary	
  to	
   develop	
  and	
  implement	
  a	
  training	
  schedule	
  for	
  all	
  staff	
  providing	
   care	
  for	
  youth	
  with	
  regard	
  to	
  mental	
  health	
  issues.	
  This	
  training	
  must	
   also	
  address	
  staff	
  recognition	
  of	
  and	
  response	
  to	
  the	
  signs	
  and	
   symptoms	
  of	
  a	
  serious	
  mental	
  illness	
  in	
  evolution.	
  	
  Staff	
  challenges	
   with	
  this	
  particular	
  task	
  were	
  noted	
  in	
  both	
  the	
  most	
  recent	
  and	
   prior	
  monitoring	
  visit.	
  
	
  
The	
  training	
  schedule	
  must	
  be	
  reasonable	
  and	
  address	
  specific	
  topics	
   to	
  ensure	
  that	
  staff	
  are	
  able	
  to	
  implement	
  the	
  facility	
  mental	
  health	
   program.	
  	
  It	
  was	
  concerning	
  that	
  in	
  the	
  intervening	
  period	
  since	
  the	
   last	
  monitoring	
  visit,	
  while	
  multiple	
  training	
  sessions	
  were	
   conducted,	
  staff	
  were	
  reportedly	
  required	
  to	
  attend	
  so	
  many	
   trainings	
  that	
  they	
  were	
  unable	
  to	
  perform	
  their	
  basic	
  job	
  duties.	
  	
   While	
  training	
  is	
  important,	
  the	
  facility	
  must	
  be	
  able	
  to	
  maintain	
   sufficient	
  staff	
  onsite	
  to	
  ensure	
  that	
  treatment	
  and	
  security	
  services	
   are	
  available.	
  
	
  
Another	
  recommendation	
  from	
  the	
  previous	
  monitoring	
  visit	
  was	
  to	
   create	
  a	
  spreadsheet	
  that	
  delineates	
  staff	
  attendance	
  and	
   completion	
  of	
  required	
  training	
  modules.	
  This	
  spreadsheet	
  was	
  

	
  

74	
  

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submitted	
  with	
  the	
  documents	
  requested.	
  There	
  were	
  297	
  staff	
   identified	
  from	
  various	
  disciplines.	
  The	
  trainings	
  identified	
  for	
  2011	
   were:	
  1.	
  Meal	
  Refusal	
  Policy	
  (1	
  hour);	
  2.	
  MYR	
  1st	
  Quarter	
  (4	
  hours);	
  3.	
   PSB	
  Review	
  (1	
  hour);	
  4.	
  MIS	
  Test	
  Out	
  (.5	
  hour);	
  5.	
  Safety	
  and	
  Security	
   Policy	
  Test	
  Out	
  (.5	
  hour);	
  6.	
  MYR	
  2nd	
  Quarter	
  (4	
  hours);	
  7.	
  Child	
  Abuse	
   and	
  Neglect	
  (.5	
  hour);	
  8.	
  Youth	
  Grievance	
  (.5	
  hour);	
  9.	
  Emergency	
   Response	
  (1	
  hour);	
  10.	
  Blood	
  Borne	
  Pathogens	
  (.5	
  hour);	
  11.	
  Ethics	
   (.5	
  hour);	
  12.	
  PREA	
  (.5	
  hour);	
  13.	
  General	
  Work	
  Rules	
  (.5	
  hour);	
  14.	
   Equal	
  Employment	
  Opportunity	
  (.5	
  hour).	
  It	
  was	
  unclear	
  which,	
  if	
   any,	
  of	
  these	
  trainings	
  were	
  considered	
  to	
  be	
  mental	
  health	
  related,	
   as	
  curriculum	
  for	
  the	
  individual	
  training	
  programs	
  was	
  not	
  included	
   in	
  the	
  documents	
  received,	
  however,	
  per	
  the	
  facesheet	
  attached	
  to	
   this	
  document	
  request,	
  these	
  were	
  “mandated	
  trainings”	
  for	
  active	
   staff.	
  	
  Per	
  the	
  provided	
  spreadsheet,	
  attendance	
  at	
  the	
  required	
   trainings	
  varied	
  from	
  88.77%	
  to	
  89.98%	
  of	
  required	
  attendees.	
  This	
   demonstrates	
  that	
  further	
  work	
  needs	
  to	
  be	
  done	
  in	
  order	
  to	
  ensure	
   all	
  staff	
  are	
  being	
  trained	
  appropriately,	
  while	
  ensuring	
  available	
  staff	
   for	
  job	
  duties	
  as	
  noted	
  above.	
  	
  
	
  
Additionally,	
  the	
  2010	
  training	
  spreadsheet	
  was	
  provided	
  in	
  the	
   document	
  review.	
  The	
  trainings	
  for	
  2010	
  were:	
  1.	
  Medical	
  Risks	
  with	
   Restraint	
  Use	
  (1	
  hour);	
  2.	
  Strengths	
  Based	
  Behavior	
  Management	
   System	
  (2	
  or	
  24	
  hours);	
  3.	
  Emergency	
  Response	
  Training	
  (2.5	
  hours);	
   4.	
  Verbal	
  Strategies	
  (2	
  hours);	
  5.	
  Mental	
  Health	
  Training	
  (2	
  hours);	
   and	
  6.	
  Behavioral	
  Health	
  Policies	
  (2	
  or	
  8	
  hours).	
  For	
  5	
  of	
  the	
  6	
   trainings,	
  the	
  completion	
  rate	
  was	
  between	
  89.51%	
  and	
  97.9%.	
   However,	
  Behavioral	
  Health	
  Policies	
  had	
  a	
  63.64%	
  completion	
  rate.	
   This	
  may	
  explain	
  some	
  of	
  the	
  facility	
  challenges	
  with	
  respect	
  to	
   implementation	
  of	
  behavioral	
  health	
  interventions.	
  As	
  there	
  was	
  no	
   curriculum	
  provided,	
  it	
  was	
  not	
  possible	
  to	
  explore	
  the	
   appropriateness	
  of	
  these	
  trainings	
  based	
  on	
  their	
  content.	
   Additionally,	
  it	
  was	
  unclear	
  whether	
  these	
  trainings	
  were	
  completed	
   one	
  time	
  or	
  whether	
  these	
  were	
  annual	
  trainings	
  focused	
  on	
  the	
   review	
  and	
  improvement	
  of	
  skills	
  related	
  to	
  behavioral	
  health	
   interventions.	
  
	
  
Per	
  the	
  documents	
  provided,	
  “since	
  February	
  2011	
  SJCF	
  Staff	
  have	
   participated	
  in	
  three	
  (3)	
  different	
  trainings,	
  preparing	
  them	
  to	
   implement	
  and	
  oversee	
  the	
  New	
  Freedom	
  Phoenix	
  Program.”	
  It	
  was	
   reported	
  during	
  the	
  monitoring	
  visit	
  and	
  in	
  the	
  documentation	
   provided	
  for	
  review	
  that	
  174	
  staff	
  members	
  attended	
  a	
  three-­‐day	
   training	
  that	
  included	
  an	
  overview	
  of	
  the	
  New	
  Freedom	
  Phoenix	
   Program.	
  One	
  of	
  the	
  stated	
  goals	
  of	
  this	
  training,	
  “to	
  provide	
  Youth	
   Specialists	
  and	
  Social	
  Workers	
  with	
  facilitation	
  skill	
  training.”	
   However,	
  the	
  groups	
  observed	
  during	
  the	
  monitoring	
  visit	
  indicated	
  

	
  

75	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 76 of 104 PAGEID #: 1939

Recommendations	
  

that	
  further	
  training	
  and	
  supervision	
  was	
  needed.	
  	
   	
   According	
  to	
  the	
  self-­‐assessment,	
  additional	
  mental	
  health	
  training	
   was	
  provided	
  including:	
  	
  CBT	
  training;	
  sex	
  offender	
  training;	
  Gang	
   curriculum,	
  training	
  the	
  trainer;	
  SBBMS	
  training,	
  IDT	
  training;	
   Progress/transition	
  training;	
  site	
  specific	
  training	
  regarding	
  youth	
   transferred	
  into	
  the	
  facility	
  from	
  ORV	
  and	
  Circleville;	
  Behavior	
   Management	
  training	
  for	
  Progress	
  and	
  Transition	
  teams;	
  and	
   Behavioral	
  Analysis	
  training.	
  	
  Information	
  regarding	
  training	
   attendance	
  or	
  curriculum	
  for	
  these	
  trainings	
  was	
  not	
  included	
  in	
  the	
   documents	
  available	
  for	
  review.	
   	
   As	
  can	
  be	
  seen	
  from	
  the	
  information	
  documented	
  above,	
  multiple	
   trainings	
  regarding	
  a	
  myriad	
  of	
  topics	
  have	
  been	
  offered	
  to	
  facility	
   staff	
  in	
  the	
  intervening	
  period	
  since	
  the	
  previous	
  monitoring	
  report.	
  	
   Unfortunately,	
  given	
  the	
  multiple	
  trainings	
  and	
  the	
  shift	
  in	
  facility	
   focus	
  and	
  mission	
  over	
  the	
  six	
  months	
  prior	
  to	
  this	
  monitoring	
  tour,	
  it	
   appeared	
  that	
  trainings	
  and	
  program	
  initiatives	
  were	
  occurring	
   haphazardly,	
  with	
  little	
  organization	
  or	
  planning.	
  	
  The	
  review	
  of	
   trainings	
  was	
  very	
  confusing	
  for	
  the	
  monitor,	
  so	
  the	
  monitor	
  can	
  only	
   imagine	
  how	
  difficult	
  this	
  must	
  be	
  for	
  staff	
  attempting	
  to	
  provide	
   behavioral	
  health	
  services	
  or	
  security	
  services	
  at	
  the	
  facility.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Develop	
  an	
  organized	
  training	
  schedule	
  and	
  training	
   curriculum	
  for	
  facility	
  staff	
  that	
  addresses	
  the	
  requirements	
  of	
   this	
  provision	
  and	
  addresses	
  the	
  facility	
  mental	
  health	
   programming	
  initiatives.	
  	
  	
  
2. Over	
  time,	
  the	
  facility	
  may	
  identify	
  the	
  need	
  for	
  enhanced	
   training	
  on	
  a	
  particular	
  topic	
  (i.e.,	
  more	
  time	
  devoted	
  to	
  a	
   particular	
  topic)	
  or	
  additional	
  specialty	
  topics	
  via	
  quality	
   assurance	
  or	
  staff	
  recommendation	
  that	
  may	
  be	
  useful	
  (e.g.,	
   abuse	
  reporting).	
  	
  
3. Consider	
  offering	
  multiple	
  trainings	
  for	
  each	
  topic	
  so	
  that	
  staff	
   can	
  schedule	
  trainings	
  while	
  ensuring	
  that	
  their	
  regular	
  job	
   duties	
  are	
  addressed.	
  
4. Continue	
  to	
  track	
  staff	
  attendance	
  and	
  compliance	
  with	
   training	
  requirements.	
  

Sources	
  of	
   Information	
  
	
  

• Review	
  of	
  provided	
  documents.	
   • Staff	
  interviews.	
  

	
  

76	
  

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III.B.16	
  	
  Suicide	
  Prevention.	
  	
  The	
  State	
  shall	
  review	
  and,	
  as	
  appropriate,	
  revise	
  current	
   suicide	
  prevention	
  practices	
  to	
  ensure	
  that	
  suicide	
  preventions	
  and	
  interventions	
  are	
   implemented	
  consistently	
  and	
  appropriately,	
  consistent	
  with	
  generally	
  accepted	
   professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

According	
  to	
  the	
  facility	
  self-­‐assessment,	
  “the	
  revised	
  Suicide	
   Prevention	
  and	
  Response	
  policy	
  became	
  effective	
  11/1/2011.”	
  This	
   policy	
  was	
  not	
  included	
  in	
  the	
  provided	
  documents,	
  where	
  policy	
  and	
   procedure	
  (both	
  currently	
  implemented	
  and	
  draft	
  documents)	
  were	
   requested.	
  The	
  self-­‐assessment	
  further	
  stated	
  that	
  quality	
  assurance	
   for	
  suicide	
  precautions	
  “is	
  an	
  ongoing	
  process	
  by	
  way	
  of	
  direct	
   supervision	
  and	
  discussion	
  of	
  all	
  recommendations	
  for	
  precautionary	
   status	
  made	
  by	
  unlicensed	
  psychology	
  staff,	
  daily	
  updating	
  of	
  a	
   shared	
  Precautionary	
  Status	
  table	
  that	
  documents	
  each	
  incident	
  of	
   placement	
  on	
  or	
  change	
  in	
  Precautionary	
  Status,	
  and	
  continual	
   review	
  of	
  incidents	
  and	
  patterns	
  of	
  behavior	
  during	
  the	
  group	
  and	
   individual	
  supervision	
  meetings.”	
  	
  
	
  
Per	
  the	
  document	
  request,	
  a	
  written	
  description	
  of	
  the	
  process	
  by	
   which	
  psychiatry	
  is	
  informed	
  of	
  youth’s	
  placement	
  on	
  suicide	
  watch	
   was	
  provided.	
  This	
  document	
  indicated	
  “psychology	
  staff	
  will	
  send	
  an	
   email	
  to	
  [psychiatrist]	
  when	
  they	
  place	
  a	
  youth	
  on	
  suicide	
  watch	
  or	
   when	
  they	
  learn	
  a	
  youth	
  has	
  been	
  placed	
  on	
  watch	
  when	
  psychology	
   staff	
  are	
  not	
  available	
  on	
  campus.”	
  	
  Staff	
  were	
  required	
  to	
  copy	
  this	
   email	
  to	
  the	
  psychology	
  supervisor,	
  health	
  services	
  administrator	
  and	
   mental	
  health	
  nurse.	
  Several	
  emails	
  were	
  provided	
  as	
  evidence	
  of	
   this	
  process.	
  	
  
	
  
Per	
  the	
  email	
  documentation,	
  a	
  review	
  of	
  the	
  listing	
  of	
  youth	
   requiring	
  precautionary	
  status	
  over	
  the	
  previous	
  three	
  months,	
  and	
  a	
   review	
  of	
  available	
  youth	
  medical	
  and	
  mental	
  health	
  records,	
  youth	
   444	
  was	
  placed	
  on	
  precautionary	
  status	
  on	
  9.8.11.	
  	
  A	
  review	
  of	
  this	
   youth’s	
  medical	
  record	
  revealed	
  that	
  the	
  youth	
  was	
  not	
  evaluated	
  by	
   psychiatry	
  in	
  a	
  timely	
  manner	
  following	
  placement	
  on	
  watch	
  status.	
  	
   This	
  youth	
  was	
  ultimately	
  evaluated	
  by	
  psychiatry	
  one	
  month	
  later	
   on	
  10.7.11.	
  	
  A	
  review	
  of	
  the	
  mental	
  health	
  record	
  revealed	
  that	
  this	
   youth	
  was	
  seen	
  by	
  psychology	
  staff	
  8.23.11,	
  approximately	
  two	
   weeks	
  prior	
  to	
  placement	
  on	
  precautionary	
  status.	
  	
  Following	
   placement	
  on	
  precautionary	
  status,	
  he	
  was	
  seen	
  by	
  psychology	
  staff	
   9.9.11,	
  9.12.11,	
  9.13.11,	
  and	
  9.17.11.	
  	
  It	
  should	
  be	
  noted	
  that	
  this	
   youth	
  resides	
  on	
  the	
  Progress	
  Unit,	
  where	
  he	
  spends	
  a	
  great	
  deal	
  of	
   time	
  in	
  his	
  cell.	
  	
  The	
  absence	
  of	
  documented	
  daily	
  mental	
  health	
  

	
  

77	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 78 of 104 PAGEID #: 1941

contacts	
  for	
  this	
  youth,	
  or	
  any	
  youth	
  in	
  similar	
  circumstances	
  was	
   unacceptable.	
  
	
  
Youth	
  777	
  required	
  suicide	
  precautions	
  8.19.11.	
  	
  The	
  psychiatrist	
   ultimately	
  saw	
  this	
  youth	
  over	
  two	
  months	
  later	
  on	
  10.25.11.	
  	
  A	
   review	
  of	
  this	
  youth’s	
  psychology	
  file	
  revealed	
  no	
  documents	
  other	
   than	
  those	
  generated	
  at	
  intake.	
  	
  There	
  was	
  no	
  documentation	
  of	
   mental	
  health	
  contact	
  visits	
  included.	
  
	
  
Youth	
  888	
  required	
  suicide	
  precautions	
  9.11.11.	
  	
  Per	
  a	
  review	
  of	
  this	
   youth’s	
  medical	
  record,	
  there	
  were	
  no	
  psychiatric	
  clinical	
  encounters	
   as	
  of	
  the	
  date	
  of	
  the	
  monitoring	
  tour	
  10.24.11.	
  	
  A	
  review	
  of	
  this	
   youth’s	
  psychology	
  file	
  revealed	
  no	
  documents	
  other	
  than	
  those	
   generated	
  at	
  intake.	
  	
  There	
  was	
  no	
  documentation	
  of	
  mental	
  health	
   contact	
  visits	
  included.	
  
	
  
On	
  a	
  positive	
  note,	
  Youth	
  555	
  was	
  admitted	
  to	
  the	
  facility	
  on	
   precautionary	
  status.	
  	
  This	
  youth	
  had	
  reportedly	
  attempted	
  suicide	
   prior	
  to	
  admission,	
  and	
  was	
  therefore	
  placed	
  on	
  precautionary	
  status	
   immediately.	
  	
  This	
  youth	
  was	
  admitted	
  9.14.11	
  and	
  was	
  evaluated	
  by	
   the	
  psychiatrist	
  9.15.11.	
  	
  A	
  review	
  of	
  this	
  youth’s	
  psychology	
  file	
   revealed	
  consistent	
  contact	
  with	
  a	
  mental	
  health	
  treatment	
  provider.	
  
	
  
The	
  above	
  review	
  was	
  performed	
  regarding	
  youth	
  who	
  reportedly	
   required	
  precautionary	
  status	
  during	
  their	
  stay	
  at	
  SJCF.	
  	
  It	
  is	
   recognized	
  that	
  although	
  additional	
  documentation	
  may	
  exist,	
  this	
   documentation	
  was	
  not	
  provided	
  for	
  review	
  off	
  site.	
  
	
  
Per	
  the	
  document	
  request	
  submitted	
  for	
  this	
  monitoring	
  tour,	
  a	
  copy	
   of	
  any	
  reviews	
  or	
  quality	
  assurance	
  data	
  regarding	
  suicide	
   precautions	
  was	
  requested.	
  	
  Per	
  the	
  document	
  request	
  response,	
  the	
   “Suicide	
  Precaution	
  Performance	
  Indicators	
  are	
  audited	
  during	
  the	
   annual	
  Ohio	
  Standards	
  audit.	
  	
  The	
  audit	
  for	
  Scioto…is	
  scheduled	
  for	
   later	
  this	
  year;	
  therefore,	
  we	
  do	
  not	
  have	
  any	
  new	
  audit	
  data	
  since	
   February	
  2011.”	
  
	
  
It	
  is	
  generally	
  accepted	
  that	
  youth	
  in	
  seclusion	
  are	
  at	
  higher	
  risk	
  of	
   self-­‐injury	
  and	
  suicide.	
  	
  In	
  reviewing	
  the	
  Seclusion	
  Tracking	
  data	
   provided	
  as	
  part	
  of	
  the	
  quality	
  assurance	
  materials,	
  there	
  were	
  noted	
   concerns.	
  Specifically,	
  when	
  youth	
  were	
  in	
  seclusion,	
  documentation	
   available	
  for	
  off	
  site	
  review	
  revealed	
  that	
  mental	
  health	
  staff	
  did	
  not	
   assess	
  some	
  for	
  over	
  24	
  hours.	
  For	
  example	
  during	
  the	
  week	
  of	
   6.30.2011-­‐7.6.2011:	
  	
  

	
  

78	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 79 of 104 PAGEID #: 1942

	
  
• Youth	
  999	
  was	
  assessed	
  at	
  9:55am	
  and	
  then	
  was	
  not	
   reassessed	
  until	
  4pm	
  the	
  following	
  day.	
  	
  
• Youth	
  010	
  had	
  an	
  undocumented	
  time	
  for	
  one	
  assessment.	
  	
   Therefore,	
  it	
  was	
  impossible	
  to	
  determine	
  if	
  the	
  assessment	
   was	
  performed	
  within	
  an	
  appropriate	
  margin	
  of	
  time.	
  	
  
• Youth	
  020	
  was	
  assessed	
  at	
  11:45am	
  and	
  not	
  until	
  9:30pm	
  the	
   following	
  day.	
  This	
  is	
  over	
  33	
  hours	
  without	
  review	
  of	
  mental	
  
health	
  staff.	
  	
  
During	
  the	
  week	
  of	
  9.1.11-­‐9.7.11:	
   	
  
• Youth	
  030	
  was	
  on	
  seclusion	
  status	
  from	
  9.4.11-­‐9.7.11;	
   however,	
  there	
  were	
  no	
  documented	
  visits	
  on	
  9.5.11	
  or	
   9.6.11.	
  	
  
	
   The	
  above	
  are	
  selected	
  examples,	
  further	
  review	
  of	
  the	
  data	
   revealed	
  multiple	
  similar	
  situations.	
  	
  When	
  youth	
  are	
  placed	
  in	
   seclusion,	
  they	
  must	
  be	
  seen	
  a	
  minimum	
  of	
  every	
  twenty-­‐four	
  hours.	
  	
   Similar	
  deficiencies	
  were	
  observed	
  in	
  the	
  Progress	
  Unit,	
  where	
  youth	
   were	
  decompensated	
  with	
  regard	
  to	
  their	
  mental	
  health	
  status,	
   however,	
  as	
  they	
  were	
  not	
  evaluated	
  daily,	
  their	
  condition	
  could	
  go	
   unchecked	
  for	
  a	
  period	
  of	
  time,	
  leading	
  to	
  further	
  decompensation.	
  	
   During	
  this	
  monitoring	
  tour,	
  mental	
  health	
  staff	
  indicated	
  that	
  they	
   were	
  assessing	
  youth	
  on	
  the	
  Progress	
  Unit	
  approximately	
  three	
  times	
   per	
  week.	
  	
  Per	
  discussions	
  with	
  mental	
  health	
  staff,	
  some	
  youth	
  had	
   extended	
  periods	
  where	
  they	
  did	
  not	
  engage	
  with	
  a	
  mental	
  health	
   treatment	
  provider	
  because	
  they	
  were	
  “asleep”	
  or	
  refused	
  to	
  talk	
  to	
   the	
  provider.	
  	
  One	
  such	
  youth,	
  Youth	
  040,	
  was	
  described	
  by	
  the	
   mental	
  health	
  staff	
  as	
  “always	
  asleep…he	
  doesn’t	
  want	
  to	
  talk.”	
  	
  The	
   psychiatrist	
  evaluated	
  Youth	
  040	
  during	
  the	
  monitoring	
  tour	
  at	
  the	
   monitor’s	
  insistence.	
  	
  This	
  youth	
  was	
  observed	
  by	
  the	
  monitor	
  to	
  be	
   psychotic.	
  	
  Given	
  the	
  youth’s	
  presentation,	
  the	
  facility	
  psychiatrist	
   arranged	
  for	
  transfer	
  to	
  a	
  mental	
  health	
  unit	
  at	
  another	
  DYS	
  facility.	
  	
  	
   	
   This	
  event	
  raised	
  multiple	
  concerns,	
  including	
  but	
  not	
  limited	
  to	
  the	
   appropriateness	
  of	
  all	
  youth	
  currently	
  housed	
  on	
  the	
  Progress	
  Unit,	
   the	
  need	
  for	
  daily	
  mental	
  health	
  contact	
  with	
  youth	
  housed	
  on	
  the	
   Progress	
  Unit,	
  mental	
  health	
  staff’s	
  ability	
  to	
  recognize	
  and	
  respond	
   to	
  signs	
  and	
  symptoms	
  of	
  serious	
  mental	
  illness,	
  and	
  the	
  facilities	
   ability	
  to	
  advocate	
  for	
  and	
  transfer	
  those	
  youth	
  with	
  serious	
  mental	
   illness	
  to	
  a	
  more	
  appropriate	
  setting.	
   	
  

	
  

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Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Review	
  and	
  revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  time	
  limits	
  for	
   psychiatric	
  evaluation	
  following	
  a	
  youth’s	
  placement	
  on	
  suicide	
   precautions.	
  
2. Review	
  and	
  revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  the	
  minimum	
   frequency	
  of	
  clinical	
  contact	
  with	
  mental	
  health	
  treatment	
   providers	
  following	
  a	
  youth’s	
  placement	
  on	
  suicide	
  precautions.	
  
3. Review	
  and	
  revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  the	
  frequency	
   of	
  clinical	
  contact	
  with	
  youth	
  on	
  the	
  Progress	
  Unit.	
  	
  Youth	
  must	
   be	
  evaluated	
  on	
  a	
  daily	
  basis.	
  
4. Review	
  and	
  revise	
  if	
  necessary	
  policy	
  and	
  procedure	
  to	
  reflect	
   the	
  frequency	
  of	
  clinical	
  contact	
  with	
  youth	
  in	
  seclusion.	
  	
  Youth	
   must	
  be	
  evaluated	
  on	
  a	
  daily	
  basis.	
  
5. Define	
  the	
  requirements	
  for	
  and	
  documentation	
  necessary	
  for	
   youth	
  assessed	
  while	
  in	
  seclusion	
  or	
  housed	
  in	
  the	
  Progress	
   Unit.	
  
6. Ensure	
  that	
  all	
  mental	
  health	
  staff	
  are	
  appropriately	
  trained	
  to	
   recognize	
  and	
  respond	
  to	
  signs	
  and	
  symptoms	
  of	
  serious	
  mental	
   illness.	
  	
  	
  
7. Consider	
  a	
  mental	
  health	
  re-­‐evaluation	
  of	
  all	
  youth	
  currently	
   housed	
  on	
  the	
  Progress	
  Unit	
  in	
  an	
  effort	
  to	
  determine	
  the	
   appropriateness	
  of	
  their	
  placement	
  in	
  this	
  program.	
  

Sources	
  of	
   Information	
  

• Review	
  of	
  provided	
  documents.	
   • Staff	
  interview.	
   • Youth	
  interview.	
  

	
  

	
  

	
  

	
  

80	
  

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III.B.17	
  	
  Transition	
  Planning.	
  	
  The	
  State	
  shall	
  ensure	
  that	
  staff	
  create	
  transition	
  plans	
  for	
   youth	
  leaving	
  the	
  facilities,	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
   care.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

In	
  response	
  to	
  a	
  document	
  request	
  for	
  transition	
  plans	
  for	
  the	
  last	
   ten	
  youth	
  prescribed	
  psychotropic	
  medication	
  discharged	
  from	
  the	
   facility,	
  the	
  monitor	
  was	
  provided	
  with	
  medical	
  release	
  summary	
   documents	
  for	
  the	
  youth,	
  as	
  well	
  as	
  the	
  psychological	
  services	
   summary	
  form.	
  Of	
  these	
  ten	
  youth,	
  nine	
  were	
  prescribed	
   psychotropic	
  medication	
  at	
  the	
  time	
  of	
  release.	
  Also	
  examined	
  were	
   the	
  facility	
  self-­‐assessment	
  and	
  policies	
  related	
  to	
  transition	
   planning.	
  Per	
  the	
  facility	
  self-­‐report,	
  transition	
  planning	
  continues	
  to	
   be	
  an	
  area	
  of	
  development.	
  Per	
  the	
  facility	
  self-­‐assessment,	
  while	
   there	
  are	
  treatment	
  teams	
  that	
  have	
  the	
  experience	
  to	
  develop	
   comprehensive	
  transition	
  plans,	
  this	
  strength	
  is	
  not	
  consistent	
   throughout	
  the	
  facility.	
  	
  “As	
  young,	
  inexperienced	
  teams,	
  transition	
   planning	
  is	
  and	
  has	
  been	
  minimal,	
  with	
  great	
  reliance	
  on	
  the	
  social	
   work	
  staff	
  being	
  able	
  to	
  make	
  a	
  connection	
  with	
  regional	
  staff	
  and	
   parole…experienced	
  treatment	
  teams…routinely	
  engage	
  in	
   detailed…transition	
  planning	
  that	
  frequently	
  includes	
  day	
  trips	
  to	
   counties	
  for	
  interviews	
  and	
  planning	
  meetings…parents…court	
   appearances	
  to	
  advocate…for	
  a	
  particular	
  placement	
   recommendation.”	
  
	
  
In	
  reviewing	
  both	
  the	
  self-­‐assessment	
  and	
  policies	
  related	
  to	
   transition	
  planning,	
  there	
  was	
  ambiguity	
  regarding	
  who	
  the	
   responsible	
  party	
  is	
  for	
  creating	
  and	
  implementing	
  transition	
  plans	
   prior	
  to	
  release,	
  particularly	
  with	
  regard	
  to	
  mental	
  health	
  follow-­‐up.	
   It	
  will	
  be	
  necessary	
  to	
  determine	
  what	
  tasks	
  need	
  to	
  be	
  completed	
  as	
   part	
  of	
  transition	
  planning	
  and	
  who	
  the	
  responsible	
  party	
  will	
  be	
  in	
   order	
  to	
  ensure	
  youth	
  leave	
  the	
  facility	
  with	
  appropriate	
  scheduled	
   follow-­‐up	
  services.	
  	
  
	
  
For	
  example,	
  in	
  the	
  policy	
  entitled	
  “Transition	
  Planning	
  for	
  Age	
  21	
   Youth,”	
  the	
  policy	
  clearly	
  states	
  that	
  the	
  juvenile	
  parole	
  officer	
  “shall	
   provide	
  each	
  youth	
  with	
  a	
  comprehensive	
  list	
  of	
  community	
  based	
   resources	
  specific	
  to	
  the	
  youth’s	
  needs.”	
  	
  This	
  is	
  to	
  include	
   “treatment	
  links/mental	
  health	
  services.”	
  	
  With	
  regard	
  to	
  youth	
   under	
  age	
  21,	
  there	
  was	
  no	
  specific	
  policy	
  included	
  in	
  the	
  documents	
   for	
  review	
  regarding	
  transition	
  planning;	
  rather	
  this	
  is	
  incorporated	
   into	
  the	
  policy	
  entitled,	
  “Behavioral	
  Health	
  Services.”	
  	
  Per	
  this	
  policy,	
  

	
  

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“youth	
  in	
  need	
  of	
  continued	
  mental	
  health	
  services	
  shall	
  receive,	
  as	
   part	
  of	
  their	
  re-­‐entry	
  plans,	
  referrals	
  for	
  continued	
  treatment.	
  	
   Efforts	
  shall	
  be	
  made	
  to	
  connect	
  the	
  youth	
  and	
  family	
  directly	
  with	
   the	
  community	
  provider.”	
  The	
  policy	
  does	
  not	
  denote	
  which	
  staff	
  are	
   responsible	
  for	
  this	
  task.	
  
	
  
Of	
  the	
  transition	
  documents	
  regarding	
  ten	
  youth	
  provided	
  through	
   the	
  document	
  request,	
  nine	
  of	
  the	
  psychology	
  summaries	
  were	
   completed	
  between	
  one	
  day	
  and	
  two	
  weeks	
  of	
  release	
  from	
  the	
   facility.	
  As	
  discussed	
  in	
  the	
  previous	
  report,	
  transition	
  planning	
   should	
  be	
  examined	
  from	
  intake	
  throughout	
  a	
  youth’s	
  incarceration.	
  	
  
	
  
There	
  was	
  little	
  documentation	
  that	
  the	
  recommendations	
  made	
  for	
   needed	
  services	
  were	
  completed	
  by	
  mental	
  health	
  staff.	
  One	
  youth	
   was	
  being	
  transitioned	
  to	
  adult	
  custody,	
  but	
  of	
  the	
  remaining	
  nine,	
   only	
  three	
  had	
  follow-­‐up	
  appointments	
  scheduled	
  upon	
  release.	
   These	
  appointments	
  were	
  scheduled	
  by	
  the	
  mental	
  health	
  nurse.	
  It	
   was	
  unclear	
  whether	
  the	
  referrals	
  coincide	
  with	
  the	
   recommendations	
  made	
  by	
  psychology	
  staff	
  based	
  on	
  youth	
  needs.	
  	
  
	
  
Due	
  to	
  the	
  state	
  of	
  outpatient	
  mental	
  health	
  services,	
  appointments	
   may	
  take	
  more	
  than	
  30	
  days	
  advanced	
  notice	
  to	
  schedule.	
  As	
  youth	
   are	
  released	
  with	
  30	
  days	
  of	
  medications,	
  it	
  is	
  vital	
  that	
  they	
  have	
   appointments	
  scheduled	
  in	
  advance	
  to	
  ensure	
  continuity	
  of	
  care.	
   One	
  positive	
  example	
  was	
  Youth	
  111,	
  who	
  was	
  scheduled	
  for	
  an	
   outpatient	
  mental	
  health	
  appointment	
  the	
  same	
  day	
  of	
  his	
  release.	
   However,	
  youth	
  with	
  intensive	
  mental	
  health	
  follow-­‐up	
  needs	
  were	
   not	
  all	
  linked	
  to	
  services	
  or	
  scheduled	
  appointments	
  prior	
  to	
  release.	
  
	
  
Other	
  challenges	
  at	
  the	
  time	
  of	
  transition	
  included	
  incomplete	
  or	
   unjustified	
  diagnoses.	
  For	
  example,	
  Youth	
  222	
  had	
  a	
  psychological	
   services	
  summary	
  completed	
  the	
  day	
  before	
  his	
  release	
  with	
   recommendations	
  for	
  follow-­‐up	
  services.	
  This	
  youth	
  had	
  diagnoses	
  of	
   Schizophrenia;	
  Conduct	
  Disorder;	
  Sexual	
  Abuse	
  of	
  a	
  Child	
   (Perpetrator);	
  and	
  Borderline	
  Intellectual	
  Functioning,	
  by	
  history.	
  His	
   intellectual	
  functioning	
  was	
  apparently	
  not	
  determined	
  through	
   testing	
  during	
  his	
  five-­‐year	
  incarceration,	
  as	
  per	
  the	
  Psychological	
   Services	
  Summary	
  Form	
  completed	
  the	
  day	
  prior	
  to	
  his	
  transition,	
   “no	
  intellectual	
  testing	
  is	
  on	
  record.	
  	
  He	
  has	
  a	
  history	
  of	
  borderline	
   intellectual	
  functioning.	
  	
  It	
  was	
  also	
  indicated	
  that	
  he	
  may	
  have	
  ‘MR	
   functioning.’”	
  	
  This	
  youth’s	
  intellectual	
  functioning	
  would	
  impact	
  his	
   treatment	
  needs	
  post-­‐discharge.	
  
	
  
At	
  the	
  time	
  of	
  his	
  release,	
  Youth	
  222	
  was	
  prescribed	
  the	
  

	
  

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Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 83 of 104 PAGEID #: 1946

antipsychotic	
  medication,	
  Haldol	
  D,	
  via	
  a	
  monthly	
  injection.	
  The	
   psychological	
  summary	
  of	
  services	
  form	
  noted	
  “at	
  this	
  time,	
  youth’s	
   symptoms	
  appear	
  to	
  have	
  stabilized	
  but	
  he	
  will	
  continue	
  to	
  require	
  a	
   high	
  level	
  of	
  wrap	
  around	
  services	
  in	
  the	
  community.”	
  The	
   medication	
  management	
  and	
  consistency	
  that	
  an	
  intramuscular	
   medication	
  provides	
  would	
  assist	
  in	
  stabilization.	
  However,	
  this	
   youth’s	
  history	
  indicates	
  a	
  need	
  for	
  continuity	
  of	
  care	
  in	
  order	
  to	
   avoid	
  a	
  relapse	
  of	
  symptoms	
  once	
  released.	
  This	
  youth	
  has	
  a	
   documented	
  history	
  of	
  psychosis	
  including	
  command	
  auditory	
   hallucinations	
  that	
  tell	
  him	
  to	
  kill	
  himself.	
  He	
  has	
  a	
  documented	
   history	
  of	
  suicidal	
  ideation,	
  gestures,	
  and	
  attempts.	
  Although	
  a	
   community	
  treatment	
  provider	
  was	
  identified,	
  no	
  follow-­‐up	
   appointment	
  was	
  scheduled.	
  As	
  he	
  was	
  prescribed	
  an	
  intramuscular	
   medication,	
  he	
  will	
  need	
  services	
  based	
  on	
  the	
  last	
  date	
  his	
  injection	
   was	
  given.	
  As	
  noted	
  in	
  the	
  medical	
  release	
  summary,	
  he	
  was	
   released	
  1/11/11	
  with	
  his	
  next	
  injection	
  due	
  2/9/11.	
  	
  A	
  contact	
  name	
   and	
  telephone	
  number	
  was	
  provided	
  via	
  the	
  medical	
  release	
   summary;	
  however,	
  an	
  appointment	
  was	
  not	
  scheduled.	
  	
  Any	
  delay	
   in	
  services	
  and	
  medication	
  administration	
  may	
  lead	
  to	
   decompensation	
  of	
  his	
  mental	
  status.	
  Further,	
  it	
  is	
  unclear	
  whether	
   the	
  identified	
  treatment	
  provider	
  matches	
  the	
  level	
  of	
  care	
  this	
   youth	
  will	
  need	
  upon	
  release.	
  It	
  is	
  necessary	
  to	
  identify	
  the	
  services	
   youth	
  are	
  being	
  referred	
  to	
  and	
  make	
  a	
  determination	
  as	
  to	
  whether	
   these	
  are	
  the	
  appropriate	
  services.	
  	
  
	
  
Youth	
  333	
  had	
  diagnoses	
  including	
  Pervasive	
  Development	
  Disorder,	
   NOS;	
  Conduct	
  Disorder;	
  Bipolar	
  I	
  Disorder,	
  most	
  recent	
  episode	
   depressed;	
  Alcohol	
  Abuse;	
  and	
  Cannabis	
  Abuse.	
  This	
  youth’s	
   psychological	
  services	
  summary	
  was	
  completed	
  2.7.11	
  and	
  she	
  was	
   not	
  released	
  until	
  9.6.11.	
  The	
  recommendations	
  include	
  “With	
  PDD	
   and	
  [youth’s]	
  other	
  mental	
  health	
  symptoms	
  in	
  mind	
  it	
  is	
  very	
   important	
  for	
  [youth]	
  to	
  maintain	
  on	
  going	
  mental	
  health	
   treatment…”	
  The	
  writer	
  of	
  the	
  psychological	
  services	
  summary	
  form	
   identified	
  that	
  this	
  youth	
  would	
  likely	
  need	
  respite	
  services	
  and/or	
   residential	
  treatment	
  in	
  the	
  future.	
  In	
  providing	
  appropriate	
   transition	
  planning	
  and	
  continuity	
  of	
  care,	
  it	
  was	
  necessary	
  for	
  this	
   youth’s	
  treatment	
  provider	
  discuss	
  future	
  treatment	
  needs	
  and	
  assist	
   the	
  family	
  in	
  understanding	
  how	
  to	
  link	
  with	
  services	
  that	
  may	
  be	
   needed	
  in	
  the	
  future.	
  Despite	
  the	
  advanced	
  recommendations	
  in	
  the	
   psychological	
  services	
  summary,	
  there	
  was	
  not	
  a	
  follow-­‐up	
  mental	
   health	
  appointment	
  scheduled	
  for	
  this	
  youth	
  at	
  the	
  time	
  of	
  her	
   release.	
  In	
  reviewing	
  transition	
  documents,	
  it	
  was	
  clear	
  that	
  this	
   youth	
  would	
  need	
  intensive	
  mental	
  health	
  and	
  rehabilitation	
   services,	
  family	
  counseling,	
  substance	
  abuse	
  treatment,	
  and	
  further	
   evaluation.	
  However,	
  none	
  of	
  these	
  services	
  were	
  arranged	
  prior	
  to	
  

	
  

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her	
  release	
  from	
  ODYS	
  custody.	
  
	
  
Also	
  reviewed	
  were	
  ten	
  examples	
  of	
  mental	
  health	
  case	
   formulations,	
  which	
  were	
  provided	
  through	
  two	
  different	
   psychological	
  services	
  summary	
  forms,	
  one	
  a	
  progress	
  form	
  and	
  one	
   a	
  summary	
  form.	
  On	
  the	
  progress	
  forms	
  (five	
  of	
  which	
  were	
   provided),	
  there	
  was	
  space	
  to	
  discuss	
  discharge	
  needs	
  including	
   continuity	
  of	
  care,	
  referral	
  information,	
  and	
  aftercare	
  options.	
  In	
   three	
  of	
  these	
  care	
  formulations;	
  discharge	
  issues	
  were	
  not	
   addressed	
  in	
  detail.	
  In	
  two,	
  it	
  was	
  stated	
  that	
  youth	
  “recently	
   transferred	
  to	
  SJCF	
  and	
  is	
  new	
  to	
  this	
  institution	
  and	
  the	
  treatment	
   team.”	
  Two	
  of	
  these	
  summaries	
  indicated	
  plans	
  for	
  discharge	
  had	
   been	
  discussed	
  with	
  youth’s	
  PO	
  and	
  were	
  in	
  the	
  planning	
  stages.	
  It	
  is	
   important	
  that	
  discussions	
  surrounding	
  discharge	
  needs	
  and	
   appropriate	
  community	
  services	
  consistently	
  begin	
  at	
  the	
  time	
  of	
   intake	
  to	
  the	
  facility.	
  Other	
  summaries	
  were	
  provided	
  on	
  a	
  similar	
   but	
  different	
  psychological	
  services	
  summary	
  form.	
  This	
  form	
  also	
   has	
  space	
  for	
  recommendations/plans.	
  In	
  these	
  sections,	
  vague	
   recommendations	
  regarding	
  level	
  of	
  care	
  needed	
  in	
  the	
  community	
   were	
  provided.	
  	
  
	
  
These	
  above	
  examples	
  are	
  similar	
  to	
  those	
  documented	
  in	
  the	
   previous	
  monitoring	
  report,	
  where	
  recommendations	
  were	
  made,	
   and	
  the	
  need	
  for	
  community	
  linkages	
  and	
  appointments	
  was	
  clear,	
   but	
  there	
  were	
  no	
  resources	
  documented.	
  	
  Given	
  the	
  facility	
  staff’s	
   self-­‐assessment	
  documented	
  above,	
  it	
  was	
  apparent	
  that	
  they	
  were	
   aware	
  of	
  the	
  need	
  to	
  develop	
  transition	
  planning	
  services	
  at	
  the	
   facility	
  to	
  include	
  linkage	
  with	
  community	
  resources.	
  
	
  
Transition	
  planning	
  for	
  all	
  youth	
  should	
  include	
  referral	
  to	
  appropriate	
   community	
  resources.	
  For	
  mentally	
  ill	
  youth	
  this	
  is	
  especially	
   important,	
  and	
  must	
  include	
  linkages	
  to	
  community	
  mental	
  health	
   clinics	
  and	
  a	
  scheduled	
  appointment	
  such	
  that	
  youth	
  can	
  access	
   follow	
  up	
  care	
  without	
  an	
  interruption	
  in	
  medication	
  treatment.	
  	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Revise	
  Behavioral	
  Health	
  Policy	
  and	
  Procedure	
  to	
  reflect	
  the	
   requirements	
  of	
  this	
  provision.	
  	
  This	
  should	
  include	
   delineating	
  the	
  responsible	
  party	
  for	
  transition	
  planning	
  to	
   include	
  mental	
  health	
  aftercare	
  appointments.	
  
2. Begin	
  transition	
  planning	
  at	
  the	
  time	
  of	
  admission	
  to	
  ensure	
   that	
  youth	
  receive	
  appropriate	
  services	
  at	
  the	
  time	
  of	
   discharge.	
  	
  This	
  must	
  include	
  involvement	
  of	
  the	
  youth’s	
   parent	
  or	
  guardian.	
  

	
  

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Sources	
  of	
   Information	
  
	
   	
  

3. Provide	
  clinical	
  supervision	
  to	
  treatment	
  teams	
   inexperienced	
  in	
  transition	
  planning.	
  
• Review	
  of	
  provided	
  documents.	
  	
   • Staff	
  interview	
  
	
  

	
  

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III.B.18	
  	
  Oversight	
  of	
  Mental	
  Health	
  Services.	
  	
  The	
  facilities	
  shall	
  ensure	
  that	
  youth	
  receive	
   the	
  care	
  they	
  need	
  by	
  developing	
  and	
  implementing	
  an	
  adequate	
  mental	
  health	
  Quality	
   Assurance/Improvement	
  Program;	
  annually	
  assessing	
  the	
  overall	
  efficacy	
  of	
  the	
  staffing,	
   treatments	
  and	
  interventions	
  used	
  at	
  the	
  facilities;	
  and	
  as	
  appropriate	
  revising	
  such	
  staffing,	
   treatments	
  and	
  interventions.	
  	
  

Compliance	
  Rating	
   Non	
  Compliance	
  

Self	
  Assessment	
   N/A,	
  the	
  facility	
  did	
  not	
  assign	
  a	
  compliance	
  rating	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

The	
  facility	
  has	
  developed	
  policy	
  and	
  procedure	
  regarding	
  Quality	
   Assurance/Improvement.	
  	
  This	
  policy,	
  with	
  an	
  effective	
  date	
  of	
   January	
  1,	
  2011	
  entitled	
  “Behavioral	
  Health	
  Quality	
   Assurance/Quality	
  Improvement.”	
  	
  This	
  policy	
  outlines	
  the	
   process	
  for	
  clinical	
  supervision	
  and	
  audit	
  of	
  clinical	
   documentation.	
  
	
  
Completed	
  quality	
  assurance	
  audits	
  dated	
  9/13/11	
  and	
  9/14/11	
   were	
  provided	
  for	
  review.	
  	
  These	
  audits	
  included:	
  Clinical	
   Supervision	
  Document	
  Review,	
  IDT	
  Document	
  Review,	
   Group/Activity	
  Document	
  Review,	
  Behavioral	
  Health	
  Service	
   Meeting,	
  and	
  Follow-­‐up.	
  Eight	
  clinicians	
  were	
  reviewed	
  on	
  the	
   quality	
  assurance	
  audit	
  dated	
  9/14,	
  five	
  out	
  of	
  eight	
  had	
  three	
   months	
  of	
  supervision	
  documented	
  in	
  their	
  supervision	
  file.	
  Of	
   these	
  clinicians,	
  three	
  had	
  clinical	
  licensure	
  documents	
  updated.	
  	
  	
  
	
  
A	
  review	
  of	
  clinical	
  supervision	
  documentation	
  required	
  by	
  the	
   facility	
  policy	
  and	
  procedure	
  revealed	
  marked	
  differences	
  in	
  the	
   documentation	
  between	
  disciplines.	
  	
  While	
  there	
  was	
  room	
  for	
   improvement	
  in	
  social	
  services	
  supervision	
  documentation,	
  there	
   was	
  a	
  paucity	
  of	
  documentation	
  regarding	
  psychology	
   supervision.	
  It	
  was	
  apparent	
  that	
  the	
  supervisee	
  was	
  responsible	
   for	
  completing	
  the	
  psychology	
  supervision	
  form,	
  which	
  was	
  then	
   signed	
  by	
  the	
  psychology	
  supervisor.	
  Additionally,	
  QA	
  documents	
   reviewed	
  indicated	
  that	
  IDT	
  Documentation	
  Review	
  and	
   Group/Activity	
  Documentation	
  Review	
  were	
  not	
  completed	
   because	
  “psychology	
  supervisor	
  does	
  not	
  have	
  time	
  to	
  attend	
  IDT	
   meetings	
  due	
  to	
  his	
  host	
  of	
  other	
  duties.”	
  
	
   An	
  undated	
  document	
  entitled	
  “2nd	
  Quarter	
  SJCF	
  QA	
   Documentation	
  Review,”	
  was	
  a	
  review	
  of	
  two	
  youth	
  health	
   records	
  for	
  the	
  months	
  of	
  April,	
  May,	
  and	
  June	
  2011.	
  While	
  the	
   effort	
  with	
  regard	
  to	
  the	
  review	
  was	
  laudable,	
  the	
  use	
  of	
  only	
   two	
  records	
  rendered	
  results	
  of	
  limited	
  utility.	
  	
  For	
  QA	
  of	
  this	
  sort	
   to	
  be	
  meaningful,	
  a	
  percentage	
  of	
  youth	
  records	
  would	
  need	
  to	
  

	
  

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be	
  reviewed	
  (i.e.	
  a	
  10%	
  sample).	
  	
  Additionally,	
  both	
  youth	
   records	
  utilized	
  in	
  the	
  above	
  sample	
  were	
  female	
  youth	
  and	
  as	
   such,	
  not	
  a	
  diverse	
  sample,	
  which	
  further	
  inhibited	
  the	
  utility	
  of	
   the	
  resultant	
  information.	
  
	
  
Review	
  of	
  available	
  documentation	
  regarding	
  quality	
  assurance	
   revealed	
  a	
  disjointed	
  process	
  that	
  did	
  not	
  lend	
  itself	
  to	
  a	
  cogent	
   review	
  of	
  the	
  system	
  or	
  services	
  provided.	
  	
  During	
  the	
  most	
   recent	
  monitoring	
  tour,	
  the	
  monitor	
  was	
  informed	
  that	
  the	
   facility	
  had	
  identified	
  individuals	
  who	
  would	
  be	
  responsible	
  for	
   the	
  development	
  of	
  a	
  system	
  of	
  quality	
  assurance	
  and	
  quality	
   improvement.	
  	
  Additionally,	
  at	
  the	
  time	
  of	
  this	
  monitoring	
  tour,	
   there	
  was	
  no	
  formal	
  quality	
  assurance	
  monitoring	
  occurring	
  with	
   respect	
  to	
  the	
  psychiatric	
  physician.	
  	
  Per	
  interviews	
  conducted	
   during	
  the	
  tour,	
  DYS	
  had	
  recently	
  identified	
  and	
  hired	
  an	
   administrative	
  psychiatrist,	
  who	
  reportedly	
  would	
  be	
  responsible	
   for	
  implementing	
  audits	
  in	
  this	
  area.	
  	
  	
  
	
  
While	
  these	
  were	
  important	
  steps,	
  as	
  stated	
  previously	
  in	
  this	
   monitoring	
  report,	
  the	
  facility	
  has	
  been	
  in	
  a	
  state	
  of	
  flux	
  for	
  the	
   previous	
  six	
  months.	
  	
  There	
  was	
  little	
  cohesive	
  mental	
  health	
   programming	
  or	
  treatment	
  occurring.	
  	
  In	
  order	
  for	
  QA	
  to	
  be	
   meaningful	
  and	
  effective,	
  there	
  must	
  be	
  a	
  functioning	
  program	
   for	
  review.	
  	
  
	
  
Per	
  information	
  obtained	
  via	
  the	
  monitoring	
  tour,	
  there	
  were	
   plans	
  to	
  revise	
  the	
  facility	
  behavioral	
  health	
  policies.	
  Therefore,	
   at	
  this	
  time,	
  the	
  implementation	
  of	
  QA	
  other	
  than	
  direct	
  clinical	
   supervision,	
  observation	
  of	
  group	
  therapeutic	
  interactions,	
  and	
   document	
  review	
  was	
  premature.	
  	
  As	
  stated	
  in	
  the	
  facility	
  self-­‐ assessment,	
  the	
  facility	
  staff	
  were	
  aware	
  of	
  the	
  immediate	
  tasks	
   that	
  must	
  be	
  accomplished	
  and	
  they	
  must	
  focus	
  on	
  these	
  in	
  order	
   to	
  ensure	
  the	
  health	
  and	
  safety	
  of	
  the	
  youth	
  and	
  staff.	
  	
  Once	
   mental	
  health	
  programming	
  is	
  fully	
  implemented,	
  the	
  facility	
   should	
  consider	
  the	
  development	
  or	
  review	
  of	
  youth	
  outcomes	
   to	
  determine	
  the	
  efficacy	
  of	
  the	
  treatment	
  program.	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Revise	
  behavioral	
  health	
  policy	
  and	
  procedure.	
   2. Develop	
  quality	
  assurance	
  monitoring	
  based	
  on	
  policy	
  
and	
  procedure.	
   3. Improve	
  documentation	
  of	
  clinical	
  supervision.	
  

	
  

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Sources	
  of	
   Information	
  
	
  

• Staff	
  Interview.	
   • Review	
  of	
  the	
  provided	
  documents.	
  
	
  

	
  

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G.1	
  Progress	
  Notes.	
  The	
  Facilities	
  shall	
  promulgate	
  and	
  implement	
  a	
  policy	
  requiring	
  that	
   all	
  health	
  professionals	
  be	
  required	
  to	
  create	
  and	
  use	
  progress	
  notes	
  to	
  document,	
  on	
  a	
   regular	
  basis,	
  interactions	
  and	
  each	
  assessment	
  of	
  youth	
  with	
  mental/behavioral	
  health	
  or	
   substance	
  abuse	
  needs.	
  In	
  particular,	
  progress	
  notes	
  shall:	
  	
   a.)	
  In	
  the	
  assessment,	
  address	
  the	
  efficacy	
  of	
  interventions,	
  currently	
  presenting	
  problems,	
   and	
  the	
  available	
  options	
  to	
  address	
  those	
  problems;	
  and	
  	
   b.)	
  Provide	
  thorough	
  documentation	
  of	
  all	
  crisis	
  interventions	
  or,	
  if	
  not	
  thoroughly	
   documented	
  in	
  the	
  progress	
  notes,	
  provide	
  a	
  reference	
  to	
  alert	
  staff	
  to	
  another	
  document	
   in	
  the	
  youth’s	
  file	
  containing	
  the	
  details	
  of	
  the	
  crisis	
  intervention.	
  	
  

Compliance	
  Rating	
  	
   Non-­‐Compliance	
  	
  

Self	
  Assessment	
  	
  

The	
  facility	
  self-­‐assessment	
  did	
  not	
  include	
  information	
  regarding	
   this	
  provision.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  	
  

Per	
  interviews	
  with	
  mental	
  health	
  staff	
  from	
  both	
  the	
  facility	
  and	
   DYS	
  administration,	
  a	
  review	
  and	
  revision	
  of	
  mental	
  health	
  policy	
   and	
  procedure	
  is	
  pending.	
  Mental	
  health	
  documentation	
  reviewed	
   for	
  the	
  preparation	
  of	
  this	
  monitoring	
  report	
  revealed	
  deficiencies	
  in	
   clinical	
  documentation.	
  	
   	
   Specifically,	
  mental	
  health	
  assessments	
  did	
  not	
  include	
  case	
   conceptualization	
  information	
  required	
  to	
  develop	
  a	
  treatment	
  plan.	
   Treatment	
  plans	
  did	
  not	
  include	
  measurable	
  goals	
  and	
  objectives.	
  As	
   such,	
  the	
  documentation	
  included	
  in	
  the	
  individual	
  youth	
  progress	
   notes	
  did	
  not	
  reflect	
  interventions	
  aimed	
  at	
  addressing	
  specific	
   treatment	
  goals.	
  	
  There	
  was	
  wide	
  variability	
  in	
  the	
  quality	
  of	
   progress	
  notes	
  documenting	
  treatment.	
  As	
  discussed	
  during	
  the	
   monitoring	
  tour,	
  this	
  was	
  an	
  area	
  that	
  may	
  be	
  amenable	
  to	
  quality	
   assurance	
  monitoring.	
  	
   	
   Crisis	
  intervention	
  documentation	
  was	
  improved	
  over	
  the	
  previous	
   monitoring	
  tours.	
  What	
  was	
  missing	
  was	
  routinely	
  documented	
   follow-­‐up	
  with	
  the	
  youth’s	
  assigned	
  clinician	
  at	
  the	
  subsequent	
   clinical	
  encounter	
  with	
  regard	
  to	
  the	
  mental	
  health	
  crisis	
  situation.	
  	
  

Recommendations	
  	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
   State	
  must:	
  	
  
1. Ensure	
  that	
  progress	
  notes	
  reflect	
  interventions	
  aimed	
  at	
   addressing	
  specific	
  treatment	
  goals.	
  	
  
2. Ensure	
  that,	
  in	
  their	
  follow-­‐up	
  care,	
  clinicians	
  reference	
   youth’s	
  previous	
  crises	
  in	
  the	
  progress	
  notes.	
  	
  
3. Complete	
  the	
  planned	
  review	
  and	
  revision	
  of	
  policy	
  and	
   procedure.	
  

Sources	
  of	
   Information	
  	
  
	
  

• Mental	
  health	
  records	
  	
   • Interviews	
  with	
  DYS	
  and	
  facility	
  mental	
  health	
  staff	
  	
  

	
  

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G.2	
  Accessibility	
  of	
  Relevant	
  Information.	
  The	
  Facilities	
  shall	
  ensure	
  that	
  youth	
  records	
  are	
   organized	
  in	
  a	
  manner	
  providing	
  treatment	
  teams	
  prompt	
  access	
  to	
  relevant,	
  complete,	
   and	
  accurate	
  documentation	
  regarding	
  the	
  youth’s	
  status.	
  	
  

Compliance	
  Rating	
  	
   Non-­‐Compliance	
  

Self	
  Assessment	
  	
  

The	
  facility	
  self-­‐assessment	
  did	
  not	
  include	
  information	
  regarding	
   this	
  provision.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  	
  

Currently,	
  the	
  record-­‐keeping	
  program	
  at	
  the	
  facility	
  is	
  cumbersome.	
   There	
  are	
  multiple	
  databases	
  where	
  information	
  is	
  stored,	
  making	
   access	
  to	
  information	
  challenging.	
  Per	
  interviews	
  with	
  DYS	
   administration,	
  there	
  are	
  plans	
  to	
  implement	
  the	
  OYAS	
  system	
  at	
  the	
   facility,	
  which	
  will	
  reportedly	
  allow	
  for	
  staff	
  to	
  access	
  information	
   from	
  one	
  database	
  allowing	
  for	
  electronic	
  access	
  to	
  mental	
  health	
   information.	
  Pending	
  this	
  improvement,	
  mental	
  health	
  staff	
   (including	
  psychiatry	
  staff)	
  are	
  hampered	
  by	
  the	
  current	
   documentation	
  system.	
  	
   	
   A	
  review	
  of	
  the	
  records	
  provided	
  for	
  off	
  site	
  review	
  did	
  not	
  include	
   the	
  documentation	
  of	
  social	
  workers.	
  	
  The	
  provided	
  documents	
  were	
   limited	
  to	
  psychology-­‐derived	
  documentation.	
  	
  As	
  such,	
  a	
  review	
  of	
   the	
  completeness	
  and	
  accuracy	
  of	
  the	
  documentation	
  was	
  limited.	
   	
   Regardless,	
  as	
  stated	
  in	
  G1	
  above,	
  per	
  the	
  review	
  of	
  youth	
  records	
   and	
  mental	
  health	
  documentation	
  available	
  for	
  off	
  site	
  review,	
  there	
   was	
  considerable	
  variability	
  in	
  the	
  quality	
  of	
  documentation	
   regarding	
  mental	
  health	
  treatment.	
  	
  This	
  is	
  an	
  area	
  that	
  would	
  be	
   amenable	
  to	
  quality	
  assurance	
  (with	
  associated	
  corrective	
  action)	
   and	
  peer	
  review.	
  	
  	
  

Recommendations	
  	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
   State	
  must:	
  	
  
1. Ensure	
  that	
  all	
  mental	
  health	
  staff,	
  including	
  psychiatrists,	
   have	
  access	
  to	
  relevant,	
  complete	
  and	
  accurate	
   documentation	
  regarding	
  the	
  youth’s	
  mental	
  health	
  status	
   and	
  treatment.	
  	
  
2. Continue	
  and	
  expand	
  quality	
  assurance	
  monitoring	
  of	
  mental	
   health	
  documentation.	
  	
  This	
  would	
  include	
  a	
  review	
  of	
  a	
   percentage	
  of	
  mental	
  health	
  records	
  along	
  with	
  corrective	
   action	
  plans	
  as	
  needed.	
  

Sources	
  of	
   Information	
  	
  

• Mental	
  health	
  records	
  	
   • Interviews	
  with	
  DYS	
  and	
  facility	
  mental	
  health	
  staff	
  	
  

	
  

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MEDICAL	
  SERVICES	
  
	
   	
  
III.C.1	
  	
  General	
  Medical	
  Care.	
  The	
  facilities	
  shall	
  ensure	
  that	
  the	
  individuals	
  they	
  serve	
   receive	
  routine,	
  preventive,	
  and	
  emergency	
  medical	
  and	
  dental	
  care	
  consistent	
  with	
   current,	
  generally	
  accepted	
  professional	
  standards.	
  The	
  facilities	
  shall	
  ensure	
  that	
   individuals	
  with	
  health	
  problems	
  are	
  identified,	
  assessed,	
  diagnosed,	
  and	
  treated	
  consistent	
   with	
  current,	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Ohio	
  Department	
  of	
  Youth	
  Services	
  (ODYS)	
  self	
  assessment	
  rated	
   the	
  level	
  of	
  medical	
  and	
  dental	
  care	
  at	
  SJCF	
  at	
  or	
  above	
  the	
  level	
  that	
   was	
  observed	
  for	
  the	
  Third	
  Compliance	
  Report,	
  wherein	
  SJCF	
  received	
   a	
  rating	
  of	
  substantial	
  compliance.	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Off	
  site	
  review	
  of	
  ten	
  youth	
  health	
  records	
  housed	
  at	
  the	
  Scioto	
   Facility.	
  Review	
  of	
  Youth	
  Injury	
  and	
  Assessment	
  Forms	
  of	
  eleven	
   youth	
  exposed	
  to	
  OC	
  spray,	
  three	
  of	
  which	
  were	
  at	
  Scioto.	
  Health	
   records	
  of	
  three	
  female	
  youth	
  at	
  Scioto	
  in	
  response	
  to	
  a	
  complaint	
   made	
  to	
  the	
  Monitor	
  on	
  the	
  October	
  2011	
  site	
  visit.	
  A	
  review	
  was	
  also	
   made	
  of	
  internal	
  quality	
  assurance	
  monitoring	
  documents	
  for	
  2011.	
  	
   	
   In	
  general,	
  according	
  to	
  the	
  documents	
  provided	
  to	
  me	
  by	
  ODYS,	
  the	
   medical	
  and	
  dental	
  care	
  continues	
  to	
  be	
  consistent	
  with	
  the	
  third	
   compliance	
  report.	
  	
  The	
  health	
  record	
  review	
  included	
  assessing	
   completeness	
  of	
  the	
  Problem	
  List,	
  the	
  presence	
  and	
  timeliness	
  of	
  the	
   Nursing	
  Intake	
  Screening,	
  Mental	
  Health	
  Screening,	
  Physical	
  Exam,	
   Dental	
  Exam,	
  Oral	
  Hygiene	
  Instruction	
  and	
  Growth	
  Chart.	
  	
  Admission	
   labs	
  were	
  checked	
  for	
  completion	
  and	
  results	
  within	
  20	
  days.	
  STD	
   screening	
  for	
  Gonorrhea	
  and	
  Chlamydia	
  was	
  completed	
  on	
  all	
  youth	
   except	
  one.	
  It	
  was	
  commendable	
  that	
  ODYS	
  was	
  screening	
  for	
  HIV	
   and	
  Hepatitis	
  C	
  on	
  all	
  admissions.	
  All	
  youth	
  received	
  tuberculosis	
   screening	
  with	
  documented	
  results.	
  One	
  youth	
  was	
  enrolled	
  in	
   chronic	
  care	
  clinic	
  as	
  a	
  result	
  of	
  a	
  positive	
  PPD	
  skin	
  test	
  for	
   tuberculosis	
  exposure.	
  Dental	
  treatment	
  was	
  provided	
  as	
  a	
  result	
  of	
   the	
  dental	
  examination	
  or	
  as	
  in	
  one	
  case,	
  from	
  a	
  Health	
  Request.	
  All	
   youth	
  allergies	
  were	
  noted	
  in	
  their	
  health	
  record.	
  There	
  were	
  only	
   two	
  youth	
  with	
  chronic	
  medical	
  conditions	
  provided	
  in	
  the	
  ten	
  health	
   records	
  provided.	
  Both	
  received	
  appropriate	
  assessments,	
  treatment	
   plans,	
  and	
  specialty	
  consultations.	
  Seven	
  of	
  the	
  ten	
  youth	
  records	
   reviewed	
  had	
  some	
  indication	
  of	
  a	
  mental	
  health	
  diagnosis,	
  either	
   through	
  the	
  mental	
  health	
  screening,	
  transfer	
  notes	
  or	
  psychiatric	
   evaluations	
  in	
  the	
  health	
  record.	
  Most	
  of	
  these	
  diagnoses	
  were	
  not	
  on	
   the	
  youth’s	
  problem	
  list	
  nor	
  contained	
  much	
  detail	
  in	
  the	
  psychiatry	
   tab	
  of	
  the	
  health	
  record.	
  There	
  was	
  documentation	
  of	
  special	
  diets,	
  

	
  

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Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 92 of 104 PAGEID #: 1955

optometry	
  consults	
  and	
  eyeglasses	
  provided.	
  One	
  youth	
  even	
   received	
  a	
  second	
  pair	
  after	
  losing	
  the	
  first.	
  	
   	
   Health	
  Requests	
  were	
  reviewed	
  and	
  in	
  each	
  case	
  traced	
  back	
  to	
  a	
   corresponding	
  progress	
  note	
  to	
  determine	
  if	
  the	
  complaint	
  had	
  been	
   addressed.	
  In	
  all	
  cases,	
  the	
  requests	
  had	
  been	
  adequately	
  assessed	
   and	
  treated	
  by	
  registered	
  nursing	
  staff	
  and	
  in	
  some	
  cases	
  by	
  the	
   physician.	
  Progress	
  notes	
  also	
  included	
  assessments	
  that	
  did	
  not	
  have	
   a	
  corresponding	
  Health	
  Request	
  slip	
  in	
  the	
  health	
  record.	
  When	
   nurses	
  made	
  isolation	
  checks,	
  they	
  were	
  documented	
  in	
  the	
  progress	
   notes.	
  I	
  cannot	
  determine	
  if	
  all	
  youth	
  housed	
  in	
  segregation/isolation	
   were	
  assessed	
  daily	
  by	
  the	
  nursing	
  staff	
  based	
  on	
  the	
  information	
   provided	
  to	
  me	
  for	
  review.	
  	
  One	
  youth	
  in	
  particular	
  had	
  several	
   seclusion	
  checks	
  documented	
  while	
  there	
  were	
  others	
  that	
  did	
  not	
   have	
  any.	
  Daily	
  checks	
  of	
  youth	
  in	
  seclusion/segregation	
  by	
  medical	
   staff	
  are	
  a	
  requirement	
  of	
  the	
  National	
  Commission	
  on	
  Correctional	
   Health	
  Care	
  Standards	
  for	
  Juvenile	
  Detention	
  and	
  Confinement	
   Facilities.	
  Documentation	
  on	
  the	
  Youth	
  injury	
  and	
  Assessment	
   Reports	
  for	
  youth	
  sprayed	
  with	
  OC	
  did	
  not	
  always	
  include	
  vital	
  signs,	
   flushing	
  of	
  all	
  exposed	
  areas	
  with	
  water,	
  showering	
  or	
  documentation	
   of	
  clothing	
  decontamination.	
  	
   	
   Medication	
  administration	
  records	
  and	
  physician	
  orders	
  were	
  also	
   reviewed	
  for	
  accuracy	
  and	
  medication	
  compliance.	
  Immunization	
   records	
  were	
  reviewed	
  for	
  completeness.	
  With	
  the	
  exception	
  of	
   Hepatitis	
  A	
  and	
  HPV,	
  youth	
  immunizations	
  were	
  current.	
  Internal	
   Quality	
  Assurance	
  documents	
  were	
  reviewed	
  that	
  were	
  provided	
  by	
   ODYS.	
  The	
  overwhelming	
  majority	
  of	
  the	
  items	
  monitored	
  were	
  found	
   to	
  be	
  in	
  100%	
  compliance.	
  	
   	
   Three	
  female	
  youth	
  health	
  records	
  were	
  reviewed	
  as	
  a	
  result	
  of	
   allegations	
  of	
  unresponsive	
  health	
  requests.	
  One	
  female	
  complained	
   of	
  a	
  “bump”	
  in	
  the	
  genital	
  area.	
  Two	
  health	
  requests	
  were	
  in	
  her	
   health	
  record.	
  She	
  was	
  seen	
  by	
  the	
  nurse	
  for	
  both	
  requests.	
  She	
  was	
   referred	
  to	
  the	
  physician	
  and	
  the	
  bump	
  was	
  examined	
  by	
  the	
  MD	
  and	
   diagnosed	
  as	
  a	
  carbuncle.	
  	
  The	
  other	
  two	
  females	
  complained	
  of	
   menstrual	
  irregularities,	
  but	
  both	
  were	
  on	
  DepoProvera	
  injections	
  for	
   birth	
  control,	
  which	
  is	
  a	
  common	
  side	
  effect	
  of	
  this	
  medication.	
  	
  Both	
   female’s	
  health	
  requests	
  were	
  addressed	
  appropriately	
  in	
  the	
  health	
   record.	
  One	
  female	
  with	
  abdominal	
  pain	
  complaints	
  received	
  a	
  CT	
   scan	
  and	
  pelvic	
  ultrasound,	
  with	
  negative	
  results.	
  Youth	
  with	
   complaints	
  of	
  menstrual	
  cramps	
  were	
  prescribed	
  anti-­‐inflammatory	
   medications	
  for	
  pain	
  as	
  needed.	
  One	
  female	
  expressed	
  concern	
  over	
   having	
  a	
  male	
  gynecologist	
  to	
  examine	
  her.	
  Chaperones	
  of	
  the	
  same	
   sex	
  as	
  the	
  patient	
  are	
  always	
  required	
  whenever	
  a	
  medical	
  

	
  

92	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 93 of 104 PAGEID #: 1956

professional	
  examines	
  the	
  female	
  patient’s	
  breasts	
  or	
  genitalia.	
  

Recommendations	
  

The	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  In	
  the	
  spirit	
   of	
  continually	
  improving	
  services,	
  the	
  following	
  are	
  recommended:	
  
1. Expand	
  the	
  immunization	
  program	
  to	
  Include	
  Hepatitis	
  A	
  and	
   HPV	
  vaccinations	
  of	
  youth.	
  	
  
2. Develop	
  protocols	
  for	
  decontamination	
  and	
  medical	
   assessment	
  of	
  youth	
  after	
  exposure	
  to	
  OC	
  spray.	
   Documentation	
  on	
  the	
  Youth	
  injury	
  and	
  Assessment	
  Reports	
   for	
  youth	
  sprayed	
  with	
  OC	
  did	
  not	
  always	
  include	
  vital	
  signs,	
   flushing	
  of	
  all	
  exposed	
  areas	
  with	
  water,	
  showering	
  or	
   documentation	
  of	
  clothing	
  decontamination.	
  
3. Provide	
  AEDs	
  (Automated	
  External	
  Defibrillators)	
  on	
  site,	
  train	
   staff	
  in	
  its	
  use	
  and	
  include	
  them	
  in	
  the	
  Emergency	
  Medical	
   Response	
  and	
  Services	
  Policy.	
  
4. Improve	
  completeness	
  of	
  youth	
  Problem	
  List	
  in	
  health	
  record	
   to	
  include	
  all	
  chronic	
  diagnoses,	
  including	
  mental	
  health,	
   substance	
  abuse	
  and	
  acute	
  diagnoses	
  such	
  as	
  headache,	
   shoulder	
  pain,	
  etc.	
  
5. Improve	
  Quality	
  Assurance	
  (QA)	
  activities	
  by	
  considering	
  a	
   review	
  at	
  least	
  annually	
  by	
  a	
  source	
  external	
  to	
  ODYS	
  Health	
   Services.	
  ODYS	
  should	
  also	
  consider	
  expansion	
  of	
  the	
  QA	
   process	
  to	
  include	
  some	
  additional	
  quality	
  indicators.	
  	
  

Sources	
  of	
   Information	
  
	
   	
   	
  

• Review	
  of	
  ten	
  youth	
  health	
  records:	
  ID	
  #	
  216224,	
  215725,	
   211428,	
  215728,	
  214897,	
  217657,	
  217487,	
  215980,	
  217724,	
   and	
  216734.	
  Youth	
  Injury	
  and	
  Assessment	
  Forms:	
   5505111337,	
  2105111709,	
  2105111710,	
  5505111288,	
   2105111712,	
  2105111716,	
  2105111715,	
  and	
  2105111711.	
   Health	
  records	
  of	
  three	
  female	
  youth	
  at	
  Scioto:	
  ID#217709,	
   217497,	
  and	
  217002	
  	
  
	
  

	
  

93	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 94 of 104 PAGEID #: 1957

III.C.2	
  	
  Health	
  Records.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
   practices	
  to	
  ensure	
  that,	
  consistent	
  with	
  State	
  and	
  federal	
  law,	
  at	
  a	
  minimum,	
  the	
  juvenile	
   courts	
  in	
  the	
  State,	
  all	
  juvenile	
  detention	
  facilities	
  and	
  all	
  placement	
  settings	
  from	
  which	
   youth	
  are	
  committed	
  shall	
  timely	
  forward	
  to	
  Scioto,	
  or	
  to	
  the	
  facility	
  of	
  placement	
  (if	
  the	
   records	
  arrive	
  after	
  the	
  youth	
  has	
  been	
  placed),	
  all	
  pertinent	
  youth	
  records	
  regarding	
   medical	
  and	
  mental	
  health	
  care.	
  The	
  facilities	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  ensure	
  that	
  health	
  care	
  staff,	
  including	
  mental	
  health	
  care	
  staff,	
   have	
  access	
  to	
  documents	
  that	
  are	
  relevant	
  to	
  the	
  care	
  and	
  treatment	
  of	
  the	
  youth.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  relevant	
  policies,	
  procedures,	
  and	
  practices	
  are	
  at	
  or	
  above	
  the	
   level	
  that	
  was	
  observed	
  for	
  the	
  Third	
  Compliance	
  Report,	
  wherein	
  it	
   was	
  observed	
  that	
  the	
  State	
  “demonstrate[s]	
  a	
  commitment	
  to	
   continuity	
  of	
  care	
  for	
  Scioto’s	
  youth.”	
  [See	
  Doc.	
  79-­‐1,	
  at	
  56].	
  SJCF	
  is	
  no	
   longer	
  a	
  reception	
  facility.	
  Therefore,	
  the	
  provision	
  about	
  forwarding	
   to	
  the	
  facility	
  of	
  placement	
  is	
  moot.	
  In	
  the	
  Third	
  Compliance	
  Report,	
   the	
  Department	
  of	
  Justice	
  (DOJ)	
  stated	
  that	
  substantial	
  compliance	
   with	
  this	
  provision	
  would	
  be	
  achieved	
  by	
  “combin[ing]	
  medical	
  and	
   psychology	
  records.”	
  See	
  id.	
  Due	
  to	
  the	
  physical	
  layout	
  of	
  SJCF,	
   combining	
  medical	
  and	
  psychology	
  records	
  into	
  one	
  record	
  would	
   prove	
  extremely	
  difficult,	
  if	
  not	
  impossible.	
  There	
  is	
  a	
  great	
  distance	
   between	
  the	
  Clinic	
  and	
  the	
  nine	
  housing	
  units.	
  Removal	
  of	
  a	
  medical	
   record	
  from	
  the	
  clinic	
  could	
  lead	
  to	
  the	
  lack	
  of	
  access	
  to	
  critical	
   medical	
  information	
  in	
  an	
  emergency	
  situation.	
   	
   SJCF	
  has	
  a	
  Mental	
  Health	
  Database	
  that	
  psychologists	
  may	
  access.	
   Although	
  not	
  all	
  inclusive,	
  this	
  database	
  includes	
  diagnosis,	
   medication	
  information	
  and	
  medication	
  compliance.	
  Psychology	
  staff	
   directly	
  involved	
  with	
  the	
  care	
  and	
  treatment	
  of	
  the	
  Youth	
  at	
  SJCF	
   have	
  access	
  to	
  the	
  psychiatry	
  notes	
  via	
  the	
  Mental	
  Health	
  Nurse.	
  And	
   treatment	
  teams	
  are	
  verbally	
  informed	
  of	
  medication	
  compliance	
  by	
   the	
  psychology	
  staff	
  when	
  necessary	
  and	
  relevant	
  on	
  a	
  weekly	
  basis	
   to	
  allow	
  any	
  issues	
  to	
  be	
  addressed.	
  Because	
  all	
  relevant	
  staff	
  have	
   access	
  to	
  the	
  relevant	
  health	
  records	
  (and	
  because	
  the	
  policies,	
   procedures,	
  and	
  practices	
  continue	
  to	
  be	
  in	
  place	
  as	
  stated	
  above),	
   SJCF	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Review	
  of	
  ten	
  youth	
  health	
  records.	
  Review	
  of	
  Policies	
  and	
   Procedures	
  and	
  Standard	
  Operating	
  Procedures	
  (SOP)	
  effective	
   7/1/11	
  provided	
  by	
  ODYS.	
  A	
  few	
  health	
  records	
  contained	
  some	
   transfer	
  health	
  information	
  from	
  the	
  county	
  probation	
  offices	
  or	
   other	
  facilities.	
  Since	
  Scioto	
  is	
  no	
  longer	
  a	
  reception	
  center,	
  transfer	
   information	
  is	
  no	
  longer	
  required.	
  As	
  stated	
  in	
  the	
  first	
  section,	
  there	
   was	
  little	
  mental	
  health	
  information	
  housed	
  within	
  the	
  health	
  record	
   of	
  youth	
  in	
  the	
  majority	
  of	
  cases.	
  Since	
  this	
  assessment	
  was	
   completed	
  based	
  on	
  the	
  information	
  submitted,	
  I	
  cannot	
  determine	
  

	
  

94	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 95 of 104 PAGEID #: 1958

how	
  successful	
  the	
  process	
  for	
  sharing	
  health	
  information	
  occurs	
   between	
  medical	
  and	
  mental	
  health.	
  A	
  better	
  determination	
  would	
   be	
  made	
  based	
  on	
  a	
  facility	
  site	
  visit.	
  

Recommendations	
  

The	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  In	
  the	
  spirit	
   of	
  continually	
  improving	
  services,	
  the	
  following	
  are	
  recommended:	
  
1. Continue	
  to	
  improve	
  process	
  for	
  sharing	
  of	
  health	
  information	
   between	
  medical	
  and	
  mental	
  health	
  to	
  include	
  psychologists,	
   possibly	
  through	
  the	
  use	
  of	
  a	
  summary	
  sheets	
  provided	
  to	
   medical	
  for	
  inclusion	
  in	
  the	
  health	
  record	
  and	
  pertinent	
   medical	
  information	
  provided	
  for	
  the	
  mental	
  health	
  record.	
  	
  	
  
2. Consider	
  implementation	
  of	
  electronic	
  health	
  record	
  or	
  if	
  not	
   possible	
  now,	
  allow	
  medical	
  staff	
  to	
  access	
  to	
  the	
  Mental	
   Health	
  database.	
  
3. Continue	
  to	
  review	
  and	
  update	
  policies	
  and	
  procedures	
   annually.	
  There	
  was	
  a	
  five	
  and	
  a	
  half	
  year	
  period	
  lapsed	
   between	
  the	
  current	
  ODYS	
  Policies	
  and	
  Procedures	
   implemented	
  7/2011	
  and	
  the	
  previous	
  set	
  of	
  ODYS	
  Policies	
   and	
  Procedures	
  implemented	
  1/2006.	
  	
  
4. Reduce	
  length	
  of	
  policies	
  and	
  procedures	
  and	
  attempt	
  to	
   consolidate	
  some.	
  	
  Try	
  to	
  eliminate	
  references	
  back	
  to	
  other	
   policy	
  numbers	
  within	
  the	
  text.	
  Some	
  policies	
  and	
  Standard	
   Operating	
  Procedures	
  (SOP)	
  should	
  be	
  shortened	
  and	
  some	
   details	
  removed	
  and	
  placed	
  into	
  protocols	
  (for	
  example,	
  the	
   details	
  of	
  the	
  World	
  Health	
  Organization’s	
  Pandemic	
  Phases	
   included	
  in	
  the	
  18-­‐page	
  Pandemic	
  Response	
  Plan	
  for	
  Medical	
   and	
  Mental	
  Health	
  Services	
  SOP).	
  When	
  policies	
  become	
  too	
   lengthy	
  and	
  cumbersome,	
  it	
  is	
  more	
  difficult	
  for	
  staff	
  to	
   understand	
  them	
  and	
  maintain	
  compliance.	
  

Sources	
  of	
   Information	
  

• Review	
  of	
  ten	
  youth	
  health	
  records:	
  ID	
  #	
  216224,	
  215725,	
   211428,	
  215728,	
  214897,	
  217657,	
  217487,	
  215980,	
  217724,	
   and	
  216734.	
  
• Review	
  of	
  Policies	
  and	
  Procedures	
  supplied	
  to	
  me	
  by	
  ODYS	
   effective	
  July	
  1,	
  2011	
  to	
  include:	
  Pharmaceutical	
   Management;	
  Health	
  Education	
  and	
  Prevention;	
  Emergency	
   Medical	
  Response	
  and	
  Services;	
  Communicable	
  Disease	
   Management;	
  Health	
  Services	
  Internal	
  Review,	
  Quality	
   Assurance	
  Monitoring	
  and	
  Reporting.	
  Review	
  of	
  Standard	
   Operating	
  Procedures	
  (SOP)	
  effective	
  July	
  1,	
  2011:	
   Pharmaceutical	
  Prescribing,	
  Procurement	
  and	
  Documentation	
   Procedures;	
  Pharmaceutical	
  Receipt,	
  Storage,	
  Inventory,	
  and	
   Disposal	
  Management;	
  Medication	
  Administration	
  and	
   Documentation;	
  Pharmaceutical	
  Transfer	
  within	
  the	
   Department;	
  Aftercare	
  Pharmaceuticals;	
  First	
  Aid	
  and	
   Emergency	
  Care;	
  HIV	
  Screening,	
  Testing	
  and	
  Management;	
  

	
  

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Hepatitis	
  Screening,	
  Testing	
  and	
  Management;	
  Tuberculosis	
   Testing	
  and	
  Management;	
  Chicken	
  Pox	
  Management;	
   Ectoparasite	
  Management;	
  Immunization	
  Program;	
  Exposure	
   Control	
  and	
  Standard	
  Precautions;	
  Pandemic	
  Response	
  Plan	
   for	
  Medical	
  and	
  Mental	
  Health	
  Services;	
  Methicillin-­‐Resistant	
   Staphylococcus	
  Aureus	
  (MRSA);	
  Supervisor	
  and	
  Peer	
  review-­‐	
   Health	
  Services	
  Administrators;	
  Peer	
  Review-­‐	
  Physicians	
  and	
   Dental	
  Personnel;	
  Peer	
  Review-­‐	
  Nursing;	
  and	
  Peer	
  review-­‐	
   Psychology.	
  

	
  

	
  

	
  

	
  

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III.C.5	
  	
  Access	
  to	
  Health	
  Services.	
  The	
  facilities	
  shall	
  ensure	
  that	
  youth	
  can	
  request	
  to	
  be	
   seen	
  by	
  medical	
  staff	
  confidentially	
  and	
  independent	
  from	
  JCOs	
  and	
  custodial	
  staff.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

All	
  youth	
  assessments	
  are	
  completed	
  by	
  Registered	
  Nurses.	
  The	
  Ohio	
   Department	
  of	
  Youth	
  Services	
  has	
  abolished	
  the	
  LPN	
  positions.	
  Every	
   youth	
  at	
  SJCF	
  has	
  direct	
  access	
  to	
  medical	
  care	
  whether	
  emergent	
  or	
   non-­‐emergent.	
  Upon	
  admission	
  to	
  SJCF,	
  all	
  youth	
  are	
  educated	
  on	
  the	
   process	
  to	
  access	
  healthcare.	
  Youth	
  have	
  the	
  ability	
  to	
  confidentially	
   request	
  an	
  assessment	
  by	
  the	
  medical	
  staff	
  by	
  placing	
  a	
  written	
   request	
  in	
  one	
  of	
  the	
  locked	
  Healthcall	
  boxes	
  on	
  campus.	
  More	
   urgent	
  matters	
  require	
  the	
  youth	
  to	
  have	
  the	
  unit	
  staff	
  notify	
  the	
   clinic.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Progress	
  Notes	
  and	
  Nurse	
  Health	
  Requests	
  were	
  reviewed	
  in	
  all	
  10	
   health	
  records	
  selected	
  and	
  provided	
  by	
  Ohio	
  DYS	
  for	
  youth	
  at	
  the	
   Scioto	
  Facility.	
  No	
  Nurse	
  Health	
  Request	
  Forms	
  were	
  present	
  in	
  3	
  of	
  7	
   records.	
  Two	
  of	
  these	
  3	
  health	
  records	
  contained	
  progress	
  notes	
  that	
   indicated	
  medical	
  care	
  was	
  provided	
  by	
  nursing	
  staff	
  without	
  a	
  health	
   request.	
  	
  Health	
  requests	
  included	
  in	
  these	
  7	
  health	
  records	
  were	
   responded	
  to	
  adequately	
  and	
  documented	
  by	
  medical	
  staff	
  100%	
  of	
   the	
  time.	
  A	
  few	
  examples	
  of	
  Nurse	
  Health	
  Request	
  responses	
   included,	
  a	
  youth	
  that	
  complained	
  of	
  feeling	
  like	
  he	
  was	
  “breathing	
   through	
  a	
  straw”	
  that	
  received	
  a	
  complete	
  assessment	
  including	
  peak	
   flow	
  and	
  O2	
  saturation	
  evaluation;	
  youth	
  complaining	
  of	
  shoulder	
   pain	
  from	
  an	
  old	
  injury	
  received	
  an	
  orthopedic	
  consult,	
  MRI	
  and	
  anti-­‐ inflammatory	
  medications	
  creating	
  a	
  common	
  abdominal	
  pain	
  side	
   effect	
  that	
  was	
  appropriately	
  treated;	
  youth	
  with	
  a	
  complaint	
  of	
  a	
   “bump”	
  received	
  an	
  incision	
  and	
  drainage	
  for	
  treatment.	
  All	
  records	
   included	
  documentation	
  that	
  the	
  youth	
  had	
  received	
  information	
  on	
   how	
  to	
  access	
  health	
  services	
  at	
  the	
  facility.	
  During	
  the	
  site	
  visit	
  in	
   October	
  2011,	
  Dr.	
  Dedel	
  directly	
  observed	
  the	
  nurse	
  health	
  request	
   boxes	
  on	
  the	
  Sycamore/Cedar	
  Units	
  as	
  accessible	
  to	
  youth.	
  None	
  of	
   the	
  youth	
  on	
  those	
  two	
  units	
  expressed	
  any	
  complaints	
  about	
  access	
   to	
  medical	
  treatment.	
  	
  

Recommendations	
  

The	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  In	
  the	
  spirit	
   of	
  continually	
  improving	
  services,	
  the	
  following	
  are	
  recommended:	
  
1. Encourage	
  youth	
  to	
  complete	
  Health	
  Call	
  forms	
  in	
  non-­‐ emergency	
  situations	
  in	
  order	
  to	
  fully	
  document	
  medical	
   responses	
  to	
  youth	
  requests.	
  Again,	
  in	
  many	
  instances	
  nurses	
   provided	
  services	
  to	
  youth	
  documented	
  in	
  progress	
  notes	
   without	
  the	
  presence	
  of	
  a	
  Health	
  Request	
  form.	
  This	
  becomes	
   important	
  when	
  you	
  review	
  medical	
  response	
  times	
  to	
  youth	
   requests,	
  as	
  well	
  as	
  to	
  determine	
  if	
  youth	
  are	
  going	
  through	
   JCO	
  and	
  custodial	
  staff	
  in	
  order	
  to	
  be	
  seen	
  by	
  medical.	
  

	
  

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Sources	
  of	
   Information	
  
	
   	
   	
   	
  

Without	
  a	
  health	
  request	
  form	
  completed	
  by	
  the	
  youth	
  with	
   the	
  date,	
  there	
  is	
  no	
  way	
  to	
  know	
  if	
  the	
  nursing	
  assessment	
   completed	
  and	
  documented	
  in	
  the	
  progress	
  notes	
  was	
  the	
   result	
  of	
  a	
  medical	
  complaint	
  today	
  or	
  a	
  week	
  ago.	
  Also,	
  I	
   cannot	
  tell	
  if	
  the	
  youth	
  had	
  to	
  request	
  to	
  be	
  seen	
  by	
  medical	
   through	
  a	
  JCO	
  without	
  a	
  health	
  request	
  form	
  completed.	
  	
  The	
   location	
  of	
  the	
  health	
  call	
  boxes	
  in	
  common	
  areas	
  and	
   designated	
  pick	
  up	
  times	
  by	
  medical	
  staff	
  should	
  be	
  included	
   in	
  a	
  Standard	
  Operating	
  Procedure.	
  
• Review	
  of	
  ten	
  youth	
  health	
  records:	
  ID	
  #	
  216224,	
  215725,	
   211428,	
  215728,	
  214897,	
  217657,	
  217487,	
  215980,	
  217724,	
   and	
  216734;	
  email	
  correspondence	
  from	
  Dr.	
  Dedel.	
  

	
  

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SPECIAL	
  EDUCATION	
  
	
  
III.E.1	
  Provision	
  of	
  Special	
  Education.	
  The	
  State	
  shall,	
  at	
  all	
  times,	
  provide	
  all	
  youth	
  confined	
   at	
  the	
  facilities	
  with	
  adequate	
  special	
  education	
  in	
  compliance	
  with	
  the	
  Individuals	
  with	
   Disabilities	
  Education	
  Act	
  (IDEA),	
  20	
  U.S.C.	
  §	
  1400-­‐1482,	
  and	
  regulations	
  promulgated	
   thereunder,	
  and	
  this	
  Stipulation.	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

Prior	
  to	
  the	
  Monitor’s	
  visit,	
  the	
  State	
  was	
  asked	
  to	
  produce	
  data	
  and	
   explanations	
  for	
  a	
  limited	
  range	
  of	
  issues	
  related	
  to	
  the	
  three	
   education-­‐related	
  provisions	
  that	
  are	
  included	
  in	
  the	
  Amended	
   Stipulation.	
  The	
  first	
  provision	
  pertains	
  to	
  the	
  provision	
  of	
  special	
   education	
  services	
  in	
  general.	
  In	
  the	
  past,	
  the	
  key	
  compliance	
  issues	
   were	
  related	
  to	
  providing	
  education	
  services	
  to	
  youth	
  who	
  were	
   removed	
  from	
  school	
  during	
  the	
  day	
  or	
  who	
  were	
  held	
  on	
  the	
  unit	
  for	
   disciplinary	
  reasons.	
  	
   	
   In	
  the	
  past,	
  youth	
  who	
  exhibited	
  non-­‐compliant	
  behavior	
  in	
  the	
   classroom	
  could	
  be	
  suspended	
  from	
  school	
  and	
  returned	
  to	
  their	
   living	
  units	
  where	
  they	
  did	
  not	
  receive	
  education	
  services	
  of	
  any	
  kind.	
   The	
  State	
  ceased	
  suspending	
  students	
  in	
  June	
  2011,	
  relying	
  more	
   heavily	
  on	
  its	
  in-­‐school	
  suspension	
  room	
  (the	
  ABC	
  room)	
  and	
  a	
  newly	
   developed	
  procedure	
  for	
  Unit	
  Instruction.	
  	
   	
   The	
  ABC	
  room	
  allows	
  youth	
  an	
  opportunity	
  to	
  regain	
  control	
  of	
  their	
   behavior	
  and	
  to	
  be	
  returned	
  to	
  the	
  classroom	
  setting	
  without	
  going	
   back	
  to	
  their	
  living	
  units.	
  Between	
  February	
  and	
  mid-­‐September	
  2011,	
   262	
  students	
  were	
  referred	
  to	
  the	
  ABC	
  room	
  (approximately	
  33	
  per	
   month)	
  for	
  rule	
  violations	
  pertaining	
  to	
  offensive	
  or	
  threatening	
   conduct	
  or	
  being	
  outside	
  an	
  authorized	
  area.	
  Of	
  these,	
  approximately	
   95%	
  satisfactorily	
  completed	
  the	
  requirements	
  of	
  the	
  ABC	
  room	
  and	
   were	
  returned	
  to	
  their	
  classrooms.	
  Beginning	
  mid-­‐September,	
  a	
  Youth	
   Specialist	
  was	
  permanently	
  assigned	
  to	
  the	
  ABC	
  room,	
  which	
  should	
   strengthen	
  the	
  already	
  effective	
  program	
  model.	
  	
   	
   Over	
  the	
  past	
  six	
  months,	
  the	
  State	
  negotiated	
  an	
  agreement	
  with	
  the	
   Parties	
  to	
  the	
  S.H.	
  lawsuit	
  regarding	
  the	
  delivery	
  of	
  education	
  services	
   to	
  youth	
  who	
  are	
  confined	
  to	
  the	
  living	
  units	
  for	
  disciplinary	
  reasons.	
   Beginning	
  in	
  July	
  2011,	
  students	
  in	
  seclusion	
  must	
  now	
  receive	
   instruction	
  from	
  a	
  certified	
  teacher	
  four	
  times	
  per	
  day,	
  for	
  at	
  least	
  30	
   minutes	
  per	
  visit	
  (i.e.,	
  Unit	
  Instruction).	
  While	
  the	
  facility	
  asserted	
   that	
  students	
  received	
  the	
  services	
  as	
  required,	
  problems	
  with	
  the	
   data	
  tracking	
  system	
  for	
  these	
  services	
  prevented	
  their	
  producing	
   data	
  to	
  verify	
  this	
  assertion.	
  	
  

	
  

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Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 100 of 104 PAGEID #: 1963

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

When	
  interviewed,	
  youth	
  reported	
  short	
  stays	
  in	
  the	
  ABC	
  room	
  and	
   the	
  opportunity	
  to	
  talk	
  through	
  their	
  issues	
  with	
  staff.	
  Many	
  of	
  those	
   who	
  had	
  spent	
  time	
  in	
  disciplinary	
  seclusion	
  reported	
  that	
  they	
  did	
   not	
  receive	
  instruction	
  from	
  teachers	
  or	
  work	
  packets	
  during	
  the	
  time	
   in	
  their	
  room.	
  An	
  attempt	
  was	
  made	
  to	
  verify	
  these	
  claims	
  using	
  the	
   Unit	
  Instruction	
  binder	
  maintained	
  by	
  the	
  school,	
  but	
  as	
  reported	
  by	
   the	
  Assistant	
  Principal,	
  many	
  of	
  the	
  records	
  were	
  missing	
  or	
   incomplete.	
  Although	
  these	
  data	
  are	
  therefore	
  not	
  sufficient	
  to	
   demonstrate	
  compliance	
  with	
  this	
  provision,	
  the	
  Unit	
  Instruction	
   paperwork	
  and	
  process	
  appear	
  to	
  be	
  sufficient	
  to	
  the	
  task	
  once	
  fully	
   implemented	
  (i.e.,	
  data	
  is	
  captured	
  for	
  all	
  youth	
  in	
  seclusion,	
  every	
   school	
  day).	
  	
   	
   Since	
  my	
  last	
  visit,	
  the	
  facility	
  began	
  to	
  operate	
  a	
  maximum-­‐security	
   segregation	
  unit,	
  the	
  PROGRESS	
  Unit.	
  This	
  unit	
  consists	
  of	
  two	
  18-­‐bed	
   housing	
  units.	
  Students	
  on	
  the	
  PROGRESS	
  unit	
  attend	
  school	
   separately	
  from	
  the	
  general	
  population,	
  in	
  two	
  mobile	
  units	
   specifically	
  dedicated	
  for	
  this	
  purpose.	
  The	
  classrooms	
  are	
  well	
   appointed	
  and	
  sufficiently	
  spacious	
  to	
  serve	
  students	
  from	
  both	
  units.	
  	
   	
   To	
  assess	
  the	
  extent	
  to	
  which	
  youth	
  on	
  the	
  PROGRESS	
  units	
  have	
   access	
  to	
  the	
  education	
  program,	
  attendance	
  records	
  for	
  the	
  two	
   weeks	
  following	
  the	
  October	
  Intersession	
  were	
  reviewed.	
  These	
   records	
  revealed	
  very	
  sporadic	
  attendance.	
  On	
  both	
  units,	
  school	
  was	
   held	
  on	
  the	
  unit	
  for	
  3	
  of	
  the	
  10	
  days.	
  It	
  is	
  unknown	
  whether	
  youth	
   received	
  services	
  in	
  their	
  rooms,	
  or	
  whether	
  instruction	
  complied	
   with	
  the	
  Unit	
  Instruction	
  format	
  recently	
  developed	
  with	
  the	
  S.H.	
   monitors.	
  	
   	
   Attendance	
  for	
  the	
  remaining	
  7	
  days	
  was	
  coded	
  using	
  the	
  following	
   schema:	
  a	
  youth	
  was	
  considered	
  to	
  have	
  been	
  “present”	
  for	
  the	
  day	
  if	
   he	
  attended	
  at	
  least	
  3	
  of	
  the	
  4	
  academic	
  classes.	
  A	
  youth	
  was	
   considered	
  to	
  have	
  been	
  “excused”	
  for	
  the	
  day	
  if	
  he	
  was	
  excused	
   from	
  2	
  or	
  more	
  academic	
  periods.	
  A	
  youth	
  was	
  considered	
  to	
  be	
   “unexcused”	
  for	
  the	
  day	
  if	
  he	
  refused	
  or	
  was	
  removed	
  from	
  2	
  or	
  more	
   academic	
  periods.	
  	
   	
   Of	
  the	
  12	
  youth	
  on	
  the	
  Sycamore	
  unit,	
  only	
  one	
  youth	
  was	
  considered	
   “present”	
  for	
  all	
  7	
  days.	
  Another	
  youth	
  was	
  present	
  for	
  4	
  of	
  the	
  7	
   days.	
  The	
  remaining	
  10	
  youth	
  (83%	
  of	
  Sycamore	
  youth)	
  were	
  present	
   on	
  2	
  or	
  fewer	
  days.	
  Equal	
  proportions	
  had	
  “excused”	
  and	
   “unexcused”	
  absences.	
  	
   	
   Of	
  the	
  11	
  youth	
  on	
  the	
  Cedar	
  unit,	
  four	
  youth	
  were	
  considered	
   “present”	
  for	
  6	
  or	
  7	
  of	
  the	
  days.	
  The	
  remaining	
  7	
  youth	
  (64%	
  of	
  Cedar	
  

	
  

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youth)	
  were	
  present	
  on	
  2	
  or	
  fewer	
  days,	
  with	
  2	
  of	
  those	
  never	
   attending	
  school	
  at	
  all.	
  Equal	
  proportions	
  had	
  “excused”	
  and	
   “unexcused”	
  absences.	
  	
   	
   Clearly,	
  additional	
  work	
  is	
  needed	
  to	
  increase	
  the	
  level	
  of	
  attendance	
   at	
  school	
  among	
  PROGRESS	
  youth.	
  First,	
  the	
  reasons	
  underlying	
  the	
   high	
  rates	
  of	
  excused	
  absences	
  should	
  be	
  reviewed	
  to	
  determine	
  if	
   these	
  activities	
  could	
  be	
  scheduled	
  in	
  a	
  way	
  that	
  does	
  not	
  conflict	
   with	
  the	
  school	
  day.	
  Second,	
  the	
  incentives	
  for	
  school	
  attendance	
  and	
   the	
  consequences	
  for	
  refusing	
  should	
  be	
  reviewed	
  to	
  determine	
  how	
   to	
  make	
  school	
  attendance	
  more	
  compelling	
  to	
  youth	
  on	
  the	
   PROGRESS	
  units.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Document	
  the	
  provision	
  of	
  Unit	
  Instruction	
  to	
  all	
  youth	
  held	
  in	
   disciplinary	
  isolation.	
  This	
  instruction	
  should	
  include	
  four	
  daily	
   visits	
  of	
  at	
  least	
  30	
  minutes	
  each	
  by	
  certified	
  teachers.	
  Audit	
   these	
  data	
  on	
  a	
  monthly	
  basis	
  to	
  ensure	
  sustained	
  compliance	
   with	
  the	
  requirements	
  of	
  this	
  provision	
  and	
  the	
  S.H.	
   Agreement.	
  	
  
2. Increase	
  the	
  level	
  of	
  attendance	
  at	
  school	
  among	
  youth	
  on	
   the	
  PROGRESS	
  units.	
  	
  
3. Reach	
  substantial	
  compliance	
  with	
  the	
  other	
  two	
  education-­‐ related	
  provisions	
  in	
  the	
  Amended	
  Stipulation.	
  	
  

Sources	
  of	
   Information	
  
	
   	
  

• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.1,	
  prepared	
  at	
  my	
  request	
  
• Interviews	
  with	
  n=20	
  general	
  population	
  youth	
  conducted	
  by	
   the	
  DOJ	
  attorney	
  in	
  late	
  October	
  2011,	
  along	
  with	
  interviews	
   with	
  n=29	
  youth	
  on	
  the	
  PROGRESS	
  units	
  conducted	
  by	
  the	
   Monitor	
  and	
  DOJ	
  attorney	
  in	
  October	
  2011	
  
• Unit	
  Instruction	
  binder	
  maintained	
  by	
  Scioto	
  school	
   administrators	
  
• Attendance	
  records	
  for	
  Cedar	
  and	
  Sycamore	
  units,	
  October	
  18	
   through	
  31,	
  2011	
  	
  
	
  

	
  

101	
  

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III.E.7	
  Individual	
  Education	
  Plans.	
  (a)	
  The	
  State	
  shall	
  develop	
  an	
  IEP	
  as	
  defined	
  in	
  34	
  C.F.R.	
   §300.320	
  for	
  each	
  youth	
  who	
  qualifies	
  for	
  an	
  IEP.	
  Following	
  development	
  of	
  the	
  IEP,	
  the	
   State	
  shall	
  implement	
  the	
  IEP	
  as	
  soon	
  as	
  possible.	
  As	
  part	
  of	
  satisfying	
  this	
  requirement,	
  the	
   State	
  shall	
  conduct	
  required	
  annual	
  reviews	
  of	
  IEPs,	
  adequately	
  document	
  the	
  provision	
  of	
   special	
  education	
  services,	
  and	
  comply	
  with	
  requirements	
  regarding	
  participation	
  by	
  the	
   professional	
  staff,	
  parents	
  and	
  student	
  in	
  the	
  IEP	
  process.	
  The	
  State	
  shall,	
  if	
  necessary,	
   develop,	
  review	
  or	
  revise	
  IEPs	
  for	
  qualified	
  special	
  education	
  students;	
  (b)	
  In	
  developing	
  or	
   modifying	
  the	
  IEP,	
  the	
  State	
  shall	
  ensure	
  that:	
  the	
  IEP	
  reflects	
  the	
  individualized	
  educational	
   needs	
  of	
  the	
  youth	
  and	
  that	
  services	
  are	
  provided	
  accordingly;	
  each	
  IEP	
  includes	
   documentation	
  of	
  the	
  team’s	
  consideration	
  of	
  the	
  youth’s	
  need	
  for	
  related	
  services	
  and	
   transition	
  planning,	
  and	
  identifies	
  the	
  party	
  responsible	
  for	
  providing	
  such	
  transition	
   services;	
  the	
  student’s	
  educational	
  progress	
  in	
  monitored;	
  teachers	
  are	
  trained	
  on	
  how	
  to	
   monitor	
  progress	
  toward	
  IEP	
  goals	
  and	
  objectives;	
  and	
  teachers	
  understand	
  and	
  use	
   functional	
  behavioral	
  assessment	
  and	
  behavior	
  intervention	
  programs	
  in	
  IEP	
  planning	
  and	
   implementation.	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

The	
  State	
  provided	
  data	
  on	
  youth	
  recently	
  admitted	
  to	
  the	
  facility	
  in	
   July,	
  August	
  and	
  September	
  2011.	
  A	
  total	
  of	
  17	
  special	
  education	
   students	
  were	
  admitted,	
  9	
  of	
  whom	
  entered	
  the	
  facility	
  with	
  an	
   expired	
  IEP.	
  These	
  student’s	
  IEPs	
  were	
  updated	
  in	
  a	
  timely	
  manner	
  (or	
   scheduled	
  to	
  be	
  updated,	
  for	
  those	
  admitted	
  in	
  September).	
  The	
   other	
  students’	
  IEPs	
  were	
  either	
  adopted	
  or	
  an	
  IEP	
  meeting	
  was	
   schedule	
  to	
  correct	
  deficiencies	
  on	
  the	
  incoming	
  documents.	
  	
   	
   According	
  to	
  the	
  facility’s	
  self-­‐assessment,	
  a	
  total	
  of	
  22	
  students’	
  IEPs	
   were	
  updated	
  in	
  the	
  previous	
  90	
  days.	
  All	
  of	
  the	
  meetings	
  included	
   the	
  required	
  participants;	
  82%	
  of	
  the	
  IEPs	
  adequately	
  described	
  the	
   students’	
  present	
  levels	
  of	
  performance;	
  approximately	
  70%	
  included	
   measurable	
  goals	
  that	
  were	
  clearly	
  articulated;	
  and	
  all	
  of	
  the	
  IEPs	
   described	
  the	
  transition	
  resources	
  to	
  be	
  mobilized	
  on	
  behalf	
  of	
   students	
  (although	
  about	
  30%	
  needed	
  to	
  identify	
  the	
  staff	
  persons	
   responsible	
  for	
  assisting	
  the	
  students).	
  	
   	
   My	
  last	
  report	
  expressed	
  concerns	
  about	
  teachers’	
  failing	
  to	
  monitor	
   student	
  progress	
  and	
  prepare	
  IEP	
  progress	
  reports	
  at	
  the	
  conclusion	
   of	
  each	
  grading	
  period.	
  Facilitating	
  students’	
  progress	
  through	
  the	
   curriculum	
  is	
  the	
  entire	
  point	
  of	
  special	
  education,	
  and	
  without	
   assessing	
  progress,	
  the	
  program	
  cannot	
  identify	
  whether	
  it	
  is	
  meeting	
   students’	
  special	
  education	
  needs.	
  The	
  State	
  reported	
  that	
  progress	
   reports	
  were	
  drafted	
  for	
  each	
  of	
  the	
  64	
  students	
  who	
  were	
  at	
  Scioto	
   at	
  the	
  end	
  of	
  a	
  grading	
  period	
  in	
  July-­‐September	
  2011.	
  This	
  is	
  a	
   significant	
  improvement	
  from	
  the	
  rates	
  observed	
  in	
  the	
  previous	
   report.	
  However,	
  the	
  facility’s	
  audit	
  of	
  the	
  content	
  of	
  these	
  reports	
  

	
  

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Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 103 of 104 PAGEID #: 1966

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  
Recommendations	
   Sources	
  of	
   Information	
   	
   	
  

indicated	
  that	
  63%	
  lacked	
  specific	
  data	
  related	
  to	
  the	
  goals	
  listed	
  on	
   the	
  IEP.	
  Non-­‐specific	
  indicators	
  of	
  student	
  progress	
  (e.g.,	
  “Completes	
   work”	
  “Adequate	
  progress”)	
  offer	
  little	
  to	
  the	
  assessment	
  of	
  whether	
   the	
  student	
  is	
  acquiring	
  the	
  skills	
  needed	
  to	
  progress	
  through	
  the	
   curriculum.	
  	
  
A	
  random	
  sample	
  of	
  four	
  IEPs	
  (18%	
  of	
  the	
  22	
  IEPs	
  revised	
  in	
  the	
   previous	
  90	
  days)	
  was	
  reviewed	
  to	
  verify	
  the	
  findings	
  of	
  the	
  self-­‐ assessment.	
  In	
  all	
  cases,	
  portions	
  of	
  the	
  IEPs	
  were	
  extremely	
  well	
   written.	
  The	
  description	
  of	
  the	
  student’s	
  present	
  levels	
  of	
   performance	
  was	
  connected	
  to	
  goals	
  in	
  each	
  area	
  and	
  led	
  to	
  a	
  clear	
   roadmap	
  for	
  supporting	
  students	
  in	
  the	
  regular	
  or	
  special	
  education	
   classrooms.	
  	
   	
   A	
  set	
  of	
  progress	
  reports	
  from	
  the	
  most	
  recent	
  grading	
  period	
  (ending	
   September	
  2011)	
  was	
  reviewed	
  for	
  four	
  special	
  education	
  students.	
   Their	
  quality	
  was	
  inconsistent—some	
  student’s	
  progress	
  reports	
  were	
   well-­‐written	
  and	
  featured	
  specific	
  data	
  to	
  describe	
  the	
  youth’s	
   progress,	
  but	
  others	
  were	
  not	
  updated	
  or	
  were	
  vague	
  and	
  lacked	
   specific	
  indicators	
  of	
  progress	
  that	
  reflected	
  each	
  goal.	
  These	
  findings	
   mirror	
  those	
  of	
  the	
  State’s	
  self-­‐assessment.	
  	
   	
   So,	
  while	
  the	
  teachers	
  have	
  shown	
  great	
  improvement	
  in	
  complying	
   with	
  progress	
  reporting	
  requirements,	
  the	
  content	
  of	
  those	
  progress	
   reports	
  needs	
  to	
  be	
  grounded	
  in	
  data	
  that	
  are	
  responsive	
  to	
  the	
  way	
   in	
  which	
  the	
  goals	
  were	
  articulated.	
  If	
  the	
  incoming	
  IEP	
  did	
  not	
   articulate	
  measurable	
  goals,	
  the	
  IEP	
  must	
  be	
  revised	
  upon	
  admission.	
   Particularly	
  now	
  that	
  youth	
  are	
  committed	
  to	
  Scioto	
  are	
  likely	
  to	
   spend	
  significant	
  periods	
  of	
  time	
  there,	
  the	
  facility	
  must	
  improve	
  its	
   practices	
  around	
  measuring	
  student	
  progress	
  in	
  order	
  to	
  maximize	
   the	
  ability	
  of	
  the	
  special	
  education	
  program	
  to	
  meet	
  students’	
  needs.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Ensure	
  that	
  the	
  content	
  of	
  IEP	
  progress	
  reports	
  is	
  grounded	
  in	
   data	
  that	
  are	
  responsive	
  to	
  a	
  set	
  of	
  realistic,	
  measurable	
  IEP	
   goals.	
  If	
  needed,	
  update	
  incoming	
  IEPs	
  to	
  ensure	
  that	
   students’	
  goals	
  are	
  properly	
  articulated.	
  	
  
• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.7,	
  prepared	
  at	
  my	
  request	
  
• Review	
  of	
  n=4	
  IEPs	
  of	
  current	
  Scioto	
  students’	
  IEPs	
  and	
   progress	
  reports	
  from	
  the	
  most	
  recent	
  grading	
  period	
  
	
  

	
  

103	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 104 of 104 PAGEID #: 1967

	
  
III.E.8	
  Vocational	
  Education.	
  The	
  State	
  shall	
  provide	
  appropriate	
  vocational	
  services	
  that	
  are	
   required	
  transition	
  services	
  for	
  disabled	
  youth	
  under	
  the	
  IDEA.	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

The	
  State	
  submitted	
  data	
  on	
  student	
  enrollment	
  in	
  the	
  three	
   currently	
  available	
  vocational	
  classes.	
  Of	
  the	
  168	
  youth	
  at	
  Scioto:	
  
• 22	
  students	
  (18	
  boys,	
  4	
  girls;	
  13%	
  of	
  the	
  population)	
  are	
   enrolled	
  in	
  Administrative	
  Office	
  Technology;	
  
• 10	
  students	
  (5	
  boys,	
  5	
  girls;	
  6%	
  of	
  the	
  population)	
  are	
  enrolled	
   in	
  Career-­‐Based	
  Intervention	
  (a	
  work	
  program	
  that	
  includes	
   Math	
  and	
  English	
  courses);	
  and	
  	
  
• 23	
  students	
  (18	
  boys,	
  5	
  girls;	
  13%	
  of	
  the	
  population)	
  are	
   enrolled	
  in	
  Transition	
  Skills.	
  
	
   The	
  State	
  also	
  provided	
  information	
  on	
  a	
  recently	
  established	
   community	
  partnership.	
  This	
  partnership	
  will	
  allow	
  both	
  students	
  and	
   graduates	
  to	
  obtain	
  industry-­‐standard	
  certificates	
  in	
  restaurant	
   hospitality,	
  customer	
  service,	
  and	
  OSHA	
  regulations.	
  Other	
  courses	
   may	
  be	
  added	
  depending	
  on	
  student	
  needs	
  and	
  interests.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Opportunities	
  for	
  students	
  to	
  develop	
  job	
  skills	
  are	
  very	
  limited,	
  with	
   less	
  than	
  half	
  of	
  Scioto	
  students	
  participating	
  in	
  any	
  meaningful	
   vocational	
  coursework	
  or	
  employment	
  experience.	
  The	
  community	
   partnership	
  is	
  very	
  promising	
  and,	
  if	
  implemented	
  as	
  designed,	
  should	
   provide	
  sufficient	
  program	
  slots	
  to	
  meet	
  demand	
  and	
  should	
  offer	
   valuable	
  job	
  skill	
  development	
  and	
  work	
  experience.	
  Once	
  this	
   program	
  is	
  implemented,	
  the	
  State	
  will	
  need	
  to	
  develop	
  additional	
   self-­‐assessment	
  measures	
  to	
  capture	
  the	
  relevant	
  data.	
  Technical	
   assistance	
  toward	
  this	
  end	
  is	
  available	
  upon	
  request.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Develop	
  sufficient	
  vocational	
  opportunities	
  to	
  engage	
  all	
   students	
  in	
  meaningful	
  job	
  skill	
  development	
  and/or	
  work	
   experience.	
  	
  

Sources	
  of	
   Information	
  
	
  

• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.8,	
  prepared	
  at	
  my	
  request	
  

	
  

104	
  

 Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 1 of 109 PAGEID #: 2072
U.S. Department of Justice v. The State of Ohio
Civil Action No: 2:08-cv-475 Monitor’s Second Report on the Amended Stipulation dated June 28, 2011
Kelly Dedel, Ph.D., Lead Monitor Daphne Glindmeyer, M.D., Subject Matter Expert Michelle Staples-Horne, M.D., Subject Matter Expert One in 37 Research, Inc. 16 Rock Street Cody, WY 82414 (503)799-0915 kelly.dedel@gmail.com
Draft Submitted May 25, 2012 Final Submitted June 22, 2012

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 2 of 109 PAGEID #: 2073

TABLE OF CONTENTS
Introduction ....................................................................................................... 3 Executive Summary.............................................................................................. 4
Protection from Harm..................................................................................................................................... 12 General Protection From Harm .................................................................................................................. 12 Seclusion.................................................................................................................................................... 18 Investigation of Serious Incidents.............................................................................................................. 25 Grievances ................................................................................................................................................. 29 Grievances Explained to Youth .................................................................................................................. 32 Structured Programming ........................................................................................................................... 34 Orientation ................................................................................................................................................. 38
Mental Health Services .......................................................................................................................... 41 Mental Health Screening ........................................................................................................................... 41 Immediate Referral to QMHP .................................................................................................................... 43 Identification of Previously Unidentified Youth.......................................................................................... 45 Mental Health Assessment........................................................................................................................ 47 Adequate Care and Treatment.................................................................................................................. 50 Treatment Planning................................................................................................................................... 54 Treatment Teams ...................................................................................................................................... 55 Integrated Treatment Plans ...................................................................................................................... 58 Access to QMHP........................................................................................................................................ 60 Mental Health Involvement in Housing and Placement............................................................................. 63 Staffing...................................................................................................................................................... 66 Medication Notice ..................................................................................................................................... 70 Mental Health Medications........................................................................................................................ 72 MH/DD Training for Direct Care Staff ........................................................................................................ 76 Staff Mental Health Training...................................................................................................................... 77 Suicide Prevention .................................................................................................................................... 80 Transition Planning ................................................................................................................................... 83 Oversight of Mental Health ....................................................................................................................... 86
Documentation .......................................................................................................................................... 89 Progress Notes ......................................................................................................................................... 89 Accessibility of Information ....................................................................................................................... 90
Medical Services ...................................................................................................................................... 91 General Medical Care ................................................................................................................................ 91 Health Records ......................................................................................................................................... 95 Access to Health Systems ......................................................................................................................... 97
Special Education Services .................................................................................................................. 99 Provision of Special Education.................................................................................................................. 99 Individual Education Plans ...................................................................................................................... 103 Vocational Education .............................................................................................................................. 108

	
  

2.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 3 of 109 PAGEID #: 2074
INTRODUCTION
On June 4, 2008, The United States Department of Justice (DOJ) and the State of Ohio (the State) signed a stipulation for injunctive relief (the Stipulation) concerning conditions at the Scioto Juvenile Correctional Facility (Scioto) and the Marion Juvenile Correctional Facility (Marion; which was closed shortly after the Stipulation was signed). Fred Cohen, the Lead Monitor of the concurrent conditions of confinement lawsuit, S.H. v Reed et al., served as the monitor for the Stipulation until late 2009. At that point, Mr. Cohen resigned and the DOJ assumed the role of Monitor, with Dr. Kelly Dedel, Dr. Daphne Glindmeyer, and Dr. Michelle Staples-Horne serving as subject matter experts.
As the original stipulation expired, the Parties recognized that the State had not yet reached substantial compliance with several key portions of the Stipulation. Thus, the Stipulation was renegotiated to include a subset of the original provisions. The Amended Stipulation terminates when the State has achieved substantial compliance with each provision and has maintained substantial compliance for two reporting periods (i.e., 12 months). The Parties also agreed that the Amended Stipulation is subject to the termination provisions of the Prison Litigation Reform Act.
The Monitor for the Amended Stipulation is Dr. Kelly Dedel, who evaluates the State’s progress in the areas of Protection From Harm, Grievances, Programming and Special Education. She is assisted by two Subject Matter Experts, Dr. Daphne Glindmeyer, who evaluates the State’s progress on provisions related to Mental Health Services, and Dr. Michelle Staples-Horne, who evaluates the State’s progress on provisions related to Medical Care.
As the Monitor, Dr. Dedel is the primary liaison between the Monitoring Team and the Parties and she compiles the Monitor’s Report. To do so, she combines Drs. Glindmeyer’s and Staples-Horne’s reports with her own to form a coherent whole, but does not change the substance of the reports by either of the Subject Matter Experts, who are responsible for forming their own opinions about the level of compliance for each provision in their areas of expertise.
This is the Monitor’s second report on the State’s progress toward the reforms required by the Amended Stipulation. The monitoring period is October 1, 2011 through March 31, 2012. Progress reports will be issued approximately every six months hereafter.

	
  

3.

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EXECUTIVE SUMMARY
The Amended Stipulation includes 33 provisions related to Protection From Harm (n=3); Grievances (n=2); Programming (n=2); Mental Health Care (n=18) and Documentation (n=2); Medical Care (n=3); and Special Education (n=3). Each provision is listed in the table below, along with the Monitor’s or Subject Matter Expert’s compliance rating.
The Monitor’s first report used only two compliance levels: substantial compliance and non-compliance. This report uses a three-tiered system (substantial compliance, partial compliance and non-compliance), defined as follows:
· Substantial Compliance means that the facility has drafted relevant policies and procedures; has trained the staff responsible for implementation; has sufficient staff to implement the required reform; has demonstrated the ability to properly implement the procedures during the majority of the monitoring period; and has ascertained that the procedures accomplish the outcome envisioned by the provision. Non-compliance with mere technicalities or a temporary failure to comply (due to staff vacancy or illness, facility disruptions, or other short-term events) during an otherwise sustained period of compliance do not constitute a failure to achieve or maintain substantial compliance. Conversely, temporary compliance during a period of sustained non-compliance does not constitute substantial compliance.
· Partial Compliance means that the facility has drafted policies and procedures, has trained staff responsible for implementation, and has sufficient staff to implement the required reform. While progress has been made toward implementing the procedures described by policy, performance has been inconsistent throughout the monitoring period and additional modifications are needed to ensure that procedures are sufficiently comprehensive to translate policy into practice.
· Non-Compliance means that the facility has made only very preliminary efforts to implement the required reform, but significant work remains. Policy may need to be overhauled, the majority of staff may need to be trained, procedures may not have been developed, and no one has begun to ascertain whether the procedures accomplish the outcome envisioned by the provision.

The Monitor does not intend to change the meaning, spirit or requirements of the Stipulation in any way. Rather, the rating scheme was expanded in an effort to better recognize the State’s progress (which is essential for staff morale during long-term reform efforts), to provide an easy mechanism for determining which provisions will require the greatest amount of time and effort to reach substantial compliance, and to promote greater compatibility with the S.H. v. Reed, et al. Monitor’s report on Scioto, which also uses a three-tiered system. In order to highlight the areas in which progress has been made or slippage has been noted, the Monitor and subject matter experts revised the compliance levels from the first report, using the new three-tiered system. Both ratings are presented in the chart below. Ratings that were upgraded since the previous Monitor’s Report are presented in green; ratings that were downgraded are presented in red.
The DOJ disagrees with this change, particularly the revisions to the compliance levels for the Monitor’s First Report (used as the basis for comparison to the current compliance ratings in the table below). While the Monitor recognizes that the Parties did not have an opportunity to comment on the revised compliance

	
  

4.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 5 of 109 PAGEID #: 2076
levels, the Monitor believes that using a revised rating provides a more accurate sense of whether the State has made progress since the prior reporting period. Otherwise, many provisions would show a NonCompliance rating for the first monitoring period (although the provision would have been rated in Partial Compliance had the three-tiered system been in use), and then would appear to have been promoted to Partial Compliance when, in reality, the level of compliance remains the same. The Monitor apologizes for the disruption caused by this mid-course correction, but truly believes it is the best course of action to support the State’s progress in complying with the Stipulation.

	
  

5.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 6 of 109 PAGEID #: 2077

Table 1. Compliance Ratings for Each Provision

No.

Provision

Protection From Harm

III.A. 1

General Protection From Harm

III.A.3

Seclusion

III.A.5

Investigation of Serious Incidents

III.D.1

Grievances

III.D.2

Grievances Explained to Youth

III.F.1

Structured Programming

III.F.2

Orientation

Mental Health Services

III.B.1

Mental Health Screening

III.B.2

Immediate Referral to QMHP

III.B.3

Identification of Previously Unidentified Youth

III.B.4

Mental Health Assessment

III.B.5

Adequate Care and Treatment

III.B.6

Treatment Planning

III.B.7

Treatment Teams

III.B.8

Integrated Treatment Plans

III.B.9

Access to QMHP

III.B.10

Mental Health Involvement in Housing and Plcmt

III.B.11

Staffing

III.B.12

Medication Notice

III.B.13

Mental Health Medications

III.B.14

MH/DD Training for Direct Care Staff

III.B.15

Staff Mental Health Training

III.B.16

Suicide Prevention

III.B.17

Transition Planning

III.B.18

Oversight of Mental Health

III.G.1

Progress Notes

III.G.2

Accessibility of Information

	
  

1st Report (revised)
NC NC SC PC PC NC PC
PC PC NC NC NC NC PC NC NC NC NC PC PC NC PC PC PC NC PC NC

2nd Report
PC PC PC PC SC NC PC
PC PC PC PC PC PC PC PC PC PC PC PC PC NC PC PC PC NC PC NC 	
  

	
  

6.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 7 of 109 PAGEID #: 2078

Medical Services

III.C.1

General Medical Care

III.C.2

Health Records

III.C.5

Access to Health Services

Special Education Services

III.E.1

Provision of Special Education

III.E.7

Individual Education Plans

III.E.8

Vocational Education

SC

PC

SC

PC

SC

SC

PC

PC

PC

PC

NC

NC

Overall, the State is in substantial compliance with 2 of the 33 provisions (6%), in partial compliance with 26 provisions (79%) and in non-compliance with 5 provisions (15%). As noted earlier, the Monitor and subject matter experts revised the ratings from the previous monitoring period using the three-tiered system, so that comparisons could be made. Across the 33 provisions, the compliance rating was upgraded for 11 provisions (33%) and downgraded for 3 provisions (9%). Compliance ratings for each section and key issues to be addressed are highlighted below.
Protection from Harm (includes Grievances and Programming)
The facility is in substantial compliance with 1 of the 7 provisions (14%) related to protecting youth from harm. It is in non-compliance with the provision related to Structured Programming. The following actions should be prioritized:
• Continue to utilize aggregate data on youth violence to identify trends that threaten youth and staff safety. Identify the underlying causes of youth violence and develop targeted violence prevention strategies to address the factors that contribute to assaultive behavior among youth.
• Ensure that adequate numbers of well-trained staff are present on each unit so that youth do not endure unnecessary seclusion and have access to the full range of academic, rehabilitative and other structured programming.
• Launch the planned initiative to expand the conversation surrounding the allegations by some of the female residents that a few staff engage in sexually inappropriate talk and behavior. Reinforce the prohibition against this type of behavior with staff and ensure staff know how to recognize and respond to such behavior.
• Revisit the duration of pre-hearing seclusion prescribed by the IRAV to ensure that youth remain in pre-hearing seclusion no longer than necessary to de-escalate their behavior and ensure they do not pose a threat to the safety of other youth or staff.
• Limit the use of disciplinary seclusion, relying instead on sanctions that provide an opportunity for skill-development and treatment in order to create behavior change.
• Operate the PROGRESS Unit as it was designed, adhering to the prescribed limits on a youth’s time in cell (i.e., address staff shortages, design a strategy to address the interference of Phase 1 youth movement on Phase 2 youth’s time out of cell; facilitate youth’s advancement through the phases and to the Transition Unit with quality treatment plans and progress reporting). Ensure

	
  

7.

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that PROGRESS youth have access to intensive programming and support that addresses their violent behavior. Finalize the PROGRESS Unit’s policy and Youth Handbook. • Address the serious deficits in the quality of investigations that are conducted by facility staff. • Ensure grievances are resolved in a timely manner and are supported by appropriate documentation, attached to the grievance. • Fully implement the process for notifying youth of the outcome of any investigation referred by the grievance process. • Develop an appropriately focused rehabilitative program for youth who have graduated from High School or obtained their GED. Include both post-secondary educational opportunities and job skills and vocational training.
Mental Health Services
The facility is not in substantial compliance with any (0%) of the 20 provisions related to mental health services and documentation. It is in partial compliance with 17 (85%) of the provisions and in noncompliance with 3 of the provisions (15%). The following actions are required:
• ODYS has recently completed a collaborative policy and procedure review and revision process. These policies are currently in the process of review by the Monitors in both this case and S.H. v. Reed. The policies must be completed and implemented.
• The facility must be staffed with sufficient psychiatric (both psychiatric physicians and psychiatric nurses) resources to provide psychiatric evaluation, medication monitoring, and treatment team interaction.
• Develop an organized training schedule for mental health staff. • Train direct care staff and mental health staff to understand the behavior and needs of youth with
mental illnesses and developmental disabilities and recognize and respond to signs and symptoms of serious mental illness. • Train mental health staff to develop high-quality case conceptualizations that integrate the information generated by the multiple assessments administered to youth upon admission. • Train, coach and adequately supervise direct care staff and mental health staff to implement the Phoenix New Freedom curriculum, particularly in skills for leading group therapy sessions to ensure the interactions and documentation reflect generally accepted practices for mental health care. This should include treatment integrity checks (e.g. observation of group interaction with subsequent education and training as necessary). • Develop procedures to ensure, and to document, that youth are assessed by a qualified mental health professional within 12 hours when a serious risk to the youth’s safety is identified. • Ensure mental health staff assesses youth on suicide precautions, those in seclusion, and those on the Progress Units every 24 hours. • Ensure youth with acute mental illnesses requiring extensive mental health treatment have access to more appropriate placements. • Ensure treatment plans are individualized including measurable goals and targeted interventions to address the goals. Update treatment plans regularly and monitor youth’s progress toward achieving treatment goals. Adapt treatment plans for youth who are not progressing.

	
  

8.

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• Ensure Interdisciplinary Treatment Team meetings include representatives from the major sectors of the facility including social workers, direct care staff and psychiatrists and that Treatment Teams are focused on treatment issues and the youth’s progress toward treatment goals.
• Ensure youth on the Progress Units are appropriate for the secure setting and receive appropriate treatment. Conduct thorough assessments of all youth proposed for placement in the future.
• Continue the current practice of assigning all youth housed in the Progress Units to the mental health caseload.
• Ensure youth receive proper laboratory examinations and side-effect monitoring commensurate with the psychotropic medications prescribed and reflecting generally accepted practices.
• Develop a coherent, coordinated quality assurance process that provides a cogent review of social work, psychological and psychiatric services at the facility. This should include peer review. It should also include both process and outcome measures.
• Address limitations to treatment resulting from the fragmented recordkeeping process via the creation of a unified record.

Medical Services
The facility is in substantial compliance with one of the provisions (33%) related to medical services and in partial compliance with the other 2 provisions (66%). The provisions related to General Medical Care and Health Records were downgraded to partial compliance.
During this assessment period, the Scioto facility for the most part ensured that youth received routine, preventive, medical and care consistent with current, generally accepted professional standards. Concerns identified during this period were a result of being on site at the facility as opposed to only an off-site medical record review and the charts reviewed on this audit. The Subject Matter Expert’s concern is whether youth were being adequately assessed while in seclusion for very long periods of time and after fight-related injuries occurred. Many times youth are refusing to be seen by the nurse after a fight or use of restraints or the nurse completes an assessment with the youth still inside the cell. Youth assessments should be done at a time that youth is cooperative enough to conduct an adequate face-to-face examination including vital signs. It is unacceptable to conduct clinical assessments on youth while they are still inside their cell. Policy time frames may need to be adjusted to allow a later assessment in these cases. This is also why the Subject Matter Expert recommended the addition of a satellite clinic and medication room for the Buckeye units. It is often difficult to get these youth down to the main medical clinic for an adequate medical evaluation.
The Subject Matter Expert had no concerns about individuals with health problems being identified at intake, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care. There were no concerns regarding dental care. With the exception of one unit that failed to have the health request slips out next to the drop box, the facility was ensuring that youth could request to be seen by medical staff confidentially and independent from JCOs and custodial staff. The health call slips are kept in a separate binder rather than the medical record. A self-assessment is needed to be sure all health requests from the slips are addressed within each youth’s medical record progress notes.
The health record is still fragmented due to the psychological and counseling notes being housed separately on the housing units. However, after the site visit and observation of the facility layout, it would

	
  

9.

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be impractical to have a combined physical health record. It is imperative that an electronic health record is established for the sharing of the mental health and medical information by expansion of the existing mental health database to include pertinent health data, and if not, purchase of a new electronic medical record computer program.
Policies, procedures and forms reviewed for the March 2012 effective date were very good. There were cases were the effective date had not been revised to show as current. All policies should be reviewed on an annual basis. All Quality Assurance activities are not fully operational as outlined in the National Commission on Correctional Health Care Juvenile Health Standards. Based on those QA audit tools provided for review, there were the same compliance issues identified as found by the Subject Matter Expert, such as not charting vital signs for all assessments and failure to adequately complete the Problem List.
Resolution of these identified issues will allow the facility to obtain substantial compliance in all areas.
Special Education
The facility is not in substantial compliance with any of the 3 education-related provisions (0%). The following actions should be prioritized:
• Ensure that sufficient direct care staff and education staff are available to provide students with dependable access to education services.
• Address students’ chronic absenteeism with individualized plans to improve attendance and by delivering services to youth in alternative settings as needed.
• Provide dependable staffing and space to ensure that the ABC room is available to teachers and students each school day.
• Improve the consistency with which Unit Instruction data are recorded and entered so that compliance with this policy can be demonstrated. Toward this end, cross-referencing with the list of youth on Disciplinary Seclusion will be necessary to demonstrate that all eligible youth receive services.
• Improve the specificity of 1) Student Profiles and 2) Present Levels of Academic and Functional Performance sections of IEP documents to ensure that the skills students need to acquire in order to progress through the curriculum are clearly articulated in IEP goals. Develop objectives that address these skill deficits.
• Ensure that IEP Progress Reports are skill-specific and provide a clear description of what the student has mastered and what still needs to be addressed in order for the student to meet the goal.
• Develop sufficient vocational opportunities to engage all students in meaningful job skill development and/or work experience. The choice among the vocational options should be tailored to the risks and needs of youth at Scioto.

The facility has undergone a massive transformation since the Stipulation was amended. Originally, Scioto was the central reception facility for all DYS facilities. In the summer of 2011, DYS began to de-centralize its reception process to convert Scioto to a long-term facility that houses medium and close custody boys. Scioto remains the reception center for girls and also operates a long-term girls’ program and a mental health unit for girls. This change in mission required staff to adjust to a new type of youth (generally higher-risk) and to new responsibilities for their long-term care and treatment. In addition, the facility

	
  

10.

Case: 2:08-cv-00475-ALM-MRA Doc #: 104 Filed: 06/22/12 Page: 11 of 109 PAGEID #: 2082
received an entirely new Administrative Team in February 2012. This new team has an impressive array of skills, experience and enthusiasm and the Monitor is encouraged by their approach to the facility’s reform.
One of the common themes affecting compliance in nearly all areas of the Stipulation is staffing. Ensuring that a facility is adequately staffed to implement the reform consistently is a complicated endeavor. First, the facility must have an adequate number of funded positions to ensure that youth are supervised at the proper ratios. Facilities must also ensure that the number of vacancies is not excessive and must address any systemic barriers to filling open positions. In addition, facilities must ensure that staff who are filling the positions actually report to work. Once these conditions are met, the facility must address the usual and customary staff resignations efficiently to ensure that security is maintained and youth’s access to programming is not disrupted.
At various points throughout this report, the Monitor comments on the impact of staffing on the State’s ability to comply with the Stipulation. In the area of Protection From Harm, the facility appears to have an adequate number of funded positions. While there are several vacant direct care staff positions, the main barrier to adequate staffing is the number of staff who are currently filling a position but who do not report to work. Remedies, currently underway, are discussed in III.A.1, below. In Education, the facility appears to have an adequate number of funded teachers’ positions but struggled to fill key vacancies throughout the past two grading periods. At the time this report was drafted, these vacancies had reportedly been filled for the upcoming grading period. The Monitor has endeavored to explain the nuances of the staffing issues in each area and to identify the systemic barriers to the facility’s having a sufficient number of trained staff actually reporting to work so that youth and staff safety and programming are not compromised.

	
  

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PROTECTION FROM HARM

III.A.1 General Protection From Harm. The State shall, at all times, provide youth in the facilities with safe living conditions. As part of this requirement, the State shall take appropriate measures to ensure that youth are protected from abuse and neglect, use of excessive force, undue seclusion, undue restraint, and over-familiarization.

Compliance Rating Partial Compliance

Self Assessment

The State provided an array of data to illustrate the trends in youth violence, restraints, seclusion, and allegations of employee misconduct, along with an interpretation of the trends and the underlying causes of any changes. While the interpretation of these data leads to significant concern for the safety of youth and staff at Scioto (particularly the rate of youth-on-staff assault, the facility’s response to allegations of misconduct and inappropriate treatment by staff, and the overreliance on seclusion as a response to non-compliant behavior of all types, discussed throughout this report), the fact that the facility continues to collect and analyze these data related to key indicators of youth safety is very positive. Without this capacity, the facility would be unable to craft new violence prevention initiatives to address the underlying causes of the youths’ behavior. When the facility’s target population changed, so did the factors that contributed to youth violence. The facility’s new Administrative Team has brought an increased focus on the use of data to manage the facility. Weekly team meetings discuss data related to youth safety and delve into the underlying causes of notable trends. Since the previous monitoring period, the State has also produced lower rates of youth violence, restraints and seclusion, which are the key outcome indicators associated with this provision. While additional reductions are needed in specific areas (discussed below and throughout this report), the progress in this area is recognized by upgrading the compliance rating to Partial Compliance.

Trends in youth violence, restraints, and allegations of over-familiarization are discussed here, while detailed discussions about the use of seclusion and staff misconduct can be found in III.A.3 and III.A.5 respectively.

Youth Violence

As noted in the Introduction, at the end of the previous monitoring period, Scioto converted from a reception center and boys’ mental health unit to a long-term program. Scioto’s boys’ program now includes general population housing for medium and close custody boys and a maximum-security segregation unit. Scioto’s girls’ program continues to include reception, general population and an intensive mental health program. With this conversion came rather immediate and significant increases in the rates of youth violence compared to historical trends. The rate of youth-on-youth violence in September 2011 was .54. As shown in the table below, the rates of youth-on-youth violence have decreased significantly throughout the monitoring period, from a high of .22/.23 in the beginning of the

	
  

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monitoring period, to .07/.06 at its end.

Youth Violence, October 2011 through March 2011

Month

# Youth-Youth Rate

Oct 2011

36 .22

Nov 2011

38 .23

Dec 2011

21 .13

Jan 2012

23 .14

Feb 2012

10 .07

Mar 2012

8 .06

# Youth-Staff Rate
31 .19
36 .22
12 .08
33 .21
24 .18
20 .16

However, the rate of youth-on-staff violence has been more resistant to change. Discussions with facility administrators revealed that many of these assaults do not involve youth striking a staff person per se, but rather throwing a bodily fluid on the staff person. In March 2012, the facility adopted “container-less meals” as a sanction for this behavior. These meals meet the all of the State’s nutritional requirements but vary in the way the food is packaged, and are perceived by the youth to be less desirable. For the first offense, youth are provided container-less meals for a one-week period. The second offense is sanctioned with two weeks of these meals, etc. Anecdotal reports suggest this environmental strategy (i.e., a response that does not attempt to impact the offender, but rather the environment which provides the tools used for the offense) is producing the intended effects. Data for the next monitoring period will provide more objective evidence.
The facility identified factors believed to contribute to youth-on-youth violence and implemented the following strategies:
• Assigning an Operations Manager to the school, where many of the assaults were occurring.
• Separating close custody youth from medium custody youth during the school day to limit opportunities for gang recruitment and intimidation.
• Ensuring that all units have a Unit Manager (two units did not have a UM during the beginning of the monitoring period).
• Expanding the weekly Administrative Team meeting to include a broader range of staff and to review data on youth violence collectively and to discuss targeted intervention strategies.

	
  

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Restraints Decreases in the rates of restraint are proportionate to the decreases in acts of violence, discussed above. During the beginning of the monitoring period, the number of restraints was very high (average 240 per month for the first three months), but decreased significantly during the last half of the monitoring period (average 128 per month). Based on the Monitor’s experience in other facilities throughout the United States, even with this decrease, the number of restraints at Scioto is excessive. [Caveat: the mental health population at Scioto makes it unique compared to other similarly sized facilities, and this population generates a significant proportion of the restraints.] Overall, significant work remains to reduce the number of restraints. This is not to say that staff should not restrain youth who pose a legitimate threat to the safety of other youth, staff or themselves, but rather that the facility as a whole needs to better address the underlying causes of the misconduct and distress that leads to the restraint.

Over the past six months, Scioto investigated 18 allegations of excessive or inappropriate uses of force. Two of these (11%) were substantiated for improper technique. The facility’s well-developed use of force review by the Operations Administrator and Deputy for Direct Services and its vigilance surrounding adherence to policy and procedure contributes to the number of referrals, but also to greater protection from harm by staff. These 18 allegations flowed from nearly 1,100 restraints during this time period (rate of allegations is 2%; rate of substantiated allegation is less than 1%).

However, although the rate of allegations is relatively low, the poor quality of the investigations completed by facility-based staff creates concern about the extent to which staff who use force improperly can be accurately identified via the investigation process. These concerns are discussed in detail in III.A.5, below, but are relevant to this provision insofar as a poor constructed investigation does not adequately protect youth from harm at the hands of staff, as required by this provision.

Steps Taken to Assess Compliance

Overall, the major indices of youth violence suggest that safety issues at the facility stabilized toward the end of the monitoring period. The new Administrative Team’s use of data to identify hot spots for violence and other contributing factors appears to have properly targeted the underlying causes, has led to creative interventions, and has begun to produce the desired effects.

Staffing One of the major contributors to the facility’s difficulty in reaching substantial compliance with the Stipulation (e.g., programming, seclusion in the operation of the PROGRESS Unit) is direct care staffing. When insufficient numbers of staff are present, youth are denied access to programming and the safety of both youth and staff is compromised by inadequate supervision. The facility appears to have an adequate number of funded direct care positions, however, many of the individuals filling those positions do not regularly report to work. A significant

	
  

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number of staff are off work on Occupational Injury Leave (OIL) or FMLA. Historically, little effort was made to bring these staff back to work, even when they had exhausted their benefits. In January 2012, the facility began to hold Involuntary Disability Separation (IDS) hearings. If the staff has exhausted his/her benefits and cannot return to work, he/she is terminated and the position becomes vacant—which means the agency is able to recruit and fill the position with someone who is able to report to work. Since the IDS hearings began, the number of vacant positions that can now be filled has doubled (e.g., in December 2011, there were 8 vacant positions; 21 in January, 18 in February and 17 in March 2012). Conversely, the number of staff who were not reporting to work has decreased from approximately 40 at the beginning of the monitoring period to approximately 20 at the end of the monitoring period. In other words, these dormant positions have been transformed into positions that can now be filled by an able-bodied individual who can report to work as expected. The Central Office gave approval for a special pre-service training class so that recruits could come on the job more quickly. This is an extremely positive development, and signs of relief were clearly visible toward the end of March 2012.
The facility has also used data on staff turnover to develop strategies to increase retention. In 2011, the turnover rate was 64%. Further, 47% of those who went through pre-service training were not at DYS one year later. Initiatives to improve coaching for new staff, increases in staff safety, and efforts to provide a more welcoming community for new staff are underway. New procedures to bring services (e.g., laundry, meals) to the unit, rather than staff having to go fetch them, will further support Youth Specialists in their youth supervision roles.
These initiatives are absolutely essential to the State’s ability to comply with the Stipulation. Without sufficient numbers of well-trained staff, the facility will be unable to reduce violence, limit the use of seclusion, and provide adequate programming, as required.
Allegations of Sexually Inappropriate Comments or Relationships The previous Monitor’s report discussed the historical frequency with which Scioto youth have alleged to the DOJ attorneys and the Monitor that staff make sexually inappropriate comments, touch youth inappropriately, or engage in inappropriate relationships with youth. DYS had not received the same volume of allegations through its grievance process or other avenues for youth to report mistreatment, and thus the DOJ and the Monitor encouraged the State to develop additional avenues for reporting mistreatment and for increasing the integrity of the response to these claims. In order to ensure that DYS is providing adequate opportunities for girls to voice this type of concern and to reinforce the prohibition on these types of behaviors among staff, the new Administrative Team has planned the following initiatives, to be implemented in April 2012:
• The topics of inappropriate conduct by staff, boundary issues, etc. will be added to the girls’ Trauma Group curriculum and youth will be given the opportunity to discuss any problems they experience with the

	
  

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psychologist who facilitates the groups. Even though the Trauma Group’s dialog had not yet begun, several of the girls the Monitor interviewed commented that the issue of inappropriate staff behavior, and how to report it had been a topic of discussion during community meetings on the unit. • The topic of over-familiarization and boundary issues between staff and youth will become a standing topic on the agenda of the girls’ units weekly Interdisciplinary Team meetings (IDTs). The Unit Managers will initiate discussions about girls who may have sexualized behavior and will provide staff with guidance about how to respond in these difficult situations. Staff will also be taught how to recognize and respond to indicators of over-familiarization if they occur on the unit. The prohibition on sexualized language, inappropriate touching and personal relationships will also be reinforced.
Three cases involving sexually inappropriate relationships are pending with the CIO. The nature of the allegations include a) staff having inappropriate contact with a youth following release from the facility; b) two staff having a sexual relationship with a youth; and c) staff making sexually inappropriate comments to and having inappropriate physical contact with a youth. The youth’s parent reported one allegation to a facility social worker and the youth’s mental health clinician reported the other allegation. The source of the third referral was not clear in the documents received by the Monitor. Each of the allegations was entered into AMS on the day they were received (which triggers the CIO response) and were also reported to Child Protective Services as required by law.
The Chief Inspector also submitted a list of investigations into sexually inappropriate conduct completed by the State since 2007 (n=42). Investigations from 2010 and 2011 were reviewed (n=13; the 3 investigations opened in 2012 were still pending). Across the 13 completed investigations:
• 8 were unsubstantiated or unfounded (62%); • 5 were substantiated (38%). Many of these did not substantiate the
original allegation, but substantiated a less serious form of misconduct: o Staff had contact with a paroled and discharged youth via Facebook. o Staff lingered in front of a youth’s door for an extended period of time during her shift. o Staff placed her hand on a youth’s leg and hugged him. o Staff engaged in inappropriate conversations with youth regarding each person’s personal life and dating history. o Staff told a youth she loved her and hugged her.
As noted in the discussion for provision III.A.5, below, investigations conducted by the CIO are high-quality and exhibit sound interviewing techniques with a broad range of witnesses, clear efforts to use other sources of evidence (e.g., videotapes) to corroborate or refute the allegation, and result in findings that

	
  

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Recommendations
Sources of Information

have a sound basis in the available evidence. The 13 sexual abuse related investigations were all completed by the CIO and were of equally high quality.
The Monitor and the DOJ attorney both interviewed a sample of girls while on site. Across these 17 interviews, we heard of only one situation in which staff was alleged to have engaged in sexually inappropriate behavior. Those who mentioned the incident indicated they had spoken with an investigator about the issue. Further, the accused staff had been placed on administrative leave.
In summary, evidence suggests that the facility is handling matters regarding reported allegations of sexually inappropriate contact appropriately. In addition, the forthcoming initiative to broaden the dialog with both youth and staff about this issue will afford even greater protection to youth.
In order to reach substantial compliance with this provision, the State must: 1. Reach substantial compliance with provisions related to seclusion and investigations of abuse and neglect. 2. Continue to utilize aggregate data on youth violence to identify trends that threaten youth and staff safety. Identify the underlying causes youth violence and develop targeted violence prevention strategies to address the factors that contribute to assaultive behavior among youth. 3. Ensure that adequate numbers of well-trained staff are present on each unit so that youth do not endure unnecessary seclusion and have access to the full range of academic, rehabilitative and other structured programming required by the Stipulation. 4. Launch the planned initiative to expand the conversation surrounding the perception of female residents that some staff engage in sexually inappropriate talk and behavior. Reinforce the prohibition against this type of behavior with staff and ensure staff know how to recognize, respond to, and report such behavior.
• Self-assessment data and oral presentation of its interpretation for III.A.1, prepared at my request
• Interviews with n=6 girls currently housed at Scioto; consultation with DOJ attorney who interviewed an additional n=11 girls
• Review of CIO log of investigations into sexually inappropriate conduct since 2007
• Review of 13 investigations of sexual abuse allegations completed by the CIO in 2010 and 2011

	
  

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III.A.3 Seclusion. The State shall develop and implement policies, procedures and practices so that staff use seclusion only in accordance with policy and in an appropriate manner and so that staff document fully the use and administrative review of any imposition of seclusion, including the placing of youth in their rooms outside normal sleeping hours.

Compliance Rating Partial Compliance

Self Assessment

The State presented data on the use of seclusion across the previous six months.

Regular Seclusion Regular seclusion is a time-out, or short period of isolation imposed by direct care staff in response to mid-level, non-violent misconduct such as throwing things, property damage, storming around the unit, etc. As discussed in the previous Monitor’s report, the facility witnessed a huge spike in the use of regular seclusion just after the facility converted to a long-term facility. Historically, the facility averaged about 70 regular seclusions per month. In August and September 2011, the number skyrocketed to approximately 400 and well over 50% of the seclusions lasted longer than 4 hours. [Note: staff must obtain approval from a supervisor before placing a youth in regular seclusion and at the one-hour mark. If the youth remains in seclusion at the three-hour mark, the supervisor must document in writing the reason that seclusion remains necessary.]

The current monitoring period witnessed the use of regular seclusion returning to historical levels. In October 2011, the most disruptive youth were placed in the PROGRESS Unit (PU), which explains the rather immediate, large decrease in the use of regular seclusion. With the facility’s new Administrative Team’s emphasis on CBT groups and the SBBMS along with recent stability in Unit Manager and social worker staffing, the use of regular seclusion decreased even more. The rate of regular seclusion in February/March 2012 was down about 25% from the previous 4 months. Further, the vast majority of regular seclusions last 4 hours or less. [Note: Four hours is an arbitrary cut point. Most of the regular seclusion documentation reviewed indicated that youth spent an hour or less in regular seclusion.]

Regular Seclusion, September 2011 through March 23, 2012

Month

#

Rate

% 4hrs or less

(#/ADP)

Sept 2011

430

?

~50%

Oct 2011

68

.42

93%

Nov 2011

77

.48

81%

Dec 2011

73

.46

88%

Jan 2012

71

.45

96%

Feb 2012

54

.39

73%

March 2012

47

.38

94%

	
  

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Pre-Hearing Seclusion Pre-Hearing Seclusion (PHS) is a period of isolation imposed following an act of violence, pending a disciplinary hearing. Youth on PHS remain in their rooms except for showers, rec and Unit Instruction (i.e., education)). The length of time a youth remains on PHS is determined by his or her IRAV score, which is based primarily on the severity of the current rule violation, but also attends to the youth’s history of non-compliant behavior. Subject-matter experts on the S.H. case are currently working with the State to pilot test revisions to the IRAV policy that will permit reductions in the length of stay in PHS based on the youth’s current behavior.
Data on PHS showed significant decreases throughout the monitoring period. In October and November 2011, the number of PHS was still elevated due to the increase in AOV that occurred when the facility changed to a long-term, close custody population. Beginning in December 2011, the rate of PHS began to decrease, impacted most significantly by reductions in the number and seriousness of AOV, discussed in III.A.1, above.

Pre-Hearing Seclusion, October 2011 through March 23, 2012

Month

#

Rate

% 24+ hours

(#/ADP)

Oct 2011

99

.61

67%

Nov 2011

110

.68

65%

Dec 2011

53

.33

58%

Jan 2012

75

.47

69%

Feb 2012

47

.30

74%

March 2012

31

..25

68%

While this is a promising trend, PHS continues to be the major contributor to the total number of seclusion hours experienced by Scioto youth. The facility has made important strides in developing alternatives to Intervention Seclusion (discussed in the next section), but it must examine its use of PHS to determine whether the lengths of stay generated by IRAV are excessive. IRAV is a structured decision-making tool designed to classify youth according to their risk of harm to other youth and staff. Depending on the risk category IRAV prescribes the length of stay in PHS. Self-assessment data revealed that youth who scored in the Arange on the IRAV (high risk) spent an average of 56 hours in PHS during the current monitoring period [typically, about ½ of youth in PHS score as A-level on the IRAV]. Data-driven, thoughtful modifications to the IRAV could produce significant reductions in the length of PHS, without jeopardizing facility safety.

	
  

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Intervention Seclusion Intervention hearings are held to determine whether youth are culpable for serious misconduct and whether additional time in seclusion is warranted. While on Intervention Seclusion, youth remain in their rooms except for showers, recreation and Unit Instruction (i.e., education). The rate of Intervention Seclusion has decreased significantly (by about 60%) since the beginning of the monitoring period, due in part to an overall reduction in AOVs and also to the new Administrative Team’s commitment to use alternatives sanctions more frequently.

Intervention Seclusion, October 2011 through March 23, 2012

Month

# Seclusion

ADP

Rate

Oct 2011

80

163

.49

Nov 2011

64

161

.40

Dec 2011

73

159

.45

Jan 2012

40

158

.25

Feb 2012

21

137

.15

March 2012

22

125

.18

Although the number of youth who serve seclusion as a disciplinary sanction has decreased significantly, no major changes were noted in the duration of Intervention Seclusion. Throughout the monitoring period, roughly 25% of seclusions were for less than 24 hours, between 60 and 75% were for 24 to 72 hours, and the remaining 10 to 20% were for more than 72 hours. Of additional concern is the accumulation of time spent behind a locked door if youth do not receive credit for time served on PHS. Anecdotally, the new Scioto administration appears to award credit for time served on PHS often, but the Monitor did not collect aggregate data.

Steps Taken to Assess Compliance

Overall, the total number of hours of seclusion utilized in the day-to-day operation of the facility has decreased significantly from the high rates witnessed surrounding the facility’s conversion to a long-term, close custody population. In February and March 2012, the total number of seclusion hours hit all-time low levels. However, these data should be interpreted with caution—while the use of seclusion has decreased, it remains the primary vehicle for sanctioning misconduct. As discussed in previous reports, not only is seclusion one of the least effective tools for managing youth behavior, it also decreases youth’s access to needed treatment programs and increases their risk of self-harm. Efforts to reduce the duration of PHS and to reduce the reliance on seclusion as a sanction must continue.
The facility’s self-assessment accurately depicted trends in the use of the various types of seclusion. While significant work remains to comply with the various requirements of this provision, progress toward the key outcomes associated with

	
  

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this provision (i.e., seclusion is used less often and for shorter periods of time) was sufficient to justify an upgrade to Partial Compliance. A few issues deserved additional attention.
First, with regard to Pre-Hearing Seclusion, significant changes to policy and practice appear to be forthcoming. Guided by the S.H. monitoring team, the State has begun to recalibrate IRAV in order to reduce the length of time youth spend in PHS. The initial impact of these changes began to emerge in March 2012, where the average length of A-level youth decreased to 39 hours. This is a promising trend and the facility should continue to push forward to examine how the IRAV can be adapted to reduce the amount of time youth spend in PHS, without jeopardizing the safety of other youth and staff.
Second, with regard to the use of Intervention Seclusion as a response to serious misconduct, the new Administrative Team is clearly committed to develop appropriate alternative sanctions. A sample of IH documents from March 2012 was reviewed to examine the types of alternative sanctions currently in use. Of the 16 IH packets reviewed, no seclusion was ordered for 6 youth (38%), despite their having committed relatively serious AOVs. Instead, these youth received some combination of privilege suspension, Intervention Time (time added to their sentence), treatment work, apology letters or essays on a topic related to their misconduct. This trend is very encouraging and should be maximized.
Third, in the past, a major concern related to the use of seclusion was the extent to which staff followed required procedures to mitigate the risk of self-harm posed by youth confined to their rooms for disciplinary reasons. For over one year, the facility has conducted random reviews of videotaped footage to ensure that staff were conducting safety and welfare checks at the required intervals. These checks continue to reveal that staff properly and consistently implement these procedures. A review of 5 sets of Intervention Monitoring logs completed in March 2012 revealed that staff make entries throughout the period of confinement. While most of the checks are properly documented, staff should be reminded not to make entries at exact 15-minute intervals (not only is this contrary to the requirement for random checks, but this level of punctuality is nearly impossible to accomplish; staff should use the actual clock time when documenting their checks). Also, in the event that the youth has covered his window with something, the staff must still verify and record the youth’s activity while in the room (i.e., “window covered” is not an acceptable entry). While the facility should still make spot checks to ensure monitoring procedures are properly implemented, this component of seclusion practices appears to operate according to policy.
Finally, the proper method for categorizing and recording the time that PROGRESS Unit (PU) youth spend in their rooms has been discussed since the previous monitoring period, when the PU was first opened. For the sake of clarity,

	
  

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the term Programmatic Seclusion is used when referring to time that youth spend in their room by virtue of being a Phase 1 or Phase 2 youth on the PU. Phase 1 youth are permitted out of their cells for school, one hour of large muscle activity, treatment, and showers. Meals and leisure time are spent in-cell. Once promoted to Phase 2, youth may also spend their leisure time out-of-cell. Several problems have plagued the implementation of the PU which have resulted in youth spending a great deal of time in their rooms when, according to the program design, they should be out on the dayroom, in school, or in group treatment.
The first problem is direct care staffing. The unit log on the Cedar side of the PU was reviewed in depth to ascertain the impact of short staffing on the implementation of the program. In March 2012, youth were locked down for at least part of the day because of staff shortages on 42% of the days (13 of 31 days). Comments throughout the logbook note that school, recreation, and group sessions could not be held because of insufficient staffing. As a result, PU youth spent all of this time in programmatic seclusion. Compounding this problem are shortages in the education staff, which caused school to be cancelled on 4 of 21 school days (18%). Instead of spending the 5-hour school day in a classroom, youth were confined in their rooms. In addition to this perfect storm of staffing shortages, the program is further impacted by the complexity of housing youth who must be restrained anytime they are out of their room (Phase 1 youth) on the same living unit as youth who are not restrained, but cannot be in the vicinity of youth who are in restraints (Phase 2 youth). Even though Phase 2 youth are supposed to be out of their rooms during leisure time, the need to transport Phase 1 youth to different locations on the unit means that Phase 2 youth are constantly returned to their rooms during the transports. This occurs frequently throughout the Phase 2 leisure time.
The State bears the burden of demonstrating that youth are in their rooms only as much as the original program design permitted. The PU logbooks have a form for recording the location of each youth, each hour of the day. If completed properly, the facility would have a record of precisely how much time each PU youth spends in his cell. However, staff do not exercise adequate care in completing this form. Most often, they simply place an “X” in each box, indicating that the youth is on the unit, but without distinguishing whether the youth is in his room, the dayroom, the group room, etc. The previous Monitor’s report discussed the various problems with the PU’s documentation, but improvements have yet to be made.
One way to limit the amount of time youth spend in their cells is to expedite their movement through the PU and onto the Transition Unit as quickly as possible. In order to do so, treatment plans must set up realistic, measurable behavioral goals and objectives that are regularly assessed to determine whether a youth is adequately prepared to advance to a less restrictive phase. The Monitor reviewed approximately 10 treatment plans for PU youth. Goal development is, and needs to be, a major source of emphasis among mental health staff. Goals were often

	
  

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overly vague, not measurable, or not appropriately focused on the behavior change that needs to occur in order for a youth to move to the Transition unit. Further, when youth are spending so much time in their cells, they have little opportunity to learn, practice and display the skills and behaviors that are prerequisites for phase advancement. As a result, youth stagnate in the PU and continue to suffer long periods of programmatic seclusion, both warranted (when they are Phase 1) and unwarranted (due to staff shortages and youth movement complexities).
While solutions to all of these problems are reportedly underway (e.g., direct care staff positions are being freed up, as discussed in III.A.1; education staff has reportedly been hired for the upcoming grading period as discussed in III.E.1; and the facility intends to separate Phase 1 and 2 youth on opposite sides of the PU), throughout the current monitoring period, youth housed on the PU experienced far more programmatic seclusion than ever envisioned by the original program design. Unless this program begins to operate as a true segregation unit (where youth are segregated from the general population but NOT secluded), the facility will not be able to reach substantial compliance with this provision.

Recommendations Sources of Information

In order to reach substantial compliance with this provision, the State must: 1. Revisit the duration of pre-hearing seclusion prescribed by the IRAV to ensure that youth remain in pre-hearing seclusion no longer than necessary to de-escalate their behavior and ensure they do not pose a threat to the safety of other youth or staff. 2. Limit the use of disciplinary seclusion, relying instead on sanctions that provide an opportunity for skill development and treatment in order to create behavior change. 3. Operate the PROGRESS Unit as it was designed, adhering to the prescribed limits on youth’s time in cell (i.e., a) address staff shortages; b) design a strategy to address the interference of Phase 1 youth movement on Phase 2 youth’s time out cell; c) facilitate youth’s advancement through the phases and to the Transition Unit with quality treatment plans and progress reporting). 4. Improve the quality of record keeping on the PROGRESS Unit so that the precise number of hours youth spend locked inside their rooms can be ascertained.
• Self-assessment data and oral presentation of its interpretation for III.A.3, prepared at my request
• Youth Intervention Monitoring Logs for n=5 youth in seclusion in March 2012
• Intervention Hearing packets for n=16 youth with hearings in March 2012
• Interviews with n=6 female youth currently housed at Scioto

	
  

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• Observation of IDT meeting on Cedar Unit on April 5, 2012 • Treatment plans and IDT minutes for n=10 youth from the Cedar and
Sycamore units • Unit logbooks for Cedar unit, March 2011

	
  

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III.A.5 Investigation of Serious Incidents. The State shall develop and implement policies, procedures and practices so that appropriate investigations are conducted of all incidents of: use of force; staff-on-youth violence; serious youth-on-youth violence; inappropriate relationships with youth; sexual misconduct between youth; and abusive institutional practices. Investigations shall be conducted by persons who do not have direct or immediate indirect responsibility for the employee being investigated.

Compliance Rating Partial Compliance

Self Assessment

The State submitted a log of all investigations related to excessive uses of force, allegations of abuse, allegations of verbal abuse, and inappropriate relationships completed during the current monitoring period. The Chief Inspector’s Office (CIO) investigated the more serious allegations, while facility-based investigators addressed the less serious allegations.

Between October 2011 and February 2012, the facility completed 32 investigations related to the topics covered by this provision. Four additional investigations were pending at the time of this report. In contrast to the previous reporting period where 39% of investigations were substantiated, only 3 of the 32 investigations (10%) resulted in a substantiated finding (2 for improper use of force, one for an inappropriate relationship with youth). The reasons for this sharp decrease are uncertain—the decrease may signify stronger adherence to policy and procedure among staff or, more likely, may be the result of inadequacies in the investigatory process (discussed below) that prevented staff misconduct from being accurately identified.

The CIO conducts audits of the facility’s investigations every quarter. These audits generally occur 2-3 months after the close of the quarter (Q3 2011 was conducted in November 2011; Q4 2011 was conducted in March 2012; Q1 2012 had not been conducted at the time of the site visit). As a result, no new information was available from the CIO’s audits.

Steps Taken to Assess Compliance

Investigations Conducted by the Chief Inspectors Office (CIO)
Given the high quality of the investigations conducted by the CIO in the past, a 50% sample (7 of 13 investigations) was selected for in-depth review. As in the past, the investigations were well done. They featured comprehensive interviews with all key witnesses, utilized videotaped footage effectively, and pursued tangential issues that emerged during the course of the initial inquiry. Across the sample, the findings appeared to be reasonable and the basis for the conclusions was clearly identified among the evidence.

In terms of timeliness, only one of the 13 reports (8%) conducted by the CIO was completed within the timeline required by policy (i.e., 14 business days for use of force investigations; 30 calendar days for all others). Nine of the CIO use of force investigations were granted an extension (with the average time to complete 39 days). Throughout the CIO investigative reports, frequent references to staff callouts and staff shortages when trying to conduct interviews with staff witnesses

	
  

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suggest that the facility’s staffing problems create a systemic barrier to the timely completion of the investigations.
Investigations Conducted by Scioto Staff
The previous Monitor’s report noted the poor quality of a segment of the internal investigations and cautioned the State that the quality of the internal investigations needed to improve in order to maintain the substantial compliance rating. A review of all 19 internal investigations completed during the current monitoring period revealed that the quality-related issues have become even more pervasive, and thus the compliance rating has been downgraded to Partial Compliance.
Further, most of the internal investigations were not completed within the timelines required by policy. Of the 19 investigations reviewed, 7 were completed on time (37%) and 4 were granted an extension (21%; reasons not provided). A significant proportion (42%) was late without explanation. Timely investigations are essential for a robust process to address allegations of employee misconduct. Should the allegation be substantiated, staff training or discipline needs to occur as soon as possible so the individual can either return to duty, be retrained, or be terminated, as appropriate. If the allegation is not substantiated, the employee needs to be cleared so that he or she may return to full duty and be relieved of the stress and stigma of being “under investigation.”
Detailed feedback on each case was provided to the State to develop consensus around the essential elements of a quality investigation. To summarize:
• Allegation statements need to be specific (who is alleged to have done what to whom, and when?) in order to set the context for the subsequent information. Too often, key facts were missing and it was not until several pages into the investigation that the nature of the allegation could be understood.
• Any delays in assigning or initiating the investigation need to be explained. Long delays in initiating investigations were noted, and were unexplained. In part, the situation could be clarified if the investigator explained how and when the facility became aware of the allegation (which would account for those situations when the youth did not report the concern immediately after it happened).
• Everyone who can contribute to the understanding of what occurred should be interviewed. In several cases, the investigator identified a very limited set of witnesses (e.g., the accused staff, the victim and possibly one other witness) even though other people were in the vicinity when the incident allegedly occurred.
• Witnesses should be asked to describe what happened in their own words, and the investigator should seek clarification or additional detail through appropriate follow-up questions. Many times, it appeared that

	
  

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the witness was simply asked to respond to a set of yes/no questions.
• The sequence of the interviews is important. The alleged victim should be interviewed first in order to obtain a complete accounting of the youth’s concerns and to obtain details that can be used to construct questions with the witnesses and the accused staff. The accused staff should be interviewed last, so that he or she can be asked to respond to the specific allegations discovered during the previous interviews. In several cases, the accused staff was interviewed first, and thus the interview did not reflect the variety of issues raised in subsequent interviews.
• The basis for the conclusions must be clearly articulated and must rest upon facts that were gathered during the investigation. Many of the investigators do not write coherent narratives and do not summarize the facts that supported the conclusion, and did not explain why they discounted facts that didn’t fit.

The underlying causes of this problem with the internal investigations are complex. The investigations are distributed across a large number of staff—in fact, 19 different people completed the 19 investigations reviewed. Dispersing the responsibility this broadly will inevitably lead to inconsistency, and because each staff person may only do one or two investigations per year, their opportunities to develop the appropriate skill set are very limited. Reducing the number of people who are authorized to conduct an internal investigation is strongly recommended, as is providing specific, intensive training to develop appropriate investigatory skills among those so authorized. Once properly trained, accountability measures should be enacted to address poor performance by staff tasked with the responsibility to investigate these issues.

The poor quality of these investigations is of great concern. Although the allegations investigated at the facility-level are generally less serious in nature, the nature of the complaints is at the heart of the culture that the new Administrative Team hopes to change.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Produce high-quality investigations of all allegations of inappropriate conduct by staff. Whether completed by the CIO or by a facility-based investigator, the investigations must reflect timely, comprehensive interviews with all key witnesses and must arrive at reasonable conclusions based on the facts in evidence. Enact accountability measures to address poor performance by staff tasked with the responsibility to investigated allegations of all types. 2. Address direct care staff shortages that have historically made witnesses unavailable for interview by CIO and facility-based investigators, leading to the inability to complete investigations within the timelines required by policy.

Sources of Information

• Self-assessment data and oral presentation of its interpretation for

	
  

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III.A.5, prepared at my request • Log, “Investigations of Serious Incidents, October 2011 through March
2012” • Review of 7 CIO investigations completed since October 2011 (53% of
total) • Review of 19 internal investigations completed since October
2011(100% of total)

	
  

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III.D.1 Grievances. The State shall develop and implement policies, procedures and practices to ensure that the facility has an adequate grievance system including: no formal or informal preconditions to the completion and submission of a grievance; review of grievances by the Chief Inspector; timely initiation and resolution of grievances; appropriate corrective action; and written notification provided to the youth of the final resolution of the grievance.

Compliance Rating Partial Compliance

Self Assessment

Since the previous Monitor’s report, the Grievance Coordinator retired and an individual holding another facility position was transferred to the Grievance Coordinator position. Shortly before this report was issued, the position became vacant.

The CIO conducts quarterly audits of the grievance process at Scioto. The 2011 Q4 audit was published in January 2012. As noted in the previous Monitor’s report, when the facility changed its mission, Scioto youth began to submit more grievances. The number of grievances submitted in each of the 4 quarters of 2011 was 110, 94, 149 and 181, respectively. Historically, the rate of grievances (number of grievances divided by the average daily population for the month) was 0.8; in the latter part of 2011, the rate increased 50% to approximately 1.2. This increase has been attributed to both youth and staff’s efforts to become adjusted to Scioto as a long-term placement, rather than a reception center. In Q1 2012, the number of grievances filed decreased about 34% to 119 (rate .85), which approximates the volume of grievances prior to the shift in the facility’s mission.

Across the 181 grievances from Q4 2011, complaints about the decisions by staff remained the largest category (14%), followed by living conditions (13%), concerns about personal possessions (11%) and program concerns (9%). In contrast to previous quarters, complaints about medical services were no longer in the top 4 grievance categories. The monthly grievance reports highlighted hotbutton issues in the population. In October 2011, many youth were concerned that their personal possessions (mail and photographs) had not transferred with them when they moved to Scioto. From December 2011 through February 2012, grievances focused primarily on program disruptions caused by short staffing (e.g., no movement off unit; lockdown in cells; education delivered on unit or in room). Youth on the PROGRESS Units (PU) vocalized concerns about phase demotions and the “container-less meals” delivered to youth as a sanction for using food containers to assault staff with bodily fluids.

The CIO reviews each grievance to ensure an adequate resolution that complies with policy and procedure. Of the 176 grievances reviewed for Q4 2011, 18% required clarification or supporting documentation. The proportion requiring this type of follow-up has increased significantly with the change in personnel. In Q1 2012, 38% required follow-up action. Most often, the action required was to attach supporting documentation, but in a small number of cases, facility policy had been misinterpreted (e.g., the SBBMS photo incentive) or needed to be discussed with the Administration (e.g., a number of the grievances complained

	
  

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about the lack of access to outdoor recreation).

Data on the timeliness of grievances reveals that slippage has also occurred over the past few months. The Q4 2011 CIO report showed that of the 181 grievances, 16% were not resolved within the 14 days permitted by policy. (Historically, the facility has had very few, if any, overdue grievances). In Q1 2012, of the 119 grievances filed, 56% were not resolved timely.

The Q4 2011 CIO report included a youth survey. This survey revealed that 87% of the youth at Scioto reported they knew how to use the grievance process, and that the grievance coordinator met with them face-to-face to discuss their concerns. However, the survey also identified a number of shortcomings to the grievance process. First, youth reported that a significant proportion of their grievances were resolved late. In response, the CIO changed the policy, which now requires CIO approval on all extensions. Further, significant numbers of youth reported that staff told them that they could not use the grievance process to report staff misconduct (17%), that staff treated them badly after filing a grievance (20%), or that staff told them nothing would happen if they filed a grievance (53%). In response, the grievance training module for staff has been adapted to address these concerns and to discuss more generally the ways in which staff may unintentionally impede or diminish the effectiveness of the grievance process.

Although these findings are troubling, it is also clear that the State has a welldeveloped internal ability to identify and address its problems related to grievances. Hopefully, the actions taken in response to the youth survey will lead to improvements in the various performance measures required by this provision.

Steps Taken to Assess Compliance

The CIO’s data included in the self-assessment revealed two key issues:
• Lack of clarity in the resolution or a need to provide supporting documentation (38%; in Q1 2012, 45 of 119 grievances required additional information)
• Timeliness (56%; in Q1 2012, 67 of 119 grievances were not resolved in 14 days, as required by policy)

A sample of approximately 200 grievances submitted between October 2011 and March 2012 were reviewed, along with the follow-up action required by the CIO for 45 of them. In general, supporting documentation was needed to verify the Grievance Coordinator’s statement that another staff member had handled the youth’s concern or that the youth had received the service requested. Again, the quality of internal review of individual grievances is excellent; however, the grievance process must meet the outcomes envisioned by this provision (e.g., timeliness, appropriate corrective action or resolution) in order to be rated in substantial compliance.

The previous Monitor’s report required the State to develop a feedback

	
  

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mechanism to inform youth about the outcome of investigations that were initiated by their grievances. For several years, the policy has required youth to be informed that their grievance was forwarded for investigation and to be given the investigation number and the Scioto grievance coordinator complied with this policy. In March 2012, the procedure was expanded to include written notification to the youth of the outcome of that investigation. A letter to the youth from the facility’s Labor Relations Officer (LRO) refers to the investigation number and indicates whether the allegation was substantiated or unsubstantiated. The Investigation Policy (#101.15) and the Youth Handbook have been updated to reflect this change in procedure.

Historically, approximately 10 grievances are forwarded for investigation each quarter (Q4 2011 had 12; Q1 2012 had 7). Because the new policy was implemented in early March 2012, not enough time has passed to assess the implementation of the new procedure. Two letters have been issued to date; both included all of the required information, and one of the letters was mailed to a youth who had been released to the community. Anecdotes from the Chief Inspector and LRO suggest that the youth have been satisfied with this information and have not pressed for additional details that would violate personnel privacy regulations.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Ensure that grievances are resolved in a timely manner and that all resolutions are supported by appropriate documentation, attached to the grievance. 2. Throughout the upcoming monitoring period, fully implement the new procedure for notifying youth of the outcome of any investigation referred via the grievance process.

Sources of Information

• Self-assessment data and oral presentation of its interpretation for III.D.1, prepared at my request
• Q4 2011 Grievance Audit by the Chief Inspector’s Office • Q1 2012 Grievance data, prepared at the request of the Monitor • Grievance Monthly Reports, October 2011 through March 2012 • AMS Grievance Summary and handwritten Youth Grievances from October
2011 through February 2012

	
  

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III.D.2 Grievances Explained to Youth. A clear explanation of the grievance process shall be provided to each youth upon admission to the facilities during orientation and to their parents or guardians, and the youth’s understanding of the process shall be at least verbally verified.

Compliance Rating Substantial Compliance

Self Assessment

The Orientation process includes two videos—one is a general Orientation video covering several topics including Youth Rights and the purpose of the grievance system. A second video focuses on the grievance process and includes information about what to do if the youth has a problem with living conditions, medical care, staff treatment, education services, etc. The video describes the differing roles of the Grievance Coordinator, the Chief Inspector’s Office, and the Legal Assistance Program attorneys. Finally, youth are provided step-by-step instructions for navigating the grievance system. The information in the video is reinforced by a written Youth Grievance Handbook, which an intake staff member discusses with the youth. Youth are also provided in-depth information about sexual abuse and sexual assault in the correctional setting, and how to handle situations in which they may feel threatened or that the staff is being inappropriate.

All youth are required to sign several forms indicating that they received and understand information about the grievance process. The facility audits a random sample of admissions files every month to ensure compliance with policy and procedure. Each month, October 2011 through February 2012, 100% of the youth sampled (21 total youth; 10% of all admissions) received a complete orientation to the facility, which included information on how to access the grievance system.

The Grievance Officer also held “Grievance Clinics” with all youth in December 2011 and January 2012. The clinics included instructions on how to use the grievance process, how to address non-grievable issues (e.g., Intervention Hearing appeals; Release Authority decisions), and information on other, more informal processes designed to meet the youth’s needs (e.g., clothing requests; mediation with staff; etc.). Each of the 6 youth interviewed by the Monitor understood the grievance process and how to use it.

As discussed above, the Grievance policy was revised in early March 2012 to include procedures for informing youth about the outcome investigations that were initiated by their grievances. The new policy was introduced to current residents during February and March 2012 and the Youth Handbook and other Orientation materials were adapted to provide this information to new residents upon admission.

Steps Taken to Assess Compliance

I did not need to conduct any additional inquiry to assess compliance.

Recommendations The State is in substantial compliance with this provision.

	
  

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Sources of Information

• Self-assessment data and oral presentation of its interpretation for III.D.2, prepared at my request
• Intake Audit Report, October 2011 through February 2012

	
  

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III.F.1 Structured Programming. The State shall provide adequate structured rehabilitative services, including an appropriate mix of physical, recreational or leisure activities during non-school hours and days. The State shall develop and implement structured programming from the end of the school day until youth go to bed, and on weekends. For youth housed in closed-cell environments, programming shall be designed to ensure that youth are not confined in locked cells except: a) from after programming to wake up; b) as necessary where youth pose an immediate risk of harm to self or others; c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanctions. The programming shall be designed to modify behaviors, provide rehabilitation to the types of youth committed at the facility, address general health and mental health needs, and be coordinated with the youth’s individual behavioral and treatment plans. The State shall use teachers, school administrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualified assistance to develop and implement structured programming. The State shall provide youth with access to programming activities that are required for parole eligibility.

Compliance Rating Non-Compliance

Self Assessment

Structured Programming

The new Administrative Team has decided not to use the Youth Activity Tracking System, citing pervasive problems with implementation and unreliable data. They are seeking ways to track the involvement of youth in structured programming so that they can demonstrate compliance with this provision. Until then, the Monitor must rely on anecdotes and more indirect sources of information to determine the level of programming activity. While staff reports and unit schedules suggest that a variety of programming activities are scheduled (e.g., recreation, religious programming, programs delivered by mental health staff, social workers, volunteers and direct care staff), youth reports and other documentation suggest that staffing shortages at the facility often interfere with the actual delivery of these programs. While the facility provided detailed information about the staffing situation (see Provision III.A.1), it did not attempt to quantify the resulting program reductions, saying only that staffing problems have negatively impacted the ability to deliver the full range of programs on the unit schedules.

SBBMS With the appointment of a new Unit Manager Administrator, the implementation of the behavior management system has been strengthened. Weekly meetings with the Unit Managers provide a forum to discuss implementation problems. Over the past couple months, Unit Managers are asked to address grievances submitted by youth on their units. In so doing, they have begun to ensure that youth receive their daily incentives, do not have access to privileges they have not earned, and that youth complete the assignments and sanctions as required before their privileges are re-instated. When the facility first changed over from a reception center to a long-term facility, youth frequently submitted grievances about the staff’s implementation of the SBBMS. The volume of complaints about the SBBMS has decreased noticeably, particularly with the Operations Deputy’s focus on this issue.

	
  

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Steps Taken to Assess Compliance

The staffing issues discussed during the facility’s self-assessment suggest that structured programming was frequently disrupted during the current monitoring period. Youth interviews and facility observations confirmed that direct care staffing is a major impediment to the delivery of rehabilitative programming required by this provision. A simple tracking system should be developed quickly so that a baseline for program delivery can be established and so that expanded access to programming can be tracked as the staffing issues are resolved.

Programming for Graduates

As discussed in the previous Monitor’s report, graduates continue to voice complaints that they have nothing to do during the day. Indeed, information submitted by the State demonstrates the paucity of options for these youth. Across the facility, 22 students have graduated or obtained their GED. Of these, only 2 have permanent jobs (9%) and 4 have jobs on an “as needed” basis (18%). While short-term pilot programs serving a small number of students have come and gone over the years, on-going post-secondary education options (e.g., college courses, vocational training) are not available to graduate youth at Scioto. While the Administrative Team has created a few job opportunities, these involve too few youth, too sporadically to have an impact on the experience of the average graduate at Scioto. Historically, no one has “owned” this issue and the State is encouraged to invest both time and energy to develop a comprehensive, sustainable program for graduates.

PROGRESS Unit (PU)

The language of this provision also addresses programming for youth in closedcell environments to ensure they are not confined to their cells unnecessarily and that they have access to rehabilitative services that meet their needs. The facility operates the PROGRESS unit (PU), which is a closed-cell program. Concerns about the amount of time these youth spend in their rooms due to staff shortages were discussed in III.A.3, Seclusion.

Not only do the staff shortages cause youth to spend excessive amounts of time in their rooms, they also interfere with the delivery of the programming opportunities (e.g., recreation, education, group counseling, individual counseling) that are supposed to address the youth’s behavior concerns and prepare them to reintegrate into the general population. The unit log on the Cedar side of the PU was reviewed in depth. In March 2012, youth were locked down for at least part of the day because of staff shortages on 42% of the days (13 of 31 days). In addition, there were at lease 4 days where school was not held due to both Youth Specialist and education staff shortages (4 of 22 days; 18%). Comments throughout the log note that groups were not held, recreation was not held or shortened, and youth could not be transported for medical or dental appointments because of short staffing.

	
  

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These shortages mean that the original design of the PU has not and cannot be implemented. By design, the programming on the PU was supposed to be intensive. Whether because the concept was not fully developed (as discussed in the previous Monitor’s report) or because staffing has interfered with its operation, the PU has not been properly implemented and thus is not currently capable of creating the kind of behavior change needed for the youth housed there to be integrated into the general population. The sad irony is that these youth are the most in need of services, but seem to be receiving the least amount of service of any youth at Scioto.

Youth progress through the Phases on the PU is an essential performance measure to ensure they have increasing access to programming that is more broadly available in the general population. Data on the movement of youth through the Phases should be maintained to identify systemic barriers (in contrast to those related to the youth’s behavior). For example, in order for a youth to be promoted to Phase 2, he must first have the opportunity to demonstrate the skills required by his treatment plan. However, if he is rarely let out of his room because of staffing shortages, he will have very limited opportunities to do so.

Recommendations Sources of Information

On a positive note, the PU interdisciplinary teams (IDT) have invested a great deal of time and energy in crafting Treatment Plans and holding weekly meetings to facilitate youth’s progress through the behavior management system (i.e. Phases). Additional skill building is still needed, particularly on the Sycamore unit where the staff have more recent tenure, but progress on the Cedar unit is notable from the previous monitoring period. However, unless PU youth can be assured of dependable, consistent access to the full range of programming opportunities, the Treatment Teams and IDT meetings will have no hope of facilitating the type of behavior change that is so sorely needed by the PU youth.
In order to reach substantial compliance with this provision, the State must: 1. Provide sufficient staffing in both the general population units and Progress Unit (PU) to ensure that youth have consistent, dependable access to all scheduled programming, including education, recreation, treatment groups, religious services and volunteer programming. 2. Develop an appropriately focused, rehabilitative program for youth who have graduated from High School or obtained their GED. The program should include both post-secondary educational opportunities and job skill and vocational training. 3. Fully develop the PROGRESS unit’s program features (e.g., treatment plans, treatment teams, individual sessions, etc.) to ensure youth progress through the Phases and have maximal access to structured programming, given their legitimate safety concerns.
• Self-assessment data and oral presentation of its interpretation for III.F.1, prepared at my request
• Interviews with n=20 general population youth conducted by the DOJ

	
  

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attorney in late October 2011; interviews with n=29 youth on PROGRESS units conducted by the Monitor and DOJ attorney in October 2011 • SOP 303.01.07 “PROGRESS Unit”, draft dated 10/20/11 • Draft “PROGRESS Unit Handbook” and “Transition Unit Manual”, received October 26, 2011 • “Unit PROGRESS and Transition Training,” PowerPoint presentation slides, received October 26, 2011

	
  

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III.F.2 Orientation. a) Admissions Intake and Orientation. The State shall develop and implement policies, procedures and practices to establish a consistent, orderly admissions intake system, conducive to gathering necessary information about youth, disseminating information to staff providing services and care for youth, and maintaining youth safety. The orientation shall also clearly set forth the rules youth must follow at the facility, explain how to access medical and mental health care and the grievance system, and provide other information pertinent to the youth’s participation in facility programs. b) Notice to Youth of Facility Rules and Incentives/Consequences for Compliance. The State shall explain the structured programming to all youth during an orientation session that shall set forth the facility rules, the positive incentives for compliance and good behavior and the sanctions for rule violations. The State shall provide the facility rules in writing. c) Introductory Handbook, Orientation and Reporting Abuse. Each youth entering the facilities shall be given an orientation that shall include simple directions for reporting abuse and assuring youth of his/her right to be protected from retaliation for reporting allegations of abuse.

Compliance Rating Partial Compliance

Self Assessment

The facility continues to audit a random 10% sample of admissions files every month to ensure compliance with policy and procedure. Between October 2011 and February 2012, 210 youth were admitted to the facility; 10%, or 21 youth, were included in the audit. Each month, 100% of the youth sampled received a complete orientation to the facility which included, among other things:
• Youth Handbook • Orientation Video • Facility rules and consequences (IRAV) • Strength Based Behavior Management System (SBBMS) • Obtaining legal assistance • Accessing medical and mental health care • Sexual abuse and sexual assault information • Grievance system

Steps Taken to Assess Compliance

Religious Accommodations
The previous Monitor’s report required the State to provide youth with information that clearly described the youth’s rights related to practicing their religion of choice, in particular, how they make seek accommodations for religious beliefs, practices or observance. The State revised the handbook by inserting the following language:

Every youth has the right to practice their religion. You are permitted to have the resources of your faith as long as it does not affect the safety of the facility.

The revised Handbook was put into use on January 12, 2012. Department heads and supervisors provided information to their staff on the requirement to accommodate youth’s religious beliefs. As of March 15, 2012, 87% of all staff had been trained and completed a post-test about the facility’s religious

	
  

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accommodations policy.
During the current monitoring period, two grievances were submitted by youth who wanted the freedom to practice their religion of choice. One youth wrote that he did not want to cut his hair—that it was against his religion. In response to the youth’s request, he was given an exemption to the facility’s grooming policy, he was placed on a vegetarian diet, and was provided Rastafarian study materials. Another youth indicated that he wanted to convert to Rastafarianism. The Grievance Coordinator provided clear instructions for how to go about this conversion.
The revised Youth Handbook clearly articulates that youth are free to practice their religion of choice and the facility has demonstrated its willingness to make religious accommodations when the issue has arisen.
PROGRESS Unit Orientation While most of the youth at Scioto undergo an orientation to the general Scioto population, youth can also be admitted directly to the PROGRESS Unit (PU), and thus the orientation for that program is relevant to this provision. Draft SOP 303.01.07 “Progress Unit” requires the Unit Manager to ensure that the PU Youth Handbook is available to all youth and that a staff member provides a thorough orientation to youth upon their admission to the Unit. Youth must sign the Handbook’s signature page to acknowledge receipt of the information.
The previous Monitor’s Report noted that documentation to substantiate that youth received a timely orientation to the PU could not be located. To assess whether the orientation process had become more reliable, signature pages for youth currently housed on the PU were requested for review. [Only those youth who were admitted since the previous Monitor’s report was issued were reviewed, given that the facility was not aware of the problem before that time.] A total of 7 youth housed in the Progress Unit during the site visit had been admitted since January 1, 2012. Documentation was provided for all but one youth (86%) to substantiate that youth receive a complete orientation on the day of their admission to the Progress Unit.
The most recent version of the PU Youth Handbook is dated January 10, 2012 and remains in draft form. It includes information on the Unit’s rules and expectations; phases, treatment planning and treatment team meetings; programs (education, mental health, recreation, religion); telephone use, mail and visitation; grievance procedures; and access to legal services. The Monitor provided feedback to the State on the draft version of the Handbook on February 8, 2012, but as of the drafting of this report, the Handbook had yet to be finalized. It is essential for the PU Youth Handbook to provide youth with current and accurate information about the operation of the unit, and the version currently in use omits important details. Once the Handbook has been finalized, the State will be in substantial compliance with this provision.

	
  

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Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Finalize the PU Youth Handbook and policy so that they provide an accurate description of the current operation of the PROGRESS unit.

Sources of Information

• Self-assessment data and oral presentation of its interpretation for III.F.2, prepared at my request
• Intake Audit Report, October 2011 through February 2012 • Scioto Youth Handbook, dated January 10, 2012 • Grievances related to religious accommodation (n=3), submitted since
October 2011
• Draft SOP 303.01.07 “Progress Unit,” dated October 20, 2010 • Draft PROGRESS Unit Youth Handbook, dated January 10, 2012 • Orientation records for youth admitted to the PROGRESS Unit since
January 1, 2012 and still residing there during the site visit

	
  

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MENTAL HEALTH SERVICES

III.B. 1 Mental Health Screening. The State shall implement policies, procedures and practices to ensure that all youth admitted to the facilities are comprehensively screened for mental disorders, including substance abuse, depression, and serious mental illness, within twenty-four hours of admission. This screening shall be performed by qualified personnel, as part of the intake process, consistent with generally accepted professional standards of care.

Compliance Rating Partial Compliance

Self Assessment

Per the SJCF self-assessment, “this provision stipulates a comprehensive screening for mental disorders within 24 hours of admission to the facility. The specific components of this screening that we perform include the MAYSI-2 and an assessment for suicide risk by nursing staff. The risk assessment conducted by nursing staff is completed within 1 hours of admission. The MAYSI-2…is completed for every youth admitted to the facility with 24 hours of admission.”

Steps Taken to Assess Compliance

Per a review of ten intake packets provided for off site review revealed that all youth admitted had Reception Screening for Assaultive Behavior, Sexually Aggressive Behavior, and Risk for Sexual Victimization on the day of admission. Substance Abuse Screening was included via documents, such as the Juvenile Automated Substance Evaluation. These documents although completed, were not dated within 24 hours. It was notable however, that every assessment example provided recommended further assessment by psychology staff to complete a Behavioral Health Appraisal. The intake packets provided for review did not include documentation of the immediate screening by nursing staff, nor did include MAYSI-2 results.

Per interviews performed during the monitoring visit, it was apparent that current policy and procedure regarding this process was confusing, mostly related to the multiple assessment documents and terminology utilized. In an effort to address this issue, and to simplify all Behavioral Health policies, ODYS promoted a review and revision of all policies with the involvement of central office leadership, facility administration, and facility behavioral health staff. Individuals were assigned to work groups with responsibility to review and revise policy as part of an integrated behavioral health system of care. This policy revision has been provided to the monitors in both this and the S.H. vs. Reed matter for review and comment. This policy review is currently in progress.

Please note that throughout the mental health report, there are multiple references regarding the need to finalize policy and procedure. While policy and procedure is in existence and has been implemented to address processes associated with the delivery of mental health care, ODYS is currently in the process of a review and simplification of said policy. As such, the recommendation for finalizing policy is in reference to the revision and simplification process. There are existing policies in place that are fully implemented and as such the individual provisions below would

	
  

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meet the criteria for a partial compliance rating. The plan to simplify policy and via this process integrate the various mental health disciplines into a behavioral health team is positive and may result in more cohesive mental health treatment for the youth.

Recommendations Sources of Information

While it is apparent that multiple assessment instruments are utilized for youth admitted to ODYS, this remains a complicated process, highlighting the need for policy and procedure revision and quality assurance monitoring. Materials provided for off site review did not clearly reveal to the monitor the response to this provision.
In order to reach substantial compliance with this provision, the State must: 1. Fully implement policy and procedure “Behavioral Health Assessment,
Screening, Appraisal and Evaluation.” Given the change in facility mission, review and revise this policy as necessary. 2. Begin quality assurance monitoring or clinical supervision regarding the reception assessment summary documents. 3. Begin quality assurance monitoring to ensure that timelines required by policy and procedure are adhered to.
• Review of provided documents • Staff interview

	
  

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III.B.2 Immediate Referral. If the mental health screen identifies an issue that places the youth’s safety at immediate risk, the youth shall be immediately referred to a qualified mental health professional for assessment, treatment and any other appropriate action, such as transfer to another, more appropriate setting. The State shall ensure that, absent extraordinary circumstances, qualified mental health professionals are available for consultation within 12 hours of such referrals.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “ODYS has submitted examples…of youth identified through the initial mental health screen as needing to be referred to a mental health professional or alternative placement.”

Steps Taken to Assess Compliance

This was an area of apparent improvement in the intervening period since the previous monitoring review. Discussions with behavioral health staff revealed that they felt empowered to advocate for the youth in the facility without fear of reprisal. There were examples of active advocacy noted. For example, previously, if a youth were suspected of acute mental health needs requiring transfer to the mental health unit, there was a cumbersome process to arrange this transfer. With recent shifts in process and administration, this is now reportedly a relatively painless process.

For example, following the monitoring visit, a youth 999 was readmitted to the facility. Staff were familiar with this youth, and aware of his history of treatment on the mental health unit in the past. The staff wasted no time in contacting ODYS central office to request immediate transfer of this youth to the mental health unit. Following the initial contact by email, a return email was sent within ten minutes with a central office approval for transfer. Per documentation, this youth was transferred to the mental health unit the following day.

In a second example, youth 111 was experiencing a deteriorating mental status. Facility behavioral health staff were noted to have made valiant efforts to address this youths increasing mental health needs; however, this youth required more intensive services than could be provided in a correctional facility. Ultimately, this youth was referred, accepted, and transferred to a residential behavioral health program.

Given the review of the current behavioral health staff schedule, staff are working a flex schedule with one required evening per week and one required weekend per month. This allows for broad behavioral health coverage. One weakness of the schedule was the lack of behavioral health staff scheduled on holidays. There was an on-call schedule, and the Psychology Supervisor was responsible for this, specifically after hours telephone contact. The Psychology supervisor was also reportedly available to come to the facility for face-to-face assessments if the need arose.

Given the review of documents performed for this and other paragraphs, it was apparent that there was an improvement in referral to a mental health provider,

	
  

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Recommendations Sources of Information

response from mental health providers, and access to other mental health treatment programs as needed. As such, this provision will be placed in Partial Compliance. In order to improve this level, ongoing efforts must be made to ensure that youth obtain the level of care that is necessary. In addition, quality assurance monitoring will be necessary with regard to timely response to referral and access to other behavioral health care options.
In order to reach substantial compliance with this provision, the State must: 1. Collect data regarding the time lapse between referral and actual evaluation
or assessment for quality assurance monitoring. 2. Ensure that staff are aware of the process by which a youth may access
other appropriate mental health services (e.g. a facility based mental health unit or an inpatient psychiatric facility).
• Review of provided documents • Observation • Staff interview

	
  

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III.B.3 Identification of Previously Unidentified Youth. The facilities shall implement policies, procedures and practices consistent with generally accepted professional standards of care to identify and address potential manifestations of mental or behavioral disorder in youth who have not been previously identified as presenting mental health or behavioral needs requiring treatment.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “we have provided examples…demonstrating appropriate identification of mental health needs as well as appropriate actions to transfer youth to our mental health unit and/or an alternative facility. ODYS will continue to monitor and improve the process of identifying youth with mental health needs that were not previously identified.”

Steps Taken to Assess Compliance

With regard to the identification of youth previously unidentified as having mental health challenges, the facility has made changes to the facility environment in an effort to ensure that all youth requiring services are identified as such. For example, there are behavioral health staff (both psychology and social workers) housed on the units. There was also enhanced mental health presence on the Progress Units.

A review of the total number of youth currently on the mental health caseload revealed that 26/27 female youth (96%) were identified. With regard to male youth 64/107 (59%) were currently identified. Additionally, via a review of the caseloads of psychology staff assigned to the Progress Units, it was apparent that 100% of the youth currently housed on those units were identified and currently receiving mental health services. Per discussions with facility staff, it was planned that all youth admitted to the Progress Units would join the mental health caseload while housed on those units.

Recommendations

The goal of this provision was to ensure that youth who may not present with a history of mental illness and who are not identified at the time of initial assessment as being at risk for mental illness or behavioral challenges, are monitored over the course of their incarceration for exacerbations of symptoms and referred for mental health treatment. Administrative staff were aware of the need for ongoing and improved quality assurance to review documentation and the decision making process regarding youth mental health needs. As discussed in provision 4 below, multiple assessment documents were being generated, however, there was wide variability with regard to case formulations reviewed in the documents that tied all the information obtained together in a coherent package for the reader. This was an area that would be amenable to quality assurance, peer review process and clinical supervision.
In order to reach substantial compliance with this provision, the State must: 1. Quality assurance monitoring regarding re-evaluation of youth who
experience an exacerbation of mental health symptoms or behavioral challenges. 2. Ensure the creation of a case conceptualization for each youth.

	
  

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Sources of Information

3. Ensure that direct care staff and behavioral health staff are trained to recognize and respond to signs and symptoms of serious mental illness.
4. Maintain the practice of assigning all youth admitted to the Progress Units to the mental health caseload.
• Review of provided documents (e.g. Policy and Procedure, draft Policy and Procedure, youth records).
• Staff interview

	
  

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III.B.4 Mental Health Assessment. The State shall implement policies, procedures and practices to ensure that, as part of an overall assessment of the youth’s health, risks, strengths and needs, youth who are identified in screening as having possible mental health needs receive timely, comprehensive and accurate assessments by qualified mental health professionals, consistent with generally accepted professional standards of care. Assessments shall be designed and implemented so as to identify youth with mental disorders in need of specific treatment and contribute to a full plan for managing the youth’s risk. Assessments shall be updated as additional diagnostic and treatment information becomes available.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self assessment “Our QA/QI efforts continue to evolve and develop, with increasing focus given to case conceptualization. Individual and group supervision, both clinical and administrative, are the central components of this effort…We believe the contract in regards to this provision between the treatment teams on the girl’s dorms and the boy’s dorms highlights a critical structural issue... The treatment teams on the girl’s dorms are more mature…and function as the primary unit of identification for staff members...treatment teams on the boy’s dorms are less mature, continue to have difficulty with consistent staff attendance and assignments, and do not function as the primary unit of identification for staff members… traditional divisions between the different professions and departments continue to the primary identifiers for staff members, resulting in less communication and collaboration…..We believe the shift to viewing the treatment team as one’s primary unit of identification is in process on the boy’s units, with our Cedar and Sycamore teams having made the most progress to date…discussions in treatment teams are more animated, detailed, clinically rich, and directed. Team members increasingly are developing more detailed and inclusive assessments and understandings of the youths with whom they are working… With continuing support from Social Work and Psychology Supervisors, clinical leadership on the team, and increased stability among unit staff, we believe we will see continuing improvement in matters related to this provision…we currently are reviewing and revising Behavioral Health Services policies and the requirements and intent of this provision will be addressed in those revisions.”

Steps Taken to Assess Compliance

Per the previous monitoring report, policy and procedure entitled “Behavioral Health Assessment, Screening, Appraisal and Evaluation” was scheduled for full implementation 3.1.11. Per interviews with facility administrative and mental health staff as well as DYS administration, there were plans to review and revise current policy and procedure regarding behavioral health. This was necessary not only due to omissions in the previously authored documents, but due to the recent change in mission incurred at SJCF. This policy, along with others regarding Behavioral Health services have been reviewed and revised in a collaborative manner between ODYS administration and facility behavioral health staff. The policies have been submitted to the monitors for review and comment. This review is currently in process.

A necessary part of any mental health assessment is the case conceptualization

	
  

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or diagnostic formulation. This information is intended to review specific symptoms experienced by the youth in order to justify a specific diagnosis. In addition, the diagnostic formulation or case conceptualization must integrate relevant factors impacting a youth’s development/behavior/mental status, including biological, psychological, social, and cultural perspectives that can be utilized by the clinician to identify specific risk factors or targets for ongoing behavioral and mental health therapies. From this information, an individualized and integrated treatment plan could be derived.
Ten examples of case formulations were provided. This included five psychological services summaries and five behavioral health appraisals. As discussed in paragraph 10, the Behavioral Health Appraisal forms have been revised, and include more pertinent information. The quality of these documents as well as the psychological services summary was variable and would likely benefit from quality assurance monitoring. For example, two of the documents provided for review were incomplete. It was noted that there are plans for training regarding case formulation in July 2012 via the subject matter expert from the S.H. vs. Reed team.
For example, a good case conceptualization was authored in the case of youth 777. This youth had diagnoses including among others Posttraumatic Stress Disorder. Per the case formulation, “progress is affected by her history of complex developmental history of trauma and loss. Complex trauma involves multiple, chronic, and prolonged traumatic events, which are usually interpersonal in nature, have an early life onset, and have negative effects on normal development. The level of trauma can interfere with neurological development and the capacity to integrate sensory, emotional, and cognitive information. Someone who experiences developmental trauma often have difficulties learning how to modulate their emotions and regulate internal states, may develop disorganized and insecure attachment styles, or have trouble understanding themselves and their surroundings. [Youth name] in particular appears to have difficulties with attachment, affect regulation, self concept, and behavioral control. Secondary to the early interpersonal trauma a child will develop insecure attachments to caregivers and other people. The youth does not learn how to regulate themselves or trust and count on people to take care of them. These attachment difficulties are evident when a youth has problems with boundaries, social isolation, interpersonal difficulties, and problems with perspective taking…[Youth name] response to treatment has varied, at times she has been eager to address issues, but when she is angry she will become defiant and state she does not feel she needs to …These responses are often heard when she is non-compliant with her psychotropic medication. Her lack of maturity and social skills has interfered with her ability to integrate the things she has learned.” The above conceptualization provides information regarding the developmental and psychological processes affecting the youth’s ability to engage in programming.

	
  

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Other examples were less satisfactory. For example, in the case of youth 888, who had diagnoses including conduct disorder, cannabis abuse, cocaine abuse, and Dysthymic disorder, “committed to ODYS for receiving stolen property…did report episodes of low mood, loss of interest in activities that are usually enjoyable to him. He reported a subjective sense of confusion, ambivalence regarding his future- vocational interests, a life plan, or skills needs, or wants. He reported that his mother has a history of drug abuse, and that their relationship is estranged. He reported that he has an extensive history of substance abuse. His father and brother have a history of legal problems…has been in substance abuse two times [sic]; however, he continues to abuse substances he is placed on the mental health caseload to address his substance abuse, and his mood, which appears Dysthymic. It is likely that addressing these issues may assist him in clarifying a direction for his life.” This case formulation was basic and written essentially from the youth’s self report. There is little information here that would assist the treatment team in treatment planning, other than then need for substance abuse treatment. It is not possible to determine what premorbid risk factors contributed to his current situation.

Recommendations Sources of Information

As indicated in the previous monitoring report, despite the generation of multiple assessment forms, there was no document to tie all the information obtained together in a coherent package for the reader, treatment team, or future treatment provider inclusive of a diagnostic formulation or case conceptualization. The current documentation was an attempt to improve upon that process, but there is work to be done from a quality perspective. It is hoped that specific training regarding this process will be beneficial for staff. Following training, peer review and quality improvement efforts will be necessary.
In order to reach substantial compliance with this provision, the State must: 1. Continue and expand quality assurance measures including a peer review
process and clinical supervision to ensure the development of a case conceptualization that ties together information gleaned in the assessment process. 2. Consider individual clinical supervision regarding the assessment process and development of the case formulation. 3. Ensure that behavioral health staff are aware of the necessary components of a quality case formulation. 4. Review and revise policy and procedure to reflect the requirements of this provision and the new facility mission.
• Review of policy and procedure • Review of youth records • Review of other provided documents • Staff interview

	
  

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III.B.5 Adequate Mental Health Care and Treatment. The State shall implement policies, procedures and practices to ensure that adequate mental health and substance abuse care and treatment services (including timely emergency services), and adequate rehabilitative services are provided to youth in the facilities by qualified mental health professionals consistent with generally accepted professional standards of care.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “The facility has begun to implement Cognitive Behavior Therapy for all Pre-Service classes during…first week the new staff is on grounds…participate in the training which includes practice with leading groups, understanding the basis for Cognitive Behavior Therapy and its effectiveness with working with youth in this type of setting…learn how to implement some of the tools…Decisional Balance Worksheet, Thinking Report and ABC Worksheet into every day practices on the unit to reinforce the use of the …concepts with the youth when they encounter problems…All three supervisors conduct ongoing clinical supervision with their staff to provide oversight and work toward improvement of clinical documentation and services in SJCF…If social services staff is going to be out for leave, they are instructed to leave the youth with packets of material to complete, and then the clinician will work with the youth when they return to review the information. In addition, we have had staff provide ongoing services if there is a vacancy on a unit either by paying overtime to cover the caseload, or the other clinician on the unit will see the youth to provide services…We monitor continually the mental health needs of youths on Progress Unit…psychology staff is housed on the units with immediate and direct access to youth…Clinical supervision with psychology staff on the Progress Units now occurs weekly…the psychology supervisor is an active participant in all meetings having to do with the Progress Units and maintains direct contact and involvement with the treatment teams on both units. Past confidently concerns have been addressed and other concerns of proper and ethical practice, as well as competent clinical practice, are primarily matters addressed in supervision meetings…We consider the question of appropriate placement on the Progress Units to be of paramount importance, and have identified and made alternative arrangements for youths in the past who were not appropriate for this unit. We have enhanced our ability to identify contraindications for placement on Progress Units. We recognize this to be an ongoing responsibility and obligation.”

Steps Taken to Assess Compliance

In reviewing the Freedom New Phoenix Cognitive Behavioral Health program curriculum, the inclusion of direct care staff is vital to the success of the program. Per the observation conducted during this monitoring period, documents provided and the self-assessment, it was reported that youth specialists are being integrated into treatment team meetings to further involve them in group process and gather information regarding their observations of youth (see the discussion below regarding paragraph 7 for additional information).

	
  

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Youth specialists facilitate CBT groups on the units. It appeared from the three youth specialist run groups observed during the monitoring tour that there was wide variability in the ability of individual staff and as additional training, coaching, modeling was required. Basic tenets of effective group facilitation were not utilized consistently, these included environment, review of group rules, direction of group topic, and engagement of the youth.
In one group interaction led by youth specialists, youth were initially reluctant to participate. They indicated that they had heard the material before, and it wasn’t helpful. Ultimately, the facilitator engaged the youth by allowing them to present a skit illustrating the day’s concept. This was an excellent intervention by the youth specialist, which unfortunately, due to the youth specialist inexperience with group dynamics ended with one youth essentially taking over the group and taunting the other group members. This illustrated the need for improved coaching for staff facilitators.
In the second youth specialist facilitated group observed, youth were seated haphazardly, not in a circle or semicircle conducive to engagement. The youth specialist was observed to be making sincere effort to engage the youth in the topic and the discussion. Approximately 15 minutes into the group, the unit manager entered and requested youth rearrange seating to improve the interaction. Following the rearrangement, the group facilitator was excluded from the circle, further impeding her ability to engage the youth. At this point, the unit manager began leading the discussion, with the focus on unit activities planned for the upcoming week. Ultimately, the discussion reverted to the scheduled topic, however, the youth would have benefitted from alternate modalities to promote learning (e.g. role model, skit, visual aid). This event highlights the need for routine treatment integrity checks by supervisory staff in order to ensure that staff administers the group therapeutic interactions appropriately.	
  
The above examples indicate that while there have been some improvements to the youth specialist facilitated group therapies, additional improvements are needed. Quality assurance in the form of treatment integrity checks to determine the need for increased supervision or facilitation skills for staff is necessary. Following these reviews, the training provided to youth specialists with regard to group facilitation may need to be reviewed and revised in order to ensure that principles are being appropriately addressed. In addition, staff could consider allowing youth to co-facilitate. Also the development of learning based activities for group therapies would assist in maintaining youth interest.
With regard to group therapeutic interaction facilitated by behavioral health staff, a trauma treatment group co –facilitated by psychology and occupational therapy was observed. The group leaders were obviously well prepared. Unfortunately, the start of group was delayed by fifteen minutes due to a

	
  

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scheduling conflict. Administrative staff reported plans to review the schedule in an effort to reduce conflicts that impacted therapeutic interaction. This group functioned less as an interaction between staff and youth and more like a lecture or education regarding specific concepts. There were multiple opportunities for facilitators to explore specific topics with the youth; however, these were not utilized in favor of adhering to the prepared course outline. In fact, one youth attempted further discussion of a topic and was instructed by the leader to “stay on track.” He was obviously upset by this. Ultimately, the occupational therapy staff sat at the table with the youth and engaged them. This was beneficial, and at the end of the scheduled group time, youth did not want to leave.
A second group therapy observed with Behavioral Health staff revealed a girls trauma group where youth were actively engaged in the therapeutic process. The therapist followed the youth’s lead in the discussion. The group leader was obviously more skilled, and thus led an effective group. A similar observation was made during the brief observation of a social worker facilitated group on a male general population unit.
These latter two group observations revealed that there are skilled group therapy providers who could provide role modeling to other less experienced clinical staff. Additionally, they could assist with the development of activities to enhance the youth’s participation in the group therapeutic process. All of the above indicate the need for quality assurance monitoring inclusive of observation and coaching for both behavioral health and youth specialist staff.
With regard to the number of scheduled groups and the number of youth participating in any one group therapy encounter, this was discussed in detail in the discussion regarding paragraph 11 below. There was documentation of attendance at groups that exceed recommendations for conducting a meaningful group interaction.
Review of progress notes regarding both group process and individual treatment was limited during this monitoring visit, as youth records were not provided for off site review. Rather, there were isolated examples of youth individual therapy progress notes provided as examples for other items. In review of these documents, there was variability in the quality of the documentation, the duration of the therapeutic interactions and the frequency of the therapeutic interactions. Some mental health providers were noted to meet frequently with youth for brief periods of time (15 minutes to 30 minutes), where others met less frequently for longer periods (45 minutes). A review of treatment planning documents did not reveal documentation regarding the level of care or frequency of interaction prescribed for each individual youth. Therefore, it was not possible to determine if the frequency noted via record review was appropriate for a particular youth.
Given the above, it was apparent that while some treatment was occurring,

	
  

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Recommendations Sources of Information

improvements to the overall treatment program and documentation of treatment planned and provided will be necessary for the facility to meet the requirements of this provision. Specific concerns were noted regarding the treatment program for youth housed in the Progress unit during the prior monitoring visit. It was noted that given the increased presence of behavioral health staff on these units with the corresponding decrease in youth census on these units that there was improvement in the overall monitoring and treatment provided for these youth. As discussed with the facility administration, facility mental health staff and DYS administration, the programming on this unit must continue to be a priority and will be the focus of future monitoring visits.
In order to reach substantial compliance with this provision, the State must: 1. Improve documentation of group and individual therapeutic interaction and
review this documentation via a quality assurance process. 2. Ensure the provision of evidence based group therapeutic interactions 3. Increase modeling and coaching for youth specialists responsible for group
therapeutic interactions. This should include group therapy observation and resultant corrective action inclusive of training, supervision, etc. Administrative staff may determine that revised training for youth specialists is required. 4. Determine and ensure that appropriate numbers of youth are assigned to specific group therapy sessions. 5. Continue the integration of treatment provider disciplines in order to achieve an interdisciplinary model. 6. Continue to engage and encourage direct care staff to participate in group modalities and in the overall treatment program for the youth. 7. Begin quality assurance monitoring regarding the mental health treatment program that addresses both adherence to the required procedural elements but also measures youth outcomes related to the treatment modality (e.g. reduction in SHU referrals, reduction in facility violence). 8. Review the Progress program, and ensure that youth are receiving appropriate mental health treatment via this program.
• Review of provided documents (e.g. group schedule, youth records, policy and procedure, description of treatment modalities)
• Observation of three group interactions
• Youth interview
• Staff interview

	
  

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III.B.6 Treatment Planning. The State shall develop and implement policies, procedures and practices so hat treatment service determinations, including ongoing treatment and discharge planning, are consistently made by an interdisciplinary team through integrated treatment planning and embodied in a single, integrated treatment plan.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self assessment, “the OYAS system is not ready to be operationalized at this time…staff from across the agency have been using it on a trial basis…to allow them to give feedback…the facility is using a WORD document to write the youth Integrated Treatment Plans.” The self-assessment also outlined process by which ODYS Behavioral Health administrative staff performed a review and training with regard to staff authorship of ITP documents (this process was discussed further in the discussion regarding Paragraph 8 below). There are also plans for additional training by the subject matter expert in the S.H. vs. Reed case scheduled for July 2012.

Steps Taken to Assess Compliance

As part of the ODYS Behavioral Health administrative review, there are plans for continuing monitoring with regard to the authorship of ITP documents. As discussed in paragraph 18 below, the facility must develop a quality assurance process to review both compliance with process and to determine outcomes associated with behavioral health treatment. For additional discussion regarding Treatment Planning and IDT meetings, please see the discussion regarding the provisions below (7 and 8).

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Review, revise, and implement policy and procedure regarding treatment
planning and the IDT process. 2. Develop quality assurance monitoring regarding ITP development,
implementation, and progress. 3. Address recommendations provided regarding provisions 7 and 8 below.

Sources of Information

• Staff interview
• Review of provided documents (e.g. Policy and Procedure, Integrated Treatment Plans)

	
  

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III.B.7 Treatment Teams. At a minimum, the interdisciplinary treatment team for each youth in need of mental/behavioral health and/or substance abuse treatment should: a) be guided by a trained treatment professional who shall provide clinical oversight and ensure the proper functioning of treatment team meetings; b) consist of a stable core of members, including at least the youth, the social worker, a JCO, one of the youth’s teachers, the Unit Manager, and as warranted by the needs of the youth, the treating psychiatrist, the treating psychologist, registered nurse, and, as appropriate, other staff; c) ensure that needed psychiatric evaluations are conducted on a youth before administering psychotropic medications to the youth; d) monitor as appropriate but at least monthly, the efficacy and the side effects of psychotropic medications, including consultation with family medical, counseling and other staff who are familiar with the youth; e) for youth under a psychiatrist’s care: ensure the provision of individual counseling and psychotherapy when needed, in coordination with facility psychologists; ensure that all youth referred as possibly in need of psychiatric services are evaluated and treated in a timely manner; and provide adequate documentation of treatment in the facility medical records; f) include to the fullest extent practicable, proactive efforts to obtain the participation of parents or guardians, unless their participation would be inappropriate for some reason (e.g., the child has been removed from the parent’s custody), in order to obtain relevant information, understand family goals and concerns, and foster ongoing engagement; g) meet to assess the treatment plan’s efficacy at least every 30 days and more often as necessary; and h) document treatment team meetings and planning in the youth’s mental health records.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “The treatment team consists of a Unit Manager, Clinician(s), Providers(s), Youth Specialist(s), and staff from Mental Health Services, Psychiatry, Education, Psychology, and Recreation. Other participating staff maybe included, such as from medical services, religious services or administration. If the psychiatrist is unable to attend then he or she sends any pertinent information about a youth in his or her care to the IDT via alternate means of communication, i.e., email, telephone conversation with another team member. ODYS is continually looking at ways to increase psychiatric hours.”

Steps Taken to Assess Compliance

Two treatment team meetings were observed during this monitoring visit. In both observations appropriate staff were present. In no case was a parent participating. One team, well established on the girls mental health unit, did a good job of reviewing the youth and their progress toward goals. There were challenges noted, as one youth was experiencing side effects due to her prescribed medications. This youth was reportedly experiencing sedation, and in an effort to address this, the team entered into a discussion regarding rearranging her daily schedule to accommodate her sedation. This was an instance where having the psychiatrist, as an integral part of the team would be beneficial. Rather than arranging the youth’s schedule (which would not be possible in the community), the psychiatrist could adjust the medication regimen in an attempt to avoid medication side effects.

The second team observed, on the Progress Unit, was not as well established. The team discussed the youth’s progress toward treatment goals; however, much of the review was anecdotal and did not rely on actual behavioral data. In the case of one youth reviewed, the treatment team members had varying opinions

	
  

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Recommendations

on the youth’s diagnosis and motivations for behavioral challenges. There was an obvious need for better integration of services and the formulation of a collaborative case conceptualization so that all team members could “be on the same page” with regard to the management of this youth. It was opined that as this team was newly formed, they would need the benefit of time to increase team cohesion and collaboration. In discussions with some team members, they were aware of the shortcomings of the team process and the need for improvement. This was encouraging, as in previous visits, Behavioral Health staff were not able to identify their own weaknesses.
In previous monitoring reports, a shortcoming addressed was that in general:
IDT minutes reflected significant time spent in the discussion of “housekeeping” issues such as the unit schedule and youth rules. With the exception of the girls mental health unit (where documentation of IDT addressed youth mental health issues) documented discussions, particularly regarding mental health treatment issues appeared to be minimal. This had improved over prior visits. Per discussions with ODYS Behavioral Health administrative staff, there were plans to move the discussion of unit issues to the end of the IDT meeting in order to minimize the “housekeeping” discussion and highlight the importance of the youth’s treatment.
One of the recommendations from the March 2011 report was to integrate youth specialists into weekly IDT meetings. The self-assessment reported “a QI process was implemented regarding the integration of direct care staff…there has been an increase in Youth Specialist presence and involvement in all Interdisciplinary Teams.” Unfortunately, results of this QI process or other quality assurance monitoring regarding IDT meetings were not presented for review. During the two observed IDT meetings, youth specialists were present and were noted to actively participate in the discussion. This was indicative of some effort to include all disciplines in review and planning of youth treatment. Documentation regarding activities performed to integrate youth specialists with regard to mental health treatment revealed, “there have been no activities performed in the previous six months regarding efforts to integrate youth specialists with regard to mental health treatment.”
Reportedly due to an ongoing paucity of psychiatric resources, the psychiatrist was not a consistent participant in IDT meetings other than the girls mental health unit. This was not acceptable as there were mentally ill youth housed on units other than Davey who required the presence of their treating psychiatrist at their IDT meeting.
In order to reach substantial compliance with this provision, the State must: 1. Ensure psychiatric resources are available to allow participation in Interdisciplinary Treatment Team meetings. 2. Increase efforts to include the youth’s parent or guardian in the

	
  

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Sources of Information

treatment planning process. 3. Ensure that direct care staff are included in and valued members of
the IDT. 4. Begin Quality Assurance monitoring of treatment planning efforts and
IDT meetings. This would include both process and outcome measures. 5. Increase staff training/education regarding the timely formulation of a treatment plan and interventions developed as a result of, among other things, the discussion in IDT. These plans must then be implemented, first via training direct care staff.
• Staff Interview • Observation of Interdisciplinary Treatment Team meeting • Review of provided documents • Youth interview

	
  

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III.B.8 Integrated Treatment Plans. The State shall ensure that each youth in need of mental/behavioral health and/or substance abuse treatment shall have an appropriate, integrated treatment plan, including an appropriate behavior management plan that addresses such needs. The integrated treatment plan shall be driven by individualized risks and needs, be strengths-based (i.e., builds on an individual’s current strengths), account for the youth’s motivation for engaging in activities contributing to his/her wellness, and be reasonably calculated to lead to improvement in the individual’s mental/behavioral health and well being, consistent with generally accepted professional standards of care.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “the facility has had training from…Central Office…ITP’s [Integrated Treatment Plans] that have been created by the teams reviewed and critiqued by them for quality…quality…will continue to be monitored by the clinical supervisors.” In addition, there are plans for a two day training by the subject matter expert in the S.H. v. Reed case regarding case formulations and ITP writing for Behavioral Health Staff at SJCF. This is scheduled for July 2012.

Steps Taken to Assess Compliance

Document review revealed some improvement in ITP documentation. Specifically, youth strengths and measurable goals were identified on some documents. There was room for improvements with regard to ensuring goals were measurable. In the majority of examples, interventions were identified. For example in the case of youth 555, the goal was, “I will decrease my risk for violence by increasing my understanding of risk factors underlying my aggression and violence while preparing for transition back to the community.” This is a multipart goal that is not measurable. There were specific interventions identified, “…completion of Understanding Yourself Workbook pages 25-33 and process with my Social Worker.” This youth reportedly had strengths with regard to writing poetry, which could be utilized as a therapeutic intervention. With regard to process, “[youth name] has completed all of his assignments, but he has regressed and he has not made any progress.” It would be necessary to identify other interventions that may be utilized with this youth. Review of minutes from treatment teams regarding this and other youth revealed that youth goals were documented as discussed on a regular basis. There were notations, specifically 3.8.12 stating, “he needs to decrease assaultive behavior.” There was no notation of what adjustments in treatment interventions would be to assist the youth in attaining this goal. Observation of treatment teams revealed that in general youth treatment goals and their progress (or lack thereof) was being reviewed, however, as in the case outline above, identification of specific interventions for youth remained a relative weakness.

What was positive was that ODYS had recognized the staff weakness with regard to development of the ITP and proactively began a training and review program for staff. As stated in multiple areas of this document, Behavioral Health policy and procedure, including policy regarding treatment planning has recently been revised and presented to monitors for review. This review is pending.

	
  

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As stated previously:

Acceptable Integrated Treatment Plans must include measurable goals and objectives, with available targeted interventions to address each goal. Progress notes authored regarding the youth’s treatment should refer to the youth’s treatment goals and document the response (or lack thereof) to the prescribed interventions…Integrated Treatment Plans should be reviewed at each Interdisciplinary Treatment Team meeting scheduled for the youth, and must be authored and reviewed with the participation of the youth and their parent or guardian (if appropriate).

Recommendations

It was apparent that ODYS is attempting to improve their treatment planning services in order to achieve compliance with generally accepted practices. As this process evolves, quality assurance monitoring with corrective action (inclusive of additional staff education and training) will be necessary.
In order to reach substantial compliance with this provision, the State must: 1. Finalize and implement policy and procedure regarding Integrated
Treatment Plans. 2. Continue training for Behavioral Health Staff regarding development of
Integrated Treatment Plans. 3. Ensure that Integrated Treatment Teams utilize the Integrated Treatment
Plans as a road map for youth treatment and progress, and that the Integrated Treatment Plans are updated regularly as per policy and procedure pending review of revision. 4. Develop quality assurance monitoring tools that are both process (e.g. were the targeted interventions appropriate for a particular youth; were measurable goals and objectives identified; per a review of the youth’s progress notes, did treatment provided to the youth follow the outline of the Integrated Treatment Plan) and outcome oriented (e.g. did the youth improve over the course of treatment per the Integrated Treatment Plan).

Sources of Information

• Staff interview • Review of provided documents (e.g. draft policy and procedure) • Review of youth records

	
  

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III.B.9 Access to a QMHP. The State shall develop and implement policies, procedures and practices to ensure that youth who seek access to a qualified mental health professional are provided appropriate access in a timely manner.

Compliance Rating Partial Compliance

Self Assessment

Per the Self-Assessment review “To enable youths to access mental health services directly without having to go through unit staff or another staff, locked boxes have been placed on each living unit for submission of written requests for services. However, the structure of our living units and placement of mental health staff offices on the living units has encouraged a pattern of youths asking psychology staff directly if they wish to talk or to be seen by mental health staff,. Because youths learn staff schedules within a short time of arrival on a unit, they seldom make a formal request by any other means, choosing instead to wait until their psychologist is back on grounds.”

Steps Taken to Assess Compliance

Per review of policy and procedure entitled “Mental Health Referral, Evaluation and Disposition,” and the associated policy entitled “Referrals to Mental Health Services” performed for the previous monitoring report, these documents outline the process for any facility staff to refer a youth for an assessment to determine the need for mental health services. There are designated time limits for response to requests. Psychology must respond within five working days, psychiatry within ten working days and if the request is for additional evaluation, there is a fourteen working day response window. Per report of behavioral health staff, the above policies have been revised as part of the overall review and revision of policy. These policies have been presented to monitors/subject matter experts in both this case and the S.H. v. Reed case for review and comment. This commentary is pending.
In an effort show compliance with the above provision, ten examples of youth contact with psychology staff were provided (these were for nine different youth, two examples were for the same youth). Supervisory staff indicated that currently, the practice is for psychology staff to indicate the time of the youth’s request and the time that the assessment began. Of the provided examples, all were seen due to the verbal request of the youth. All of the youth were seen within minutes to one hour of their request, with seven seen immediately upon their request.

Per the self-assessment and observation, secure mailboxes have been provided on the units for youth to request services without reliance upon direct care staff to communicate their request. Psychology or social work staff check these boxes daily. Youth interviewed during this monitoring tour were able to show the monitor the box within which to place their requests for services on their individual units. It is imperative that youth are able to independently access mental health care; as unfortunately, there may be situations where direct care staff could unintentionally or purposefully impede the youth’s access to necessary mental health treatment with resultant negative outcomes. Given the Behavioral Health presence on the units, this is less of a concern, however,

	
  

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there are times (nights and weekends) where Behavioral Health staff are not immediately available, and youth must be able to make independent requests for services.

One concern noted and communicated during the previous and current monitoring tours was access to mental health services for youth housed on the Progress unit. These youth were assigned to single cells where they remained the majority of the day. Youth on phase one of the program are in ambulatory restraints (“gators”) when they are outside of their cells. There have been changes to the procedure for monitoring on the Progress Units, specifically, psychology and social work staff are required to make daily contact with youth on phase one which includes a mini mental status examination and encouraging youth to meet with and talk to the Behavioral Health staff. Per record review performed during the monitoring visit, documentation of these encounters was located. Staff interviewed indicated that in some cases, “documentation is behind…it may be handwritten.” This process must be codified in policy and procedure and reviewed via quality assurance.

It should be noted that in general, youth interviewed in general population and on the girls mental health units believed that they had good access to their counselor and that their needs were addressed in a timely manner. Youth housed in the Progress Units were less satisfied with their mental health treatment and contact. Interestingly, the youth interviewed on the Progress Unit were able to state their goals of treatment. Additionally, per the treatment team meeting observed during this visit, staff were more knowledgeable about the youth in general, this was opined to be indicative of the enhanced Behavioral Health presence on these units.

Recommendations Sources of Information

Per a review of mental health staff schedules provided, mental health staff scheduling included both evening (until 8:00 p.m.) and weekend hours, allowing for better daily coverage of youth mental health needs. However, of the mental health staff, only the psychology supervisor was on-call 24 hours per day.
In order to reach substantial compliance with this provision, the State must: 1. Revise policy and procedure to reflect requirements for daily mental health
assessments for those youth on Phase One housed on the Progress unit. 2. Determine the mental health assessment requirements for those youth on
Phase Two housed on the Progress Unit. 3. Develop quality assurance monitoring to ensure timeliness and adequacy of
clinical contact with those youth housed on the Progress Unit. 4. Develop quality assurance monitoring to audit requests for mental health
services inclusive of staff response time as well as timelines for completion of other mental health services as outlined by facility policy and procedure. 5. Ensure the youth’s open access to mental health services
• Facility self-assessment • Review of provided documents

	
  

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• Youth interviews • Staff interviews

	
  

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III.B.10 Mental Health Involvement in Housing and Placement Decisions. The State shall develop and implement a system for ensuring that significantly mentally ill youth who do not have the adaptive functioning to manage the activities of daily living within the general population are provided appropriate housing and supports to assist them in managing within the institutional setting.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “we have made changes in both the BHRP [behavioral health review panel] form and process that we believe will improve the development of treatment plans and contribute significantly to the goal of case conceptualization within the treatment teams...revised…reporting form provides a direct link from the OYAS results to the individual’s ITP, and provides clear guidance and direction for identification of treatment goals and objectives…it allows for adaptation and change to address unique circumstances each youth presents…moved the process form the orientation unit directly to the treatment team that will be working with the youth throughout his program…this will enhance the team’s knowledge and understanding of each youth…increase the possibility of smooth and successful transition...this change…will be included in the revised Behavioral Health Services policy…youth admitted…are screened, appraised and assessed within 30 days of admission…with the boy’s population, greater than 65% are identified as being in need of mental health services, with approximately 5 – 8% of these identified at the time of admission or at some later point…as being in need of…a specialized mental health unit or life skills unit…girl’s population, greater then 95% are identified as being in need of mental health services…20% identified as being in need of placement on the…mental health unit…at admission or…later in their incarceration…Monitor(s) have expressed concern…that mental health staff might be inadequately trained to identify signs and symptoms of serious mental illness in need of specialized care…supervisors…as well as…Administrative Psychiatrist…continue to monitor this…one alternative explanation of this might be that our population consists of adolescents who are in a state of rapid…changes, some of which may be related to the gradual emergence of symptoms of mental illness and/or a changing response to various psychotropic medication.”

Steps Taken to Assess Compliance

During the monitoring visit, it was discussed that policy and procedure was in the process of review and revision. The revised policies have been provided to the monitors and are in the process of a detailed review. Per staff interview, a new form has been developed that is completed by the assessing clinician for presentation to the treatment team, who then functions as the Behavioral Health Review Panel making the determination regarding housing decisions.

With regard to placement on the Progress Units, the census on these units had decreased substantially from the previous monitoring visit. Previously, there were 18 youth housed on each Progress Unit, currently both units together had a total population of 18 youth (11 youth housed on Cedar and seven youth housed on Sycamore). In order for youth to enter the Progress Units, a new

	
  

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Recommendations

referral process had been developed. Staff are now required to complete referral packets that must be presented facility administration for approval. Once placement is approved at the facility level, these admission packets must be approved by ODYS central office. For those youth with current mental health diagnoses or conditions, central office Behavioral Health staff are consulted. Unfortunately, no examples of this process were provided for off site review. As noted previously, policy and procedure is in the process of review, and this process will reportedly be included in the resultant drafts.
Ten examples of intake assessment and subsequent Behavioral Health Appraisal documents were reviewed. In the sample provided, all youth were referred for a Behavioral Health Appraisal at intake. Included in the Behavioral Health Appraisal was a recommendation for placement. The monitor was not able to determine how youth who are not recommended for further assessment via the Behavioral Health Appraisal are assigned to a housing unit.
Per a review of provided documents, the Behavioral Health Appraisal documents had been revised. The revision had resulted in a comprehensive document including demographic information, previous living situation, social history, developmental issues, school functioning, employment history, alcohol/drug history, mental health treatment history, history of suicidal/self injurious behavior, abuse history, problem checklist, mental status examination, assessment of cognitive functioning, diagnosis, and summary/recommendations. Recommendations included behavioral alerts, placement recommendations, treatment recommendations, recommendation for placement on the mental health caseload, considerations for specific treatment programming, and PREA recommendations. While overall there were improvements noted in the quality of documentation, variability remained. Some documents were completed; others were not. This is an area that should be monitored via quality improvement.
In order to reach substantial compliance with this provision, the State must: 1. Review and revise policy and procedure to reflect the change in practices. 2. For those youth who require enhanced treatment following the initial
placement determination, consider performing retrospective record review (e.g. QA) in order to improve assessment and placement process. 3. Begin quality assurance monitoring regarding intake and placement documentation and processes. 4. Indicate the method by which youth who are not referred for a Behavioral
Health Appraisal are assessed for appropriate placement within the facility. 5. Improve documentation promulgated by the Behavioral Health Appraisal.

Sources of Information

• Staff interview • Review of provided documents

	
  

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• Review of youth records • Youth interview and observation

	
  

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III.B.11 Staffing. The State shall staff, by contract or otherwise, the facilities with adequate numbers of psychiatrists, psychologists, social workers, and other mental health professionals qualified through training and practical experience to meet the mental health needs of youth residents, as determined by the acuity of those needs. Mental health care shall be integrated with other medical and mental health services and shall comport with generally accepted practices. The State shall ensure that there are sufficient numbers of adequately trained direct care and supervisory staff to allow youth reasonable access to structured programming.

Compliance Rating Partial Compliance

Self Assessment

The facility self-assessment for this monitoring period did not include information regarding this paragraph. Per staff interviews and a review of provided documents, it was clear that there continued to be mental health staff shortages at the Scioto facility. Currently, the psychiatrist contract is for 20 hours per week. Please see the discussion in provision 13 for further information regarding psychiatric staffing issues.

Steps Taken to Assess Compliance

Per interviews with current staff, there had been a shift with regard to their perceived ability to engage in mental health treatment. The focus of staff interviews revealed that staff felt “empowered” by facility administration to do their jobs, and believed that their opinions regarding the youth’s mental health needs would be accepted and acted upon accordingly. This was a shift from the prior monitoring visits where staff did not express this sentiment. Given this shift, staff morale was obviously improved. This improvement in morale should also reflect in improved mental health treatment for the youth.

A review of the provided documents revealed a spreadsheet of all mental health positions. There were a total of 18 filled social work positions (including two supervisory positions). Of these, 13 were licensed. There were two vacant social worker positions. One of these positions was noted as vacant as of 3.23.12. The second as of 5.9.12. This second vacancy date was likely a typographical error, as these documents were created in April 2012. It should be noted that of the 18 filled positions, two social work staff were out of work due to accessing family and medical leave via FMLA (Family and Medical Leave Act).

There were a total of eight filled psychology positions (including one supervisor). Of these four were psychology assistants (unlicensed). Four were licensed psychology staff (inclusive of the psychology supervisor). There were two vacant psychology positions, one assistant and one psychologist. These positions were noted as vacant as of 3.11.12 and 4.1.12 respectively. There was one licensed psychiatric nurse and one psychiatric nursing vacancy. The nursing position was noted as vacant as of 12.18.11. Other mental health staff positions included two occupational therapists, a transcription service, and the facility psychiatrist.

Schedules for psychology staff were provided for review. Per this document,

	
  

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psychology staff work a flex 80 hour schedule every two weeks. Regular hours are 8:30 am to 4:30 pm, and they are required to work one late night per week and one weekend per month in an effort to provide greater clinical coverage at the facility. The exception to this coverage is holidays, where per the schedule examples provided, no psychology staff is on duty. Per staff report, the psychology supervisor is on call after hours and on holidays and will present to the facility as needed.
In an effort to address clinical need on the Progress Units, mental health staff resources have been shifted. Each unit now includes one psychology staff (either psychology assistant or psychologist), and two social workers (one individually licensed). Additionally, there have been efforts to assign both a psychologist and social worker to each housing unit. These shifts were the initial phase of a larger plan verbalized by ODYS to create a behavioral health team in contrast to the previous silos inherent in having artificial divisions between the departments of social work and psychology. The revision process for policy and procedure was also a step toward this integration as per staff interview, staff from various disciplines were assigned to work groups in order to provide input into the policy and procedure documents.
Per the previous monitoring report, the workload for psychology staff had increased due to vacancies in social work staff positions. It was opined by the monitor that once social work positions were filled, it would be advantageous to examine the current psychology staffing pattern and required psychology workload in order to objectively determine the need for additional staff. With the planned integration of departments and creation of a behavioral health team focus, this may be premature. In addition, there has been great improvement in social work staffing since the previous monitoring visit where there were seven vacancies (as opposed to two current vacancies).
Per staff interviews and documentation provided regarding support staff for psychiatry, the psychiatric nurse was carrying a large workload. According to the documents reviewed, the nurse provided the following support services to psychiatry: scheduling new and follow-up appointments; preparing medical records for review; providing dictated reports for review; updating the mental health database; attending team meetings and providing updates to the psychiatrist when he was unavailable to attend; responding to staff concerns and preparing assessment information for psychiatry; assisting with the notification of parents/guardians of any changes in the youth’s mental health status or treatment; providing updates, changes, and concerns regarding youth to psychiatry; assisting in education of youth regarding mental health issues; monitoring, counseling, and reporting regarding medication compliance; and communicating day to day issues regarding psychiatric care to the health services administrator.
This list of tasks was daunting, and physically impossible for one individual to

	
  

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complete, although the individual currently in this position was doing her best to manage the workload and did not complain. In previous monitoring visits, it was reported that the second mental health nurse position had been eliminated. Documentation provided for this monitoring visit revealed that the position exists and remains open. Given the severe shortage in this department, recruitment efforts must be intensified in order to fill this position. In the absence of a full time employee, the facility could consider agency or pool nursing staff.
There were several examples in the provided documentation of the increased ingroup therapeutic activities in the intervening period since the last monitoring visit. For example, per the document review regarding youth attendance at group:
• Between 12.6.11 and 3.10.12 there were 211 male youth group units (e.g. youth attending group regarding any topic) performed by psychology or occupational therapy staff.
• Between 12.15.11 and 3.17.12 there were 1171 male youth group units performed by social work staff.
• Between 12.19.11 and 3.16 11 there were 232 female youth group units performed by psychology or occupational therapy staff.
• Between 12.15.11 and 3.17.12 there were 786 female group units performed by social work staff.
While these group therapy units are an improvement from prior contact reports, there remain issues. For example, the number of youth attending a group session was frequently noted to be excessive. This was noted more frequently with group activities led by social worker staff. For example, Core Modules provided 12.17.11 by social work staff included 22 female youth. Social worker led groups for male youth routinely included 11 or 12 male youth. This number of youth in a group interaction is not conducive to either learning or process. Behavioral health staff should determine the maximum amount of youth who may attend any one group therapy.
Additionally, while the number of units has increased, there remain improvements with regard to the number of group therapy opportunities are available. For example, per the facility roster provided for this monitoring visit, there were a total of 27 female youth housed in the facility. Taking the total number of group therapy units provided to female youth (1018) and using the current female population (27), there were a total of 37 group therapies provided to each female over the three months of data provided. This would equate to 3 group encounters per week for the three month period. As all the female youth housed in the facility were engaged in treatment on a mental health unit, it is opined that this number would be higher, with daily group encounters (e.g. a minimum of 5 per week).
For male youth, the total population per the facility roster was 107 on the date

	
  

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of the monitoring visit. Taking the total number of group therapy units provided to male youth (1382) and using the current male population as an average (107), there were a total of 12.9 group therapies provided to each male over the three months of data provided. This would equate to one group encounter for each male youth per week for the three month period.

As the behavioral health treatment program stabilizes, increased group therapeutic encounters are expected. Please note that the above group statistics do not include those groups facilitated by youth specialits. During the monitoring visit, discussions with administrative staff revealed a focus on increasing group encounters, and holding staff accountable for group. For example, previously, groups would be cancelled frequently, the new administration requires that any group cancellation must be approved by the facility program deputy. With the current behavioral health staff, each clinician should be expected to engage in a minimum number of group therapy activities per week. Quality assurance monitoring to ensure that appropriate services with regard to both quantity (number of contact hours) and quality (with regard to fidelity to the model) are necessary.

Given the serious staff shortages in psychiatry (discussed below) and mental health nursing and the need to ensure that current staff are able to provide the appropriate number of group and individual therapies to youth via a quality assurance process, this paragraph is in partial compliance.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Recruit and fill current vacancies 2. Determine the need for additional staff via workload indicators 3. Improve coordination between staff disciplines via the development of the
behavioral health team. 4. Ensure coverage for staff during required trainings and other absences. 5. Recruit and fill the mental health nursing vacancy. 6. Per the discussion included in provision 13 below, address the need for
additional psychiatric clinical resources at the facility. 7. Begin quality assurance to review both the quantity and quality of group
therapeutic interactions provided to youth.

Sources of Information

• Staff interview • Review of provided documents

	
  

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III.B.12 Medication Notice. Before renewing a psychoactive medication prescription from a community provider or commencing the administration of a psychoactive medication to a youth, the State shall ensure that the youth and to the fullest extent practicable and appropriate, his or her parent or caregiver, are provided with information regarding the goals, risks, benefits and the potential side effects of the medication and given an explanation of the potential consequences of not treating with the medication, and that the youth has an opportunity to consent to such medication. A) Involuntary administration of psychotropic medications to juveniles shall comply with applicable federal and state laws and regulations. The DYS clinical director, in consultation with the DYS medical director, shall review and request with DYS Legal Services prior to the approval for involuntary administration.

Compliance Rating Partial Compliance

Self Assessment

The facility’s self-assessment did not include information on this provision.

Steps Taken to Assess Compliance

Per the draft policy and procedure reviewed for this monitoring report entitled “Psychotropic Medication, Use and Management” education including “addressing the goals, risks, benefits, and potential side effects associated with any given medication is given to each youth and his or her parent or guardian… the prescribing physician provides an explanation of the potential consequences of not taking the medication and explains that the youth has an opportunity a consent or withhold consent to be treated…provides guidelines within which medical professionals may petition the court to authorize involuntary administration of psychotropic medication.” A revised policy and procedure has been provided for review. This review of policy and procedure is quite extensive, as it is inclusive of all the recently revised behavioral health policies. The review is being performed in conjunction with the subject matter expert in the S.H. vs. Reed matter, and is currently in progress.

Ten examples of informed consent documentation were provided via the document request. These examples included a form entitled “Information about and consent for medications for youth with mental health diagnoses.” These forms, competed by the youth, outlined what information the youth retained following their discussion with the psychiatrist regarding the prescribed medication. The form also allows for documentation by the psychiatrist of attempts to or successful contact with the youth’s parent or guardian in order to review potential psychotropic medications and obtain parental consent. Additional information (i.e. medication information sheets) are reportedly provided to the youth and their parents via the psychiatric nurse for their review such that full disclosure of potential medication side effects is provided.

Of the ten examples provided, eight were signed by the psychiatrist, with two unsigned documents. All examples were signed by the youth and included brief descriptions of side effect information retained by the youth following discussion with the psychiatrist. Two of the youth were over the age of eighteen, and as such, parental consent was not required. Of the eight examples where parental consent was required, six documents indicated that the parent consented to treatment with the medication. The two remaining documents included the parent’s name and phone number, one indicated that despite two attempts, the

	
  

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parent was not contacted (telephone numbers disconnected) and a letter was ultimately mailed to the parent. The second document noted one attempt to contact the parent on 1.4.12; however, the results of this attempt were not noted. The second attempt occurred over two months later, 3.27.12; and the results of this attempt were not documented.

Unfortunately, the facility psychiatrist was not available for interview during this monitoring visit. In an effort to determine compliance with policy and procedure as well as with generally accepted practices for informed consent, quality assurance monitoring is required. The review of the documents outlined above indicates the need for a quality assurance process. Per the facility selfassessment, given the presence of the Administrative Psychiatrist, there are plans to begin peer review with regard to this and other psychiatric treatment issues in June 2012.

Interviews with youth at the facility revealed that in general, youth were able to name their prescribed medication. Youth also had some knowledge regarding the potential side effects associated with their prescribed medication. This indicated that informed consent practices were occurring on some level with respect to treatment with psychotropic medications.

Recommendations Sources of Information

Per the document request, there were no court petitions for involuntary administration of psychotropic medications in the 90 days prior to this monitoring visit.
In order to reach substantial compliance with this provision, the State must: 1. Continue and improve documentation regarding informed consent that is
consistent with generally accepted practices and facility policy and procedure. 2. Finalize policy and procedure regarding informed consent in conjunction with other behavioral health policy. 3. Begin a peer review or quality assurance process for informed consent and other psychiatric documentation. 4. Ensure that medication information sheets currently available at the facility are provided to the youth and sent via mail to their parent or guardian.
• Youth record review • Review of provided documents • Youth interview • Staff interview

	
  

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III.B.13 Mental Health Medications. The State shall develop and implement policies, procedures and practices to ensure that psychoactive medications are prescribed, distributed and monitored properly and safely, and consistent with generally accepted practices. The State shall provide regular training to all health and mental health staff on current issues in psychopharmacological treatment, including information necessary to monitor for side effects and efficacy. The State shall issue and implement policies and procedures for the administration of appropriate tests (including, for example, blood tests, EKGs, and Abnormal Involuntary Movement Scale tests) to monitor the efficacy and any side effects of psychoactive medications in accordance with generally accepted professional standards. The State shall also: a) share medication compliance data with the psychiatrist and document the sharing of this information; b) not withhold the provision of psychostimulants to youth when such treatment is clinically warranted.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “the first series of revised Behavioral Health Services policies have been provided to the monitor…Administrative Psychiatrist will begin psychiatric peer review in June 20102…Administrative Psychiatrist is in the process of developing trainings on current issues in psychopharmacological treatment, including information necessary to monitor side effects.”

Steps Taken to Assess The review of this paragraph was limited as the facility psychiatrist was not

Compliance

available during the monitoring visit. As such, the physician was not interviewed

and clinic was not observed.

Psychiatric documentation was received for six youth. There was documentation with regard to psychiatric evaluation and ongoing medication management. There was psychiatric documentation with regard to the request for specific laboratory examinations. There was also documentation indicating that in some cases, the requested labs were not completed. There were flow sheets generated by the psychiatric nurse that included information such as weight, vital signs, dates of request of specific laboratory examinations, and medication compliance percentages. These forms were not complete, and had missing information on many dates. This was not surprising given the lack of psychiatric nurse resources. Given the presence of the Administrative Psychiatrist, the facility must begin the peer review/quality assurance process for psychiatric treatment.

The administrative psychiatrist reported that he was in the process of revising the laboratory matrix, which designated required laboratory examinations for youth prescribed particular psychotropic medications. It is necessary that this document is revised, as there are obvious omissions. For example, for youth prescribed antipsychotic medication, there was no requirement noted for abnormal involuntary movement monitoring, however, in two cases, this documentation was located (one examination for each year for one youth). It was recognized that as only minimal documents were received, that abnormal movement monitoring documentation may exist, but was not included in the copies. Abnormal Involuntary Movement monitoring must be performed regularly (quarterly) during treatment with antipsychotic medications.

	
  

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For youth prescribed the antipsychotic medication Seroquel there was no requirement for annual eye exams, which are required due to the increased risk of cataract formation with this medication. For Lithium there was no mention of the need for an annual 24-hour urine creatinine clearance due to the risk of kidney damage inherent in treatment with this medication. For these and other noted omissions, this document must be reviewed and edited. Given continuous advances in psychiatric treatment, this document should be reviewed and updated periodically to ensure compliance with generally accepted standards of care. Once the initial review is completed and the laboratory protocol is implemented, quality assurance monitoring to determine physician compliance with the requirements, their review of the laboratory results, and their use of this information in clinical decision-making will be necessary.
From the records provided, it was determined via a review of the mental health caseload document and the medication sheet for each of the youth that at the time of this monitoring visit, 71 youth were prescribed medication by the psychiatrist. This was a similar result to the previous monitoring period where 74 youth were prescribed psychotropic medication. As stated in the previous monitoring report, there had previously been over a 100% increase in the number of youth requiring psychiatric services at the facility with no corresponding increase in psychiatric clinical resources.
In the previous monitoring report, inaccuracies in the tracking data for youth on the mental health caseload were discussed. Per the review of the data for this period, there were improvements. The dates of treatment plans, caseload assignments, medication start dates, medication dosage, compliance with psychotropic medications, and current diagnoses appeared to be updated. From a system perspective, it was difficult to look at trends of data (e.g. trends of prescribing, trends with regard to medication compliance) as the data were supplied for each individual youth with no compilation provided. It would be useful to determine if the data management system can be adjusted to provide reporting of data points for groups of youth over a period of time. This could also allow for some quality assurance monitoring and the identification of possible issues for further quality assurance studies.
Given the manner of the data presentation, it was difficult to determine the timeliness of psychiatric treatment. Per a review of the psychiatric clinic schedule, it was apparent that clinic occurred approximately twice weekly in the previous 90 days with the exception of a 13 day gap between 1.10.12 and1.23.12. Given current contracts and the paucity of available psychiatric treatment providers, there was no clinician available to cover for the current provider in his absence. While per interviews and review of the self-assessment from previous monitoring visits it was stated that a psychiatrist from another DYS facility was available to cover psychiatric clinic, there was no documentation that another psychiatrist ever performed clinical consultation at Scioto. As a result of

	
  

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Recommendations

this, psychiatric treatment of some youth was likely delayed.
It was not possible to determine the time period between the youth’s admission to the facility and their referral for a psychiatric evaluation. There were some notations in the data with regard to referral dates. In the period between 1.3.12 and 3.27.12, there were a total of 30 referrals for psychiatric treatment. Of these, eight were referrals for initial assessments. The average time lapse between referral and evaluation for these youth was 5.7 days (range 1 to 14 days). There were 22 existing patients referred to psychiatry clinic. The average time lapse between referral and evaluation for these youth was 6.6 days (range 1 to 22 days). These timelines must be addressed via policy and procedure, and they should be monitored via quality assurance.
Another challenge with the data presentation was determining timeliness of psychiatry clinic follow up. In an effort to determine this, the clinic schedule was reviewed in the month of March 2012. It was noted that there were ten youth who were last seen in January 2012, indicating that they were delayed with regard to monthly assessment. Generally accepted practices and draft facility policy and procedure require that youth treated with psychotropic medications are assessed by the psychiatrist at least monthly. This was another area where quality assurance monitoring may be beneficial.
Once coverage needs are addressed, the facility will still require additional clinical resources, as the current contract for 20 hours of psychiatric time per week was inadequate to provide clinical services, participate in treatment team meetings, for response to crisis situations, for provision of on-call/after hours consultations; and for the psychiatrist to function as an integral member of the treatment team. As such, the facility must investigate other avenues in order to address the paucity of psychiatric clinical services. These could include telemedicine; developing an association with a residency training program where residents or fellows (with appropriate clinical supervision) could provide services; or if they remain unable to recruit a child and adolescent psychiatrist, contracting with an adult psychiatrist to provide services. In the latter case, the adult psychiatrist could appropriately evaluate and treat youth aged sixteen years and older. For younger youth, clinical supervision for a treating adult psychiatrist with a child and adolescent psychiatrist could be considered.
In order to reach substantial compliance with this provision, the State must: 1. Update policy and procedure regarding behavioral health to include
timelines for psychiatric services. 2. Investigate other avenues to increase psychiatry clinical resources at the
facility (e.g. telemedicine, association with academic institutions, use of residents or fellows with appropriate supervision). 3. In order to determine the appropriate number of full time equivalent psychiatric clinicians required by the facility, consider workload indicators inclusive of all clinical responsibilities required of the physician (e.g. clinic,

	
  

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Sources of Information

documentation, treatment team meetings, crisis response). 4. Ensure clinical coverage for the current psychiatric treatment provider. 5. Maintain the document regarding the current mental health caseload. Edits
to this document may assist in quality assurance. 6. Begin the peer review/quality assurance monitoring for psychiatric
treatment and documentation. This would include a review evaluation and diagnostics, of treatment planning for psychotropic medication, of target symptom identification for treatment with psychotropic medication, assessment for side effects with psychotropic medications, and the assessment of benefit from psychotropic medication. 7. Ensure that youth are receiving proper laboratory examinations and side effect monitoring commensurate with the psychotropic medication they are prescribed. This would require updating of the laboratory matrix and quality assurance monitoring.
• Staff interview • Clinic observation • Treatment Team observation • Youth record review • Review of provided documents • Youth interview

	
  

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III.B.14 Mental Health and Developmental Disability Training for Direct Care Staff. The State shall develop and implement strategies for providing direct care and other appropriate staff with training on mental health and developmental disabilities sufficient for staff to understand the behaviors and needs of youth residents in order to supervise them appropriately.

Compliance Rating Non-Compliance

Self Assessment

Per the facility self-assessment, staff interviews performed during the most recent monitoring tour, and the review of provided documents (outlined in the discussion regarding provision 15 below), specific training regarding mental health and developmental disabilities as required by this provision had begun, however, evidence of same was not received by the monitor.

Steps Taken to Assess Compliance

As stated in the previous report, the goal of this provision paragraph is to provide training to facility staff such that they have a working knowledge of the youth’s challenges (both from a mental health and developmental perspective) and to provide them with strategies to assist in their daily supervisory tasks with the youth. Training for direct care staff is important as in the correctional setting; they function as the de facto parents of the youth in their care. As direct care staff are an integral part of the youth’s treatment team, they should be aware that due to specific mental health diagnoses, youth may have special needs (i.e. a youth diagnosed with ADHD may not respond to you the first or even second time that you call his name because he is distracted by extraneous stimuli). They should also be aware of which youth are being treated with psychotropic medication and have a basic knowledge of the potential side effects of the medication so that they can monitor the youth in their care.

Per the facility self-assessment, the administrative psychiatrist is collaborating with the psychology supervisor to develop training for all staff to educate them on psychiatric medications, side effects, benefits and long term concerns. This training curriculum should be provided to the monitor for review. For additional information regarding training, please see the discussion regarding paragraph 15 below.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Develop an organized training schedule and training curriculum for facility
staff that addresses the requirements of this provision and addresses the facility mental health programming initiatives. 2. Provide curriculum of newly developed training to the monitor for review. 3. Track staff compliance with training requirements and provide documentation to the monitor.

Sources of Information

• Review of provided documents • Staff interview

	
  

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III.B.15 Staff Mental Health Training. The facilities shall train: a) all staff who directly interact with youth (e.g., JCOs , social workers, teachers, etc.) on: (i) basic mental health information (e.g., diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern) and recognition of signs and symptoms evidencing a response to trauma; and (ii) teenage development, strength-based treatment strategies, suicide, and for staff who work with female youth, female development; b) clinical staff on the prevalence, signs and symptoms of Post Traumatic Stress Disorder and other disorders associated with trauma.

Compliance Rating Partial Compliance

Self Assessment

Per the facility self-assessment, “curriculum for specific and detailed training in mental health issues and treatment has been prepared and delivered to staff assigned to mental health and other specialty programs. We will be modifying this training program for the entire facility, to be presented to staff assigned to general population units, Progress Units and specialty units alike…we will develop a continuing education component addressing mental health issues and treatment for all staff twice annually…the administrative psychiatrist, in collaboration with the psychology supervisor, are…developing a training for all staff to educate them on psychiatric medications, side effects, benefits and long term concerns…this training will be provided annually to all facility staff.”

Steps Taken to Assess Compliance

Although the self-assessment indicated that curriculum for specific and detailed training in mental health issues and treatment had been prepared and delivered to staff, there was no documentation of attendance provided. Additionally, per the document request, copies of any newly developed mental health training curriculum were requested and none were received.

Documentation of training provided in the six months prior to the monitoring visit was requested. This documentation noted training received by 252 staff members occurring between February 2011 and November 2011. Per a review of the positions, four were psych assistants, eight social workers, one school psychologist, two staff psychologists, and the psychology supervisor.

The training topics were reviewed, and did not include those topics required by the agreement. However, the State invested considerable time and resources in training that is needed to fully comply with the Stipulation. Training topics included: meal refusal, performance based standards, safety and security policy, child abuse and neglect, youth grievance, emergency response, blood borne pathogens, ethics, prison rape elimination act, general work rules, equal employment opportunity, and cardiopulmonary resuscitation. An additional topic entitled “Managing Youth Resistance” was provided in the first and second quarter. Documentation revealed that this training was also scheduled for the fourth quarter; however, it was cancelled “due to staff shortages.” In the absence of curriculum, it was not possible to determine the content or adequacy of this training, or if it was directly related to behavioral health.

Additional documentation provided via the facility self-assessment included, “all

	
  

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staffs [sic] have been trained on BHS [Behavioral Health Services] policies and procedures. Staff receive a minimum of 40 hours of in-service yearly. In addition, ODYS brings in outside experts to train frontline staff as well.” The self-assessment then discussed draining performed by Dr. Lisa Boesky in August 2011, with plans for an additional two-day training provided by Dr. Boesky in May 2012. The self-assessment also indicated, “staff have been trained extensively in CBT, motivational interviewing and strength based approaches.” No new documentation of completed training with regard to these topics was provided for the current monitoring period. Additionally, ODYS is currently in the process of a significant review and revision of behavioral health policy and procedure, which would require review/refresher training for staff.
The development of an organized, mandatory training schedule was a recommendation from the previous monitoring visits. Per the documentation provided via the self-assessment, it appears that ODYS is in the process of developing this type of program. It is absolutely necessary to develop and implement a training schedule for all staff providing care for youth with regard to mental health issues. This training must also address staff recognition of and response to the signs and symptoms of a serious mental illness in evolution as well as the specific training topics required by the agreement.
The training schedule must be reasonable and address specific topics to ensure that staff are able to implement the facility mental health program. It was noted that in the intervening period since the last monitoring visit, training regarding “Managing Youth Resistance” was cancelled in late 2011 due to staff shortages. While training is important, the facility must be able to maintain sufficient staff onsite to ensure that treatment and security services are available.
Per the documents provided for the previous monitoring visit, “since February 2011 SJCF Staff have participated in three (3) different trainings, preparing them to implement and oversee the New Freedom Phoenix Program.” It was reported during the previous monitoring visit and in the documentation provided for review that 174 staff members attended a three-day training that included an overview of the New Freedom Phoenix Program. One of the stated goals of this training, “to provide Youth Specialists and Social Workers with facilitation skill training.” However, the groups observed during the current monitoring visit, while improved over those observed previously, indicated that further training and supervision was needed.
As the monitoring visit performed to complete this report occurred in early April 2012, it was concerning that the last documented training for staff occurred in November 2011. As stated in the previous report, the review of trainings was very confusing for the monitor, so the monitor can only imagine how difficult this must be for staff attempting to provide behavioral health services or security services at the facility. The self-assessment indicated a more proactive approach to providing training was occurring, and this is positive, however, both

	
  

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curriculum and spreadsheets indicating completion must be provided to the monitor.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Develop an organized training schedule and training curriculum for facility
staff that addresses the requirements of this provision and addresses the facility mental health programming initiatives. Provide the curriculum for behavioral health training topics and spreadsheets regarding attendance to the monitor for review. 2. Consider offering multiple trainings for each topic so that staff can schedule trainings while ensuring that their regular job duties are addressed. 3. Track staff attendance and compliance with training requirements.

Sources of Information

• Review of provided documents. • Staff interviews.

	
  

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III.B.16 Suicide Prevention. The State shall review and, as appropriate, revise current suicide prevention practices to ensure that suicide preventions and interventions are implemented consistently and appropriately, consistent with generally accepted professional standards of care.

Compliance Rating Partial Compliance

Self Assessment

According to the facility self-assessment, “the current suicide prevention and response policy, effective in November of 2011 and drafted in accordance with the guidelines set forth by Lindsay Hayes, Juvenile Suicide and Confinement: A National Survey (2004) was previously approved by federal court monitor Will Harrell. In addition, ODYS’s suicide prevention and intervention process is in compliance with the Commission on Accreditation for Corrections nationally accepted performance based standards for juvenile correctional facilities.”

Steps Taken to Assess Compliance

The policy and procedure entitled “Suicide Prevention and Response” revised October 3, 2011 was provided for review. Specific issues identified with this policy include:
1. Procedures a. Screening and Assessment i. Reception - There is no designated time within which the Risk Assessment Interview must be completed (as attachments were not provided with the policy received, it was not possible to review the Risk Assessment Interview document). ii. Transfer – There was no mention of the assessment or watch precautions to be provided to youth on watch status during or following a facility transfer. There is a requirement for the “immediate” completion of a Risk Assessment Interview following positive responses to questions concerning suicide ideation and self-injurious behavior during the transfer process. The time limit for the completion of this assessment was not indicated. b. Communication i. “Psychology staff are required to review psychology file information within five days of a youth’s admission to a facility in order to identify possible areas of concern regarding mental status, suicide or self injury and the need for any follow up services.” The policy does not designate where this review is to be documented, nor does it indicate if this review is for all youth admitted or only for those youth who have positive responses to the intake health screen. c. Precautionary Status i. This section of the policy indicates that youth placed on precautionary status must have a Risk Assessment Interview within four hours. This is the first mention

	
  

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of a time frame within which this assessment must be completed. ii. Youth placed on “watch” and who are “assessed as being at the highest risk for suicide…engaged in critical suicide attempts” are required to have “constant visual monitoring within close proximity (i.e closer than 15 feet)…line of sight shall be unencumbered.” With these requirements, the staff to youth ratio is required to be “not greater than one staff to three youth. Where an adjustment pod exists the rations shall be not greater than one staff to six youth.” These ratios do not allow for close monitoring of youth. For youth who are actively suicidal, one to one monitoring is required. The policy does not allow for this level of monitoring except in the case of “youth designated as making a critical suicide attempt.” The level of monitoring should be determined clinically, given the results of behavioral health assessments. Regardless of a critical suicide attempt, if youth are at serious risk, there must be the ability to access one to one supervision. iii. With regard to “observation” status, there is no staff to youth ratio designated. iv. With regard to “behavioral” status, there is no staff to youth ratio designated. d. Additional comments: The policy does not designate the process by which psychiatrist is notified of a youth requiring watch status. Currently, per the document request, this is performed informally via email; however, it must be codified in policy.
Per information received via the SH v. Reed action, the Suicide Prevention and Response policy was not formally approved by the monitor in that case. The policy is currently under review by the mental health subject matter expert, and there are plans to request a review of the document by Lindsay Hayes. Given the issues identified with this policy and procedure as outlined above, the review of this document by Mr. Hayes would be desirable.
In addition, the agreement requires that ODYS demonstrate that interventions are implemented consistently and appropriately. In order for ODYS to ensure this, quality assurance data would be required. Per the policy review, there is a requirement for monitoring associated with this policy, “ongoing reviews shall be conducted by the designated Interdisciplinary team on a quarterly basis as part of the Departments Continuous Quality Improvement Process.” Per the document request for this monitoring period, “any reviews or quality assurance data regarding suicide precautions” were requested. The response received

	
  

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Recommendations Sources of Information

indicated, “there have not been any reviews or quality assurance data regarding suicide precautions.” In the previous three months, there were a total of six youth placed on suicide watch, and as such, there were youth records that could have been reviewed to assess compliance with policy. Based on the existing policy and procedure, partial compliance will be assigned.
In order to reach substantial compliance with this provision, the State must: 1. Review and revise current policy to address timelines and ensure
appropriate ratios for youth supervision. 2. Consider a review of this policy by Lindsay Hayes as recommended by the
mental health subject matter expert in S.H. v. Reed. 3. Perform quality assurance monitoring to ensure compliance with policy and
procedure as well as the need for corrective action.
• Review of provided documents.
• Staff interview.
• Youth interview.

	
  

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III.B.17 Transition Planning. The State shall ensure that staff create transition plans for youth leaving the facilities, consistent with generally accepted professional standards of care.

Compliance Rating Partial Compliance

Self Assessment

Review of the facility self-assessment document revealed no documentation from the facility with regard to this provision.

Steps Taken to Assess Compliance

In response to a document request for transition plans for ten youth (five of whom were prescribed psychotropic medication) discharged from the facility, the monitor was provided with the psychological services summary at discharge for ten youth, six of whom were prescribed medications at the time of discharge. The medical release summary for these youth was not provided. The medical release summary documents reviewed for previous monitoring visits contained the nursing component of transition planning inclusive of specific follow up plans (e.g. clinic contact information or appointments).

The ten psychological services summary documents provided for review included a review of the youth’s presenting problem; history of suicidal ideation, suicide attempts, and self injurious behavior; diagnostic impressions at intake; diagnosis history; five axis diagnosis; overall progress in treatment; goals; services provided; current medications; clients response to treatment; continuity of care/referral information; and aftercare options. The completeness of documentation was variable between documents, and would be amenable to quality assurance monitoring and corrective action.

The documents provided were inconsistent in terms of specific discharge plans and lacked definitive plans with regard to referrals, support services, and parent education. Most recommendations were stated as “most likely” or “will probably.” The transition plan recommendations should include concrete discharge plans for the youth and as such, should define a plan of action that the youth and their parent/guardian can follow. Again, there was marked variability in these documents.

For example, youth 222 with diagnoses of Polysubstance Abuse, Conduct Disorder, and Posttraumatic Stress Disorder was documented to have “intensive substance dependency issues.” The plan for discharge indicated, “upon release, youth was placed in a rehabilitation treatment facility to continue to work on her substance dependency issues.” This discharge plan revealed an arrangement for ongoing treatment.

Less concrete information was included in the transition plan for youth 333. This youth was diagnosed with Conduct Disorder; Polysubstance Dependence, Attention Deficit Hyperactivity Disorder, and Disruptive Behavior disorder, not otherwise specified. The discharge plan stated, “youth is likely to require follow up in the community for her history of substance abuse and possible ADHD considerations. She may also require ongoing supervision based on her history

	
  

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of criminal behaviors and current risk factors present. Youth may benefit from being released to a halfway house, residential treatment facility or day care based on the intensity of her previous substance dependence.” This summary did not provide concrete referrals for treatment, nor did identify community resources that could be accessed by the youth.
For youth prescribed psychotropic medication, follow up recommendations did not include the identification of clinical resources for follow up. There was no mention of a designated medical provider to perform continued monitoring of the prescribed medications on an outpatient basis.
These summary documents may not be reflective of the discharge and transition planning activities performed by the behavioral health staff. During the monitoring visit, transition activities were observed with regard to youth 444. This youth was being linked with resources in the community and during the monitoring visit the youth and her psychologist travelled to the home that had been identified for her, met with the woman who will be providing personal supports for her following discharge, and visited the clinic where she will be receiving mental health services. This was an excellent example of transition planning.
In reviewing existing policies related to transition planning, there was ambiguity regarding who the responsible party is for creating and implementing transition plans prior to release, particularly with regard to mental health follow-up. For example, in the policy entitled “Transition Planning for Age 21 Youth,” the policy clearly states that the juvenile parole officer “shall provide each youth with a comprehensive list of community based resources specific to the youth’s needs.” This is to include “treatment links/mental health services.” With regard to youth under age 21, there was no specific policy included in the documents for review regarding transition planning; rather this is incorporated into the policy entitled, “Behavioral Health Services.” Per this policy, “youth in need of continued mental health services shall receive, as part of their re-entry plans, referrals for continued treatment. Efforts shall be made to connect the youth and family directly with the community provider.” The policy does not denote which staff are responsible for this task. It will be necessary to determine what tasks need to be completed as part of transition planning and who the responsible part will be in order to ensure youth leave the facility with appropriate scheduled follow-up services. As stated in the discussion for many of the paragraphs in this report, ODYS was in the process of a review of policy and procedure that should address these challenges.
These above examples (with the exception of youth 444) are similar to those documented in the previous monitoring report, where recommendations were made, and the need for community linkages and appointments was clear, but there were no resources documented. Transition planning for all youth should include referral to appropriate community resources. For mentally ill youth this is

	
  

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Recommendations Sources of Information

especially important, and must include linkages to community mental health clinics and a scheduled appointment such that youth can access follow up care without an interruption in medication treatment. The documentation provided for review did not include designated follow-up appointments for care following transition into the community. Due to the state of outpatient mental health services, appointments may take more than 30 days advanced notice to schedule. As youth are released with 30 days of medications, it is vital that they have appointments scheduled in advance to ensure continuity of care.
In order to reach substantial compliance with this provision, the State must: 1. Revise Behavioral Health Policy and Procedure to reflect the requirements
of this provision. This should include delineating the responsible party for transition planning to include mental health aftercare appointments. 2. Begin transition planning at the time of admission to ensure that youth receive appropriate services at the time of discharge. This must include involvement of the youth’s parent or guardian. 3. Document transition activities in the transition/discharge documents. 4. Begin quality assurance monitoring of transition planning.
• Review of provided documents. • Staff interview

	
  

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III.B.18 Oversight of Mental Health Services. The facilities shall ensure that youth receive the care they need by developing and implementing an adequate mental health Quality Assurance/Improvement Program; annually assessing the overall efficacy of the staffing, treatments and interventions used at the facilities; and as appropriate revising such staffing, treatments and interventions.

Compliance Rating Non-Compliance

Self Assessment

Review of the facility self-assessment document revealed no documentation from the facility with regard to this provision.

Steps Taken to Assess Compliance

As noted in the previous monitoring report, the facility had developed policy and procedure regarding Quality Assurance/Improvement. This policy, with an effective date of January 1, 2011 entitled “Behavioral Health Quality Assurance/Quality Improvement” outlined the process for clinical supervision and audits of clinical documentation.

As noted above in this monitoring report, there was a recent effort undertaken by ODYS administration to perform a global review and rewrite of policy and procedure regarding behavioral health services. The goal of this process was to streamline policy and to promote the integration of mental health services (psychiatry, psychology, and social work) into one behavioral health program. In order to achieve this goal, ODYS designated work groups to review and edit policy and procedure. The revised policies, including policy and procedure regarding quality assurance are in the process of presentation and review by monitors (specifically monitors assigned via the S.H. v. Reed agreement). Quality assurance audits with respect to process should be developed to address specific policy and procedure requirements.

Quality assurance audits were provided for review. These were performed via the clinical supervision sessions. Documents had been revised in the intervening period since the last monitoring report, and included reviews of the “first day appraisal” and “caseload review.” There were challenges with this type of review. For example, the “first day appraisal” audits available for review were conducted 1.5.12, 1.19.12, 2.6.12, and 2.20.12. These four audits included reviews of a total of 14 youth. It was not possible to determine from these audits what percentage of the total number of first day appraisals performed these 14 audits represented. As data was not presented in a collated format, it was also not possible to determine trends, or the need for corrective action with regard to one particular area.

Similar challenges were noted with “caseload review” audits. In the absence of tabulated data, it was not possible to determine trends or issues requiring systems review. It was noted on each individual audit that there were either compliments for the clinician’s work or specific issues reviewed with the clinician under review; however documentation provided revealed that no formal corrective action had been instituted from quality assurance

	
  

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monitoring in the 90 days prior to the monitoring visit.
One behavioral health peer review was provided for review. This review, including comments by six behavioral health staff occurred 2.13.12. The youth reviewed had a challenging course in the facility complicated by selfinjurious behavior and frequent restraints. All documentation provided by the peer reviewers was complimentary, and offered little in the way of constructive criticism or recommendations for alternate treatment strategies. None of the reviewed documented a suggestion for behavioral health treatment in excess of what could be provided in the facility. It was notable that the monitoring team reviewed this youth’s case and recommended ODYS consider a transfer to a comprehensive behavioral health facility.
As noted above, the review of available documentation regarding quality assurance revealed a disjointed process that did not lend itself to a cogent review of the system or services provided. Additionally, at the time of this monitoring tour, there was no formal quality assurance monitoring occurring with respect to the psychiatric physician.
It will be necessary that ODYS quality assurance monitoring review four specific areas and include corrective action as needed. Additionally, a predetermined percentage of all available records should be reviewed (e.g. 10%).
1. Process measures- this type of quality assurance would determine if behavioral health services are provided in keeping with implemented policy and procedure (e.g. were evaluations performed within a specific timeline; were laboratory examinations required via laboratory parameters ordered, reviewed and addressed). For process measures regarding psychiatric evaluation and treatment, monitoring should be done via a medical model in concert with quality assurance monitoring performed for medical services.
2. Outcome measures- this type of quality assurance would determine if behavioral health services provided were of benefit to the youth. Specifically, did they result in a reduction of youth symptoms and improvement in youth functioning? This could be determined via review of youth on youth violence statistics, youth aggression statistics, and the use of segregation. Additionally, pre and post testing measures could be utilized (e.g. reduction in the scores on depression scales). It is recognized that improvements in the indices discussed above would be multifactorial and not solely the result of behavioral health services. Other outcome measures could include youth satisfaction surveys.
3. Peer review/Treatment integrity- this type of quality assurance would include a critical review of behavioral health services

	
  

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Recommendations Sources of Information

provided via a peer-review process (e.g. psychiatrists would periodically review each other’s work and provide feedback). Additionally, group therapeutic process could be observed with feedback provided to the clinician or youth specialist leading group in order to ensure adherence to the model and provide opportunities for coaching and improvement of the provided services. 4. Selected studies – If a specific issue is suspected, or specific difficulties are observed with one particular unit, specific quality assurance studies could be performed with a critical analysis of the data in order to determine the need to adjust processes or treatments in order to improve efficacy. 5. Corrective action – Any comprehensive quality assurance process must include both the synthesis and review of collected data on a regular basis. Data must be collected on a continuous basis and reviewed so that issues can be addressed in a timely manner. These issues may include challenges with the practice and documentation attributed to a specific staff member or they may identify system issues. Issues that are identified must be addressed via a corrective action plan (e.g. staff training, staff supervision, policy/procedure review).
In order to reach substantial compliance with this provision, the State must: 1. Complete the revision of behavioral health policy and procedure. 2. Develop quality assurance monitoring based on policy and procedure.
This would include process measures, outcome measures, peer review/treatment integrity, and data analysis/corrective action.
• Staff Interview.
• Review of the provided documents.

	
  

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G.1 Progress Notes. The Facilities shall promulgate and implement a policy requiring that all health professionals be required to create and use progress notes to document, on a regular basis, interactions and each assessment of youth with mental/behavioral health or substance abuse needs. In particular, progress notes shall: a.) In the assessment, address the efficacy of interventions, currently presenting problems, and the available options to address those problems; and b.) Provide thorough documentation of all crisis interventions or, if not thoroughly documented in the progress notes, provide a reference to alert staff to another document in the youth’s file containing the details of the crisis intervention.

Compliance Rating

Partial Compliance

Self Assessment

The facility self­‐assessment did not include information regarding this provision.

Steps Taken to Assess Compliance

Per interviews with mental health staff from both the facility and DYS administration, a review and revision of mental health policy and procedure is pending. Mental health documentation reviewed for the preparation of this monitoring report revealed deficiencies in clinical documentation.

Recommendations Sources of Information

Specifically, mental health assessments did not routinely evidence adequate case conceptualization information required to develop a treatment plan. Treatment plans did not routinely include measurable goals and objectives. As such, the documentation included in the individual youth progress notes did not reflect interventions aimed at addressing specific treatment goals. There was wide variability in the quality of progress notes documenting treatment. There were noted improvements in isolated instances, as discussed in the paragraphs regarding mental health services above. As discussed during the monitoring tour, this was an area that may be amenable to quality assurance monitoring.
In order to reach substantial compliance with this provision, the State must: 1. Ensure that case formulations are complete, outlining criteria for specific diagnoses and indicating specific youth risk factors for ongoing challenges. That treatment plans include measurable goals/objectives with targeted interventions included to address each treatment goal and that progress notes reflect interventions aimed at addressing specific treatment goals. 2. Complete the planned review and revision of policy and procedure.
• Mental health records • Interviews with ODYS and facility mental health staff

	
  

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G.2 Accessibility of Relevant Information. The Facilities shall ensure that youth records are organized in a manner providing treatment teams prompt access to relevant, complete, and accurate documentation regarding the youth’s status.

Compliance Rating Non-Compliance

Self Assessment

The facility self­‐assessment did not include information regarding this provision.

Steps Taken to Assess Compliance

Currently, the record­‐keeping program at the facility is cumbersome. There are multiple databases where information is stored, making access to information challenging. Per interviews with ODYS administration, there are plans to implement the OYAS system at the facility, which will reportedly allow for staff to access information from one database allowing for electronic access to mental health information. Pending this improvement, mental health staff (including psychiatry staff) are hampered by the current documentation system.

A review of the records provided for off site review did not include the documentation of social workers. The provided documents were limited to psychology-derived documentation. As such, a review of the completeness and accuracy of the documentation was limited.

Recommendations Sources of Information

Regardless, as stated in G1 above, per the review of youth records and mental health documentation available for off site review, there was considerable variability in the quality of documentation regarding mental health treatment. This is an area that would be amenable to quality assurance (with associated corrective action) and peer review.
In order to reach substantial compliance with this provision, the State must: 1. Ensure that all mental health staff, including psychiatrists, have access to relevant, complete and accurate documentation regarding the youth’s mental health status and treatment. 2. Continue and expand quality assurance monitoring of mental health documentation. This would include a review of a percentage of mental health records along with corrective action plans as needed.
• Mental health records • Interviews with DYS and facility mental health staff

	
  

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MEDICAL SERVICES

III.C.1 Generally. The facilities shall ensure that the individuals they serve receive routine, preventive, and emergency medical and dental care consistent with current, generally accepted professional standards. The facilities shall ensure that individuals with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care.

Compliance Rating Partial Compliance

Self Assessment

The Ohio Department of Youth Services (ODYS) did not conduct a self-assessment for the level of medical and dental care provided at SJCF during this assessment period.

Steps Taken to Assess Compliance

An onsite visit was conducted at the Scioto Juvenile Correctional Facility on April 4-6, 2012. It was this monitor’s first visit to the facility. All previous reviews of health information and other related documents had been conducted off site from records provided by ODYS.

All living units were visited and procedural operations and access related to health care were observed. Locations for clinic space and pill call housed on the living unit and dining hall were inspected. The food service area was toured and staff questioned regarding access to youth special diets. Food service staff was aware of and able to verbalize the process for youth receiving special diets. There were satellite clinics and medication rooms on all the living units except Buckeye. The dining hall had a medication room. The main clinic was toured and found to be fully equipped with appropriate space, medical supplies and equipment for medical and dental care of the youth. There are three AEDs (Automated External Defibrillators) at SJCF, one each in the clinic, administration, and the progress unit. The facility areas toured appeared clean and orderly.

Unit logs were checked to note whether nursing staff were conducting rounds on the units for youth in segregation. In many cases, custody staff was completing documentation that the nurse was on the unit. They often did not identify which nurse was there or the reason for the visit. The segregation room logs were not always posted on the door for the nurse to sign them after seeing youth, although multiple segregation checks were noted by nurses in the youth progress notes reviewed in the health records.

A review of ten youth health records housed at the Scioto Facility was conducted. This included any Youth Injury and Assessment Forms present in the chart. The health record review included assessing completeness of the Problem List, the presence and timeliness of the Nursing Intake Screening, Mental Health Screening, Physical Exam, Dental Exam, Dental Treatment, Oral Hygiene Instruction and Growth Chart. Admission labs were checked for completion and results within 20 days; STD screening for Gonorrhea and Chlamydia; Chronic Care and Specialty Care Consult documentation; Transfer of Health Records;

	
  

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Immunizations and Tuberculosis Screening; Medication Administration Records; Mental Health Documentation; Progress Notes and Physician Orders were checked in each health record.
All records documented timely completion of intake assessments such as nurse screenings health appraisals and physical examinations usually on the same day of admission. Growth Charts were present for all youth. There was documentation of admission labs being drawn with results charted within a few days. STD screening results were documented or shown as pending with one recent admission. Immunization records were up to date except for one youth (217931). However, HPV vaccine is not being administered to all youth. HPV vaccination is generally accepted and recommended for use in males and females. I was told the HPV vaccine was not available through the free Federal Vaccines for Children Program, which is the source of all their other vaccines. All youth received tuberculosis screening with documented results. Dental examinations were completed within a week of admission with instruction given on oral hygiene. Dental treatment was provided as a result of the dental examination or as a result of a Health Request. Youth are being recalled every 6 months for dental care. All youth allergies were noted in their health record.
Medication administration records and physician orders were also reviewed for accuracy and medication compliance. One female youth had complained that blood was drawn on her rather than another youth by mistake. Upon review of both female’s health record, laboratory orders were found for both. There was documentation of two special diets, one activity restriction, four optometry consults and eyeglasses provided when needed. One youth failed his hearing screening and received an audiology consult. There were four youth with chronic medical conditions provided in the ten health records provided including acne, diabetes and asthma. All received appropriate assessments and treatment plans. There was one diabetic female that had complained of not receiving her insulin the night of admission. Upon review of the record, she was receiving two different types of insulin. One type of insulin was transferred with her from the sending facility and administered when due. The other, that is only required when her blood sugar is elevated, in spite of taking the first type insulin, was ordered from the local pharmacy on the day of admission. Records indicated that she did not require its use. She also complained of not having her own personal glucometer to check her blood sugar levels. The clinic provides her blood sugar monitoring with its own machine. Six of the ten youth records reviewed had some indication of a mental health diagnosis, either through the mental health screening, transfer notes or psychiatric evaluations in the health record. Most of these mental health diagnoses were not included on the youth’s problem list.
When nurses made isolation checks, they were documented in the progress notes. I cannot determine if all youth housed in seclusion/isolation were assessed daily by the nursing staff based on the information provided to me for review. There were some inconsistencies found for documentation of these checks on the

	
  

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Recommendations

unit. The only verification that seclusion rounds are occurring would be the presence of documentation. There were several "seclusion checks" noted in the youth's medical progress note, but there was not always a note on the unit by the nurses. At the next visit, I will cross check the unit logs with the seclusion list and youth medical record to be certain all youth are seen and a more extensive note is added to the medical record as to the physical status of the youth. Daily checks of youth in seclusion/segregation by medical staff are a requirement of the National Commission on Correctional Health Care Standards for Juvenile Detention and Confinement Facilities. Some youth spent several days in seclusion. One youth spent 6 days in seclusion based on documentation of daily seclusion checks in the progress notes. Progress notes simply state “seclusion check” without details of the youth’s health status. A more thorough review of segregation checks will be made at the next site visit.
Documentation on the Youth injury and Assessment Reports were reviewed for those included in the ten health records. Youth often refused medical assessments or nurses conducted assessments through cell doors, especially after fights or the use of restraints. Internal Quality Assurance documents were reviewed that were provided by ODYS which included several Quality Assurance audit instruments. Medication Administration Record reviews for November 2011, December 2011, January 2012 and February 2012 showed a slight trend in decreasing compliance from the end of 2011 to the beginning of 2012, most likely due to some major staffing turnover that occurred during that same time period. The Medical Record Review audit instruments showed 100% compliance for November 2011, January, February, and March 2012. February 2012 Dental Services audit instrument showed 100% compliance. The documentation of vital signs audit showed non-compliance in some records on the Emergency Services instrument and the Vital Signs at Encounter Review, supporting earlier findings. The March 2012 Processing of Specialty Consults audit instrument showed 100% compliance. There was one Intra-system Transfer that occurred with review of that record with 9 out of 10 criteria met. March 2012 Nursing Health Call audit instrument was mostly compliant; also it found vital signs were not being taken at all encounters. On the last day of the site visit, I met with Dr. John Brady, Medical Director and Pamela Robbins, Director of Nursing along with Scioto Nurse Manager, Vickie Donohue to discuss the medical findings.
In order to reach substantial compliance with this provision, the State must: 1. Expand the immunization program to include HPV vaccinations of youth as soon as available on the Vaccines for Children Program. 2. Add satellite clinic and medication room to Buckeye Units for adequate injury assessments of youth and medication administration on the unit. Youth that require restraint or use of force need to be assessed in a timely manner. It is easier to move them to a clinic on the unit for the assessment than attempting to get an already angry youth out of the unit and across campus to the medical building to be assessed.	
   3. Youth assessments should be done at a time that youth is cooperative enough to conduct an adequate face to face examination including vital

	
  

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Sources of Information

signs. It is unacceptable to conduct clinical assessments on youth while they are still inside their cell. 4. Limit time of youth in seclusion and improve documentation of health status during segregation. 5. Improve completeness of youth Problem List in health record to include all chronic diagnoses, including mental health, substance abuse and acute diagnoses such as headache, shoulder pain, etc. This area has shown some improvement since the last review however most are still incomplete (of the ten records reviewed, none had a complete problem list including the mental health diagnoses or acute medical problems). 6. Improve Quality Assurance (QA) activities by considering a review at least annually by a source external to ODYS Health Services. ODYS should also consider expansion of the QA process to include some additional quality indicators. Conduct Quality Assurance Program as outlined in the National Commission on Correctional Health Care Juvenile Health Standards. 7. Conduct self assessment
• Site visit tour; Review of ten youth health records: ID # 217011; 218026; 217809; 217931; 217246; 217655; 217246; 217951; 217732 and 217926; Quality Assurance Documentation as outlined above.

	
  

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III.C.2 Health Records. The State shall develop and implement policies, procedures and practices to ensure that, consistent with State and federal law, at a minimum, the juvenile courts in the State, all juvenile detention facilities and all placement settings from which youth are committed shall timely forward to Scioto, or to the facility of placement (if the records arrive after the youth has been placed), all pertinent youth records regarding medical and mental health care. The facilities shall develop and implement policies, procedures and practices to ensure that health care staff, including mental health care staff, have access to documents that are relevant to the care and treatment of the youth.

Compliance Rating Partial Compliance

Self Assessment

The Ohio Department of Youth Services (ODYS) did not conduct a self assessment for the level of medical and dental care provided at SJCF during this assessment period.

Steps Taken to Assess Compliance

Review of ten youth health records. Demonstration of Mental Health Data Base while on site at facility. Review of Policies and Procedures and Standard Operating Procedures (SOP) effective 3/1/12 provided by ODYS. All health records reviewed contained some health information transferred from the county probation offices or other facilities. I do have a concern that the offense data contained within the Disposition Investigative Report is included in some of the health records along with the medical information on the youth. The offense information is irrelevant to the provision of the youth’s health care and should not be included in the health record. The health record is still fragmented due to the psychological and counseling notes being housed separately on the housing units. However, after the site visit and observation of the facility layout, it would be impractical to have a combined physical health record. It is imperative that an electronic health record is established for the sharing of the mental health and medical information. SJCF currently has a Mental Health Database that I observed during the April 2012 visit. Although not all inclusive, this database includes diagnosis, medication information and medication compliance. Psychology staff that are directly involved with the care and treatment of the Youth at SJCF have access to the psychiatry notes via the Mental Health Nurse and treatment teams are verbally informed of medication compliance by the psychology staff when necessary and relevant on a weekly basis to allow any issues to be addressed. This existing database could be expanded to include other medical information, if the cost of a new EMR is cost prohibitive.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Continue to improve process for sharing of health information between medical and mental health to include psychologists, by expansion of the existing mental health database to include pertinent health data, if not purchase of a new electronic medical record. 2. Continue to review and update policies and procedures annually. 3. Correct Effective Dates on new policies (see below).

Sources of Information

• Site visit tour; Review of ten youth health records: ID # 217011; 218026; 217809; 217931; 217246; 217655; 217246; 217951; 217732 and 217926.

	
  

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• Review of Policies and Procedures with supporting forms supplied to me by ODYS effective March 1, 2012 to include: Dental Services; Dental Record Form; Environmental Health and Radiation Safety Form; Dental Radiology SOP effective date 3/31/10; Dental Sterilization and Infection Control; Dental Tracking Form; Dental Examination (03/31/10 effective date); Dental Treatment Plan; Dental Tracking; Nursing Protocols for Screening Assessment and Stabilization of Dental Conditions (effective date 3/31/10); Removal of Precious Metal (effective date 03/31/10); Youth Dental Appliance and Precious Metal Receipt and Routing Form; Health Care Treatment Plans for Youth with Special Needs; Medical Problem List; Chronic Care; Chronic Care Management Forms for Asthma, Diabetes, Hepatitis, Hypertension, Seizures, Tuberculosis +PPD, Generic Chronic Care Condition; Chronic Care Monitoring Tool; Consent for Medications for Youth with Mental Health Diagnoses; Chronic Care Management Mental Health Treatment with Antipsychotics; Dietary Consultation Form; and Food Consumption Form.

	
  

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III.C.5 Access to Health Services. The facilities shall ensure that youth can request to be seen by medical staff confidentially and independent from JCOs and custodial staff.

Compliance Rating Substantial Compliance

Self Assessment

The Ohio Department of Youth Services (ODYS) did not conduct a self assessment for the level of medical and dental care provided at SJCF during this assessment period.

Steps Taken to Assess Compliance

Health Request call drop boxes were present on all the living units. Only one housing unit had to locate Health Request slips when asked, rather than having them readily available near the drop box. When I asked for one, the staff immediately replaced them and explained that youth sometimes will take them down and they had not been replaced. Health Request Slips were out and accessible to youth on every other unit.	
  Progress Notes and Nurse Health Requests were reviewed in 10 health records, five selected by the monitor on site and 5 provided electronically by ODYS for youth at the Scioto Facility. Health requests included in these health records were responded to adequately and documented by medical staff 100% of the time. Health Requests were reviewed and in each case traced back to a corresponding progress note to determine if the complaint had been addressed. In all cases, the requests had been adequately assessed and treated by registered nursing staff and in some cases by the physician. Progress notes also included assessments that did not have a corresponding Health Request slip in the health record. As a result of conducting the site visit, I discovered a separate notebook of Health Call Requests that were not stored in the health record. This explains why there are more nursing notes addressing youth complaints in the progress notes than there were health request slips in the record. Additional progress notes documented responses to health call requests that may have been kept in the Health Request Binder. A few examples of Nurse Health Requests included, a youth that complained of a chipped tooth that was seen by the dentist the following day with coat and bonding treatment provided; youth complaint of difficulty sleeping triggering a sleep log and mental health referral; youth minor complaints of acne, constipation, lip sores, and soap irritation that were addressed by nurses the following day. One youth with Asthma that complained of chest tightness received an appropriate assessment and treatment with follow up by the physician. During the site visit in April 2012, youth interviewed by Dr. Dedel did not express any complaints regarding health requests not being addressed by health care staff.

Recommendations

In order to continue substantial compliance with this provision, the State must: 1. Ensure Health Request slips are readily available to youth on the all housing units in proximity to the drop boxes. Youth should not have to rely on custody staff to request forms. 2. Conduct self assessment to correlate health call requests from youth stored in notebook binder with documentation of the health call request assessment in the progress notes.

Sources of Information

• Site visit tour; Review of ten youth health records: ID # 217011;

	
  

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218026; 217809; 217931; 217246; 217655; 217246; 217951; 217732 and 217926.

	
  

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SPECIAL EDUCATION

III.E.1 Provision of Special Education. The State shall, at all times, provide all youth confined at the facilities with adequate special education in compliance with the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. § 1400-1482, and regulations promulgated thereunder, and this Stipulation.

Compliance Rating Partial Compliance

Self Assessment

Prior to the Monitor’s visit, the State was asked to produce data and explanations for a limited range of issues related to the three education-related provisions that are included in the Amended Stipulation. The first provision pertains to the provision of special education services in general. In the past, the key compliance issues were related to providing education services to youth who were removed from school during the day or who were held on the unit for disciplinary reasons. More recently, education and direct care staff shortages have interfered with the ability to provide consistent services to the general population and have caused a major disruption to the PROGRESS Unit’s (PU) educational program.

Staffing Issues Shortly after the facility converted to a long-term placement for medium and close custody youth, the rates of youth violence increased significantly. The school addressed this problem by separating the housing units during the school day (previously, the units were comingled and medium custody boys were thought to be threatened, intimidated and victimized by the close custody boys). During the current monitoring period, the schedules were shifted so that medium custody and close custody boys attended school in different buildings, and the girls attending school separately as well. This appears to have created a safer environment that is much more conducive to learning.

In addition, the education program was seriously disrupted by teacher vacancies. The facility appears to have an adequate number of funded teachers’ positions. However, due to teacher resignations and disability leave toward the end of the monitoring period, the school was short two special education teachers, one math teacher and one science teacher. School Administrators reported that class cancellations occurred a few times per month since January 2012, but more frequently in March 2012 because the attendance person went out on maternity leave and the facility’s only substitute teacher had to fill that position. Lacking additional substitute teacher resources, many classes could not be covered and youth had to remain on their housing units.

These education staffing problems were compounded by direct care staffing problems. In the general population, units often did not have sufficient Youth Specialists to transport youth to school so the teachers had to travel to the units to deliver services. The logistics were challenging and in general, this strategy did not work well to deliver quality educational services. In the Spring grading period, units were rotated in and out of the school so that everyone got a half-day in the school building. This occurred on about 5 occasions during the 2.5 month

	
  

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grading period. School was cancelled altogether on three days in March 2012, and while some youth received instruction on their units, some youth did not.
On the PROGRESS Unit (PU), the direct care staff shortages were particularly dire. Without 3 Youth Specialists on duty, PU youth cannot move to the designated classrooms. A review of March 2012 attendance records for the PU revealed that on 17 days, youth did not attend school in the classrooms. Instead, they received worksheets under their doors for most of the four academic periods.
ABC Room In the past, youth who exhibited non-compliant behavior in the classroom could be suspended from school and returned to their living units where they did not receive education services of any kind. The State ceased suspending students in June 2011, relying more heavily on its in-school suspension room (the ABC room) and a newly developed procedure for Unit Instruction.
The ABC room allows youth an opportunity to regain control of their behavior and to be returned to the classroom setting without going back to their living units. Between October 2011 and March 2012, 180 youth were referred to the ABC room. This rate of referral is significantly lower than the previous monitoring period, when 262 youth were referred. The reasons for this decrease are discussed below. Youth were referred to the ABC room for rule violations pertaining to offensive or threatening conduct, being disruptive, distracting other students or being outside an authorized area. Of these, approximately 90% satisfactorily completed the requirements of the ABC room and were returned to their classrooms.
Unit Instruction Previously, the Parties to the S.H. lawsuit negotiated an agreement regarding the delivery of education services to youth who are confined to the living units for disciplinary reasons. Students in seclusion must receive instruction from a certified teacher four times per day, for at least 30 minutes per visit (i.e., Unit Instruction). The State submitted documentation for Unit Instruction provided during the October-December 2011 and January-March 2012 grading periods. A total of 16 students reportedly required Unit Instruction for the OctoberDecember 2011 period; and 33 students reportedly required it for the following grading period. Documentation verified that all of these students received some level of service, but comparisons to other data submitted by the State bring these numbers into question.
Recall that in Provision III.A.3, a total of 217 uses of Intervention Seclusion were recorded for the October-December 2011 period, and 88 were recorded for the January-March 2012 period. While only a subset of these youth would meet the criteria for Unit Instruction (i.e., have been in Intervention Seclusion for at least 72 hours), the number of students served by the school still appears to be too small. The State will need to confirm the number of students in Intervention

	
  

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Seclusion at the 72-hour threshold, and then verify that all of these students received Unit Instruction. This cross-referencing should be submitted during the next monitoring period, particularly as the data entry problems with Unit Instruction (discussed below) are resolved.

Steps Taken to Assess Compliance

The Unit Instruction recordkeeping had improved somewhat compared to the previous monitoring period, but was still fraught with problems. The attendance clerk position was unfilled for the entire monitoring period, and various individuals have filled the position on a temporary basis. As a result, attendance codes were not used consistently and the time thresholds for Unit Instruction were sometimes confused. Second, teachers misunderstood the requirements for Unit Instruction and were only providing coursework in the four academic subjects, when they should have been providing coursework for students’ two elective subjects as well. The Education Administrators were well aware of the on-going problems and quite candid about the areas in need of improvement.
Staffing Issues The School Administrators were completely candid about the obstacles they faced during the current monitoring period, and thus no additional data collection was needed to assess compliance. From all reports, the situation should improve dramatically during the upcoming grading period. Nine new Youth Specialists have completed pre-service training, the school received three new substitute teachers and the teachers on maternity and disability leave are schedule to return to work.

Clearly, compliance cannot be achieved if youth do not have dependable access to the school program. Furthermore, for some youth on the PU, attending school is the nearly the only time they are permitted to leave their rooms, and many youth have treatment goals tied to school attendance. Staffing problems that cause these youth to spend the entire day locked in their cells can have very grave consequences in terms of the youth’s mental health and ability to transition off the PU.

Absenteeism For some students, disruption in access to school caused by staff shortages is compounded by their own absenteeism. A sample of IEP Progress Reports was reviewed for the purpose of determining compliance with the provision related to IEPs. (III.E.7). This review suggested that a number of youth have serious attendance problems. At least 5 of the 26 students (20%) reviewed had such significant absenteeism that progress on their IEP goals could not be measured. These students were not listed on the Unit Instruction rosters so it is unclear how their time out of the classroom is categorized and recorded, and whether services were provided to them some other way. As noted with the staffing issue discussed above, if students do not have dependable access to educational services, the State cannot demonstrate its compliance with this provision.

ABC Room

	
  

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Recommendations

While youth who actually serve their ABC sanction appear to adjust their behavior so that they can return to the classroom in a relatively short period of time, several problems plagued the implementation of the ABC room. First, the aforementioned teacher resignations required the ABC teacher to be pulled into the main school to cover classes. As a result, teachers and students in the main school often did not have access to the ABC classroom. Further, close custody boys were served in the Fitness Center’s classrooms and the Fitness Center does not have sufficient classroom space to operate an ABC room, meaning the ABC option was unavailable to this segment of the population as well.
As a result, students were supposed to serve their ABC time on the housing units. However, there were many logistical problems associated with this strategy, so youth did not always serve their ABC time and even when they did, they were not required to do the assignment, the work was not returned to the teacher, and/or the documentation was not completed properly.
A review of the existing ABC documentation suggests that staff need to exercise more care in completing the ABC form. The descriptions of the student’s behavior from the referring teacher were often blank or overly vague (e.g., “disruptive,” “disrespect,” or “creating distraction”). More precise behavioral descriptions would allow school administrators to identify teachers who may need additional help with classroom behavior management and would also allow the youth’s treatment teams to identify the precise situations that are interfering with the student’s ability to fully engage in school. Further, the documentation often lacked exact start/stop times and the time credits were not always tracked.
In the past, the ABC room has proved to be a useful tool to intervene with disruptive youth so that the learning environment of the classrooms can be preserved. While space and staffing shortages caused a major disruption in this service during the current monitoring period, several teachers have been hired and space has been reallocated so that teachers and students will have dependable access in the upcoming grading period.
Unit Instruction Without a list of youth who spent time in Intervention Seclusion, it is impossible to know whether the Unit Instruction practices are sufficient to identify and serve all of the youth who do not report to school for that reason. These data will be requested and reviewed for the next monitoring period. Hopefully, the existing problems with coding and data entry will be resolved so that the cross-referencing will be both accurate and reliable.
In order to reach substantial compliance with this provision, the State must: 1. Ensure that sufficient direct care staff and education staff are available to provide students with dependable access to education services. 2. Address students’ chronic absenteeism with individualized plans to improve attendance and by delivering services to youth in alternative

	
  

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Sources of Information

settings as needed. 3. Provide dependable staffing and space to ensure that the ABC room is
available to teachers and students each school day. 4. Improve the consistency with which Unit Instruction data are recorded
and entered so that compliance with this policy can be demonstrated. Toward this end, cross-referencing with the list of youth on Disciplinary Seclusion will be necessary to demonstrate that all eligible youth receive services. 5. Reach substantial compliance with the other two education-related provisions in the Amended Stipulation.
• Oral presentation and underlying documentation for provision III.E.1, prepared at my request
• Interviews with n=20 general population youth conducted by the DOJ attorney in late October 2011, along with interviews with n=29 youth on the PROGRESS units conducted by the Monitor and DOJ attorney in October 2011
• Unit Instruction binder maintained by Scioto school administrators • Attendance records for Cedar and Sycamore units, October 18 through
31, 2011

	
  

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III.E.7 Individual Education Plans. (a) The State shall develop an IEP as defined in 34 C.F.R. §300.320 for each youth who qualifies for an IEP. Following development of the IEP, the State shall implement the IEP as soon as possible. As part of satisfying this requirement, the State shall conduct required annual reviews of IEPs, adequately document the provision of special education services, and comply with requirements regarding participation by the professional staff, parents and student in the IEP process. The State shall, if necessary, develop, review or revise IEPs for qualified special education students; (b) In developing or modifying the IEP, the State shall ensure that: the IEP reflects the individualized educational needs of the youth and that services are provided accordingly; each IEP includes documentation of the team’s consideration of the youth’s need for related services and transition planning, and identifies the party responsible for providing such transition services; the student’s educational progress in monitored; teachers are trained on how to monitor progress toward IEP goals and objectives; and teachers understand and use functional behavioral assessment and behavior intervention programs in IEP planning and implementation.

Compliance Rating Partial Compliance

Self Assessment

The State provided data on the 57 special education students in custody as of March 15, 2012 (approximately 55% of the total population). Of these youth, three student’s IEPs were expired. The other 54 youth (95%) had current IEPs. Historically, the State has struggled ensure that IEPs include measurable goals and objectives. Training and technical assistance has been on-going, with both the Special Education Administrator and Intervention Specialist reviewing draft IEP documents prior to the meetings’ being held.

Only when the IEP goals and objectives are clearly stated can meaningful progress reporting be accomplished. Facilitating students’ progress through the curriculum is the entire point of special education, and without assessing progress, the program cannot identify whether it is meeting students’ special education needs. The State reported that progress reports were drafted for each of the 53 students (100%) who were at Scioto at the end of the January-March 2012 grading period. Of these, 32 youth were still working toward mastering the IEP goals and thus no IEP revision was required. The other 21 students required IEP meetings to revise goals (student met the goal, goals needed to be better articulated, a Behavior Intervention Plan was required, etc.). This focus on whether students are actually acquiring the skills and competencies prescribed by the IEP is very positive.

Steps Taken to Assess Compliance

A sample of 10 IEPs (the last 10 IEPs written by Scioto prior to the Monitor’s April site visit; 18% of the total special education population) were reviewed to assess the quality of goal articulation and the extent to which progress monitoring and reporting facilitated student progress. Eight of the 10 students qualified under the Emotional Disability category and 2 had Specific Learning Disabilities. In terms of the prescribed level of service, six students (60%) were served entirely in the regular education classrooms (with consultation from the Intervention Specialist), 3 students (30%) were served in the Resource Room for one or two periods per day, and 1 student (10%) was placed in the self-contained classroom on the mental health unit. Two students (20%) received services from the Occupational

	
  

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Therapist and 3 students (30%) received services from the Speech and Language pathologist. These placements seemed appropriate given the description of the youth’s academic and functional performance contained in the IEPs.
IEP Goal Development
The question of whether progress can be accurately measured rests on the quality of articulation of the IEP goals and objectives, which depends, in turn, on clear descriptions of the students’ skill deficits. While a few of the IEPs’ Student Profiles contained excellent descriptions of the youth’s strengths and weaknesses, overall, the Profiles tended to focus heavily on the students’ classroom behavior. While all of the Profiles featured input from the students’ teachers (an excellent practice), teachers’ input was often overly focused on the youth’s behavior and did not specify the specific skill deficits that inhibited the student’s progress in the curriculum.
Similarly, the Present Level of Performance section used to set up each IEP goal, was often non-specific, generally limited to the youth’s recent scores on the relevant achievement test. While the goals were indeed measurable (nearly all of them identified an increase in achievement test scores), about half of the students’ objectives were not anchored to the specific skills the youth needed to acquire in order to achieve the goal (e.g., “satisfactorily complete assignments requiring reading fluency, comprehension, and writing activities to earn 60% each quarter”). Math objectives tended to be better articulated than Language Arts objectives, as they identified the specific skills needed to accomplish the goal (e.g., subtracting and multiplying fractions; multiplication problems involving onedigit numbers; etc.).
Further, behavior goals tended to be overly general and not individualized. While the description of students’ behavioral challenges was usually comprehensive and multi-faceted, the goals and objectives were nearly identical across students. Some students did not have a clearly articulated basis for the behavior goal (i.e., the Student Profile indicated that the youth had regular attendance, had only a few negative behavior reports, and generally remained on-task in class). Other students had behavioral objectives that did not reflect the nature of their particular challenges (e.g., objectives would set attendance thresholds or a reduction in YBIRs when the youth had neither attendance problems nor YBIRs but instead could not stay on task, was distracted, talked excessively to peers, and did not follow directions well). Greater specificity in the language used to construct objectives would surely make progress reporting easier and more meaningful.
While transition goals were nearly identical for all students, the similarities in tasks to be accomplished make these similarities reasonable. However, from there, goals need to be further developed for each student so that they reflect the likely

	
  

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post-secondary education and post-release path of the student. Unfortunately, students will be challenged in pursuit of these goals given the very limited vocational training and job opportunities available at the facility (see III.E.8, below).
Progress Reporting
Past Monitor’s reports have voiced concern about the frequency and quality of progress reporting on IEP goals. Progress reports specific to each goal on the IEP must be compiled and mailed to parents at the conclusion of each grading period. The facility has made significant progress in sending these reports (reports were sent for 100% of special education students for both the OctoberDecember 2011 and January-March 2012 grading periods).
While still not at the level required to reach substantial compliance with this provision, the quality of content in the Progress Reports is improving. For the October-December 2011 grading period, a random sample of 14 Progress Reports were reviewed from the 72 that were created (19%). In just under half of the cases (42%), the reports included clear, specific information about the student’s acquisition of necessary skills or their persistent problems in mastering the required material. Reports on behavior goals were multi-faceted and included behavior in a variety of settings.
However, over half (58%) of the Progress Reports had significant problems, such as:
• The goal was not measurable to begin with, so the progress report was vague and non-specific.
• The data reported did not respond to the way the goal was supposed to be measured (e.g., teachers reported a course grade when they were supposed to be tracking a variety of problem behaviors; teachers gave behavioral descriptions when they were supposed to report grades on a set of assignments). If a student was supposed to receive 80% or better on a series of reading assignments and tests, those specific results should be reported.
• The report did not give any sense of the skills that needed to be mastered in order to achieve the goal, or which skills had been acquired. This was particularly obvious when the goal related to increasing the student’s grade equivalence score on an achievement test—the following discussion stated only whether the youth took the test or not, but did not discuss the skill areas in which deficits remained.
For the January-March 2012 grading period, the Monitor altered the methodology upon recognizing that the progress reporting had improved. Rather than assessing a student’s progress report as a whole, the student’s goals were assessed individually so that more incremental progress could be detected. Across the 12 Progress Reports reviewed, a total of 38 goals were assessed.

	
  

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Among these, approximately 70% of the reports clearly stated whether the student had acquired the necessary skills to achieve the goal and with what types of tasks the student continued to struggle. In so doing, these reports gave a much clearer sense of the distance the student needed to travel to achieve the goal and how instruction could be better focused in the subsequent grading period. This is very encouraging. The remaining 30% of goals did not have sufficiently detailed reports. [It is worth noting that many of these were Transition goals, which have been newly added to the Progress Reporting process. Their inclusion is very positive, but also reinforces the importance of these goals being clearly articulated, measurable and attainable during the period the youth will be housed at the facility.]

Particularly now that youth committed to Scioto are likely to spend significant periods of time there, the facility must improve its practices around measuring student progress in order to maximize the ability of the special education program to meet students’ needs. Of course, the problems pertaining to access to education services described in III.E.1, above, preclude the reliable delivery of special education services, particularly for youth on the PROGRESS Unit, where services were delivered through the youth’s door approximately 80% of the time.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Improve the specificity of a) Student Profiles and b) Present Levels of Academic and Functional Performance in IEP documents to ensure that the skills students need to acquire in order to progress through the curriculum are clearly articulated in the IEP goals. Develop objectives that address these skill deficits. 2. Ensure that Progress Reports are skill-specific and provide a clear description of what the student has mastered and what still needs to be addressed in order for the student to meet the goal. 3. Ensure that sufficient direct care staff and education staff are available to provide youth with dependable access to education services.

Sources of Information

• Oral presentation and underlying documentation for provision III.E.7, prepared at my request
• Review of n=10 IEPs of current Scioto students’ IEPs (18% of the total population)
• Review of n=14 Progress Reports from the October-December 2011 grading period (19% sample) and n=12 Progress Reports from the January-March 2012 grading period (21% sample)

	
  

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III.E.8 Vocational Education. The State shall provide appropriate vocational services that are required transition services for disabled youth under the IDEA.

Compliance Rating Non-Compliance

Self Assessment

In its self-assessment, the State discussed data on student enrollment in the three currently available vocational classes. Of the 88 students at Scioto:
• 9 students (6 boys, 3 girls; 10% of the population) are enrolled in Administrative Office Technology (a course that teaches students how to use various computer applications to prepare them for clerical, data entry, graphics, or other office-based jobs);
• 10 students (7 boys, 3 girls; 11% of the population) are enrolled in Career-Based Intervention (i.e., a campus job; students get credit); and
• 13 students (15% of the population) are enrolled in Transition Skills (students must take this course prior to release; includes job skills, resume building, interview skills).

So, course offerings continue to be quite limited and only about one-third of Scioto’s students are involved in semester-long vocational courses. [During the most recent intersession, seven students participated in a 16-hour ServeSafe program in which students could earn a certificate in safe food handling.]

Steps Taken to Assess Compliance

Students who have graduated or obtained a GED are not protected by this provision since they are no longer eligible for special education. The dearth of available programming for these youth is discussed in III.F.1, above. Although not directly relevant to this provision, fully developed programs for graduates and a robust array of vocational opportunities for students would be mutually beneficial. The DYS is urged to take responsibility for the post-secondary educational opportunities for graduates.

Opportunities for students to develop job skills are very limited, with less than half of Scioto students participating in any meaningful vocational coursework or employment experience. The DYS has had several loosely conceptualized plans for developing the vocational program since the inception of the Stipulation, and yet none of them has gained any traction. This is the least well-developed of all of the Stipulation’s provisions that are currently overseen by the Monitor. Immediate and significant attention is required.

Recommendations

In order to reach substantial compliance with this provision, the State must: 1. Develop sufficient vocational opportunities to engage all students in meaningful job skill development and/or work experience. The choice among the vocational options should be tailored to the risks and needs of the youth at Scioto.

Sources of Information

• Oral presentation and underlying documentation for provision III.E.8, prepared at my request
• Interview with Bonnie Sweeny, newly appointed Education Superintendent

	
  

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IN THB UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

UNlTED STATES OF AMERICA,
Plaintiff,
v. THE STATE OF OHIO~ eta/.,
Defendants.

)

)

CONSEN'r ORDER

)

)

) Civil Action No. 2:08·cv475-ALM

)

)

)

)

I. INTRODUCTION
1. On June 28, 20 I I. the Court entered an Amended Stipulation for Injunctive Relief
r'Amended Stipulation") (Doc. 85), resolving the United States' claims regarding conditions
at the Scioto Juvenile Correctional Facility ("Scioto'').
2. Section UI.A.3 of the Amended Stipulation provides:
Seclusion: Tho State shall develop and implement policies. procedures and practices so that staff use seclusion (as defined in this Stipulation) only in accordance with policy and in an appropriate manner and so that staff document fully the use and administrative review of any imposition of seclusion, including the placing ofyouth in their rooms outside nonnal sleeping hours.
"Seclusion" is defined in the Amended Stipulation as "isolating a youth in a
room from which the youth's ability to egress is blocked. 1l1e term seclusion
docs not apply to locking a youth in a room during normal hours of sleep."
3. Section III.F.l of the Amended Stipulation provides:
Structured Programming: The State shall provide adequate, structured Rehabilitative Services, including an appropriate mix of physical, recreational. or leisure activities. during non-school hours

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and days C'Structured Programming"). The State shall develop and implement Structured Programming at each facility from the end ofthe school day until youth &o to bed, and on weekends. For youth housed in closed~cell environments, Structured Programming shall be designed to ensure that youth are not confined in locked cells except: (1) from after Structured. Programming to wake-up; (b) as necessary where the youth poses an immediate risk of harm to self or others; or (c) following an adequate disciplinary hearing, pursuant to an appropriate disciplinary sanction. The Structured Programming shall be designed to modify behaviors. provide rehabilitation to the types of youth committed to each facility, address general health and mental health needs, and be coordinated with youth's individual behavioral and treatment plans. The State shall use teachers, school adininistrators, correctional officers, caseworkers, school counselors, cottage staff, and any other qualifi.ed assistance to develop and implement the Structured Programmins. The State shall provide youth with access to programming activities that are required for parole eligibility.
4. By letter dated September 26,2012, the United States notified the State of its determination
that che State is not in substantial compliance with Sections III.A.3 and III.F.l of the
Amended Stipulation and that, therefore, pursuant to Section VII.D and E of the Amended
Stipulation, the United States was initiating the dispute resolution process set forth in
paragraph 256 of the Stipulation.for Injunctive ReJief inS. H. v. Reed (No. 2:04-cv-1206) (the
"S.H. Stipulation"). S~cificallyt the Plaintiffs contend that the State continues to subject
youth housed on Scioto's special management unit, currently referred to as the f'PROORESS
Unit,. and currently consisting of three "phases" (Phase I, Phase II, and Transition), to
excessive seclusion, and fails to provide these youth with adequate structured programming.
5. On October 15 -19, 2012, the monitor team conducted a site visit at Scioto, to assess the
State's implementation of the Amended Stipulation and prepare the semi-annual compliance
report required under Section V.H. of the Amended Stipulation. Based on the Monitor,s
2

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Third Draft Report. the United States contends that these practices vioh:~te the constitutional rights ofyouth housed on the PROGRESS Units. 6. On October 17, 20 12, representatives of the parties in this action met with the Monitor, KeUy Dedel, and the S./1. Monitor, Will Harrell, pursuant to Paragraph 256.b. of the S.H. Stipulation, in an au.empt to resolve this dispute. The parties have conferred numerous times thereafter, and have agreed that this Consent Order complies in all respects with the requirements of 18 U.S.C. § 3626(a)(l)(A), and that the record in this case may serve as the factual and legal basis for a Court order issued pursuant those requirements. 7. Based on the record before it, the Court finds that the prospective relief provided by this Consent Order is narrowly drawn, extends no further than necessary to correct the constitutional violations in the PROGRESS Units' operation, and is the least intrusive means of doing so. The Court shall retain jurisdiction to enforce this Consent Order's terms and shall have the power to enforce the Consent Order through specific performance and all other remedies permitted by Jaw. 8. This Consent Order shall tenninate when the State has substantially complied with each of the Consent Order's provisions and has maintained substantial compliance for six months. The burden shaH be on the State to demonstrate this level ofcompliance. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time. temporary compliance during a period of sustained noncompliance shall not constitute substantial compliance.
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II. SUBSTANJ'IVE REMEDIAL MEASURES To ensure that youths on the PROGRESS Unit, and any special management unit at Scioto that the State may subsequently create to replace the PROGRESS Unit, are not subjected to excessive seclusion and receive adequate structured programming, particularly programming reasonably calculated to facilitate youths' prompt and successful re-entry into the general popu1ation, consistent with the Amended Stipulation and the Constitution, the State shall implement the following remedial measures on the PROGRESS Unit: 9. Admissions Screen: The State shall develop and implement an assessment and screening
process designed to ensure that the youth behaviors that led to referral to ~he PROGRESS Unit are not the symptoms of mental illness, including undiagnosed and/or untreated mental illness.
a. Youths with the following diagnoses (as defined in the Diagnostic and Statistical Manual of Mental Disorders-IV (''DSM-IV'") or most current version of this docwnent} shall not be placed on the PROGRESS Unit: i. Thoughc Disorders (e.g., Schizophrenia, Schizophrenifonn Disorder, Schlzoaffective Disorder, Delusion Disorder, BriefPsychotic Disorder, Psychosis for any underlying reason); ii. Mood Disorders (e.g., M~or Depressive Disorder, any Bipolar Disorder) unless the disorder is in full remission as defined by the DSM-IV; and iii. Developmental Disorder (e.g., Mental Retardation, Pervasive Developmental Disorder, Autism Spectrum Disorders).
b. Youths with any recurring display ofself-injurious behavior or suicidal ideation shall not be placed on the PROGRESS Unit.
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I
c. Youths with attention deficit hyperactivity disorder (ADHD) who are placed on the PROGRESS Unit shall be offered at least one hour ofrecreation per day, in the gym or outside. without restraints.
d. On the fifteenth day of each month. the State shall submit to the Monitor and the
United States a list identifying all youth referred to the PROGRESS Unit in the
previous month, whether each youth was admitted, the DSM-IV diagnoses assigned to that youth, and the basis for the decision to admit or not admit the youth. e. The State shall provide a youth's referral packet to the Monitor and/or the United States within five business days ofa request for the packet by the Monitor or the United Stales. 10. Dldly Scheduls;: 'J'hc State shall develop and implement a daily schedule for youths on the PROGRESS Unit lbal includes as much out-of-room time as youths on the general population (except lbr a thirty~minute earlier bedtime on the PROGRESS Unit), and that ensures youths haw ac<:ess to the rehabilitative treatment necessary to return to the general population, provided that the State shall not cite the lack of daytime hours as a basis to fail to provide treatment. a. All youth on the PROGRESS Unit shall be permitted out oflheir rooms at all times, except for the following:
i. Sleeping hours from 7:00p.m. to 7:00a.m. (except that the State shall ensure that youths have aecess to showers after bedtime);
ii. Shift Change (no more than 40 minutes daily)~ iii. Medication Pass (no more than 30 minutes daily);
s

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•
iv. Treatment Team (no more than three hours per week when school is in session, for non-graduates, and no more than four hours per week when school is not in session or for graduates); and
v. Seclusion time that results from a disciplinary issue. b. While out of their rooms, youths must be offered the following activities:
i. meals; ii. 330 minutes ofeducation offered per day for non-graduates, except for
weekends or intersession; m. one hour of large muscle activity, during which no youth shall be restrained.
Foro period commencing 30 days from the effective date hereof, at least 60 days ofmonitoring shall demonstrate that youth generally are availing themselves of the offered rccroation, failing which the Parties shall confer on any necessary modification to that recreation; iv, a combination of individual treatment, group treatment, and structured programming led by youth specialists and/or volunteers; and v. unstructured leisure time which shall be offered on no more than one hour per day on school days and two hours per day on non-school days. For the first 60 days from the effective date hereof, youth who have graduated from high school or obtained aGED are exempt from this requirement so that DYS can develop additional structured activities for these youth. Thereafter, all youth shall be offered limited unstructured leisure time, as described in this section.
6

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c. For each youth on the PROORESS Unit, the State shall create a weekly tracking sheet that identifies the number of hours the youth spends out of his room, engaged in the specific activities identified in Sections II.9.b.i-v, above. i. For any activity in which the youth's actual weekly engagement is less than required by the PROGRESS Unit schedule, as set forth in Section 11.9.b, abov~ the State shall provide an explanation for the deviation from the schedule as set forth in Section 11.9d. below. ii. On a weekly basis, the State shall provide to the Monitor and the United States the weekly tracking sheets for the prior week.
d. On a monthly basis, the State shall track and identify patterns in the causes of deviations from the schedule, and develop written corrective action plans to address identified patterns. On the fifteenth of each month, the State shall submit to the Monitor and the United States a written summary of any implementation problems identified for the prior month.
II. Staffing: The Stale shall ensure that a sufficient number of direct care staff is available to implement the PROGRESS Unit program as scheduled. The State shall ensure adequate staffing on the PROGRESS Unit without compromising the safety, security or programming on the general population units at Scioto. a. Absent minor, inciden1al deviations, a unit manager shall work on the PROGRESS Unit during all waking hours (7:00 a.m.- 7:00 p.m.), seven days per week. b. AU direct care staff(i.e.1 nonclinieal stafl) assigned to work on the PROGRESS Unit must have completed training specifically relating to working with youths on the PROGRESS Unit and implementing the PROGRESS Unit program as designed. If a
7

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i

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direct care staff is assigned to the PROGRESS Unit he or she must complete the PROGRESS Unit training within three months of being assigned to the PROGRESS Unit. Every three months, the State shall provide the Monitor and the United States . with a current roster ofall direct care staff who have been assigned to the PROGRESS Unit and the dates on which they attended the PROGRESS Unit training or are scheduled to do so. c. All direct care staff working on the PROGRESS Unit, whether posted or relief, shall read and initial the Post Orders that govern the PROGRESS Unit posts. d. The State shall track data and create monthly stafftng reports that identify the number and identity ofyouth specialists who report to work on all shifts for each day of the month and, for each day of·the month, the unit manager schedule and list of unit managers on extended leave. e. The State shall track performance measures related to youth and staff safety by collecting data on all acts of violence committed by PROGRESS Unit youth identifying the date, the type of violence and the involved youth. f. The State shaJI provide each staffing report and youth violence report to the Monitor (and the United States) on the fifteenth day of the month immediately following the month addressed in the report, beginning on the fifteenth day ofthe month from the effective date of this agreement. 12. Treatment Planning: Treatment plans will be individualized and include concrete, realistic, measurable goals that arc designed to address the specific behaviors that led to the youth's placement on the PROGRESS Unit, end that will guide the youth's promotion through the program's phases and ultimately back to the general population.
8

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a. Phase l will focus on youth acquiring dte skills and meeting the behavioral expectations needed for them to move about safely on the PROGRESS Unit, without the use of restraints once they are promoted to Phase 11. Youths shall be provided adequate opportunity to demonstrate acquisition of these skills and meeting behavioral expectations during their stay on Phase I so that progress can be tracked.
· b. Phase 11 goals and objectives will focus on acquiring the additional skills needed to refrain from aggressive behavior once returned to the general population.
c. Success in meeting these goals and objectives or behavioral expectations shall be measured on a weekly basis. However, behaviors unrelated to the following shall not be a basis to withhold promotion on the PROORESS Unit: i. Any act ofviolence to include fights or assaults; ii. Any possession of STO material that promotes or directs an individual to carry out an act of violence; iii. Any possession of major contraband that poses a threat to the safety and security of others, i.e. weapons, illegal drugs, lighters, etc.; iv. Repeated verbal threats to cause serious physical harm to staff and/or peers.
d. lOTs shall develop weekly tracking sheets for each youth on Phase I which clearly identifY each behavioral expectation, along with specific data related to the youth's perfonnance on each behavioraJ expectation for that week. The youth's lTP shall focus on skill acquisition that will assist him in successfully meeting the behavioral expectations. However, a lack of progress relating to the attainment ofthese goals and objectives shall not impede prornotion to Phase II so long as the behavioral expectations have been met. The goals and objectives, along with specific data related
9

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to the youth·s performance on each goal and objective for that week, will be documented in the JOT minutes and cfearly articulated in the Progress Notes. e. The most recent Treatment Plan for each youth on the PROGRESS Unit will be submitted to the Monitor and the United States within one week following the effective date of this agreement. When new youth are admined to the PROGRESS Unit, the State will submit their treatment plans to the Monitor and the United States within one \Yeek of initiation of the Treatment Plan. The Monitor will provide
feedback and technical assistance as necessary to ensure that the substance of the Treatment Plans meets generally accepted practices.
f. The lOT shaH ~view each youth on a weekly basisJ whether or not the youth appears before the Team in person. The lOT review will invoJve a structured discussion of each youth's goa]s and objectives and/or behavioral expectations and the progress he has demonstrated toward meeting them. The IDT shall identify areas of needed improvement so that the youth knows what, specifically, is required to progress to the next phase ofthe program.
g. Each youth shall attend an IDT review no less than bi-weekly. i, During non-appearance weeks, the youth's IDT shall review the youth's progress on all goals and objectives and/or behavioral expectations for the week, make a decision about promoting, a recommendation about demoting, or a decision about maintaining the youth's current Phase, and complete the weekly tracking fonn, for Ph~ I, and the Progress Note, all of which shall be documented in the IDT minutes. The youth's social worker shall then review the tracking fom1 or the Progress Note with the youth, discussing each ofhis
10

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gools and objectives and/or behavioral expectations, the progress he has demonstrated toward meeting them, and the areas of needed improvement so that the youth knows what, specifically, is required to progress to the next phase of the program. ii. For each youth who does not meet identified goals and objectives or behuvioral expectations within the treatment plan's specified time frame~ the IDT shall determine the reasons why the youth continues to engage in unwanted behaviors and shall revise the treatment plan or its implementation, in order to better address these underlying causes. h. On a weekly basis. the State shall provide the Monitor and the United States with the minutes from the IDT meetings held the previous week. These minutes shall provide a detailed discussion of geneml unit issues along with a description of the clinical fonnulation for each youth and its relationship to their progress in meeting each treatment goal. A list of Phase changes shall also be incorporated (i.e., whicll youth were promoted or demoted). i. For each youth on the PROGRESS Unit, the State shall create a "Length of Stay" ("LOSt'} record that identifies: (I) the date the youth was placed on Phase I; (2) the date the youth was placed on Phase 11; (3) the date the youth was placed on the Transition Unit; and (4) lhe date the youth was moved to the general population. For any youth who is demoted from one phase to a lower phase, this record shall also identifY the date of, and reason for, this demotion. This record shall be updated immediately upon a change in status, whether promoted or demoted. An initial LOS reeord shall be submitted to the Monitor and the United States within 45 days of the
1 J

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effective date hereof, and updated LOS records shall be submitted to the Monitor and the United States weekly thereafter. j. Central Office Review Board: The State shall convene a 11Central Office Review Board" to provide an external review of any youth who has been on any phase of the I)ROORESS Unit (i.e., Phase 1, Phase IJ, or Transition) for more than 28 days. Either the social \'IOrker or the primary clinici811 for the youth being reviewed shall be immediately available to the Board during their deliberations regarding that youth. The Board shaJI consist of, at a minimum, individuals holding the foJiowing positions within DYS' Central Office: an Administrative Psychiatrist, the Bureau Chief of Facility Programst and Behavioral Health Service Administrators. For at least the flrst six months of the Central Office Review Board's existence, the State shall notify the Monitor of any upcoming external reviews, and the Monitor or the appointed subject-matter expert shall be invited·to observe the Central Office Review Board's deliberations and provide feedback, as warranted. k. For the flrst 45 days following the effe<:tive date ofthis Agreement, any youth who has not progressed to the next phase by the 28th day of his stay on his current phase shall be assessed by the Review Board by the 42nd day in order to provide adequate time for the referral packet to be prepared and for the Review Board to convene. Thereafter, any youth who has not progressed to the next phase by the 281h day of his stay on his current phase shall be assessed by the Review Board by the 35u. day. I. Prior to the Review Board meeting, either the lOT or the youth's primary clinician shall meet with the youth to infonn him of the upcoming consultation and solicit his
V2

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input as to why he is not progressing through the program and what wou1d assist him
in doing so. m. The youth's primary clinician will prepare a summary of the youth's clinical
formulation~ treatmentt progress, and challenges to date. The summary shall indude the youth's history, mental· health diagnoses and past treatment (including medication), psychiatric progress notes, results ofany psychological testing, case formulation, treatment goals, attempted interventions and responses to those interventions while on the PROGRESS Unit, whether any needed treatment has not been delivered and why, and the IDT's conclusions regarding the reasons the youth is not progressing. The summary sball be disseminated to the Review Board and the Monitor in advance of its meeting to discuss the case. The Review Board shall review the swnmary and then consider any factors that the JOT may have missed with regard to the youth's treatment. The Review Board shall then make recommendations with regard to re~focusing the youth's treatment. and set a timeline for subsequent review ifthe youth has not progressed to the next phase. All team decisions shaU be submitted to the Monitor within one week of the Review Board's recommendations.
' n. The youth's rDT shaJI meet with the youth at the next scheduled IDT of the youth's
unit following the Review Board's assessment to discuss the Board's recommendations and any new treatment plan or goals. 13. Phase Demotion: The State shaiJ implement objective criteria setting forth specific, limited reasons that a youth may be demoted frorn one phase to a lower phase consistent with ·this section.
13

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a. Phase demotion shall only be considered after either a deliberative process by the IDT or the Intervention Hearing Officer concludes that the youth has committed: i. Any net ofviolence, to include fights or assaults; ii. Any possession of STG material that promotes or directs an individual to carry out an act of violence; iii. Any possession of mt\}or contraband that poses a threat to the safety and security of others, i.e. weapons, illegal drugs, lighters, etc.; or iv. Repeated verbal threats to cause serious physical harm to staff and/or peers.
b. Scioto's superintendent must approve all phase demotions prior to implementation. c. On a weekly basis, the State shall provide the Monitor and parties with the names of
youth who have been demoted and a report of the incident(s) leading to the demotion. 14. Policies, Procedures and Youth Handbook: The substantive remedial measures set forth
herein shall be memorialized in DYS standard operating policies and procedurest and the DYS Youth Handbook within 60 days of the effective date hereof. 15. Effective Date: The effective date of this Conse~t Order shall be the date it is signed by this Court.
14

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IT IS SO STIPULATED AND AGREED. FOR THE UNITED STATES:

;;j, I DATE: Cj /t 2.
THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Section Chief Special Litigation Section
BENJAMIN 0. TAYLOE, JR. Deputy Chief Special Litigation Section
~~ j(JUCliilecuncannan Trial Attorney Special Litigation Section U.S. Department of Justice Civil Rights Division 950 Pennsylvania Avenue, NW Washington, D.C. 20530 Telephone: (202) 616-2556 Fax: (202) 514-4883 JacqueJine.Cuncannan@usdoj .gov

15

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 16 of 17 PAGEID #: 2352 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 16 of 17 PAGEID #: 2204

IT IS SO STIPULATED AND AGREED. FOR THE STATE:

I I\ ~ q DATE: J

z._

v- -;-ru-v~. 1/tJ o-J..
Mindy WorlyfT Principal Assistant Attorney General
Ohio Attorney General's Office Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, OH 43215

16

Case: 2:08-cv-00475-ALM-MRA Doc #: 109 Filed: 01/18/13 Page: 17 of 17 PAGEID #: 2353 Case: 2:08-cv-00475-ALM-MRA Doc#: 107-1 Filed: 12/19/12 Page: 17 of 17 PAGEID #: 2205
- WHEREFORE, for good cause shown,
it is SO ORDERED this ffday of J~'-'tto/20!J.
17

 Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 1 of 129 PAGEID #: 2354

	
   	
   	
   	
   	
   	
   	
  

U.S.	
  Department	
  of	
  Justice	
  v.	
  The	
  State	
  of	
  Ohio	
  

Civil	
  Action	
  No:	
  2:08-­‐cv-­‐475	
  

Monitor’s	
  Third	
  Report	
  on	
  the	
  Amended	
  Stipulation	
  signed	
  June	
  28,	
  2011	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

Kelly	
  Dedel,	
  Ph.D.,	
  Lead	
  Monitor	
  

Daphne	
  Glindmeyer,	
  M.D.,	
  Subject	
  Matter	
  Expert	
  

Michelle	
  Staples-­‐Horne,	
  M.D.,	
  Subject	
  Matter	
  Expert	
  

	
  

One	
  in	
  37	
  Research,	
  Inc.	
  

16	
  Rock	
  Street	
  	
  Cody,	
  WY	
  	
  82414	
  

(503)799-­‐0915	
  

kelly.dedel@gmail.com	
  

	
  

	
  

	
  

Draft	
  Submitted	
  November	
  30,	
  2012	
  

Final	
  Submitted	
  January	
  23,	
  2013	
  

	
  

	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 2 of 129 PAGEID #: 2355

TABLE	
  OF	
  CONTENTS	
  
	
   Introduction	
  ............................................................................................................................	
  3	
   Executive	
  Summary	
  .................................................................................................................	
  4	
  
Protection	
  from	
  Harm	
.   ..................................................................................................................	
  10	
   General	
  Protection	
  From	
  Harm	.
  ................................................................................................	
  10	
   Seclusion	
 .  ..................................................................................................................................	
  21	
   Investigation	
  of	
  Serious	
  Incidents	
 .  ............................................................................................	
  30	
   Grievances	.
  ................................................................................................................................	
  35	
   Grievances	
  Explained	
  to	
  Youth	
  .................................................................................................	
  39	
   Structured	
  Programming	
  ..........................................................................................................	
  41	
   Orientation	.
  ...............................................................................................................................	
  49	
  
	
   Mental	
  Health	
  Services	
  ................................................................................................................	
  52	
  
Mental	
  Health	
  Screening	
.   .........................................................................................................	
  52	
   Immediate	
  Referral	
  to	
  QMHP	
  ..................................................................................................	
  54	
   Identification	
  of	
  Previously	
  Unidentified	
  Youth	
 .  ......................................................................	
  56	
   Mental	
  Health	
  Assessment	
  ......................................................................................................	
  58	
   Adequate	
  Care	
  and	
  Treatment	.
   ................................................................................................	
  60	
   Treatment	
  Planning	.
   .................................................................................................................	
  64	
   Treatment	
  Teams	
 .  ....................................................................................................................	
  65	
   Integrated	
  Treatment	
  Plans	
  .....................................................................................................	
  69	
   Access	
  to	
  QMHP	
 .  ......................................................................................................................	
  72	
   Mental	
  Health	
  Involvement	
  in	
  Housing	
  and	
  Placement	.
  ..........................................................	
  75	
   Staffing	
  .....................................................................................................................................	
  80	
   Medication	
  Notice	
.   ...................................................................................................................	
  84	
   Mental	
  Health	
  Medications	.
  .....................................................................................................	
  87	
   MH/DD	
  Training	
  for	
  Direct	
  Care	
  Staff	.
  ......................................................................................	
  92	
   Staff	
  Mental	
  Health	
  Training	
 .  ...................................................................................................	
  95	
   Suicide	
  Prevention	.
  ...................................................................................................................	
  98	
   Transition	
  Planning	.
  ................................................................................................................	
  101	
   Oversight	
  of	
  Mental	
  Health	
.   ...................................................................................................	
  104	
   Documentation	.
   ..........................................................................................................................	
  107	
   Progress	
  Notes	
  .......................................................................................................................	
  107	
   Accessibility	
  of	
  Information	.
  ...................................................................................................	
  109	
   	
   Medical	
  Services	
 .  ........................................................................................................................	
  110	
   General	
  Medical	
  Care	
.   ............................................................................................................	
  110	
   Health	
  Records	
 .  ......................................................................................................................	
  114	
   Access	
  to	
  Health	
  Systems	
.   ......................................................................................................	
  116	
   	
   Special	
  Education	
  Services	
  .........................................................................................................	
  117	
   Provision	
  of	
  Special	
  Education	
  ...............................................................................................	
  117	
   Individual	
  Education	
  Plans	
  .....................................................................................................	
  123	
   Vocational	
  Education	
  .............................................................................................................	
  127	
   	
   	
  

	
  

2.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 3 of 129 PAGEID #: 2356

INTRODUCTION	
  
	
  

On	
  June	
  4,	
  2008,	
  The	
  United	
  States	
  Department	
  of	
  Justice	
  (DOJ)	
  and	
  the	
  State	
  of	
  Ohio	
  (the	
  State)	
  

signed	
  a	
  stipulation	
  for	
  injunctive	
  relief	
  (the	
  Stipulation)	
  concerning	
  conditions	
  at	
  the	
  Scioto	
  

Juvenile	
  Correctional	
  Facility	
  (Scioto)	
  and	
  the	
  Marion	
  Juvenile	
  Correctional	
  Facility	
  (Marion;	
  

which	
  was	
  closed	
  shortly	
  after	
  the	
  Stipulation	
  was	
  signed).	
  Fred	
  Cohen,	
  the	
  Lead	
  Monitor	
  of	
  the	
  

concurrent	
  conditions	
  of	
  confinement	
  lawsuit,	
  S.H.	
  v	
  Reed	
  et	
  al.,	
  served	
  as	
  the	
  monitor	
  for	
  the	
  

Stipulation	
  until	
  late	
  2009.	
  At	
  that	
  point,	
  Mr.	
  Cohen	
  resigned	
  and	
  the	
  DOJ	
  assumed	
  the	
  role	
  of	
  

Monitor,	
  with	
  Dr.	
  Kelly	
  Dedel,	
  Dr.	
  Daphne	
  Glindmeyer,	
  and	
  Dr.	
  Michelle	
  Staples-­‐Horne	
  serving	
  as	
  

subject	
  matter	
  experts.	
  	
  

	
  

In	
  June	
  2011,	
  as	
  the	
  original	
  stipulation	
  expired,	
  the	
  Parties	
  recognized	
  that	
  the	
  State	
  had	
  not	
  

yet	
  reached	
  substantial	
  compliance	
  with	
  several	
  key	
  portions	
  of	
  the	
  Stipulation.	
  Thus,	
  the	
  

Stipulation	
  was	
  renegotiated	
  to	
  include	
  a	
  subset	
  of	
  the	
  original	
  provisions.	
  The	
  Amended	
  

Stipulation	
  terminates	
  when	
  the	
  State	
  has	
  achieved	
  substantial	
  compliance	
  with	
  each	
  provision	
  

and	
  has	
  maintained	
  substantial	
  compliance	
  for	
  two	
  reporting	
  periods	
  (i.e.,	
  12	
  months).	
  The	
  

Parties	
  also	
  agreed	
  that	
  the	
  Amended	
  Stipulation	
  is	
  subject	
  to	
  the	
  termination	
  provisions	
  of	
  the	
  

Prison	
  Litigation	
  Reform	
  Act.	
  	
  

	
  

The	
  Monitor	
  for	
  the	
  Amended	
  Stipulation	
  is	
  Dr.	
  Kelly	
  Dedel,	
  who	
  evaluates	
  the	
  State’s	
  progress	
  

in	
  the	
  areas	
  of	
  Protection	
  From	
  Harm,	
  Grievances,	
  Programming	
  and	
  Special	
  Education.	
  She	
  is	
  

assisted	
  by	
  two	
  Subject	
  Matter	
  Experts,	
  Dr.	
  Daphne	
  Glindmeyer,	
  who	
  evaluates	
  the	
  State’s	
  

progress	
  on	
  provisions	
  related	
  to	
  Mental	
  Health	
  Services,	
  and	
  Dr.	
  Michelle	
  Staples-­‐Horne,	
  who	
  

evaluates	
  the	
  State’s	
  progress	
  on	
  provisions	
  related	
  to	
  Medical	
  Care.	
  	
  

	
  

As	
  the	
  Monitor,	
  Dr.	
  Dedel	
  is	
  the	
  primary	
  liaison	
  between	
  the	
  Monitoring	
  Team	
  and	
  the	
  Parties	
  

and	
  she	
  compiles	
  the	
  Monitor’s	
  Report.	
  To	
  do	
  so,	
  she	
  combines	
  Drs.	
  Glindmeyer’s	
  and	
  Staples-­‐

Horne’s	
  reports	
  with	
  her	
  own	
  to	
  form	
  a	
  coherent	
  whole,	
  but	
  does	
  not	
  change	
  the	
  substance	
  of	
  

the	
  reports	
  by	
  either	
  of	
  the	
  Subject	
  Matter	
  Experts,	
  who	
  are	
  responsible	
  for	
  forming	
  their	
  own	
  

opinions	
  about	
  the	
  level	
  of	
  compliance	
  for	
  each	
  provision	
  in	
  their	
  areas	
  of	
  expertise.	
  	
  

	
  

This	
  is	
  the	
  Monitor’s	
  third	
  report	
  on	
  the	
  State’s	
  progress	
  toward	
  the	
  reforms	
  required	
  by	
  the	
  

Amended	
  Stipulation.	
  The	
  monitoring	
  period	
  is	
  April	
  1	
  through	
  September	
  30,	
  2012.	
  Progress	
  

reports	
  are	
  issued	
  approximately	
  every	
  six	
  months.	
  	
  

	
  

	
  

	
  

	
  

3.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 4 of 129 PAGEID #: 2357

EXECUTIVE	
  SUMMARY	
  

	
  

The	
  Amended	
  Stipulation	
  includes	
  33	
  provisions	
  related	
  to	
  Protection	
  From	
  Harm	
  (n=3);	
  

Grievances	
  (n=2);	
  Programming	
  (n=2);	
  Mental	
  Health	
  Care	
  (n=18)	
  and	
  Documentation	
  (n=2);	
  

Medical	
  Care	
  (n=3);	
  and	
  Special	
  Education	
  (n=3).	
  Each	
  provision	
  is	
  listed	
  in	
  the	
  table	
  below,	
  

along	
  with	
  the	
  Monitor’s	
  or	
  Subject	
  Matter	
  Expert’s	
  compliance	
  rating.	
  	
  

	
  

The	
  Monitor’s	
  first	
  report	
  used	
  only	
  two	
  compliance	
  levels:	
  substantial	
  compliance	
  and	
  non-­‐

compliance.	
  The	
  subsequent	
  reports	
  use	
  a	
  three-­‐tiered	
  system	
  (substantial	
  compliance,	
  partial	
  

compliance	
  and	
  non-­‐compliance),	
  defined	
  as	
  follows:	
  

	
  

·∙	
  	
  	
  	
  	
  Substantial	
  Compliance	
  means	
  that	
  the	
  facility	
  has	
  drafted	
  relevant	
  policies	
  and	
  procedures;	
  

has	
  trained	
  the	
  staff	
  responsible	
  for	
  implementation;	
  has	
  sufficient	
  staff	
  to	
  implement	
  the	
  

required	
  reform;	
  has	
  demonstrated	
  the	
  ability	
  to	
  properly	
  implement	
  the	
  procedures	
  during	
  

the	
  majority	
  of	
  the	
  monitoring	
  period;	
  and	
  has	
  ascertained	
  that	
  the	
  procedures	
  accomplish	
  

the	
  outcome	
  envisioned	
  by	
  the	
  provision.	
  Non-­‐compliance	
  with	
  mere	
  technicalities	
  or	
  a	
  

temporary	
  failure	
  to	
  comply	
  (due	
  to	
  staff	
  vacancy	
  or	
  illness,	
  facility	
  disruptions,	
  or	
  other	
  

short-­‐term	
  events)	
  during	
  an	
  otherwise	
  sustained	
  period	
  of	
  compliance	
  do	
  not	
  constitute	
  a	
  

failure	
  to	
  achieve	
  or	
  maintain	
  substantial	
  compliance.	
  Conversely,	
  temporary	
  compliance	
  

during	
  a	
  period	
  of	
  sustained	
  non-­‐compliance	
  or	
  partial	
  compliance	
  does	
  not	
  constitute	
  

substantial	
  compliance.	
  

	
  	
  

·∙	
  	
  	
  	
  	
  	
  Partial	
  Compliance	
  means	
  that	
  the	
  facility	
  has	
  drafted	
  policies	
  and	
  procedures,	
  has	
  trained	
  

staff	
  responsible	
  for	
  implementation,	
  and	
  has	
  sufficient	
  staff	
  to	
  implement	
  the	
  required	
  

reform.	
  While	
  progress	
  has	
  been	
  made	
  toward	
  implementing	
  the	
  procedures	
  described	
  by	
  

policy,	
  performance	
  has	
  been	
  inconsistent	
  throughout	
  the	
  monitoring	
  period	
  and	
  additional	
  

modifications	
  are	
  needed	
  to	
  ensure	
  that	
  procedures	
  are	
  sufficiently	
  comprehensive	
  to	
  

translate	
  policy	
  into	
  practice.	
  	
  

	
  	
  

·∙	
  	
  	
  	
  	
  Non-­‐Compliance	
  means	
  that	
  the	
  facility	
  has	
  made	
  only	
  very	
  preliminary	
  efforts	
  to	
  implement	
  

the	
  required	
  reform,	
  but	
  significant	
  work	
  remains.	
  Policy	
  may	
  need	
  to	
  be	
  overhauled,	
  the	
  

majority	
  of	
  staff	
  may	
  need	
  to	
  be	
  trained,	
  procedures	
  may	
  not	
  have	
  been	
  developed,	
  and	
  no	
  

one	
  has	
  begun	
  to	
  ascertain	
  whether	
  the	
  procedures	
  accomplish	
  the	
  outcome	
  envisioned	
  by	
  

the	
  provision.	
  	
  

	
  

	
  

The	
  Monitor	
  wants	
  to	
  emphasize	
  that	
  the	
  substantial	
  compliance	
  rating	
  is	
  given	
  only	
  when	
  the	
  

required	
  reforms	
  address	
  all	
  of	
  the	
  issues	
  discussed	
  in	
  the	
  Provision	
  and	
  when	
  solid	
  

implementation	
  of	
  the	
  reforms	
  has	
  been	
  consistently	
  demonstrated,	
  through	
  reliable	
  data,	
  

observations	
  and	
  reports	
  from	
  staff	
  and	
  youth,	
  for	
  a	
  majority	
  of	
  the	
  monitoring	
  period.	
  Partial	
  

compliance	
  indicates	
  that	
  some	
  of	
  the	
  issues	
  addressed	
  in	
  the	
  Provision	
  have	
  been	
  resolved,	
  but	
  

that	
  problems,	
  some	
  of	
  them	
  serious,	
  still	
  remain.	
  The	
  application	
  of	
  the	
  partial	
  compliance	
  

rating	
  is	
  only	
  a	
  brief	
  indicator—the	
  entire	
  discussion	
  should	
  be	
  read	
  to	
  fully	
  understand	
  the	
  type	
  

and	
  magnitude	
  of	
  remaining	
  problems.	
  	
  

	
  

	
  

	
  

	
  

	
  

4.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 5 of 129 PAGEID #: 2358

Table	
  1.	
  Compliance	
  Ratings	
  for	
  Each	
  Provision	
  

No.	
  

Provision	
  

Protection	
  From	
  Harm	
  

III.A.	
  1	
  

General	
  Protection	
  From	
  Harm	
  

III.A.3	
  

Seclusion	
  

III.A.5	
  

Investigation	
  of	
  Serious	
  Incidents	
  

III.D.1	
  

Grievances	
  

III.D.2	
  

Grievances	
  Explained	
  to	
  Youth	
  

III.F.1	
  

Structured	
  Programming	
  

III.F.2	
  

Orientation	
  

Mental	
  Health	
  Services	
  

III.B.1	
  

Mental	
  Health	
  Screening	
  

III.B.2	
  

Immediate	
  Referral	
  to	
  QMHP	
  

III.B.3	
  

Identification	
  of	
  Previously	
  UnID	
  Youth	
  	
  

III.B.4	
  

Mental	
  Health	
  Assessment	
  

III.B.5	
  

Adequate	
  Care	
  and	
  Treatment	
  

III.B.6	
  

Treatment	
  Planning	
  

III.B.7	
  

Treatment	
  Teams	
  

III.B.8	
  

Integrated	
  Treatment	
  Plans	
  

III.B.9	
  

Access	
  to	
  QMHP	
  

III.B.10	
  

MH	
  Involvement	
  in	
  Housing	
  and	
  Plcmt	
  

III.B.11	
  

Staffing	
  

III.B.12	
  

Medication	
  Notice	
  

III.B.13	
  

Mental	
  Health	
  Medications	
  

III.B.14	
  

MH/DD	
  Training	
  for	
  Direct	
  Care	
  Staff	
  

III.B.15	
  

Staff	
  Mental	
  Health	
  Training	
  

III.B.16	
  

Suicide	
  Prevention	
  

III.B.17	
  

Transition	
  Planning	
  

III.B.18	
  

Oversight	
  of	
  Mental	
  Health	
  

III.G.1	
  

Progress	
  Notes	
  

III.G.2	
  

Accessibility	
  of	
  Information	
   	
  

1st	
  Report	
  	
   2nd	
  Report	
   3rd	
  Report	
  

NC	
  

PC	
  

PC	
  

NC	
  

PC	
  

PC	
  

SC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

SC	
  

SC	
  

NC	
  

NC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

SC	
  

PC	
  

PC	
  

SC	
  

NC	
  

PC	
  

PC	
  

NC	
  

PC	
  

PC	
  

NC	
  

PC	
  

PC	
  

NC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

NC	
  

PC	
  

PC	
  

NC	
  

PC	
  

SC	
  

NC	
  

PC	
  

PC	
  

NC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

NC	
  

NC	
  

NC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

PC	
  

NC	
  

NC	
  

NC	
  

PC	
  

PC	
  

PC	
  

NC	
  

NC	
  

NC	
  

	
  

	
  

5.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 6 of 129 PAGEID #: 2359

Medical	
  Services	
  

III.C.1	
  

General	
  Medical	
  Care	
  

SC	
  

PC	
  

PC	
  

III.C.2	
  

Health	
  Records	
  

SC	
  

PC	
  

PC	
  

III.C.5	
  

Access	
  to	
  Health	
  Services	
  

SC	
  

SC	
  

SC	
  

Special	
  Education	
  Services	
  

III.E.1	
  

Provision	
  of	
  Special	
  Education	
  

PC	
  

PC	
  

PC	
  

III.E.7	
  

Individual	
  Education	
  Plans	
  

PC	
  

PC	
  

SC	
  

III.E.8	
  

Vocational	
  Education	
  

NC	
  

NC	
  

SC	
  

	
   	
   	
   Overall,	
  the	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  7	
  of	
  the	
  33	
  provisions	
  (21%,	
  compared	
  to	
  6%	
   during	
  the	
  previous	
  monitoring	
  period),	
  in	
  partial	
  compliance	
  with	
  23	
  provisions	
  (70%;	
   compared	
  to	
  79%	
  during	
  the	
  previous	
  monitoring	
  period)	
  and	
  in	
  non-­‐compliance	
  with	
  3	
   provisions	
  (9%,	
  compared	
  to	
  15%	
  during	
  the	
  previous	
  monitoring	
  period).	
  Across	
  the	
  33	
   provisions,	
  the	
  compliance	
  rating	
  was	
  upgraded	
  for	
  6	
  provisions	
  (18%).	
  The	
  compliance	
  rating	
   was	
  not	
  downgraded	
  for	
  any	
  provision.	
  Compliance	
  ratings	
  for	
  each	
  section	
  and	
  key	
  issues	
  to	
  be	
   addressed	
  are	
  highlighted	
  below.	
  	
   	
   	
   Protection	
  from	
  Harm	
  (includes	
  Grievances	
  and	
  Programming)	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  1	
  of	
  the	
  7	
  provisions	
  (14%)	
  related	
  to	
  protecting	
   youth	
  from	
  harm	
  and	
  in	
  partial	
  compliance	
  with	
  the	
  remaining	
  6	
  provisions	
  (86%).	
  The	
  following	
   actions	
  should	
  be	
  prioritized:	
   	
  
• Conduct	
  a	
  problem-­‐solving	
  analysis	
  to	
  determine	
  the	
  nature	
  of	
  youth-­‐on-­‐staff	
  assaults	
   and	
  implement	
  interventions	
  that	
  target	
  the	
  underlying	
  causes	
  and	
  patterns.	
  
• Improve	
  the	
  quality	
  of	
  FIA	
  reviews	
  of	
  the	
  use	
  of	
  physical	
  restraint	
  to	
  ensure	
  that	
  staff	
   have	
  exhausted	
  all	
  other	
  means	
  for	
  resolving	
  problems	
  with	
  youth.	
  Ensure	
  that	
  staff	
  are	
   provided	
  with	
  coaching	
  to	
  help	
  develop	
  their	
  skills	
  in	
  this	
  area	
  and	
  to	
  ensure	
  their	
   compliance	
  with	
  all	
  related	
  policies.	
  	
  
• Ensure	
  that	
  sufficient	
  direct	
  care	
  staff	
  are	
  recruited,	
  hired	
  and	
  retained	
  in	
  order	
  to	
   reduce	
  the	
  reliance	
  on	
  mandated	
  overtime	
  to	
  meet	
  minimum	
  staffing	
  requirements.	
  	
  
• Reinforce	
  the	
  prohibition	
  against	
  provoking,	
  taunting,	
  belittling	
  and	
  otherwise	
   disrespecting	
  youth.	
  Investigate	
  complaints	
  vigorously	
  and	
  enforce	
  the	
  conduct	
   standards	
  when	
  they	
  are	
  violated.	
  	
  
• Modify	
  the	
  IRAV	
  to	
  ensure	
  that	
  youth	
  remain	
  in	
  pre-­‐hearing	
  seclusion	
  no	
  longer	
  than	
   necessary	
  to	
  de-­‐escalate	
  their	
  behavior	
  and	
  ensure	
  they	
  do	
  not	
  pose	
  a	
  threat	
  to	
  the	
   safety	
  of	
  other	
  youth	
  and	
  staff.	
  Ensure	
  that	
  Intervention	
  Hearings	
  are	
  held	
  in	
  a	
  timely	
   manner.	
  	
  
• Limit	
  the	
  use	
  of	
  intervention	
  seclusion,	
  relying	
  instead	
  of	
  sanctions	
  that	
  provide	
  an	
   opportunity	
  for	
  skill	
  development	
  and	
  treatment	
  in	
  order	
  to	
  create	
  behavior	
  change,	
   and	
  collect	
  data	
  to	
  demonstrate	
  the	
  extent	
  to	
  which	
  this	
  has	
  occurred.	
  Develop	
  quality	
  

	
  

6.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 7 of 129 PAGEID #: 2360

assurance	
  mechanisms	
  around	
  the	
  use	
  of	
  seclusion	
  in	
  Intervention	
  Hearings	
  and	
  to	
   determine	
  whether	
  the	
  IDT	
  sanctioning	
  process	
  is	
  a	
  viable	
  strategy	
  for	
  reducing	
  the	
   reliance	
  on	
  seclusion	
  and	
  increasing	
  safety.	
  	
   • Ensure	
  that	
  youth	
  on	
  the	
  PROGRESS	
  Unit	
  are	
  not	
  scheduled	
  to	
  be	
  in	
  their	
  rooms	
  in	
  any	
   greater	
  measure	
  than	
  youth	
  in	
  the	
  general	
  population.	
   • Ensure	
  that	
  youth	
  on	
  the	
  PROGRESS	
  Unit	
  are	
  out	
  of	
  their	
  rooms,	
  attending	
  treatment	
   education	
  or	
  other	
  structured	
  programming	
  throughout	
  the	
  day.	
  This	
  programming	
   must	
  be	
  delivered	
  with	
  integrity	
  so	
  that	
  the	
  youth	
  are	
  able	
  to	
  meet	
  their	
  treatment	
   goals	
  and	
  return	
  to	
  the	
  general	
  population	
  within	
  a	
  reasonable	
  period	
  of	
  time.	
  	
   • Finalize	
  the	
  PROGRESS	
  Unit	
  policies,	
  SOP	
  and	
  Youth	
  Handbook	
  so	
  that	
  they	
  provide	
  an	
   accurate	
  description	
  of	
  the	
  current	
  operation	
  of	
  the	
  Unit.	
  Revise	
  these	
  documents	
  as	
   the	
  program	
  evolves.	
  	
   • Reduce	
  the	
  number	
  of	
  individuals	
  authorized	
  to	
  conduct	
  facility-­‐based	
  investigations	
   and	
  ensure	
  that	
  these	
  individuals	
  have	
  the	
  requisite	
  skills	
  for	
  the	
  task.	
  Ensure	
  that	
   producing	
  timely,	
  high-­‐quality	
  investigations	
  is	
  a	
  specific	
  job	
  responsibility	
  and	
  that	
   employees	
  are	
  held	
  accountable	
  for	
  their	
  failure	
  to	
  produce	
  reports	
  that	
  meet	
   professional	
  standards.	
  	
   • Promptly	
  notify	
  youth	
  of	
  the	
  outcome	
  of	
  any	
  grievance	
  referred	
  for	
  investigation.	
   Construct	
  a	
  plan	
  to	
  respond	
  to	
  the	
  problems	
  discovered	
  by	
  the	
  CIO’s	
  2011	
  grievance	
   survey.	
  	
   • Ensure	
  that	
  individual	
  and	
  group	
  treatment	
  is	
  delivered	
  at	
  the	
  required	
  frequency	
  and	
   duration	
  on	
  all	
  units.	
  	
   	
   	
   Mental	
  Health	
  Services	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  3	
  (15%)	
  of	
  the	
  20	
  provisions	
  related	
  to	
  mental	
   health	
  services	
  and	
  documentation.	
  It	
  is	
  in	
  partial	
  compliance	
  with	
  14	
  (70%)	
  of	
  the	
  provisions	
   and	
  in	
  non-­‐compliance	
  with	
  3	
  of	
  the	
  provisions	
  (15%).	
  	
  The	
  following	
  actions	
  are	
  required:	
   	
   • Finalize	
  and	
  implement	
  policies.	
  ODYS	
  has	
  recently	
  completed	
  a	
  collaborative	
  policy	
  and	
   procedure	
  review	
  and	
  revision	
  process.	
  	
  The	
  Monitors	
  in	
  both	
  this	
  case	
  and	
  S.H.	
  v.	
  Reed	
   have	
  reviewed	
  these	
  policies.	
  	
  	
   • Staff	
  the	
  facility	
  with	
  sufficient	
  psychiatric	
  (both	
  psychiatric	
  physicians	
  and	
  psychiatric	
   nurses)	
  resources	
  to	
  provide	
  psychiatric	
  evaluation,	
  medication	
  monitoring,	
  and	
   treatment	
  team	
  interaction.	
   • Develop	
  an	
  organized	
  training	
  schedule	
  for	
  mental	
  health	
  staff.	
  	
   • Train	
  direct	
  care	
  staff	
  and	
  mental	
  health	
  staff	
  to	
  understand	
  the	
  behavior	
  and	
  needs	
  of	
   youth	
  with	
  mental	
  illnesses	
  and	
  developmental	
  disabilities	
  and	
  recognize	
  and	
  respond	
   to	
  signs	
  and	
  symptoms	
  of	
  serious	
  mental	
  illness.	
  	
   • Train	
  mental	
  health	
  staff	
  to	
  develop	
  high-­‐quality	
  case	
  conceptualizations	
  that	
  integrate	
   the	
  information	
  generated	
  by	
  the	
  multiple	
  assessments	
  administered	
  to	
  youth	
  upon	
   admission.	
  	
   • Train,	
  coach	
  and	
  adequately	
  supervise	
  direct	
  care	
  staff	
  and	
  mental	
  health	
  staff	
  to	
   implement	
  the	
  Phoenix	
  New	
  Freedom	
  curriculum,	
  particularly	
  in	
  skills	
  for	
  leading	
  group	
   therapy	
  sessions	
  to	
  ensure	
  the	
  interactions	
  and	
  documentation	
  reflect	
  generally	
   accepted	
  practices	
  for	
  mental	
  health	
  care.	
  	
  This	
  should	
  include	
  treatment	
  integrity	
  

	
  

7.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 8 of 129 PAGEID #: 2361

checks	
  (e.g.	
  observation	
  of	
  group	
  interaction	
  with	
  subsequent	
  education	
  and	
  training	
  as	
   necessary).	
   • Develop	
  procedures	
  to	
  ensure,	
  and	
  to	
  document,	
  that	
  youth	
  are	
  assessed	
  by	
  a	
  qualified	
   mental	
  health	
  professional	
  within	
  12	
  hours	
  when	
  a	
  serious	
  risk	
  to	
  the	
  youth’s	
  safety	
  is	
   identified.	
  	
   • Ensure	
  mental	
  health	
  staff	
  assesses	
  youth	
  on	
  suicide	
  precautions,	
  those	
  in	
  seclusion,	
   and	
  those	
  on	
  the	
  PROGRESS	
  Units	
  every	
  24	
  hours.	
  	
   • Ensure	
  youth	
  with	
  acute	
  mental	
  illnesses	
  requiring	
  extensive	
  mental	
  health	
  treatment	
   have	
  access	
  to	
  more	
  appropriate	
  placements.	
   • Ensure	
  treatment	
  plans	
  are	
  individualized	
  including	
  measurable	
  goals	
  and	
  targeted	
   interventions	
  to	
  address	
  the	
  goals.	
  Update	
  treatment	
  plans	
  regularly	
  and	
  monitor	
   youth’s	
  progress	
  toward	
  achieving	
  treatment	
  goals.	
  Adapt	
  treatment	
  plans	
  for	
  youth	
   who	
  are	
  not	
  progressing.	
   • Ensure	
  Interdisciplinary	
  Treatment	
  Team	
  meetings	
  include	
  representatives	
  from	
  the	
   major	
  sectors	
  of	
  the	
  facility	
  including	
  social	
  workers,	
  direct	
  care	
  staff,	
  educators,	
  and	
   psychiatrists	
  and	
  that	
  Treatment	
  Teams	
  are	
  focused	
  on	
  treatment	
  issues	
  and	
  the	
  youth’s	
   progress	
  toward	
  treatment	
  goals.	
   • Ensure	
  youth	
  on	
  the	
  PROGRESS	
  Units	
  are	
  appropriate	
  for	
  the	
  secure	
  setting	
  and	
  receive	
   appropriate	
  treatment.	
  Conduct	
  thorough	
  assessments	
  of	
  all	
  youth	
  proposed	
  for	
   placement	
  in	
  the	
  future.	
  	
   • Continue	
  the	
  current	
  practice	
  of	
  assigning	
  all	
  youth	
  housed	
  in	
  the	
  PROGRESS	
  Units	
  to	
   the	
  mental	
  health	
  caseload.	
   • Ensure	
  youth	
  receive	
  proper	
  laboratory	
  examinations	
  and	
  side-­‐effect	
  monitoring	
   commensurate	
  with	
  the	
  psychotropic	
  medications	
  prescribed	
  and	
  reflecting	
  generally	
   accepted	
  practices.	
  	
   • Develop	
  a	
  coherent,	
  coordinated	
  quality	
  assurance	
  process	
  that	
  provides	
  a	
  cogent	
   review	
  of	
  social	
  work,	
  psychological	
  and	
  psychiatric	
  services	
  at	
  the	
  facility.	
  This	
  should	
   include	
  peer	
  review.	
  	
  It	
  should	
  also	
  include	
  both	
  process	
  and	
  outcome	
  measures	
  with	
   corrective	
  action	
  inclusive	
  of	
  individual	
  supervision,	
  staff	
  training,	
  or	
  adjustment	
  of	
   systems	
  as	
  necessary.	
   • Address	
  limitations	
  to	
  treatment	
  resulting	
  from	
  the	
  fragmented	
  recordkeeping	
  process	
   via	
  the	
  creation	
  of	
  a	
  unified	
  record.	
   	
   	
   Medical	
  Services	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  one	
  of	
  the	
  provisions	
  (33%)	
  related	
  to	
  medical	
   services	
  and	
  in	
  partial	
  compliance	
  with	
  the	
  other	
  2	
  provisions	
  (66%).	
  The	
  following	
  actions	
   should	
  be	
  prioritized:	
   	
   • Complete	
  satellite	
  clinic	
  and	
  medication	
  room	
  on	
  Buckeye	
  Units	
  for	
  adequate	
  injury	
   assessments	
  of	
  youth	
  and	
  medication	
  administration	
  on	
  the	
  unit.	
  	
   • Limit	
  time	
  of	
  youth	
  in	
  seclusion	
  and	
  improve	
  documentation	
  of	
  health	
  status	
  during	
   segregation.	
   • Continue	
  to	
  improve	
  Quality	
  Assurance	
  (QA)	
  activities	
  by	
  considering	
  a	
  review	
  at	
  least	
   annually	
  by	
  a	
  source	
  external	
  to	
  ODYS	
  Health	
  Services.	
  ODYS	
  should	
  also	
  consider	
   expansion	
  of	
  the	
  QA	
  process	
  to	
  include	
  some	
  additional	
  quality	
  indicators.	
  Conduct	
  

	
  

8.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 9 of 129 PAGEID #: 2362

Quality	
  Assurance	
  Program	
  as	
  outlined	
  in	
  the	
  National	
  Commission	
  on	
  Correctional	
  

Health	
  Care	
  Juvenile	
  Health	
  Standards.	
  This	
  would	
  satisfy	
  the	
  need	
  for	
  a	
  self-­‐

assessment.	
  

• Continue	
  to	
  improve	
  the	
  process	
  for	
  sharing	
  of	
  health	
  information	
  between	
  medical	
  and	
  

mental	
  health	
  to	
  include	
  psychologists	
  through	
  implementation	
  of	
  eClinical	
  Works	
  EHR.	
  

ODYS	
  medical	
  management	
  staff	
  should	
  be	
  intimately	
  involved	
  in	
  the	
  process	
  of	
  

customization	
  of	
  the	
  EMR	
  to	
  be	
  relevant	
  to	
  youth	
  medical	
  services.	
  

	
  

	
  

Special	
  Education	
  

	
  

The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  2	
  of	
  the	
  3	
  education-­‐related	
  provisions	
  (66%)	
  and	
  is	
  

in	
  partial	
  compliance	
  with	
  one	
  provision	
  (33%).	
  The	
  following	
  actions	
  should	
  be	
  prioritized:	
  

• Address	
  the	
  preventable	
  causes	
  of	
  absenteeism,	
  address	
  data	
  entry	
  and	
  data	
  

management	
  issues,	
  and	
  ensure	
  average	
  attendance	
  rates	
  of	
  85%	
  or	
  better	
  are	
  achieved	
  

for	
  each	
  housing	
  unit.	
  	
  

• Continue	
  to	
  provide	
  access	
  to	
  alternative	
  education	
  services	
  for	
  youth	
  in	
  seclusion	
  

through	
  the	
  use	
  of	
  Unit	
  Instruction.	
  Ensure	
  that	
  the	
  type,	
  quality	
  and	
  duration	
  of	
  

instruction	
  comply	
  with	
  the	
  S.H.	
  Parties’	
  agreement.	
  Come	
  to	
  an	
  agreement	
  with	
  the	
  SH	
  

Parties	
  as	
  to	
  whether	
  youth	
  will	
  be	
  served	
  behind	
  their	
  doors	
  or	
  may	
  be	
  brought	
  out	
  

into	
  the	
  dayroom,	
  when	
  that	
  can	
  be	
  accomplished	
  safely.	
  	
  

	
  

	
  

	
  

	
  

The	
  facility	
  has	
  undergone	
  several	
  transformations	
  since	
  the	
  original	
  Stipulation	
  was	
  signed.	
  

Originally,	
  Scioto	
  was	
  the	
  central	
  reception	
  facility	
  for	
  all	
  DYS	
  facilities.	
  In	
  the	
  summer	
  of	
  2011,	
  

DYS	
  began	
  to	
  de-­‐centralize	
  its	
  reception	
  process	
  to	
  convert	
  Scioto	
  to	
  a	
  long-­‐term	
  facility	
  that	
  

houses	
  medium	
  and	
  close	
  custody	
  boys.	
  Scioto	
  remains	
  the	
  reception	
  center	
  for	
  girls	
  and	
  also	
  

operates	
  a	
  long-­‐term	
  girls’	
  program	
  and	
  a	
  mental	
  health	
  unit	
  for	
  girls.	
  The	
  facility	
  also	
  houses	
  a	
  

special	
  management	
  unit	
  (the	
  PROGRESS	
  Unit),	
  which	
  has	
  been	
  the	
  topic	
  of	
  much	
  controversy	
  

during	
  the	
  current	
  monitoring	
  period.	
  	
  

	
  

The	
  change	
  in	
  the	
  facility’s	
  mission	
  required	
  staff	
  to	
  adjust	
  to	
  a	
  new	
  type	
  of	
  youth	
  (generally	
  

higher-­‐risk)	
  and	
  to	
  new	
  responsibilities	
  for	
  their	
  long-­‐term	
  care	
  and	
  treatment.	
  In	
  addition,	
  the	
  

facility	
  received	
  an	
  entirely	
  new	
  Administrative	
  Team	
  in	
  February	
  2012,	
  and	
  then	
  received	
  a	
  new	
  

Superintendent	
  in	
  September	
  2012.	
  The	
  multitude	
  of	
  changes	
  have	
  made	
  steady	
  progress	
  

toward	
  substantial	
  compliance	
  difficult	
  to	
  achieve.	
  	
  

	
  

The	
  remainder	
  of	
  this	
  report	
  is	
  organized	
  as	
  follows:	
  1)	
  each	
  Provision	
  is	
  presented,	
  verbatim;	
  2)	
  

the	
  compliance	
  rating	
  is	
  noted;	
  3)	
  information	
  the	
  State	
  presented	
  to	
  demonstrate	
  compliance	
  

with	
  the	
  Provision	
  is	
  summarized;	
  4)	
  additional	
  activities	
  undertaken	
  by	
  the	
  Monitor	
  or	
  subject	
  

matter	
  expert	
  to	
  determine	
  the	
  level	
  of	
  compliance	
  are	
  discussed;	
  5)	
  the	
  steps	
  required	
  to	
  

achieve	
  substantial	
  compliance	
  with	
  the	
  Provision	
  are	
  listed;	
  6)	
  the	
  sources	
  of	
  information	
  the	
  

Monitor	
  or	
  subject	
  matter	
  expert	
  used	
  to	
  form	
  her	
  opinion	
  are	
  listed.	
  	
  

	
  

	
  

	
  

9.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 10 of 129 PAGEID #: 2363

PROTECTION	
  FROM	
  HARM	
  	
  
	
   	
  
III.A.1	
  General	
  Protection	
  From	
  Harm.	
  The	
  State	
  shall,	
  at	
  all	
  times,	
  provide	
  youth	
  in	
  the	
  facilities	
   with	
  safe	
  living	
  conditions.	
  As	
  part	
  of	
  this	
  requirement,	
  the	
  State	
  shall	
  take	
  appropriate	
   measures	
  to	
  ensure	
  that	
  youth	
  are	
  protected	
  from	
  abuse	
  and	
  neglect,	
  use	
  of	
  excessive	
  force,	
   undue	
  seclusion,	
  undue	
  restraint,	
  and	
  over-­‐familiarization.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  State	
  provided	
  an	
  array	
  of	
  data	
  to	
  illustrate	
  the	
  trends	
  in	
  youth	
   violence,	
  restraints,	
  seclusion,	
  and	
  allegations	
  of	
  employee	
  misconduct,	
   along	
  with	
  an	
  interpretation	
  of	
  the	
  trends	
  and	
  the	
  underlying	
  causes	
  of	
   any	
  changes.	
  The	
  structure	
  of	
  the	
  Monitor’s	
  most	
  recent	
  visit	
  did	
  not	
   provide	
  as	
  much	
  time	
  to	
  discuss	
  the	
  interpretation	
  of	
  the	
  data	
  as	
  in	
   previous	
  monitoring	
  periods.	
  As	
  a	
  result,	
  much	
  of	
  the	
  following	
  discussion	
   is	
  based	
  on	
  the	
  Monitor’s	
  own	
  analysis	
  but	
  is	
  contained	
  in	
  the	
  self-­‐ assessment	
  section	
  for	
  the	
  sake	
  of	
  clarity.	
  	
   	
   While	
  on	
  site,	
  the	
  Monitor	
  learned	
  of	
  several	
  quality	
  assurance	
   mechanisms	
  that,	
  if	
  data	
  are	
  interpreted	
  properly	
  and	
  used	
  as	
  a	
  basis	
  for	
   action,	
  will	
  improve	
  the	
  State’s	
  ability	
  to	
  protect	
  youth	
  from	
  harm.	
  Trends	
   in	
  youth	
  violence,	
  restraints,	
  and	
  allegations	
  of	
  over-­‐familiarization	
  are	
   discussed	
  here,	
  while	
  detailed	
  discussions	
  about	
  the	
  use	
  of	
  seclusion	
  and	
   staff	
  misconduct	
  can	
  be	
  found	
  in	
  III.A.3	
  and	
  III.A.5	
  respectively.	
  	
   	
   Youth	
  Violence	
   	
   The	
  table	
  below	
  presents	
  the	
  rate	
  of	
  youth-­‐on-­‐youth	
  and	
  youth-­‐on-­‐staff	
   violence	
  for	
  the	
  past	
  18	
  months.	
  These	
  data	
  reveal	
  a	
  steady	
  reduction	
  in	
   youth-­‐on-­‐youth	
  violence.	
  The	
  average	
  rate	
  for	
  the	
  past	
  three	
  six-­‐month	
   monitoring	
  periods	
  was	
  .24,	
  .13	
  and	
  .08.	
  Changes	
  in	
  the	
  rates	
  of	
  violence	
   are	
  customarily	
  related	
  to	
  a	
  complex	
  constellation	
  of	
  factors	
  including	
   staffing,	
  programming,	
  treatment,	
  the	
  type	
  of	
  youth	
  housed,	
  amount	
  of	
   idle	
  time,	
  and	
  the	
  staff’s	
  skill	
  at	
  de-­‐escalating	
  the	
  tension	
  that	
  arise.	
  Most	
   recently,	
  the	
  facility	
  attributed	
  its	
  lower	
  rates	
  of	
  youth-­‐on-­‐youth	
  violence	
   to	
  changes	
  in	
  staffing.	
  Specifically,	
  permanent	
  assignments	
  were	
  made	
   for	
  both	
  the	
  Operations	
  Administrator	
  and	
  Unit	
  Management	
   Administrator,	
  who	
  worked	
  and	
  collaborated	
  on	
  daily	
  issues	
  and	
  used	
   proactive	
  approaches	
  to	
  ensure	
  that	
  youth	
  were	
  protected	
  from	
  harm.	
  In	
   addition,	
  since	
  March	
  2012,	
  all	
  units	
  have	
  had	
  a	
  Unit	
  Manager.	
  Finally,	
  the	
   facility	
  did	
  not	
  operate	
  below	
  minimum	
  staffing	
  levels	
  at	
  any	
  time	
  during	
   the	
  current	
  monitoring	
  time.	
  [Recall	
  that	
  short	
  staffing	
  was	
  identified	
  as	
  a	
   major	
  contributor	
  to	
  a	
  variety	
  of	
  operational	
  problems	
  in	
  the	
  2nd	
   Monitor’s	
  Report.]	
   	
   In	
  addition,	
  the	
  PROGRESS	
  Unit	
  (PU)	
  school	
  was	
  identified	
  as	
  a	
  hot	
  spot	
   for	
  youth-­‐on-­‐youth	
  violence.	
  The	
  level	
  of	
  surveillance	
  in	
  the	
  school	
  was	
  

	
  

10.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 11 of 129 PAGEID #: 2364

drastically	
  increased	
  to	
  include	
  five	
  Youth	
  Specialists	
  to	
  assist	
  with	
  school	
   movement	
  and	
  support	
  during	
  school	
  hours.	
  Support	
  for	
  this	
  change	
  was	
   offered	
  by	
  nearly	
  everyone	
  with	
  whom	
  the	
  Monitor	
  spoke	
  while	
  on	
  site,	
   and	
  it	
  is	
  strongly	
  recommended	
  that	
  the	
  State	
  take	
  steps	
  to	
  ensure	
  that	
   this	
  level	
  of	
  staff	
  support	
  is	
  permanently	
  available.	
  [Currently,	
  the	
  five	
  YSs	
   voluntarily	
  leave	
  their	
  assigned	
  posts	
  to	
  provide	
  this	
  assistance.]	
  In	
   addition,	
  the	
  school	
  environment	
  was	
  “hardened”	
  by	
  bolting	
  down	
   furniture	
  and	
  computers	
  and	
  replacing	
  keyboards	
  that	
  youth	
  had	
  been	
   using	
  as	
  weapons.	
  	
   	
   Youth	
  violence	
  also	
  tended	
  to	
  occur	
  among	
  the	
  close	
  custody	
  youth	
   during	
  2nd	
  shift.	
  As	
  discussed	
  in	
  the	
  review	
  of	
  structured	
  programming	
  in	
   Provision	
  III.F.1,	
  the	
  Gang	
  Intervention	
  Specialist	
  began	
  running	
  groups	
   with	
  this	
  population	
  in	
  the	
  afternoons	
  and	
  has	
  been	
  more	
  present	
  on	
  the	
   units	
  during	
  the	
  evenings	
  and	
  weekends.	
  Finally,	
  recreation	
  staff	
  and	
   Youth	
  Specialists	
  have	
  collaborated	
  to	
  provide	
  additional	
  programming	
   opportunities	
  to	
  youth	
  on	
  the	
  weekends	
  to	
  reduce	
  the	
  amount	
  of	
  idle	
   time.	
  All	
  of	
  these	
  efforts	
  appear	
  to	
  have	
  accomplished	
  the	
  intended	
   objective	
  of	
  reducing	
  the	
  rate	
  of	
  youth-­‐on-­‐youth	
  violence.	
  	
   	
  
Youth	
  Violence,	
  April	
  2011	
  through	
  September	
  2012	
  

Month	
  

Youth-­‐Youth	
  

#	
  

ADP	
   Rate	
  

Youth-­‐Staff	
  

#	
  

ADP	
  

Rate	
  

Apr	
  11	
  

30	
  

128	
  

.23	
  

13	
  

128	
  

.10	
  

May	
  11	
  

40	
  

114	
  

.35	
  

14	
  

114	
  

.12	
  

June	
  11	
  

25	
  

110	
  

.23	
  

13	
  

110	
  

.12	
  

July	
  11	
  

19	
  

101	
  

.19	
  

9	
  

101	
  

.09	
  

Aug	
  11	
  

24	
  

108	
  

.22	
  

15	
  

108	
  

.14	
  

Sept	
  11	
  

29	
  

138	
  

.21	
  

45	
  

138	
  

.33	
  

Oct	
  11	
  

31	
  

164	
  

.19	
  

29	
  

164	
  

.18	
  

Nov	
  11	
  

29	
  

161	
  

.18	
  

29	
  

161	
  

.18	
  

Dec	
  11	
  

18	
  

159	
  

.11	
  

11	
  

159	
  

.07	
  

Jan	
  12	
  

21	
  

158	
  

.13	
  

30	
  

158	
  

.19	
  

Feb	
  12	
  

10	
  

137	
  

.07	
  

19	
  

137	
  

.14	
  

Mar	
  12	
  

9	
  

125	
  

.07	
  

21	
  

125	
  

.17	
  

Apr	
  12	
  

9	
  

118	
  

.08	
  

31	
  

118	
  

.26	
  

May	
  12	
  

11	
  

101	
  

.11	
  

16	
  

101	
  

.16	
  

June	
  12	
  

4	
  

91	
  

.04	
  

14	
  

91	
  

.15	
  

July	
  12	
  

10	
  

83	
  

.12	
  

18	
  

83	
  

.22	
  

Aug	
  12	
  

11	
  

88	
  

.12	
  

22	
  

88	
  

.25	
  

Sept	
  12	
  

1	
  

86	
  

.01	
  

14	
  

86	
  

.16	
  

	
  

	
  

11.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 12 of 129 PAGEID #: 2365

Unfortunately,	
  the	
  rate	
  of	
  youth-­‐on-­‐staff	
  violence	
  has	
  been	
  more	
   resistant	
  to	
  change.	
  The	
  average	
  rate	
  of	
  youth-­‐on-­‐staff	
  violence	
  has	
   actually	
  increased	
  about	
  30%	
  over	
  the	
  past	
  three	
  monitoring	
  periods	
  (1st	
   monitoring	
  period	
  =	
  .15;	
  2nd	
  monitoring	
  period	
  =	
  .16;	
  and	
  3rd	
  monitoring	
   period	
  =	
  .20).	
  	
   	
   Previous	
  discussions	
  with	
  facility	
  administrators	
  centered	
  around	
  the	
   belief	
  that	
  the	
  largest	
  contributor	
  to	
  the	
  rate	
  of	
  youth-­‐on-­‐staff	
  assaults	
   was	
  the	
  throwing	
  of	
  bodily	
  fluids	
  and	
  other	
  liquids	
  on	
  staff	
  in	
  the	
  PU.	
  The	
   use	
  of	
  container-­‐less	
  meals	
  (where	
  youth	
  receive	
  the	
  same	
  food,	
  but	
  it	
  is	
   served	
  without	
  cups	
  or	
  cartons,	
  trays	
  with	
  hard	
  dividers	
  or	
  other	
   structures	
  that	
  youth	
  could	
  use	
  to	
  store	
  liquid	
  to	
  be	
  used	
  as	
  a	
  projectile)	
   was	
  said	
  to	
  significantly	
  decrease	
  the	
  frequency	
  of	
  this	
  behavior.	
  While	
   the	
  number	
  of	
  these	
  types	
  of	
  assaults	
  has	
  indeed	
  declined,	
  the	
  rate	
  of	
   youth-­‐on-­‐staff	
  assaults	
  remains	
  high,	
  indicating	
  that	
  other	
  types	
  of	
  youth	
   violence	
  against	
  staff	
  need	
  to	
  be	
  addressed.	
   	
   The	
  recent	
  efforts	
  to	
  increase	
  staffing	
  levels	
  and	
  shore	
  up	
  the	
  security	
  of	
   the	
  classroom	
  environments	
  on	
  the	
  PU	
  should	
  be	
  assessed	
  for	
  their	
   impact	
  on	
  youth	
  on	
  staff	
  violence.	
  If	
  the	
  desired	
  results	
  are	
  not	
  being	
   obtained,	
  the	
  facility	
  should	
  undertake	
  a	
  facility-­‐wide	
  problem-­‐solving	
   analysis	
  to	
  specify	
  the	
  types	
  of	
  assaults	
  (e.g.,	
  unprovoked	
  physical	
  assault	
   versus	
  assault	
  that	
  occurs	
  while	
  resisting	
  a	
  physical	
  restraint),	
  the	
  severity	
   of	
  these	
  assaults,	
  the	
  places	
  and	
  times	
  where	
  they	
  occur,	
  and	
  the	
   characteristics	
  of	
  the	
  youth	
  involved	
  (e.g.,	
  are	
  they	
  gang-­‐related	
  assaults;	
   are	
  the	
  youth	
  on	
  the	
  mental	
  health	
  caseload;	
  what	
  skills	
  do	
  the	
  youth	
  and	
   staff	
  lack	
  for	
  managing	
  their	
  behavior	
  appropriately?),	
  and	
  the	
  general	
   demeanor	
  of	
  staff	
  involved	
  (did	
  they	
  somehow	
  provoke	
  the	
  youth	
  or	
   otherwise	
  escalate	
  the	
  incident?).	
  Once	
  more	
  is	
  known	
  about	
  the	
  nature	
   of	
  the	
  problem,	
  the	
  facility	
  should	
  launch	
  targeted	
  interventions	
  designed	
   to	
  address	
  these	
  specific	
  causes	
  and	
  features	
  of	
  the	
  problem.	
  	
   	
   For	
  example,	
  throughout	
  the	
  Monitors’	
  interviews,	
  youth	
  reported	
   frustration	
  with	
  certain	
  staff	
  who	
  were	
  described	
  as	
  antagonizing,	
   provoking,	
  and	
  otherwise	
  speaking	
  and	
  behaving	
  in	
  ways	
  that	
  could	
   increase	
  youth’s	
  propensity	
  for	
  violence	
  toward	
  them.	
  This	
  solution	
  to	
   this	
  problem	
  has	
  many	
  facets,	
  including	
  skill	
  development	
  among	
  youth	
   to	
  tolerate	
  frustration,	
  make	
  requests	
  appropriately,	
  control	
  impulses,	
   etc.	
  along	
  with	
  reiterating	
  and	
  enforcing	
  requirements	
  around	
   appropriate	
  behavior	
  and	
  demeanor	
  among	
  staff,	
  teaching	
  them	
  skills	
  for	
   tolerating	
  their	
  frustrations	
  with	
  youth,	
  and	
  holding	
  them	
  accountable	
  for	
   failing	
  to	
  meet	
  these	
  standards.	
   	
   Use	
  of	
  Restraints	
   	
   The	
  previous	
  Monitor’s	
  Report	
  registered	
  concern	
  about	
  the	
  use	
  of	
   physical	
  restraints.	
  Restraint	
  use	
  was	
  very	
  high	
  at	
  the	
  beginning	
  of	
  the	
  

	
  

12.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 13 of 129 PAGEID #: 2366

previous	
  monitoring	
  period,	
  but	
  had	
  begun	
  to	
  decrease	
  during	
  the	
  last	
   half	
  of	
  the	
  previous	
  monitoring	
  period.	
   	
   The	
  use	
  of	
  physical	
  restraints	
  decreased	
  slightly	
  during	
  the	
  current	
   monitoring	
  period.	
  The	
  average	
  rate	
  of	
  restraint	
  for	
  the	
  total	
  population	
   during	
  the	
  previous	
  monitoring	
  period	
  was	
  .72,	
  compared	
  to	
  .62	
  for	
  the	
   current	
  monitoring	
  period.	
  However,	
  looking	
  only	
  at	
  the	
  total	
  population	
   masks	
  the	
  significant	
  gender	
  difference	
  and	
  thus	
  obscures	
  an	
  area	
  that	
  is	
   ripe	
  for	
  a	
  problem-­‐solving	
  effort.	
  	
   	
   Nearly	
  all	
  of	
  the	
  decrease	
  in	
  the	
  use	
  of	
  physical	
  restraint	
  can	
  be	
  attributed	
   to	
  the	
  decreases	
  witnessed	
  among	
  the	
  female	
  population	
  at	
  Scioto.	
   Although	
  the	
  girls	
  had	
  a	
  higher	
  average	
  rate	
  across	
  the	
  current	
  6-­‐month	
   period	
  (.73	
  versus	
  .58),	
  the	
  patterns	
  across	
  the	
  months	
  tell	
  a	
  different	
   story.	
  The	
  boy’s	
  rate	
  of	
  restraint	
  remained	
  relatively	
  constant,	
  at	
  .45	
  or	
   higher.	
  However,	
  the	
  girls’	
  rate	
  of	
  restraint	
  decreased	
  significantly	
   throughout	
  the	
  monitoring	
  period,	
  from	
  a	
  high	
  of	
  2.08	
  at	
  the	
  beginning	
  of	
   the	
  period	
  down	
  to	
  .08	
  at	
  the	
  end	
  of	
  the	
  period.	
  Most	
  likely,	
  this	
  can	
  be	
   attributed	
  to	
  the	
  reduction	
  in	
  the	
  size	
  of	
  the	
  girls’	
  mental	
  health	
   population.	
  While	
  the	
  use	
  of	
  a	
  rate	
  controls	
  for	
  changes	
  in	
  the	
  size	
  of	
  the	
   population,	
  it	
  does	
  not	
  account	
  for	
  the	
  differing	
  management	
  issues	
  that	
   come	
  with	
  serving	
  a	
  population	
  with	
  serious	
  mental	
  health	
  issues.	
  	
   	
   	
  

Physical	
  Restraints,	
  January	
  through	
  September	
  2012	
  

Month	
  

Total	
  

Males	
  

Females	
  

#	
   ADP	
   rate	
   #	
   ADP	
   rate	
   #	
   ADP	
   rate	
  

Oct	
  11	
   150	
   164	
   .91	
   103	
   128	
   .81	
   47	
   36	
   1.31	
  

Nov	
  11	
   177	
   161	
   1.10	
   111	
   128	
   .87	
   66	
   33	
   2.00	
  

Dec	
  11	
   99	
   159	
   .62	
   49	
   124	
   .40	
   50	
   35	
   1.43	
  

Jan	
  12	
   93	
   158	
   .59	
   61	
   125	
   .48	
   32	
   33	
   .97	
  

Feb	
  12	
   88	
   137	
   .64	
   50	
   106	
   .47	
   38	
   31	
   1.23	
  

Mar	
  12	
   59	
   125	
   .47	
   34	
   97	
   .35	
   25	
   28	
   .89	
  

Apr	
  12	
   94	
   118	
   .80	
   40	
   92	
   .43	
   54	
   26	
   2.08	
  

May	
  12	
   55	
   101	
   .54	
   35	
   77	
   .45	
   20	
   24	
   .83	
  

Jun	
  12	
   52	
   91	
   .57	
   36	
   68	
   .53	
   16	
   23	
   .70	
  

July	
  12	
   70	
   83	
   .84	
   60	
   64	
   .94	
   10	
   20	
   .50	
  

Aug	
  12	
   51	
   88	
   .58	
   48	
   72	
   .67	
   3	
   16	
   .19	
  

Sep	
  12	
   35	
   86	
   .41	
   34	
   75	
   .45	
   1	
   12	
   .08	
  

	
   	
   The	
  facility	
  should	
  be	
  applauded	
  for	
  its	
  efforts	
  to	
  move	
  girls	
  with	
  serious	
   mental	
  health	
  issues	
  to	
  a	
  more	
  appropriate	
  setting,	
  but	
  the	
  Monitor	
  

	
  

13.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 14 of 129 PAGEID #: 2367

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

remains	
  concerned	
  that	
  the	
  use	
  of	
  physical	
  restraint	
  among	
  the	
  boys’	
   population	
  at	
  Scioto	
  has	
  not	
  shown	
  much	
  improvement	
  over	
  the	
  past	
  12	
   months.	
  This	
  is	
  not	
  to	
  say	
  that	
  staff	
  should	
  not	
  restrain	
  youth	
  who	
  pose	
  a	
   legitimate	
  threat	
  to	
  the	
  safety	
  of	
  other	
  youth,	
  staff	
  or	
  themselves,	
  but	
   rather	
  that	
  the	
  facility	
  as	
  a	
  whole	
  needs	
  to	
  better	
  address	
  the	
  underlying	
   causes	
  of	
  their	
  misconduct	
  and	
  distress	
  that	
  leads	
  to	
  the	
  restraint.	
  	
   	
   A	
  comprehensive	
  internal	
  and	
  external	
  quality	
  assurance	
  process	
  has	
   been	
  in	
  place	
  for	
  several	
  years,	
  and	
  should	
  be	
  engaged	
  to	
  determine	
   whether	
  opportunities	
  exist	
  to	
  reduce	
  the	
  need	
  for	
  restraints	
  (i.e.,	
   whether	
  incidents	
  could	
  be	
  better	
  handled	
  before	
  escalating	
  to	
  the	
  point	
   of	
  needing	
  a	
  restraint	
  to	
  ensure	
  staff	
  or	
  youth	
  safety).	
  The	
  Facility	
   Intervention	
  Administrator	
  (FIA)	
  is	
  responsible	
  for	
  reviewing	
  every	
   incident	
  involving	
  restraints	
  and	
  determining	
  whether	
  staff’s	
  actions	
   complied	
  with	
  policy.	
  The	
  FIA	
  has	
  the	
  option	
  to	
  approve	
  the	
  use	
  of	
  force	
   as	
  appropriate,	
  to	
  identify	
  a	
  “teachable	
  moment”	
  and	
  provide	
  specific	
   coaching	
  to	
  the	
  staff	
  involved,	
  or	
  to	
  refer	
  the	
  incident	
  for	
  investigation.	
   Each	
  month,	
  the	
  FIA’s	
  assessment	
  and	
  decision-­‐making	
  is	
  reviewed	
  by	
  a	
   Facility	
  Resource	
  Administrator	
  (FRA)	
  from	
  DYS	
  Central	
  Office.	
  Over	
  the	
   past	
  few	
  months,	
  the	
  FRA	
  has	
  identified	
  a	
  number	
  of	
  problems	
  that	
   suggest	
  the	
  FIA	
  review	
  process	
  is	
  not	
  as	
  robust	
  as	
  it	
  should	
  be.	
  	
   	
   First,	
  the	
  FRA	
  has	
  consistently	
  found	
  that	
  the	
  FIA	
  has	
  missed	
  several	
   “teachable	
  moments”	
  in	
  his	
  reviews.	
  These	
  include	
  things	
  like	
  the	
  way	
  a	
   particular	
  MYR	
  technique	
  was	
  executed,	
  the	
  use	
  of	
  the	
  hand-­‐held	
   camera,	
  or	
  the	
  presence	
  and	
  actions	
  of	
  the	
  Supervisors	
  on	
  the	
  scene.	
  The	
   FRA’s	
  monthly	
  reports	
  encourage	
  the	
  FIA	
  to	
  be	
  more	
  vigilant	
  about	
  such	
   things	
  and	
  to	
  ensure	
  that	
  he	
  documents	
  the	
  coaching	
  and	
  training	
   delivered	
  to	
  staff	
  (which	
  is	
  the	
  whole	
  point	
  of	
  the	
  review—to	
  help	
  staff	
   develop	
  skills	
  to	
  manage	
  the	
  next	
  incident	
  better).	
  The	
  number	
  of	
   “teachable	
  moments”	
  identified	
  by	
  the	
  FIA	
  increased	
  sharply	
  toward	
  the	
   end	
  of	
  the	
  monitoring	
  period,	
  perhaps	
  in	
  response	
  to	
  this	
  feedback	
  from	
   the	
  FRA.	
  While	
  the	
  fact	
  that	
  the	
  FRA	
  was	
  detecting	
  so	
  many	
  unidentified	
   problems	
  indicated	
  that	
  the	
  FIA	
  review	
  process	
  was	
  not	
  functioning	
  as	
   designed,	
  the	
  multi-­‐layered	
  audit	
  process—all	
  focused	
  around	
  whether	
   staff	
  are	
  being	
  provided	
  with	
  the	
  feedback	
  they	
  need	
  to	
  increase	
  their	
   skills—is	
  a	
  tremendous	
  asset.	
  The	
  State’s	
  ability	
  to	
  identify	
  and	
  resolve	
  to	
   its	
  own	
  problems,	
  absent	
  DOJ	
  oversight,	
  is	
  a	
  very	
  important	
  part	
  of	
  their	
   ability	
  to	
  achieve	
  substantial	
  compliance	
  with	
  the	
  Stipulation.	
  	
  
Staffing	
   	
   The	
  previous	
  monitoring	
  period	
  identified	
  staffing	
  as	
  one	
  of	
  the	
  major	
   contributors	
  to	
  the	
  facility’s	
  difficulty	
  in	
  reaching	
  substantial	
  compliance	
   with	
  the	
  Stipulation.	
  Youth	
  in	
  the	
  general	
  population	
  were	
  denied	
  access	
   to	
  programming,	
  youth	
  on	
  the	
  Progress	
  Unit	
  were	
  spending	
  exorbitant	
   amount	
  of	
  time	
  in	
  their	
  rooms,	
  and	
  the	
  prevalence	
  of	
  youth	
  violence	
  was	
   attributed,	
  in	
  part,	
  to	
  not	
  having	
  sufficient	
  numbers	
  of	
  staff	
  available	
  to	
  

	
  

14.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 15 of 129 PAGEID #: 2368

supervise	
  the	
  youth.	
  	
   	
   When	
  the	
  facility	
  began	
  to	
  hold	
  Involuntary	
  Disability	
  Separation	
  (IDS)	
   hearings	
  in	
  January	
  2012,	
  the	
  staffing	
  situation	
  began	
  to	
  improve	
   noticeably	
  because	
  positions	
  historically	
  filled	
  by	
  staff	
  who	
  had	
  exhausted	
   their	
  leave	
  benefits	
  became	
  vacant	
  and	
  could	
  be	
  filled	
  by	
  someone	
  who	
   was	
  able	
  to	
  report	
  to	
  work.	
  	
   	
   In	
  2011,	
  the	
  facility	
  averaged	
  approximately	
  8	
  vacant	
  YS	
  positions,	
  but	
   had	
  approximately	
  40	
  staff	
  who	
  were	
  not	
  reporting	
  to	
  work	
  because	
  of	
   OIL,	
  FMLA,	
  etc.	
  Throughout	
  2012,	
  IDS	
  hearings	
  lead	
  to	
  an	
  increase	
  to	
   approximately	
  20	
  vacant	
  positions	
  (which	
  could	
  then	
  be	
  filled)	
  and	
  a	
   reduction	
  to	
  approximately	
  20	
  staff	
  who	
  were	
  not	
  reporting	
  to	
  work.	
   Obviously,	
  the	
  IDS	
  hearings	
  broke	
  the	
  logjam	
  and	
  have	
  improved	
  the	
   facility’s	
  capacity	
  to	
  rectify	
  its	
  staffing	
  problem.	
  	
   	
   In	
  addition,	
  the	
  facility	
  utilized	
  data	
  on	
  its	
  YS	
  turnover	
  rate	
  to	
  justify	
  the	
   need	
  to	
  overhire,	
  which	
  resulted	
  in	
  a	
  net	
  increase	
  in	
  the	
  number	
  of	
  staff.	
   Knowing	
  that	
  the	
  turnover	
  rate	
  among	
  YS	
  staff	
  was	
  approximately	
  50%,	
   between	
  March	
  and	
  September	
  2012,	
  the	
  facility	
  hired	
  41	
  staff.	
  When	
   balanced	
  against	
  the	
  21	
  positions	
  that	
  became	
  vacant	
  via	
  resignation	
  or	
   termination,	
  the	
  facility	
  had	
  20	
  new	
  staff	
  remaining,	
  which	
  mitigated	
  the	
   overall	
  number	
  of	
  vacancies.	
  Still,	
  facility	
  and	
  DYS	
  administrators	
  report	
   that	
  the	
  turnover	
  rate	
  at	
  Scioto	
  is	
  the	
  highest	
  across	
  the	
  system	
  and	
   continued	
  efforts	
  are	
  necessary	
  to	
  ensure	
  that	
  sufficient	
  numbers	
  of	
  staff	
   are	
  available.	
  On	
  any	
  given	
  day,	
  approximately	
  25%	
  of	
  the	
  YS	
  positions	
   are	
  either	
  vacant	
  or	
  occupied	
  by	
  someone	
  who	
  is	
  not	
  reporting	
  to	
  work.	
   While	
  this	
  shortage	
  if	
  offset	
  to	
  some	
  extent	
  by	
  interim	
  staff,	
  even	
  with	
   those	
  additional	
  staff,	
  the	
  facility’s	
  staffing	
  levels	
  still	
  come	
  up	
  short.	
  	
   	
   On	
  several	
  days	
  during	
  the	
  previous	
  monitoring	
  period,	
  insufficient	
   numbers	
  of	
  YS	
  reported	
  to	
  work	
  causing	
  several	
  units	
  to	
  be	
  locked	
  down.	
   During	
  the	
  current	
  monitoring	
  period,	
  while	
  the	
  facility	
  continued	
  to	
   require	
  staff	
  to	
  work	
  overtime	
  in	
  order	
  to	
  meet	
  required	
  staffing	
  levels,	
   the	
  levels	
  of	
  staff	
  were	
  sufficient	
  to	
  avoid	
  lockdowns	
  and	
  to	
  provide	
   youth	
  with	
  access	
  to	
  education	
  and	
  other	
  required	
  programming.	
   However,	
  excessive	
  reliance	
  on	
  overtime	
  is	
  neither	
  a	
  practically	
  nor	
   fiscally	
  sustainable	
  strategy	
  for	
  managing	
  the	
  facility.	
  Each	
  month,	
  the	
   Superintendent’s	
  Report	
  identifies	
  the	
  number	
  of	
  times	
  a	
  Youth	
  Specialist	
   was	
  required	
  to	
  work	
  overtime	
  in	
  order	
  to	
  meet	
  required	
  minimum	
   staffing	
  levels.	
  As	
  a	
  crude	
  measure	
  of	
  frequency,	
  note	
  that	
  there	
  are	
   approximately	
  90	
  shifts	
  in	
  a	
  month	
  (30	
  days	
  x	
  3	
  shifts	
  =	
  90).	
  The	
  number	
   of	
  times	
  staff	
  were	
  held	
  over	
  varied	
  significantly	
  across	
  the	
  monitoring	
   period	
  (March	
  77;	
  April	
  51;	
  May	
  48;	
  June	
  19;	
  July	
  22;	
  August	
  48;	
  and	
   September	
  80),	
  with	
  an	
  average	
  of	
  49	
  times	
  per	
  month	
  (or,	
  on	
  a	
  little	
  over	
   half	
  of	
  the	
  shifts).	
  Clearly,	
  at	
  some	
  points	
  during	
  the	
  monitoring	
  period,	
   the	
  use	
  of	
  overtime	
  was	
  relatively	
  low,	
  while	
  at	
  other	
  times,	
  overtime	
  was	
  

	
  

15.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 16 of 129 PAGEID #: 2369

needed	
  far	
  more	
  frequently.	
  High	
  overtime	
  months	
  were	
  associated	
  with	
   serious	
  staff	
  assaults	
  and	
  the	
  resulting	
  resignations	
  of	
  staff,	
  along	
  with	
   the	
  beginning	
  of	
  football	
  season,	
  when	
  staff	
  were	
  more	
  likely	
  to	
  call	
  out	
   on	
  the	
  weekends.	
  	
   	
   Continued	
  efforts	
  to	
  ensure	
  that	
  vacancies	
  are	
  kept	
  to	
  a	
  minimum	
  and	
   that	
  staff	
  report	
  to	
  work	
  as	
  expected	
  are	
  absolutely	
  essential	
  to	
  the	
   State’s	
  ability	
  to	
  comply	
  with	
  the	
  Stipulation.	
  Without	
  sufficient	
  numbers	
   of	
  well-­‐trained,	
  well-­‐rested	
  staff,	
  the	
  facility	
  will	
  be	
  unable	
  to	
  reduce	
   violence,	
  limit	
  the	
  use	
  of	
  seclusion,	
  and	
  provide	
  adequate	
  programming,	
   as	
  required.	
  Moving	
  forward,	
  the	
  facility	
  intends	
  to	
  continue	
  with	
  its	
  IDS	
   hearings	
  and	
  increase	
  the	
  number	
  of	
  interim	
  staff	
  to	
  reduce	
  the	
  number	
   of	
  days	
  the	
  facility	
  is	
  running	
  short.	
  Further,	
  recent	
  improvements	
  to	
  On-­‐ The-­‐Job	
  training	
  were	
  designed	
  to	
  improve	
  job	
  satisfaction	
  and	
  increase	
   retention	
  levels.	
  Finally,	
  in	
  January	
  2012,	
  the	
  facility	
  intends	
  to	
  combine	
   two	
  of	
  the	
  boys’	
  general	
  population	
  units	
  (accomplished	
  in	
  large	
  part	
  by	
   transferring	
  approximately	
  15	
  to	
  18	
  boys	
  to	
  other	
  facilities)	
  which	
  will	
   reduce	
  the	
  overall	
  number	
  of	
  staff	
  required	
  on	
  any	
  given	
  day	
  by	
   approximately	
  12	
  staff.	
  	
   	
   Investigations	
  Related	
  to	
  Use	
  of	
  Force,	
  Seclusion	
  and	
  Abusive	
  Practices	
   	
   Over	
  the	
  past	
  six	
  months,	
  28	
  allegations	
  of	
  excessive	
  or	
  inappropriate	
   uses	
  of	
  force	
  were	
  investigated,	
  6	
  by	
  the	
  Chief	
  Inspector’s	
  Office	
  (CIO)	
   and	
  22	
  by	
  a	
  facility-­‐based	
  investigator.	
  Eleven	
  of	
  the	
  facility-­‐based	
   investigations	
  were	
  pending,	
  nearly	
  all	
  of	
  which	
  had	
  far	
  exceeded	
  the	
  14	
   days	
  permitted	
  for	
  their	
  completion.	
  	
   	
   Of	
  the	
  17	
  investigations	
  that	
  had	
  been	
  completed,	
  two	
  (11%;	
  one	
  CIO,	
   one	
  facility-­‐based)	
  were	
  substantiated	
  for	
  unnecessary	
  or	
  excessive	
  force.	
   Although	
  these	
  28	
  referrals	
  flowed	
  from	
  nearly	
  350	
  restraints	
  during	
  this	
   time	
  period	
  (rate	
  of	
  allegations	
  is	
  7%),	
  the	
  poor	
  quality	
  of	
  the	
   investigations	
  completed	
  by	
  facility-­‐based	
  staff	
  creates	
  concern	
  about	
  the	
   extent	
  to	
  which	
  staff	
  who	
  use	
  force	
  improperly	
  can	
  be	
  accurately	
   identified	
  via	
  the	
  investigation	
  process.	
  These	
  concerns	
  are	
  discussed	
  in	
   detail	
  in	
  III.A.5,	
  below,	
  but	
  are	
  relevant	
  to	
  this	
  provision	
  insofar	
  as	
  a	
   poorly	
  constructed	
  investigation	
  does	
  not	
  adequately	
  protect	
  youth	
  from	
   harm	
  at	
  the	
  hands	
  of	
  staff,	
  as	
  required	
  by	
  this	
  provision.	
   	
   In	
  addition	
  to	
  the	
  use	
  of	
  force	
  investigations,	
  the	
  CIO	
  also	
  investigated	
   and	
  sustained	
  3	
  allegations	
  of	
  abusive	
  practices:	
  
• After	
  an	
  initial	
  refusal	
  to	
  come	
  out	
  of	
  the	
  shower	
  when	
  directed	
   to	
  do	
  so	
  by	
  staff,	
  a	
  youth	
  was	
  left	
  in	
  a	
  locked	
  bathroom	
  overnight;	
  	
  
• Several	
  youth	
  were	
  denied	
  dinner	
  and	
  were	
  left	
  in	
  soft	
  restraints	
   overnight;	
  and	
  
• A	
  staff	
  member	
  turned	
  off	
  two	
  youth’s	
  air	
  vents	
  and	
  water	
  supply	
   over	
  night	
  because	
  they	
  refused	
  to	
  close	
  their	
  cuff	
  ports.	
  	
  

	
  

16.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 17 of 129 PAGEID #: 2370

All	
  of	
  these	
  incidents	
  occurred	
  on	
  the	
  PROGRESS	
  Unit.	
  While	
  it	
  is	
  positive	
   that	
  the	
  incidents	
  were	
  reported,	
  investigated	
  thoroughly,	
  substantiated	
   based	
  on	
  the	
  facts,	
  and	
  staff	
  were	
  held	
  accountable,	
  the	
  fact	
  that	
  staff	
   continue	
  to	
  engage	
  in	
  these	
  types	
  of	
  behaviors,	
  particularly	
  during	
  a	
  time	
   when	
  the	
  PROGRESS	
  Unit	
  has	
  been	
  under	
  such	
  scrutiny,	
  is	
  disturbing.	
  	
   	
   	
   Allegations	
  of	
  Verbal	
  Mistreatment	
  or	
  Inappropriate	
  Sexual	
  Relationships	
   	
   Each	
  of	
  the	
  previous	
  Monitor’s	
  reports	
  has	
  discussed	
  the	
  problem	
  of	
   allegations	
  of	
  verbal	
  abuse	
  by	
  staff	
  and	
  inappropriate	
  relationships	
   between	
  Scioto	
  staff	
  and	
  youth.	
  The	
  usual	
  tools	
  to	
  combat	
  this	
  type	
  of	
   problem	
  (e.g.,	
  staff	
  training,	
  a	
  robust	
  grievance	
  process,	
  and	
  procedures	
   for	
  investigating	
  allegations)	
  have	
  not	
  been	
  sufficient,	
  as	
  youth	
  continue	
   to	
  report	
  inappropriate	
  comments	
  and	
  behaviors	
  by	
  staff	
  to	
  both	
  the	
   Monitors,	
  DOJ	
  attorneys	
  and	
  facility	
  staff.	
  Although	
  the	
  frequency	
  of	
   allegations	
  of	
  a	
  sexual	
  nature	
  has	
  decreased	
  somewhat,	
  more	
  prevalent	
   are	
  reports	
  from	
  youth	
  that	
  staff	
  provoke,	
  antagonize,	
  belittle	
  or	
   otherwise	
  interact	
  in	
  unprofessional,	
  counterproductive	
  and	
  hurtful	
  ways	
   with	
  youth.	
  	
   	
   Indeed,	
  there	
  were	
  approximately	
  12	
  new	
  allegations	
  of	
  such	
  behaviors	
   referred	
  for	
  investigation	
  during	
  the	
  current	
  monitoring	
  period	
  (6	
  related	
   to	
  inappropriate	
  sexual	
  relationships	
  between	
  staff	
  and	
  youth	
  and	
  6	
   related	
  to	
  verbal	
  threatening,	
  name-­‐calling,	
  or	
  unprofessional	
  conduct	
  by	
   staff	
  in	
  their	
  interactions	
  with	
  youth).	
  Five	
  allegations	
  of	
  a	
  sexual	
  nature	
   were	
  unsubstantiated	
  by	
  the	
  CIO,	
  although	
  one	
  is	
  still	
  pending.	
  As	
  noted	
   in	
  previous	
  reports	
  and	
  in	
  Provision	
  III.A.5,	
  below,	
  the	
  investigations	
  by	
   the	
  CIO	
  are	
  high-­‐quality,	
  thorough,	
  and	
  certainly	
  capable	
  of	
  sustaining	
  a	
   true	
  allegation	
  if	
  the	
  evidence	
  were	
  available.	
  On	
  the	
  other	
  hand,	
  facility-­‐ based	
  investigations	
  were	
  undertaken	
  for	
  the	
  other	
  six	
  allegations,	
  none	
   of	
  which	
  were	
  substantiated.	
  As	
  noted	
  in	
  the	
  discussion	
  of	
  Provision	
   III.A.5,	
  the	
  poor	
  quality	
  of	
  the	
  investigations	
  results	
  in	
  the	
  likely	
  inability	
   to	
  sustain	
  a	
  true	
  allegation,	
  even	
  if	
  the	
  evidence	
  were	
  available.	
  	
   	
   Also	
  troubling	
  is	
  youth’s	
  continued	
  belief	
  that	
  neither	
  the	
  grievance	
   process	
  nor	
  the	
  investigation	
  process	
  can	
  protect	
  them	
  because	
  neither	
   will	
  result	
  in	
  staff	
  being	
  held	
  accountable	
  for	
  their	
  behavior.	
  During	
  the	
   site	
  visit	
  week,	
  the	
  vast	
  majority	
  of	
  the	
  youth	
  currently	
  housed	
  at	
  Scioto	
   were	
  interviewed	
  either	
  by	
  Monitors	
  of	
  the	
  DOJ	
  case,	
  the	
  Lead	
  Monitor	
  of	
   the	
  SH	
  case,	
  or	
  the	
  DOJ	
  attorney.	
  Nearly	
  all	
  of	
  the	
  youth	
  reported	
   concerns	
  about	
  a	
  number	
  of	
  staff	
  who	
  appear	
  to	
  act	
  with	
  impunity,	
  who	
   treat	
  the	
  youth	
  poorly	
  and	
  then	
  taunt	
  the	
  youth	
  to	
  write	
  a	
  grievance	
   because	
  “nothing	
  will	
  happen.”	
  When	
  youth	
  gave	
  examples	
  of	
  poor	
   treatment	
  by	
  staff,	
  the	
  interviewers	
  asked	
  if	
  they	
  had	
  reported	
  the	
   incident	
  to	
  anyone	
  at	
  the	
  facility.	
  In	
  some	
  cases	
  they	
  had,	
  in	
  other	
  cases	
   they	
  hadn’t,	
  but	
  in	
  all	
  cases	
  their	
  experience	
  suggested	
  to	
  them	
  that	
  it	
  

	
  

17.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 18 of 129 PAGEID #: 2371

would	
  not	
  change	
  the	
  environment	
  for	
  the	
  better.	
  While	
  the	
  Monitor	
   recognizes	
  that	
  youth	
  are	
  not	
  always	
  truthful	
  when	
  interviewed,	
  the	
   similarities	
  in	
  their	
  descriptions	
  of	
  staff’s	
  bravado	
  suggest	
  that	
  the	
  facility	
   needs	
  to	
  address	
  the	
  manner	
  in	
  which	
  some	
  staff	
  relate	
  to	
  the	
  youth	
  in	
   their	
  care.	
  	
   	
   During	
  the	
  previous	
  monitoring	
  period,	
  the	
  facility’s	
  administrative	
  team	
   committed	
  to	
  implement	
  two	
  new	
  initiatives	
  designed	
  to	
  address	
   allegations	
  of	
  inappropriate	
  sexual	
  relationships	
  in	
  particular,	
  but	
  which	
   could	
  also	
  be	
  useful	
  in	
  addressing	
  the	
  more	
  general	
  complaints	
  about	
   staff	
  verbal	
  mistreatment.	
  The	
  State	
  was	
  asked	
  to	
  provide	
  an	
  update	
  on	
   the	
  status	
  of	
  these	
  initiatives:	
  
• Although	
  the	
  previous	
  facility	
  Superintendent	
  indicated	
  that	
  the	
   topic	
  of	
  inappropriate	
  conduct	
  by	
  staff,	
  boundary	
  issues,	
  etc.	
   would	
  be	
  added	
  to	
  the	
  girls’	
  Trauma	
  Group	
  curriculum	
  in	
  April	
   2012,	
  it	
  was	
  not	
  implemented	
  until	
  August	
  2012.	
  The	
  6-­‐week	
   “Healthy	
  Boundaries	
  and	
  Relationships”	
  group	
  was	
  led	
  by	
  a	
  social	
   worker	
  who	
  works	
  for	
  a	
  contracted	
  treatment	
  provider	
  and	
  was	
   co-­‐facilitated	
  by	
  Scioto	
  social	
  workers	
  on	
  the	
  Davey	
  and	
  Allman	
   units.	
  	
   	
   Progress	
  notes	
  from	
  6	
  girls	
  who	
  participated	
  in	
  the	
  program	
  were	
   reviewed.	
  The	
  curriculum	
  included	
  an	
  appropriate	
  range	
  of	
  topics	
   (e.g.,	
  characteristics	
  of	
  healthy/unhealthy	
  relationships,	
   boundaries,	
  inappropriate	
  relationships	
  due	
  to	
  age	
  or	
  roles,	
   grooming	
  behaviors	
  to	
  encourage	
  girls	
  to	
  acquiesce,	
  etc.).	
  Various	
   homework	
  assignments	
  were	
  given	
  including	
  discussing	
  people	
   with	
  whom	
  they’ve	
  had	
  boundary	
  issues	
  and	
  the	
  different	
  choices	
   they	
  could	
  have	
  made,	
  or	
  writing	
  a	
  letter	
  to	
  a	
  sibling	
  to	
  describe	
   what	
  was	
  learned	
  in	
  the	
  group.	
  None	
  of	
  the	
  girls	
  in	
  either	
  of	
  the	
   groups	
  raised	
  issues	
  related	
  to	
  inappropriate	
  relationships	
  or	
   conduct	
  by	
  Scioto	
  staff.	
  	
   	
   The	
  group	
  was	
  reportedly	
  well	
  received,	
  with	
  several	
  girls	
  asking	
   to	
  continue	
  the	
  discussion	
  and	
  to	
  incorporate	
  role	
  play	
  so	
  that	
   they	
  could	
  practice	
  the	
  skills	
  they	
  were	
  learning.	
  The	
  facility	
  also	
   plans	
  to	
  incorporate	
  materials	
  available	
  through	
  the	
  NIC/PREA	
   curriculum.	
  A	
  timeline	
  for	
  restarting	
  the	
  group	
  was	
  not	
  provided	
   to	
  the	
  Monitor.	
  	
   	
  
• In	
  the	
  last	
  Monitor’s	
  report,	
  the	
  Monitor	
  also	
  advised	
  the	
  facility	
   to	
  incorporate	
  the	
  topics	
  of	
  over-­‐familiarization	
  and	
  boundary	
   issues	
  between	
  staff	
  and	
  youth	
  into	
  the	
  weekly	
  Interdisciplinary	
   Treatment	
  (IDT)	
  meetings.	
  The	
  topic	
  was	
  added	
  to	
  the	
  IDT	
   agendas	
  beginning	
  in	
  August	
  2012	
  and	
  was	
  broadly	
  defined	
  to	
   include	
  youth	
  who	
  may	
  be	
  touching	
  each	
  other	
  inappropriately	
   and	
  youth	
  who	
  seem	
  to	
  be	
  developing	
  crushes	
  on	
  staff	
  an	
  

	
  

18.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 19 of 129 PAGEID #: 2372

Recommendations	
  

behaving	
  in	
  inappropriate	
  ways.	
  This	
  addition	
  to	
  the	
  agenda	
   reportedly	
  helped	
  staff	
  to	
  be	
  able	
  to	
  address	
  issues	
  with	
  a	
   number	
  of	
  youth	
  and	
  helped	
  staff	
  to	
  discusses	
  what	
  may	
  have	
   otherwise	
  been	
  sensitive	
  topics.	
  New	
  staff	
  were	
  reminded	
  not	
  to	
   be	
  alone	
  with	
  girls	
  in	
  areas	
  where	
  there	
  were	
  no	
  cameras	
  and	
   were	
  instructed	
  to	
  take	
  another	
  youth	
  or	
  staff	
  with	
  them	
  to	
   ensure	
  there	
  was	
  a	
  witness	
  to	
  all	
  of	
  their	
  interactions.	
   	
   Unfortunately,	
  record	
  keeping	
  in	
  this	
  area	
  was	
  substandard	
  and	
   does	
  not	
  provide	
  for	
  a	
  review	
  of	
  the	
  actual	
  interactions	
  that	
  took	
   place	
  during	
  the	
  IDT	
  meetings.	
  The	
  facility	
  has	
  identified	
   improvements	
  in	
  the	
  quality	
  and	
  detail	
  of	
  the	
  IDT	
  minutes	
  as	
  an	
   area	
  in	
  need	
  of	
  development.	
  	
   	
   The	
  “Healthy	
  Relationships	
  and	
  Boundaries”	
  groups	
  have	
  clearly	
  provided	
   new	
  opportunities	
  for	
  youth	
  to	
  think	
  about	
  and	
  discuss	
  any	
  inappropriate	
   relationships	
  they	
  may	
  have	
  had.	
  The	
  Monitor	
  fully	
  supports	
  the	
   continuation	
  of	
  this	
  group,	
  along	
  with	
  any	
  other	
  efforts	
  to	
  fortify	
  the	
   screening	
  and	
  vetting	
  of	
  staff	
  for	
  their	
  appropriateness	
  to	
  work	
  with	
  girls.	
  	
   	
   However,	
  from	
  the	
  discussions	
  with	
  youth,	
  it	
  appears	
  that	
  the	
  problem	
   does	
  not	
  entirely	
  reside	
  in	
  their	
  not	
  having	
  any	
  forum	
  to	
  voice	
  their	
   concerns,	
  but	
  rather	
  in	
  their	
  belief	
  that	
  the	
  facility	
  will	
  not	
  act	
  on	
  their	
   complaints.	
  This	
  was	
  an	
  issue	
  for	
  both	
  the	
  boys	
  and	
  girls	
  housed	
  at	
  Scioto.	
   The	
  facility	
  has	
  indicated	
  its	
  intention	
  to	
  work	
  with	
  the	
  YS	
  union	
  in	
  order	
   to	
  be	
  able	
  to	
  reassign	
  staff	
  who	
  garner	
  a	
  number	
  of	
  complaints	
  from	
   youth.	
  More	
  broadly,	
  emphasizing	
  appropriate	
  communication	
  skills	
  for	
   staff	
  and	
  clear	
  prohibitions	
  against	
  the	
  use	
  of	
  any	
  language	
  that	
  could	
  be	
   construed	
  as	
  taunting,	
  provoking	
  or	
  belittling	
  should	
  become	
  a	
   centerpiece	
  of	
  shift-­‐briefings,	
  staff	
  meetings,	
  training,	
  and	
  any	
  other	
   forum	
  available	
  to	
  reinforce	
  this	
  central	
  value.	
  Finally,	
  improving	
  the	
   quality	
  of	
  the	
  facility-­‐based	
  investigation	
  process	
  may	
  provide	
  the	
  facility	
   with	
  additional	
  opportunities	
  to	
  hold	
  staff	
  accountable	
  in	
  a	
  way	
  that	
  may	
   be	
  persuasive	
  to	
  staff	
  who	
  persist	
  in	
  acting	
  with	
  impunity.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Reach	
  substantial	
  compliance	
  with	
  provisions	
  related	
  to	
   seclusion,	
  investigations	
  of	
  abuse	
  and	
  neglect,	
  grievances	
  and	
   programming.	
  	
  
2. Conduct	
  a	
  problem-­‐solving	
  analysis	
  to	
  determine	
  the	
  nature	
  of	
   youth	
  on	
  staff	
  assaults	
  and	
  implement	
  interventions	
  that	
  target	
   the	
  underlying	
  causes	
  and	
  patterns.	
  	
  
3. Improve	
  the	
  quality	
  of	
  FIA	
  reviews	
  of	
  the	
  use	
  of	
  physical	
  restraint	
   to	
  ensure	
  that	
  staff	
  have	
  exhausted	
  all	
  other	
  means	
  for	
  resolving	
   problems	
  with	
  youth.	
  Ensure	
  that	
  staff	
  are	
  provided	
  with	
   coaching	
  to	
  help	
  develop	
  their	
  skills	
  in	
  this	
  area	
  and	
  to	
  ensure	
   their	
  compliance	
  with	
  all	
  related	
  policies.	
  	
  

	
  

19.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 20 of 129 PAGEID #: 2373

Sources	
  of	
   Information	
  
	
   	
   	
  

4. Maximize	
  the	
  number	
  of	
  permanent,	
  full-­‐time	
  staff	
  who	
  are	
   recruited,	
  hired	
  and	
  retained	
  so	
  that	
  staff	
  turnover	
  and	
  mandated	
   overtime	
  can	
  be	
  minimized.	
  	
  
5. Continue	
  to	
  provide	
  forums	
  for	
  female	
  youth	
  to	
  discuss	
  their	
   problematic	
  relationships	
  with	
  staff,	
  whether	
  sexually	
   inappropriate,	
  verbally	
  abusive	
  or	
  otherwise	
  unprofessional.	
   Consider	
  developing	
  a	
  similar	
  forum	
  for	
  male	
  youth.	
  Investigate	
   and	
  enforce	
  the	
  prohibition	
  against	
  inappropriate	
  sexual	
   behavior,	
  verbal	
  mistreatment	
  and	
  policies	
  prohibiting	
  male	
  staff	
   from	
  being	
  alone	
  with	
  female	
  youth.	
  Ensure	
  staff	
  know	
  how	
  to	
   recognize,	
  respond	
  to,	
  and	
  report	
  such	
  behavior.	
  
6. Reinforce	
  the	
  prohibition	
  against	
  provoking,	
  taunting,	
  belittling	
   and	
  otherwise	
  disrespecting	
  youth.	
  Investigate	
  complaints	
   vigorously	
  and	
  enforce	
  the	
  conduct	
  standards	
  when	
  they	
  are	
   violated.	
  	
  
• Self-­‐assessment	
  data	
  and	
  its	
  interpretation	
  for	
  III.A.1,	
  prepared	
  at	
   my	
  request	
  
• Interviews	
  with	
  facility	
  Superintendent	
  and	
  Deputies,	
  along	
  with	
   staff	
  from	
  DYS	
  Central	
  Office	
  
• Monthly	
  Superintendent’s	
  Reports,	
  April	
  through	
  September	
   2012	
  
• Monitor’s	
  Monthly	
  Data,	
  Scioto	
  Male	
  and	
  Female	
  Population,	
   2011	
  and	
  2012,	
  to	
  date	
  
• CIO	
  and	
  facility	
  based	
  investigation	
  log,	
  April	
  through	
  September	
   2012	
  
• CIO	
  and	
  facility-­‐based	
  investigations	
  completed	
  between	
  April	
   and	
  September	
  2012	
  
• Description	
  and	
  Group	
  Notes	
  from	
  “Healthy	
  Relationships	
  and	
   Boundaries”	
  groups,	
  August	
  through	
  October	
  2012	
  
• Description	
  of	
  Overfamiliarization	
  Initiative,	
  prepared	
  at	
  my	
   request	
  
• Interviews	
  with	
  n=16	
  youth	
  housed	
  at	
  Scioto	
  on	
  October	
  19,	
   2012,	
  and	
  consultation	
  with	
  other	
  Monitors	
  and	
  the	
  DOJ	
  attorney	
   who	
  interviewed	
  approximately	
  30	
  other	
  youth	
  housed	
  at	
  the	
   facility	
  in	
  October	
  2012	
  
	
  

	
  

20.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 21 of 129 PAGEID #: 2374

III.A.3	
  Seclusion.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
  practices	
  so	
   that	
  staff	
  use	
  seclusion	
  only	
  in	
  accordance	
  with	
  policy	
  and	
  in	
  an	
  appropriate	
  manner	
  and	
  so	
  that	
   staff	
  document	
  fully	
  the	
  use	
  and	
  administrative	
  review	
  of	
  any	
  imposition	
  of	
  seclusion,	
  including	
   the	
  placing	
  of	
  youth	
  in	
  their	
  rooms	
  outside	
  normal	
  sleeping	
  hours.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  State	
  presented	
  data	
  on	
  the	
  use	
  of	
  seclusion	
  during	
  the	
  previous	
  six	
   months.	
  The	
  Monitor	
  structured	
  the	
  site	
  visit	
  such	
  that	
  the	
  opportunities	
   for	
  interpreting	
  the	
  trends	
  was	
  more	
  limited	
  than	
  it	
  had	
  been	
  in	
  the	
  past.	
   In	
  addition,	
  the	
  Facility	
  Superintendent	
  had	
  only	
  been	
  in	
  place	
  for	
   approximately	
  two	
  weeks	
  and	
  thus	
  was	
  not	
  in	
  a	
  position	
  to	
  explain	
  the	
   practices	
  of	
  the	
  prior	
  Superintendent	
  nor	
  had	
  he	
  had	
  an	
  opportunity	
  to	
   demonstrate	
  the	
  direction	
  in	
  which	
  he	
  hoped	
  to	
  take	
  the	
  facility	
  with	
   regard	
  to	
  the	
  issue	
  of	
  seclusion.	
  Thus,	
  the	
  Monitor	
  interpreted	
  the	
  trends	
   in	
  regular,	
  pre-­‐hearing	
  and	
  intervention	
  seclusion	
  data	
  without	
   significant	
  input	
  from	
  the	
  State.	
  	
  	
  	
   	
   The	
  Monitor	
  became	
  aware	
  of	
  several	
  quality	
  assurance	
  tools	
  that	
  instill	
   confidence	
  in	
  the	
  State’s	
  capacity	
  to	
  make	
  data-­‐driven	
  decisions	
  and	
  to	
   measure	
  the	
  effect	
  of	
  reforms.	
  The	
  State	
  has	
  offered	
  verbal	
   commitments	
  to	
  reform	
  its	
  use	
  of	
  seclusion,	
  the	
  particulars	
  of	
  which	
  are	
   discussed	
  below.	
  	
  	
   	
   Finally,	
  over	
  the	
  past	
  few	
  months,	
  the	
  Monitor	
  has	
  engaged	
  in	
  lengthy	
   conversations	
  with	
  the	
  State,	
  Plaintiff’s	
  counsel,	
  and	
  monitoring	
  teams	
   for	
  both	
  this	
  and	
  the	
  S.H.	
  case	
  about	
  the	
  implementation	
  of	
  the	
   PROGRESS	
  Unit	
  (PU).	
  These	
  conversations	
  are	
  well-­‐documented	
   elsewhere	
  and	
  will	
  not	
  be	
  repeated	
  here.	
  For	
  its	
  part,	
  the	
  State	
   acknowledged	
  that	
  the	
  amount	
  of	
  in-­‐room	
  time	
  (a.k.a.,	
  seclusion)	
   endured	
  by	
  the	
  average	
  PU	
  youth	
  was	
  higher	
  than	
  desired	
  during	
  the	
   current	
  monitoring	
  period	
  and	
  that	
  a	
  complex	
  constellation	
  of	
  staffing,	
   treatment,	
  philosophical	
  and	
  environmental	
  issues	
  needed	
  to	
  be	
   addressed.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Regular	
  Seclusion	
   Regular	
  seclusion	
  is	
  a	
  time-­‐out,	
  or	
  short	
  period	
  of	
  isolation	
  imposed	
  by	
   direct	
  care	
  staff	
  in	
  response	
  to	
  mid-­‐level,	
  non-­‐violent	
  misconduct	
  such	
  as	
   throwing	
  things,	
  property	
  damage,	
  storming	
  around	
  the	
  unit,	
  etc.	
  Staff	
   must	
  obtain	
  approval	
  from	
  a	
  supervisor	
  before	
  placing	
  a	
  youth	
  in	
  regular	
   seclusion	
  and	
  again	
  at	
  the	
  one-­‐hour	
  mark.	
  If	
  the	
  youth	
  remains	
  in	
   seclusion	
  at	
  the	
  three-­‐hour	
  mark,	
  the	
  supervisor	
  must	
  document	
  in	
   writing	
  the	
  reason	
  that	
  seclusion	
  remains	
  necessary.	
   	
   As	
  discussed	
  in	
  the	
  1st	
  Monitors’	
  Report,	
  the	
  facility	
  witnessed	
  a	
  huge	
   spike	
  in	
  the	
  use	
  of	
  regular	
  seclusion	
  just	
  after	
  the	
  facility	
  converted	
  to	
  a	
   long-­‐term	
  facility.	
  Historically,	
  the	
  facility	
  averaged	
  about	
  70	
  regular	
   seclusions	
  per	
  month.	
  In	
  August	
  and	
  September	
  2011,	
  however,	
  the	
   number	
  skyrocketed	
  to	
  approximately	
  400	
  and	
  well	
  over	
  50%	
  of	
  the	
  

	
  

21.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 22 of 129 PAGEID #: 2375

seclusions	
  lasted	
  longer	
  than	
  4	
  hours.	
  The	
  Second	
  Monitor’s	
  Report	
   noted	
  that	
  the	
  use	
  of	
  regular	
  seclusion	
  had	
  returned	
  to	
  historical	
  levels,	
   with	
  an	
  average	
  of	
  65	
  seclusions	
  per	
  month	
  (average	
  rate	
  per	
  youth	
  =	
   .43).	
  Across	
  the	
  previous	
  monitoring	
  period,	
  88%	
  of	
  the	
  seclusions	
  lasted	
   less	
  than	
  4	
  hours	
  and	
  12%	
  lasted	
  more	
  than	
  4	
  hours.	
  	
   	
   As	
  shown	
  in	
  the	
  table	
  below,	
  during	
  the	
  current	
  monitoring	
  period,	
  the	
   number	
  of	
  regular	
  seclusions	
  decreased	
  again	
  to	
  an	
  average	
  of	
  50	
  per	
   month;	
  however,	
  because	
  of	
  the	
  declining	
  population,	
  the	
  rate	
  of	
  regular	
   seclusion	
  actually	
  increased	
  to	
  an	
  average	
  of	
  .53	
  (an	
  increase	
  of	
   approximately	
  23%).	
  An	
  increase	
  in	
  the	
  use	
  of	
  regular	
  seclusion	
  is	
  not	
   necessarily	
  a	
  bad	
  thing,	
  if	
  the	
  time	
  in	
  seclusion	
  allows	
  the	
  youth	
  to	
  regain	
   control	
  of	
  his	
  behavior	
  and	
  prevents	
  a	
  subsequent	
  act	
  of	
  violence.	
   However,	
  the	
  length	
  of	
  stay	
  in	
  seclusion	
  should	
  be	
  carefully	
  monitored	
  to	
   ensure	
  that	
  staff	
  do	
  not	
  resort	
  to	
  seclusion	
  as	
  a	
  way	
  to	
  avoid	
  working	
   with	
  the	
  youth	
  to	
  resolve	
  the	
  problem.	
  	
   	
   Compared	
  to	
  the	
  previous	
  monitoring	
  period,	
  the	
  proportion	
  of	
  seclusion	
   episodes	
  lasting	
  more	
  than	
  4	
  hours	
  increased.	
  Currently,	
  19%	
  of	
  regular	
   seclusions	
  last	
  more	
  than	
  4	
  hours.	
  The	
  average	
  length	
  of	
  stay	
  varied	
   considerably,	
  between	
  3	
  and	
  13	
  hours	
  across	
  the	
  six-­‐month	
  period,	
  with	
   an	
  overall	
  average	
  of	
  7	
  hours.	
  [The	
  facility	
  attributed	
  these	
  increases	
  to	
   the	
  influx	
  of	
  close	
  custody	
  youth	
  from	
  IRJCF	
  and	
  CJCF.]	
  The	
  shift	
  away	
   from	
  previous	
  trends—where	
  approximately	
  90%	
  of	
  the	
  youth	
  in	
  regular	
   seclusion	
  were	
  released	
  in	
  less	
  than	
  4	
  hours—coupled	
  with	
  an	
  increasing	
   average	
  length	
  of	
  stay—which	
  means	
  that	
  the	
  youth	
  who	
  stay	
  in	
  regular	
   seclusion	
  are	
  there	
  for	
  a	
  significant	
  period	
  of	
  time—is	
  concerning.	
  In	
  July	
   and	
  August	
  2012,	
  approximately	
  15-­‐20%	
  of	
  the	
  population	
  had	
  a	
  stay	
  in	
   regular	
  seclusion	
  that	
  lasted	
  well	
  beyond	
  what	
  is	
  customarily	
  considered	
   to	
  be	
  a	
  “cool-­‐off.”	
  	
   	
  

Regular	
  Seclusion,	
  April	
  through	
  September	
  2012	
  

Month	
  

#	
  

Rate	
   (#/ADP)	
  

%	
  4hrs	
  or	
   less	
  

ALOS	
   (hrs)	
  

April	
  2012	
  

59	
  

.50	
  

83%	
  

8	
  

May	
  2012	
  

55	
  

.55	
  

97%	
  

3	
  

June	
  2012	
  

41	
  

.45	
  

91%	
  

5	
  

July	
  2012	
  

45	
  

.54	
  

71%	
  

8	
  

Aug	
  2012	
  

45	
  

.51	
  

60%	
  

13	
  

Sept	
  2012	
  

56	
  

.65	
  

88%	
  

5	
  

Source:	
  Data	
  prepared	
  by	
  DYS	
  to	
  respond	
  to	
  the	
  Monitor’s	
  request	
  for	
  information	
  on	
   the	
  use	
  of	
  seclusion.	
  	
  
	
   Quality	
  assurance	
  audits	
  of	
  the	
  use	
  of	
  regular	
  seclusion	
  need	
  to	
  be	
   conducted	
  to	
  ensure	
  that	
  supervisors	
  are	
  assessing	
  youth	
  for	
  their	
  

	
  

22.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 23 of 129 PAGEID #: 2376

readiness	
  for	
  release	
  at	
  the	
  required	
  intervals	
  and	
  that	
  continued	
  time	
  in	
   seclusion	
  is	
  warranted	
  and	
  properly	
  documented.	
  These	
  data	
  should	
  be	
   submitted	
  to	
  the	
  Monitor	
  for	
  review	
  over	
  the	
  next	
  monitoring	
  period.	
  	
   	
   Pre-­‐Hearing	
  Seclusion	
   Pre-­‐Hearing	
  Seclusion	
  (PHS)	
  is	
  a	
  period	
  of	
  isolation	
  imposed	
  following	
  an	
   act	
  of	
  violence	
  (AOV),	
  pending	
  a	
  disciplinary	
  hearing.	
  Youth	
  on	
  PHS	
   remain	
  in	
  their	
  rooms	
  except	
  for	
  showers.	
  Youth	
  are	
  supposed	
  to	
  receive	
   recreation	
  and	
  Unit	
  Instruction	
  (i.e.,	
  education)	
  outside	
  of	
  their	
  rooms,	
   but	
  as	
  discussed	
  in	
  the	
  Special	
  Education	
  section	
  of	
  this	
  report,	
  this	
  has	
   not	
  yet	
  been	
  accomplished.	
  The	
  length	
  of	
  time	
  a	
  youth	
  remains	
  on	
  PHS	
  is	
   primarily	
  determined	
  by	
  his	
  or	
  her	
  IRAV	
  score,	
  which	
  is	
  based	
  on	
  the	
   severity	
  of	
  the	
  current	
  rule	
  violation	
  and	
  the	
  youth’s	
  history	
  of	
  non-­‐ compliant	
  behavior.	
  	
   	
   The	
  rate	
  of	
  PHS	
  generally	
  tracks	
  increases	
  and	
  decreases	
  in	
  the	
  rate	
  of	
   AOV	
  and	
  does	
  not	
  give	
  much	
  insight	
  into	
  the	
  facility’s	
  seclusion	
  practices.	
   Rather,	
  it	
  is	
  changes	
  in	
  the	
  youth’s	
  lengths	
  of	
  stay	
  that	
  reflect	
  whether	
   practices	
  around	
  the	
  use	
  of	
  PHS	
  are	
  being	
  reformed	
  as	
  required	
  by	
  this	
   Provision.	
  During	
  the	
  previous	
  monitoring	
  period,	
  the	
  time	
  spent	
  in	
  PHS	
   was	
  relatively	
  stable	
  across	
  the	
  months,	
  with	
  67%	
  remaining	
  in	
  PHS	
  for	
   more	
  than	
  24	
  hours.	
  	
   	
   Throughout	
  the	
  current	
  monitoring	
  period,	
  an	
  increasing	
  proportion	
  of	
   youth	
  spent	
  at	
  least	
  24	
  hours	
  on	
  PHS.	
  During	
  the	
  last	
  4	
  months	
  of	
  the	
   monitoring	
  period,	
  nearly	
  all	
  youth	
  spent	
  over	
  24	
  hours	
  in	
  PHS.	
  The	
   average	
  length	
  of	
  stay	
  (ALOS)	
  in	
  PHS	
  also	
  increased	
  throughout	
  the	
   monitoring	
  period.	
  Across	
  the	
  6-­‐month	
  period,	
  the	
  average	
  youth	
  spent	
   over	
  two	
  days	
  in	
  PHS	
  (53	
  hours).	
  These	
  patterns	
  remain	
  when	
  the	
  length	
   of	
  stay	
  is	
  viewed	
  within	
  the	
  IRAV	
  risk	
  groups.	
  In	
  other	
  words,	
  both	
  high	
   risk	
  (A	
  level)	
  and	
  moderate	
  risk	
  (B	
  level)	
  youth’s	
  ALOS	
  increased	
   throughout	
  the	
  monitoring	
  period.	
  [There	
  were	
  too	
  few	
  low	
  risk	
  (C-­‐level)	
   youth	
  for	
  meaningful	
  analysis.]	
   	
  
Pre-­‐Hearing	
  Seclusion,	
  April	
  through	
  September	
  2012	
  

Month	
  

#	
  

Rate	
  

%	
  24+	
  hours	
  

ALOS	
  

(#/ADP)	
  

(hrs)	
  

April	
  2012	
  

48	
  

.41	
  

73%	
  

54	
  

May	
  2012	
  

32	
  

.32	
  

75%	
  

37	
  

June	
  2012	
  

27	
  

.30	
  

89%	
  

45	
  

July	
  2012	
  

49	
  

.59	
  

90%	
  

54	
  

Aug	
  2012	
  

46	
  

.52	
  

88%	
  

61	
  

Sept	
  2012	
  

26	
  

.30	
  

96%	
  

67	
  

Source:	
  Data	
  prepared	
  by	
  DYS	
  to	
  respond	
  to	
  the	
  Monitor’s	
  request	
  for	
  information	
  on	
   the	
  use	
  of	
  seclusion.	
  	
  

	
  

23.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 24 of 129 PAGEID #: 2377

In	
  addition	
  to	
  the	
  trend	
  data	
  discussed	
  above,	
  the	
  State	
  also	
  provided	
   disaggregated	
  data	
  that	
  better	
  illustrate	
  the	
  problems	
  in	
  this	
  area.	
   Spreadsheets	
  tracking	
  each	
  individual	
  act	
  of	
  violence	
  (AOV)	
  reveal	
  that	
  in	
   July	
  2012,	
  most	
  youth	
  spent	
  well	
  over	
  two	
  days	
  in	
  PHS,	
  although	
  the	
   individual	
  lengths	
  of	
  stay	
  varied	
  and	
  thus	
  appeared	
  to	
  be	
  individually	
   derived.	
  However,	
  in	
  August	
  and	
  September	
  2012,	
  nearly	
  all	
  of	
  the	
  PHS	
   episodes	
  lasted	
  the	
  maximum	
  of	
  72	
  hours.	
  The	
  purpose	
  of	
  PHS	
  is	
  to	
   ensure	
  allow	
  the	
  youth	
  sufficient	
  time	
  to	
  regain	
  control	
  of	
  his	
  behavior	
   and	
  for	
  staff	
  to	
  talk	
  to	
  the	
  youth	
  to	
  understand	
  what	
  occurred	
  and	
   whether	
  a	
  risk	
  of	
  subsequent	
  violence	
  (i.e.,	
  retaliation)	
  exists.	
  PHS	
  should	
   not	
  be	
  used	
  as	
  a	
  punishment—however,	
  given	
  the	
  uniformity	
  in	
  duration	
   across	
  youth	
  and	
  the	
  fact	
  that	
  nearly	
  all	
  youth	
  are	
  held	
  to	
  the	
  maximum	
   allowable	
  time,	
  it	
  appears	
  that	
  the	
  facility	
  has	
  been	
  using	
  PHS	
  punitively.	
  	
   	
   The	
  trends	
  witnessed	
  in	
  the	
  previous	
  monitoring	
  period—of	
  a	
  decreasing	
   length	
  of	
  stay	
  on	
  PHS	
  for	
  youth	
  at	
  all	
  IRAV	
  levels—have	
  apparently	
   reversed.	
  Although	
  the	
  Monitor	
  supports	
  the	
  use	
  of	
  structured	
  decision-­‐ making	
  tools	
  in	
  general,	
  it	
  appears	
  that	
  IRAV	
  has	
  gone	
  too	
  far	
  in	
   removing	
  staff	
  discretion	
  in	
  determining	
  a	
  youth’s	
  readiness	
  for	
  release.	
   Rather	
  than	
  making	
  a	
  considered	
  assessment	
  of	
  the	
  youth’s	
  current	
   behavior	
  and	
  readiness	
  to	
  safely	
  return	
  to	
  the	
  general	
  population,	
  IRAV	
   seems	
  to	
  have	
  resulted	
  in	
  staff’s	
  leaning	
  toward	
  the	
  top	
  end	
  of	
  the	
   ranges	
  prescribed	
  by	
  IRAV.	
  Revisions	
  to	
  the	
  IRAV	
  lengths	
  of	
  stay	
  ranges	
   were	
  pilot	
  tested	
  at	
  CJCF	
  during	
  the	
  current	
  monitoring	
  period.	
   Discussions	
  with	
  the	
  S.H.	
  subject	
  matter	
  expert	
  overseeing	
  these	
  reforms	
   indicated	
  that	
  the	
  significant	
  reductions	
  in	
  the	
  lengths	
  of	
  stay	
  for	
  each	
   IRAV	
  category	
  were	
  accomplished	
  without	
  an	
  escalation	
  of	
  violence	
  at	
   the	
  facility.	
  These	
  data	
  are	
  compelling	
  and	
  suggest	
  that	
  the	
  IRAV	
  is	
  ripe	
   for	
  further	
  modification.	
  	
   	
   While	
  on	
  site,	
  the	
  Monitor	
  discussed	
  ideas	
  for	
  reforming	
  IRAV	
  with	
  DYS	
   administrators.	
  A	
  tempered	
  approach	
  to	
  this	
  reform	
  is	
  absolutely	
   necessary	
  in	
  order	
  to	
  create	
  buy-­‐in	
  among	
  staff	
  (who	
  could	
  be	
  persuaded	
   by	
  showing	
  that	
  incremental	
  reductions	
  in	
  the	
  duration	
  of	
  PHS	
  do	
  not	
   result	
  in	
  more	
  youth	
  violence,	
  as	
  shown	
  by	
  the	
  Circleville	
  IRAV	
  pilot)	
  and	
   to	
  constrain	
  the	
  extent	
  to	
  which	
  youth	
  attempt	
  to	
  “test	
  the	
  limits”	
  of	
  the	
   new	
  procedures.	
  The	
  Monitor	
  recommends	
  that,	
  as	
  an	
  initial	
  first	
  step,	
   the	
  DYS	
  maintain	
  the	
  minimum	
  thresholds	
  being	
  proposed	
  by	
  the	
  SH	
   monitor	
  for	
  each	
  risk	
  level,	
  but	
  that,	
  thereafter,	
  a	
  youth’s	
  readiness	
  for	
   release	
  is	
  evaluated	
  at	
  3-­‐hour	
  intervals.	
  This	
  assessment	
  must	
  include	
  a	
   broad	
  range	
  of	
  indicators	
  (e.g.,	
  youth’s	
  willingness	
  to	
  discuss	
  the	
  issue	
   with	
  staff,	
  mediate	
  the	
  issue	
  with	
  the	
  youth/staff	
  involved,	
  undertake	
   some	
  sort	
  of	
  restorative	
  activity,	
  etc.),	
  but	
  should	
  NOT	
  be	
  based	
  on	
  the	
   staff’s	
  disapproval	
  of	
  the	
  youth’s	
  original	
  rule	
  violation.	
  PHS	
  is	
  not	
  about	
   punishment—it	
  is	
  about	
  protecting	
  other	
  youth	
  and	
  staff	
  from	
   subsequent	
  violence	
  from	
  the	
  youth	
  involved.	
  Retribution	
  should	
  not	
  be	
   a	
  part	
  of	
  the	
  length	
  of	
  stay	
  calculation.	
  At	
  each	
  three-­‐hour	
  interval,	
  if	
  the	
  

	
  

24.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 25 of 129 PAGEID #: 2378

Supervisor	
  determines	
  that	
  the	
  youth	
  cannot	
  be	
  returned	
  safely	
  to	
  the	
   general	
  population,	
  the	
  specific	
  reasons	
  for	
  this	
  decision	
  must	
  be	
   articulated	
  in	
  writing.	
  Conversations	
  with	
  DYS	
  and	
  the	
  S.H.	
  subject	
   matter	
  expert	
  during	
  the	
  review	
  phase	
  of	
  this	
  report	
  resulted	
  in	
  a	
  broad	
   consensus	
  about	
  the	
  next	
  phase	
  of	
  revisions	
  to	
  the	
  IRAV.	
  The	
  Monitor	
   approved	
  the	
  policy	
  revision	
  on	
  December	
  24,	
  2012.	
  Changes	
  in	
  the	
   length	
  of	
  stay	
  in	
  PHS	
  will	
  be	
  tracked	
  throughout	
  the	
  next	
  monitoring	
   period.	
  Hopefully,	
  the	
  policy	
  revision	
  will	
  produce	
  the	
  intended	
   reductions	
  and	
  outcome	
  data	
  will	
  lay	
  the	
  foundation	
  for	
  additional	
   reductions	
  in	
  the	
  minimum	
  length	
  of	
  stay	
  for	
  A-­‐level	
  youth.	
  	
   	
   At	
  Scioto,	
  the	
  duration	
  of	
  PHS	
  does	
  not	
  appear	
  to	
  be	
  at	
  all	
  related	
  to	
  the	
   length	
  of	
  time	
  required	
  to	
  prepare	
  for	
  the	
  Intervention	
  Hearing	
  (IH),	
   which	
  is	
  how	
  many	
  jurisdictions	
  anchor	
  the	
  “top	
  end”	
  of	
  PHS	
  (i.e.,	
  the	
   youth	
  is	
  held	
  in	
  PHS	
  until	
  the	
  hearing,	
  which	
  must	
  occur	
  within	
  a	
   designated	
  period	
  of	
  time).	
  While	
  facility	
  administrators	
  reported	
  that	
   the	
  IH	
  “should”	
  occur	
  within	
  72	
  hours,	
  the	
  disaggregated	
  AOV	
  data	
   indicate	
  that	
  it	
  rarely	
  does.	
  The	
  IH	
  was	
  usually	
  held	
  7-­‐10	
  after	
  the	
   incident	
  occurred.	
  The	
  delay	
  between	
  the	
  incident	
  and	
  the	
  procedure	
   employed	
  to	
  hold	
  youth	
  accountable	
  severely	
  compromises	
  the	
   effectiveness	
  of	
  the	
  sanctions	
  imposed.	
  [Sanctions	
  are	
  more	
  effective	
   when	
  they	
  are	
  imposed	
  soon	
  after	
  the	
  behavior	
  of	
  concern].	
  	
   	
   The	
  IH	
  officer	
  needs	
  some	
  time	
  to	
  ensure	
  that	
  the	
  incident	
  is	
  investigated	
   thoroughly	
  and	
  the	
  youth	
  must	
  be	
  provided	
  notice	
  of	
  the	
  proceedings	
   and	
  have	
  an	
  opportunity	
  to	
  prepare	
  his	
  or	
  her	
  defense.	
  However,	
   requiring	
  staff	
  to	
  hold	
  these	
  proceedings	
  sooner	
  rather	
  than	
  later	
  is	
   certainly	
  in	
  the	
  interest	
  of	
  justice	
  (because	
  it	
  would	
  remove	
  the	
  claim	
   that	
  the	
  youth	
  is	
  serving	
  the	
  punishment	
  in	
  the	
  form	
  of	
  PHS,	
  before	
  the	
   hearing	
  is	
  held),	
  would	
  afford	
  greater	
  protection	
  from	
  the	
  risk	
  of	
  self-­‐ harm	
  (a	
  significant	
  proportion	
  of	
  successful	
  suicides	
  in	
  juvenile	
   correctional	
  facilities	
  occur	
  among	
  youth	
  who	
  are	
  in	
  some	
  form	
  of	
   disciplinary	
  seclusion),	
  and	
  would	
  speed	
  the	
  process	
  for	
  actually	
   addressing	
  the	
  underlying	
  causes	
  of	
  the	
  	
  youth’s	
  behavior	
  through	
  the	
   consequences	
  that	
  are	
  selected	
  by	
  the	
  hearing	
  officer	
  or	
  IDT.	
  During	
  the	
   review	
  period	
  for	
  this	
  report,	
  DYS	
  shared	
  plans	
  for	
  an	
  upcoming	
  policy	
   revision	
  (Policy	
  #	
  303.01.03	
  “Youth	
  Intervention	
  Hearings”).	
  When	
  the	
   new	
  policy	
  takes	
  effect	
  (projected	
  for	
  February	
  2013),	
  the	
  timeline	
  for	
  IH	
   hearings	
  will	
  be	
  7	
  days.	
  While	
  this	
  is	
  an	
  improvement,	
  the	
  Monitor	
   encourages	
  DYS	
  to	
  continue	
  efforts	
  to	
  hold	
  hearings	
  in	
  closer	
  proximity	
   to	
  the	
  incident	
  for	
  which	
  the	
  youth	
  is	
  being	
  sanctioned.	
   	
   Intervention	
  Seclusion	
   Intervention	
  hearings	
  are	
  held	
  to	
  determine	
  whether	
  youth	
  are	
  culpable	
   for	
  serious	
  misconduct	
  and	
  whether	
  additional	
  time	
  in	
  seclusion	
  is	
   warranted.	
  While	
  on	
  Intervention	
  Seclusion,	
  youth	
  remain	
  in	
  their	
  rooms	
   except	
  for	
  showers.	
  Youth	
  should	
  receive	
  recreation	
  and	
  Unit	
  Instruction	
  

	
  

25.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 26 of 129 PAGEID #: 2379

(i.e.,	
  education)	
  out	
  of	
  their	
  rooms,	
  but	
  anecdotal	
  reports	
  from	
  youth	
   suggest	
  that	
  they	
  do	
  not.	
  By	
  policy,	
  youth	
  can	
  receive	
  a	
  maximum	
  of	
  5	
   days	
  of	
  Intervention	
  Seclusion,	
  but	
  the	
  policy	
  also	
  allows	
  for	
  the	
  use	
  of	
   alternative	
  sanctions	
  to	
  respond	
  to	
  primary	
  rule	
  violation.	
  Recently,	
  a	
   some	
  of	
  the	
  major	
  rule	
  violations	
  are	
  being	
  handled	
  by	
  the	
  IDT,	
  which	
  is	
   a	
  promising	
  practice	
  given	
  that	
  treatment	
  teams	
  tend	
  to	
  design	
  sanctions	
   that	
  are	
  more	
  responsive	
  to	
  the	
  underlying	
  causes	
  of	
  the	
  youth’s	
   behavior.	
  In	
  contrast,	
  seclusion	
  serves	
  only	
  to	
  suppress	
  a	
  youth’s	
   negative	
  behavior	
  during	
  the	
  time	
  that	
  he	
  or	
  she	
  is	
  behind	
  a	
  locked	
  door	
   and	
  also	
  denies	
  youth	
  access	
  to	
  the	
  very	
  treatment	
  programs	
  they	
  need	
   in	
  order	
  to	
  change	
  their	
  behavior.	
  	
   	
   The	
  previous	
  Monitor’s	
  report	
  discussed	
  the	
  significant	
  decreases	
  in	
  the	
   use	
  of	
  Intervention	
  Seclusion,	
  due	
  in	
  part	
  to	
  an	
  overall	
  reduction	
  in	
  AOVs	
   and	
  also	
  to	
  the	
  former	
  Superintendent’s	
  commitment	
  to	
  use	
  alternative	
   sanctions	
  more	
  frequently.	
  Evidence	
  of	
  the	
  more	
  limited	
  use	
  of	
  seclusion	
   as	
  a	
  sanction	
  continued	
  into	
  the	
  beginning	
  of	
  the	
  monitoring	
  period,	
  but	
   then	
  the	
  use	
  of	
  intervention	
  seclusion	
  increased	
  sharply.	
  The	
  total	
  IS	
   hours	
  imposed	
  increased,	
  as	
  did	
  the	
  number	
  of	
  hours	
  per	
  youth	
  (which	
  is	
   calculated	
  only	
  to	
  neutralize	
  changes	
  in	
  the	
  number	
  of	
  youth	
  involved	
  in	
   AOV.	
  Since	
  some	
  youth	
  do	
  not	
  receive	
  any	
  seclusion	
  time,	
  the	
  actual	
   number	
  of	
  hours	
  in	
  seclusion	
  for	
  those	
  who	
  received	
  it	
  is	
  longer	
  than	
  the	
   average	
  number	
  would	
  indicate.)	
   	
   	
  
Intervention	
  Seclusion	
  Hours,	
  April	
  through	
  September	
  2012	
  

Month	
  

#	
  Y	
  involved	
  	
   in	
  AOV	
  

Total	
  IS	
   hours	
  

Hours	
  per	
   Youth	
  

April	
  2012	
  

46	
  

76	
  

1.65	
  

May	
  2012	
  

40	
  

159	
  

3.98	
  

June	
  2012	
  

29	
  

24	
  

0.83	
  

July	
  2012	
  

34	
  

186	
  

5.47	
  

Aug	
  2012	
  

30	
  

163	
  

5.43	
  

Sept	
  2012	
  

29	
  

899	
  

31.00	
  

Source:	
  Monthly	
  Superintendent’s	
  Report,	
  which	
  counts	
  the	
  number	
   of	
  youth	
  involved	
  in	
  AOV	
  (not	
  AOV	
  incidents)	
  and	
  the	
  total	
  number	
   of	
  IS	
  hours	
  
	
   Other	
  data	
  submitted	
  by	
  the	
  State	
  (AOV	
  spreadsheets)	
  revealed	
  that	
  the	
   proportion	
  of	
  Intervention	
  Hearings	
  that	
  utilized	
  seclusion	
  as	
  a	
  sanction	
   also	
  increased	
  throughout	
  the	
  monitoring	
  period.	
  In	
  July	
  2012,	
  only	
  3%	
   of	
  the	
  IH	
  resulted	
  in	
  seclusion,	
  compared	
  to	
  August	
  and	
  September	
  2012	
   when	
  40%	
  and	
  79%	
  of	
  IHs	
  resulted	
  in	
  the	
  use	
  of	
  seclusion	
  as	
  a	
  sanction.	
  	
   	
   These	
  increases	
  are	
  concerning	
  and	
  their	
  underlying	
  causes	
  are	
  

	
  

26.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 27 of 129 PAGEID #: 2380

undoubtedly	
  complex,	
  including	
  but	
  by	
  no	
  means	
  limited	
  to	
  a	
   combination	
  of	
  the	
  facility’s	
  leadership’s	
  philosophy,	
  the	
  severity	
  of	
  the	
   AOV,	
  and	
  the	
  alternative	
  sanctions	
  available.	
  	
  As	
  discussed	
  in	
  previous	
   reports,	
  not	
  only	
  is	
  seclusion	
  one	
  of	
  the	
  least	
  effective	
  tools	
  for	
  managing	
   youth	
  behavior,	
  it	
  also	
  decreases	
  youth’s	
  access	
  to	
  needed	
  treatment	
   programs	
  and	
  increases	
  frustration	
  and	
  anger	
  and	
  thus	
  elevates	
  their	
  risk	
   of	
  self-­‐harm.	
  	
   	
   The	
  recent	
  assignment	
  of	
  the	
  IDT	
  to	
  handle	
  certain	
  rule	
  violations	
  is	
   certainly	
  positive.	
  IDTs	
  can	
  pull	
  on	
  the	
  resources	
  of	
  their	
  multi-­‐ disciplinary	
  members	
  to	
  construct	
  sanctions	
  that	
  are	
  balanced	
  between	
   treatment	
  and	
  supervision,	
  and	
  provide	
  an	
  ideal	
  opportunity	
  for	
  direct	
   care	
  staff	
  to	
  engage	
  in	
  the	
  important	
  work	
  of	
  supporting	
  the	
  skill	
   development	
  that	
  takes	
  place	
  in	
  treatment.	
  However,	
  IDTs	
  should	
  be	
   cautioned	
  not	
  to	
  order	
  sanctions	
  of	
  questionable	
  value	
  (e.g.,	
  rote	
  writing	
   assignments,	
  “sitting	
  on	
  the	
  door”	
  for	
  days	
  on	
  end	
  without	
  adjunct	
   treatment	
  work,	
  community	
  service	
  work	
  or	
  other	
  restorative	
  activity).	
   While	
  the	
  Monitor	
  did	
  not	
  have	
  aggregate	
  data	
  regarding	
  the	
  types	
  of	
   sanctions	
  the	
  IDTs	
  imposed,	
  anecdotes	
  from	
  youth	
  suggested	
  that	
  at	
   times,	
  the	
  sanctions	
  imposed	
  were	
  of	
  questionable	
  value.	
  The	
  AOV	
   spreadsheets	
  identify	
  the	
  proportion	
  of	
  AOVs	
  that	
  were	
  handled	
  by	
  the	
   IDT	
  rather	
  than	
  the	
  IH	
  process.	
  The	
  IDTs	
  handled	
  fewer	
  cases	
  toward	
  the	
   end	
  of	
  the	
  monitoring	
  period—in	
  July	
  30%	
  of	
  AOVs	
  were	
  handled	
  by	
  the	
   IDT,	
  compared	
  to	
  only	
  22%	
  in	
  August	
  and	
  12%	
  in	
  September	
  2012.	
  The	
   reasons	
  for	
  this	
  decline	
  are	
  unknown.	
  	
   	
   The	
  State	
  did	
  not	
  offer	
  any	
  quality	
  assurance	
  data	
  related	
  to	
  this	
  function	
   of	
  the	
  IDT	
  meetings	
  and,	
  if	
  it	
  has	
  not	
  already	
  done	
  so,	
  should	
  develop	
   performance	
  measures	
  that	
  are	
  regularly	
  assessed	
  to	
  determine	
  whether	
   this	
  process	
  has	
  been	
  implemented	
  as	
  intended	
  (e.g.,	
  types	
  of	
  sanctions	
   that	
  are	
  imposed)	
  and	
  whether	
  the	
  intended	
  outcomes	
  are	
  being	
   achieved	
  (e.g.,	
  youth’s	
  subsequent	
  involvement	
  in	
  violent	
  misconduct).	
  A	
   new	
  sanctions	
  grid	
  will	
  be	
  rolled	
  out	
  in	
  February	
  2013	
  and	
  DYS	
  should	
  be	
   conscientious	
  about	
  collecting	
  data	
  to	
  assess	
  the	
  impact	
  of	
  the	
  changes.	
   The	
  new	
  grid	
  reduces	
  the	
  amount	
  of	
  intervention	
  seclusion	
  time	
  and	
   intervention	
  time	
  that	
  may	
  be	
  added	
  to	
  youth’s	
  sentences.	
  These	
   changes	
  are	
  very	
  positive,	
  but	
  good	
  data	
  are	
  needed	
  to	
  demonstrate	
  to	
   the	
  various	
  constituents	
  that	
  sanctions	
  conform	
  to	
  the	
  new	
  prescriptions	
   and	
  that	
  they	
  were	
  accomplished	
  without	
  compromising	
  the	
  safety	
  and	
   security	
  of	
  the	
  facility.	
  	
   	
   Seclusion	
  among	
  Youth	
  on	
  the	
  Progress	
  Units	
  (PU)	
   	
   The	
  Monitor	
  has	
  voiced	
  serious	
  concerns	
  about	
  the	
  operation	
  of	
  the	
  PU	
   since	
  its	
  inception	
  at	
  Scioto	
  in	
  September	
  2011.	
  The	
  Parties	
  and	
   Monitoring	
  Team	
  members	
  have	
  had	
  multiple	
  conversations	
  about	
  the	
   term	
  “seclusion”	
  and	
  whether	
  it	
  applied	
  to	
  the	
  in-­‐room	
  time	
  on	
  the	
  PU.	
  

	
  

27.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 28 of 129 PAGEID #: 2381

Until	
  the	
  new	
  schedule	
  was	
  implemented	
  on	
  October	
  15,	
  2012	
   (discussed	
  below),	
  youth	
  on	
  the	
  PU	
  spent	
  nearly	
  all	
  of	
  their	
  waking	
  hours	
   in	
  their	
  rooms.	
  This	
  in-­‐room	
  time	
  was	
  not	
  a	
  sanction	
  for	
  a	
  proximate	
   disciplinary	
  offense	
  (like	
  the	
  seclusion	
  discussed	
  above),	
  but	
  was	
   imposed	
  only	
  by	
  virtue	
  of	
  their	
  being	
  housed	
  on	
  the	
  PU	
  as	
  a	
  result	
  of	
   their	
  history	
  of	
  misconduct	
  and	
  the	
  State’s	
  failure	
  to	
  schedule	
   programming	
  throughout	
  the	
  day	
  for	
  these	
  youth.	
  	
   	
   The	
  Monitor	
  inadvertently	
  implied	
  that	
  this	
  in-­‐room	
  time	
  was	
  part	
  of	
  the	
   PU	
  treatment	
  program	
  by	
  calling	
  it	
  “Programmatic	
  Seclusion”	
  in	
  previous	
   Monitor’s	
  Reports.	
  This	
  label	
  was	
  selected	
  only	
  to	
  differentiate	
  these	
  in-­‐ room	
  hours	
  from	
  those	
  endured	
  by	
  youth	
  as	
  an	
  immediate	
  consequence	
   for	
  an	
  AOV	
  and	
  was	
  not	
  intended	
  to	
  imply	
  that	
  in-­‐room	
  time	
  was	
  an	
   acceptable	
  component	
  of	
  the	
  PU	
  program	
  design.	
  In	
  fact,	
  a	
  label	
  was	
   applied	
  in	
  order	
  to	
  stress	
  the	
  importance	
  of	
  eradicating	
  the	
  practice.	
   Protracted	
  arguments	
  about	
  the	
  label	
  that	
  should	
  be	
  applied	
  appeared	
   to	
  steer	
  conversation	
  away	
  from	
  the	
  fact	
  that	
  a	
  program	
  intended	
  to	
   treat	
  and	
  manage	
  the	
  system’s	
  most	
  violent	
  youth	
  cannot	
  rely	
  on	
  the	
  use	
   of	
  in-­‐room	
  time	
  to	
  the	
  extent	
  that	
  the	
  PU	
  has	
  since	
  its	
  inception.	
  Youth	
   on	
  these	
  units	
  should	
  be	
  engaged	
  in	
  meaningful	
  treatment,	
  education	
   and	
  programming	
  throughout	
  their	
  waking	
  hours	
  (as	
  required	
  by	
   Provision	
  III.F.1,	
  below).	
  Extensive	
  time	
  in	
  their	
  rooms	
  will	
  only	
  lead	
  to	
   frustration	
  and	
  anger,	
  which	
  most	
  of	
  these	
  youth	
  will	
  express	
  in	
  the	
  form	
   of	
  violence—the	
  very	
  behavior	
  that	
  the	
  PU	
  purports	
  to	
  want	
  to	
  minimize.	
   The	
  extent	
  to	
  which	
  PU	
  youth	
  were	
  actually	
  engaged	
  in	
  programming	
   during	
  the	
  current	
  monitoring	
  period	
  is	
  discussed	
  in	
  III.F.1,	
  below.	
  	
   	
   Only	
  recently	
  (just	
  after	
  the	
  current	
  monitoring	
  period	
  ended)	
  were	
   tangible	
  changes	
  made	
  to	
  the	
  program	
  design	
  to	
  try	
  to	
  reduce	
  the	
   extreme	
  over-­‐reliance	
  on	
  in-­‐room	
  time	
  to	
  manage	
  youth’s	
  behavior.	
  In	
   addition	
  to	
  increasing	
  the	
  staffing	
  of	
  all	
  types	
  (education,	
  direct	
  care,	
   mental	
  health,	
  recreation	
  and	
  Supervisors)	
  on	
  the	
  unit,	
  a	
  24-­‐hour	
   schedule	
  in	
  which	
  all	
  PU	
  youth	
  are	
  out	
  of	
  their	
  rooms	
  during	
  waking	
   hours	
  in	
  the	
  same	
  measure	
  as	
  youth	
  from	
  the	
  general	
  population	
  was	
   implemented	
  on	
  October	
  15,	
  2012.	
  The	
  key	
  performance	
  measures	
  must	
   be	
  tracked	
  on	
  an	
  individual	
  level	
  over	
  a	
  sustained	
  period	
  of	
  time	
  (e.g.,	
  in-­‐ room	
  time	
  for	
  each	
  youth,	
  over	
  a	
  90-­‐day	
  period)	
  in	
  order	
  to	
  develop	
   even	
  a	
  preliminary	
  finding	
  that	
  the	
  schedule	
  has	
  been	
  properly	
   implemented.	
  At	
  this	
  point,	
  the	
  schedule	
  is	
  far	
  too	
  new	
  to	
  make	
  any	
   conclusions	
  about	
  whether	
  it	
  has	
  resolved	
  the	
  extreme	
  overreliance	
  on	
   seclusion	
  that	
  has	
  characterized	
  the	
  PU	
  since	
  its	
  inception.	
  	
  	
   	
   Other	
  planned	
  modifications	
  to	
  the	
  PU	
  program	
  design	
  should	
  be	
   implemented	
  to	
  further	
  reduce	
  the	
  amount	
  of	
  time	
  that	
  PU	
  youth	
  spend	
   on	
  intervention	
  seclusion	
  (in	
  addition	
  to	
  the	
  system-­‐wide	
  reforms	
  to	
   IRAV	
  discussed	
  above).	
  These	
  include	
  improvements	
  in	
  treatment	
   planning,	
  measuring	
  youth’s	
  progress	
  toward	
  tangible	
  goals	
  and	
  

	
  

28.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 29 of 129 PAGEID #: 2382

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
  

procedures	
  for	
  re-­‐examining	
  the	
  treatment	
  approach	
  with	
  youth	
  who	
  are	
   not	
  progressing	
  as	
  planned.	
  The	
  details	
  for	
  these	
  modifications	
  have	
  not	
   yet	
  been	
  finalized,	
  nor	
  has	
  a	
  quality	
  assurance	
  process	
  to	
  ensure	
  that	
  key	
   outcomes	
  (e.g.,	
  decreased	
  involvement	
  in	
  violent	
  misconduct,	
  shortened	
   length	
  of	
  stay	
  on	
  each	
  Phase,	
  shortened	
  overall	
  stay	
  on	
  PU)	
  are	
  being	
   achieved.	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Identify	
  and	
  address	
  the	
  underlying	
  causes	
  of	
  recent	
  increases	
  in	
   the	
  length	
  of	
  stay	
  in	
  regular	
  seclusion.	
  	
  
2. Modify	
  the	
  IRAV	
  to	
  ensure	
  that	
  youth	
  remain	
  in	
  pre-­‐hearing	
   seclusion	
  no	
  longer	
  than	
  necessary	
  to	
  de-­‐escalate	
  their	
  behavior	
   and	
  ensure	
  they	
  do	
  not	
  pose	
  a	
  threat	
  to	
  the	
  safety	
  of	
  other	
   youth	
  or	
  staff.	
  Consider	
  adjusting	
  the	
  requirements	
  surrounding	
   the	
  timing	
  of	
  Intervention	
  Hearings	
  to	
  improve	
  the	
  effectiveness	
   of	
  the	
  sanctioning	
  process.	
  
3. Limit	
  the	
  use	
  of	
  intervention	
  seclusion,	
  relying	
  instead	
  on	
   sanctions	
  that	
  provide	
  an	
  opportunity	
  for	
  skill	
  development	
  and	
   treatment	
  in	
  order	
  to	
  create	
  behavior	
  change,	
  and	
  collect	
  data	
  to	
   demonstrate	
  the	
  extent	
  to	
  which	
  this	
  change	
  has	
  occurred.	
   Develop	
  quality	
  assurance	
  mechanisms	
  around	
  the	
  use	
  of	
   seclusion	
  in	
  Intervention	
  Hearings	
  and	
  to	
  determine	
  whether	
  the	
   recently	
  implemented	
  IDT	
  sanctioning	
  process	
  is	
  a	
  viable	
  strategy	
   for	
  reducing	
  the	
  reliance	
  on	
  intervention	
  seclusion.	
  	
  
4. Ensure	
  that	
  youth	
  on	
  the	
  PROGRESS	
  Unit	
  are	
  not	
  scheduled	
  to	
  be	
   in	
  their	
  rooms	
  in	
  any	
  greater	
  measure	
  than	
  youth	
  in	
  the	
  general	
   population.	
  Ensure	
  their	
  daily	
  access	
  to	
  a	
  full	
  range	
  of	
  education,	
   treatment,	
  recreation	
  and	
  structured	
  programming.	
  	
  
5. Ensure	
  that	
  the	
  PROGRESS	
  Unit’s	
  program	
  design	
  (e.g.,	
  staffing,	
   treatment,	
  programming,	
  etc.)	
  is	
  sufficient	
  to	
  reduce	
  youth’s	
   involvement	
  in	
  violent	
  misconduct	
  so	
  that	
  the	
  use	
  of	
  pre-­‐hearing	
   and	
  intervention	
  seclusion	
  is	
  limited.	
  	
  
• Self-­‐assessment	
  data	
  for	
  III.A.3,	
  prepared	
  at	
  my	
  request	
   • Monthly	
  Superintendent’s	
  Reports,	
  April	
  through	
  September	
  
2012	
   • Consultation	
  with	
  Steve	
  Martin,	
  subject	
  matter	
  expert	
  for	
  S.H.	
  v.	
  
The	
  State	
  of	
  Ohio,	
  regarding	
  modifications	
  to	
  IRAV	
   • On-­‐going	
  discussions	
  with	
  the	
  Parties	
  regarding	
  the	
  design	
  and	
  
operation	
  of	
  the	
  PROGRESS	
  Unit	
  
	
  

	
  

29.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 30 of 129 PAGEID #: 2383

	
  
III.A.5	
  Investigation	
  of	
  Serious	
  Incidents.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  so	
  that	
  appropriate	
  investigations	
  are	
  conducted	
  of	
  all	
  incidents	
  of:	
   use	
  of	
  force;	
  staff-­‐on-­‐youth	
  violence;	
  serious	
  youth-­‐on-­‐youth	
  violence;	
  inappropriate	
   relationships	
  with	
  youth;	
  sexual	
  misconduct	
  between	
  youth;	
  and	
  abusive	
  institutional	
  practices.	
   Investigations	
  shall	
  be	
  conducted	
  by	
  persons	
  who	
  do	
  not	
  have	
  direct	
  or	
  immediate	
  indirect	
   responsibility	
  for	
  the	
  employee	
  being	
  investigated.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  State	
  submitted	
  a	
  log	
  of	
  all	
  investigations	
  related	
  to	
  excessive	
  uses	
  of	
   force,	
  allegations	
  of	
  abuse,	
  allegations	
  of	
  verbal	
  abuse,	
  and	
  inappropriate	
   relationships	
  completed	
  during	
  the	
  current	
  monitoring	
  period.	
  The	
  Chief	
   Inspector’s	
  Office	
  (CIO)	
  investigated	
  the	
  more	
  serious	
  allegations,	
  while	
   facility-­‐based	
  investigators	
  addressed	
  the	
  less	
  serious	
  allegations.	
  	
   	
   Between	
  April	
  2012	
  and	
  September	
  2012,	
  a	
  total	
  of	
  32	
  investigations	
   were	
  completed	
  related	
  to	
  the	
  topics	
  covered	
  by	
  this	
  provision	
  (17	
  of	
   these	
  were	
  completed	
  by	
  facility-­‐based	
  investigators	
  and	
  15	
  were	
   completed	
  by	
  the	
  CIO).	
  Only	
  1	
  of	
  the	
  17	
  facility-­‐based	
  investigations	
  (6%)	
   was	
  substantiated	
  (unnecessary	
  use	
  of	
  force).	
  This	
  represents	
  a	
  generally	
   declining	
  trend	
  in	
  the	
  proportion	
  of	
  investigations	
  that	
  are	
  substantiated	
   (1st	
  Monitors’	
  Report	
  reported	
  39%;	
  2nd	
  Monitors’	
  Report	
  reported	
  10%).	
   As	
  noted	
  in	
  the	
  previous	
  Monitors’	
  report,	
  the	
  low	
  proportion	
  of	
   substantiated	
  allegations	
  is	
  likely	
  due	
  to	
  the	
  poor	
  quality	
  of	
  the	
  facility-­‐ based	
  investigatory	
  process.	
  	
   	
   Five	
  the	
  15	
  CIO	
  investigations	
  (33%)	
  resulted	
  in	
  a	
  substantiated	
  finding.	
   Staff	
  were	
  cited	
  for:	
  
• Inappropriate	
  contact	
  with	
  a	
  youth	
  after	
  she	
  was	
  released;	
   • Unnecessary	
  use	
  of	
  force;	
   • Leaving	
  a	
  youth	
  locked	
  in	
  a	
  shower/bathroom	
  overnight;	
   • Denying	
  several	
  youth	
  dinner	
  and	
  leaving	
  them	
  in	
  soft-­‐restraints	
  
overnight;	
  and	
   • Turning	
  off	
  the	
  air	
  vents	
  and	
  water	
  flow	
  to	
  two	
  youth’s	
  rooms.	
  	
   As	
  discussed	
  in	
  the	
  next	
  section,	
  in	
  contrast	
  to	
  the	
  facility-­‐based	
   investigations,	
  the	
  CIO	
  investigations	
  are	
  generally	
  of	
  high	
  quality.	
  	
   	
   Historically,	
  the	
  CIO	
  has	
  conducted	
  quarterly	
  audits	
  of	
  the	
  facility’s	
   investigations	
  and	
  provided	
  detailed	
  technical	
  assistance	
  in	
  its	
  written	
   reports.	
  The	
  most	
  recent	
  CIO	
  report	
  covered	
  Q1	
  2012	
  (prior	
  to	
  the	
   beginning	
  of	
  the	
  current	
  monitoring	
  period)	
  although	
  the	
  report	
  was	
   issued	
  in	
  July	
  2012.	
  The	
  Q1	
  report	
  focused	
  exclusively	
  on	
  the	
  AMS	
   incident	
  reporting	
  procedures	
  and	
  not	
  on	
  the	
  process	
  or	
  quality	
  of	
  the	
   facility-­‐based	
  investigations.	
  However,	
  recent	
  technical	
  assistance	
  and	
   training	
  has	
  been	
  provided	
  to	
  the	
  Labor	
  Relations	
  Officer	
  (who	
  is	
  tasked	
   with	
  assigning	
  and	
  tracking	
  the	
  investigations)	
  and	
  the	
  Deputy	
   Superintendents	
  who	
  are	
  responsible	
  for	
  reviewing	
  and	
  approving	
  the	
  

	
  

30.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 31 of 129 PAGEID #: 2384

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

quality	
  of	
  the	
  investigations.	
  Given	
  the	
  findings	
  detailed	
  below,	
   additional	
  training	
  for	
  investigators	
  is	
  sorely	
  needed.	
  	
   	
   Moving	
  forward,	
  the	
  CIO	
  plans	
  to	
  shift	
  its	
  monitoring	
  strategy	
  so	
  that	
   each	
  DYS	
  facility	
  will	
  be	
  monitored	
  every	
  4	
  months.	
  This	
  shift	
  will	
  permit	
   a	
  more	
  rigorous	
  review	
  and	
  more	
  timely	
  reports,	
  since	
  the	
  facilities	
  will	
   now	
  be	
  audited	
  one	
  at	
  a	
  time.	
  	
  
Investigations	
  Conducted	
  by	
  the	
  Chief	
  Inspectors	
  Office	
  (CIO)	
   	
   Timeliness.	
  Of	
  the	
  15	
  investigations	
  reviewed,	
  10	
  (66%)	
  were	
  completed	
   within	
  the	
  timelines	
  prescribed	
  by	
  policy	
  (i.e.,	
  14	
  business	
  days	
  for	
  use	
  of	
   force	
  investigations;	
  30	
  calendar	
  days	
  for	
  all	
  others)	
  or	
  were	
  granted	
  an	
   extension	
  for	
  cause	
  (e.g.,	
  key	
  witness	
  was	
  unavailable;	
  delay	
  in	
  obtaining	
   permission	
  to	
  proceed	
  from	
  the	
  OSHP).	
  The	
  remaining	
  5	
  investigations	
   (36%)	
  were	
  submitted	
  beyond	
  the	
  timelines	
  permitted	
  by	
  policy	
  but	
  had	
   not	
  been	
  granted	
  an	
  extension	
  (average	
  number	
  of	
  days	
  late	
  =	
  6).	
  While	
   the	
  goal	
  of	
  producing	
  a	
  high-­‐quality	
  investigation	
  is	
  paramount,	
   investigators	
  must	
  either	
  complete	
  investigations	
  within	
  the	
  prescribed	
   timelines	
  or	
  should	
  obtain	
  an	
  extension,	
  even	
  when	
  only	
  a	
  few	
  extra	
  days	
   are	
  needed.	
  Occasional	
  timeline	
  violations	
  are	
  unavoidable,	
  but	
  the	
   current	
  rate	
  of	
  timeliness	
  (66%)	
  is	
  simply	
  not	
  sufficient.	
  	
  	
  	
   	
   At	
  the	
  time	
  of	
  the	
  Monitor’s	
  site	
  visit,	
  the	
  CIO	
  also	
  had	
  8	
  pending	
   investigations,	
  3	
  of	
  which	
  had	
  not	
  yet	
  reached	
  their	
  due	
  dates	
  and	
  the	
   other	
  5	
  had	
  legitimate	
  reasons	
  for	
  an	
  extension	
  (e.g.,	
  suspect	
  was	
  in	
  jail;	
   awaiting	
  DNA	
  evidence;	
  key	
  witness	
  had	
  been	
  in	
  car	
  accident).	
   	
   Quality.	
  Each	
  of	
  the	
  15	
  CIO	
  investigations	
  completed	
  during	
  the	
   Monitoring	
  period	
  was	
  reviewed.	
  As	
  in	
  the	
  past,	
  the	
  investigations	
  were	
   very	
  well	
  done.	
  They	
  featured	
  comprehensive	
  interviews	
  with	
  all	
  key	
   witnesses,	
  utilized	
  videotaped	
  footage	
  effectively,	
  and	
  pursued	
   tangential	
  issues	
  that	
  emerged	
  during	
  the	
  course	
  of	
  the	
  initial	
  inquiry.	
   Across	
  the	
  sample,	
  the	
  findings	
  appeared	
  to	
  be	
  reasonable	
  and	
  the	
  basis	
   for	
  the	
  conclusions	
  was	
  clearly	
  identified	
  among	
  the	
  evidence.	
  	
   	
   Investigations	
  Conducted	
  by	
  Scioto	
  Staff	
   	
   Timeliness.	
  Of	
  the	
  17	
  investigations	
  conducted	
  by	
  Scioto	
  staff	
  during	
  the	
   current	
  monitoring	
  period,	
  only	
  4	
  (23%)	
  were	
  completed	
  within	
  the	
   timelines	
  prescribed	
  by	
  policy.	
  The	
  remaining	
  13	
  (77%)	
  were	
  late	
  (an	
   average	
  of	
  18	
  business	
  days),	
  which	
  is	
  a	
  significant	
  increase	
  from	
  the	
   previous	
  monitoring	
  period	
  where	
  42%	
  were	
  late.	
  	
   	
   In	
  addition,	
  at	
  the	
  time	
  of	
  the	
  Monitor’s	
  site	
  visit,	
  11	
  facility-­‐based	
   investigations	
  were	
  pending	
  and	
  overdue	
  (average	
  days	
  overdue	
  was	
  57).	
   Two	
  other	
  pending	
  cases	
  had	
  not	
  yet	
  reach	
  their	
  due	
  dates.	
  The	
  State	
   reported	
  that	
  it	
  was	
  aware	
  of	
  these	
  problems	
  and	
  had	
  recently	
  made	
  

	
  

31.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 32 of 129 PAGEID #: 2385

changes	
  to	
  the	
  assignment,	
  oversight	
  and	
  review	
  process	
  in	
  an	
  effort	
  to	
   correct	
  these	
  deficiencies.	
  	
   	
   Timely	
  investigations	
  are	
  essential	
  for	
  a	
  robust	
  process	
  to	
  address	
   allegations	
  of	
  employee	
  misconduct.	
  Should	
  the	
  allegation	
  be	
   substantiated,	
  staff	
  training	
  or	
  discipline	
  needs	
  to	
  occur	
  as	
  soon	
  as	
   possible	
  so	
  the	
  individual	
  can	
  either	
  return	
  to	
  duty,	
  be	
  retrained,	
  or	
  be	
   terminated,	
  as	
  appropriate.	
  If	
  the	
  allegation	
  is	
  not	
  substantiated,	
  the	
   employee	
  needs	
  to	
  be	
  cleared	
  so	
  that	
  he	
  or	
  she	
  may	
  return	
  to	
  full	
  duty	
   and	
  be	
  relieved	
  of	
  the	
  stress	
  and	
  stigma	
  of	
  being	
  “under	
  investigation.”	
  	
   	
   Quality.	
  The	
  previous	
  Monitor’s	
  report	
  downgraded	
  the	
  compliance	
   rating	
  for	
  this	
  provision	
  to	
  Partial	
  Compliance	
  upon	
  finding	
  that	
  the	
   quality	
  of	
  the	
  investigations	
  conducted	
  by	
  Scioto	
  staff	
  had	
  sunk	
  far	
  below	
   professional	
  standards.	
  Unfortunately,	
  the	
  quality	
  of	
  the	
  investigations	
   has	
  not	
  improved	
  at	
  all.	
  	
  	
  	
   	
   As	
  in	
  the	
  previous	
  monitoring	
  period,	
  the	
  Monitor	
  provided	
  detailed	
   feedback	
  on	
  each	
  of	
  the	
  17	
  cases	
  to	
  develop	
  consensus	
  around	
  the	
   essential	
  elements	
  of	
  a	
  quality	
  investigation	
  and	
  to	
  highlight	
  the	
  many	
   features	
  that	
  were	
  lacking	
  from	
  the	
  most	
  recent	
  set	
  of	
  investigations.	
  To	
   summarize:	
  
• Allegation	
  statements	
  need	
  to	
  be	
  specific	
  (who	
  is	
  alleged	
  to	
  have	
   done	
  what	
  to	
  whom,	
  and	
  when?)	
  in	
  order	
  to	
  set	
  the	
  context	
  for	
   the	
  subsequent	
  information.	
  Too	
  often,	
  key	
  facts	
  were	
  missing	
   and	
  it	
  was	
  not	
  until	
  several	
  pages	
  into	
  the	
  investigation	
  that	
  the	
   nature	
  of	
  the	
  allegation	
  could	
  be	
  understood.	
  	
  	
  
• Any	
  delays	
  in	
  assigning	
  or	
  initiating	
  the	
  investigation	
  need	
  to	
  be	
   explained.	
  Long	
  delays	
  in	
  initiating	
  investigations	
  were	
  noted,	
   and	
  were	
  unexplained.	
  In	
  part,	
  the	
  situation	
  could	
  be	
  clarified	
  if	
   the	
  investigator	
  explained	
  how	
  and	
  when	
  the	
  facility	
  became	
   aware	
  of	
  the	
  allegation	
  (which	
  would	
  account	
  for	
  those	
   situations	
  when	
  the	
  youth	
  did	
  not	
  report	
  the	
  concern	
   immediately	
  after	
  it	
  happened).	
  	
  
• Everyone	
  who	
  can	
  contribute	
  to	
  the	
  understanding	
  of	
  what	
   occurred	
  should	
  be	
  interviewed.	
  In	
  several	
  cases,	
  the	
   investigator	
  identified	
  a	
  very	
  limited	
  set	
  of	
  witnesses	
  (e.g.,	
  the	
   accused	
  staff,	
  the	
  victim	
  and	
  possibly	
  one	
  other	
  staff	
  witness)	
   even	
  though	
  other	
  people	
  were	
  in	
  the	
  vicinity	
  when	
  the	
  incident	
   allegedly	
  occurred.	
  None	
  of	
  the	
  investigations	
  reviewed	
  included	
   a	
  single	
  youth	
  witness	
  interview.	
  	
  
• Witnesses	
  should	
  be	
  asked	
  to	
  describe	
  what	
  happened	
  in	
  their	
   own	
  words,	
  and	
  the	
  investigator	
  should	
  seek	
  clarification	
  or	
   additional	
  detail	
  through	
  appropriate	
  follow-­‐up	
  questions.	
  Many	
   times,	
  it	
  appeared	
  that	
  the	
  witness	
  was	
  simply	
  asked	
  to	
  respond	
   to	
  a	
  set	
  of	
  yes/no	
  questions.	
  Without	
  providing	
  an	
  actual	
   transcript,	
  the	
  full	
  exchange	
  between	
  the	
  investigator	
  and	
  the	
  

	
  

32.	
  

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Recommendations	
  

witness	
  needs	
  to	
  be	
  captured	
  in	
  the	
  interview	
  summary.	
  	
   • The	
  sequence	
  of	
  the	
  interviews	
  is	
  important.	
  The	
  alleged	
  victim	
  
should	
  be	
  interviewed	
  first	
  in	
  order	
  to	
  obtain	
  a	
  complete	
   accounting	
  of	
  the	
  youth’s	
  concerns	
  and	
  to	
  obtain	
  details	
  that	
   can	
  be	
  used	
  to	
  construct	
  questions	
  with	
  the	
  witnesses	
  and	
  the	
   accused	
  staff.	
  The	
  accused	
  staff	
  should	
  be	
  interviewed	
  last,	
  so	
   that	
  he	
  or	
  she	
  can	
  be	
  asked	
  to	
  respond	
  to	
  the	
  specific	
  allegations	
   discovered	
  during	
  the	
  previous	
  interviews.	
  In	
  several	
  cases,	
  the	
   accused	
  staff	
  was	
  interviewed	
  first,	
  and	
  thus	
  the	
  interview	
  did	
   not	
  reflect	
  the	
  variety	
  of	
  issues	
  raised	
  in	
  subsequent	
  interviews.	
  	
   • The	
  basis	
  for	
  the	
  conclusions	
  must	
  be	
  clearly	
  articulated	
  and	
   must	
  rest	
  upon	
  facts	
  that	
  were	
  gathered	
  during	
  the	
   investigation.	
  Many	
  of	
  the	
  investigators	
  do	
  not	
  write	
  coherent	
   narratives	
  and	
  do	
  not	
  summarize	
  the	
  facts	
  that	
  supported	
  the	
   conclusion,	
  and	
  did	
  not	
  explain	
  why	
  they	
  discounted	
  facts	
  that	
   didn’t	
  fit.	
  	
   	
   It	
  is	
  worth	
  noting	
  that	
  this	
  is	
  the	
  exact	
  same	
  list	
  of	
  problems	
  articulated	
   in	
  the	
  previous	
  Monitors’	
  Report.	
  It	
  appears	
  that	
  the	
  State	
  has	
  made	
  no	
   progress	
  whatsoever	
  in	
  improving	
  the	
  quality	
  of	
  this	
  essential	
  function.	
   The	
  primary	
  contributor	
  to	
  this	
  problem	
  appears	
  to	
  be	
  the	
  continued	
   practice	
  of	
  distributing	
  the	
  investigations	
  across	
  a	
  large	
  number	
  of	
  staff	
   (16	
  different	
  people	
  completed	
  the	
  17	
  investigations	
  reviewed).	
   Dispersing	
  the	
  responsibility	
  so	
  broadly	
  will	
  inevitably	
  lead	
  to	
   inconsistency,	
  and	
  because	
  each	
  staff	
  person	
  may	
  only	
  do	
  one	
  or	
  two	
   investigations	
  per	
  year,	
  their	
  opportunities	
  to	
  develop	
  the	
  appropriate	
   skill	
  set	
  are	
  very	
  limited.	
  	
   	
   In	
  order	
  to	
  accelerate	
  the	
  State’s	
  progress	
  toward	
  compliance	
  with	
  this	
   provision,	
  the	
  Monitor	
  strongly	
  recommends	
  that	
  the	
  State	
  significantly	
   reduce	
  the	
  number	
  of	
  people	
  who	
  are	
  authorized	
  to	
  conduct	
  an	
  internal	
   investigation	
  and	
  that	
  this	
  responsibility	
  is	
  assigned	
  only	
  to	
  individuals	
   who	
  have	
  demonstrated	
  that	
  they	
  have	
  the	
  requisite	
  skill	
  set.	
  Of	
  great	
   concern	
  is	
  the	
  fact	
  that	
  several	
  investigations	
  were	
  assigned	
  to	
  staff	
  who	
   have	
  not	
  attended	
  the	
  investigators’	
  training.	
  The	
  poor	
  quality	
  of	
  these	
   reports	
  cannot	
  continue.	
  Although	
  the	
  allegations	
  investigated	
  at	
  the	
   facility-­‐level	
  are	
  generally	
  less	
  serious,	
  the	
  nature	
  of	
  the	
  allegations	
  are	
   at	
  the	
  heart	
  of	
  the	
  facility’s	
  staff	
  culture	
  that	
  has	
  been	
  labeled	
  as	
   problematic	
  by	
  past	
  administrations	
  and	
  that	
  was	
  the	
  chief	
  complaint	
   among	
  the	
  youth	
  interviewed	
  during	
  the	
  current	
  monitoring	
  period.	
   Youth	
  often	
  described	
  staff	
  behaving	
  with	
  impunity,	
  boasting	
  that	
   “nothing	
  will	
  happen”	
  if	
  the	
  youth	
  filed	
  a	
  compliant.	
  The	
  lack	
  of	
   accountability	
  brought	
  to	
  bear	
  by	
  the	
  shoddy	
  internal	
  investigation	
   process	
  is	
  a	
  major	
  contributing	
  factor	
  to	
  this	
  problem.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Reduce	
  the	
  number	
  of	
  individuals	
  authorized	
  to	
  conduct	
  facility-­‐

	
  

33.	
  

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Sources	
  of	
   Information	
  
	
   	
  

based	
  investigations	
  and	
  ensure	
  that	
  these	
  individuals	
  have	
  the	
   requisite	
  skills	
  for	
  the	
  task.	
  Ensure	
  that	
  producing	
  timely,	
  high-­‐ quality	
  investigations	
  is	
  a	
  specific	
  job	
  responsibility	
  and	
  that	
   employees	
  are	
  held	
  accountable	
  for	
  their	
  failure	
  to	
  produce	
   reports	
  that	
  meet	
  professional	
  standards.	
  	
  	
   2. Produce	
  high-­‐quality	
  investigations	
  of	
  all	
  allegations	
  of	
   inappropriate	
  conduct	
  by	
  staff.	
  Whether	
  completed	
  by	
  the	
  CIO	
   or	
  by	
  a	
  facility-­‐based	
  investigator,	
  the	
  investigations	
  must	
   reflect	
  timely,	
  comprehensive	
  interviews	
  with	
  all	
  key	
  witnesses	
   and	
  must	
  arrive	
  at	
  reasonable	
  conclusions	
  based	
  on	
  the	
  facts	
  in	
   evidence.	
  Enact	
  accountability	
  measures	
  to	
  address	
  poor	
   performance	
  by	
  staff	
  tasked	
  with	
  the	
  responsibility	
  to	
   investigated	
  allegations	
  of	
  all	
  types.	
  	
  	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.A.5,	
  prepared	
  at	
  my	
  request	
  	
  
• CIO’s	
  2012	
  Q1	
  “AMS	
  Incident	
  Report	
  &	
  Investigation	
  Coaching	
   Review,”	
  July	
  2012	
  
• Log,	
  “Investigation	
  Tracking	
  Log,	
  April	
  through	
  September	
  2012”	
   • Log,	
  “Investigation	
  Tracking	
  Log—PENDING,	
  April	
  through	
  
September	
  2012”	
   • Email	
  communication	
  with	
  J.	
  Fears,	
  CIO,	
  related	
  to	
  CIO	
  cases	
  
pending	
  as	
  of	
  October	
  31,	
  2012	
   • “List	
  of	
  staff	
  currently	
  authorized	
  and	
  trained	
  to	
  conduct	
  facility-­‐
based	
  investigations,”	
  prepared	
  at	
  my	
  request	
   • Review	
  of	
  15	
  CIO	
  investigations	
  completed	
  since	
  April	
  2012	
  
(100%	
  of	
  total)	
   • Review	
  of	
  17	
  investigations	
  conducted	
  by	
  Scioto	
  staff	
  since	
  April	
  
2012	
  (100%	
  of	
  total)	
  
	
  

	
  

34.	
  

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III.D.1	
  Grievances.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
  practices	
  to	
   ensure	
  that	
  the	
  facility	
  has	
  an	
  adequate	
  grievance	
  system	
  including:	
  no	
  formal	
  or	
  informal	
   preconditions	
  to	
  the	
  completion	
  and	
  submission	
  of	
  a	
  grievance;	
  review	
  of	
  grievances	
  by	
  the	
   Chief	
  Inspector;	
  timely	
  initiation	
  and	
  resolution	
  of	
  grievances;	
  appropriate	
  corrective	
  action;	
  and	
   written	
  notification	
  provided	
  to	
  the	
  youth	
  of	
  the	
  final	
  resolution	
  of	
  the	
  grievance.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

At	
  the	
  time	
  of	
  the	
  previous	
  Monitor’s	
  Report,	
  the	
  grievance	
  process	
  at	
   Scioto	
  was	
  experiencing	
  difficulties	
  due	
  to	
  staffing	
  instability	
  and	
  staff	
   performance	
  issues.	
  In	
  May	
  2012,	
  a	
  new	
  Grievance	
  Coordinator	
  was	
   hired,	
  followed	
  by	
  a	
  back-­‐up	
  Coordinator	
  in	
  July	
  2012,	
  and	
  these	
   problems	
  have	
  largely	
  been	
  resolved.	
  	
   	
   The	
  CIO	
  conducts	
  quarterly	
  audits	
  of	
  the	
  grievance	
  process	
  at	
  Scioto.	
  The	
   2012	
  Q1	
  report	
  was	
  published	
  in	
  May	
  2012	
  and	
  details	
  the	
  variety	
  of	
   problems	
  with	
  the	
  grievance	
  process	
  discussed	
  in	
  the	
  previous	
  Monitor’s	
   report.	
  The	
  2012	
  Q2	
  and	
  Q3	
  reports	
  were	
  published	
  in	
  July	
  and	
  October	
   2012,	
  respectively.	
  These	
  reports	
  showed	
  that	
  the	
  number	
  of	
  grievances	
   submitted	
  has	
  been	
  unstable	
  (Q1	
  =	
  105;	
  Q2	
  =	
  201;	
  Q3	
  =	
  74)	
  and	
   accurately	
  notes	
  that	
  there	
  is	
  no	
  “correct”	
  number	
  of	
  grievances.	
  Rather,	
   the	
  underlying	
  causes	
  of	
  trends	
  should	
  be	
  examined	
  to	
  determine	
   whether	
  youth	
  simply	
  have	
  more/fewer	
  complaints	
  or	
  whether	
  they	
   access	
  to	
  or	
  belief	
  in	
  the	
  system	
  has	
  been	
  somehow	
  compromised.	
  	
   	
   Fortunately,	
  the	
  various	
  performance	
  measures	
  improved	
  significantly	
   from	
  those	
  reported	
  in	
  the	
  previous	
  Monitor’s	
  report.	
  With	
  regard	
  to	
   timeliness,	
  compared	
  to	
  Q1	
  when	
  61%	
  were	
  resolved	
  past	
  the	
  14-­‐day	
   timeline	
  permitted	
  by	
  policy,	
  only	
  23%	
  of	
  grievances	
  were	
  overdue	
  in	
  Q2	
   and	
  only	
  3%	
  were	
  overdue	
  in	
  Q3.	
  With	
  regard	
  to	
  the	
  quality	
  of	
   resolution,	
  the	
  proportion	
  of	
  grievances	
  requiring	
  follow-­‐up	
   documentation	
  has	
  decreased	
  steadily	
  from	
  62%	
  (Q1)	
  to	
  49%	
  (Q2)	
  to	
   39%	
  (Q3).	
  The	
  improvements	
  were	
  attributed	
  to	
  the	
  significant	
  support	
   received	
  from	
  the	
  DYS	
  Central	
  Office	
  at	
  the	
  beginning	
  of	
  the	
  monitoring	
   period	
  and	
  the	
  arrival	
  of	
  the	
  new	
  Grievance	
  Coordinator	
  at	
  the	
  end	
  of	
   May	
  2012.	
  	
   	
   The	
  youth’s	
  chief	
  concerns	
  discussed	
  in	
  the	
  2012	
  Q2	
  report	
  included	
   complaints	
  about	
  staff’s	
  decisions	
  (25%	
  of	
  the	
  201	
  grievances	
  submitted),	
   medical	
  care	
  (11%),	
  verbal	
  abuse	
  by	
  staff	
  (8%)	
  and	
  the	
  behavior	
   management	
  system	
  (7%).	
  In	
  Q3,	
  the	
  top	
  complaints	
  were	
  about	
  staff	
   decisions	
  (18%),	
  medical	
  care	
  (11%),	
  food	
  (10%),	
  living	
  conditions	
  (10%)	
   and	
  education	
  (10%).	
  	
  These	
  have	
  remained	
  relatively	
  stable	
  over	
  time.	
  	
  	
   	
   The	
  CIO’s	
  quarterly	
  review	
  process	
  continues	
  to	
  satisfy	
  the	
  Monitor’s	
   requirement	
  for	
  the	
  State	
  to	
  demonstrate	
  an	
  internal	
  ability	
  to	
  identify	
   and	
  address	
  its	
  problems	
  related	
  to	
  grievances.	
  The	
  CIO	
  has	
  recently	
   shifted	
  its	
  monitoring	
  schedule	
  to	
  ensure	
  that	
  reports	
  are	
  issued	
  more	
  

	
  

35.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 36 of 129 PAGEID #: 2389

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

quickly.	
  Scioto	
  will	
  be	
  monitored	
  on	
  a	
  rotating	
  schedule	
  every	
  4	
  months	
   so	
  that	
  the	
  CIO	
  auditors	
  are	
  completing	
  only	
  one	
  audit	
  at	
  a	
  time,	
  rather	
   than	
  trying	
  to	
  complete	
  quarterly	
  audits	
  for	
  all	
  four	
  DYS	
  facilities	
  every	
   quarter.	
  This	
  shift	
  in	
  the	
  monitoring	
  schedule	
  appears	
  to	
  be	
  prudent	
  so	
   that	
  facility	
  staff	
  can	
  become	
  aware	
  of	
  and	
  address	
  any	
  deficiencies	
  more	
   quickly.	
  	
  	
  
In	
  addition	
  to	
  an	
  obvious	
  commitment	
  to	
  addressing	
  youth’s	
  grievances	
   by	
  mobilizing	
  the	
  resources	
  available	
  at	
  the	
  facility,	
  the	
  Grievance	
   Coordinator	
  also	
  has	
  a	
  refreshing	
  commitment	
  to	
  teach	
  youth	
  how	
  to	
   resolve	
  their	
  own	
  problems	
  (e.g.,	
  how	
  to	
  access	
  the	
  sick	
  call	
  mechanism)	
   and	
  to	
  reinforce	
  the	
  skills	
  they	
  learn	
  in	
  group	
  therapy	
  related	
  to	
  asking	
   for	
  assistance	
  and	
  making	
  requests	
  in	
  an	
  appropriate	
  manner.	
  	
   	
   Quality	
  of	
  Resolution	
   As	
  discussed	
  in	
  the	
  previous	
  section,	
  the	
  quality	
  of	
  the	
  resolution	
  has	
   steadily	
  improved.	
  It	
  is	
  important	
  to	
  understand	
  that	
  the	
  “Follow	
  Up	
   Needed”	
  status	
  in	
  AMS	
  is	
  dynamic.	
  When	
  the	
  problems	
  is	
  cured,	
  the	
  AMS	
   status	
  is	
  changed	
  to	
  “Completed,”	
  which	
  means	
  that	
  it	
  is	
  difficult	
  to	
   obtain	
  a	
  running	
  total	
  of	
  the	
  proportion	
  that	
  required	
  additional	
   information	
  in	
  a	
  given	
  time	
  period.	
  However,	
  point-­‐in-­‐time	
  snapshots	
  are	
   useful	
  toward	
  this	
  end.	
  	
   	
   At	
  the	
  Monitor’s	
  request,	
  the	
  State	
  produced	
  a	
  list	
  of	
  the	
  cases	
  needing	
   follow	
  up	
  action	
  as	
  of	
  October	
  11,	
  2012.	
  In	
  contrast	
  to	
  the	
  Q2	
  CIO	
  report	
   where	
  98	
  cases	
  required	
  follow	
  up,	
  only	
  16	
  cases	
  needed	
  additional	
   information	
  in	
  order	
  to	
  be	
  considered	
  “Complete”	
  by	
  the	
  CIO.	
  Of	
  these,	
   50%	
  (8	
  cases)	
  were	
  grievances	
  submitted	
  prior	
  to	
  the	
  current	
  Grievance	
   Coordinator’s	
  tenure	
  at	
  the	
  facility.	
  During	
  an	
  interview	
  with	
  the	
   Monitor,	
  he	
  discussed	
  his	
  on-­‐going	
  efforts	
  to	
  clear	
  the	
  backlog	
  of	
   problems	
  that	
  he	
  inherited	
  when	
  he	
  assumed	
  the	
  position.	
  That	
  he	
  has	
   reduced	
  the	
  number	
  still	
  in	
  need	
  of	
  attention	
  to	
  only	
  8	
  is	
  commendable.	
  	
   	
   As	
  for	
  the	
  other	
  8,	
  all	
  of	
  them	
  were	
  submitted	
  in	
  September	
  2012.	
  The	
   absence	
  of	
  any	
  cases	
  submitted	
  in	
  June,	
  July	
  or	
  August	
  testifies	
  to	
  the	
   Grievance	
  Coordinator’s	
  commitment	
  to	
  address	
  and	
  rectify	
  problems	
   that	
  are	
  identified	
  by	
  the	
  CIO.	
  This	
  is	
  precisely	
  the	
  purpose	
  and	
   anticipated	
  outcome	
  of	
  the	
  CIO	
  review	
  process.	
  Feedback	
  on	
  the	
  8	
  cases	
   from	
  September	
  included	
  reminders	
  to	
  scan	
  documentation	
  into	
  AMS,	
   suggestions	
  to	
  strengthen	
  the	
  quality	
  of	
  the	
  response,	
  and	
  notification	
   about	
  applicable	
  policy	
  (e.g.,	
  if	
  a	
  youth	
  indicates	
  a	
  safety	
  concern,	
  he	
   should	
  have	
  a	
  Safety	
  Plan).	
  The	
  input	
  appears	
  to	
  be	
  the	
  type	
  of	
  on-­‐going	
   coaching	
  required	
  by	
  all	
  new	
  staff.	
  	
  Two	
  other	
  grievances	
  were	
  classified	
   as	
  “Corrective	
  Action	
  Needed,”	
  referring	
  to	
  the	
  Grievance	
  Coordinator’s	
   need	
  for	
  additional	
  instruction	
  around	
  referring	
  incidents	
  for	
   investigation.	
  The	
  Grievance	
  Coordinator	
  does	
  not	
  appear	
  to	
  need	
  an	
   excessive	
  amount	
  of	
  coaching	
  and	
  the	
  types	
  of	
  things	
  for	
  which	
  he	
   receives	
  guidance	
  are	
  reasonable.	
  	
  

	
  

36.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 37 of 129 PAGEID #: 2390

	
   Thus,	
  the	
  new	
  grievance	
  coordinator	
  appears	
  to	
  have	
  resolved	
  all	
  of	
  the	
   issues	
  with	
  timeliness	
  and	
  quality	
  of	
  response	
  that	
  were	
  of	
  concern	
  in	
   the	
  previous	
  Monitor’s	
  Report.	
  	
   	
   Youth	
  Survey	
   	
   As	
  discussed	
  in	
  the	
  previous	
  Monitor’s	
  Report,	
  the	
  CIO’s	
  2011	
  Youth	
   Survey	
  found	
  significant	
  numbers	
  of	
  youth	
  who	
  reported	
  that	
  staff	
  told	
   them	
  that	
  they	
  could	
  not	
  use	
  the	
  grievance	
  process	
  to	
  report	
  staff	
   misconduct	
  (17%),	
  that	
  staff	
  treated	
  them	
  badly	
  after	
  filing	
  a	
  grievance	
   (20%),	
  or	
  that	
  staff	
  told	
  them	
  nothing	
  would	
  happen	
  if	
  they	
  filed	
  a	
   grievance	
  (53%).	
  The	
  CIO	
  required	
  each	
  facility	
  Superintendent	
  to	
   construct	
  a	
  plan	
  to	
  address	
  these	
  concerns.	
  The	
  Scioto	
  plan	
  has	
  not	
  yet	
   been	
  developed.	
  The	
  new	
  Superintendent	
  has	
  been	
  tasked	
  with	
  doing	
  so	
   before	
  the	
  end	
  of	
  the	
  year.	
  The	
  CIO	
  plans	
  to	
  conduct	
  a	
  follow-­‐up	
  Youth	
   Survey	
  at	
  the	
  end	
  of	
  2012.	
  If	
  the	
  Scioto	
  plan	
  is	
  not	
  implemented	
  soon,	
  it	
   is	
  unlikely	
  that	
  the	
  facility	
  will	
  see	
  any	
  improvement	
  in	
  this	
  area.	
  	
   	
   Notification	
  to	
  Youth	
  about	
  the	
  Outcome	
  of	
  Investigations	
   	
   Grievances	
  involving	
  verbal	
  or	
  physical	
  abuse	
  or	
  serious	
  policy	
  violations	
   are	
  usually	
  referred	
  for	
  investigation	
  by	
  the	
  facility	
  or	
  by	
  the	
  CIO.	
   However,	
  if	
  a	
  youth	
  makes	
  an	
  allegation	
  of	
  verbal	
  abuse	
  and	
  the	
  initial	
   contact	
  by	
  the	
  Grievance	
  Coordinator	
  indicates	
  that	
  no	
  witnesses	
  were	
   present,	
  the	
  grievance	
  may	
  be	
  closed	
  without	
  referral.	
  While	
  it	
  is	
  true	
   that	
  an	
  investigation	
  of	
  a	
  verbal	
  exchange	
  with	
  no	
  witnesses	
  is	
  unlikely	
  to	
   be	
  productive,	
  the	
  Monitor	
  recommends	
  that	
  the	
  employee’s	
  supervisor	
   be	
  notified	
  of	
  the	
  allegation,	
  in	
  case	
  a	
  pattern	
  should	
  emerge	
  (e.g.,	
   problems	
  between	
  the	
  same	
  individuals,	
  or	
  allegations	
  containing	
  the	
   same	
  unique	
  language,	
  gestures,	
  etc.)	
   	
   In	
  March	
  2012,	
  the	
  Grievance	
  Policy	
  (#	
  304.03)	
  was	
  revised	
  to	
  include	
   written	
  notification	
  to	
  the	
  youth	
  of	
  the	
  outcome	
  of	
  investigations	
  that	
   were	
  triggered	
  by	
  a	
  youth’s	
  grievance.	
  A	
  letter	
  to	
  the	
  youth	
  from	
  the	
   facility’s	
  Labor	
  Relations	
  Officer	
  (LRO)	
  refers	
  to	
  the	
  investigation	
  number	
   and	
  indicates	
  whether	
  the	
  allegation	
  was	
  substantiated	
  or	
   unsubstantiated.	
  The	
  Investigation	
  Policy	
  (#101.15)	
  and	
  the	
  Youth	
   Handbook	
  were	
  also	
  updated	
  to	
  reflect	
  this	
  change	
  in	
  procedure.	
   	
   During	
  the	
  current	
  monitoring	
  period,	
  a	
  total	
  of	
  11	
  grievances	
  were	
   referred	
  for	
  investigation.	
  Youth’s	
  allegations	
  included	
  not	
  being	
   permitted	
  to	
  use	
  the	
  toilet,	
  staff’s	
  use	
  of	
  threatening	
  language,	
  staff’s	
   teasing	
  the	
  youth,	
  being	
  denied	
  food,	
  and	
  excessive	
  time	
  in	
  restraints.	
   Across	
  the	
  11	
  cases,	
  two	
  investigations	
  are	
  still	
  pending	
  and	
  the	
  location	
   of	
  two	
  youth	
  who	
  were	
  released	
  is	
  still	
  trying	
  to	
  be	
  discerned.	
  Letters	
  to	
   youth	
  notifying	
  them	
  of	
  the	
  outcome	
  of	
  the	
  investigation	
  were	
  presented	
  

	
  

37.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 38 of 129 PAGEID #: 2391

Recommendations	
   Sources	
  of	
   Information	
  
	
   	
  

to	
  the	
  remaining	
  7	
  youth	
  (100%).	
  Youth	
  signed	
  the	
  letters	
  to	
   acknowledge	
  their	
  receipt	
  of	
  the	
  information.	
  Although	
  letters	
  were	
  sent	
   out	
  in	
  every	
  case,	
  many	
  of	
  the	
  cases	
  had	
  a	
  significant	
  delay	
  between	
  the	
   date	
  the	
  investigation	
  was	
  completed	
  and	
  the	
  day	
  the	
  letter	
  was	
  drafted.	
   The	
  number	
  of	
  business	
  days	
  from	
  investigation	
  completion	
  to	
  letter	
   drafting	
  ranged	
  from	
  2	
  to	
  29,	
  with	
  an	
  average	
  of	
  15	
  business	
  days.	
   Perhaps	
  coincidentally,	
  letters	
  were	
  drafted	
  in	
  3	
  of	
  the	
  7	
  cases	
  on	
  the	
  day	
   the	
  Monitor	
  requested	
  the	
  documents.	
  These	
  cases	
  had	
  delays	
  of	
  6,	
  17	
   and	
  21	
  business	
  days.	
  Thus,	
  youth	
  are	
  being	
  notified	
  of	
  the	
  outcome	
  of	
   the	
  investigations,	
  but	
  the	
  notification	
  needs	
  to	
  be	
  far	
  more	
  timely	
  in	
   order	
  to	
  meet	
  the	
  spirit	
  of	
  the	
  requirement	
  and	
  to	
  address	
  youth’s	
   persistent	
  belief	
  that	
  staff	
  are	
  not	
  held	
  accountable	
  for	
  their	
  behavior	
  in	
   any	
  meaningful	
  way.	
  	
  Prompt	
  notification	
  could	
  help	
  to	
  counteract	
  this	
   belief.	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Promptly	
  notify	
  youth	
  of	
  the	
  outcome	
  of	
  any	
  investigation	
   referred	
  via	
  the	
  grievance	
  process.	
  	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.D.1,	
  prepared	
  at	
  my	
  request	
  
• 2012	
  Q2	
  and	
  Q3	
  Grievance	
  Audits	
  completed	
  by	
  the	
  Chief	
   Inspector’s	
  Office	
  
• 2012	
  Q3	
  Grievance	
  data,	
  prepared	
  at	
  the	
  request	
  of	
  the	
  Monitor	
   • Grievance	
  Monthly	
  Reports,	
  April	
  through	
  September	
  2012	
   • AMS	
  Grievance	
  Summary	
  for	
  grievances	
  submitted	
  April	
  through	
  
September	
  2012	
   • List	
  of	
  grievances	
  referred	
  for	
  investigation,	
  April	
  through	
  
September	
  2012	
   • Copies	
  of	
  Youth	
  notification	
  letters	
  for	
  grievances	
  referred	
  for	
  
investigation,	
  April	
  through	
  September	
  2012	
  
	
  

	
  

38.	
  

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III.D.2	
  Grievances	
  Explained	
  to	
  Youth.	
  A	
  clear	
  explanation	
  of	
  the	
  grievance	
  process	
  shall	
  be	
   provided	
  to	
  each	
  youth	
  upon	
  admission	
  to	
  the	
  facilities	
  during	
  orientation	
  and	
  to	
  their	
  parents	
   or	
  guardians,	
  and	
  the	
  youth’s	
  understanding	
  of	
  the	
  process	
  shall	
  be	
  at	
  least	
  verbally	
  verified.	
  	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Orientation	
  process	
  includes	
  two	
  videos—one	
  is	
  a	
  general	
   Orientation	
  video	
  covering	
  several	
  topics	
  including	
  Youth	
  Rights	
  and	
  the	
   purpose	
  of	
  the	
  grievance	
  system.	
  A	
  second	
  video	
  focuses	
  on	
  the	
   grievance	
  process	
  and	
  includes	
  information	
  about	
  what	
  to	
  do	
  if	
  the	
  youth	
   has	
  a	
  problem	
  with	
  living	
  conditions,	
  medical	
  care,	
  staff	
  treatment,	
   education	
  services,	
  etc.	
  The	
  video	
  describes	
  the	
  differing	
  roles	
  of	
  the	
   Grievance	
  Coordinator,	
  the	
  Chief	
  Inspector’s	
  Office,	
  and	
  the	
  Legal	
   Assistance	
  Program	
  attorneys.	
  Finally,	
  youth	
  are	
  provided	
  step-­‐by-­‐step	
   instructions	
  for	
  navigating	
  the	
  grievance	
  system.	
  The	
  information	
  in	
  the	
   video	
  is	
  reinforced	
  by	
  a	
  written	
  Youth	
  Grievance	
  Handbook,	
  which	
  an	
   intake	
  staff	
  member	
  discusses	
  with	
  the	
  youth.	
  Youth	
  are	
  also	
  provided	
   in-­‐depth	
  information	
  about	
  sexual	
  abuse	
  and	
  sexual	
  assault	
  in	
  the	
   correctional	
  setting,	
  and	
  how	
  to	
  handle	
  situations	
  in	
  which	
  they	
  may	
  feel	
   threatened	
  or	
  that	
  the	
  staff	
  is	
  being	
  inappropriate.	
  	
   	
   The	
  CIO	
  is	
  also	
  developing	
  a	
  formal	
  Lesson	
  Plan	
  for	
  each	
  DYS	
  facility’s	
   orientation	
  in	
  order	
  to	
  ensure	
  that	
  consistent,	
  accurate	
  information	
  is	
   delivered	
  to	
  all	
  DYS	
  youth.	
  The	
  Lesson	
  Plans	
  are	
  scheduled	
  to	
  be	
  rolled	
   out	
  in	
  Q4	
  2012.	
  	
   	
   All	
  youth	
  are	
  required	
  to	
  sign	
  several	
  forms	
  indicating	
  that	
  they	
  received	
   and	
  understand	
  information	
  about	
  the	
  grievance	
  process.	
  The	
  facility	
   audits	
  a	
  random	
  sample	
  of	
  admissions	
  files	
  every	
  month	
  to	
  ensure	
   compliance	
  with	
  policy	
  and	
  procedure.	
  Each	
  month,	
  April	
  through	
   September	
  2012,	
  100%	
  of	
  the	
  youth	
  sampled	
  (30	
  total	
  youth;	
  10%	
  of	
  all	
   admissions)	
  received	
  a	
  complete	
  orientation	
  to	
  the	
  facility,	
  which	
   included	
  information	
  on	
  how	
  to	
  access	
  the	
  grievance	
  system.	
  Signed	
   Orientation	
  Acknowledgement	
  Forms	
  were	
  submitted	
  for	
  the	
  Monitor’s	
   verification.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

At	
  the	
  end	
  of	
  the	
  previous	
  monitoring	
  period,	
  the	
  facility’s	
  veteran	
   Grievance	
  Coordinator	
  retired	
  and	
  a	
  new	
  Coordinator	
  had	
  been	
  hired.	
   This	
  staff	
  eventually	
  moved	
  on	
  and	
  the	
  facility	
  had	
  to	
  rely	
  on	
  support	
   from	
  Central	
  Office	
  to	
  keep	
  the	
  grievance	
  process	
  limping	
  along.	
  At	
  the	
   end	
  of	
  May	
  2012,	
  a	
  new	
  Grievance	
  Coordinator	
  was	
  hired.	
  Upon	
  arriving	
   at	
  Scioto,	
  the	
  Grievance	
  Coordinator	
  began	
  attending	
  UM	
  meetings	
  and	
   unit	
  community	
  meetings	
  to	
  explain	
  the	
  grievance	
  process,	
  his	
   expectations	
  for	
  both	
  youth	
  and	
  staff,	
  and	
  to	
  answer	
  questions.	
  The	
   Coordinator	
  makes	
  himself	
  available	
  to	
  all	
  youth	
  and	
  staff	
  to	
  mediate	
   disputes	
  or	
  respond	
  to	
  crises.	
  	
   	
   The	
  Monitor	
  interviewed	
  15	
  youth	
  while	
  on-­‐site.	
  Although	
  all	
  of	
  them	
  

	
  

39.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 40 of 129 PAGEID #: 2393

Recommendations	
   Sources	
  of	
   Information	
  
	
   	
   	
  

understood	
  the	
  grievance	
  process	
  and	
  how	
  to	
  use	
  it,	
  over	
  half	
  of	
  them	
   appeared	
  to	
  lack	
  confidence	
  in	
  the	
  system,	
  believing	
  it	
  was	
  “fixed”	
  or	
   otherwise	
  not	
  capable	
  of	
  addressing	
  their	
  needs.	
  Oddly,	
  approximately	
   half	
  of	
  these	
  same	
  youth	
  had	
  accessed	
  the	
  grievance	
  system	
  and	
   reported	
  that	
  the	
  issue	
  was	
  resolved	
  to	
  their	
  satisfaction.	
  As	
  noted	
  in	
  the	
   previous	
  provision,	
  the	
  facility	
  is	
  required	
  by	
  the	
  CIO	
  to	
  plan	
  an	
  initiative	
   to	
  bolster	
  the	
  standing	
  of	
  the	
  grievance	
  process,	
  which	
  may	
  improve	
  its	
   reputation	
  among	
  the	
  youth.	
  
The	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.D.2,	
  prepared	
  at	
  my	
  request	
  
• Interview	
  with	
  the	
  Grievance	
  Coordinator	
   • Interviews	
  with	
  15	
  youth	
  housed	
  at	
  Scioto	
  on	
  October	
  19,	
  2012	
  
	
  

	
  

40.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 41 of 129 PAGEID #: 2394

III.F.1	
  Structured	
  Programming.	
  The	
  State	
  shall	
  provide	
  adequate	
  structured	
  rehabilitative	
   services,	
  including	
  an	
  appropriate	
  mix	
  of	
  physical,	
  recreational	
  or	
  leisure	
  activities	
  during	
  non-­‐ school	
  hours	
  and	
  days.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  structured	
  programming	
  from	
   the	
  end	
  of	
  the	
  school	
  day	
  until	
  youth	
  go	
  to	
  bed,	
  and	
  on	
  weekends.	
  	
   	
   For	
  youth	
  housed	
  in	
  closed-­‐cell	
  environments,	
  programming	
  shall	
  be	
  designed	
  to	
  ensure	
  that	
   youth	
  are	
  not	
  confined	
  in	
  locked	
  cells	
  except:	
  a)	
  from	
  after	
  programming	
  to	
  wake	
  up;	
  b)	
  as	
   necessary	
  where	
  youth	
  pose	
  an	
  immediate	
  risk	
  of	
  harm	
  to	
  self	
  or	
  others;	
  c)	
  following	
  an	
   adequate	
  disciplinary	
  hearing,	
  pursuant	
  to	
  an	
  appropriate	
  disciplinary	
  sanctions.	
  	
   	
   The	
  programming	
  shall	
  be	
  designed	
  to	
  modify	
  behaviors,	
  provide	
  rehabilitation	
  to	
  the	
  types	
  of	
   youth	
  committed	
  at	
  the	
  facility,	
  address	
  general	
  health	
  and	
  mental	
  health	
  needs,	
  and	
  be	
   coordinated	
  with	
  the	
  youth’s	
  individual	
  behavioral	
  and	
  treatment	
  plans.	
  The	
  State	
  shall	
  use	
   teachers,	
  school	
  administrators,	
  correctional	
  officers,	
  caseworkers,	
  school	
  counselors,	
  cottage	
   staff,	
  and	
  any	
  other	
  qualified	
  assistance	
  to	
  develop	
  and	
  implement	
  structured	
  programming.	
   The	
  State	
  shall	
  provide	
  youth	
  with	
  access	
  to	
  programming	
  activities	
  that	
  are	
  required	
  for	
  parole	
   eligibility.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Structured	
  Programming	
   The	
  facility	
  offers	
  multiple	
  types	
  of	
  programs	
  that	
  can	
  be	
  tracked	
  using	
   multiple	
  databases:	
  
• All	
  youth	
  who	
  have	
  not	
  graduated	
  from	
  High	
  School	
  or	
  obtained	
   a	
  GED	
  are	
  required	
  to	
  attend	
  330	
  minutes	
  of	
  instruction	
  per	
  day.	
   Their	
  attendance	
  is	
  tracked	
  using	
  the	
  Chancery	
  database.	
  
• All	
  youth	
  should	
  receive	
  one-­‐hour	
  of	
  large	
  muscle	
  activity	
   (recreation)	
  per	
  day.	
  The	
  Unit	
  Managers	
  are	
  responsible	
  for	
   ensuring	
  that	
  recreation	
  is	
  delivered	
  each	
  day	
  by	
  the	
  General	
   Activity	
  Therapists	
  (GAT).	
  Disruptions	
  to	
  the	
  recreation	
  schedule	
   should	
  be	
  logged	
  in	
  the	
  Unit	
  Log.	
  	
  
• All	
  youth	
  attend	
  some	
  combination	
  of	
  group	
  and	
  individual	
   therapy,	
  depending	
  upon	
  their	
  needs.	
  The	
  Social	
  Workers	
  and	
   Psychologists,	
  using	
  the	
  CaseNotes	
  database,	
  track	
  youth’s	
   participation	
  in	
  these	
  groups.	
  	
  
• Youth	
  also	
  have	
  the	
  opportunity	
  to	
  attend	
  religious	
  services,	
   programs	
  delivered	
  by	
  volunteers	
  and	
  activities	
  earned	
  through	
   the	
  SBBMS.	
  IRJCF	
  is	
  currently	
  piloting	
  a	
  database	
  to	
  track	
  youth’s	
   participation	
  in	
  these	
  activities	
  and	
  Scioto	
  is	
  planning	
  to	
  adopt	
   this	
  database	
  in	
  the	
  near	
  future.	
  	
   	
  
Strength-­‐Based	
  Behavior	
  Management	
  System	
  (SBBMS)	
   The	
  facility	
  provided	
  an	
  update	
  on	
  the	
  on-­‐going	
  efforts	
  to	
  ensure	
  that	
  the	
   SBBMS	
  is	
  properly	
  implemented.	
  Reportedly,	
  youth	
  continue	
  to	
  receive	
   privileges	
  that	
  they	
  have	
  not	
  earned,	
  which	
  dampens	
  their	
  motivation	
  to	
   conduct	
  themselves	
  in	
  a	
  manner	
  that	
  would	
  allow	
  them	
  to	
  promote	
   phases.	
  UMs	
  continue	
  to	
  coach	
  the	
  YSs	
  assigned	
  to	
  their	
  units,	
  many	
  of	
   whom	
  are	
  new,	
  on	
  how	
  to	
  use	
  the	
  SBBMS	
  effectively.	
  In	
  addition,	
  

	
  

41.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 42 of 129 PAGEID #: 2395

videogames	
  were	
  moved	
  off	
  the	
  unit	
  into	
  a	
  game	
  room	
  to	
  ensure	
  that	
   youth	
  who	
  have	
  not	
  earned	
  the	
  privilege	
  cannot	
  play	
  them	
  without	
   permission.	
  Further,	
  the	
  OM	
  often	
  makes	
  rounds	
  at	
  bedtime	
  to	
  ensure	
   that	
  YSs	
  are	
  not	
  allowing	
  youth	
  to	
  stay	
  up	
  past	
  their	
  prescribed	
  bedtimes.	
   These	
  modifications	
  indicate	
  that	
  the	
  facility	
  administration	
  remains	
   vigilant	
  to	
  the	
  various	
  ways	
  in	
  which	
  the	
  SBBMS	
  can	
  be	
  circumvented	
   and	
  then	
  develops	
  solutions	
  to	
  ensure	
  that	
  the	
  program	
  is	
  implemented	
   with	
  fidelity.	
  	
   	
   Programming	
  for	
  Graduates	
   During	
  the	
  current	
  monitoring	
  period,	
  the	
  facility	
  made	
  significant	
   progress	
  in	
  developing	
  programming	
  for	
  youth	
  who	
  have	
  graduated	
  from	
   high	
  school	
  or	
  obtained	
  their	
  GED.	
  Graduates	
  are	
  now	
  occupied	
   throughout	
  the	
  day	
  in	
  a	
  combination	
  of	
  post-­‐secondary	
  education	
  and	
   employment.	
  	
  
• The	
  primary	
  academic	
  program	
  is	
  delivered	
  by	
  Ashland	
  College,	
   which	
  provides	
  coursework	
  for	
  students	
  in	
  English	
  101,	
  Basic	
   Financial	
  Literacy,	
  Entrepreneurship	
  (Fall)	
  and	
  Problem	
  Solving	
   and	
  Life	
  Skills	
  (Summer).	
  Classes	
  are	
  held	
  twice	
  per	
  week	
  for	
  4.5	
   hours.	
  (Classes	
  were	
  held	
  three	
  times	
  per	
  week	
  during	
  the	
  May-­‐ August	
  grading	
  period).	
  On	
  the	
  “off	
  days,”	
  study	
  hall	
  is	
  held.	
  	
  
• An	
  additional	
  academic	
  program	
  is	
  delivered	
  by	
  Henkles	
  &	
   McCoy.	
  TechBridges/Employability	
  Skills	
  is	
  an	
  intensive	
  one-­‐ week	
  class,	
  held	
  from	
  8a	
  to	
  4:30p	
  each	
  day	
  and	
  offered	
  once	
  per	
   grading	
  period.	
  Youth	
  learn	
  how	
  to	
  disassemble	
  and	
  rebuild	
   computers,	
  and	
  also	
  learn	
  essential	
  employability	
  skills	
  to	
   prepare	
  them	
  for	
  release.	
  Upon	
  release,	
  students	
  are	
  connected	
   to	
  Henkels	
  &	
  McCoy’s	
  community	
  facility	
  where	
  they	
  may	
   continue	
  the	
  academic	
  instruction	
  and	
  also	
  receive	
  assistance	
   with	
  job	
  preparation	
  and	
  interview	
  skills.	
  	
  
• The	
  Youth	
  Work	
  Program	
  was	
  designed	
  to	
  provide	
  jobs	
  for	
   graduates.	
  [Note:	
  non-­‐graduates	
  may	
  still	
  obtain	
  employment	
   through	
  Career	
  Based	
  Intervention.]	
  Graduates	
  must	
  under	
  go	
  an	
   application	
  and	
  interview	
  process	
  and	
  once	
  hired,	
  are	
  paid	
  $0.50	
   per	
  hour.	
  The	
  work	
  supervisor	
  communicates	
  regularly	
  with	
  the	
   youth’s	
  treatment	
  team	
  to	
  ensure	
  that	
  youth	
  are	
  maintaining	
  a	
   high	
  standard	
  of	
  behavior	
  and	
  performance	
  on	
  the	
  job.	
  	
   	
   Available	
  jobs	
  include:	
  cafeteria,	
  storeroom,	
  maintenance,	
   porters	
  for	
  the	
  living	
  units,	
  religious	
  services,	
  program	
  services,	
   school,	
  recreation	
  and	
  cosmetology	
  aides.	
  An	
  academic	
  tutor,	
  to	
   be	
  paid	
  $0.90	
  per	
  hour,	
  will	
  be	
  added	
  in	
  the	
  near	
  future.	
  Hours	
   vary	
  according	
  to	
  the	
  Department’s	
  need	
  and	
  the	
  youth’s	
   availability.	
  Graduates	
  may	
  work	
  up	
  to	
  35	
  hours	
  per	
  week	
  but	
   must	
  also	
  ensure	
  that	
  they	
  attend	
  all	
  required	
  treatment	
   programs.	
  There	
  are	
  enough	
  jobs	
  available	
  to	
  support	
  all	
  youth	
   who	
  desire	
  to	
  have	
  one.	
  	
  

	
  

42.	
  

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Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Structured	
  Programming	
   The	
  previous	
  Monitors’	
  Report	
  discussed	
  the	
  staffing	
  problems	
  that	
   frequently	
  disrupted	
  the	
  delivery	
  of	
  education	
  and	
  other	
  programming.	
   Fortunately,	
  the	
  staffing	
  problems	
  have	
  been	
  largely	
  resolved.	
  While	
  the	
   facility	
  often	
  uses	
  mandated	
  overtime	
  to	
  meet	
  minimum	
  staffing	
  levels,	
   they	
  have	
  been	
  able	
  to	
  ensure	
  sufficient	
  staff	
  are	
  available	
  to	
  deliver	
  all	
   youth	
  programs	
  during	
  the	
  current	
  monitoring	
  period.	
  Interviews	
  with	
   youth	
  indicated	
  that	
  recreation	
  and	
  volunteer	
  programs	
  are	
  delivered	
  as	
   scheduled,	
  even	
  though	
  youth	
  often	
  wished	
  for	
  a	
  different	
  composition	
   to	
  the	
  recreation	
  program	
  (e.g.,	
  wanting	
  to	
  be	
  outside;	
  wanting	
  to	
  be	
  in	
   the	
  gym;	
  more	
  basketball;	
  less	
  basketball).	
  If	
  it	
  does	
  not	
  already	
  do	
  so,	
   the	
  facility	
  should	
  implement	
  a	
  structured	
  way	
  to	
  verify	
  that	
  recreation	
  is	
   delivered	
  each	
  day	
  (e.g.,	
  this	
  could	
  be	
  part	
  of	
  the	
  UM’s	
  weekly	
  report	
   and/or	
  the	
  Superintendent’s	
  Monthly	
  Report).	
  These	
  data	
  should	
  be	
   presented	
  to	
  the	
  Monitor	
  for	
  inclusion	
  in	
  the	
  next	
  Monitors’	
  Report.	
  	
  	
   	
   A	
  review	
  of	
  monthly	
  activity	
  schedules	
  revealed	
  a	
  broad	
  range	
  of	
   volunteer	
  programs	
  available	
  to	
  the	
  general	
  population	
  youth	
  at	
  Scioto.	
   These	
  include	
  religious	
  services	
  (Protestant	
  and	
  Catholic	
  services;	
  bible	
   study;	
  and	
  other	
  programs	
  offering	
  guidance	
  to	
  youth	
  from	
  faith-­‐based	
   organizations),	
  gender-­‐specific	
  services	
  for	
  girls,	
  academic	
  tutoring,	
   sports	
  programs	
  and	
  a	
  variety	
  of	
  creative/art	
  programs.	
  The	
  activity	
   schedules	
  revealed	
  that	
  the	
  programs	
  are	
  slated	
  for	
  delivery	
  to	
  all	
  of	
  the	
   general	
  population	
  units	
  on	
  a	
  rotating	
  basis.	
  Moving	
  forward,	
  the	
  State	
   needs	
  to	
  adopt	
  the	
  database	
  being	
  piloted	
  at	
  IRJCF	
  so	
  that	
  it	
  can	
   demonstrate,	
  to	
  both	
  the	
  Monitor	
  and	
  the	
  Release	
  Authority,	
  that	
  the	
   youth	
  was	
  engaged	
  in	
  a	
  range	
  of	
  structured	
  activities	
  throughout	
  their	
   stay	
  at	
  Scioto.	
  	
   	
   A	
  sample	
  of	
  10	
  youth’s	
  files	
  from	
  the	
  CaseNotes	
  database	
  was	
  requested	
   to	
  ascertain	
  attendance	
  rates	
  for	
  group	
  and	
  individual	
  counseling	
  during	
   the	
  month	
  of	
  September.	
  While	
  more	
  detail	
  will	
  be	
  provided	
  in	
  the	
   Mental	
  Health	
  section	
  of	
  this	
  report,	
  the	
  review	
  of	
  treatment	
   participation	
  was	
  not	
  encouraging:	
  
• Gang	
  Intervention.	
  This	
  was	
  the	
  most	
  reliably	
  delivered	
  group.	
   Three	
  of	
  the	
  youth	
  participated	
  in	
  the	
  9	
  sessions	
  that	
  were	
  held	
   in	
  September.	
  Groups	
  were	
  held	
  between	
  2	
  and	
  4	
  times	
  per	
   week.	
  	
  
• Core	
  A.	
  Even	
  though	
  all	
  youth	
  are	
  supposed	
  to	
  receive	
  this	
   group,	
  only	
  4	
  of	
  the	
  10	
  youth’s	
  participation	
  was	
  documented.	
   Core	
  A	
  groups	
  are	
  held	
  much	
  more	
  dependably	
  on	
  the	
  girls’	
  units	
   (15	
  sessions	
  in	
  September)	
  than	
  the	
  boys’	
  units	
  (2-­‐4	
  sessions	
  in	
   September).	
  	
  
• Core	
  B.	
  None	
  of	
  the	
  8	
  boys	
  received	
  this	
  group.	
  The	
  two	
  girls	
   participated	
  in	
  the	
  group	
  2	
  and	
  4	
  times,	
  respectively,	
  during	
   September.	
  	
  
• Core	
  C.	
  Two	
  of	
  the	
  boys	
  had	
  entries	
  for	
  this	
  group	
  showing	
  

	
  

43.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 44 of 129 PAGEID #: 2397

participation	
  in	
  1	
  and	
  2	
  sessions,	
  respectively,	
  in	
  September.	
  	
   • Healthy	
  Relationships.	
  As	
  discussed	
  in	
  III.A.1,	
  this	
  9-­‐session	
  group	
  
was	
  delivered	
  to	
  the	
  girls	
  between	
  August	
  and	
  October.	
  There	
   were	
  2	
  sessions	
  in	
  September.	
  	
   • Extended	
  Stay.	
  Three	
  of	
  the	
  youth	
  had	
  entries	
  for	
  this	
  group	
   showing	
  participation	
  in	
  1,	
  2	
  and	
  4	
  sessions,	
  respectively,	
  in	
   September.	
   • Substance	
  Abuse.	
  Only	
  one	
  youth	
  participated	
  in	
  this	
  group,	
  and	
   only	
  for	
  one	
  session.	
  Another	
  youth’s	
  notes	
  indicated	
  that	
  he	
   needed	
  these	
  services	
  for	
  parole,	
  but	
  was	
  not	
  yet	
  enrolled.	
  	
   • Individual	
  treatment.	
  All	
  10	
  youth	
  had	
  entries,	
  but	
  the	
  frequency	
   and	
  duration	
  of	
  the	
  sessions	
  varied.	
  Nearly	
  all	
  of	
  the	
  youth	
  had	
   only	
  one	
  or	
  two	
  sessions	
  in	
  September,	
  although	
  one	
  youth	
  had	
   4	
  sessions.	
  Most	
  of	
  the	
  sessions	
  were	
  30	
  minutes	
  in	
  length,	
  or	
   shorter.	
  	
   While	
  the	
  treatment	
  contact	
  standards	
  and	
  the	
  extent	
  to	
  which	
  they	
  are	
   being	
  met	
  will	
  be	
  discussed	
  in	
  detail	
  in	
  the	
  Mental	
  Health	
  section	
  of	
  the	
   report,	
  it	
  appears	
  that	
  this	
  component	
  of	
  the	
  facility’s	
  Programming	
   initiative	
  needs	
  additional	
  oversight	
  to	
  ensure	
  that	
  youth	
  are	
  engaged	
  in	
   the	
  various	
  groups	
  at	
  the	
  expected	
  frequency.	
  	
  	
   	
   Programming	
  for	
  Graduates	
   Work	
  records	
  were	
  reviewed	
  for	
  each	
  of	
  the	
  12	
  graduates	
  currently	
   housed	
  at	
  the	
  facility	
  (18%	
  of	
  the	
  total	
  population).	
  One	
  of	
  the	
  youth	
  was	
   pending	
  transfer	
  to	
  CJCF	
  and	
  did	
  not	
  have	
  a	
  job.	
  Across	
  the	
  other	
  11	
   youth,	
  5	
  were	
  working	
  the	
  café,	
  3	
  were	
  working	
  as	
  porters,	
  1	
  was	
   working	
  in	
  the	
  storeroom,	
  1	
  was	
  working	
  in	
  maintenance,	
  and	
  1	
  was	
   assisting	
  the	
  Chaplain.	
  Work	
  schedules	
  and	
  timesheets	
  verified	
  that	
  the	
   youth	
  had	
  been	
  consistently	
  employed,	
  often	
  for	
  several	
  months.	
  	
   	
   A	
  list	
  of	
  vacant	
  job	
  positions	
  included	
  additional	
  porter	
  positions,	
  school	
   office	
  aide,	
  several	
  maintenance	
  positions	
  and	
  an	
  academic	
  tutor.	
  The	
   facility	
  clearly	
  has	
  the	
  capacity	
  to	
  accommodate	
  more	
  graduates	
  with	
   jobs,	
  if	
  needed.	
  	
   	
   Attendance	
  records	
  indicated	
  that	
  all	
  but	
  two	
  youth	
  were	
  enrolled	
  in	
  at	
   least	
  one	
  of	
  the	
  college	
  courses	
  (most	
  were	
  enrolled	
  in	
  two	
  or	
  three).	
   The	
  two	
  youth	
  who	
  were	
  not	
  enrolled	
  were	
  new	
  to	
  the	
  facility	
  and,	
   because	
  the	
  courses	
  are	
  co-­‐ed,	
  needed	
  to	
  undergo	
  a	
  period	
  of	
   observation	
  to	
  ensure	
  that	
  no	
  security	
  risk	
  would	
  be	
  presented	
  by	
  their	
   attendance.	
  Courses	
  had	
  been	
  ongoing	
  for	
  both	
  the	
  2012	
  Summer	
  and	
   Fall	
  semesters	
  and	
  had	
  sufficient	
  capacity	
  to	
  serve	
  more	
  students,	
  if	
   needed.	
  	
   	
   The	
  facility	
  has	
  sufficient	
  funding	
  for	
  at	
  least	
  one	
  more	
  semester	
  of	
  these	
   programs	
  and	
  is	
  currently	
  seeking	
  continuation	
  funding	
  so	
  that	
  the	
   programs	
  can	
  continue	
  and	
  expand.	
  Interviews	
  with	
  three	
  students	
  in	
  

	
  

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the	
  graduate	
  program	
  suggested	
  tremendous	
  satisfaction	
  with	
  the	
   opportunities	
  now	
  available	
  to	
  them.	
  Students	
  who	
  had	
  been	
  at	
  Scioto	
   for	
  a	
  long	
  period	
  of	
  time	
  kept	
  reminding	
  the	
  new	
  student,	
  “You	
  have	
  no	
   idea	
  how	
  much	
  better	
  things	
  are	
  now!!”	
  The	
  facility’s	
  progress	
  in	
   meeting	
  the	
  needs	
  of	
  Scioto	
  graduates	
  is	
  reflected	
  in	
  the	
  upgrade	
  to	
   Partial	
  Compliance.	
  	
   	
   PROGRESS	
  Unit	
  (PU)	
   	
   The	
  upgrade	
  to	
  partial	
  compliance	
  is	
  credited	
  entirely	
  to	
  the	
   improvements	
  related	
  to	
  graduate	
  programming;	
  unfortunately,	
  no	
   improvements	
  were	
  evident	
  in	
  increasing	
  the	
  quantity	
  of	
  programming	
   available	
  to	
  youth	
  on	
  the	
  Progress	
  Unit	
  (PU).	
  As	
  discussed	
  elsewhere	
  in	
   this	
  report,	
  the	
  facility	
  only	
  attempted	
  to	
  meet	
  the	
  minimum	
   requirements	
  of	
  this	
  provision—for	
  youth	
  in	
  closed-­‐cell	
  environments	
  to	
   be	
  engaged	
  in	
  programming	
  during	
  all	
  waking	
  hours,	
  except	
  when	
  in	
   intervention	
  seclusion—on	
  October	
  15,	
  2012	
  when	
  the	
  24-­‐hour	
  schedule	
   was	
  first	
  implemented.	
  Sufficient	
  time	
  has	
  not	
  yet	
  passed	
  to	
  determine	
   whether	
  the	
  schedule	
  has	
  been	
  implemented	
  with	
  fidelity	
  to	
  its	
  design	
   and	
  whether	
  youth	
  are	
  accessing	
  the	
  range	
  of	
  programs	
  designed	
  to	
   address	
  their	
  violent	
  and	
  aggressive	
  behavior.	
  	
  	
   	
   Unfortunately,	
  throughout	
  the	
  current	
  monitoring	
  period,	
  the	
  PU	
  did	
  not	
   provide	
  youth	
  with	
  dependable	
  access	
  to	
  programming	
  and	
  services.	
   Late	
  in	
  the	
  monitoring	
  period	
  (June	
  2012),	
  the	
  facility	
  began	
  to	
   emphasize	
  with	
  PU	
  staff	
  the	
  need	
  to	
  bring	
  the	
  youth	
  out	
  of	
  their	
  rooms	
   for	
  school,	
  recreation	
  and	
  treatment	
  groups.	
  However,	
  a	
  review	
  of	
  Unit	
   Logs	
  from	
  the	
  end	
  of	
  the	
  monitoring	
  period	
  indicated	
  that	
  this	
  effort	
  was	
   not	
  particularly	
  successful.	
  While	
  the	
  PU	
  was	
  no	
  longer	
  operating	
  as	
  a	
  23-­‐ hour	
  lockdown	
  (as	
  it	
  had	
  during	
  its	
  previous	
  incarnation	
  at	
  another	
   facility	
  and	
  during	
  the	
  early	
  stages	
  of	
  its	
  implementation	
  at	
  Scioto),	
  PU	
   youth	
  still	
  did	
  not	
  have	
  dependable	
  access	
  to	
  essential	
  activities	
  and	
   remained	
  locked	
  in	
  their	
  cells	
  far	
  beyond	
  the	
  hours	
  permitted	
  by	
  this	
   Provision.	
  	
   	
   The	
  Sycamore	
  Unit	
  Log	
  was	
  reviewed	
  for	
  a	
  9-­‐day	
  period	
  at	
  the	
  end	
  of	
   September	
  2012.	
  A	
  random	
  sample	
  of	
  4	
  youth	
  (44%	
  of	
  the	
  Sycamore	
   population)	
  was	
  selected	
  and	
  the	
  number	
  of	
  times	
  each	
  youth	
  was	
   engaged	
  in	
  various	
  activities	
  was	
  tallied.	
  The	
  findings	
  were	
  discouraging:	
  
• Across	
  the	
  9-­‐day	
  period,	
  youth	
  were	
  engaged	
  in	
  recreation/unit	
   leisure	
  time	
  an	
  average	
  of	
  4	
  times	
  (range	
  3	
  to	
  5).	
  Most	
  youth	
  did	
   not	
  receive	
  recreation	
  on	
  the	
  weekdays.	
  All	
  youth	
  should	
  have	
   large	
  muscle	
  activity	
  at	
  least	
  once	
  per	
  day.	
  	
  
• Across	
  the	
  9-­‐day	
  period,	
  youth	
  were	
  engaged	
  in	
  a	
  treatment	
   activity	
  (e.g.,	
  group	
  or	
  individual	
  session)	
  an	
  average	
  of	
  5	
  times	
   (range	
  4	
  to	
  7).	
  This	
  is	
  less	
  than	
  once	
  per	
  day	
  and	
  obviously	
   counter	
  to	
  the	
  idea	
  of	
  intensive	
  programming,	
  which	
  should	
  be	
  

	
  

45.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 46 of 129 PAGEID #: 2399

at	
  the	
  core	
  of	
  a	
  special	
  management	
  unit	
  if	
  behavior	
  change	
  is	
   truly	
  the	
  goal.	
  	
   • Across	
  the	
  9-­‐day	
  period,	
  youth	
  were	
  offered	
  showers	
  an	
  average	
   of	
  7.25	
  times	
  (range	
  5	
  to	
  8).	
  While	
  this	
  may	
  be	
  a	
  documentation	
   problem,	
  it	
  highlights	
  the	
  difficulty	
  the	
  facility	
  has	
  had	
  in	
  offering	
   and/or	
  recording	
  even	
  the	
  most	
  straightforward	
  activities	
  on	
  the	
   PU.	
  	
   • Youth	
  appeared	
  to	
  be	
  attending	
  school	
  consistently	
  on	
  school	
   days,	
  although	
  sometimes	
  it	
  appeared	
  that	
  afternoon	
  sessions	
   were	
  cut	
  short.	
  	
   • Meals	
  were	
  documented	
  consistently,	
  three	
  times	
  per	
  day.	
  	
   Considered	
  another	
  way,	
  most	
  of	
  the	
  youth	
  on	
  this	
  unit	
  attended	
  in	
   school	
  on	
  the	
  weekdays	
  and	
  were	
  involved	
  in	
  a	
  single	
  therapeutic	
  activity	
   after	
  school	
  about	
  half	
  the	
  time,	
  but	
  remained	
  locked	
  in	
  their	
  rooms	
  until	
   the	
  next	
  morning	
  the	
  other	
  half.	
  On	
  weekends,	
  most	
  youth	
  were	
  out	
  of	
   their	
  rooms	
  for	
  only	
  one	
  or	
  two	
  hours	
  each	
  day.	
  	
   	
   A	
  similar	
  review	
  was	
  conducted	
  using	
  the	
  Cedar	
  Unit	
  Logs	
  during	
  a	
  10-­‐ day	
  period	
  in	
  late	
  September	
  2012.	
  A	
  random	
  sample	
  of	
  5	
  youth	
   (approximately	
  36%	
  of	
  the	
  population,	
  which	
  fluctuated	
  during	
  the	
   period	
  reviewed)	
  was	
  selected	
  and	
  their	
  engagement	
  in	
  various	
  activities	
   was	
  tallied.	
  The	
  findings	
  were	
  somewhat	
  better,	
  but	
  still	
  far	
  from	
   sufficient	
  to	
  meet	
  the	
  requirements	
  of	
  this	
  provision:	
  	
   • Across	
  the	
  10-­‐day	
  period,	
  youth	
  were	
  engaged	
  in	
  recreation/unit	
   leisure	
  an	
  average	
  of	
  5	
  times	
  (range	
  0	
  to	
  8).	
  Most	
  youth	
  did	
  not	
   receive	
  recreation	
  on	
  the	
  weekdays.	
  	
   • Youth	
  were	
  engaged	
  in	
  a	
  treatment	
  activity	
  an	
  average	
  of	
  9.4	
   times	
  (range	
  7	
  to	
  11),	
  or	
  about	
  once	
  per	
  day.	
  	
   • Youth	
  were	
  offered	
  the	
  opportunity	
  to	
  shower	
  an	
  average	
  of	
  3	
   times	
  (range	
  2	
  to	
  4).	
  Again,	
  this	
  may	
  be	
  a	
  documentation	
   problem,	
  but	
  highlights	
  the	
  difficulty	
  the	
  facility	
  has	
  had	
  in	
   offering	
  and/or	
  recording	
  even	
  the	
  most	
  straightforward	
   activities	
  on	
  the	
  PU.	
  	
   • Youth	
  attended	
  school	
  for	
  a	
  full	
  day	
  each	
  weekday.	
  The	
  one	
   exception	
  was	
  a	
  youth	
  who	
  was	
  a	
  graduate,	
  who	
  remained	
  in	
  his	
   room	
  throughout	
  the	
  school	
  hours.	
  	
   	
   Note	
  that	
  the	
  time	
  period	
  reviewed	
  was	
  well	
  after	
  DYS	
  enhanced	
  the	
  PU	
   staffing	
  and	
  began	
  to	
  emphasize	
  the	
  need	
  for	
  out-­‐of-­‐cell	
  time.	
  One	
  can	
   assume	
  that	
  services	
  to	
  PU	
  youth	
  were	
  similarly	
  limited	
  during	
  the	
  early	
   part	
  of	
  the	
  monitoring	
  period,	
  before	
  the	
  DYS	
  had	
  even	
  begun	
  to	
  rethink	
   its	
  program	
  implementation	
  strategy.	
  Thus,	
  during	
  the	
  current	
   monitoring	
  period,	
  on	
  the	
  typical	
  weekday,	
  PU	
  youth	
  spent	
   approximately	
  16	
  hours	
  in	
  their	
  rooms.	
  While	
  11	
  of	
  these	
  hours	
  were	
   sleeping	
  hours,	
  the	
  other	
  5	
  were	
  hours	
  during	
  which	
  the	
  State	
  should	
   have	
  been	
  providing	
  access	
  to	
  treatment,	
  recreation	
  and	
  other	
   structured	
  programming	
  designed	
  to	
  rehabilitate	
  youth	
  and	
  facilitate	
  

	
  

46.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 47 of 129 PAGEID #: 2400

Recommendations	
  

their	
  return	
  to	
  the	
  general	
  population.	
  On	
  the	
  weekend,	
  most	
  youth	
   spent	
  about	
  22	
  hours	
  in	
  their	
  rooms,	
  remaining	
  idle	
  and	
  secluded	
  during	
   the	
  approximately	
  11	
  hours	
  that	
  should	
  have	
  been	
  used	
  to	
  deliver	
   programming.	
  	
   	
   Further,	
  the	
  PU	
  has	
  a	
  dearth	
  of	
  programming	
  for	
  youth	
  who	
  have	
   graduated	
  from	
  high	
  school	
  or	
  obtained	
  a	
  GED.	
  For	
  security	
  reasons,	
   none	
  of	
  the	
  programs	
  that	
  have	
  been	
  developed	
  for	
  the	
  general	
   population	
  are	
  available	
  to	
  youth	
  housed	
  on	
  the	
  PU.	
  As	
  a	
  result,	
  while	
   their	
  counterparts	
  are	
  in	
  school,	
  graduates	
  spend	
  most	
  of	
  the	
  weekdays	
   in	
  their	
  rooms.	
  In	
  the	
  past,	
  youth	
  have	
  reported	
  the	
  dearth	
  of	
   programming	
  to	
  be	
  a	
  disincentive	
  to	
  their	
  completing	
  their	
  degree	
   requirements,	
  which	
  is	
  obviously	
  counter	
  to	
  the	
  overall	
  intent	
  of	
  the	
   Stipulation	
  and	
  DYS’	
  own	
  mission.	
  This	
  situation	
  must	
  be	
  rectified	
   immediately.	
  	
   	
   In	
  the	
  original	
  concept,	
  the	
  programming	
  on	
  the	
  PU	
  was	
  supposed	
  to	
  be	
   intensive.	
  However,	
  the	
  vast	
  amount	
  of	
  time	
  that	
  youth	
  on	
  the	
  PU	
  spend	
   in	
  their	
  rooms	
  has	
  interfered	
  with	
  the	
  delivery	
  of	
  services	
  and	
  the	
  PU	
  has	
   not	
  been	
  capable	
  of	
  creating	
  the	
  kind	
  of	
  behavior	
  change	
  needed	
  for	
  the	
   youth	
  housed	
  there	
  to	
  be	
  integrated	
  into	
  the	
  general	
  population.	
  The	
  sad	
   irony	
  is	
  that	
  these	
  youth	
  are	
  the	
  most	
  in	
  need	
  of	
  services,	
  but	
  yet	
  are	
   receiving	
  the	
  least	
  amount	
  of	
  service	
  of	
  any	
  youth	
  at	
  Scioto.	
  This	
   situation	
  must	
  be	
  rectified—youth	
  must	
  be	
  out	
  of	
  their	
  rooms,	
  attending	
   treatment,	
  education	
  or	
  other	
  structured	
  programming	
  throughout	
  the	
   day.	
  The	
  programming	
  must	
  be	
  delivered	
  with	
  integrity	
  so	
  that	
  youth	
   learn	
  to	
  control	
  their	
  aggressive	
  behavior	
  without	
  the	
  imposition	
  of	
  the	
   security	
  features	
  of	
  the	
  PU	
  and	
  are	
  able	
  to	
  return	
  to	
  the	
  general	
   population	
  within	
  a	
  reasonable	
  period	
  of	
  time.	
  	
   	
   Given	
  the	
  long-­‐history	
  of	
  non-­‐compliance	
  with	
  this	
  provision,	
  a	
   significant	
  period	
  of	
  time	
  in	
  which	
  youth	
  are	
  actively	
  engaged	
  in	
   structured	
  programing	
  throughout	
  their	
  waking	
  hours	
  will	
  be	
  needed	
  to	
   demonstrate	
  that	
  the	
  changes	
  are	
  durable	
  and	
  that	
  the	
  State	
  is	
  capable	
   of	
  delivering	
  the	
  24-­‐hour	
  schedule	
  even	
  as	
  the	
  youth	
  characteristics	
  and	
   size	
  of	
  the	
  population	
  changes.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Develop	
  the	
  capacity	
  to	
  track	
  youth’s	
  involvement	
  in	
  volunteer	
   and	
  religious	
  programming	
  and	
  to	
  ensure	
  that	
  recreation	
   programming	
  is	
  delivered	
  at	
  the	
  required	
  frequency.	
  	
  	
  
2. Ensure	
  that	
  individual	
  and	
  group	
  treatment	
  is	
  delivered	
  at	
  the	
   required	
  frequency	
  and	
  duration	
  on	
  all	
  units.	
  	
  
3. Ensure	
  that	
  youth	
  on	
  the	
  PROGRESS	
  Unit	
  are	
  out	
  of	
  their	
  rooms,	
   attending	
  treatment,	
  education	
  or	
  other	
  structured	
   programming	
  throughout	
  the	
  day.	
  Develop	
  quality	
  weekday	
   program	
  for	
  youth	
  who	
  have	
  graduated	
  from	
  high	
  school	
  or	
  

	
  

47.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 48 of 129 PAGEID #: 2401

Sources	
  of	
   Information	
  
	
   	
  

obtained	
  a	
  GED.	
  This	
  programming	
  must	
  be	
  delivered	
  with	
   integrity	
  so	
  that	
  the	
  youth	
  are	
  able	
  to	
  meet	
  their	
  treatment	
  goals	
   and	
  return	
  to	
  the	
  general	
  population	
  within	
  a	
  reasonable	
  period	
   of	
  time.	
  	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.F.1,	
  prepared	
  at	
  my	
  request	
  
• CaseNote	
  records	
  for	
  10	
  randomly	
  selected	
  youth	
  housed	
  at	
   Scioto	
  on	
  October	
  18,	
  2012	
  
• Work	
  schedules,	
  timesheets	
  and	
  job	
  descriptions	
  for	
  all	
  12	
   graduates	
  housed	
  at	
  Scioto	
  as	
  of	
  October	
  15,	
  2012	
  
• Course	
  descriptions	
  and	
  attendance	
  records	
  for	
  all	
  post-­‐ secondary	
  courses	
  for	
  the	
  Summer	
  and	
  Fall	
  semesters	
  2012	
  
• Interviews	
  with	
  15	
  youth	
  housed	
  at	
  Scioto	
  on	
  October	
  19,	
  2012	
   • Draft	
  schedule	
  for	
  the	
  PROGRESS	
  Unit,	
  as	
  of	
  October	
  15,	
  2012	
  
	
  

	
  

48.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 49 of 129 PAGEID #: 2402

	
  
III.F.2	
  Orientation.	
  	
   a) Admissions	
  Intake	
  and	
  Orientation.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  establish	
  a	
  consistent,	
  orderly	
  admissions	
  intake	
  system,	
   conducive	
  to	
  gathering	
  necessary	
  information	
  about	
  youth,	
  disseminating	
  information	
   to	
  staff	
  providing	
  services	
  and	
  care	
  for	
  youth,	
  and	
  maintaining	
  youth	
  safety.	
  The	
   orientation	
  shall	
  also	
  clearly	
  set	
  forth	
  the	
  rules	
  youth	
  must	
  follow	
  at	
  the	
  facility,	
  explain	
   how	
  to	
  access	
  medical	
  and	
  mental	
  health	
  care	
  and	
  the	
  grievance	
  system,	
  and	
  provide	
   other	
  information	
  pertinent	
  to	
  the	
  youth’s	
  participation	
  in	
  facility	
  programs.	
   b) Notice	
  to	
  Youth	
  of	
  Facility	
  Rules	
  and	
  Incentives/Consequences	
  for	
  Compliance.	
  The	
  State	
   shall	
  explain	
  the	
  structured	
  programming	
  to	
  all	
  youth	
  during	
  an	
  orientation	
  session	
  that	
   shall	
  set	
  forth	
  the	
  facility	
  rules,	
  the	
  positive	
  incentives	
  for	
  compliance	
  and	
  good	
  behavior	
   and	
  the	
  sanctions	
  for	
  rule	
  violations.	
  The	
  State	
  shall	
  provide	
  the	
  facility	
  rules	
  in	
  writing.	
  	
  	
   c) Introductory	
  Handbook,	
  Orientation	
  and	
  Reporting	
  Abuse.	
  Each	
  youth	
  entering	
  the	
   facilities	
  shall	
  be	
  given	
  an	
  orientation	
  that	
  shall	
  include	
  simple	
  directions	
  for	
  reporting	
   abuse	
  and	
  assuring	
  youth	
  of	
  his/her	
  right	
  to	
  be	
  protected	
  from	
  retaliation	
  for	
  reporting	
   allegations	
  of	
  abuse.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  continues	
  to	
  audit	
  a	
  random	
  10%	
  sample	
  of	
  admissions	
  files	
   every	
  month	
  to	
  ensure	
  compliance	
  with	
  policy	
  and	
  procedure.	
  Between	
   April	
  2012	
  and	
  September	
  2012,	
  approximately	
  300	
  youth	
  were	
  admitted	
   to	
  the	
  facility;	
  10%,	
  or	
  30	
  youth,	
  were	
  included	
  in	
  the	
  audit.	
  Each	
  month,	
   100%	
  of	
  the	
  youth	
  sampled	
  received	
  a	
  complete	
  orientation	
  to	
  the	
   facility	
  which	
  included,	
  among	
  other	
  things:	
  
• Youth	
  Handbook	
   • Orientation	
  Video	
   • Facility	
  rules	
  and	
  consequences	
  (IRAV)	
   • Strength	
  Based	
  Behavior	
  Management	
  System	
  (SBBMS)	
   • Obtaining	
  legal	
  assistance	
   • Accessing	
  medical	
  and	
  mental	
  health	
  care	
   • Sexual	
  abuse	
  and	
  sexual	
  assault	
  information	
   • Grievance	
  system	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Religious	
  Accommodations	
   	
   The	
  previous	
  Monitor’s	
  report	
  required	
  the	
  State	
  to	
  provide	
  youth	
  with	
   information	
  that	
  clearly	
  described	
  the	
  youth’s	
  rights	
  related	
  to	
  practicing	
   their	
  religion	
  of	
  choice,	
  in	
  particular,	
  how	
  they	
  make	
  seek	
   accommodations	
  for	
  religious	
  beliefs,	
  practices	
  or	
  observance.	
  The	
  State	
   revised	
  the	
  handbook	
  by	
  inserting	
  the	
  following	
  language:	
   	
   Every	
  youth	
  has	
  the	
  right	
  to	
  practice	
  their	
  religion.	
  You	
  are	
  permitted	
  to	
   have	
  the	
  resources	
  of	
  your	
  faith	
  as	
  long	
  as	
  it	
  does	
  not	
  affect	
  the	
  safety	
  of	
   the	
  facility.	
  	
   	
   The	
  revised	
  Handbook	
  was	
  put	
  into	
  use	
  on	
  January	
  12,	
  2012.	
  Department	
  

	
  

49.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 50 of 129 PAGEID #: 2403

heads	
  and	
  supervisors	
  provided	
  information	
  to	
  their	
  staff	
  on	
  the	
   requirement	
  to	
  accommodate	
  youth’s	
  religious	
  beliefs.	
  As	
  of	
  March	
  15,	
   2012,	
  87%	
  of	
  all	
  staff	
  had	
  been	
  trained	
  and	
  completed	
  a	
  post-­‐test	
  about	
   the	
  facility’s	
  religious	
  accommodations	
  policy.	
   	
   During	
  the	
  current	
  monitoring	
  period,	
  three	
  grievances	
  were	
  submitted	
   by	
  youth	
  who	
  wanted	
  the	
  freedom	
  to	
  practice	
  their	
  religion	
  of	
  choice.	
  	
  
• A	
  youth	
  requested	
  a	
  copy	
  of	
  the	
  Holy	
  Quran,	
  and	
  was	
  dissatisfied	
   that	
  he’d	
  received	
  the	
  Glorious	
  Quran	
  (the	
  two	
  versions	
  have	
  the	
   same	
  content,	
  but	
  different	
  covers,	
  per	
  an	
  area	
  Islamic	
   bookstore).	
  The	
  youth	
  was	
  provided	
  with	
  this	
  information,	
   accepted	
  the	
  Glorious	
  Quran	
  and	
  was	
  also	
  permitted	
  to	
  receive	
  a	
   copy	
  of	
  the	
  Holy	
  Quran	
  from	
  his	
  parents	
  if	
  he	
  preferred.	
  
• A	
  youth	
  requested	
  permission	
  to	
  grow	
  his	
  hair	
  into	
  dreadlocks	
  in	
   order	
  to	
  practice	
  his	
  faith,	
  Rastafarianism.	
  An	
  application	
  for	
   religious	
  hair	
  accommodation	
  was	
  submitted	
  on	
  his	
  behalf	
  and	
   an	
  appointment	
  with	
  the	
  cosmetologist	
  was	
  scheduled	
  so	
  that	
  he	
   could	
  learn	
  the	
  proper	
  techniques	
  to	
  care	
  for	
  his	
  hairstyle.	
  	
  
• A	
  youth	
  indicated	
  that	
  he	
  is	
  Muslim	
  and	
  therefore	
  should	
  be	
   exempt	
  from	
  facility	
  policies	
  that	
  require	
  him	
  to	
  shave.	
  The	
   Chaplain	
  consulted	
  with	
  the	
  youth,	
  who	
  retracted	
  his	
  request,	
   indicating	
  that	
  “Islam	
  is	
  too	
  confusing	
  to	
  follow.”	
  	
  
	
  	
   The	
  revised	
  Youth	
  Handbook	
  clearly	
  articulates	
  that	
  youth	
  are	
  free	
  to	
   practice	
  their	
  religion	
  of	
  choice	
  and	
  the	
  facility	
  has	
  demonstrated	
  its	
   willingness	
  to	
  make	
  religious	
  accommodations	
  when	
  the	
  issue	
  has	
  arisen.	
  	
   	
   PROGRESS	
  Unit	
  Orientation	
   While	
  most	
  of	
  the	
  youth	
  at	
  Scioto	
  undergo	
  an	
  orientation	
  to	
  the	
  general	
   population,	
  youth	
  can	
  also	
  be	
  admitted	
  directly	
  to	
  the	
  PROGRESS	
  Unit	
   (PU),	
  and	
  thus	
  the	
  orientation	
  for	
  that	
  program	
  is	
  relevant	
  to	
  this	
   provision.	
  Draft	
  SOP	
  303.01.07	
  “Progress	
  Unit”	
  requires	
  the	
  Unit	
   Manager	
  to	
  ensure	
  that	
  the	
  PU	
  Youth	
  Handbook	
  is	
  available	
  to	
  all	
  youth	
   and	
  that	
  a	
  staff	
  member	
  provides	
  a	
  thorough	
  orientation	
  to	
  youth	
  upon	
   their	
  admission	
  to	
  the	
  Unit.	
  Youth	
  must	
  sign	
  the	
  Handbook’s	
  signature	
   page	
  to	
  acknowledge	
  receipt	
  of	
  the	
  information.	
  	
   	
   The	
  PU	
  Handbook	
  remains	
  in	
  draft	
  form,	
  along	
  with	
  the	
  SOP.	
  Given	
  the	
   recent	
  modifications	
  to	
  the	
  PU	
  program	
  (discussed	
  in	
  III.A.3	
  and	
  III.F.1,	
   above),	
  the	
  draft	
  Handbook	
  will	
  need	
  to	
  be	
  revised	
  from	
  its	
  current	
   incarnation,	
  and	
  finalized	
  along	
  with	
  the	
  SOP,	
  in	
  order	
  for	
  the	
  State	
  to	
   reach	
  substantial	
  compliance	
  with	
  this	
  provision.	
  [The	
  PU	
  has	
  never	
  been	
   governed	
  by	
  a	
  formal	
  policy—it	
  has	
  only	
  ever	
  existed	
  in	
  draft	
  form.	
  Once	
   initially	
  signed	
  into	
  effect,	
  subsequent	
  modifications	
  to	
  the	
  SOP	
  or	
  the	
   Handbook	
  to	
  keep	
  pace	
  with	
  the	
  program’s	
  evolution	
  will	
  not	
  cause	
  the	
   State	
  to	
  fall	
  out	
  of	
  substantial	
  compliance.]	
   	
  

	
  

50.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 51 of 129 PAGEID #: 2404

Recommendations	
  
Sources	
  of	
   Information	
  
	
   	
   	
  

To	
  assess	
  the	
  extent	
  to	
  which	
  youth	
  admitted	
  to	
  the	
  PU	
  received	
  an	
   orientation	
  (even	
  if	
  it	
  is	
  not	
  yet	
  required	
  by	
  policy),	
  Orientation	
   Acknowledgement	
  Forms	
  were	
  requested	
  and	
  reviewed	
  for	
  the	
  17	
  youth	
   admitted	
  during	
  the	
  monitoring	
  period,	
  April	
  through	
  September	
  2012.	
   Signed	
  orientation	
  sheets	
  were	
  available	
  for	
  all	
  of	
  17	
  youth.	
  At	
  times,	
  the	
   dates	
  on	
  the	
  sheets	
  curiously	
  pre-­‐dated	
  the	
  youth’s	
  transfer	
  to	
  the	
  unit.	
   Additional	
  investigation	
  revealed	
  that	
  the	
  youth’s	
  transition	
  dates	
  were	
   not	
  entered	
  immediately	
  upon	
  their	
  placement.	
  While	
  this	
  problem	
  does	
   not	
  affect	
  compliance	
  with	
  this	
  provision,	
  it	
  should	
  be	
  rectified	
  given	
  that	
   the	
  length	
  of	
  stay	
  on	
  the	
  PU	
  is	
  a	
  topic	
  of	
  much	
  concern	
  and	
  it	
  is	
   important	
  for	
  admission	
  dates	
  to	
  be	
  correct.	
  	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Finalize	
  the	
  PU	
  Youth	
  Handbook	
  and	
  SOP	
  so	
  that	
  they	
  provide	
  an	
   accurate	
  description	
  of	
  the	
  current	
  operation	
  of	
  the	
  PROGRESS	
   unit.	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.F.2,	
  prepared	
  at	
  my	
  request	
  
• Intake	
  Audit	
  Report,	
  April	
  2012	
  through	
  September	
  2012	
   • Scioto	
  Youth	
  Handbook,	
  last	
  modified	
  March	
  16,	
  2012	
   • Grievances	
  related	
  to	
  religious	
  accommodation	
  (n=3),	
  submitted	
  
between	
  April	
  and	
  September	
  2012	
   • Admission	
  dates	
  and	
  orientation	
  records	
  for	
  youth	
  admitted	
  to	
  
the	
  PROGRESS	
  Unit	
  since	
  April	
  1,	
  2012	
  	
  
	
  

	
  

51.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 52 of 129 PAGEID #: 2405

MENTAL	
  HEALTH	
  SERVICES	
  
	
   	
  
III.B.	
  1	
  Mental	
  Health	
  Screening.	
  	
  The	
  State	
  shall	
  implement	
  policies,	
  procedures	
  and	
  practices	
  to	
   ensure	
  that	
  all	
  youth	
  admitted	
  to	
  the	
  facilities	
  are	
  comprehensively	
  screened	
  for	
  mental	
   disorders,	
  including	
  substance	
  abuse,	
  depression,	
  and	
  serious	
  mental	
  illness,	
  within	
  twenty-­‐four	
   hours	
  of	
  admission.	
  This	
  screening	
  shall	
  be	
  performed	
  by	
  qualified	
  personnel,	
  as	
  part	
  of	
  the	
   intake	
  process,	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

Per	
  the	
  SJCF	
  oral	
  self-­‐assessment,	
  policy	
  and	
  procedure	
  regarding	
  this	
   process	
  remains	
  pending.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  a	
  review	
  of	
  ten	
  intake	
  packets	
  provided	
  for	
  off	
  site	
  review	
  revealed	
   that	
  all	
  youth	
  admitted	
  had	
  Reception	
  Screening	
  for	
  Assaultive	
   Behavior,	
  Sexually	
  Aggressive	
  Behavior,	
  and	
  Risk	
  for	
  Sexual	
  Victimization	
   on	
  the	
  day	
  of	
  admission.	
  	
  Substance	
  Abuse	
  Screening	
  was	
  included	
  via	
   documents,	
  such	
  as	
  the	
  Juvenile	
  Automated	
  Substance	
  Evaluation.	
  It	
   was	
  notable	
  that	
  every	
  assessment	
  example	
  provided	
  recommended	
   further	
  assessment	
  by	
  psychology	
  staff	
  to	
  complete	
  a	
  Behavioral	
  Health	
   Appraisal.	
  	
  The	
  intake	
  packets	
  initially	
  provided	
  for	
  review	
  did	
  not	
   include	
  documentation	
  of	
  the	
  immediate	
  screening	
  by	
  nursing	
  staff,	
  nor	
   did	
  they	
  include	
  MAYSI-­‐2	
  results.	
  	
  Following	
  submission	
  of	
  the	
  draft	
   report,	
  nursing	
  screening	
  and	
  MAYSI	
  results	
  were	
  provided	
  for	
  review.	
  	
   These	
  were	
  completed	
  appropriately	
  with	
  the	
  exception	
  of	
  the	
  date	
  on	
   the	
  MAYSI	
  screen.	
  	
  Each	
  document	
  had	
  a	
  sticker	
  with	
  the	
  youth’s	
  name	
   and	
  date	
  of	
  admission;	
  however,	
  the	
  space	
  on	
  the	
  MAYSI	
  form	
  where	
   the	
  date	
  was	
  to	
  be	
  entered	
  was	
  blank	
  in	
  five	
  out	
  of	
  ten	
  examples.	
  	
  	
  Per	
   discussions,	
  it	
  was	
  determined	
  that	
  the	
  MAYSI	
  is	
  performed	
  on	
  the	
  date	
   of	
  admission;	
  however,	
  as	
  discussed	
  with	
  ODYS	
  administrative	
  staff,	
  it	
  is	
   necessary	
  for	
  the	
  date	
  blank	
  to	
  be	
  completed	
  by	
  the	
  individual	
   administering	
  the	
  MAYSI	
  and	
  any	
  other	
  assessment	
  documents.	
  	
  This	
  is	
   an	
  issue	
  that	
  should	
  be	
  followed	
  via	
  ongoing	
  QA.	
   	
   Per	
  interviews	
  performed	
  during	
  the	
  previous	
  monitoring	
  visit,	
  it	
  was	
   apparent	
  that	
  current	
  policy	
  and	
  procedure	
  regarding	
  this	
  process	
  was	
   confusing,	
  mostly	
  related	
  to	
  the	
  multiple	
  assessment	
  documents	
  and	
   terminology	
  utilized.	
  	
  In	
  an	
  effort	
  to	
  address	
  this	
  issue,	
  and	
  to	
  simplify	
  all	
   Behavioral	
  Health	
  policies,	
  ODYS	
  promoted	
  a	
  review	
  and	
  revision	
  of	
  all	
   policies	
  with	
  the	
  involvement	
  of	
  central	
  office	
  leadership,	
  facility	
   administration,	
  and	
  facility	
  behavioral	
  health	
  staff.	
  	
  Individuals	
  were	
   assigned	
  to	
  work	
  groups	
  with	
  responsibility	
  to	
  review	
  and	
  revise	
  policy	
   as	
  part	
  of	
  an	
  integrated	
  behavioral	
  health	
  system	
  of	
  care.	
  	
  The	
  final	
   policy	
  was	
  pending;	
  however,	
  per	
  discussions	
  with	
  behavioral	
  health	
   administrative	
  staff,	
  policies	
  and	
  procedures	
  have	
  been	
  completed,	
  and	
   are	
  in	
  the	
  final	
  stages	
  of	
  review	
  with	
  full	
  implementation	
  planned	
  for	
   the	
  first	
  quarter	
  of	
  2013.	
  	
  	
  

	
  

52.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 53 of 129 PAGEID #: 2406

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
   	
  

	
   Please	
   note	
   that	
   throughout	
   the	
   mental	
   health	
   report,	
   there	
   are	
   multiple	
  references	
  regarding	
  the	
  need	
  to	
  finalize	
  policy	
  and	
  procedure.	
  	
   While	
   policy	
   and	
   procedure	
   is	
   in	
   existence	
   and	
   has	
   been	
   implemented	
   to	
  address	
  processes	
  associated	
  with	
  the	
  delivery	
  of	
  mental	
  health	
  care,	
   ODYS	
   is	
   currently	
   in	
   the	
   final	
   process	
   of	
   a	
   review	
   and	
   simplification	
   of	
   said	
   policy.	
   	
   As	
   such,	
   the	
   recommendation	
   for	
   finalizing	
   policy	
   is	
   in	
   reference	
   to	
   the	
   revision	
   and	
   simplification	
   process.	
   	
   There	
   are	
   existing	
   policies	
   in	
   place	
   that	
   are	
   fully	
   implemented	
   and	
   as	
   such	
   the	
   individual	
   provisions	
  below	
  would	
  meet	
  the	
  criteria	
  for	
  a	
  partial	
  compliance	
  rating.	
  	
   The	
   plan	
   to	
   simplify	
   policy	
   and	
   via	
   this	
   process	
   integrate	
   the	
   various	
   mental	
   health	
   disciplines	
   into	
   a	
   behavioral	
   health	
   team	
   is	
   positive	
   and	
   may	
  result	
  in	
  more	
  cohesive	
  mental	
  health	
  treatment	
  for	
  the	
  youth.	
   	
   While	
  it	
  is	
  apparent	
  that	
  multiple	
  assessment	
  instruments	
  are	
  utilized	
   for	
  youth	
  admitted	
  to	
  ODYS,	
  this	
  remains	
  a	
  complicated	
  process,	
   highlighting	
  the	
  need	
  for	
  policy	
  and	
  procedure	
  revision	
  and	
  quality	
   assurance	
  monitoring.	
  	
  
In	
  order	
  to	
  maintain	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
   State	
  must:	
   1. Fully	
  implement	
  policy	
  and	
  procedure	
  “Behavioral	
  Health	
  
Assessment,	
  Screening,	
  Appraisal	
  and	
  Evaluation.”	
  	
  Given	
  the	
   change	
  in	
  facility	
  mission,	
  review	
  and	
  revise	
  this	
  policy	
  as	
  necessary.	
   2. Begin	
  quality	
  assurance	
  monitoring	
  or	
  clinical	
  supervision	
  regarding	
   the	
  reception	
  assessment	
  summary	
  documents.	
   3. Begin	
  quality	
  assurance	
  monitoring	
  to	
  ensure	
  that	
  timelines	
   required	
  by	
  policy	
  and	
  procedure	
  are	
  adhered	
  to.	
  
• Review	
  of	
  provided	
  documents	
  	
   • Staff	
  interview	
  
	
  

	
  

53.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 54 of 129 PAGEID #: 2407

III.B.2	
  	
  Immediate	
  Referral.	
  If	
  the	
  mental	
  health	
  screen	
  identifies	
  an	
  issue	
  that	
  places	
  the	
  youth’s	
   safety	
  at	
  immediate	
  risk,	
  the	
  youth	
  shall	
  be	
  immediately	
  referred	
  to	
  a	
  qualified	
  mental	
  health	
   professional	
  for	
  assessment,	
  treatment	
  and	
  any	
  other	
  appropriate	
  action,	
  such	
  as	
  transfer	
  to	
   another,	
  more	
  appropriate	
  setting.	
  The	
  State	
  shall	
  ensure	
  that,	
  absent	
  extraordinary	
   circumstances,	
  qualified	
  mental	
  health	
  professionals	
  are	
  available	
  for	
  consultation	
  within	
  12	
   hours	
  of	
  such	
  referrals.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

Per	
  the	
  oral	
  facility	
  self-­‐assessment,	
  facility	
  mental	
  health	
  staff	
  were	
   using	
  central	
  office	
  as	
  a	
  “safety	
  net”	
  in	
  order	
  to	
  effect	
  transfers	
  to	
  other	
   programs	
  if	
  necessary.	
  	
  There	
  were	
  examples	
  provided	
  of	
  youth	
   transferred	
  to	
  other	
  facilities	
  to	
  access	
  programs.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

This	
  was	
  an	
  area	
  of	
  ongoing	
  improvement	
  in	
  the	
  intervening	
  period	
   since	
  the	
  previous	
  monitoring	
  review.	
  	
  Discussions	
  with	
  behavioral	
   health	
  staff	
  revealed	
  that	
  they	
  felt	
  empowered	
  to	
  advocate	
  for	
  the	
   youth	
  in	
  the	
  facility	
  without	
  fear	
  of	
  reprisal.	
  	
  There	
  were	
  examples	
  of	
   active	
  advocacy	
  noted.	
  	
  For	
  example,	
  previously,	
  if	
  a	
  youth	
  were	
   suspected	
  of	
  acute	
  mental	
  health	
  needs	
  requiring	
  transfer	
  to	
  the	
  mental	
   health	
  unit,	
  there	
  was	
  a	
  cumbersome	
  process	
  to	
  arrange	
  this	
  transfer.	
  	
   With	
  recent	
  shifts	
  in	
  process	
  and	
  administration,	
  this	
  is	
  now	
  reportedly	
  a	
   relatively	
  painless	
  process.	
  	
  	
   	
   For	
  example,	
  in	
  April	
  2012,	
  Youth	
  #404	
  was	
  assessed	
  on	
  intake	
  at	
  SJCF	
   and	
  noted	
  to	
  be	
  experiencing	
  symptoms	
  of	
  psychosis.	
  	
  He	
  was	
   immediately	
  referred	
  for	
  transfer	
  to	
  the	
  mental	
  health	
  unit.	
  	
  	
  In	
  May	
   2012,	
  Youth	
  #505	
  was	
  assessed	
  on	
  intake	
  at	
  SJCF	
  and	
  noted	
  to	
  have	
  a	
   developmental	
  disability.	
  	
  He	
  was	
  immediately	
  referred	
  for	
  transfer	
  to	
   the	
  life	
  skills	
  unit.	
  	
  In	
  September,	
  two	
  additional	
  youth	
  were	
  identified	
  at	
   intake	
  at	
  SJCF	
  as	
  having	
  developmental	
  disabilities	
  and	
  referred	
  to	
  the	
   life	
  skills	
  unit.	
  	
  In	
  September	
  2012,	
  Youth	
  #606	
  experienced	
  an	
   exacerbation	
  of	
  mental	
  health	
  symptoms	
  and	
  was	
  transferred	
  to	
  a	
   behavioral	
  health	
  facility	
  for	
  acute	
  care.	
  	
   	
   Given	
  the	
  review	
  of	
  the	
  current	
  behavioral	
  health	
  staff	
  schedule,	
  staff	
   are	
  working	
  a	
  flex	
  schedule	
  with	
  one	
  required	
  evening	
  per	
  week	
  and	
   one	
  required	
  weekend	
  per	
  month.	
  	
  This	
  allows	
  for	
  broad	
  behavioral	
   health	
  coverage.	
  	
  One	
  weakness	
  of	
  the	
  schedule	
  was	
  the	
  lack	
  of	
   behavioral	
  health	
  staff	
  scheduled	
  on	
  holidays.	
  	
  There	
  was	
  an	
  on-­‐call	
   schedule,	
  and	
  the	
  Psychology	
  Supervisor	
  was	
  responsible	
  for	
  this,	
   specifically	
  after	
  hours	
  telephone	
  contact.	
  	
  The	
  Psychology	
  supervisor	
   was	
  also	
  reportedly	
  available	
  to	
  come	
  to	
  the	
  facility	
  for	
  face-­‐to-­‐face	
   assessments	
  if	
  the	
  need	
  arose.	
   	
   Given	
  the	
  review	
  of	
  documents	
  performed	
  for	
  this	
  and	
  other	
   paragraphs,	
  it	
  was	
  apparent	
  that	
  there	
  was	
  an	
  improvement	
  in	
  referral	
   to	
  a	
  mental	
  health	
  provider,	
  response	
  from	
  mental	
  health	
  providers,	
   and	
  access	
  to	
  other	
  mental	
  health	
  treatment	
  programs	
  as	
  needed.	
  	
  As	
  

	
  

54.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 55 of 129 PAGEID #: 2408

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
   	
  

such,	
  this	
  provision	
  will	
  be	
  placed	
  in	
  Substantial	
  Compliance.	
  	
  In	
  order	
  to	
   maintain	
  this	
  level,	
  ongoing	
  efforts	
  must	
  be	
  made	
  to	
  ensure	
  that	
  youth	
   obtain	
  the	
  level	
  of	
  care	
  that	
  is	
  necessary.	
  	
  In	
  addition,	
  quality	
  assurance	
   monitoring	
  will	
  be	
  necessary	
  with	
  regard	
  to	
  timely	
  response	
  to	
  referral	
   and	
  access	
  to	
  other	
  behavioral	
  health	
  care	
  options.	
  
In	
  order	
  to	
  maintain	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
   State	
  must:	
   1. Collect	
  data	
  regarding	
  the	
  time	
  lapse	
  between	
  referral	
  and	
  actual	
  
evaluation	
  or	
  assessment	
  for	
  quality	
  assurance	
  monitoring.	
   2. Ensure	
  that	
  staff	
  are	
  aware	
  of	
  the	
  process	
  by	
  which	
  a	
  youth	
  may	
  
access	
  other	
  appropriate	
  mental	
  health	
  services	
  (e.g.	
  a	
  facility	
  based	
   mental	
  health	
  unit	
  or	
  an	
  inpatient	
  psychiatric	
  facility).	
  
• Review	
  of	
  provided	
  documents	
  	
   • Observation	
   • Staff	
  interview	
  
	
  

	
  

55.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 56 of 129 PAGEID #: 2409

III.B.3	
  	
  	
  Identification	
  of	
  Previously	
  Unidentified	
  Youth.	
  The	
  facilities	
  shall	
  implement	
  policies,	
   procedures	
  and	
  practices	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care	
  to	
   identify	
  and	
  address	
  potential	
  manifestations	
  of	
  mental	
  or	
  behavioral	
  disorder	
  in	
  youth	
  who	
   have	
  not	
  been	
  previously	
  identified	
  as	
  presenting	
  mental	
  health	
  or	
  behavioral	
  needs	
  requiring	
   treatment.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Per	
  the	
  facility	
  oral	
  self-­‐assessment,	
  the	
  majority	
  of	
  youth	
  assigned	
  to	
   the	
  Progress	
  Unit	
  (18	
  out	
  of	
  20)	
  were	
  on	
  the	
  mental	
  health	
  caseload.	
  	
   There	
  were	
  a	
  total	
  of	
  ten	
  female	
  youth,	
  with	
  all	
  of	
  them	
  on	
  the	
  mental	
   health	
  caseload.	
  	
  The	
  total	
  facility	
  population	
  at	
  the	
  time	
  of	
  the	
   monitoring	
  visit	
  was	
  72.	
  	
  The	
  mental	
  health	
  roster	
  indicated	
  that	
  there	
   were	
  a	
  total	
  of	
  50	
  youth	
  (70%)	
  assigned	
  to	
  the	
  mental	
  health	
  caseload.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

With	
  regard	
  to	
  the	
  identification	
  of	
  youth	
  previously	
  unidentified	
  as	
   having	
  mental	
  health	
  challenges,	
  the	
  facility	
  has	
  made	
  changes	
  to	
  the	
   facility	
  environment	
  in	
  an	
  effort	
  to	
  ensure	
  that	
  all	
  youth	
  requiring	
   services	
  are	
  identified	
  as	
  such.	
  	
  For	
  example,	
  there	
  are	
  behavioral	
  health	
   staff	
  (both	
  psychology	
  and	
  social	
  workers)	
  housed	
  on	
  the	
  units.	
  	
  There	
   was	
  also	
  enhanced	
  mental	
  health	
  presence	
  on	
  the	
  Progress	
  Units.	
  	
  	
   	
   A	
  full	
  time	
  mental	
  health	
  nurse	
  began	
  providing	
  services	
  at	
  the	
  facility	
   approximately	
  one	
  month	
  prior	
  to	
  the	
  end	
  of	
  the	
  monitoring	
  period.	
  	
  He	
   has	
  been	
  assigned	
  to	
  the	
  Progress	
  Unit	
  and	
  performs	
  rounds	
  every	
   weekday.	
  	
  Also,	
  a	
  psychiatrist	
  has	
  been	
  assigned	
  to	
  the	
  Progress	
  Unit,	
   beginning	
  work	
  there	
  approximately	
  two	
  weeks	
  prior	
  to	
  the	
  end	
  of	
  this	
   monitoring	
  period.	
   	
   In	
  addition,	
  facility	
  staff	
  were	
  performing	
  daily	
  mini	
  mental	
  status	
   reviews	
  for	
  youth	
  housed	
  on	
  Phase	
  One	
  of	
  the	
  Progress	
  Units.	
  	
  These	
   reviews	
  serve	
  several	
  purposes,	
  to	
  monitor	
  youth	
  housed	
  in	
  this	
  area	
  for	
   decompensation,	
  to	
  identify	
  youth	
  requiring	
  mental	
  health	
  intervention,	
   and	
  to	
  ensure	
  access	
  to	
  health	
  care	
  for	
  those	
  youth	
  housed	
  on	
  that	
  unit.	
  	
   It	
  should	
  be	
  noted	
  that	
  late	
  in	
  the	
  monitoring	
  period,	
  youth	
  were	
   allowed	
  out	
  of	
  their	
  cells	
  on	
  a	
  daily	
  basis	
  for	
  increasing	
  amounts	
  of	
  time,	
   which	
  is	
  positive.	
  	
  As	
  this	
  progresses,	
  and	
  youth	
  are	
  out	
  of	
  their	
  cells	
  for	
   the	
  majority	
  of	
  their	
  waking	
  hours,	
  the	
  need	
  for	
  daily	
  mini	
  mental	
  status	
   reviews	
  will	
  be	
  reduced.	
  	
  	
   	
   Administrative	
  behavioral	
  health	
  staff	
  instituted	
  a	
  comprehensive	
   screening	
  process	
  for	
  those	
  youth	
  proposed	
  for	
  placement	
  on	
  the	
   Progress	
  Unit.	
  	
  This	
  process	
  began	
  during	
  the	
  summer	
  of	
  2012;	
  however,	
   became	
  more	
  extensive	
  during	
  the	
  late	
  fall.	
  	
  It	
  is	
  noted	
  that	
  this	
  process	
   has	
  improved	
  overall	
  since	
  October	
  2012;	
  however,	
  needs	
  additional	
   time	
  for	
  assessment	
  prior	
  to	
  achieving	
  Substantial	
  Compliance.	
   	
   A	
  review	
  of	
  the	
  total	
  number	
  of	
  youth	
  currently	
  on	
  the	
  mental	
  health	
   caseload	
  revealed	
  that	
  10/10	
  female	
  youth	
  (100%)	
  were	
  identified.	
  	
  

	
  

56.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 57 of 129 PAGEID #: 2410

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
  

With	
  regard	
  to	
  male	
  youth	
  40/61	
  (65%)	
  were	
  identified.	
  	
  Additionally,	
   via	
  a	
  review	
  of	
  the	
  caseloads	
  of	
  psychology	
  staff	
  assigned	
  to	
  the	
   Progress	
  Units,	
  it	
  was	
  apparent	
  that	
  90%	
  of	
  the	
  youth	
  currently	
  housed	
   on	
  those	
  units	
  were	
  identified	
  and	
  currently	
  receiving	
  mental	
  health	
   services.	
  Additional	
  information	
  received	
  via	
  the	
  document	
  request	
   revealed	
  that	
  in	
  the	
  intervening	
  period	
  since	
  the	
  previous	
  monitoring	
   review,	
  “there	
  have	
  been	
  no	
  youth	
  initially	
  assigned	
  to	
  the	
  general	
   population	
  who	
  were	
  then	
  identified	
  as	
  requiring	
  mental	
  health	
   services.”	
   	
   As	
  discussed	
  in	
  the	
  ensuing	
  provisions	
  there	
  are	
  several	
  examples	
  of	
   assessment	
  and	
  diagnostic	
  issues	
  which	
  are	
  concerning.	
  	
  More	
  prevalent	
   was	
  potential	
  minimization	
  of	
  mental	
  health	
  issues	
  and	
  their	
   contribution	
  to	
  challenging	
  behavior.	
   	
   The	
  goal	
  of	
  this	
  provision	
  was	
  to	
  ensure	
  that	
  youth	
  who	
  may	
  not	
   present	
  with	
  a	
  history	
  of	
  mental	
  illness	
  and	
  who	
  are	
  not	
  identified	
  at	
  the	
   time	
  of	
  initial	
  assessment	
  as	
  being	
  at	
  risk	
  for	
  mental	
  illness	
  or	
  behavioral	
   challenges,	
  are	
  monitored	
  over	
  the	
  course	
  of	
  their	
  incarceration	
  for	
   exacerbations	
  of	
  symptoms	
  and	
  referred	
  for	
  mental	
  health	
  treatment.	
   Administrative	
  staff	
  were	
  aware	
  of	
  the	
  need	
  for	
  ongoing	
  and	
  improved	
   quality	
  assurance	
  to	
  review	
  documentation	
  and	
  the	
  decision	
  making	
   process	
  regarding	
  youth	
  mental	
  health	
  needs.	
  	
  As	
  discussed	
  in	
  provision	
   4	
  below,	
  multiple	
  assessment	
  documents	
  were	
  being	
  generated,	
   however,	
  there	
  was	
  wide	
  variability	
  with	
  regard	
  to	
  case	
  formulations	
   reviewed	
  in	
  the	
  documents	
  that	
  tied	
  all	
  the	
  information	
  obtained	
   together	
  in	
  a	
  coherent	
  package	
  for	
  the	
  reader.	
  	
  This	
  was	
  an	
  area	
  that	
   would	
  be	
  amenable	
  to	
  quality	
  assurance,	
  peer	
  review	
  process	
  and	
   clinical	
  supervision.	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Quality	
  assurance	
  monitoring	
  regarding	
  re-­‐evaluation	
  of	
  youth	
  who	
  
experience	
  an	
  exacerbation	
  of	
  mental	
  health	
  symptoms	
  or	
   behavioral	
  challenges.	
   2. Ensure	
  the	
  creation	
  of	
  a	
  case	
  conceptualization	
  for	
  each	
  youth.	
   3. Ensure	
  that	
  direct	
  care	
  staff	
  and	
  behavioral	
  health	
  staff	
  are	
  trained	
   to	
  recognize	
  and	
  respond	
  to	
  signs	
  and	
  symptoms	
  of	
  serious	
  mental	
   illness.	
   4. Maintain	
  the	
  practice	
  of	
  the	
  comprehensive	
  screening	
  of	
  all	
  youth	
   proposed	
  for	
  placement	
  on	
  the	
  Progress	
  Units.	
  
• Review	
  of	
  provided	
  documents	
  (e.g.	
  Policy	
  and	
  Procedure,	
  
draft	
  Policy	
  and	
  Procedure,	
  youth	
  records).	
  
• Staff	
  interview	
  
	
  

	
  

57.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 58 of 129 PAGEID #: 2411

III.B.4	
  	
  Mental	
  Health	
  Assessment.	
  The	
  State	
  shall	
  implement	
  policies,	
  procedures	
  and	
  practices	
   to	
  ensure	
  that,	
  as	
  part	
  of	
  an	
  overall	
  assessment	
  of	
  the	
  youth’s	
  health,	
  risks,	
  strengths	
  and	
  needs,	
   youth	
  who	
  are	
  identified	
  in	
  screening	
  as	
  having	
  possible	
  mental	
  health	
  needs	
  receive	
  timely,	
   comprehensive	
  and	
  accurate	
  assessments	
  by	
  qualified	
  mental	
  health	
  professionals,	
  consistent	
   with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  Assessments	
  shall	
  be	
  designed	
  and	
   implemented	
  so	
  as	
  to	
  identify	
  youth	
  with	
  mental	
  disorders	
  in	
  need	
  of	
  specific	
  treatment	
  and	
   contribute	
  to	
  a	
  full	
  plan	
  for	
  managing	
  the	
  youth’s	
  risk.	
  Assessments	
  shall	
  be	
  updated	
  as	
   additional	
  diagnostic	
  and	
  treatment	
  information	
  becomes	
  available.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Per	
  the	
  oral	
  facility	
  self	
  assessment,	
  staff	
  participated	
  in	
  a	
  training	
   regarding	
  case	
  formulation.	
  	
  ODYS	
  central	
  office	
  staff	
  has	
  engaged	
  in	
   review	
  of	
  some	
  of	
  these	
  documents.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  previous	
  monitoring	
  report,	
  policy	
  and	
  procedure	
  entitled	
   “Behavioral	
  Health	
  Assessment,	
  Screening,	
  Appraisal	
  and	
  Evaluation”	
   was	
  in	
  the	
  process	
  of	
  review	
  and	
  revision.	
  This	
  was	
  necessary	
  not	
  only	
   due	
  to	
  omissions	
  in	
  the	
  previously	
  authored	
  documents,	
  but	
  due	
  to	
  the	
   change	
  in	
  mission	
  incurred	
  at	
  SJCF.	
  	
  This	
  policy,	
  along	
  with	
  others	
   regarding	
  Behavioral	
  Health	
  services	
  have	
  been	
  reviewed	
  and	
  revised	
  in	
   a	
  collaborative	
  manner	
  between	
  ODYS	
  administration	
  and	
  facility	
   behavioral	
  health	
  staff.	
  	
  The	
  policies	
  were	
  submitted	
  to	
  the	
  monitors	
  for	
   review	
  and	
  comment.	
  	
  The	
  final	
  drafts	
  of	
  these	
  documents	
  was	
  pending	
   at	
  the	
  time	
  of	
  this	
  monitoring	
  review.	
   	
   A	
  necessary	
  part	
  of	
  any	
  mental	
  health	
  assessment	
  is	
  the	
  case	
   conceptualization	
  or	
  diagnostic	
  formulation.	
  	
  This	
  information	
  is	
   intended	
  to	
  review	
  specific	
  symptoms	
  experienced	
  by	
  the	
  youth	
  in	
  order	
   to	
  justify	
  a	
  specific	
  diagnosis.	
  	
  In	
  addition,	
  the	
  diagnostic	
  formulation	
  or	
   case	
  conceptualization	
  must	
  integrate	
  relevant	
  factors	
  impacting	
  a	
   youth’s	
  development/behavior/mental	
  status,	
  including	
  biological,	
   psychological,	
  social,	
  and	
  cultural	
  perspectives	
  that	
  can	
  be	
  utilized	
  by	
   the	
  clinician	
  to	
  identify	
  specific	
  risk	
  factors	
  or	
  targets	
  for	
  ongoing	
   behavioral	
  and	
  mental	
  health	
  therapies.	
  	
  From	
  this	
  information,	
  an	
   individualized	
  and	
  integrated	
  treatment	
  plan	
  could	
  be	
  derived.	
  	
   	
   Nine	
  examples	
  of	
  case	
  formulations	
  were	
  provided.	
  The	
  quality	
  of	
  these	
   documents	
  as	
  well	
  as	
  the	
  psychological	
  services	
  summary	
  was	
  variable	
   and	
  would	
  benefit	
  from	
  quality	
  assurance	
  monitoring.	
  For	
  example,	
  the	
   case	
  formulation	
  regarding	
  Youth	
  #303	
  dated	
  9.23.12	
  was	
  reviewed.	
  	
   This	
  formulation	
  provided	
  a	
  great	
  deal	
  of	
  information	
  with	
  regard	
  to	
  this	
   youth’s	
  legal	
  history	
  and	
  family	
  history.	
  	
  There	
  was	
  also	
  information	
   regarding	
  his	
  progress	
  during	
  his	
  stay	
  at	
  the	
  facility.	
  	
  The	
  document	
   indicated	
  this	
  youth	
  spent	
  nine	
  months	
  on	
  the	
  Progress	
  Units,	
  and	
  that	
   he	
  had	
  received	
  multiple	
  intervention	
  hearings	
  accruing	
  295	
  additional	
   days.	
  	
  There	
  was	
  mention	
  of	
  a	
  cannabis	
  abuse	
  diagnosis	
  at	
  the	
  time	
  of	
   admission	
  on	
  6.23.11;	
  however,	
  as	
  of	
  the	
  date	
  of	
  this	
  case	
  formulation,	
   he	
  was	
  not	
  scheduled	
  into	
  this	
  treatment	
  modality,	
  and	
  it	
  was	
  planned	
  

	
  

58.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 59 of 129 PAGEID #: 2412

Recommendations	
  
Sources	
  of	
   Information	
   	
  

for	
  this	
  to	
  occur	
  following	
  his	
  release	
  from	
  the	
  facility.	
  	
  As	
  substance	
   abuse	
  is	
  a	
  serious	
  risk	
  factor	
  for	
  recidivism,	
  it	
  was	
  not	
  acceptable	
  that	
   this	
  youth’s	
  need	
  in	
  this	
  risk	
  area	
  was	
  not	
  addressed	
  during	
  his	
  lengthy	
   stay	
  at	
  the	
  facility.	
   	
   This	
  youth	
  was	
  additionally	
  diagnosed	
  with	
  mood	
  disorder,	
  not	
   otherwise	
  specified	
  and	
  conduct	
  disorder.	
  	
  The	
  case	
  formulation	
  did	
  not	
   review	
  specific	
  symptoms	
  that	
  this	
  youth	
  was	
  experiencing.	
  	
  There	
  was	
   notation	
  that	
  this	
  youth	
  was	
  prescribed	
  mood	
  stabilizing	
  medication,	
   leading	
  the	
  reader	
  to	
  question	
  if	
  this	
  youth	
  would	
  meet	
  criteria	
  for	
  a	
   diagnosis	
  in	
  the	
  bipolar	
  spectrum.	
  	
  This,	
  along	
  with	
  his	
  history	
  of	
   behavioral	
  challenges	
  raises	
  concerns	
  that	
  a	
  misdiagnoses	
  and	
  possible	
   under	
  treatment	
  of	
  his	
  mental	
  health	
  disorder	
  served	
  to	
  exacerbate	
   unrecognized	
  mental	
  health	
  symptoms	
  prolonging	
  his	
  incarceration.	
  	
  	
   This	
  case	
  formulation	
  was	
  variable	
  with	
  regard	
  to	
  quality;	
  it	
  evidenced	
   good	
  information,	
  but	
  did	
  not	
  tie	
  this	
  information	
  together	
  such	
  that	
  it	
   could	
  be	
  utilized	
  for	
  treatment	
  planning.	
   	
   As	
  indicated	
  in	
  the	
  previous	
  monitoring	
  report,	
  despite	
  the	
  generation	
   of	
  multiple	
  assessment	
  forms,	
  there	
  was	
  the	
  need	
  for	
  a	
  document	
  to	
  tie	
   all	
  the	
  information	
  obtained	
  together	
  in	
  a	
  coherent	
  package	
  for	
  the	
   reader,	
  treatment	
  team,	
  or	
  future	
  treatment	
  provider	
  inclusive	
  of	
  a	
   diagnostic	
  formulation	
  or	
  case	
  conceptualization.	
  	
  The	
  current	
   documentation	
  was	
  an	
  attempt	
  to	
  improve	
  upon	
  that	
  process,	
  but	
  there	
   is	
  work	
  to	
  be	
  done	
  from	
  a	
  quality	
  perspective.	
  	
  It	
  is	
  hoped	
  that	
  ongoing	
   training	
  inclusive	
  of	
  peer	
  review	
  and	
  quality	
  assurance	
  monitoring	
   regarding	
  this	
  process	
  will	
  be	
  beneficial	
  for	
  staff.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Continue	
  and	
  expand	
  quality	
  assurance	
  measures	
  including	
  a	
  peer	
  
review	
  process	
  and	
  clinical	
  supervision	
  to	
  ensure	
  the	
  development	
   of	
  a	
  case	
  conceptualization	
  that	
  ties	
  together	
  information	
  gleaned	
  in	
   the	
  assessment	
  process.	
   2. Consider	
  individual	
  clinical	
  supervision	
  and	
  training	
  regarding	
  the	
   assessment	
  process	
  and	
  development	
  of	
  the	
  case	
  formulation.	
   3. Ensure	
  that	
  behavioral	
  health	
  staff	
  are	
  aware	
  of	
  the	
  necessary	
   components	
  of	
  a	
  quality	
  case	
  formulation.	
   4. Begin	
  quality	
  assurance	
  monitoring	
  of	
  case	
  formulations	
  and	
   resultant	
  ITP	
  documents.	
   5. Review	
  and	
  revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  the	
  requirements	
   of	
  this	
  provision	
  and	
  the	
  new	
  facility	
  mission.	
  
• Review	
  of	
  policy	
  and	
  procedure	
   • Review	
  of	
  youth	
  records	
   • Review	
  of	
  other	
  provided	
  documents	
   • Staff	
  interview	
  
	
  

	
  

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III.B.5	
  	
  	
  Adequate	
  Mental	
  Health	
  Care	
  and	
  Treatment.	
  	
  The	
  State	
  shall	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  ensure	
  that	
  adequate	
  mental	
  health	
  and	
  substance	
  abuse	
  care	
  and	
   treatment	
  services	
  (including	
  timely	
  emergency	
  services),	
  and	
  adequate	
  rehabilitative	
  services	
   are	
  provided	
  to	
  youth	
  in	
  the	
  facilities	
  by	
  qualified	
  mental	
  health	
  professionals	
  consistent	
  with	
   generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Per	
  the	
  oral	
  facility	
  self-­‐assessment,	
  they	
  have	
  engaged	
  in	
  modeling	
  and	
   coaching	
  for	
  youth	
  specialists	
  responsible	
  for	
  group	
  therapies.	
  	
  Evidence	
   of	
  these	
  trainings	
  was	
  not	
  provided	
  for	
  review.	
  	
  Staff	
  also	
  indicated	
   increased	
  mental	
  health	
  contact	
  hours	
  for	
  youth	
  housed	
  on	
  the	
  Progress	
   Units.	
  	
  They	
  reported	
  16.5	
  hours	
  average	
  per	
  month	
  for	
  the	
  four	
  months	
   prior	
  to	
  the	
  monitoring	
  visit.	
  	
  Actual	
  data	
  were	
  not	
  provided	
  for	
  review.	
   	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

In	
  reviewing	
  the	
  Freedom	
  New	
  Phoenix	
  Cognitive	
  Behavioral	
  Health	
   program	
  curriculum,	
  the	
  inclusion	
  of	
  direct	
  care	
  staff	
  is	
  vital	
  to	
  the	
   success	
  of	
  the	
  program.	
  Per	
  the	
  observation	
  conducted	
  during	
  this	
   monitoring	
  period,	
  documents	
  provided	
  and	
  the	
  self-­‐assessment,	
  it	
  was	
   reported	
  that	
  youth	
  specialists	
  are	
  being	
  integrated	
  into	
  treatment	
  team	
   meetings	
  to	
  further	
  involve	
  them	
  in	
  group	
  process	
  and	
  gather	
   information	
  regarding	
  their	
  observations	
  of	
  youth	
  (see	
  the	
  discussion	
   below	
  regarding	
  III.B.7	
  for	
  additional	
  information).	
  	
   	
   Youth	
  specialists	
  facilitate	
  CBT	
  groups	
  on	
  the	
  units.	
  Unfortunately,	
  due	
   to	
  time	
  constraints	
  during	
  this	
  monitoring	
  visit,	
  it	
  was	
  not	
  possible	
  to	
   observe	
  a	
  youth	
  specialist	
  facilitated	
  group.	
  	
  Historically,	
  there	
  has	
  been	
   variability	
  in	
  the	
  ability	
  of	
  staff	
  and	
  additional	
  training,	
  coaching,	
   modeling	
  was	
  required.	
  	
  Historically,	
  basic	
  tenets	
  of	
  effective	
  group	
   facilitation	
  were	
  not	
  utilized	
  consistently,	
  these	
  included	
  environment,	
   review	
  of	
  group	
  rules,	
  direction	
  of	
  group	
  topic,	
  and	
  engagement	
  of	
  the	
   youth.	
  Per	
  the	
  administrative	
  staff	
  interviews,	
  additional	
  training	
  via	
   modeling	
  and	
  coaching	
  was	
  provided.	
  	
  Quality	
  assurance	
  measures	
   inclusive	
  of	
  treatment	
  integrity	
  checks	
  with	
  resultant	
  corrective	
  action	
   were	
  reportedly	
  not	
  occurring.	
  Following	
  these	
  reviews,	
  the	
  training	
   provided	
  to	
  youth	
  specialists	
  with	
  regard	
  to	
  group	
  facilitation	
  may	
  need	
   to	
  be	
  reviewed	
  and	
  revised	
  in	
  order	
  to	
  ensure	
  that	
  principles	
  are	
  being	
   appropriately	
  addressed.	
  	
   	
   With	
  regard	
  to	
  group	
  therapeutic	
  interaction	
  facilitated	
  by	
  behavioral	
   health	
  staff,	
  two	
  group	
  therapy	
  sessions	
  were	
  observed	
  on	
  the	
  Progress	
   Units.	
  	
  The	
  first	
  group	
  was	
  led	
  by	
  a	
  social	
  worker,	
  and	
  included	
  a	
  total	
  of	
   five	
  youth.	
  	
  The	
  focus	
  of	
  the	
  group	
  was	
  aggression	
  and	
  violence.	
  	
  The	
   social	
  worker	
  made	
  good	
  attempts	
  to	
  engage	
  the	
  youth,	
  ultimately	
   engaging	
  all,	
  even	
  a	
  youth	
  who	
  was	
  initially	
  disruptive	
  to	
  the	
  group	
   process.	
  	
  The	
  youth	
  appeared	
  to	
  enjoy	
  the	
  group	
  interaction,	
  which	
  was	
   enhanced	
  by	
  the	
  social	
  worker	
  asking	
  them	
  questions	
  and	
  encouraging	
  

	
  

60.	
  

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all	
  to	
  participate.	
  The	
  social	
  worker	
  took	
  the	
  youth’s	
  lead,	
  and	
   integrated	
  cognitive	
  behavioral	
  techniques	
  into	
  the	
  discussion.	
  	
  This	
  was	
   a	
  good	
  group	
  therapy	
  example.	
   	
   The	
  second	
  group	
  therapy	
  observed	
  was	
  a	
  trauma	
  group	
  facilitated	
  by	
   psychology	
  staff.	
  	
  Four	
  youth	
  participated.	
  This	
  group	
  started	
  twenty	
   minutes	
  late.	
  	
  The	
  group	
  began	
  with	
  a	
  review	
  of	
  the	
  youth’s	
  “distress	
   thermometer”	
  where	
  youth	
  were	
  asked	
  to	
  rate	
  their	
  level	
  of	
  current	
   distress	
  on	
  a	
  scale	
  of	
  1	
  to	
  10	
  with	
  ten	
  being	
  extreme.	
  	
  One	
  youth	
  rated	
   himself	
  a	
  10,	
  and	
  the	
  group	
  leader	
  did	
  not	
  ask	
  any	
  further	
  questions	
  or	
   engage	
  this	
  youth.	
  	
  The	
  distress	
  thermometer	
  was	
  not	
  discussed	
  further,	
   and	
  therefore	
  the	
  purpose	
  of	
  this	
  activity	
  was	
  not	
  clear.	
  	
  Ultimately,	
  two	
   senior	
  mental	
  health	
  staff	
  sitting	
  in	
  as	
  observers	
  to	
  the	
  group	
  began	
  to	
   interject	
  in	
  an	
  effort	
  to	
  make	
  the	
  group	
  personal	
  and	
  meaningful	
  to	
  the	
   youth.	
  	
  Prior	
  to	
  their	
  intervention	
  the	
  group	
  was	
  superficial	
  and	
  cursory	
   with	
  little	
  useful	
  or	
  meaningful	
  information	
  provided.	
  	
  At	
  the	
  completion	
   of	
  the	
  group,	
  the	
  facilitator	
  again	
  reviewed	
  the	
  “distress	
  thermometer”	
   and	
  again	
  took	
  little	
  note	
  of	
  the	
  youth	
  who	
  again	
  rated	
  himself	
  as	
  a	
  10.	
  	
   Senior	
  mental	
  health	
  staff	
  encouraged	
  the	
  facilitator	
  to	
  follow	
  up	
  with	
   this	
  youth	
  following	
  the	
  group.	
  	
  This	
  was	
  an	
  example	
  of	
  a	
  poorly	
  run	
   group,	
  where	
  youth	
  were	
  not	
  engaged,	
  and	
  there	
  was	
  little	
  evidence	
  of	
   a	
  therapeutic	
  group	
  process.	
  	
  This	
  group	
  functioned	
  less	
  as	
  an	
   interaction	
  between	
  staff	
  and	
  youth	
  and	
  more	
  like	
  a	
  lecture	
  or	
   education	
  regarding	
  specific	
  concepts.	
  	
  There	
  were	
  multiple	
   opportunities	
  for	
  the	
  facilitator	
  to	
  explore	
  specific	
  topics	
  with	
  the	
  youth;	
   however,	
  these	
  were	
  not	
  utilized.	
   	
   The	
  first	
  group	
  observation	
  revealed	
  that	
  there	
  are	
  skilled	
  group	
  therapy	
   providers	
  who	
  could	
  provide	
  role	
  modeling	
  to	
  other	
  less	
  experienced	
   clinical	
  staff.	
  	
  Additionally,	
  they	
  could	
  assist	
  with	
  the	
  development	
  of	
   activities	
  to	
  enhance	
  the	
  youth’s	
  participation	
  in	
  the	
  group	
  therapeutic	
   process.	
  	
  All	
  of	
  the	
  above	
  indicate	
  the	
  need	
  for	
  quality	
  assurance	
   monitoring	
  inclusive	
  of	
  observation	
  and	
  coaching	
  for	
  both	
  behavioral	
   health	
  and	
  youth	
  specialist	
  staff.	
   	
   With	
  regard	
  to	
  the	
  number	
  of	
  scheduled	
  groups	
  and	
  the	
  number	
  of	
   youth	
  participating	
  in	
  any	
  one	
  group	
  therapy	
  encounter,	
  this	
  was	
   discussed	
  in	
  detail	
  in	
  the	
  discussion	
  regarding	
  paragraph	
  III.B.11	
  below.	
  	
   There	
  was	
  documentation	
  of	
  attendance	
  at	
  groups	
  that	
  exceed	
   recommendations	
  for	
  conducting	
  a	
  meaningful	
  group	
  interaction.	
  	
  It	
  was	
   recognized	
  that	
  this	
  was	
  occurring	
  less	
  frequently	
  than	
  in	
  previous	
   monitoring	
  reviews.	
   	
   Concerns	
  remain	
  with	
  regard	
  to	
  appropriate	
  diagnostic	
  assessment,	
  case	
   formulation,	
  and	
  treatment	
  plan	
  development.	
  	
  For	
  example,	
  a	
  review	
   of	
  the	
  mental	
  health	
  roster	
  revealed	
  that	
  out	
  of	
  a	
  total	
  of	
  40	
  youth,	
   there	
  were	
  15	
  youth	
  with	
  diagnoses	
  documented	
  as	
  “not	
  otherwise	
  

	
  

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Recommendations	
  

specified.”	
  	
  This	
  was	
  concerning	
  and	
  may	
  indicate	
  the	
  need	
  for	
   refinement	
  in	
  the	
  diagnostic	
  process.	
  	
  In	
  fact,	
  Youth	
  #222	
  and	
  Youth	
   #202	
  each	
  had	
  three	
  “not	
  otherwise	
  specified”	
  diagnoses.	
  	
  These	
  are	
   non-­‐specific	
  diagnoses	
  and	
  may	
  represent	
  a	
  cursory	
  diagnostic	
  process	
   or	
  lack	
  of	
  an	
  appropriate	
  case	
  formulation	
  for	
  diagnostic	
  purposes.	
  	
  This	
   is	
  another	
  area	
  where	
  systematic	
  quality	
  assurance	
  monitoring	
  would	
   be	
  beneficial.	
   	
   Review	
  of	
  progress	
  notes	
  regarding	
  both	
  group	
  process	
  and	
  individual	
   treatment	
  was	
  limited	
  during	
  this	
  monitoring	
  visit,	
  as	
  youth	
  records	
   were	
  not	
  provided	
  for	
  off	
  site	
  review.	
  	
  Rather,	
  there	
  were	
  isolated	
   examples	
  of	
  youth	
  individual	
  therapy	
  progress	
  notes	
  provided	
  as	
   examples	
  for	
  other	
  items.	
  	
  In	
  review	
  of	
  these	
  documents,	
  there	
  was	
   variability	
  in	
  the	
  quality	
  of	
  the	
  documentation,	
  the	
  duration	
  of	
  the	
   therapeutic	
  interactions	
  and	
  the	
  frequency	
  of	
  the	
  therapeutic	
   interactions.	
  	
  Some	
  mental	
  health	
  providers	
  were	
  noted	
  to	
  meet	
   frequently	
  with	
  youth	
  for	
  brief	
  periods	
  of	
  time	
  (15	
  minutes	
  to	
  30	
   minutes),	
  where	
  others	
  met	
  less	
  frequently	
  for	
  longer	
  periods	
  (45	
   minutes).	
  	
  A	
  review	
  of	
  treatment	
  planning	
  documents	
  did	
  not	
  reveal	
   consistent	
  documentation	
  regarding	
  the	
  level	
  of	
  care	
  or	
  frequency	
  of	
   interaction	
  prescribed	
  for	
  each	
  individual	
  youth.	
  	
  Therefore,	
  it	
  was	
  not	
   possible	
  to	
  determine	
  if	
  the	
  frequency	
  noted	
  via	
  record	
  review	
  was	
   appropriate	
  for	
  a	
  particular	
  youth.	
  	
  	
   	
   Given	
  the	
  above,	
  it	
  was	
  apparent	
  that	
  while	
  some	
  treatment	
  was	
   occurring,	
  improvements	
  to	
  the	
  overall	
  treatment	
  program	
  and	
   documentation	
  of	
  treatment	
  planned	
  and	
  provided	
  will	
  be	
  necessary	
  for	
   the	
  facility	
  to	
  meet	
  the	
  requirements	
  of	
  this	
  provision.	
  	
  Specific	
  concerns	
   were	
  noted	
  regarding	
  the	
  treatment	
  program	
  for	
  youth	
  housed	
  in	
  the	
   Progress	
  unit	
  during	
  this	
  and	
  prior	
  monitoring	
  visits.	
  It	
  was	
  noted	
  that	
   given	
  the	
  increased	
  presence	
  of	
  behavioral	
  health	
  staff	
  on	
  these	
  units	
   with	
  the	
  corresponding	
  decrease	
  in	
  youth	
  census	
  on	
  these	
  units	
  that	
   there	
  should	
  be	
  improvement	
  in	
  the	
  overall	
  monitoring	
  and	
  treatment	
   provided	
  for	
  these	
  youth.	
  	
  There	
  remained	
  issues	
  with	
  youth	
  receiving	
   regularly	
  scheduled	
  individual	
  therapy.	
  	
  For	
  additional	
  information	
   regarding	
  this,	
  please	
  see	
  the	
  discussion	
  under	
  III.B.18.	
  	
  As	
  discussed	
   with	
  the	
  facility	
  administration,	
  facility	
  mental	
  health	
  staff	
  and	
  DYS	
   administration,	
  the	
  programming	
  on	
  this	
  unit	
  must	
  continue	
  to	
  be	
  a	
   priority	
  and	
  will	
  be	
  the	
  focus	
  of	
  future	
  monitoring	
  visits.	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Improve	
  documentation	
  of	
  group	
  and	
  individual	
  therapeutic	
  
interaction	
  and	
  review	
  this	
  documentation	
  via	
  a	
  quality	
  assurance	
   process.	
   2. Ensure	
  the	
  provision	
  of	
  evidence	
  based	
  group	
  therapeutic	
   interactions.	
   3. Increase	
  modeling	
  and	
  coaching	
  for	
  youth	
  specialists	
  responsible	
  for	
  

	
  

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Sources	
  of	
   Information	
  
	
   	
  

group	
  therapeutic	
  interactions.	
  	
  This	
  should	
  include	
  group	
  therapy	
   observation	
  and	
  resultant	
  corrective	
  action	
  inclusive	
  of	
  training,	
   supervision,	
  etc.	
  	
  Administrative	
  staff	
  may	
  determine	
  that	
  revised	
   training	
  for	
  youth	
  specialists	
  is	
  required.	
   4. Determine	
  and	
  ensure	
  that	
  appropriate	
  numbers	
  of	
  youth	
  are	
   assigned	
  to	
  specific	
  group	
  therapy	
  sessions.	
   5. Continue	
  the	
  integration	
  of	
  treatment	
  provider	
  disciplines	
  in	
  order	
   to	
  achieve	
  an	
  interdisciplinary	
  model.	
   6. Continue	
  to	
  engage	
  and	
  encourage	
  direct	
  care	
  staff	
  to	
  participate	
  in	
   group	
  modalities	
  and	
  in	
  the	
  overall	
  treatment	
  program	
  for	
  the	
   youth.	
   7. Begin	
  quality	
  assurance	
  monitoring	
  regarding	
  the	
  mental	
  health	
   treatment	
  program	
  that	
  addresses	
  both	
  adherence	
  to	
  the	
  required	
   procedural	
  elements	
  but	
  also	
  measures	
  youth	
  outcomes	
  related	
  to	
   the	
  treatment	
  modality	
  (e.g.	
  reduction	
  in	
  SHU	
  referrals,	
  reduction	
  in	
   facility	
  violence).	
  	
  This	
  should	
  also	
  include	
  treatment	
  integrity	
   reviews.	
   8. Review	
  the	
  Progress	
  program,	
  and	
  ensure	
  that	
  youth	
  are	
  receiving	
   appropriate	
  mental	
  health	
  treatment	
  via	
  this	
  program.	
   9. Review	
  and	
  monitor	
  youth	
  case	
  formulations	
  and	
  diagnoses	
  via	
  a	
   quality	
  assurance	
  program.	
  
• Review	
  of	
  provided	
  documents	
  (e.g.	
  group	
  schedule,	
  youth	
   records,	
  policy	
  and	
  procedure,	
  description	
  of	
  treatment	
   modalities)	
  
• Observation	
  of	
  two	
  group	
  interactions	
   • Youth	
  interview	
   • Staff	
  interview	
  
	
  

	
  

63.	
  

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III.B.6	
  	
  	
  Treatment	
  Planning.	
  	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
   practices	
  so	
  that	
  treatment	
  service	
  determinations,	
  including	
  ongoing	
  treatment	
  and	
  discharge	
   planning,	
  are	
  consistently	
  made	
  by	
  an	
  interdisciplinary	
  team	
  through	
  integrated	
  treatment	
   planning	
  and	
  embodied	
  in	
  a	
  single,	
  integrated	
  treatment	
  plan.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Per	
  the	
  oral	
  facility	
  self	
  assessment,	
  the	
  facility	
  has	
  engaged	
  in	
  training	
   for	
  staff	
  with	
  regard	
  to	
  treatment	
  planning.	
  	
  Policy	
  and	
  procedure	
   revisions	
  are	
  pending,	
  as	
  is	
  formal	
  quality	
  assurance	
  monitoring.	
  	
  There	
   has	
  been	
  review	
  of	
  treatment	
  planning	
  documentation	
  via	
  central	
  office.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

As	
  part	
  of	
  the	
  ODYS	
  Behavioral	
  Health	
  administrative	
  review,	
  there	
  are	
   plans	
  for	
  continuing	
  monitoring	
  with	
  regard	
  to	
  the	
  authorship	
  of	
  ITP	
   documents.	
  	
  As	
  discussed	
  in	
  paragraph	
  18	
  below,	
  the	
  facility	
  must	
   develop	
  a	
  quality	
  assurance	
  process	
  to	
  review	
  both	
  compliance	
  with	
   process	
  and	
  to	
  determine	
  outcomes	
  associated	
  with	
  behavioral	
  health	
   treatment.	
  	
  For	
  additional	
  discussion	
  regarding	
  Treatment	
  Planning	
  and	
   IDT	
  meetings,	
  please	
  see	
  the	
  discussion	
  regarding	
  the	
  provisions	
  below	
   (7	
  and	
  8).	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Review,	
  revise,	
  and	
  implement	
  policy	
  and	
  procedure	
  regarding	
  
treatment	
  planning	
  and	
  the	
  IDT	
  process.	
   2. Develop	
  quality	
  assurance	
  monitoring	
  regarding	
  ITP	
  development,	
  
implementation,	
  and	
  progress.	
   3. Address	
  recommendations	
  provided	
  regarding	
  provisions	
  7	
  and	
  8	
  
below.	
  

Sources	
  of	
   Information	
  
	
   	
   	
  

• Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  	
  
	
  

	
  

64.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 65 of 129 PAGEID #: 2418

III.B.7	
  	
  Treatment	
  Teams.	
  	
  	
  At	
  a	
  minimum,	
  the	
  interdisciplinary	
  treatment	
  team	
  for	
  each	
  youth	
  in	
   need	
  of	
  mental/behavioral	
  health	
  and/or	
  substance	
  abuse	
  treatment	
  should:	
  a)	
  be	
  guided	
  by	
  a	
   trained	
  treatment	
  professional	
  who	
  shall	
  provide	
  clinical	
  oversight	
  and	
  ensure	
  the	
  proper	
   functioning	
  of	
  treatment	
  team	
  meetings;	
  b)	
  consist	
  of	
  a	
  stable	
  core	
  of	
  members,	
  including	
  at	
   least	
  the	
  youth,	
  the	
  social	
  worker,	
  a	
  JCO,	
  one	
  of	
  the	
  youth’s	
  teachers,	
  the	
  Unit	
  Manager,	
  and	
  as	
   warranted	
  by	
  the	
  needs	
  of	
  the	
  youth,	
  the	
  treating	
  psychiatrist,	
  the	
  treating	
  psychologist,	
   registered	
  nurse,	
  and,	
  as	
  appropriate,	
  other	
  staff;	
  c)	
  ensure	
  that	
  needed	
  psychiatric	
  evaluations	
   are	
  conducted	
  on	
  a	
  youth	
  before	
  administering	
  psychotropic	
  medications	
  to	
  the	
  youth;	
  d)	
   monitor	
  as	
  appropriate	
  but	
  at	
  least	
  monthly,	
  the	
  efficacy	
  and	
  the	
  side	
  effects	
  of	
  psychotropic	
   medications,	
  including	
  consultation	
  with	
  family	
  medical,	
  counseling	
  and	
  other	
  staff	
  who	
  are	
   familiar	
  with	
  the	
  youth;	
  e)	
  for	
  youth	
  under	
  a	
  psychiatrist’s	
  care:	
  ensure	
  the	
  provision	
  of	
   individual	
  counseling	
  and	
  psychotherapy	
  when	
  needed,	
  in	
  coordination	
  with	
  facility	
   psychologists;	
  ensure	
  that	
  all	
  youth	
  referred	
  as	
  possibly	
  in	
  need	
  of	
  psychiatric	
  services	
  are	
   evaluated	
  and	
  treated	
  in	
  a	
  timely	
  manner;	
  and	
  provide	
  adequate	
  documentation	
  of	
  treatment	
  in	
   the	
  facility	
  medical	
  records;	
  f)	
  include	
  to	
  the	
  fullest	
  extent	
  practicable,	
  proactive	
  efforts	
  to	
   obtain	
  the	
  participation	
  of	
  parents	
  or	
  guardians,	
  unless	
  their	
  participation	
  would	
  be	
   inappropriate	
  for	
  some	
  reason	
  (e.g.,	
  the	
  child	
  has	
  been	
  removed	
  from	
  the	
  parent’s	
  custody),	
  in	
   order	
  to	
  obtain	
  relevant	
  information,	
  understand	
  family	
  goals	
  and	
  concerns,	
  and	
  foster	
  ongoing	
   engagement;	
  g)	
  meet	
  to	
  assess	
  the	
  treatment	
  plan’s	
  efficacy	
  at	
  least	
  every	
  30	
  days	
  and	
  more	
   often	
  as	
  necessary;	
  and	
  h)	
  document	
  treatment	
  team	
  meetings	
  and	
  planning	
  in	
  the	
  youth’s	
   mental	
  health	
  records.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  delivered	
  orally	
  during	
  the	
  monitoring	
   visit.	
  	
  Per	
  staff	
  interviewed,	
  the	
  psychiatrist	
  has	
  been	
  participating	
  in	
   treatment	
  team	
  (IDT)	
  on	
  the	
  Progress	
  Units	
  for	
  the	
  past	
  week.	
  	
  There	
  has	
   not	
  been	
  psychiatric	
  participation	
  for	
  treatment	
  team	
  regarding	
  youth	
   housed	
  in	
  general	
  population.	
  	
  In	
  the	
  absence	
  of	
  the	
  psychiatrist,	
  mental	
   health	
  nurses	
  have	
  been	
  attending	
  IDT	
  when	
  they	
  are	
  able	
  and	
  providing	
   information	
  to	
  the	
  treating	
  psychiatrists.	
  	
  Staff	
  indicated	
  that	
  family	
   members	
  attended	
  IDT	
  regarding	
  one	
  youth	
  on	
  the	
  Progress	
  Units.	
  	
  They	
   indicated	
  that	
  effort	
  had	
  been	
  made	
  to	
  include	
  family	
  members	
  in	
  IDT	
   meeting	
  on	
  the	
  female	
  unit,	
  but	
  this	
  had	
  been	
  unsuccessful	
  due	
  to	
   technological	
  issues.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

One	
  treatment	
  team	
  meeting	
  was	
  observed	
  during	
  this	
  monitoring	
  visit.	
   There	
  were	
  no	
  representatives	
  from	
  the	
  school	
  participating.	
  	
  The	
   youth’s	
  parents	
  were	
  not	
  in	
  attendance.	
  	
  Other	
  necessary	
  staff,	
  including	
   the	
  newly	
  hired	
  psychiatrist	
  were	
  present.	
  	
  	
   	
   The	
  IDT	
  reviewed	
  the	
  youth’s	
  recent	
  behavioral	
  challenges.	
  	
  There	
  was	
   limited	
  discussion	
  with	
  regard	
  to	
  the	
  reason	
  or	
  contributing	
  factors	
  to	
   the	
  youth’s	
  behavior.	
  	
  Staff	
  were	
  knowledgeable	
  regarding	
  the	
  youth’s	
   behavior,	
  but	
  did	
  not	
  appear	
  to	
  have	
  a	
  deeper	
  understanding	
  of	
  the	
   youth’s	
  issues	
  and	
  underlying	
  motivations.	
  	
  For	
  example,	
  Youth	
  #888	
  was	
   reportedly	
  not	
  adhering	
  to	
  the	
  prescribed	
  medication	
  regimen.	
  	
  It	
  was	
   discussed	
  that	
  he	
  was	
  declining	
  to	
  take	
  his	
  morning	
  medication	
  because,	
   “he	
  just	
  doesn’t	
  feel	
  like	
  coming	
  to	
  the	
  door.”	
  	
  It	
  was	
  noted	
  that	
  after	
  

	
  

65.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 66 of 129 PAGEID #: 2419

two	
  missed	
  dosages,	
  “he	
  struggled	
  in	
  class	
  and	
  was	
  asked	
  to	
  leave	
  due	
  to	
   being	
  irritable.”	
  	
  Staff	
  did	
  a	
  cursory	
  review	
  of	
  this	
  issue	
  and	
  moved	
  on	
  to	
   the	
  next	
  youth	
  up	
  for	
  discussion.	
  	
  There	
  was	
  no	
  indication	
  that	
  anyone	
   had	
  a	
  meaningful	
  discussion	
  with	
  this	
  youth	
  in	
  order	
  to	
  determine	
  the	
   reason	
  he	
  had	
  begun	
  to	
  refuse	
  his	
  morning	
  medication	
  (e.g.	
  side	
  effects,	
   bedtime	
  medication	
  causing	
  morning	
  sedation,	
  treatment	
  resistance,	
   etc.)	
  	
  	
   	
   It	
  was	
  noted	
  that	
  several	
  youth	
  were	
  experiencing	
  difficulties	
  that	
  staff	
   attributed	
  to	
  psychotropic	
  medication.	
  ITP	
  goals	
  do	
  not	
  regularly	
  include	
   treatment	
  with	
  psychotropic	
  medication,	
  which	
  should	
  be	
  added	
  to	
  the	
   ITP	
  for	
  those	
  youth	
  with	
  prescribed	
  psychotropic	
  medications.	
  	
  As	
  the	
   psychiatrist	
  becomes	
  an	
  integral	
  part	
  of	
  the	
  IDT,	
  it	
  is	
  hoped	
  that	
  these	
   issues	
  can	
  be	
  addressed	
  in	
  concert	
  with	
  him.	
   	
   A	
  review	
  of	
  the	
  IDT	
  minutes	
  for	
  the	
  three	
  months	
  prior	
  to	
  the	
  monitoring	
   visit	
  revealed	
  scant	
  detail	
  of	
  the	
  meeting.	
  	
  For	
  example,	
  the	
  IDT	
  minutes	
   from	
  Allman	
  unit	
  dated	
  9.5.12	
  include	
  details	
  regarding	
  “announcements	
   and	
  accomplishments”	
  for	
  the	
  unit.	
  	
  Information	
  regarding	
  the	
  three	
   youth	
  reviewed	
  stated,	
  “went	
  over	
  youth’s	
  goals	
  and	
  objectives”	
  for	
  two	
   youth,	
  and	
  for	
  the	
  third,	
  “youth	
  was	
  brought	
  in	
  to	
  discuss	
  her	
  job	
   suspension	
  for	
  three	
  weeks.”	
  	
  This	
  documentation	
  was	
  not	
  reflective	
  of	
  a	
   rich	
  IDT	
  meeting.	
   	
   IDT	
  minutes	
  generated	
  on	
  Cedar	
  Unit	
  9.18.12	
  revealed	
  ongoing	
  attention	
   to	
  “announcements	
  and	
  accomplishments”	
  but	
  also	
  included	
  information	
   regarding	
  each	
  youth’s	
  goals.	
  	
  There	
  was	
  also	
  documentation	
  regarding	
   the	
  youth’s	
  progress	
  toward	
  goals.	
  	
  For	
  example	
  Youth	
  #101	
  “is	
  having	
   issues	
  in	
  all	
  areas	
  and	
  making	
  little	
  or	
  no	
  progress.”	
  	
  There	
  was	
  also	
   documentation	
  that	
  this	
  youth	
  was	
  “not	
  accepting	
  responsibility	
  for	
  his	
   actions…needs	
  to	
  work	
  on	
  peer	
  pressure	
  issues	
  and	
  criminal	
  thinking…”	
   The	
  minutes	
  did	
  not	
  include	
  information	
  regarding	
  the	
  IDT’s	
  plan	
  to	
   address	
  these	
  issues	
  with	
  the	
  youth,	
  or	
  what	
  interventions	
  would	
  be	
   added	
  or	
  changed	
  to	
  allow	
  this	
  youth	
  to	
  acquire	
  the	
  skills	
  necessary	
  to	
   progress.	
  	
  There	
  was	
  an	
  obvious	
  need	
  for	
  better	
  integration	
  of	
  services	
   and	
  the	
  formulation	
  of	
  a	
  collaborative	
  case	
  conceptualization	
  so	
  that	
  all	
   team	
  members	
  could	
  “be	
  on	
  the	
  same	
  page”	
  with	
  regard	
  to	
  the	
   management	
  of	
  this	
  youth.	
  	
  	
   	
   In	
  previous	
  monitoring	
  reports,	
  a	
  shortcoming	
  addressed	
  was	
  that	
  in	
   general:	
   IDT	
  minutes	
  reflected	
  significant	
  time	
  spent	
  in	
  the	
  discussion	
  of	
  	
   “housekeeping”	
  issues	
  such	
  as	
  the	
  unit	
  schedule	
  and	
  youth	
  rules.	
  With	
   the	
  exception	
  of	
  the	
  girls	
  mental	
  health	
  unit	
  (where	
  documentation	
  of	
  IDT	
   addressed	
  youth	
  mental	
  health	
  issues)	
  documented	
  discussions,	
   particularly	
  regarding	
  mental	
  health	
  treatment	
  issues	
  appeared	
  to	
  be	
   minimal.	
  This	
  had	
  improved	
  over	
  prior	
  visits.	
  	
  Per	
  discussions	
  with	
  ODYS	
  

	
  

66.	
  

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Recommendations	
  

Behavioral	
  Health	
  administrative	
  staff,	
  there	
  were	
  plans	
  to	
  move	
  the	
   discussion	
  of	
  unit	
  issues	
  to	
  the	
  end	
  of	
  the	
  IDT	
  meeting	
  in	
  order	
  to	
   minimize	
  the	
  “housekeeping”	
  discussion	
  and	
  highlight	
  the	
  importance	
  of	
   the	
  youth’s	
  treatment.	
   	
   One	
  of	
  the	
  recommendations	
  from	
  the	
  March	
  2011	
  report	
  was	
  to	
   integrate	
  youth	
  specialists	
  into	
  weekly	
  IDT	
  meetings.	
  The	
  self-­‐assessment	
   reported	
  “a	
  QI	
  process	
  was	
  implemented	
  regarding	
  the	
  integration	
  of	
   direct	
  care	
  staff…there	
  has	
  been	
  an	
  increase	
  in	
  Youth	
  Specialist	
  presence	
   and	
  involvement	
  in	
  all	
  Interdisciplinary	
  Teams.”	
  	
  Unfortunately,	
  results	
  of	
   this	
  QI	
  process	
  or	
  other	
  quality	
  assurance	
  monitoring	
  regarding	
  IDT	
   meetings	
  were	
  not	
  presented	
  for	
  review.	
  During	
  the	
  observed	
  IDT	
   meeting,	
  youth	
  specialists	
  were	
  present	
  and	
  were	
  noted	
  to	
  participate	
  in	
   the	
  discussion.	
  	
  This	
  was	
  indicative	
  of	
  some	
  effort	
  to	
  include	
  all	
   disciplines	
  in	
  review	
  and	
  planning	
  of	
  youth	
  treatment.	
  	
   	
   Reportedly	
  due	
  to	
  an	
  ongoing	
  paucity	
  of	
  psychiatric	
  resources,	
  the	
   psychiatrist	
  was	
  not	
  a	
  participant	
  in	
  IDT	
  meetings.	
  	
  Psychiatric	
  nurses	
   were	
  attending	
  IDT	
  in	
  lieu	
  of	
  the	
  psychiatrist.	
  	
  This	
  had	
  been	
  remedied	
  on	
   the	
  Progress	
  Units.	
  Approximately	
  one	
  week	
  prior	
  to	
  the	
  monitoring	
  visit,	
   additional	
  psychiatric	
  resources	
  had	
  been	
  obtained,	
  with	
  plans	
  for	
  this	
   new	
  staff	
  member	
  to	
  focus	
  his	
  attention	
  on	
  the	
  Progress	
  Units	
  inclusive	
   of	
  attendance	
  at	
  the	
  IDT	
  meetings.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Ensure	
  psychiatric	
  resources	
  are	
  available	
  to	
  allow	
   participation	
  in	
  Interdisciplinary	
  Treatment	
  Team	
  meetings	
  for	
   all	
  youth	
  assigned	
  to	
  the	
  mental	
  health	
  caseload.	
  
2. In	
  an	
  effort	
  to	
  maximize	
  the	
  use	
  of	
  staff	
  resources,	
  separate	
   administrative	
  or	
  “housekeeping”	
  discussions	
  from	
  IDT	
   meetings.	
  	
  	
  
3. Increase	
  efforts	
  to	
  include	
  the	
  youth’s	
  parent	
  or	
  guardian	
  in	
   the	
  treatment	
  planning	
  process.	
  
4. Ensure	
  that	
  direct	
  care	
  staff	
  are	
  included	
  in	
  and	
  valued	
   members	
  of	
  the	
  IDT.	
  
5. Ensure	
  that	
  all	
  necessary	
  staff	
  disciplines	
  participate	
  in	
  IDT,	
   inclusive	
  of	
  educational	
  staff.	
  
6. Begin	
  Quality	
  Assurance	
  monitoring	
  of	
  treatment	
  planning	
   efforts	
  and	
  IDT	
  meetings.	
  	
  This	
  would	
  include	
  the	
  development	
   of	
  both	
  process	
  and	
  outcome	
  measures	
  inclusive	
  of	
  trending	
   data	
  and	
  corrective	
  action	
  where	
  necessary.	
  
7. Increase	
  staff	
  training/education	
  regarding	
  the	
  timely	
   formulation	
  of	
  a	
  treatment	
  plan	
  and	
  interventions	
  developed	
   as	
  a	
  result	
  of,	
  among	
  other	
  things,	
  the	
  discussion	
  in	
  IDT.	
  	
  These	
   plans	
  must	
  then	
  be	
  implemented,	
  first	
  via	
  training	
  direct	
  care	
   staff.	
  

	
  

67.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 68 of 129 PAGEID #: 2421

Sources	
  of	
   Information	
  
	
   	
   	
  

• Staff	
  Interview	
   • Observation	
  of	
  Interdisciplinary	
  Treatment	
  Team	
  meeting	
   • Review	
  of	
  provided	
  documents	
  	
   • Youth	
  interview	
  
	
  

	
  

68.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 69 of 129 PAGEID #: 2422

III.B.8	
  	
  Integrated	
  Treatment	
  Plans.	
  The	
  State	
  shall	
  ensure	
  that	
  each	
  youth	
  in	
  need	
  of	
   mental/behavioral	
  health	
  and/or	
  substance	
  abuse	
  treatment	
  shall	
  have	
  an	
  appropriate,	
   integrated	
  treatment	
  plan,	
  including	
  an	
  appropriate	
  behavior	
  management	
  plan	
  that	
  addresses	
   such	
  needs.	
  The	
  integrated	
  treatment	
  plan	
  shall	
  be	
  driven	
  by	
  individualized	
  risks	
  and	
  needs,	
  be	
   strengths-­‐based	
  (i.e.,	
  builds	
  on	
  an	
  individual’s	
  current	
  strengths),	
  account	
  for	
  the	
  youth’s	
   motivation	
  for	
  engaging	
  in	
  activities	
  contributing	
  to	
  his/her	
  wellness,	
  and	
  be	
  reasonably	
   calculated	
  to	
  lead	
  to	
  improvement	
  in	
  the	
  individual’s	
  mental/behavioral	
  health	
  and	
  well	
  being,	
   consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Per	
  the	
  oral	
  facility	
  self-­‐assessment,	
  staff	
  have	
  received	
  training	
  on	
  the	
   integrated	
  treatment	
  plan	
  (ITP)	
  process	
  inclusive	
  of	
  case	
   conceptualization.	
  	
  It	
  was	
  reported	
  that	
  policy	
  and	
  procedure	
  regarding	
   ITP’s	
  remained	
  pending	
  at	
  the	
  time	
  of	
  the	
  visit.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Document	
  review	
  revealed	
  some	
  improvement	
  in	
  ITP	
  documentation.	
  	
   Specifically,	
  youth	
  strengths	
  and	
  measurable	
  goals	
  were	
  identified	
  on	
   some	
  documents.	
  	
  There	
  was	
  room	
  for	
  improvements	
  with	
  regard	
  to	
   ensuring	
  goals	
  were	
  measurable.	
  In	
  some	
  of	
  the	
  examples,	
  interventions	
   were	
  identified;	
  however,	
  they	
  did	
  not	
  routinely	
  address	
  skills	
  the	
  youth	
   needed	
  to	
  acquire	
  in	
  order	
  to	
  achieve	
  the	
  goal.	
  	
  Rather,	
  they	
  included	
   workbook	
  assignments	
  or	
  other	
  tasks	
  the	
  youth	
  was	
  to	
  complete.	
  	
  In	
   addition,	
  mental	
  health	
  and	
  medication	
  management	
  goals	
  were	
  not	
   routinely	
  addressed.	
  	
  For	
  an	
  example	
  of	
  this,	
  please	
  see	
  the	
  discussion	
  in	
   provision	
  G1	
  regarding	
  Youth	
  #111.	
   	
   In	
  a	
  second	
  example,	
  the	
  ITP	
  regarding	
  youth	
  #888	
  did	
  not	
  include	
   information	
  regarding	
  this	
  youth’s	
  mental	
  health	
  diagnoses,	
  or	
   treatment	
  with	
  psychotropic	
  medications.	
  	
  He	
  has	
  diagnoses	
  including	
   mood	
  disorder,	
  not	
  otherwise	
  specified	
  and	
  posttraumatic	
  stress	
   disorder.	
  	
  He	
  is	
  prescribed	
  atypical	
  antipsychotic	
  medication.	
  	
   	
  	
   One	
  of	
  Youth	
  #888’s	
  goals	
  was	
  to	
  “demonstrate	
  healthy	
  sexual	
   boundaries	
  with	
  females	
  within	
  ODYS.”	
  	
  The	
  objective	
  stated,	
  “I	
  will	
  not	
   expose	
  my	
  penis	
  to	
  any	
  female	
  for	
  the	
  next	
  14	
  days…monitoring	
  by	
  not	
   receiving	
  an	
  YBIR’s	
  for	
  sexual	
  conduct	
  or	
  sexual	
  assault	
  within	
  that	
  14	
   days….If	
  I	
  feel	
  the	
  urge	
  to	
  expose	
  myself	
  or	
  masturbate	
  in	
  front	
  of	
  a	
   female	
  while	
  on	
  progress,	
  I	
  will	
  complete	
  a	
  decisional	
  balance	
   worksheet	
  and	
  process	
  the	
  information	
  with	
  my	
  social	
  worker	
  during	
   weekly	
  individual	
  sessions.	
  	
  I	
  will	
  talk	
  to	
  my	
  behavioral	
  health	
  [sic]	
  at	
   least	
  one	
  time	
  per	
  week	
  during	
  my	
  sexual	
  misconduct	
  urges.”	
  This	
   treatment	
  intervention	
  does	
  not	
  address	
  specific	
  skills	
  that	
  the	
  youth	
   needs	
  to	
  learn	
  and	
  implement	
  with	
  regard	
  to	
  “healthy	
  sexual	
   boundaries.”	
  	
  It	
  also	
  does	
  not	
  indicate	
  the	
  function	
  that	
  this	
  behavior	
   serves	
  for	
  this	
  particular	
  youth	
  (e.g.	
  attention	
  seeking,	
  control,	
  etc),	
  or	
   how	
  this	
  was	
  being	
  addressed.	
   	
   The	
  ITP	
  regarding	
  youth	
  #999	
  included	
  descriptions	
  of	
  interventions	
  

	
  

69.	
  

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Recommendations	
  

utilized	
  to	
  assist	
  this	
  youth	
  in	
  meeting	
  goals.	
  	
  For	
  example,	
  “extensive	
   history	
  of	
  aggressive…behavior…will	
  work	
  toward	
  managing	
  his	
  anger	
  in	
   a	
  more	
  appropriate	
  manner.”	
  	
  The	
  objectives	
  then	
  delineated	
  specific	
   workbooks	
  and	
  processing	
  that	
  is	
  to	
  occur	
  with	
  his	
  assigned	
  social	
   worker,	
  but	
  did	
  not	
  outline	
  specific	
  skills	
  that	
  the	
  youth	
  needed	
  to	
  learn.	
  	
   Another	
  weakness	
  of	
  this	
  youth’s	
  case	
  conceptualization	
  and	
  associated	
   ITP	
  was	
  that	
  it	
  did	
  not	
  include	
  information	
  regarding	
  this	
  youth’s	
  mental	
   health	
  diagnoses	
  and	
  treatment	
  with	
  psychotropic	
  medication.	
  	
  	
   	
   What	
  was	
  positive	
  was	
  that	
  ODYS	
  had	
  recognized	
  the	
  staff	
  weakness	
   with	
  regard	
  to	
  development	
  of	
  the	
  ITP	
  and	
  proactively	
  began	
  a	
  training	
   and	
  review	
  program	
  for	
  staff.	
  	
  As	
  stated	
  in	
  multiple	
  areas	
  of	
  this	
   document,	
  Behavioral	
  Health	
  policy	
  and	
  procedure,	
  including	
  policy	
   regarding	
  treatment	
  planning	
  is	
  pending.	
   	
   As	
  stated	
  previously:	
  	
   	
   Acceptable	
  Integrated	
  Treatment	
  Plans	
  must	
  include	
  measurable	
  goals	
   and	
  objectives,	
  with	
  available	
  targeted	
  interventions	
  to	
  address	
  each	
   goal.	
  	
  Progress	
  notes	
  authored	
  regarding	
  the	
  youth’s	
  treatment	
  should	
   refer	
  to	
  the	
  youth’s	
  treatment	
  goals	
  and	
  document	
  the	
  response	
  (or	
  lack	
   thereof)	
  to	
  the	
  prescribed	
  interventions…Integrated	
  Treatment	
  Plans	
   should	
  be	
  reviewed	
  at	
  each	
  Interdisciplinary	
  Treatment	
  Team	
  meeting	
   scheduled	
  for	
  the	
  youth,	
  and	
  must	
  be	
  authored	
  and	
  reviewed	
  with	
  the	
   participation	
  of	
  the	
  youth	
  and	
  their	
  parent	
  or	
  guardian	
  (if	
  appropriate).	
  	
   	
   It	
  was	
  apparent	
  that	
  ODYS	
  is	
  attempting	
  to	
  improve	
  their	
  treatment	
   planning	
  services	
  in	
  order	
  to	
  achieve	
  compliance	
  with	
  generally	
  accepted	
   practices.	
  	
  As	
  this	
  process	
  evolves,	
  quality	
  assurance	
  monitoring	
  with	
   corrective	
  action	
  (inclusive	
  of	
  additional	
  staff	
  education	
  and	
  training)	
  will	
   be	
  necessary.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Finalize	
  and	
  implement	
  policy	
  and	
  procedure	
  regarding	
  Integrated	
  
Treatment	
  Plans.	
   2. Continue	
  training	
  for	
  Behavioral	
  Health	
  Staff	
  regarding	
  development	
  
of	
  Integrated	
  Treatment	
  Plans.	
   3. Ensure	
  that	
  Integrated	
  Treatment	
  Teams	
  utilize	
  the	
  Integrated	
  
Treatment	
  Plans	
  as	
  a	
  road	
  map	
  for	
  youth	
  treatment	
  and	
  progress,	
   and	
  that	
  the	
  Integrated	
  Treatment	
  Plans	
  are	
  updated	
  regularly	
  as	
   per	
  policy	
  and	
  procedure	
  pending	
  review	
  of	
  revision.	
   4. Develop	
  quality	
  assurance	
  monitoring	
  tools	
  that	
  are	
  both	
  process	
   (e.g.	
  were	
  the	
  targeted	
  interventions	
  appropriate	
  for	
  a	
  particular	
   youth;	
  were	
  measurable	
  goals	
  and	
  objectives	
  identified;	
  per	
  a	
   review	
  of	
  the	
  youth’s	
  progress	
  notes,	
  did	
  treatment	
  provided	
  to	
  the	
   youth	
  follow	
  the	
  outline	
  of	
  the	
  Integrated	
  Treatment	
  Plan)	
  and	
   outcome	
  oriented	
  (e.g.	
  did	
  the	
  youth	
  improve	
  over	
  the	
  course	
  of	
  

	
  

70.	
  

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Sources	
  of	
   Information	
  
	
   	
  

treatment	
  per	
  the	
  Integrated	
  Treatment	
  Plan).	
   • Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  	
   • Review	
  of	
  youth	
  records	
  
	
  

	
  

71.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 72 of 129 PAGEID #: 2425

III.B.9	
  	
  Access	
  to	
  a	
  QMHP.	
  	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
   practices	
  to	
  ensure	
  that	
  youth	
  who	
  seek	
  access	
  to	
  a	
  qualified	
  mental	
  health	
  professional	
  are	
   provided	
  appropriate	
  access	
  in	
  a	
  timely	
  manner.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally.	
  	
  Increased	
  mental	
   health	
  staffing	
  was	
  reported	
  on	
  the	
  Progress	
  Units	
  in	
  an	
  effort	
  to	
   enhance	
  youth	
  access	
  to	
  mental	
  health	
  services.	
  	
  It	
  was	
  reported	
  that	
   daily	
  “door	
  checks”	
  were	
  occurring	
  on	
  Phase	
  I.	
  	
  Youth	
  on	
  Phase	
  II	
   received	
  a	
  “door	
  check”	
  twice	
  weekly.	
  	
  Policy	
  and	
  procedure	
  regarding	
   this	
  requirement	
  was	
  pending.	
  	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

In	
  response	
  to	
  a	
  request	
  for	
  data	
  regarding	
  access	
  to	
  mental	
  health	
   services,	
  the	
  facility	
  stated,	
  “the	
  presence	
  of	
  psychology	
  offices	
  on	
  the	
   units	
  makes	
  access	
  to	
  psychology	
  staff	
  simple	
  and	
  immediate.	
  	
  The	
  use	
   of	
  forms	
  and	
  tracking	
  systems	
  to	
  measure	
  the	
  response	
  time	
  would	
  slow	
   the	
  process	
  and	
  increase	
  the	
  length	
  of	
  time	
  between	
  request	
  and	
   actually	
  being	
  seen.	
  	
  While	
  forms	
  are	
  available	
  to	
  youth	
  to	
  make	
  formal	
   requests	
  to	
  be	
  seen,	
  and	
  secure	
  boxes	
  are	
  available	
  on	
  the	
  units	
  for	
   these	
  requests,	
  the	
  vase	
  majority	
  of	
  contacts	
  are	
  by	
  the	
  schedule	
  or	
  by	
   direct,	
  face	
  to	
  face	
  requests.”	
   	
   In	
  an	
  effort	
  show	
  compliance	
  with	
  the	
  above	
  provision,	
  seven	
  examples	
   of	
  youth	
  contact	
  with	
  psychology	
  staff	
  were	
  provided	
  (five	
  of	
  these	
  were	
   for	
  female	
  youth,	
  two	
  were	
  for	
  male	
  youth).	
  	
  Five	
  examples	
  indicated	
   that	
  the	
  youth	
  requested	
  to	
  be	
  seen	
  and	
  was	
  seen	
  immediately.	
  	
  Two	
  of	
   the	
  examples	
  were	
  for	
  individual	
  sessions,	
  both	
  of	
  which	
  the	
  youth	
   declined	
  to	
  participate	
  in	
  the	
  session	
  beyond	
  a	
  few	
  minutes.	
  	
   Supervisory	
  staff	
  indicated	
  that	
  currently,	
  the	
  practice	
  is	
  for	
  psychology	
   staff	
  to	
  indicate	
  the	
  time	
  of	
  the	
  youth’s	
  request	
  and	
  the	
  time	
  that	
  the	
   assessment	
  began.	
  	
  	
  	
   	
   Per	
  the	
  document	
  request	
  and	
  observation,	
  secure	
  mailboxes	
  have	
  been	
   provided	
  on	
  the	
  units	
  for	
  youth	
  to	
  request	
  services	
  without	
  reliance	
   upon	
  direct	
  care	
  staff	
  to	
  communicate	
  their	
  request.	
  Psychology	
  or	
   social	
  work	
  staff	
  check	
  these	
  boxes	
  daily.	
  Youth	
  interviewed	
  during	
  this	
   monitoring	
  tour	
  were	
  able	
  to	
  show	
  the	
  monitor	
  the	
  box	
  within	
  which	
  to	
   place	
  their	
  requests	
  for	
  services	
  on	
  their	
  individual	
  units.	
  	
  It	
  is	
   imperative	
  that	
  youth	
  are	
  able	
  to	
  independently	
  access	
  mental	
  health	
   care;	
  as	
  unfortunately,	
  there	
  may	
  be	
  situations	
  where	
  direct	
  care	
  staff	
   could	
  unintentionally	
  or	
  purposefully	
  impede	
  the	
  youth’s	
  access	
  to	
   necessary	
  mental	
  health	
  treatment	
  with	
  resultant	
  negative	
  outcomes.	
  	
   Given	
  the	
  Behavioral	
  Health	
  presence	
  on	
  the	
  units,	
  this	
  is	
  less	
  of	
  a	
   concern,	
  however,	
  there	
  are	
  times	
  (nights	
  and	
  weekends)	
  where	
   Behavioral	
  Health	
  staff	
  are	
  not	
  immediately	
  available,	
  and	
  youth	
  must	
   be	
  able	
  to	
  make	
  independent	
  requests	
  for	
  services.	
   	
   One	
  concern	
  noted	
  and	
  communicated	
  during	
  the	
  previous	
  and	
  current	
  

	
  

72.	
  

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Recommendations	
  

monitoring	
  tours	
  was	
  access	
  to	
  mental	
  health	
  services	
  for	
  youth	
  housed	
   on	
  the	
  Progress	
  unit.	
  	
  These	
  youth	
  were	
  assigned	
  to	
  single	
  cells	
  where	
   they	
  remained	
  the	
  majority	
  of	
  the	
  day.	
  	
  Youth	
  on	
  phase	
  one	
  of	
  the	
   program	
  are	
  in	
  ambulatory	
  restraints	
  (“gators”)	
  when	
  they	
  are	
  outside	
   of	
  their	
  cells.	
  	
  There	
  have	
  been	
  changes	
  to	
  the	
  procedure	
  for	
  monitoring	
   on	
  the	
  Progress	
  Units,	
  specifically,	
  psychology	
  and	
  social	
  work	
  staff	
  are	
   required	
  to	
  make	
  daily	
  contact	
  with	
  youth	
  on	
  phase	
  one	
  which	
  includes	
   a	
  mini	
  mental	
  status	
  examination	
  and	
  encouraging	
  youth	
  to	
  meet	
  with	
   and	
  talk	
  to	
  the	
  Behavioral	
  Health	
  staff.	
  	
  Per	
  record	
  review	
  performed	
   during	
  the	
  monitoring	
  visit,	
  documentation	
  of	
  these	
  encounters	
  was	
   located.	
  	
  	
   	
   These	
  reviews	
  serve	
  several	
  purposes,	
  to	
  monitor	
  youth	
  housed	
  in	
  this	
   area	
  for	
  decompensation,	
  to	
  identify	
  youth	
  requiring	
  mental	
  health	
   intervention,	
  and	
  to	
  ensure	
  access	
  to	
  health	
  care	
  for	
  those	
  youth	
   housed	
  on	
  that	
  unit.	
  	
  It	
  should	
  be	
  noted	
  that	
  late	
  in	
  the	
  monitoring	
   period,	
  youth	
  were	
  allowed	
  out	
  of	
  their	
  cells	
  on	
  a	
  daily	
  basis	
  for	
   increasing	
  amounts	
  of	
  time,	
  which	
  is	
  positive.	
  	
  As	
  this	
  progresses,	
  and	
   youth	
  are	
  out	
  of	
  their	
  cells	
  for	
  the	
  majority	
  of	
  their	
  waking	
  hours,	
  the	
   need	
  for	
  daily	
  mini	
  mental	
  status	
  reviews	
  will	
  be	
  reduced.	
  	
  	
   	
   Review	
  of	
  the	
  documentation	
  of	
  these	
  encounters	
  revealed	
  that	
  in	
   general	
  they	
  were	
  brief	
  (one	
  to	
  three	
  minutes).	
  	
  Written	
  documentation	
   of	
  these	
  encounters	
  included	
  a	
  mental	
  status	
  examination,	
  which	
  would	
   be	
  impossible	
  to	
  complete	
  in	
  this	
  amount	
  of	
  time.	
  	
  This	
  process	
  must	
  be	
   codified	
  in	
  policy	
  and	
  procedure	
  and	
  reviewed	
  via	
  quality	
  assurance.	
   	
   It	
  should	
  be	
  noted	
  that	
  in	
  general,	
  youth	
  interviewed	
  in	
  general	
   population	
  and	
  on	
  the	
  girls	
  mental	
  health	
  units	
  believed	
  that	
  they	
  had	
   good	
  access	
  to	
  their	
  counselor	
  and	
  that	
  mental	
  health	
  needs	
  were	
   addressed	
  in	
  a	
  timely	
  manner.	
  	
  Youth	
  housed	
  in	
  the	
  Progress	
  Units	
  were	
   less	
  satisfied	
  with	
  their	
  mental	
  health	
  treatment	
  and	
  contact.	
  	
  Several	
   youth	
  interviewed	
  indicated	
  that	
  they	
  were	
  not	
  receiving	
  regular	
   individual	
  therapy	
  sessions.	
  	
  One	
  youth	
  filed	
  a	
  grievance	
  to	
  this	
  effect.	
  	
   Please	
  see	
  the	
  discussion	
  in	
  III.B.18	
  for	
  additional	
  information	
  regarding	
   this	
  issue.	
   	
   Per	
  a	
  review	
  of	
  mental	
  health	
  staff	
  schedules	
  provided,	
  mental	
  health	
   staff	
  scheduling	
  included	
  both	
  evening	
  (until	
  8:00	
  p.m.)	
  and	
  weekend	
   hours,	
  allowing	
  for	
  better	
  daily	
  coverage	
  of	
  youth	
  mental	
  health	
  needs.	
   However,	
  of	
  the	
  mental	
  health	
  staff,	
  only	
  the	
  psychology	
  supervisor	
  was	
   on-­‐call	
  24	
  hours	
  per	
  day.	
  	
  
In	
  order	
  to	
  maintain	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  requirements	
  for	
  daily	
  mental	
  
health	
  assessments	
  for	
  those	
  youth	
  housed	
  on	
  Phase	
  I	
  of	
  the	
   Progress	
  unit.	
  

	
  

73.	
  

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Sources	
  of	
   Information	
  
	
   	
  

2. Revise	
  policy	
  and	
  procedure	
  to	
  reflect	
  requirements	
  for	
  twice	
   weekly	
  mental	
  health	
  assessments	
  for	
  those	
  youth	
  housed	
  on	
  Phase	
   II	
  of	
  the	
  Progress	
  unit.	
  
3. Develop	
  quality	
  assurance	
  monitoring	
  to	
  ensure	
  timeliness	
  and	
   adequacy	
  of	
  clinical	
  contact	
  with	
  those	
  youth	
  housed	
  on	
  the	
   Progress	
  Unit.	
  
4. Develop	
  quality	
  assurance	
  monitoring	
  to	
  audit	
  requests	
  for	
  mental	
   health	
  services	
  inclusive	
  of	
  staff	
  response	
  time	
  as	
  well	
  as	
  timelines	
   for	
  completion	
  of	
  other	
  mental	
  health	
  services	
  as	
  outlined	
  by	
  facility	
   policy	
  and	
  procedure.	
  
5. Ensure	
  the	
  youth’s	
  open	
  access	
  to	
  mental	
  health	
  services	
  
• Review	
  of	
  provided	
  documents	
   • Youth	
  interviews	
   • Staff	
  interviews	
  
	
  

	
  

74.	
  

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III.B.10	
  	
  Mental	
  Health	
  Involvement	
  in	
  Housing	
  and	
  Placement	
  Decisions.	
  	
  The	
  State	
  shall	
   develop	
  and	
  implement	
  a	
  system	
  for	
  ensuring	
  that	
  significantly	
  mentally	
  ill	
  youth	
  who	
  do	
  not	
   have	
  the	
  adaptive	
  functioning	
  to	
  manage	
  the	
  activities	
  of	
  daily	
  living	
  within	
  the	
  general	
   population	
  are	
  provided	
  appropriate	
  housing	
  and	
  supports	
  to	
  assist	
  them	
  in	
  managing	
  within	
   the	
  institutional	
  setting.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally.	
  	
  ODYS	
  staff	
  indicated	
   that	
  they	
  were	
  screening	
  youth	
  referred	
  to	
  the	
  Progress	
  units	
  in	
  order	
  to	
   ensure	
  appropriate	
  referrals	
  (e.g.	
  that	
  youth	
  were	
  not	
  precluded	
  due	
  to	
   a	
  mental	
  health	
  condition).	
  	
  Facility	
  staff	
  reported	
  increased	
  ability	
  to	
   make	
  referrals	
  to	
  specialized	
  units	
  (i.e.	
  Life	
  Skills,	
  mental	
  health	
  unit).	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

During	
  the	
  monitoring	
  visit,	
  it	
  was	
  discussed	
  that	
  policy	
  and	
  procedure	
   was	
  in	
  the	
  process	
  of	
  review	
  and	
  revision.	
  	
  Per	
  staff	
  interview,	
  a	
  new	
   form	
  has	
  been	
  developed	
  that	
  is	
  completed	
  by	
  the	
  assessing	
  clinician	
  for	
   presentation	
  to	
  the	
  treatment	
  team,	
  who	
  then	
  functions	
  as	
  the	
   Behavioral	
  Health	
  Review	
  Panel	
  making	
  the	
  determination	
  regarding	
   housing	
  decisions.	
  	
  	
   	
   With	
  regard	
  to	
  placement	
  on	
  the	
  Progress	
  Units,	
  the	
  census	
  on	
  these	
   units	
  had	
  increased	
  slightly	
  from	
  the	
  previous	
  monitoring	
  visit.	
  	
   Previously,	
  there	
  were	
  18	
  youth	
  housed	
  on	
  the	
  Progress	
  units.	
  	
  This	
   monitoring	
  visit,	
  there	
  were	
  a	
  total	
  of	
  21	
  youth	
  (Phase	
  I	
  housed	
  eight	
   youth	
  and	
  Phase	
  II	
  housed	
  13	
  youth).	
  	
  	
  	
  In	
  order	
  for	
  youth	
  to	
  enter	
  the	
   Progress	
  Units,	
  the	
  referral	
  process	
  had	
  continued.	
  	
  	
  	
  Staff	
  are	
  required	
   to	
  complete	
  referral	
  packets	
  that	
  must	
  be	
  presented	
  facility	
   administration	
  for	
  approval.	
  	
  Once	
  placement	
  is	
  approved	
  at	
  the	
  facility	
   level,	
  these	
  admission	
  packets	
  must	
  be	
  approved	
  by	
  ODYS	
  central	
  office.	
  	
   For	
  those	
  youth	
  with	
  current	
  mental	
  health	
  diagnoses	
  or	
  conditions,	
   central	
  office	
  Behavioral	
  Health	
  staff	
  are	
  consulted.	
  	
  Unfortunately,	
  no	
   examples	
  of	
  this	
  process	
  were	
  provided	
  for	
  off	
  site	
  review.	
  	
  As	
  noted	
   previously,	
  policy	
  and	
  procedure	
  is	
  in	
  the	
  process	
  of	
  review,	
  and	
  this	
   process	
  will	
  reportedly	
  be	
  included	
  in	
  the	
  resultant	
  policy	
  and	
   procedure.	
  	
  Following	
  the	
  submission	
  of	
  this	
  draft	
  report,	
  some	
   examples	
  of	
  the	
  admission	
  review	
  documents	
  for	
  youth	
  considered	
  for	
   admission	
  to	
  the	
  Progress	
  Units	
  were	
  provided	
  for	
  review.	
  	
  These	
   assessments	
  had	
  improved	
  and	
  were	
  more	
  comprehensive.	
  	
  	
   	
   Observation	
  and	
  interview	
  of	
  a	
  sample	
  of	
  youth	
  currently	
  housed	
  on	
  the	
   Progress	
  Units	
  revealed	
  cause	
  for	
  concern	
  with	
  regard	
  to	
  the	
  screening	
   process.	
  	
  For	
  example,	
  Youth	
  #777	
  reported	
  a	
  history	
  of	
  multiple	
   transitions	
  between	
  Phase	
  1	
  and	
  Phase	
  2	
  of	
  the	
  Progress	
  Units.	
  	
  He	
   indicated	
  that	
  he	
  was	
  not	
  currently	
  prescribed	
  psychotropic	
   medications.	
  	
  In	
  his	
  presentation,	
  he	
  was	
  distractible,	
  exhibited	
  rapid	
   speech,	
  loosening	
  of	
  associations,	
  was	
  irritable,	
  and	
  labile.	
  	
  Staff	
   interviewed	
  indicated	
  that	
  this	
  youth	
  does	
  not	
  appear	
  to	
  appropriately	
   process	
  information	
  and	
  does	
  not	
  follow	
  directives.	
  	
  During	
  the	
  

	
  

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monitoring	
  visit,	
  it	
  was	
  recommended	
  that	
  this	
  youth	
  be	
  considered	
  for	
   a	
  psychiatric	
  evaluation	
  and	
  consideration	
  for	
  transfer	
  to	
  the	
  mental	
   health	
  unit.	
  	
  Information	
  received	
  following	
  the	
  visit	
  indicated	
  that	
  the	
   youth	
  was	
  considered	
  for	
  transfer;	
  however,	
  this	
  ultimately	
  was	
  not	
   performed.	
  	
  The	
  rationale	
  was	
  as	
  follows:	
   	
  	
   “Current	
  Functioning:	
  …recommended	
  for	
  promotion	
  to	
  Transition	
  and	
   continues	
  to	
  maintain	
  stability	
  and	
  solid	
  behavior	
  on	
  the	
  Progress	
  Unit.	
   He	
  is	
  sitting	
  for	
  the	
  official	
  GED	
  test	
  all	
  day	
  today	
  and	
  so	
  far	
  is	
  doing	
  very	
   well.	
  Based	
  on	
  his	
  improvements	
  and	
  stability,	
  …earned	
  a	
  release	
  date	
  of	
   11/28/2012	
  contingent	
  on	
  successful	
  completion	
  of	
  the	
  Progress	
  Unit	
   program.	
  	
   	
  	
   While	
  he	
  continues	
  to	
  be	
  a	
  challenge	
  with	
  regards	
  to	
  medication	
  and	
   medication	
  compliance,	
  he	
  is	
  engaged	
  in	
  the	
  process	
  and	
  has	
   demonstrated	
  an	
  openness	
  to	
  continue	
  a	
  discussion	
  of	
  the	
  issues.	
   Conversely,	
  his	
  response	
  to	
  and	
  engagement	
  in	
  psychotherapy	
  with	
  his	
   clinical	
  staff	
  has	
  become	
  consistent,	
  something	
  to	
  which	
  he	
  looks	
   forward,	
  and	
  appears	
  to	
  have	
  become	
  a	
  significant	
  source	
  of	
  support	
   and	
  a	
  catalyst	
  for	
  change	
  and	
  progress.	
  	
   	
  	
   With	
  an	
  approved	
  release	
  date	
  so	
  close,	
  it	
  is	
  not	
  at	
  all	
  clear	
  that	
  the	
   (possible,	
  but	
  not	
  certain)	
  benefits	
  of	
  transfer	
  to	
  the	
  MH	
  unit	
  would	
   surpass	
  the	
  potential	
  loss	
  and	
  harm	
  that	
  may	
  result	
  from	
  a	
  complete	
   change	
  not	
  only	
  in	
  setting	
  but	
  also	
  in	
  the	
  entire	
  team	
  and	
  clinicians	
   working	
  with	
  him.	
  While	
  the	
  original	
  notion	
  of	
  potential	
  referral,	
  and	
   ultimate	
  formal	
  referral,	
  were	
  based	
  on	
  the	
  emergence	
  and	
  recognition	
   of	
  his	
  mental	
  health	
  issues,	
  the	
  nearness	
  of	
  his	
  release	
  date	
  was	
  not	
   included	
  in	
  the	
  deliberation	
  and	
  decision.	
  Because	
  he	
  has	
  not	
  only	
  been	
   very	
  stable	
  for	
  an	
  extended	
  period,	
  but	
  is	
  in	
  fact	
  presenting	
  as	
   increasingly	
  stable,	
  the	
  release	
  date	
  clearly	
  becomes	
  a	
  matter	
  of	
  central	
   importance.	
   	
  	
   Likely	
  Gains	
  from	
  Treatment:	
  	
  Following	
  from	
  the	
  above,	
  my	
  discussions	
   over	
  the	
  last	
  24	
  hours	
  have	
  led	
  to	
  a	
  question	
  of	
  likely	
  gain	
  from	
  transfer	
   as	
  compared	
  to	
  what	
  might	
  be	
  gained	
  from	
  remaining	
  at	
  SJCF	
  with	
   promotion	
  to	
  the	
  Transition	
  Unit	
  and	
  continued	
  intensive	
  treatment	
   within	
  the	
  already	
  established	
  relationships	
  with	
  his	
  clinicians	
  here.	
   While	
  the	
  MH	
  unit	
  at	
  IRJCF	
  will	
  provide	
  a	
  solid	
  clinical	
  team	
  and	
  all	
  the	
   benefits	
  of	
  the	
  specialized	
  unit,	
  there	
  is	
  always	
  a	
  period	
  of	
  adjustment,	
   transition	
  and	
  accommodation	
  involved	
  in	
  the	
  development	
  of	
  truly	
   therapeutic	
  relationships.	
  I	
  did	
  not	
  consider	
  this	
  factor	
  adequately	
  in	
  the	
   context	
  of	
  the	
  November	
  release	
  date	
  when	
  I	
  initially	
  made	
  the	
  referral.	
   It	
  became	
  more	
  clear	
  in	
  and	
  through	
  the	
  discussion…may	
  be	
  the	
  most	
   important	
  issue	
  to	
  consider.	
  	
   	
  	
   Re-­‐entry	
  Planning:	
  	
  Finally,	
  the	
  matter	
  of	
  re-­‐entry	
  planning	
  is	
  a	
  critical	
  

	
  

76.	
  

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one	
  with	
  all	
  youths	
  but	
  I	
  would	
  venture	
  to	
  say	
  that	
  it	
  is	
  especially	
  critical	
   with	
  [him].	
  With	
  a	
  significantly	
  greater	
  level	
  of	
  involvement	
  with	
  and	
   knowledge	
  of	
  [him],	
  the	
  clinical	
  team	
  at	
  SJCF	
  is	
  better	
  prepared	
  to	
  make	
   the	
  connections	
  and	
  develop	
  the	
  mechanics	
  for	
  a	
  smooth	
  and	
  successful	
   transition	
  to	
  his	
  community.	
  We	
  believe	
  he	
  will	
  require	
  a	
  substantial	
   network	
  of	
  support	
  and	
  treatment	
  and	
  the	
  team	
  at	
  SJCF	
  is	
  in	
  a	
  better	
   position	
  to	
  make	
  that	
  happen	
  by	
  virtue	
  of	
  the	
  factors	
  I	
  identified	
  above:	
   degree	
  of	
  involvement	
  with	
  and	
  knowledge	
  of	
  [him].	
   	
  	
   As	
  a	
  result	
  of	
  these	
  considerations,	
  I	
  am	
  recommending	
  at	
  this	
  time	
  that	
   we	
  place	
  this	
  transfer	
  on	
  hold	
  and	
  continue	
  our	
  intensive	
  work	
  …on	
  the	
   Transition	
  unit	
  at	
  SJCF.	
  We	
  do	
  not	
  believe	
  it	
  would	
  be	
  in	
  his	
  best	
  interests	
   to	
  transition	
  him	
  further	
  to	
  a	
  GP	
  unit	
  and	
  would	
  plan	
  to	
  continue	
   working	
  with	
  him	
  on	
  Transition	
  until	
  his	
  release.	
  If	
  he	
  maintains	
  his	
   current	
  level	
  of	
  stability	
  I	
  would	
  recommend	
  that	
  we	
  make	
  no	
  changes	
  in	
   placement	
  and	
  work	
  towards	
  the	
  development	
  and	
  coordination	
  of	
  a	
   solid	
  re-­‐entry	
  plan.	
  If	
  he	
  begins	
  to	
  struggle	
  and/or	
  begins	
  to	
  display	
  signs	
   of	
  instability	
  and	
  regression,	
  the	
  team	
  here	
  with	
  their	
  extensive	
   experience	
  with	
  him	
  would	
  be	
  in	
  a	
  better	
  position	
  to	
  assess	
  his	
   immediate	
  needs	
  and	
  to	
  respond	
  appropriately.	
  If	
  he	
  displays	
  signs	
  of	
   decompensation,	
  we	
  have	
  everything	
  in	
  place	
  to	
  effect	
  a	
  rapid	
  transfer	
   to	
  the	
  MH	
  unit	
  if	
  needed.”	
   	
   The	
  above	
  represents	
  a	
  partial	
  response	
  to	
  the	
  consideration	
  for	
   transfer	
  to	
  the	
  mental	
  health	
  units.	
  The	
  issue	
  this	
  is	
  not	
  addressed	
   sufficiently	
  is	
  this	
  youth’s	
  mental	
  health	
  diagnoses	
  and	
  the	
  need	
  for	
   treatment	
  with	
  psychotropic	
  medication	
  to	
  address	
  his	
  symptoms.	
  	
  It	
  is	
   recognized	
  that	
  this	
  youth	
  likely	
  refused	
  mental	
  health	
  treatment;	
   however,	
  given	
  the	
  information	
  outlined	
  below,	
  it	
  was	
  apparent	
  that	
   mental	
  health	
  issues	
  contributed	
  to	
  his	
  behavior	
  prior	
  to	
  referral,	
  and	
   were	
  not	
  addressed	
  prior	
  to	
  his	
  referral.	
  	
  There	
  was	
  no	
  documentation	
   indicating	
  attempts	
  to	
  develop	
  a	
  therapeutic	
  relationship	
  with	
  this	
   youth	
  in	
  order	
  to	
  educate	
  him	
  with	
  regard	
  to	
  his	
  illness	
  and	
  increase	
  the	
   possibility	
  of	
  adherence.	
  	
  Rather,	
  he	
  was	
  transferred	
  to	
  the	
  Progress	
   Units,	
  where	
  he	
  experienced	
  a	
  long	
  term	
  stay,	
  difficulty	
  with	
   progression	
  through	
  the	
  phases,	
  likely	
  contributed	
  to	
  by	
  unaddressed	
   mental	
  health	
  issues.	
  	
  This	
  illustrates	
  the	
  need	
  for	
  improved	
  mental	
   health	
  assessment,	
  diagnostics,	
  development	
  of	
  a	
  case	
  formulation,	
  and	
   generation	
  of	
  a	
  treatment	
  plan	
  to	
  address	
  the	
  youth’s	
  identified	
  issues	
   that	
  is	
  individualized.	
   	
   This	
  youth	
  was	
  referred	
  for	
  placement	
  on	
  the	
  Progress	
  Unit	
  in	
  February	
   2012,	
  and	
  apparently	
  experienced	
  significant	
  difficulty	
  with	
  the	
   program,	
  resulting	
  in	
  an	
  extended	
  stay.	
  	
  A	
  review	
  of	
  this	
  youth’s	
  referral	
   for	
  placement	
  revealed	
  that	
  this	
  youth	
  had	
  a	
  history	
  of	
  assaultive	
   behavior	
  and	
  gang	
  involvement.	
  	
  The	
  Progress	
  referral	
  fact	
  sheet	
   indicated	
  that	
  this	
  youth	
  was	
  not	
  on	
  the	
  mental	
  health	
  caseload,	
  but	
  

	
  

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Recommendations	
  

recommended,	
  “evaluate	
  for	
  mental	
  health	
  caseload.”	
  	
  Additional	
   information	
  included	
  revealed	
  that	
  the	
  OYAS	
  performed	
  1.10.12	
   indicated	
  the	
  youth	
  was	
  moderate	
  risk	
  in	
  the	
  areas	
  of	
   “Substance/Mental	
  Health.”	
  	
   	
   Per	
  the	
  ODYS	
  unified	
  case	
  plan	
  dated	
  2.2.12,	
  this	
  youth	
  had	
  mental	
   health	
  diagnoses	
  including	
  “Bipolar	
  Disorder,	
  not	
  otherwise	
  specified;	
   Conduct	
  Disorder;	
  Cannabis	
  Dependence;	
  Alcohol	
  Abuse;	
  ADHD	
  by	
   history;	
  Tourettes	
  Syndrome;	
  and	
  Borderline	
  Intellectual	
  Functioning.”	
  A	
   review	
  of	
  the	
  treatment	
  goals	
  proposed	
  by	
  the	
  case	
  plan	
  revealed	
  that	
   there	
  were	
  “no	
  goals	
  being	
  addressed	
  for	
  this	
  domain	
  at	
  this	
  time”	
  in	
   the	
  areas	
  of	
  substance	
  abuse	
  and	
  mental	
  health..	
   	
   Per	
  a	
  psychological	
  evaluations	
  dated	
  3.29.10	
  performed	
  at	
  SJCF,	
  this	
   youth	
  presented	
  with	
  behavioral	
  observations	
  including	
  “rapid	
  and	
   pressured	
  speech…difficult	
  to	
  understand…thoughts…concrete,	
  were	
   logical	
  and	
  coherent…minor	
  attention	
  problems…easily	
  distracted…”	
   	
   Given	
  the	
  above,	
  it	
  was	
  apparent	
  that	
  mental	
  health	
  issues	
  were	
   significant	
  and	
  not	
  appropriately	
  addressed	
  prior	
  to	
  transfer	
  to	
  the	
   Progress	
  Unit	
  and	
  during	
  the	
  majority	
  of	
  his	
  stay	
  there.	
   	
  	
   Nine	
  examples	
  of	
  intake	
  assessment	
  and	
  subsequent	
  Behavioral	
  Health	
   Appraisal	
  documents	
  were	
  reviewed.	
  	
  In	
  the	
  sample	
  provided,	
  all	
  youth	
   were	
  referred	
  for	
  a	
  Behavioral	
  Health	
  Appraisal	
  at	
  intake.	
  	
  Included	
  in	
   the	
  Behavioral	
  Health	
  Appraisal	
  was	
  a	
  recommendation	
  for	
  placement.	
  	
   All	
  of	
  the	
  examples	
  received	
  were	
  recommended	
  for	
  placement	
  in	
  the	
   general	
  population.	
   While	
  overall	
  there	
  were	
  improvements	
  noted	
  in	
  the	
  quality	
  of	
   documentation,	
  variability	
  remained.	
  	
  This	
  is	
  an	
  area	
  that	
  should	
  be	
   monitored	
  via	
  quality	
  improvement.	
  	
  Some	
  documents	
  were	
  completed;	
   others	
  were	
  not.	
  	
  What	
  was	
  lacking	
  in	
  all	
  documentation	
  was	
  a	
  case	
   conceptualization	
  outlining	
  the	
  justification	
  for	
  specific	
  diagnosis.	
  	
  At	
   this	
  stage,	
  it	
  is	
  acknowledged	
  that	
  the	
  case	
  conceptualization	
  would	
  be	
   brief,	
  with	
  further	
  detail	
  and	
  refinement	
  performed	
  by	
  the	
  youth’s	
   mental	
  health	
  treatment	
  provided	
  upon	
  assignment	
  to	
  a	
  specific	
   treatment	
  provider.	
  	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Complete	
  policy	
  and	
  procedure	
  review.	
   2. Review	
  the	
  referral	
  process	
  for	
  youth	
  considered	
  for	
  placement	
  on	
  
the	
  Progress	
  Units.	
  	
  Ensure	
  that	
  appropriate	
  services	
  have	
  been	
   considered	
  and	
  provided	
  prior	
  to	
  referral.	
  	
  Determine	
  specific	
   mental	
  health	
  diagnoses	
  that	
  would	
  be	
  inappropriate	
  for	
   consideration	
  (e.g.	
  thought	
  disorders;	
  acute	
  mental	
  health	
   exacerbations;	
  developmental	
  disabilities;	
  etc.)	
   3. For	
  those	
  youth	
  who	
  require	
  enhanced	
  treatment	
  following	
  the	
  

	
  

78.	
  

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Sources	
  of	
   Information	
  
	
   	
   	
  

initial	
  placement	
  determination,	
  consider	
  performing	
  retrospective	
   record	
  review	
  (e.g.	
  QA)	
  in	
  order	
  to	
  improve	
  assessment	
  and	
   placement	
  process.	
   4. Begin	
  quality	
  assurance	
  monitoring	
  regarding	
  intake	
  and	
  placement	
   documentation	
  and	
  processes.	
   5. Indicate	
  the	
  method	
  by	
  which	
  youth	
  who	
  are	
  not	
  referred	
  for	
  a	
   Behavioral	
  Health	
  Appraisal	
  are	
  assessed	
  for	
  appropriate	
  placement	
   within	
  the	
  facility.	
   6. Improve	
  documentation	
  promulgated	
  by	
  the	
  Behavioral	
  Health	
   Appraisal.	
   	
  
• Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  	
   • Review	
  of	
  youth	
  records	
   • Youth	
  interview	
  and	
  observation	
  
	
  

	
  

79.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 80 of 129 PAGEID #: 2433

III.B.11	
  	
  	
  Staffing.	
  	
  The	
  State	
  shall	
  staff,	
  by	
  contract	
  or	
  otherwise,	
  the	
  facilities	
  with	
  adequate	
   numbers	
  of	
  psychiatrists,	
  psychologists,	
  social	
  workers,	
  and	
  other	
  mental	
  health	
  professionals	
   qualified	
  through	
  training	
  and	
  practical	
  experience	
  to	
  meet	
  the	
  mental	
  health	
  needs	
  of	
  youth	
   residents,	
  as	
  determined	
  by	
  the	
  acuity	
  of	
  those	
  needs.	
  Mental	
  health	
  care	
  shall	
  be	
  integrated	
   with	
  other	
  medical	
  and	
  mental	
  health	
  services	
  and	
  shall	
  comport	
  with	
  generally	
  accepted	
   practices.	
  The	
  State	
  shall	
  ensure	
  that	
  there	
  are	
  sufficient	
  numbers	
  of	
  adequately	
  trained	
  direct	
   care	
  and	
  supervisory	
  staff	
  to	
  allow	
  youth	
  reasonable	
  access	
  to	
  structured	
  programming.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally,	
  and	
  indicated	
  increased	
   psychiatric	
  resources.	
  	
  For	
  additional	
  information,	
  please	
  see	
  the	
   discussion	
  in	
  provision	
  III.B.13	
  below.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

A	
  review	
  of	
  the	
  provided	
  documents	
  revealed	
  a	
  spreadsheet	
  of	
  all	
   mental	
  health	
  positions.	
  	
  There	
  were	
  a	
  total	
  of	
  14	
  filled	
  social	
  work	
   positions	
  (including	
  two	
  supervisory	
  positions).	
  	
  Of	
  these,	
  11	
  were	
   licensed.	
  	
  This	
  represented	
  increased	
  vacancies	
  since	
  the	
  previous	
   report	
  where	
  there	
  18	
  filled	
  social	
  work	
  positions.	
  	
  There	
  were	
  six	
   vacant	
  social	
  worker	
  positions.	
  	
  One	
  of	
  these	
  positions	
  was	
  noted	
  as	
   vacant	
  as	
  of	
  3.11.12,	
  others	
  were	
  noted	
  as	
  vacant	
  as	
  of	
  later	
  in	
  the	
  year	
   2012,	
  with	
  one	
  vacancy	
  noted	
  as	
  a	
  “new	
  position.”	
   	
   There	
  were	
  a	
  total	
  of	
  eight	
  filled	
  psychology	
  positions	
  (including	
  one	
   supervisor).	
  	
  Of	
  these	
  four	
  were	
  psychology	
  assistants	
  (unlicensed).	
  	
   Four	
  were	
  licensed	
  psychology	
  staff	
  (inclusive	
  of	
  the	
  psychology	
   supervisor).	
  	
  There	
  were	
  two	
  vacant	
  psychology	
  positions,	
  one	
  assistant	
   and	
  one	
  psychologist.	
  	
  	
  	
  These	
  positions	
  were	
  noted	
  as	
  vacant	
  as	
  of	
   3.11.12	
  and	
  9.9.12	
  respectively.	
  	
  There	
  were	
  two	
  licensed	
  psychiatric	
   nurses.	
  	
  	
  Other	
  mental	
  health	
  staff	
  positions	
  included	
  two	
  occupational	
   therapists,	
  a	
  transcription	
  service,	
  and	
  the	
  two	
  facility	
  psychiatrists.	
   	
   Schedules	
  for	
  psychology	
  staff	
  were	
  provided	
  for	
  review.	
  	
  Per	
  this	
   document,	
  psychology	
  staff	
  work	
  a	
  flex	
  80	
  hour	
  schedule	
  every	
  two	
   weeks.	
  	
  Regular	
  hours	
  are	
  8:00	
  am	
  to	
  4:30	
  pm,	
  and	
  they	
  are	
  required	
  to	
   work	
  one	
  late	
  night	
  per	
  week	
  and	
  one	
  weekend	
  per	
  month	
  in	
  an	
  effort	
   to	
  provide	
  greater	
  clinical	
  coverage	
  at	
  the	
  facility.	
  	
  The	
  exception	
  to	
  this	
   coverage	
  is	
  holidays,	
  where	
  per	
  the	
  schedule	
  examples	
  provided,	
  no	
   psychology	
  staff	
  is	
  on	
  duty.	
  	
  Per	
  staff	
  report,	
  the	
  psychology	
  supervisor	
   is	
  on	
  call	
  after	
  hours	
  and	
  holidays	
  and	
  will	
  present	
  to	
  the	
  facility	
  as	
   needed.	
   	
   In	
  an	
  effort	
  to	
  address	
  clinical	
  need	
  on	
  the	
  Progress	
  Units,	
  mental	
  health	
   staff	
  resources	
  have	
  been	
  shifted.	
  	
  There	
  are	
  now	
  three	
  psychology	
  staff	
   assigned	
  to	
  these	
  units,	
  with	
  plans	
  for	
  the	
  youth	
  to	
  keep	
  the	
  same	
   psychology	
  staff	
  as	
  they	
  progress	
  through	
  each	
  phase,	
  including	
   transition.	
  	
  Additionally,	
  there	
  have	
  been	
  efforts	
  to	
  assign	
  both	
  a	
   psychologist	
  and	
  social	
  worker	
  to	
  each	
  housing	
  unit.	
  	
  These	
  shifts	
  were	
   the	
  initial	
  phase	
  of	
  a	
  larger	
  plan	
  verbalized	
  by	
  ODYS	
  to	
  create	
  a	
  

	
  

80.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 81 of 129 PAGEID #: 2434

behavioral	
  health	
  team	
  in	
  contrast	
  to	
  the	
  previous	
  silos	
  inherent	
  in	
   having	
  artificial	
  divisions	
  between	
  the	
  departments	
  of	
  social	
  work	
  and	
   psychology.	
  	
  The	
  revision	
  process	
  for	
  policy	
  and	
  procedure	
  was	
  also	
  a	
   step	
  toward	
  this	
  integration	
  as	
  per	
  staff	
  interview;	
  staff	
  from	
  various	
   disciplines	
  were	
  assigned	
  to	
  work	
  groups	
  in	
  order	
  to	
  provide	
  input	
  into	
   the	
  policy	
  and	
  procedure	
  documents.	
   	
   Per	
  the	
  previous	
  monitoring	
  report,	
  the	
  workload	
  for	
  psychology	
  staff	
   had	
  increased	
  due	
  to	
  vacancies	
  in	
  social	
  work	
  staff	
  positions.	
  It	
  was	
   opined	
  by	
  the	
  monitor	
  that	
  once	
  social	
  work	
  positions	
  were	
  filled,	
  it	
   would	
  be	
  advantageous	
  to	
  examine	
  the	
  current	
  psychology	
  staffing	
   pattern	
  and	
  required	
  psychology	
  workload	
  in	
  order	
  to	
  objectively	
   determine	
  the	
  need	
  for	
  additional	
  staff.	
  	
  With	
  the	
  planned	
  integration	
  of	
   departments	
  and	
  creation	
  of	
  a	
  behavioral	
  health	
  team	
  focus,	
  this	
  may	
   be	
  premature.	
  	
  The	
  deficiencies	
  in	
  social	
  work	
  staffing	
  have	
  reemerged,	
   as	
  there	
  are	
  currently	
  six	
  vacancies	
  as	
  opposed	
  to	
  two	
  vacancies	
  at	
  the	
   time	
  of	
  the	
  previous	
  monitoring	
  report.	
   	
   Per	
  staff	
  interviews	
  and	
  documentation	
  provided	
  during	
  the	
  previous	
   monitoring	
  period	
  regarding	
  support	
  staff	
  for	
  psychiatry,	
  the	
  psychiatric	
   nurse	
  was	
  carrying	
  a	
  large	
  workload.	
  According	
  to	
  the	
  documents	
   reviewed,	
  the	
  nurse	
  provided	
  the	
  following	
  support	
  services	
  to	
   psychiatry:	
  scheduling	
  new	
  and	
  follow-­‐up	
  appointments;	
  preparing	
   medical	
  records	
  for	
  review;	
  providing	
  dictated	
  reports	
  for	
  review;	
   updating	
  the	
  mental	
  health	
  database;	
  attending	
  team	
  meetings	
  and	
   providing	
  updates	
  to	
  the	
  psychiatrist	
  when	
  he	
  was	
  unavailable	
  to	
   attend;	
  responding	
  to	
  staff	
  concerns	
  and	
  preparing	
  assessment	
   information	
  for	
  psychiatry;	
  assisting	
  with	
  the	
  notification	
  of	
   parents/guardians	
  of	
  any	
  changes	
  in	
  the	
  youth’s	
  mental	
  health	
  status	
  or	
   treatment;	
  providing	
  updates,	
  changes,	
  and	
  concerns	
  regarding	
  youth	
  to	
   psychiatry;	
  assisting	
  in	
  education	
  of	
  youth	
  regarding	
  mental	
  health	
   issues;	
  monitoring,	
  counseling,	
  and	
  reporting	
  regarding	
  medication	
   compliance;	
  and	
  communicating	
  day	
  to	
  day	
  issues	
  regarding	
  psychiatric	
   care	
  to	
  the	
  health	
  services	
  administrator.	
  	
  	
   	
   This	
  list	
  of	
  tasks	
  was	
  daunting,	
  and	
  physically	
  impossible	
  for	
  one	
   individual	
  to	
  complete,	
  although	
  the	
  individual	
  in	
  this	
  position	
  was	
  doing	
   her	
  best	
  to	
  manage	
  the	
  workload	
  and	
  did	
  not	
  complain.	
  	
  Approximately	
   one	
  month	
  prior	
  to	
  this	
  monitoring	
  visit,	
  a	
  second	
  psychiatric	
  nurse	
  had	
   been	
  hired.	
  	
  The	
  two	
  nurses	
  worked	
  collaboratively	
  and	
  were	
  excited	
   regarding	
  their	
  potential	
  efforts	
  with	
  two	
  staff.	
  	
  Currently,	
  one	
  nurse	
   was	
  assigned	
  to	
  the	
  progress	
  units	
  and	
  one	
  nurse	
  was	
  assigned	
  to	
  all	
   other	
  housing	
  units.	
  	
  Each	
  nurse	
  was	
  assigned	
  to	
  a	
  specific	
  psychiatrist.	
   	
   There	
  were	
  examples	
  in	
  the	
  provided	
  documentation	
  of	
  the	
  ongoing	
   therapeutic	
  activities	
  in	
  the	
  intervening	
  period	
  since	
  the	
  last	
  monitoring	
   visit.	
  	
  For	
  example,	
  per	
  the	
  document	
  review	
  regarding	
  youth	
  mental	
  

	
  

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Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 82 of 129 PAGEID #: 2435

health	
  contacts:	
  	
  	
   • Between	
  7.1.12	
  and	
  9.29.12	
  there	
  were	
  1020	
  total	
  mental	
   health	
  contacts	
  with	
  female	
  youth.	
  	
  This	
  included	
  group,	
   individual,	
  and	
  crisis	
  intervention.	
   • Between	
  7.1.12	
  and	
  9.30.12	
  there	
  were	
  a	
  total	
  of	
  2978	
  mental	
   health	
  contacts	
  with	
  male	
  youth.	
  	
  This	
  included	
  group,	
   individual,	
  crisis	
  intervention,	
  and	
  daily	
  door	
  checks	
  on	
  Progress	
   Units.	
  
	
   While	
  these	
  mental	
  health	
  units	
  are	
  an	
  improvement	
  from	
  prior	
  contact	
   reports,	
  there	
  remain	
  issues.	
  	
  For	
  example,	
  the	
  number	
  of	
  youth	
   attending	
  a	
  group	
  session	
  was	
  noted	
  to	
  be	
  excessive.	
  	
  This	
  was	
  noted	
   more	
  frequently	
  with	
  group	
  activities	
  led	
  by	
  social	
  worker	
  staff.	
  	
  For	
   example,	
  Core	
  Modules	
  provided	
  7.1.12	
  by	
  social	
  work	
  staff	
  included	
  16	
   male	
  youth.	
  	
  “Anger,	
  Aggression	
  and	
  Violence”	
  group	
  provided	
  9.1.12	
   included	
  11	
  male	
  youth.	
  	
  	
  This	
  number	
  of	
  youth	
  in	
  a	
  group	
  interaction	
  is	
   not	
  conducive	
  to	
  either	
  learning	
  or	
  process.	
  	
  Behavioral	
  health	
  staff	
   should	
  determine	
  the	
  maximum	
  amount	
  of	
  youth	
  who	
  may	
  attend	
  any	
   one	
  group	
  therapy.	
  	
  	
   	
   Given	
  the	
  above	
  information,	
  there	
  were	
  a	
  total	
  of	
  3998	
  mental	
  health	
   contacts	
  over	
  a	
  three	
  month	
  period.	
  	
  Unfortunately,	
  the	
  average	
  daily	
   census	
  over	
  this	
  time	
  period	
  is	
  not	
  known,	
  therefore	
  it	
  was	
  not	
  possible	
   to	
  calculate	
  the	
  number	
  of	
  mental	
  health	
  contacts	
  per	
  youth.	
  	
  	
  	
  In	
   addition,	
  the	
  total	
  number	
  would	
  have	
  to	
  be	
  adjusted	
  with	
  the	
  removal	
   of	
  the	
  daily	
  door	
  checks	
  provided	
  on	
  the	
  Progress	
  Unit,	
  which	
  artificially	
   inflate	
  this	
  number	
  (daily	
  door	
  checks	
  are	
  brief	
  interactions	
  designed	
  to	
   ensure	
  that	
  youth	
  are	
  not	
  decompensating,	
  and	
  would	
  not	
  qualify	
  as	
   individual	
  therapy).	
   	
   Interviews	
  with	
  staff	
  revealed	
  that	
  ODYS	
  had	
  done	
  a	
  review	
  of	
  the	
   number	
  of	
  mental	
  health	
  contacts	
  youth	
  on	
  the	
  Progress	
  units	
  received.	
  	
   In	
  the	
  month	
  of	
  January	
  2012,	
  41	
  youth	
  received	
  an	
  average	
  of	
  7.8	
   hours	
  of	
  mental	
  health	
  services.	
  	
  The	
  average	
  over	
  the	
  four	
  months	
   prior	
  to	
  the	
  monitoring	
  visit	
  was	
  reported	
  as	
  16.56	
  hours	
  of	
  mental	
   health	
  services	
  per	
  month.	
  	
  This	
  is	
  a	
  substantial	
  increase.	
  	
  This	
   information	
  was	
  provided	
  via	
  verbal	
  report,	
  actual	
  data	
  were	
  not	
   provided	
  for	
  review.	
   	
   During	
  the	
  monitoring	
  visit,	
  discussions	
  with	
  administrative	
  staff	
   revealed	
  a	
  focus	
  on	
  increasing	
  group	
  encounters,	
  and	
  holding	
  staff	
   accountable	
  for	
  group.	
  	
  With	
  the	
  current	
  behavioral	
  health	
  staff,	
  each	
   clinician	
  should	
  be	
  expected	
  to	
  engage	
  in	
  a	
  minimum	
  number	
  of	
  group	
   therapy	
  activities	
  per	
  week.	
  	
  Quality	
  assurance	
  monitoring	
  to	
  ensure	
   that	
  appropriate	
  services	
  with	
  regard	
  to	
  both	
  quantity	
  (number	
  of	
   contact	
  hours)	
  and	
  quality	
  (with	
  regard	
  to	
  fidelity	
  to	
  the	
  model)	
  are	
   necessary.	
  

	
  

82.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 83 of 129 PAGEID #: 2436

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
  

	
   Given	
  the	
  serious	
  staff	
  shortages	
  in	
  social	
  work	
  and	
  the	
  need	
  to	
  ensure	
   that	
  current	
  staff	
  are	
  able	
  to	
  provide	
  the	
  appropriate	
  number	
  of	
  group	
   and	
  individual	
  therapies	
  to	
  youth	
  via	
  a	
  quality	
  assurance	
  process,	
  this	
   paragraph	
  is	
  in	
  partial	
  compliance.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Recruit	
  and	
  fill	
  current	
  vacancies	
   2. Determine	
  the	
  need	
  for	
  additional	
  staff	
  via	
  workload	
  indicators	
   3. Improve	
  coordination	
  between	
  staff	
  disciplines	
  via	
  the	
  development	
  
of	
  the	
  behavioral	
  health	
  department.	
   4. Ensure	
  coverage	
  for	
  staff	
  during	
  required	
  trainings	
  and	
  other	
  
absences.	
   5. Ensure	
  the	
  creation	
  of	
  a	
  unified	
  behavioral	
  health	
  team.	
   6. Begin	
  quality	
  assurance	
  to	
  review	
  both	
  the	
  quantity	
  and	
  quality	
  of	
  
individual	
  and	
  group	
  therapeutic	
  interactions	
  provided	
  to	
  youth.	
  
• Staff	
  interview	
   • Review	
  of	
  provided	
  documents	
  
	
  

	
  

83.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 84 of 129 PAGEID #: 2437

III.B.12	
  	
  Medication	
  Notice.	
  	
  	
  Before	
  renewing	
  a	
  psychoactive	
  medication	
  prescription	
  from	
  a	
   community	
  provider	
  or	
  commencing	
  the	
  administration	
  of	
  a	
  psychoactive	
  medication	
  to	
  a	
   youth,	
  the	
  State	
  shall	
  ensure	
  that	
  the	
  youth	
  and	
  to	
  the	
  fullest	
  extent	
  practicable	
  and	
   appropriate,	
  his	
  or	
  her	
  parent	
  or	
  caregiver,	
  are	
  provided	
  with	
  information	
  regarding	
  the	
  goals,	
   risks,	
  benefits	
  and	
  the	
  potential	
  side	
  effects	
  of	
  the	
  medication	
  and	
  given	
  an	
  explanation	
  of	
  the	
   potential	
  consequences	
  of	
  not	
  treating	
  with	
  the	
  medication,	
  and	
  that	
  the	
  youth	
  has	
  an	
   opportunity	
  to	
  consent	
  to	
  such	
  medication.	
  	
  A)	
  Involuntary	
  administration	
  of	
  psychotropic	
   medications	
  to	
  juveniles	
  shall	
  comply	
  with	
  applicable	
  federal	
  and	
  state	
  laws	
  and	
  regulations.	
  The	
   DYS	
  clinical	
  director,	
  in	
  consultation	
  with	
  the	
  DYS	
  medical	
  director,	
  shall	
  review	
  and	
  request	
  with	
   DYS	
  Legal	
  Services	
  prior	
  to	
  the	
  approval	
  for	
  involuntary	
  administration.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility’s	
  oral	
  self-­‐assessment	
  indicated	
  that	
  policy	
  and	
  procedure	
   development	
  remained	
  pending.	
  	
  They	
  also	
  indicated	
  a	
  peer	
   review/quality	
  assurance	
  process	
  for	
  informed	
  consent;	
  however,	
   documentation	
  of	
  completed	
  reviews	
  was	
  not	
  received	
  for	
  review.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  draft	
  policy	
  and	
  procedure	
  reviewed	
  for	
  this	
  monitoring	
  report	
   entitled	
  “Psychotropic	
  Medication,	
  Use	
  and	
  Management”	
  education	
   including	
  “addressing	
  the	
  goals,	
  risks,	
  benefits,	
  and	
  potential	
  side	
  effects	
   associated	
  with	
  any	
  given	
  medication	
  is	
  given	
  to	
  each	
  youth	
  and	
  his	
  or	
   her	
  parent	
  or	
  guardian…	
  the	
  prescribing	
  physician	
  provides	
  an	
   explanation	
  of	
  the	
  potential	
  consequences	
  of	
  not	
  taking	
  the	
  medication	
   and	
  explains	
  that	
  the	
  youth	
  has	
  an	
  opportunity	
  a	
  consent	
  or	
  withhold	
   consent	
  to	
  be	
  treated…provides	
  guidelines	
  within	
  which	
  medical	
   professionals	
  may	
  petition	
  the	
  court	
  to	
  authorize	
  involuntary	
   administration	
  of	
  psychotropic	
  medication.”	
  	
  A	
  revised	
  policy	
  and	
   procedure	
  was	
  provided	
  for	
  review	
  and	
  comments	
  were	
  given	
  during	
   the	
  monitoring	
  visit.	
   	
   Eleven	
  examples	
  of	
  informed	
  consent	
  documentation	
  were	
  provided	
  via	
   the	
  document	
  request.	
  	
  These	
  examples	
  included	
  a	
  form	
  entitled	
   “Information	
  about	
  and	
  consent	
  for	
  medications	
  for	
  youth	
  with	
  mental	
   health	
  diagnoses.”	
  	
  These	
  forms,	
  competed	
  by	
  the	
  youth,	
  outlined	
  what	
   information	
  the	
  youth	
  retained	
  following	
  their	
  discussion	
  with	
  the	
   psychiatrist	
  regarding	
  the	
  prescribed	
  medication.	
  	
  The	
  form	
  also	
  allows	
   for	
  documentation	
  by	
  the	
  psychiatrist	
  of	
  attempts	
  to	
  or	
  successful	
   contact	
  with	
  the	
  youth’s	
  parent	
  or	
  guardian	
  in	
  order	
  to	
  review	
  potential	
   psychotropic	
  medications	
  and	
  obtain	
  parental	
  consent.	
  	
  Additional	
   information	
  (i.e.	
  medication	
  information	
  sheets)	
  are	
  reportedly	
   provided	
  to	
  the	
  youth	
  and	
  their	
  parents	
  via	
  the	
  psychiatric	
  nurses	
  for	
   their	
  review	
  such	
  that	
  full	
  disclosure	
  of	
  potential	
  medication	
  side	
  effects	
   is	
  provided.	
   	
   Of	
  the	
  examples	
  provided,	
  all	
  were	
  signed	
  by	
  the	
  psychiatrist.	
  	
  All	
   examples	
  were	
  signed	
  by	
  the	
  youth	
  and	
  included	
  brief	
  descriptions	
  of	
   side	
  effect	
  information	
  retained	
  by	
  the	
  youth	
  following	
  discussion	
  with	
   the	
  psychiatrist.	
  	
  Of	
  the	
  examples	
  where	
  parental	
  consent	
  was	
  required	
  

	
  

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Recommendations	
  
Sources	
  of	
   Information	
  

(i.e.,	
  youth	
  were	
  under	
  the	
  age	
  of	
  18	
  years),	
  all	
  documents	
  indicated	
   that	
  the	
  parent	
  consented	
  to	
  treatment	
  with	
  the	
  medication	
  following	
   telephone	
  contact	
  with	
  the	
  psychiatrist.	
   	
   In	
  an	
  effort	
  to	
  determine	
  compliance	
  with	
  policy	
  and	
  procedure	
  as	
  well	
   as	
  with	
  generally	
  accepted	
  practices	
  for	
  informed	
  consent,	
  quality	
   assurance	
  monitoring	
  is	
  required.	
  	
  Per	
  the	
  facility	
  self-­‐assessment	
   provided	
  for	
  the	
  previous	
  monitoring	
  review,	
  given	
  the	
  presence	
  of	
  the	
   Administrative	
  Psychiatrist,	
  there	
  were	
  plans	
  to	
  begin	
  peer	
  review	
  with	
   regard	
  to	
  this	
  and	
  other	
  psychiatric	
  treatment	
  issues	
  in	
  June	
  2012.	
  	
   Documentation	
  of	
  the	
  peer	
  review	
  was	
  not	
  provided.	
   	
   Interviews	
  with	
  youth	
  at	
  the	
  facility	
  revealed	
  that	
  in	
  general,	
  youth	
  were	
   able	
  to	
  name	
  their	
  prescribed	
  medication.	
  	
  Youth	
  also	
  had	
  some	
   knowledge	
  regarding	
  the	
  potential	
  side	
  effects	
  associated	
  with	
  their	
   prescribed	
  medication.	
  	
  This	
  indicated	
  that	
  informed	
  consent	
  practices	
   were	
  occurring	
  on	
  some	
  level	
  with	
  respect	
  to	
  treatment	
  with	
   psychotropic	
  medications.	
  	
   	
   Interviews	
  with	
  psychiatric	
  nurses	
  revealed	
  that	
  currently	
  they	
  are	
  not	
   providing	
  group	
  medication	
  education.	
  	
  They	
  reported	
  performing	
   individualized	
  teaching	
  for	
  youth	
  prescribed	
  a	
  new	
  medication.	
  	
  They	
   reported	
  plans	
  to	
  develop	
  a	
  lesson	
  plan	
  and	
  curriculum	
  for	
  group	
   medication	
  education,	
  instituting	
  this	
  service	
  with	
  youth	
  housed	
  on	
  the	
   Progress	
  Units.	
  	
  In	
  an	
  effort	
  to	
  expedite	
  this	
  process,	
  investigation	
  of	
   commercially	
  available	
  educational	
  materials	
  is	
  recommended.	
   	
   Per	
  the	
  document	
  request,	
  there	
  were	
  no	
  court	
  petitions	
  for	
  involuntary	
   administration	
  of	
  psychotropic	
  medications	
  in	
  the	
  90	
  days	
  prior	
  to	
  this	
   monitoring	
  visit.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Continue	
  and	
  improve	
  documentation	
  regarding	
  informed	
  consent	
  
that	
  is	
  consistent	
  with	
  generally	
  accepted	
  practices	
  and	
  facility	
   policy	
  and	
  procedure.	
   2. Finalize	
  policy	
  and	
  procedure	
  regarding	
  informed	
  consent	
  in	
   conjunction	
  with	
  other	
  behavioral	
  health	
  policy.	
   3. Begin	
  a	
  peer	
  review	
  or	
  quality	
  assurance	
  process	
  for	
  informed	
   consent	
  and	
  other	
  psychiatric	
  documentation.	
   4. Ensure	
  that	
  medication	
  information	
  sheets	
  currently	
  available	
  at	
  the	
   facility	
  are	
  provided	
  to	
  the	
  youth	
  and	
  sent	
  via	
  mail	
  to	
  their	
  parent	
  or	
   guardian.	
   5. Investigate	
  commercially	
  available	
  materials	
  regarding	
  medication	
   education	
  geared	
  toward	
  adolescents.	
  
• Youth	
  record	
  review	
   • Review	
  of	
  provided	
  documents	
  	
  

	
  

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• Youth	
  interview	
  

• Staff	
  interview	
  

	
  

	
  

	
  

	
  

86.	
  

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III.B.13	
  	
  	
  Mental	
  Health	
  Medications.	
  	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  ensure	
  that	
  psychoactive	
  medications	
  are	
  prescribed,	
  distributed	
   and	
  monitored	
  properly	
  and	
  safely,	
  and	
  consistent	
  with	
  generally	
  accepted	
  practices.	
  The	
  State	
   shall	
  provide	
  regular	
  training	
  to	
  all	
  health	
  and	
  mental	
  health	
  staff	
  on	
  current	
  issues	
  in	
   psychopharmacological	
  treatment,	
  including	
  information	
  necessary	
  to	
  monitor	
  for	
  side	
  effects	
   and	
  efficacy.	
  The	
  State	
  shall	
  issue	
  and	
  implement	
  policies	
  and	
  procedures	
  for	
  the	
  administration	
   of	
  appropriate	
  tests	
  (including,	
  for	
  example,	
  blood	
  tests,	
  EKGs,	
  and	
  Abnormal	
  Involuntary	
   Movement	
  Scale	
  tests)	
  to	
  monitor	
  the	
  efficacy	
  and	
  any	
  side	
  effects	
  of	
  psychoactive	
  medications	
   in	
  accordance	
  with	
  generally	
  accepted	
  professional	
  standards.	
  The	
  State	
  shall	
  also:	
  a)	
  share	
   medication	
  compliance	
  data	
  with	
  the	
  psychiatrist	
  and	
  document	
  the	
  sharing	
  of	
  this	
  information;	
   b)	
  not	
  withhold	
  the	
  provision	
  of	
  psychostimulants	
  to	
  youth	
  when	
  such	
  treatment	
  is	
  clinically	
   warranted.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally.	
  	
  During	
  the	
  monitoring	
   visit,	
  the	
  policy	
  and	
  procedure	
  entitled	
  “Psychotropic	
  Medication,	
  Use	
   and	
  Management	
  Of”	
  was	
  reviewed	
  with	
  ODYS	
  administrative	
  staff	
  and	
   feedback	
  provided.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

The	
  review	
  of	
  this	
  paragraph	
  was	
  limited	
  as	
  one	
  facility	
  psychiatrist	
  was	
   not	
  available	
  during	
  the	
  monitoring	
  visit.	
  	
  As	
  such,	
  the	
  physician	
  was	
  not	
   interviewed	
  and	
  clinic	
  was	
  not	
  observed.	
  Approximately	
  two	
  weeks	
   prior	
  to	
  this	
  monitoring	
  visit,	
  a	
  second	
  psychiatrist	
  began	
  providing	
   services	
  at	
  the	
  facility	
  on	
  an	
  emergency	
  contract.	
  	
  During	
  the	
  visit,	
  this	
   psychiatrist’s	
  contact	
  was	
  approved	
  and	
  he	
  will	
  be	
  providing	
  an	
   additional	
  20	
  hours	
  of	
  clinical	
  services	
  weekly.	
  	
  Per	
  interviews,	
  it	
  was	
   planned	
  for	
  this	
  physician	
  to	
  focus	
  his	
  efforts	
  on	
  youth	
  housed	
  in	
  the	
   Progress	
  Units,	
  inclusive	
  of	
  participating	
  in	
  treatment	
  team	
  meetings.	
  	
   	
   It	
  should	
  be	
  noted	
  that	
  while	
  observation	
  of	
  the	
  facility	
  psychiatrist	
  is	
   preferred,	
  in	
  this	
  instance	
  the	
  current	
  facility	
  psychiatrist	
  had	
  been	
   observed	
  on	
  two	
  prior	
  visits.	
  	
  In	
  addition,	
  the	
  new	
  contract	
  psychiatrist	
   had	
  also	
  been	
  observed	
  and	
  interviewed	
  during	
  monitoring	
  at	
  another	
   ODYS	
  facility.	
  	
  As	
  such,	
  the	
  subject	
  matter	
  expert	
  was	
  familiar	
  with	
  their	
   work	
  and	
  work	
  product.	
   	
   Previously,	
  there	
  was	
  concern	
  that	
  given	
  the	
  paucity	
  of	
  available	
   psychiatric	
  treatment	
  providers,	
  there	
  was	
  no	
  clinician	
  available	
  to	
  cover	
   for	
  the	
  current	
  provider	
  in	
  his	
  absence.	
  	
  While	
  interviews	
  and	
  review	
  of	
   the	
  self-­‐assessment	
  from	
  previous	
  monitoring	
  visits	
  it	
  was	
  stated	
  that	
  a	
   psychiatrist	
  from	
  another	
  DYS	
  facility	
  was	
  available	
  to	
  cover	
  psychiatric	
   clinic,	
  there	
  was	
  no	
  documentation	
  that	
  another	
  psychiatrist	
  ever	
   performed	
  clinical	
  consultation	
  at	
  Scioto.	
  	
  As	
  a	
  result	
  of	
  this,	
  there	
  was	
   cause	
  for	
  concern	
  that	
  psychiatric	
  treatment	
  of	
  some	
  youth	
  was	
   delayed.	
  The	
  addition	
  of	
  a	
  second	
  psychiatric	
  treatment	
  provider	
  should	
   help	
  to	
  provide	
  coverage	
  and	
  ensure	
  availability	
  of	
  resources.	
   	
   The	
  newly	
  contracted	
  psychiatrist	
  is	
  an	
  adult	
  psychiatrist	
  with	
  

	
  

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experience	
  in	
  the	
  treatment	
  of	
  adolescent	
  patients.	
  	
  This	
  physician	
  can	
   appropriately	
  evaluate	
  and	
  treat	
  youth	
  aged	
  sixteen	
  years	
  and	
  older.	
  	
   For	
  younger	
  youth,	
  clinical	
  supervision	
  for	
  a	
  treating	
  adult	
  psychiatrist	
   with	
  a	
  child	
  and	
  adolescent	
  psychiatrist	
  should	
  be	
  considered.	
  	
  As	
  the	
   ODYS	
  administrative	
  psychiatrist	
  is	
  a	
  board	
  certified	
  child	
  and	
   adolescent	
  psychiatrist,	
  he	
  can	
  provide	
  the	
  necessary	
  clinical	
   consultation.	
   	
   Psychiatric	
  documentation	
  was	
  received	
  for	
  eight	
  youth.	
  	
  There	
  was	
   documentation	
  with	
  regard	
  to	
  psychiatric	
  evaluation;	
  documentation	
  of	
   ongoing	
  medication	
  management	
  was	
  not	
  received.	
  	
  There	
  was	
  no	
   psychiatric	
  documentation	
  available	
  for	
  review	
  with	
  regard	
  to	
  the	
   request	
  for	
  specific	
  laboratory	
  examinations.	
  Youth	
  interviewed	
   reported	
  undergoing	
  phlebotomy	
  ostensibly	
  for	
  laboratory	
   examinations	
  associated	
  with	
  treatment	
  with	
  psychotropic	
  medication.	
  	
   Medication	
  compliance	
  data	
  was	
  readily	
  available	
  and	
  reportedly	
   provided	
  to	
  the	
  psychiatrist	
  during	
  clinic.	
  	
  	
  Given	
  the	
  presence	
  of	
  the	
   Administrative	
  Psychiatrist,	
  the	
  facility	
  must	
  begin	
  the	
  peer	
   review/quality	
  assurance	
  process	
  for	
  psychiatric	
  treatment.	
  	
  	
   	
   During	
  the	
  previous	
  monitoring	
  visit,	
  the	
  administrative	
  psychiatrist	
   reported	
  he	
  was	
  in	
  the	
  process	
  of	
  revising	
  the	
  laboratory	
  matrix,	
  which	
   designated	
  required	
  laboratory	
  examinations	
  for	
  youth	
  prescribed	
   particular	
  psychotropic	
  medications.	
  	
  This	
  revision	
  remained	
  pending.	
  	
  It	
   is	
  necessary	
  that	
  this	
  document	
  is	
  revised,	
  as	
  there	
  are	
  obvious	
   omissions.	
  	
  For	
  example,	
  for	
  youth	
  prescribed	
  antipsychotic	
  medication,	
   there	
  was	
  no	
  requirement	
  noted	
  for	
  abnormal	
  involuntary	
  movement	
   monitoring.	
  	
  Abnormal	
  Involuntary	
  Movement	
  monitoring	
  must	
  be	
   performed	
  regularly	
  (quarterly)	
  during	
  treatment	
  with	
  antipsychotic	
   medications.	
   	
   For	
  youth	
  prescribed	
  the	
  antipsychotic	
  medication	
  Seroquel	
  there	
  was	
   no	
  requirement	
  for	
  annual	
  eye	
  exams,	
  which	
  are	
  required	
  due	
  to	
  the	
   increased	
  risk	
  of	
  cataract	
  formation	
  with	
  this	
  medication.	
  	
  For	
  Lithium	
   there	
  was	
  no	
  mention	
  of	
  the	
  need	
  for	
  an	
  annual	
  24-­‐hour	
  urine	
   creatinine	
  clearance	
  due	
  to	
  the	
  risk	
  of	
  kidney	
  damage	
  inherent	
  in	
   treatment	
  with	
  this	
  medication.	
  	
  For	
  these	
  and	
  other	
  noted	
  omissions,	
   this	
  document	
  must	
  be	
  reviewed	
  and	
  edited.	
  Given	
  continuous	
   advances	
  in	
  psychiatric	
  treatment,	
  this	
  document	
  should	
  be	
  reviewed	
   and	
  updated	
  periodically	
  to	
  ensure	
  compliance	
  with	
  generally	
  accepted	
   standards	
  of	
  care.	
  	
  Once	
  the	
  initial	
  review	
  is	
  completed	
  and	
  the	
   laboratory	
  protocol	
  is	
  implemented,	
  quality	
  assurance	
  monitoring	
  to	
   determine	
  physician	
  compliance	
  with	
  the	
  requirements,	
  their	
  review	
  of	
   the	
  laboratory	
  results,	
  and	
  their	
  use	
  of	
  this	
  information	
  in	
  clinical	
   decision-­‐making	
  will	
  be	
  necessary.	
   	
   From	
  the	
  records	
  provided,	
  it	
  was	
  determined	
  via	
  a	
  review	
  of	
  the	
  

	
  

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mental	
  health	
  caseload	
  document	
  and	
  the	
  medication	
  sheet	
  for	
  each	
  of	
   the	
  youth	
  that	
  at	
  the	
  time	
  of	
  this	
  monitoring	
  visit,	
  63	
  youth	
  were	
   prescribed	
  medication	
  by	
  the	
  psychiatrist.	
  This	
  was	
  a	
  similar	
  result	
  to	
   the	
  previous	
  monitoring	
  period	
  where	
  71	
  youth	
  were	
  prescribed	
   psychotropic	
  medication.	
  	
  	
   	
   In	
  the	
  previous	
  monitoring	
  reports,	
  inaccuracies	
  in	
  the	
  tracking	
  data	
  for	
   youth	
  on	
  the	
  mental	
  health	
  caseload	
  were	
  discussed.	
  	
  Per	
  the	
  review	
  of	
   the	
  data	
  for	
  this	
  period,	
  there	
  were	
  improvements.	
  	
  The	
  dates	
  of	
   treatment	
  plans,	
  caseload	
  assignments,	
  medication	
  start	
  dates,	
   medication	
  dosage,	
  compliance	
  with	
  psychotropic	
  medications,	
  and	
   current	
  diagnoses	
  appeared	
  to	
  be	
  updated.	
  	
  From	
  a	
  system	
  perspective,	
   it	
  was	
  difficult	
  to	
  look	
  at	
  trends	
  of	
  data	
  (e.g.	
  trends	
  of	
  prescribing,	
   trends	
  with	
  regard	
  to	
  medication	
  compliance,	
  timeliness	
  of	
  psychiatric	
   evaluation,	
  regularity	
  of	
  medication	
  management)	
  as	
  the	
  data	
  were	
   supplied	
  for	
  each	
  individual	
  youth	
  with	
  no	
  compilation	
  provided.	
  It	
   would	
  be	
  useful	
  to	
  determine	
  if	
  the	
  data	
  management	
  system	
  can	
  be	
   adjusted	
  to	
  provide	
  reporting	
  of	
  data	
  points	
  for	
  groups	
  of	
  youth	
  over	
  a	
   period	
  of	
  time.	
  	
  This	
  could	
  also	
  allow	
  some	
  quality	
  assurance	
  monitoring	
   and	
  the	
  identification	
  of	
  possible	
  issues	
  for	
  further	
  quality	
  assurance	
   studies.	
   	
   Given	
  the	
  manner	
  of	
  the	
  data	
  presentation,	
  it	
  was	
  difficult	
  to	
  determine	
   the	
  timeliness	
  of	
  psychiatric	
  treatment.	
  	
  Per	
  a	
  review	
  of	
  the	
  psychiatric	
   clinic	
  schedule,	
  it	
  was	
  apparent	
  that	
  clinic	
  occurred	
  once	
  or	
  twice	
   weekly	
  in	
  the	
  previous	
  90	
  days.	
  	
  It	
  was	
  not	
  possible	
  to	
  determine	
  the	
   time	
  period	
  between	
  the	
  youth’s	
  admission	
  to	
  the	
  facility	
  and	
  their	
   referral	
  for	
  a	
  psychiatric	
  evaluation.	
  	
  Timelines	
  must	
  be	
  addressed	
  via	
   policy	
  and	
  procedure,	
  and	
  they	
  should	
  be	
  monitored	
  via	
  quality	
   assurance.	
  	
  	
   	
   Another	
  challenge	
  with	
  the	
  data	
  presentation	
  was	
  determining	
   timeliness	
  of	
  psychiatry	
  clinic	
  follow	
  up.	
  	
  In	
  an	
  effort	
  to	
  determine	
  this,	
   the	
  clinic	
  schedule	
  was	
  reviewed,	
  in	
  general,	
  there	
  was	
  documentation	
   that	
  youth	
  were	
  seen	
  monthly.	
  	
  There	
  were	
  two	
  notable	
  exceptions:	
   Youth	
  #444	
  was	
  last	
  seen	
  in	
  January	
  2012	
  and	
  is	
  currently	
  prescribed	
   stimulant	
  medication;	
  and	
  Youth	
  #555	
  was	
  last	
  seen	
  in	
  March	
  2012	
  and	
   is	
  currently	
  prescribed	
  stimulant	
  medication	
  and	
  antidepressant	
   medication.	
  	
  Generally	
  accepted	
  practices	
  as	
  well	
  as	
  draft	
  facility	
  policy	
   and	
  procedure	
  require	
  that	
  youth	
  treated	
  with	
  psychotropic	
   medications	
  are	
  assessed	
  by	
  the	
  psychiatrist	
  at	
  least	
  monthly.	
  This	
  was	
   another	
  area	
  where	
  quality	
  assurance	
  monitoring	
  may	
  be	
  beneficial.	
   	
   Once	
  the	
  new	
  psychiatric	
  provider	
  begins	
  to	
  establish	
  clinic,	
  the	
  facility	
   will	
  need	
  to	
  determine	
  if	
  the	
  current	
  clinical	
  resources	
  are	
  adequate	
  for	
   the	
  psychiatrists	
  to	
  provide	
  clinical	
  services,	
  participate	
  in	
  treatment	
   team	
  meetings,	
  for	
  response	
  to	
  crisis	
  situations,	
  for	
  provision	
  of	
  on-­‐

	
  

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Recommendations	
  

call/after	
  hours	
  consultations;	
  and	
  for	
  the	
  psychiatrist	
  to	
  function	
  as	
  an	
   integral	
  member	
  of	
  the	
  treatment	
  team.	
  	
  If	
  necessary,	
  the	
  facility	
  must	
   investigate	
  other	
  avenues	
  in	
  order	
  to	
  address	
  the	
  paucity	
  of	
  psychiatric	
   clinical	
  services.	
  	
  These	
  could	
  include	
  telemedicine;	
  developing	
  an	
   association	
  with	
  a	
  residency	
  training	
  program	
  where	
  residents	
  or	
  fellows	
   (with	
  appropriate	
  clinical	
  supervision)	
  could	
  provide	
  services.	
  	
  	
  	
   	
   With	
  regard	
  to	
  other	
  issues	
  required	
  per	
  this	
  provision,	
  the	
   Administrative	
  Psychiatrist	
  indicated	
  during	
  the	
  previous	
  monitoring	
   visit	
  that	
  he	
  was	
  in	
  the	
  process	
  of	
  developing	
  training	
  for	
  staff	
  with	
   regard	
  to	
  current	
  issues	
  in	
  psychopharmacological	
  treatment,	
  including	
   information	
  necessary	
  to	
  monitor	
  for	
  side	
  effects	
  and	
  efficacy.	
  	
  The	
   development	
  of	
  this	
  training	
  was	
  pending.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Update	
  policy	
  and	
  procedure	
  regarding	
  behavioral	
  health	
  to	
  include	
  
timelines	
  for	
  psychiatric	
  services.	
   2. Finalize	
  policy	
  and	
  procedure	
  regarding	
  psychotropic	
  medication	
  
management.	
   3. Ensure	
  that	
  youth	
  receive	
  timely	
  evaluation	
  and	
  appropriate	
  
medication	
  management	
  follow	
  up.	
  	
  This	
  is	
  an	
  area	
  that	
  would	
  be	
   amenable	
  to	
  quality	
  improvement	
  monitoring	
  and	
  review.	
   4. In	
  order	
  to	
  determine	
  the	
  appropriate	
  number	
  of	
  full	
  time	
   equivalent	
  psychiatric	
  clinicians	
  required	
  by	
  the	
  facility,	
  consider	
   workload	
  indicators	
  inclusive	
  of	
  all	
  clinical	
  responsibilities	
  required	
   of	
  the	
  physician	
  (e.g.	
  clinic,	
  documentation,	
  treatment	
  team	
   meetings,	
  crisis	
  response).	
   5. If	
  necessary,	
  investigate	
  other	
  avenues	
  to	
  increase	
  psychiatry	
  clinical	
   resources	
  at	
  the	
  facility	
  (e.g.	
  telemedicine,	
  association	
  with	
   academic	
  institutions,	
  use	
  of	
  residents	
  or	
  fellows	
  with	
  appropriate	
   supervision).	
   6. Ensure	
  clinical	
  coverage	
  for	
  the	
  current	
  psychiatric	
  treatment	
   provider.	
   7. Maintain	
  the	
  document	
  regarding	
  the	
  current	
  mental	
  health	
   caseload.	
  	
  Edits	
  to	
  this	
  document	
  may	
  assist	
  in	
  quality	
  assurance.	
   8. Begin	
  the	
  peer	
  review/quality	
  assurance	
  monitoring	
  for	
  psychiatric	
   treatment	
  and	
  documentation.	
  	
  This	
  would	
  include	
  a	
  review	
   evaluation	
  and	
  diagnostics,	
  of	
  treatment	
  planning	
  for	
  psychotropic	
   medication,	
  of	
  target	
  symptom	
  identification	
  for	
  treatment	
  with	
   psychotropic	
  medication,	
  assessment	
  for	
  side	
  effects	
  with	
   psychotropic	
  medications,	
  and	
  the	
  assessment	
  of	
  benefit	
  from	
   psychotropic	
  medication.	
   9. Ensure	
  that	
  youth	
  are	
  receiving	
  proper	
  laboratory	
  examinations	
  and	
   side	
  effect	
  monitoring	
  commensurate	
  with	
  the	
  psychotropic	
   medication	
  they	
  are	
  prescribed.	
  	
  This	
  would	
  require	
  updating	
  of	
  the	
   laboratory	
  matrix	
  and	
  quality	
  assurance	
  monitoring.	
   10. Develop	
  and	
  implement	
  training	
  for	
  staff	
  with	
  regard	
  to	
  current	
  

	
  

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Sources	
  of	
   Information	
  
	
   	
  

issues	
  in	
  psychopharmacological	
  treatment,	
  including	
  information	
   necessary	
  to	
  monitor	
  for	
  side	
  effects	
  and	
  efficacy.	
  	
  Present	
  this	
   training	
  curriculum	
  to	
  the	
  monitor	
  for	
  review.	
  
• Staff	
  interview	
   • Treatment	
  Team	
  observation	
   • Youth	
  record	
  review	
   • Review	
  of	
  provided	
  documents	
  	
  
• Youth	
  interview	
  
	
  

	
  

91.	
  

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III.B.14	
  	
  Mental	
  Health	
  and	
  Developmental	
  Disability	
  Training	
  for	
  Direct	
  Care	
  Staff.	
  	
  The	
  State	
   shall	
  develop	
  and	
  implement	
  strategies	
  for	
  providing	
  direct	
  care	
  and	
  other	
  appropriate	
  staff	
   with	
  training	
  on	
  mental	
  health	
  and	
  developmental	
  disabilities	
  sufficient	
  for	
  staff	
  to	
  understand	
   the	
  behaviors	
  and	
  needs	
  of	
  youth	
  residents	
  in	
  order	
  to	
  supervise	
  them	
  appropriately.	
  	
  

Compliance	
  Rating	
   Non-­‐	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally.	
  	
  Staff	
  indicated	
  that	
   every	
  year,	
  all	
  staff	
  receive	
  40	
  hours	
  of	
  inservice	
  training,	
  with	
  an	
   additional	
  eight	
  hours	
  of	
  “booster”	
  sessions	
  that	
  are	
  staff	
  specific	
  and	
   tailored	
  to	
  meet	
  the	
  needs	
  of	
  the	
  facility.	
  	
  Staff	
  reported	
  that	
  in	
  the	
   upcoming	
  year,	
  it	
  was	
  planned	
  that	
  staff	
  would	
  receive	
  a	
  total	
  of	
  16	
   hours	
  of	
  “booster”	
  sessions	
  with	
  eight	
  hours	
  devoted	
  to	
  mental	
  health	
   topics.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

As	
  stated	
  in	
  the	
  previous	
  report,	
  the	
  goal	
  of	
  this	
  provision	
  paragraph	
  is	
  to	
   provide	
  training	
  to	
  facility	
  staff	
  such	
  that	
  they	
  have	
  a	
  working	
  knowledge	
   of	
  the	
  youth’s	
  challenges	
  (both	
  from	
  a	
  mental	
  health	
  and	
  developmental	
   perspective)	
  and	
  to	
  provide	
  them	
  with	
  strategies	
  to	
  assist	
  in	
  their	
  daily	
   supervisory	
  tasks	
  with	
  the	
  youth.	
  	
  	
  Training	
  for	
  direct	
  care	
  staff	
  is	
   important	
  as	
  in	
  the	
  correctional	
  setting;	
  they	
  function	
  as	
  the	
  de	
  facto	
   parents	
  of	
  the	
  youth	
  in	
  their	
  care.	
  As	
  direct	
  care	
  staff	
  are	
  an	
  integral	
  part	
   of	
  the	
  youth’s	
  treatment	
  team,	
  they	
  should	
  be	
  aware	
  that	
  due	
  to	
  specific	
   mental	
  health	
  diagnoses,	
  youth	
  may	
  have	
  special	
  needs	
  (i.e.	
  a	
  youth	
   diagnosed	
  with	
  ADHD	
  may	
  not	
  respond	
  to	
  you	
  the	
  first	
  or	
  even	
  second	
   time	
  that	
  you	
  call	
  his	
  name	
  because	
  he	
  is	
  distracted	
  by	
  extraneous	
   stimuli).	
  They	
  should	
  also	
  be	
  aware	
  of	
  which	
  youth	
  are	
  being	
  treated	
   with	
  psychotropic	
  medication	
  and	
  have	
  a	
  basic	
  knowledge	
  of	
  the	
   potential	
  side	
  effects	
  of	
  the	
  medication	
  so	
  that	
  they	
  can	
  monitor	
  the	
   youth	
  in	
  their	
  care.	
  	
   	
   Per	
  the	
  facility	
  self-­‐assessment	
  provided	
  for	
  the	
  previous	
  monitoring	
   report,	
  the	
  administrative	
  psychiatrist	
  was	
  collaborating	
  with	
  the	
   psychology	
  supervisor	
  to	
  develop	
  training	
  for	
  all	
  staff	
  to	
  educate	
  them	
  on	
   psychiatric	
  medications,	
  side	
  effects,	
  benefits	
  and	
  long	
  term	
  concerns.	
  	
   This	
  training	
  curriculum	
  has	
  yet	
  to	
  be	
  provided	
  to	
  the	
  monitor	
  for	
  review.	
   	
   There	
  was	
  documentation	
  of	
  mental	
  health	
  specific	
  training	
  provided	
  to	
   direct	
  care	
  staff	
  as	
  outlined	
  below.	
  	
  Unfortunately,	
  corresponding	
   curriculum	
  was	
  not	
  provided	
  to	
  the	
  monitor	
  for	
  review.	
  	
  Additionally,	
  per	
   a	
  review	
  of	
  the	
  topics	
  presented,	
  it	
  appears	
  that	
  this	
  training	
  would	
  be	
   an	
  excellent	
  resource	
  for	
  direct	
  care	
  staff,	
  and	
  it	
  was	
  unfortunate	
  that	
   only	
  eight	
  direct	
  care	
  staff	
  were	
  able	
  to	
  attend	
  (eight	
  attended	
  each	
  day).	
   	
  
“Juvenile	
  Offenders	
  with	
  Mental	
  Health	
  Disorders”	
  was	
  presented	
  by	
   Lisa	
  Boesky,	
  Ph.D.,	
  September	
  25	
  and	
  25,	
  2012.	
  	
  Reportedly,	
  a	
  third	
   training	
  session	
  is	
  planned	
  in	
  May	
  2013.	
  	
  Topics	
  included:	
  	
  

• Which	
  Juvenile	
  Offenders	
  REALLY	
  Have	
  a	
  Mental	
  Health	
  

	
  

92.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 93 of 129 PAGEID #: 2446

Disorder?	
   • Your	
  Role	
  with	
  Mentally	
  Ill	
  Juveniles	
   • Where	
  Are	
  You	
  on	
  the	
  MHAT	
  Continuum?	
   • Juveniles	
  with	
  Attention-­‐Deficit/Hyperactivity	
  Disorder	
  (ADHD)	
   • Juveniles	
  with	
  Conduct	
  Disorder	
  or	
  Antisocial	
  Personality	
  
Disorder	
   • Juveniles	
  with	
  Depression	
  or	
  Dysthymic	
  Disorder	
   • Juveniles	
  with	
  Bipolar	
  Disorder	
   • Psychotropic	
  Medication	
   • Suicide:	
  Which	
  Juveniles	
  Are	
  At	
  Risk	
  of	
  Dying	
   • Anxiety	
  and	
  Juvenile	
  Offenders	
   • Juveniles	
  with	
  Posttraumatic	
  Stress	
  Disorder	
  (PTSD)	
   • More	
  Than	
  Just	
  A	
  Bump	
  on	
  the	
  Head	
   • Juveniles	
  Who	
  Act	
  Bizarrely	
  or	
  Hear	
  Voices	
   • Communication	
  and	
  Collaboration	
  (juvenile	
  justice,	
  mental	
  
health,	
  medical,	
  school)	
   • Juveniles	
  Who	
  Cut	
  or	
  Carve	
  Themselves	
  to	
  Feel	
  Better	
   • Key	
  Role	
  YOU	
  Play	
  with	
  Juveniles	
  Who	
  Have	
  Mental	
  Health	
  
Disorders	
  
Reportedly,	
  eight	
  youth	
  specialists	
  (the	
  majority	
  of	
  these	
  working	
  on	
   Progress	
  Units),	
  three	
  operations	
  managers,	
  and	
  two	
  unit	
  managers	
   attended	
  this	
  two	
  day	
  training.	
  	
  Evaluations	
  completed	
  by	
  the	
   participants	
  revealed	
  that	
  72.22%	
  of	
  the	
  ratings	
  were	
  “excellent.”	
  	
  Per	
   staff	
  interviews,	
  there	
  were	
  plans	
  to	
  repeat	
  this	
  training	
  in	
  the	
  spring	
  of	
   2013.	
  	
  ODYS	
  is	
  commended	
  for	
  this	
  training	
  opportunity	
  for	
  staff.	
  	
  It	
  was	
   unfortunate	
  that	
  additional	
  staff	
  members	
  were	
  not	
  able	
  to	
  participate.	
  	
   As	
  there	
  is	
  an	
  opportunity	
  in	
  spring	
  of	
  2013,	
  it	
  is	
  hoped	
  that	
  all	
  staff	
  will	
   be	
  able	
  to	
  attend.	
  	
  Given	
  the	
  large	
  number	
  of	
  staff	
  requiring	
  specialized	
   training	
  regarding	
  specific	
  mental	
  health	
  and	
  developmental	
  disabilities,	
   this	
  provision	
  will	
  remain	
  in	
  noncompliance.
Pre-­‐service	
  for	
  new	
  employees	
  receive	
  training	
  in	
  the	
  following	
  areas:	
   • Adolescent	
  Development	
  (2hrs)	
   • Mental	
  Health	
  (1.5hrs)	
   • SBBMS	
  (2hrs)	
   • Cognitive	
  Behavior	
  Therapy	
  (1.5hrs)	
   • Sex	
  Offender(1.5hrs)	
   • Emergency	
  Response-­‐	
  Suicide	
  Prevention	
  (7hrs)	
  
	
   Current	
  8hr.	
  in-­‐service	
  (booster)	
  training	
  covers	
  the	
  following	
  areas:	
  
• Strengths	
  Based	
  Behavior	
  Management	
  System	
   • Interdisciplinary	
  Team	
   • Group	
  Process	
   • CBT	
  Skill	
  Cards	
   	
   For	
  additional	
  information	
  regarding	
  training,	
  please	
  see	
  the	
  discussion	
  

	
  

93.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 94 of 129 PAGEID #: 2447

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
  

regarding	
  paragraph	
  15	
  below.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Develop	
  an	
  organized	
  training	
  schedule	
  and	
  training	
  curriculum	
  for	
  
facility	
  staff	
  that	
  addresses	
  the	
  requirements	
  of	
  this	
  provision	
  and	
   addresses	
  the	
  facility	
  mental	
  health	
  programming	
  initiatives.	
  	
  	
   2. Provide	
  curriculum	
  of	
  newly	
  developed	
  training	
  to	
  the	
  monitor	
  for	
   review.	
   3. Track	
  staff	
  compliance	
  with	
  training	
  requirements	
  and	
  provide	
   documentation	
  to	
  the	
  monitor.	
  
• Review	
  of	
  provided	
  documents	
  	
   • Staff	
  interview	
  
	
  

	
  

94.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 95 of 129 PAGEID #: 2448

III.B.15	
  	
  Staff	
  Mental	
  Health	
  Training.	
  The	
  facilities	
  shall	
  train:	
  a)	
  all	
  staff	
  who	
  directly	
  interact	
   with	
  youth	
  (e.g.,	
  JCOs	
  ,	
  social	
  workers,	
  teachers,	
  etc.)	
  on:	
  (i)	
  basic	
  mental	
  health	
  information	
   (e.g.,	
  diagnosis,	
  specific	
  problematic	
  behaviors,	
  psychiatric	
  medication,	
  additional	
  areas	
  of	
   concern)	
  and	
  recognition	
  of	
  signs	
  and	
  symptoms	
  evidencing	
  a	
  response	
  to	
  trauma;	
  and	
  (ii)	
   teenage	
  development,	
  strength-­‐based	
  treatment	
  strategies,	
  suicide,	
  and	
  for	
  staff	
  who	
  work	
  with	
   female	
  youth,	
  female	
  development;	
  b)	
  clinical	
  staff	
  on	
  the	
  prevalence,	
  signs	
  and	
  symptoms	
  of	
   Post	
  Traumatic	
  Stress	
  Disorder	
  and	
  other	
  disorders	
  associated	
  with	
  trauma.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally,	
  and	
  reviewed	
  recent	
   trainings	
  conducted	
  including	
  the	
  ITP	
  process,	
  case	
  conceptualization,	
   and	
  “Juvenile	
  Offenders	
  with	
  Mental	
  Health	
  Disorders.”	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Per	
  the	
  document	
  request,	
  copies	
  of	
  any	
  newly	
  developed	
  mental	
   health	
  training	
  curriculum	
  were	
  requested	
  and	
  none	
  were	
  received.	
  	
   Documentation	
  of	
  training	
  provided	
  in	
  the	
  six	
  months	
  prior	
  to	
  the	
   monitoring	
  visit	
  was	
  requested.	
  	
  This	
  documentation	
  noted:	
   	
  
1.	
  	
  “Juvenile	
  Offenders	
  with	
  Mental	
  Health	
  Disorders”	
  was	
  presented	
   by	
  Lisa	
  Boesky,	
  Ph.D.,	
  September	
  25	
  and	
  25,	
  2012.	
  	
  Reportedly,	
  a	
   third	
  training	
  session	
  is	
  planned	
  in	
  May	
  2013.	
  	
  Topics	
  included:	
  	
  

• Which	
  Juvenile	
  Offenders	
  REALLY	
  Have	
  a	
  Mental	
  Health	
   Disorder?	
  
• Your	
  Role	
  with	
  Mentally	
  Ill	
  Juveniles	
   • Where	
  Are	
  You	
  on	
  the	
  MHAT	
  Continuum?	
   • Juveniles	
  with	
  Attention-­‐Deficit/Hyperactivity	
  Disorder	
  (ADHD)	
   • Juveniles	
  with	
  Conduct	
  Disorder	
  or	
  Antisocial	
  Personality	
  
Disorder	
   • Juveniles	
  with	
  Depression	
  or	
  Dysthymic	
  Disorder	
   • Juveniles	
  with	
  Bipolar	
  Disorder	
   • Psychotropic	
  Medication	
   • Suicide:	
  Which	
  Juveniles	
  Are	
  At	
  Risk	
  of	
  Dying	
   • Anxiety	
  and	
  Juvenile	
  Offenders	
   • Juveniles	
  with	
  Posttraumatic	
  Stress	
  Disorder	
  (PTSD)	
   • More	
  Than	
  Just	
  A	
  Bump	
  on	
  the	
  Head	
   • Juveniles	
  Who	
  Act	
  Bizarrely	
  or	
  Hear	
  Voices	
   • Communication	
  and	
  Collaboration	
  (juvenile	
  justice,	
  mental	
  
health,	
  medical,	
  school)	
   • Juveniles	
  Who	
  Cut	
  or	
  Carve	
  Themselves	
  to	
  Feel	
  Better	
   • Key	
  Role	
  YOU	
  Play	
  with	
  Juveniles	
  Who	
  Have	
  Mental	
  Health	
  
Disorders	
  

Reportedly,	
  eight	
  youth	
  specialists	
  (the	
  majority	
  of	
  these	
  working	
  on	
   Progress	
  Units),	
  three	
  operations	
  managers,	
  and	
  two	
  unit	
  managers	
   attended	
  this	
  two	
  day	
  training.	
  	
  Evaluations	
  completed	
  by	
  the	
   participants	
  revealed	
  that	
  72.22%	
  of	
  the	
  ratings	
  were	
  “excellent.”	
  

	
  

95.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 96 of 129 PAGEID #: 2449

2. Psychology	
  training	
  documentation	
  revealed	
  that	
  nine	
  staff	
   attended	
  an	
  eight	
  hour	
  training	
  on	
  “family	
  engagement.”	
  
3. Other	
  training	
  attended	
  by	
  psychology	
  staff	
  included,	
   “CPR/FA/AED”,	
  “MIS	
  CBTO”,	
  “Youth	
  Supervision	
  Rules	
  of	
   Conduct”,	
  “Safety	
  and	
  Security”,	
  “Child	
  Abuse	
  and	
  Neglect”,	
   “Youth	
  Grievance”,	
  “Emergency	
  Response”,	
  “Blood	
  borne	
   Pathogens”,	
  “Ethics”,	
  “PREA”,	
  “General	
  Work	
  Rules”,	
  “Equal	
   Employment	
  Opportunity”,	
  “MYR	
  1st	
  quarter”,	
  “Wellness”,	
  “MYR	
   2nd	
  quarter”,	
  “Emergency	
  Response	
  Belt	
  Review”,	
  and	
  “Shield	
   Review”.	
  
4. ITP	
  training	
  was	
  provided	
  to	
  behavioral	
  health	
  staff	
  by	
  ODYS	
   central	
  office	
  staff.	
  
5. ITP	
  training	
  and	
  case	
  formulation	
  training	
  was	
  provided	
  to	
   behavioral	
  health	
  staff	
  by	
  Andrea	
  Weisman,	
  Ph.D.	
  
Unfortunately,	
  training	
  curriculum	
  was	
  not	
  provided	
  for	
  review	
  for	
  any	
  of	
   the	
  above	
  noted	
  trainings.	
  	
  Attendance	
  was	
  only	
  available	
  for	
  those	
   trainings	
  where	
  it	
  was	
  noted	
  above.	
  	
  Given	
  the	
  confirmed	
  attendance,	
   there	
  were	
  staff	
  of	
  all	
  disciplines	
  who	
  have	
  not	
  received	
  training.	
  	
  Per	
  a	
   review	
  of	
  the	
  presented	
  topics,	
  it	
  appeared	
  that	
  the	
  two	
  day	
  training	
  via	
   Dr.	
  Boesky	
  would	
  be	
  an	
  excellent	
  resource	
  for	
  youth	
  specialists,	
  and	
  as	
   such,	
  it	
  was	
  unfortunate	
  that	
  only	
  eight	
  direct	
  care	
  staff	
  had	
  the	
  ability	
  to	
   attend.	
  	
  	
  
Per	
  the	
  review	
  of	
  the	
  training	
  topics	
  above,	
  they	
  did	
  not	
  include	
  those	
   topics	
  required	
  by	
  the	
  agreement.	
  	
  However,	
  the	
  State	
  invested	
   considerable	
  time	
  and	
  resources	
  in	
  training	
  that	
  is	
  needed	
  to	
  fully	
   comply	
  with	
  the	
  Stipulation.	
  Previous	
  monitoring	
  reports	
  have	
   indicated,	
  “the	
  facility	
  self-­‐assessment	
  included,	
  ‘all	
  staffs	
  [sic]	
  have	
   been	
  trained	
  on	
  BHS	
  [Behavioral	
  Health	
  Services]	
  policies	
  and	
   procedures.	
  	
  Staff	
  receive	
  a	
  minimum	
  of	
  40	
  hours	
  of	
  in-­‐service	
  yearly.	
  	
  In	
   addition,	
  ODYS	
  brings	
  in	
  outside	
  experts	
  to	
  train	
  frontline	
  staff	
  as	
  well.’	
  	
   The	
  self-­‐assessment	
  then	
  discussed	
  draining	
  performed	
  by	
  Dr.	
  Lisa	
   Boesky	
  in	
  August	
  2011,	
  with	
  plans	
  for	
  an	
  additional	
  two-­‐day	
  training	
   provided	
  by	
  Dr.	
  Boesky	
  in	
  May	
  2012.	
  	
  The	
  self-­‐assessment	
  also	
  indicated,	
   ‘staff	
  have	
  been	
  trained	
  extensively	
  in	
  CBT,	
  motivational	
  interviewing	
   and	
  strength	
  based	
  approaches.’	
  	
  No	
  new	
  documentation	
  of	
  completed	
   training	
  with	
  regard	
  to	
  these	
  topics	
  was	
  provided	
  for	
  the	
  current	
   monitoring	
  period.	
  	
  Additionally,	
  ODYS	
  is	
  currently	
  in	
  the	
  process	
  of	
  a	
   significant	
  review	
  and	
  revision	
  of	
  behavioral	
  health	
  policy	
  and	
   procedure,	
  which	
  would	
  require	
  review/refresher	
  training	
  for	
  staff.”	
   	
   The	
  development	
  of	
  an	
  organized,	
  mandatory	
  training	
  schedule	
  was	
  a	
   recommendation	
  from	
  the	
  previous	
  monitoring	
  visits.	
  It	
  is	
  absolutely	
   necessary	
  to	
  develop	
  and	
  implement	
  a	
  training	
  schedule	
  for	
  all	
  staff	
   providing	
  care	
  for	
  youth	
  with	
  regard	
  to	
  mental	
  health	
  issues.	
  This	
   training	
  must	
  also	
  address	
  staff	
  recognition	
  of	
  and	
  response	
  to	
  the	
  signs	
   and	
  symptoms	
  of	
  a	
  serious	
  mental	
  illness	
  in	
  evolution	
  as	
  well	
  as	
  the	
  

	
  

96.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 97 of 129 PAGEID #: 2450

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
   	
  

specific	
  training	
  topics	
  required	
  by	
  the	
  agreement.	
   	
   The	
  training	
  schedule	
  must	
  be	
  reasonable	
  and	
  address	
  specific	
  topics	
  to	
   ensure	
  that	
  staff	
  are	
  able	
  to	
  implement	
  the	
  facility	
  mental	
  health	
   program.	
  	
  While	
  training	
  is	
  important,	
  the	
  facility	
  must	
  be	
  able	
  to	
   maintain	
  sufficient	
  staff	
  onsite	
  to	
  ensure	
  that	
  treatment	
  and	
  security	
   services	
  are	
  available.	
   	
   The	
  oral	
  self-­‐assessment	
  indicated	
  a	
  more	
  proactive	
  approach	
  to	
   providing	
  training	
  was	
  occurring,	
  and	
  this	
  is	
  positive,	
  however,	
  both	
   curriculum	
  and	
  spreadsheets	
  indicating	
  completion	
  must	
  be	
  provided	
  to	
   the	
  monitor.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Develop	
  an	
  organized	
  training	
  schedule	
  and	
  training	
  curriculum	
  for	
  
facility	
  staff	
  that	
  addresses	
  the	
  requirements	
  of	
  this	
  provision	
  and	
   addresses	
  the	
  facility	
  mental	
  health	
  programming	
  initiatives.	
  	
   Provide	
  the	
  curriculum	
  for	
  behavioral	
  health	
  training	
  topics	
  and	
   spreadsheets	
  regarding	
  attendance	
  to	
  the	
  monitor	
  for	
  review.	
   2. Consider	
  offering	
  multiple	
  trainings	
  for	
  each	
  topic	
  so	
  that	
  staff	
  can	
   schedule	
  trainings	
  while	
  ensuring	
  that	
  their	
  regular	
  job	
  duties	
  are	
   addressed.	
   3. Track	
  staff	
  attendance	
  and	
  compliance	
  with	
  training	
  requirements.	
  
• Review	
  of	
  provided	
  documents.	
   • Staff	
  interviews.	
  
	
  

	
  

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III.B.16	
  	
  Suicide	
  Prevention.	
  	
  The	
  State	
  shall	
  review	
  and,	
  as	
  appropriate,	
  revise	
  current	
  suicide	
   prevention	
  practices	
  to	
  ensure	
  that	
  suicide	
  preventions	
  and	
  interventions	
  are	
  implemented	
   consistently	
  and	
  appropriately,	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
   care.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self	
  assessment	
  was	
  provided	
  orally	
  and	
  indicated	
  that	
  the	
   draft	
  policy	
  and	
  procedure	
  was	
  reviewed	
  by	
  Lindsay	
  Hayes,	
  and	
   comments	
  were	
  integrated	
  into	
  the	
  draft	
  policy	
  and	
  procedure.	
  	
  The	
   completed	
  document	
  remained	
  pending	
  at	
  the	
  time	
  of	
  this	
  monitoring	
   visit.	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

As	
  noted	
  above,	
  staff	
  reported	
  that	
  existing	
  policy	
  and	
  procedure	
  was	
   submitted	
  to	
  Lindsay	
  Hayes	
  for	
  review,	
  and	
  his	
  comments	
  had	
  been	
   incorporated	
  into	
  the	
  draft	
  document.	
  	
  The	
  current	
  draft	
  was	
  not	
   submitted	
  for	
  review	
  this	
  monitoring	
  period.	
  	
  The	
  following	
  information	
   was	
  provided	
  for	
  the	
  previous	
  monitoring	
  review,	
  and	
  will	
  be	
  included	
   here	
  for	
  comparison	
  when	
  the	
  revised	
  policy	
  is	
  completed.	
   	
   “The	
  policy	
  and	
  procedure	
  entitled	
  “Suicide	
  Prevention	
  and	
  Response”	
   revised	
  October	
  3,	
  2011	
  was	
  provided	
  for	
  review.	
  	
  Specific	
  issues	
   identified	
  with	
  this	
  policy	
  include:	
  
1. Procedures	
   a. Screening	
  and	
  Assessment	
   i. 	
  Reception	
  -­‐	
  There	
  is	
  no	
  designated	
  time	
  within	
   which	
  the	
  Risk	
  Assessment	
  Interview	
  must	
  be	
   completed	
  (as	
  attachments	
  were	
  not	
  provided	
   with	
  the	
  policy	
  received,	
  it	
  was	
  not	
  possible	
  to	
   review	
  the	
  Risk	
  Assessment	
  Interview	
   document).	
   ii. Transfer	
  –	
  There	
  was	
  no	
  mention	
  of	
  the	
   assessment	
  or	
  watch	
  precautions	
  to	
  be	
  provided	
   to	
  youth	
  on	
  watch	
  status	
  during	
  or	
  following	
  a	
   facility	
  transfer.	
  	
  There	
  is	
  a	
  requirement	
  for	
  the	
   “immediate”	
  completion	
  of	
  a	
  Risk	
  Assessment	
   Interview	
  following	
  positive	
  responses	
  to	
   questions	
  concerning	
  suicide	
  ideation	
  and	
  self-­‐ injurious	
  behavior	
  during	
  the	
  transfer	
  process.	
  	
   The	
  time	
  limit	
  for	
  the	
  completion	
  of	
  this	
   assessment	
  was	
  not	
  indicated.	
   b. Communication	
   i. “Psychology	
  staff	
  are	
  required	
  to	
  review	
   psychology	
  file	
  information	
  within	
  five	
  days	
  of	
  a	
   youth’s	
  admission	
  to	
  a	
  facility	
  in	
  order	
  to	
   identify	
  possible	
  areas	
  of	
  concern	
  regarding	
   mental	
  status,	
  suicide	
  or	
  self	
  injury	
  and	
  the	
  need	
   for	
  any	
  follow	
  up	
  services.”	
  	
  The	
  policy	
  does	
  not	
   designate	
  where	
  this	
  review	
  is	
  to	
  be	
  

	
  

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documented,	
  nor	
  does	
  it	
  indicate	
  if	
  this	
  review	
  is	
   for	
  all	
  youth	
  admitted	
  or	
  only	
  for	
  those	
  youth	
   who	
  have	
  positive	
  responses	
  to	
  the	
  intake	
   health	
  screen.	
  	
  	
   c. Precautionary	
  Status	
   i. This	
  section	
  of	
  the	
  policy	
  indicates	
  that	
  youth	
   placed	
  on	
  precautionary	
  status	
  must	
  have	
  a	
  Risk	
   Assessment	
  Interview	
  within	
  four	
  hours.	
  	
  This	
  is	
   the	
  first	
  mention	
  of	
  a	
  time	
  frame	
  within	
  which	
   this	
  assessment	
  must	
  be	
  completed.	
   ii. Youth	
  placed	
  on	
  “watch”	
  and	
  who	
  are	
  “assessed	
   as	
  being	
  at	
  the	
  highest	
  risk	
  for	
  suicide…engaged	
   in	
  critical	
  suicide	
  attempts”	
  are	
  required	
  to	
  have	
   “constant	
  visual	
  monitoring	
  within	
  close	
   proximity	
  (i.e	
  closer	
  than	
  15	
  feet)…line	
  of	
  sight	
   shall	
  be	
  unencumbered.”	
  	
  With	
  these	
   requirements,	
  the	
  staff	
  to	
  youth	
  ratio	
  is	
  required	
   to	
  be	
  “not	
  greater	
  than	
  one	
  staff	
  to	
  three	
  youth.	
   Where	
  an	
  adjustment	
  pod	
  exists	
  the	
  rations	
   shall	
  be	
  not	
  greater	
  than	
  one	
  staff	
  to	
  six	
  youth.”	
  	
  	
   These	
  ratios	
  do	
  not	
  allow	
  for	
  close	
  monitoring	
  of	
   youth.	
  	
  For	
  youth	
  who	
  are	
  actively	
  suicidal,	
  one	
   to	
  one	
  monitoring	
  is	
  required.	
  The	
  policy	
  does	
   not	
  allow	
  for	
  this	
  level	
  of	
  monitoring	
  except	
  in	
   the	
  case	
  of	
  “youth	
  designated	
  as	
  making	
  a	
   critical	
  suicide	
  attempt.”	
  	
  The	
  level	
  of	
   monitoring	
  should	
  be	
  determined	
  clinically,	
   given	
  the	
  results	
  of	
  behavioral	
  health	
   assessments.	
  	
  Regardless	
  of	
  a	
  critical	
  suicide	
   attempt,	
  if	
  youth	
  are	
  at	
  serious	
  risk,	
  there	
  must	
   be	
  the	
  ability	
  to	
  access	
  one	
  to	
  one	
  supervision.	
   iii. With	
  regard	
  to	
  “observation”	
  status,	
  there	
  is	
  no	
   staff	
  to	
  youth	
  ratio	
  designated.	
   iv. With	
  regard	
  to	
  “behavioral”	
  status,	
  there	
  is	
  no	
   staff	
  to	
  youth	
  ratio	
  designated.	
   d. Additional	
  comments:	
  	
  The	
  policy	
  does	
  not	
  designate	
  the	
   process	
  by	
  which	
  psychiatrist	
  is	
  notified	
  of	
  a	
  youth	
   requiring	
  watch	
  status.	
  	
  Currently,	
  per	
  the	
  document	
   request,	
  this	
  is	
  performed	
  informally	
  via	
  email;	
  however,	
   it	
  must	
  be	
  codified	
  in	
  policy.”	
   	
   The	
  agreement	
  requires	
  that	
  ODYS	
  demonstrate	
  that	
  interventions	
  are	
   implemented	
  consistently	
  and	
  appropriately.	
  	
  In	
  order	
  for	
  ODYS	
  to	
   ensure	
  this,	
  quality	
  assurance	
  data	
  based	
  on	
  policy	
  and	
  procedure	
   would	
  be	
  required.	
  	
  Per	
  review	
  of	
  current	
  policy,	
  there	
  is	
  a	
  requirement	
   for	
  monitoring	
  “ongoing	
  reviews	
  shall	
  be	
  conducted	
  by	
  the	
  designated	
   Interdisciplinary	
  team	
  on	
  a	
  quarterly	
  basis	
  as	
  part	
  of	
  the	
  Departments	
  

	
  

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Recommendations	
  
Sources	
  of	
   Information	
   	
   	
  

Continuous	
  Quality	
  Improvement	
  Process.”	
  	
  Per	
  the	
  document	
  request	
   for	
  this	
  monitoring	
  period,	
  “any	
  reviews	
  or	
  quality	
  assurance	
  data	
   regarding	
  suicide	
  precautions”	
  were	
  requested.	
  	
  The	
  response	
  received	
   indicated,	
  “there	
  is	
  QA	
  built	
  into	
  the	
  monitoring	
  log	
  form…any	
   discrepancies	
  are	
  to	
  be	
  noted	
  and	
  reported.	
  	
  Administration	
  is	
  also	
   required	
  to	
  review	
  monitoring	
  logs	
  when	
  making	
  round…to	
  units…the	
   OA	
  and	
  UMA	
  will	
  review	
  random	
  monitoring	
  logs	
  as	
  a	
  policy…but	
  there	
   is	
  not	
  a	
  form	
  or	
  formal	
  requirement	
  attached	
  to	
  this	
  process.”	
  	
  	
   	
   In	
  the	
  previous	
  three	
  months,	
  there	
  were	
  a	
  total	
  of	
  five	
  youth	
  placed	
  on	
   suicide	
  watch,	
  and	
  as	
  such,	
  there	
  were	
  youth	
  records	
  that	
  could	
  have	
   been	
  reviewed	
  to	
  assess	
  compliance	
  with	
  policy.	
  	
  This	
  would	
  include	
   process	
  reviews,	
  outcome	
  reviews,	
  and	
  a	
  review	
  of	
  data	
  trends	
  and	
   analysis	
  in	
  order	
  to	
  determine	
  compliance	
  with	
  policy,	
  the	
  need	
  for	
   individual	
  corrective	
  action,	
  and	
  the	
  identification	
  of	
  systems	
  issues	
   affecting	
  policy	
  implementation.	
  	
  Based	
  on	
  the	
  existing	
  policy	
  and	
   procedure,	
  partial	
  compliance	
  will	
  be	
  assigned.	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Review	
  and	
  revise	
  current	
  policy	
  to	
  address	
  timelines	
  and	
  ensure	
  
appropriate	
  ratios	
  for	
  youth	
  supervision.	
   2. Perform	
  quality	
  assurance	
  monitoring	
  to	
  ensure	
  compliance	
  with	
  
policy	
  and	
  procedure	
  as	
  well	
  as	
  the	
  need	
  for	
  corrective	
  action	
  (see	
   III.B.18	
  for	
  details).	
  
• Review	
  of	
  provided	
  documents.	
   • Staff	
  interview.	
   • Youth	
  interview.	
  
	
  

	
  

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III.B.17	
  	
  Transition	
  Planning.	
  	
  The	
  State	
  shall	
  ensure	
  that	
  staff	
  create	
  transition	
  plans	
  for	
  youth	
   leaving	
  the	
  facilities,	
  consistent	
  with	
  generally	
  accepted	
  professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally,	
  and	
  did	
  not	
  include	
   information	
  regarding	
  this	
  provision.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

In	
  response	
  to	
  a	
  document	
  request	
  for	
  transition	
  plans	
  for	
  ten	
  youth	
   (five	
  of	
  whom	
  were	
  prescribed	
  psychotropic	
  medication)	
  discharged	
   from	
  the	
  facility,	
  the	
  monitor	
  was	
  provided	
  with	
  the	
  “Regional	
   Accountability	
  and	
  Community	
  Engagement	
  Report”	
  completed	
  by	
  the	
   youth’s	
  parole	
  officer,	
  not	
  the	
  youth’s	
  treatment	
  provider	
  at	
  the	
  facility.	
  	
   Transition	
  planning	
  must	
  start	
  at	
  the	
  time	
  of	
  admission,	
  and	
  plans	
  must	
   be	
  created	
  by	
  the	
  current	
  treatment	
  provider	
  in	
  order	
  to	
  inform	
  the	
   community	
  parole	
  officer	
  and	
  other	
  community	
  providers	
  of	
  the	
  youth’s	
   needs.	
   	
   Nine	
  examples	
  of	
  the	
  facility	
  generated	
  “medical	
  release	
  summary”	
   were	
  reviewed.	
  This	
  document	
  listed	
  the	
  youth’s	
  diagnoses,	
  medication	
   and	
  dosages.	
  	
  It	
  also	
  included	
  the	
  need	
  for	
  follow	
  up	
  psychiatric	
   treatment.	
  	
  Specific	
  referrals	
  (e.g.	
  clinic	
  name,	
  phone	
  number)	
  were	
  not	
   included	
  on	
  this	
  document.	
  	
  There	
  was	
  one	
  complete	
  set	
  of	
  documents	
   (i.e.	
  a	
  “Regional	
  Accountability	
  and	
  Community	
  Engagement	
  Report”	
   and	
  “Medical	
  Release	
  Summary”	
  for	
  the	
  same	
  youth).	
  	
  Per	
  these	
   documents,	
  Youth	
  #333	
  had	
  a	
  history	
  of	
  mental	
  health	
  diagnoses,	
  and	
   was	
  prescribed	
  psychotropic	
  medication.	
  	
  Specific	
  referral	
  information	
   was	
  included	
  on	
  the	
  summary	
  with	
  regard	
  to	
  gastroenterology	
  clinic,,	
   but	
  not	
  for	
  psychiatry	
  clinic.	
  	
  The	
  “Regional	
  Accountability	
  and	
   Community	
  Engagement	
  Report”	
  indicated	
  that	
  this	
  youth	
  had	
  a	
  three	
   day	
  supply	
  of	
  medication	
  provided	
  to	
  her	
  at	
  discharge,	
  with	
  a	
  thirty	
  day	
   supply	
  of	
  medication	
  mailed	
  to	
  her.	
  	
  There	
  was	
  also	
  documentation	
  of	
   an	
  initial	
  appointment	
  with	
  a	
  mental	
  health	
  treatment	
  provider.	
  	
  	
   	
   Furthermore,	
  the	
  “Medical	
  Release	
  Summary”	
  indicated	
  that	
  this	
  youth	
   gave	
  birth	
  approximately	
  one	
  month	
  prior	
  to	
  her	
  admission	
  to	
  the	
   facility.	
  	
  There	
  was	
  no	
  note	
  of	
  the	
  infant	
  included	
  in	
  the	
  “Regional	
   Accountability	
  and	
  Community	
  Engagement	
  Report.”	
  Unfortunately,	
  the	
   transitional	
  planning	
  documentation	
  was	
  not	
  included	
  with	
  these	
   examples;	
  therefore,	
  other	
  information	
  regarding	
  the	
  infant,	
  the	
  youth’s	
   need	
  for	
  parenting	
  skills,	
  or	
  other	
  services	
  was	
  not	
  available.	
   	
   In	
  previous	
  reviews,	
  psychological	
  services	
  summary	
  documents	
  were	
   provided	
  for	
  review	
  that	
  included	
  a	
  review	
  of	
  the	
  youth’s	
  presenting	
   problem;	
  history	
  of	
  suicidal	
  ideation,	
  suicide	
  attempts,	
  and	
  self	
  injurious	
   behavior;	
  diagnostic	
  impressions	
  at	
  intake;	
  diagnosis	
  history;	
  five	
  axis	
   diagnosis;	
  overall	
  progress	
  in	
  treatment;	
  goals;	
  services	
  provided;	
   current	
  medications;	
  clients	
  response	
  to	
  treatment;	
  continuity	
  of	
   care/referral	
  information;	
  and	
  aftercare	
  options.	
  	
  Per	
  the	
  prior	
  

	
  

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monitoring	
  report,	
  “the	
  completeness	
  of	
  documentation	
  was	
  variable	
   between	
  documents,	
  and	
  would	
  be	
  amenable	
  to	
  quality	
  assurance	
   monitoring	
  and	
  corrective	
  action.	
  	
  The	
  documents	
  were	
  inconsistent	
  in	
   terms	
  of	
  specific	
  discharge	
  plans	
  and	
  lacked	
  definitive	
  plans	
  with	
  regard	
   to	
  referrals,	
  support	
  services,	
  and	
  parent	
  education.	
  	
  Most	
   recommendations	
  were	
  stated	
  as	
  “most	
  likely”	
  or	
  “will	
  probably.”	
  	
  The	
   transition	
  plan	
  recommendations	
  should	
  include	
  concrete	
  discharge	
   plans	
  for	
  the	
  youth	
  and	
  as	
  such,	
  should	
  define	
  a	
  plan	
  of	
  action	
  that	
  the	
   youth	
  and	
  their	
  parent/guardian	
  can	
  follow.	
  	
  Again,	
  there	
  was	
  marked	
   variability	
  in	
  these	
  documents…For	
  youth	
  prescribed	
  psychotropic	
   medication;	
  follow	
  up	
  recommendations	
  did	
  not	
  include	
  the	
   identification	
  of	
  clinical	
  resources	
  for	
  follow	
  up.	
  	
  There	
  was	
  no	
  mention	
   of	
  a	
  designated	
  medical	
  provider	
  to	
  perform	
  continued	
  monitoring	
  of	
  the	
   prescribed	
  medications	
  on	
  an	
  outpatient	
  basis.	
  	
  These	
  summary	
   documents	
  may	
  not	
  be	
  reflective	
  of	
  the	
  discharge	
  and	
  transition	
   planning	
  activities	
  performed	
  by	
  the	
  behavioral	
  health	
  staff…In	
   reviewing	
  existing	
  policies	
  related	
  to	
  transition	
  planning,	
  there	
  was	
   ambiguity	
  regarding	
  who	
  the	
  responsible	
  party	
  is	
  for	
  creating	
  and	
   implementing	
  transition	
  plans	
  prior	
  to	
  release,	
  particularly	
  with	
  regard	
   to	
  mental	
  health	
  follow-­‐up.	
  For	
  example,	
  in	
  the	
  policy	
  entitled	
   “Transition	
  Planning	
  for	
  Age	
  21	
  Youth,”	
  the	
  policy	
  clearly	
  states	
  that	
  the	
   juvenile	
  parole	
  officer	
  “shall	
  provide	
  each	
  youth	
  with	
  a	
  comprehensive	
   list	
  of	
  community	
  based	
  resources	
  specific	
  to	
  the	
  youth’s	
  needs.”	
  	
  This	
  is	
   to	
  include	
  “treatment	
  links/mental	
  health	
  services.”	
  	
  With	
  regard	
  to	
   youth	
  under	
  age	
  21,	
  there	
  was	
  no	
  specific	
  policy	
  included	
  in	
  the	
   documents	
  for	
  review	
  regarding	
  transition	
  planning;	
  rather	
  this	
  is	
   incorporated	
  into	
  the	
  policy	
  entitled,	
  “Behavioral	
  Health	
  Services.”	
  	
  Per	
   this	
  policy,	
  “youth	
  in	
  need	
  of	
  continued	
  mental	
  health	
  services	
  shall	
   receive,	
  as	
  part	
  of	
  their	
  re-­‐entry	
  plans,	
  referrals	
  for	
  continued	
  treatment.	
  	
   Efforts	
  shall	
  be	
  made	
  to	
  connect	
  the	
  youth	
  and	
  family	
  directly	
  with	
  the	
   community	
  provider.”	
  The	
  policy	
  does	
  not	
  denote	
  which	
  staff	
  are	
   responsible	
  for	
  this	
  task.	
  	
  It	
  will	
  be	
  necessary	
  to	
  determine	
  what	
  tasks	
   need	
  to	
  be	
  completed	
  as	
  part	
  of	
  transition	
  planning	
  and	
  who	
  the	
   responsible	
  part	
  will	
  be	
  in	
  order	
  to	
  ensure	
  youth	
  leave	
  the	
  facility	
  with	
   appropriate	
  scheduled	
  follow-­‐up	
  services.	
  	
  As	
  stated	
  in	
  the	
  discussion	
  for	
   many	
  of	
  the	
  paragraphs	
  in	
  this	
  report,	
  ODYS	
  was	
  in	
  the	
  process	
  of	
  a	
   review	
  of	
  policy	
  and	
  procedure	
  that	
  should	
  address	
  these	
  challenges.”	
   	
   Per	
  ODYS	
  staff,	
  policy	
  and	
  procedure	
  revision	
  continued,	
  and	
   completion/implementation	
  of	
  policy	
  and	
  procedure	
  was	
  pending.	
  	
   Transition	
  planning	
  for	
  all	
  youth	
  should	
  include	
  referral	
  to	
  appropriate	
   community	
  resources.	
  For	
  mentally	
  ill	
  youth	
  this	
  is	
  especially	
  important,	
   and	
  must	
  include	
  linkages	
  to	
  community	
  mental	
  health	
  clinics	
  and	
  a	
   scheduled	
  appointment	
  such	
  that	
  youth	
  can	
  access	
  follow	
  up	
  care	
   without	
  an	
  interruption	
  in	
  medication	
  treatment.	
  	
  The	
  documentation	
   provided	
  for	
  review	
  did	
  not	
  include	
  designated	
  follow-­‐up	
  appointments	
   for	
  care	
  following	
  transition	
  into	
  the	
  community.	
  	
  Due	
  to	
  the	
  state	
  of	
  

	
  

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Recommendations	
  
Sources	
  of	
   Information	
   	
   	
  

outpatient	
  mental	
  health	
  services,	
  appointments	
  may	
  take	
  more	
  than	
   30	
  days	
  advanced	
  notice	
  to	
  schedule.	
  As	
  youth	
  are	
  released	
  with	
  30	
   days	
  of	
  medications,	
  it	
  is	
  vital	
  that	
  they	
  have	
  appointments	
  scheduled	
  in	
   advance	
  to	
  ensure	
  continuity	
  of	
  care.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Revise	
  Behavioral	
  Health	
  Policy	
  and	
  Procedure	
  to	
  reflect	
  the	
  
requirements	
  of	
  this	
  provision.	
  	
  This	
  should	
  include	
  delineating	
  the	
   responsible	
  party	
  for	
  transition	
  planning	
  to	
  include	
  mental	
  health	
   aftercare	
  appointments.	
   2. Begin	
  transition	
  planning	
  at	
  the	
  time	
  of	
  admission	
  to	
  ensure	
  that	
   youth	
  receive	
  appropriate	
  services	
  at	
  the	
  time	
  of	
  discharge.	
  	
  This	
   must	
  include	
  involvement	
  of	
  the	
  youth’s	
  parent	
  or	
  guardian.	
   3. Document	
  transition	
  activities	
  in	
  the	
  transition/discharge	
   documents.	
   4. Begin	
  quality	
  assurance	
  monitoring	
  of	
  transition	
  planning.	
  
• Review	
  of	
  provided	
  documents.	
  	
   • Staff	
  interview	
  
	
  

	
  

103.	
  

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III.B.18	
  	
  Oversight	
  of	
  Mental	
  Health	
  Services.	
  	
  The	
  facilities	
  shall	
  ensure	
  that	
  youth	
  receive	
  the	
   care	
  they	
  need	
  by	
  developing	
  and	
  implementing	
  an	
  adequate	
  mental	
  health	
  Quality	
   Assurance/Improvement	
  Program;	
  annually	
  assessing	
  the	
  overall	
  efficacy	
  of	
  the	
  staffing,	
   treatments	
  and	
  interventions	
  used	
  at	
  the	
  facilities;	
  and	
  as	
  appropriate	
  revising	
  such	
  staffing,	
   treatments	
  and	
  interventions.	
  	
  

Compliance	
  Rating	
   Non-­‐Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally,	
  and	
  did	
  not	
  include	
   information	
  regarding	
  this	
  provision.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

As	
  noted	
  in	
  the	
  previous	
  monitoring	
  report,	
  the	
  facility	
  had	
   developed	
  policy	
  and	
  procedure	
  regarding	
  Quality	
   Assurance/Improvement.	
  	
  This	
  policy,	
  with	
  an	
  effective	
  date	
  of	
   January	
  1,	
  2011	
  entitled	
  “Behavioral	
  Health	
  Quality	
   Assurance/Quality	
  Improvement”	
  outlined	
  the	
  process	
  for	
  clinical	
   supervision	
  and	
  audits	
  of	
  clinical	
  documentation.	
   	
   As	
  noted	
  above	
  in	
  this	
  monitoring	
  report,	
  there	
  was	
  a	
  recent	
  effort	
   undertaken	
  by	
  ODYS	
  administration	
  to	
  perform	
  a	
  global	
  review	
  and	
   rewrite	
  of	
  policy	
  and	
  procedure	
  regarding	
  behavioral	
  health	
   services.	
  	
  The	
  goal	
  of	
  this	
  process	
  was	
  to	
  streamline	
  policy	
  and	
  to	
   promote	
  the	
  integration	
  of	
  mental	
  health	
  services	
  (psychiatry,	
   psychology,	
  and	
  social	
  work)	
  into	
  one	
  behavioral	
  health	
  program.	
  	
  In	
   order	
  to	
  achieve	
  this	
  goal,	
  ODYS	
  designated	
  work	
  groups	
  to	
  review	
   and	
  edit	
  policy	
  and	
  procedure.	
  	
  The	
  revised	
  policies,	
  including	
  policy	
   and	
  procedure	
  regarding	
  quality	
  assurance	
  remain	
  pending.	
  	
  Quality	
   assurance	
  audits	
  with	
  respect	
  to	
  process	
  should	
  be	
  developed	
  to	
   address	
  specific	
  policy	
  and	
  procedure	
  requirements.	
   	
   Quality	
  assurance	
  audits	
  were	
  provided	
  for	
  review.	
  	
  These	
  were	
   performed	
  via	
  the	
  clinical	
  supervision	
  sessions.	
  	
  The	
  forms	
  included	
   sections	
  headed	
  “caseload	
  review”,	
  “quality	
  review”,	
  and	
   “professional	
  review.”	
  	
  The	
  majority	
  of	
  the	
  forms	
  contained	
  blank	
   spaces,	
  and	
  did	
  not	
  reflect	
  a	
  systematic	
  review	
  of	
  clinical	
  quality	
  or	
   documentation.	
  	
  	
  As	
  data	
  were	
  not	
  presented	
  in	
  a	
  collated	
  format,	
  it	
   was	
  not	
  possible	
  to	
  determine	
  trends,	
  or	
  the	
  need	
  for	
  corrective	
   action	
  with	
  regard	
  to	
  one	
  particular	
  clinician,	
  one	
  particular	
  housing	
   unit,	
  or	
  if	
  there	
  were	
  issues	
  requiring	
  attention	
  from	
  a	
  systems	
   perspective.	
  	
  	
  	
   	
   It	
  was	
  noted	
  on	
  each	
  individual	
  audit	
  that	
  there	
  were	
  either	
   compliments	
  for	
  the	
  clinician’s	
  work	
  or	
  specific	
  issues	
  reviewed	
  with	
   the	
  clinician	
  under	
  review;	
  however	
  documentation	
  provided	
   revealed	
  that	
  no	
  formal	
  corrective	
  action	
  had	
  been	
  instituted	
  from	
   quality	
  assurance	
  monitoring	
  in	
  the	
  90	
  days	
  prior	
  to	
  the	
  monitoring	
   visit.	
  	
  	
   	
   Issues	
  with	
  this	
  type	
  of	
  quality	
  assurance	
  monitoring	
  can	
  be	
  

	
  

104.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 105 of 129 PAGEID #: 2458

illustrated	
  by	
  the	
  case	
  of	
  Youth	
  #222.	
  	
  This	
  youth	
  filed	
  a	
  grievance	
   indicating	
  that	
  he	
  had	
  not	
  been	
  receiving	
  individual	
  mental	
  health	
   counseling	
  sessions.	
  	
  The	
  grievance	
  was	
  dismissed	
  as	
  having	
  “no	
   merit”	
  as	
  the	
  youth	
  was	
  receiving	
  daily	
  door	
  checks	
  via	
  psychology.	
  	
   Daily	
  door	
  checks	
  are	
  not	
  a	
  substitute	
  for	
  individual	
  therapy.	
  A	
   review	
  of	
  this	
  youth’s	
  mental	
  health	
  documentation	
  revealed	
  no	
   individual	
  therapy	
  sessions	
  between	
  7.1.12	
  and	
  7.23.12.	
  	
  Regular	
   quality	
  assurance	
  could	
  monitor	
  for	
  lapses	
  in	
  treatment	
  in	
  addition	
   to	
  the	
  clinical	
  quality	
  of	
  documentation.	
   	
   One	
  behavioral	
  health	
  peer	
  review	
  narrative	
  was	
  provided	
  for	
   review.	
  	
  Unfortunately,	
  this	
  documentation	
  did	
  not	
  include	
  the	
   comments	
  of	
  the	
  peers.	
  	
  Additional	
  information	
  provided	
  with	
  this	
   example	
  indicated,	
  “the	
  new	
  peer	
  review	
  process	
  outlined	
  in	
  current	
   policy	
  has	
  not	
  yet	
  been	
  implemented	
  system	
  wide.”	
   	
   As	
  noted	
  above,	
  the	
  review	
  of	
  available	
  documentation	
  regarding	
   quality	
  assurance	
  revealed	
  a	
  disjointed	
  process	
  that	
  did	
  not	
  lend	
   itself	
  to	
  a	
  cogent	
  review	
  of	
  the	
  system	
  or	
  services	
  provided.	
  	
   Additionally,	
  at	
  the	
  time	
  of	
  this	
  monitoring	
  tour,	
  there	
  was	
  no	
   formal	
  quality	
  assurance	
  monitoring	
  occurring	
  with	
  respect	
  to	
  the	
   psychiatric	
  physician.	
  	
  	
   	
   It	
  will	
  be	
  necessary	
  that	
  ODYS	
  quality	
  assurance	
  monitoring	
  review	
   four	
  specific	
  areas,	
  include	
  a	
  review/analysis	
  of	
  the	
  resulting	
  data,	
   and	
  corrective	
  action	
  as	
  needed.	
  	
  Additionally,	
  a	
  predetermined	
   percentage	
  of	
  all	
  available	
  records	
  should	
  be	
  reviewed	
  (e.g.	
  10%).	
  	
  	
  
1. Process	
  measures-­‐	
  this	
  type	
  of	
  quality	
  assurance	
  would	
   determine	
  if	
  behavioral	
  health	
  services	
  are	
  provided	
  in	
   keeping	
  with	
  implemented	
  policy	
  and	
  procedure	
  (e.g.	
  were	
   evaluations	
  performed	
  within	
  a	
  specific	
  timeline;	
  were	
   laboratory	
  examinations	
  required	
  via	
  laboratory	
  parameters	
   ordered,	
  reviewed	
  and	
  addressed;	
  did	
  youth	
  receive	
  the	
   mental	
  health	
  services	
  as	
  directed	
  by	
  their	
  treatment	
  plan;	
   were	
  requests	
  for	
  mental	
  health	
  services	
  performed	
  in	
  a	
   timely	
  manner;	
  were	
  psychiatric	
  evaluations	
  performed	
  in	
  a	
   timely	
  manner,	
  etc.).	
  	
  For	
  process	
  measures	
  regarding	
   psychiatric	
  evaluation	
  and	
  treatment,	
  monitoring	
  should	
  be	
   done	
  via	
  a	
  medical	
  model	
  in	
  concert	
  with	
  quality	
  assurance	
   monitoring	
  performed	
  for	
  medical	
  services.	
  
2. Outcome	
  measures-­‐	
  this	
  type	
  of	
  quality	
  assurance	
  would	
   determine	
  if	
  behavioral	
  health	
  services	
  provided	
  were	
  of	
   benefit	
  to	
  the	
  youth.	
  	
  Specifically,	
  did	
  they	
  result	
  in	
  a	
   reduction	
  of	
  youth	
  symptoms	
  and	
  improvement	
  in	
  youth	
   functioning?	
  	
  This	
  could	
  be	
  determined	
  via	
  review	
  of	
  youth	
   on	
  youth	
  violence	
  statistics,	
  youth	
  aggression	
  statistics,	
  and	
   the	
  use	
  of	
  segregation.	
  	
  Additionally,	
  pre	
  and	
  post	
  testing	
  

	
  

105.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 106 of 129 PAGEID #: 2459

Recommendations	
  
Sources	
  of	
   Information	
   	
   	
  

measures	
  could	
  be	
  utilized	
  (e.g.	
  reduction	
  in	
  the	
  scores	
  on	
   depression	
  scales).	
  	
  It	
  is	
  recognized	
  that	
  improvements	
  in	
   the	
  indices	
  discussed	
  above	
  would	
  be	
  multifactorial	
  and	
  not	
   solely	
  the	
  result	
  of	
  behavioral	
  health	
  services.	
  	
  Other	
   outcome	
  measures	
  could	
  include	
  youth	
  satisfaction	
  surveys.	
   3. Peer	
  review/Treatment	
  integrity-­‐	
  this	
  type	
  of	
  quality	
   assurance	
  would	
  include	
  a	
  critical	
  review	
  of	
  behavioral	
   health	
  services	
  provided	
  via	
  a	
  peer-­‐review	
  process	
  (e.g.	
   psychiatrists	
  would	
  periodically	
  review	
  each	
  other’s	
  work	
   and	
  provide	
  feedback).	
  	
  Additionally,	
  group	
  therapeutic	
   process	
  could	
  be	
  observed	
  with	
  feedback	
  provided	
  to	
  the	
   clinician	
  or	
  youth	
  specialist	
  leading	
  group	
  in	
  order	
  to	
  ensure	
   adherence	
  to	
  the	
  model	
  and	
  provide	
  opportunities	
  for	
   coaching	
  and	
  improvement	
  of	
  the	
  provided	
  services.	
   4. Selected	
  studies	
  –	
  If	
  a	
  specific	
  issue	
  is	
  suspected,	
  or	
  specific	
   difficulties	
  are	
  observed	
  with	
  one	
  particular	
  unit,	
  specific	
   quality	
  assurance	
  studies	
  could	
  be	
  performed	
  with	
  a	
  critical	
   analysis	
  of	
  the	
  data	
  in	
  order	
  to	
  determine	
  the	
  need	
  to	
   adjust	
  processes	
  or	
  treatments	
  in	
  order	
  to	
  improve	
  efficacy.	
   5. Corrective	
  action	
  –	
  Any	
  comprehensive	
  quality	
  assurance	
   process	
  must	
  include	
  both	
  the	
  synthesis	
  and	
  review	
  of	
   collected	
  data	
  on	
  a	
  regular	
  basis.	
  	
  Data	
  must	
  be	
  collected	
  on	
   a	
  continuous	
  basis	
  and	
  reviewed	
  so	
  that	
  issues	
  can	
  be	
   addressed	
  in	
  a	
  timely	
  manner.	
  	
  These	
  issues	
  may	
  include	
   challenges	
  with	
  the	
  practice	
  and	
  documentation	
  attributed	
   to	
  a	
  specific	
  staff	
  member	
  or	
  they	
  may	
  identify	
  systems	
   issues.	
  	
  Issues	
  that	
  are	
  identified	
  must	
  be	
  addressed	
  via	
  a	
   corrective	
  action	
  plan	
  (e.g.	
  staff	
  training,	
  staff	
  supervision,	
   policy/procedure	
  review).	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
   1. Complete	
  the	
  revision	
  of	
  behavioral	
  health	
  policy	
  and	
  
procedure.	
   2. Develop	
  quality	
  assurance	
  monitoring	
  based	
  on	
  policy	
  and	
  
procedure.	
  This	
  would	
  include	
  process	
  measures,	
  outcome	
   measures,	
  peer	
  review/treatment	
  integrity,	
  and	
  data	
   analysis/corrective	
  action.	
  
• Staff	
  Interview.	
   • Review	
  of	
  the	
  provided	
  documents.	
  
	
  

	
  

106.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 107 of 129 PAGEID #: 2460

G.1	
  Progress	
  Notes.	
  The	
  Facilities	
  shall	
  promulgate	
  and	
  implement	
  a	
  policy	
  requiring	
  that	
  all	
   health	
  professionals	
  be	
  required	
  to	
  create	
  and	
  use	
  progress	
  notes	
  to	
  document,	
  on	
  a	
  regular	
   basis,	
  interactions	
  and	
  each	
  assessment	
  of	
  youth	
  with	
  mental/behavioral	
  health	
  or	
  substance	
   abuse	
  needs.	
  In	
  particular,	
  progress	
  notes	
  shall:	
  	
   a.)	
  In	
  the	
  assessment,	
  address	
  the	
  efficacy	
  of	
  interventions,	
  currently	
  presenting	
  problems,	
  and	
   the	
  available	
  options	
  to	
  address	
  those	
  problems;	
  and	
  	
   b.)	
  Provide	
  thorough	
  documentation	
  of	
  all	
  crisis	
  interventions	
  or,	
  if	
  not	
  thoroughly	
   documented	
  in	
  the	
  progress	
  notes,	
  provide	
  a	
  reference	
  to	
  alert	
  staff	
  to	
  another	
  document	
  in	
   the	
  youth’s	
  file	
  containing	
  the	
  details	
  of	
  the	
  crisis	
  intervention.	
  	
  

Compliance	
  Rating	
  	
   Partial	
  Compliance	
  

Self	
  Assessment	
  	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally,	
  and	
  did	
  not	
  include	
   information	
  regarding	
  this	
  provision.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  	
  

Per	
  interviews	
  with	
  mental	
  health	
  staff	
  from	
  both	
  the	
  facility	
  and	
  ODYS	
   administration,	
  a	
  review	
  and	
  revision	
  of	
  mental	
  health	
  policy	
  and	
   procedure	
  is	
  in	
  progress.	
  Mental	
  health	
  documentation	
  reviewed	
  for	
   the	
  preparation	
  of	
  this	
  monitoring	
  report,	
  while	
  improved	
  over	
   previous	
  reviews,	
  continued	
  to	
  reveal	
  deficiencies	
  in	
  clinical	
   documentation.	
  	
   	
   Mental	
  health	
  staff	
  were	
  authoring	
  case	
  conceptualizations;	
  however,	
   these	
  were	
  not	
  located	
  in	
  all	
  records	
  reviewed	
  on	
  site.	
  	
  Documents	
   reviewed	
  revealed	
  that	
  overall,	
  the	
  case	
  conceptualizations	
  were	
  in	
   need	
  of	
  improvement.	
  	
  For	
  example,	
  the	
  case	
  conceptualization	
   regarding	
  Youth	
  #111	
  adequately	
  described	
  this	
  youth’s	
  home	
  life	
  and	
   gang	
  involvement.	
  	
  Treatment	
  goals	
  were	
  identified	
  to	
  address	
   challenges	
  in	
  these	
  areas.	
  	
  Goals	
  were	
  not	
  measurable,	
  for	
  example,	
  “I	
   will	
  make	
  a	
  plan	
  to	
  develop	
  new	
  friends	
  in	
  the	
  community	
  and	
  practice	
   my	
  positive	
  social	
  skills	
  in	
  ODYS.”	
  	
  Treatment	
  objectives	
  included	
  a	
  time	
   limit	
  within	
  which	
  the	
  objective	
  was	
  to	
  be	
  completed,	
  “I	
  will	
  figure	
  out	
   what	
  makes	
  a	
  good	
  friend	
  as	
  evidenced	
  by	
  completing	
  workbook…and	
   process	
  it	
  with	
  my	
  social	
  worker	
  by	
  9.30.12.”	
  	
  	
  The	
  youth’s	
  progress	
   toward	
  the	
  identified	
  objective	
  was	
  documented.	
  	
  The	
  treatment	
  plan	
   would	
  have	
  been	
  strengthened	
  by	
  the	
  addition	
  of	
  measurable	
  goals	
   and	
  objectives	
  with	
  regard	
  to	
  teaching	
  positive	
  social	
  skills.	
   	
   In	
  addition,	
  this	
  youth	
  also	
  had	
  substance	
  abuse	
  and	
  mental	
  health	
   diagnoses	
  and	
  was	
  prescribed	
  psychotropic	
  medication.	
  	
  The	
  case	
   conceptualization	
  did	
  not	
  review	
  the	
  youth’s	
  mental	
  health	
  history,	
  nor	
   did	
  it	
  review	
  the	
  symptoms	
  the	
  youth	
  was	
  experiencing	
  in	
  order	
  to	
   justify	
  the	
  diagnoses.	
  	
  A	
  review	
  of	
  the	
  youth’s	
  treatment	
  plan	
  revealed	
   no	
  treatment	
  goals	
  targeting	
  substance	
  abuse,	
  the	
  mental	
  health	
   diagnosis,	
  or	
  psychotropic	
  medication.	
   	
   Specifically,	
  mental	
  health	
  assessments	
  did	
  not	
  routinely	
  evidence	
   adequate	
  case	
  conceptualization	
  information	
  required	
  to	
  develop	
  a	
   treatment	
  plan	
  addressing	
  the	
  youth’s	
  needs.	
  	
  The	
  documentation	
  was	
  

	
  

107.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 108 of 129 PAGEID #: 2461

Recommendations	
  	
  
Sources	
  of	
   Information	
  	
   	
   	
  

especially	
  weak	
  with	
  regard	
  to	
  mental	
  health	
  and	
  substance	
  abuse	
   diagnoses.	
  	
  There	
  was	
  wide	
  variability	
  in	
  the	
  quality	
  of	
  progress	
  notes	
   documenting	
  treatment.	
  There	
  were	
  noted	
  improvements	
  in	
  isolated	
   instances,	
  as	
  discussed	
  in	
  the	
  paragraphs	
  regarding	
  mental	
  health	
   services	
  above.	
  	
  As	
  discussed	
  during	
  the	
  monitoring	
  visit,	
  this	
  was	
  an	
   area	
  that	
  may	
  be	
  amenable	
  to	
  quality	
  assurance	
  monitoring.	
  	
   	
   Examples	
  of	
  documentation	
  regarding	
  crisis	
  intervention	
  were	
  limited;	
   however,	
  those	
  reviewed	
  revealed	
  improvements	
  with	
  regard	
  to	
   timeliness	
  of	
  assessment.	
  	
  Record	
  review	
  revealed	
  that	
  in	
  general,	
   documentation	
  was	
  completed	
  within	
  24	
  hours.	
  	
  In	
  addition,	
  when	
   follow	
  up	
  visits	
  were	
  recommended,	
  documentation	
  was	
  located.	
  	
  In	
   future	
  monitoring	
  visits,	
  additional	
  examples	
  of	
  crisis	
  intervention	
   documentation	
  will	
  be	
  requested.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  	
  
1. Ensure	
  that	
  case	
  formulations	
  are	
  complete,	
  outlining	
  criteria	
   for	
  specific	
  diagnoses	
  and	
  indicating	
  specific	
  youth	
  risk	
  factors	
   for	
  ongoing	
  challenges.	
  	
  	
  
2. Ensure	
  that	
  treatment	
  plans	
  include	
  measurable	
   goals/objectives	
  with	
  targeted	
  interventions	
  included	
  to	
   address	
  each	
  treatment	
  goal	
  and	
  that	
  progress	
  notes	
  reflect	
   interventions	
  aimed	
  at	
  addressing	
  specific	
  treatment	
  goals.	
  	
  
3. Complete	
  the	
  planned	
  review	
  and	
  revision	
  of	
  policy	
  and	
   procedure.	
  
• Mental	
  health	
  records	
  	
   • Interviews	
  with	
  ODYS	
  administrative	
  staff	
   • Interviews	
  with	
  facility	
  mental	
  health	
  staff	
  	
  
	
  

	
  

108.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 109 of 129 PAGEID #: 2462

G.2	
  Accessibility	
  of	
  Relevant	
  Information.	
  The	
  Facilities	
  shall	
  ensure	
  that	
  youth	
  records	
  are	
   organized	
  in	
  a	
  manner	
  providing	
  treatment	
  teams	
  prompt	
  access	
  to	
  relevant,	
  complete,	
  and	
   accurate	
  documentation	
  regarding	
  the	
  youth’s	
  status.	
  	
  

Compliance	
  Rating	
  	
   Non-­‐Compliance	
  

Self	
  Assessment	
  	
  

The	
  facility	
  self-­‐assessment	
  was	
  provided	
  orally,	
  and	
  did	
  not	
  include	
   information	
  regarding	
  this	
  provision.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  	
  

Currently,	
  the	
  record-­‐keeping	
  program	
  at	
  the	
  facility	
  is	
  cumbersome.	
   There	
  are	
  multiple	
  databases	
  where	
  information	
  is	
  stored,	
  making	
   access	
  to	
  information	
  challenging.	
  	
  For	
  example,	
  the	
  integrated	
  progress	
   notes	
  reviewed	
  contained	
  information	
  that	
  was	
  generated	
  by	
  psychiatry	
   and	
  psychology,	
  there	
  was	
  no	
  social	
  work	
  information	
  included.	
  	
  The	
   medical	
  record	
  included	
  psychiatric	
  documentation	
  (evaluations	
  and	
   medication	
  management	
  progress	
  notes),	
  but	
  did	
  not	
  include	
  other	
   mental	
  health	
  documentation.	
  	
  Given	
  the	
  multiple	
  locations	
  where	
   information	
  is	
  stored,	
  the	
  information	
  gathering	
  process	
  is	
  laborious,	
   therefore	
  increasing	
  the	
  possibility	
  of	
  error.	
  	
  	
  	
   	
   Per	
  interviews	
  with	
  ODYS	
  administration,	
  there	
  are	
  plans	
  to	
  implement	
   an	
  integrated	
  electronic	
  health	
  record,	
  but	
  at	
  the	
  time	
  of	
  this	
   monitoring	
  visit,	
  this	
  project	
  remained	
  in	
  the	
  planning	
  stages.	
  	
  Pending	
   this	
  improvement,	
  mental	
  health	
  staff	
  of	
  all	
  disciplines	
  are	
  hampered	
  by	
   the	
  current	
  documentation	
  system.	
  	
   	
   Regardless,	
  as	
  stated	
  in	
  G1	
  above,	
  per	
  the	
  review	
  of	
  youth	
  records	
  and	
   mental	
  health	
  documentation	
  available	
  for	
  off	
  site	
  review,	
  there	
  was	
   considerable	
  variability	
  in	
  the	
  quality	
  of	
  documentation	
  regarding	
   mental	
  health	
  treatment.	
  	
  This	
  is	
  an	
  area	
  that	
  would	
  be	
  amenable	
  to	
   quality	
  assurance	
  (with	
  associated	
  corrective	
  action)	
  and	
  peer	
  review.	
  	
  	
  

Recommendations	
  	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  	
  
1. Ensure	
  that	
  all	
  mental	
  health	
  staff,	
  including	
  psychiatrists,	
  have	
   access	
  to	
  relevant,	
  complete	
  and	
  accurate	
  documentation	
   regarding	
  the	
  youth’s	
  mental	
  health	
  status	
  and	
  treatment.	
  	
  
2. Continue	
  and	
  expand	
  quality	
  assurance	
  monitoring	
  of	
  mental	
   health	
  documentation.	
  	
  This	
  would	
  include	
  a	
  review	
  of	
  a	
   percentage	
  of	
  mental	
  health	
  records	
  along	
  with	
  corrective	
   action	
  plans	
  as	
  needed.	
  

Sources	
  of	
   Information	
  	
  
	
   	
   	
  
	
  

• Mental	
  health	
  records	
  	
   • Interviews	
  with	
  ODYS	
  and	
  facility	
  mental	
  health	
  staff	
  	
   • Medical	
  records	
  
	
  

	
  

109.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 110 of 129 PAGEID #: 2463

MEDICAL	
  SERVICES	
  
	
  
III.C.1	
  	
  General.	
  The	
  facilities	
  shall	
  ensure	
  that	
  the	
  individuals	
  they	
  serve	
  receive	
  routine,	
   preventive,	
  and	
  emergency	
  medical	
  and	
  dental	
  care	
  consistent	
  with	
  current,	
  generally	
  accepted	
   professional	
  standards.	
  The	
  facilities	
  shall	
  ensure	
  that	
  individuals	
  with	
  health	
  problems	
  are	
   identified,	
  assessed,	
  diagnosed,	
  and	
  treated	
  consistent	
  with	
  current,	
  generally	
  accepted	
   professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Ohio	
  Department	
  of	
  Youth	
  Services	
  (ODYS)	
  did	
  not	
  conduct	
  a	
  self-­‐ assessment	
  for	
  the	
  level	
  of	
  medical	
  and	
  dental	
  care	
  provided	
  at	
  SJCF	
   during	
  this	
  assessment	
  period.	
  However,	
  there	
  has	
  been	
  significant	
   improvement	
  in	
  their	
  quality	
  assurance	
  processes,	
  which	
  in	
  essence	
   completes	
  the	
  task	
  of	
  self-­‐assessment	
  for	
  the	
  purpose	
  of	
  this	
  report.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

An	
  onsite	
  visit	
  was	
  conducted	
  at	
  the	
  Scioto	
  Juvenile	
  Correctional	
  Facility	
   on	
  October	
  16-­‐18,	
  2012.	
  It	
  was	
  this	
  monitor’s	
  second	
  visit	
  to	
  the	
  facility.	
   All	
  previous	
  reviews	
  of	
  health	
  information	
  and	
  other	
  related	
  documents	
   had	
  been	
  conducted	
  off	
  site	
  from	
  records	
  provided	
  by	
  ODYS.	
  Some	
  of	
  the	
   living	
  units	
  were	
  undergoing	
  repairs	
  secondary	
  to	
  storm	
  damage.	
   Available	
  living	
  units	
  were	
  visited	
  and	
  procedural	
  operations	
  and	
  access	
   related	
  to	
  health	
  care	
  observed.	
  Youth	
  were	
  interviewed	
  on	
  the	
  units	
  as	
   to	
  how	
  to	
  access	
  sick	
  call	
  and	
  if	
  they	
  had	
  any	
  complaints	
  regarding	
  their	
   medical	
  care.	
  The	
  food	
  service	
  area	
  was	
  toured	
  and	
  the	
  medication	
  room	
   located	
  there	
  observed.	
  The	
  satellite	
  clinics	
  for	
  Buckeye	
  had	
  not	
  been	
   completed.	
  The	
  rooms	
  had	
  been	
  identified	
  and	
  converted	
  from	
  existing	
   cells.	
  The	
  toilet/sink	
  combinations	
  were	
  still	
  remained	
  in	
  the	
  room	
  with	
   an	
  exam	
  table.	
  There	
  was	
  not	
  an	
  appropriate	
  sink	
  or	
  adequate	
  medical	
   equipment	
  to	
  make	
  it	
  suitable	
  as	
  an	
  exam	
  room	
  or	
  to	
  use	
  to	
  dispense	
   medications.	
  	
  The	
  main	
  clinic	
  was	
  still	
  found	
  to	
  be	
  adequate,	
  with	
   appropriate	
  space,	
  medical	
  supplies	
  and	
  equipment	
  for	
  medical	
  and	
   dental	
  care	
  of	
  the	
  youth.	
   	
   Documentation	
  from	
  January	
  12,	
  2012	
  was	
  provided	
  by	
  Dr.	
  John	
  Bradley,	
   ODYS	
  Medical	
  Director	
  stating	
  completion	
  of	
  the	
  annual	
  review	
  and	
   revision	
  of	
  each	
  policy,	
  procedure	
  and	
  program	
  in	
  the	
  health	
  care	
   delivery	
  system	
  with	
  an	
  attached	
  list	
  of	
  said	
  policies	
  and	
  standard	
   operating	
  procedures.	
  	
  	
  	
   	
  	
   A	
  review	
  of	
  eight	
  youth	
  health	
  records	
  housed	
  at	
  the	
  Scioto	
  Facility	
  was	
   conducted.	
  This	
  included	
  any	
  Youth	
  Injury	
  and	
  Assessment	
  Forms	
  present	
   in	
  the	
  chart.	
  The	
  health	
  record	
  review	
  included	
  assessing	
  completeness	
   of	
  the	
  Problem	
  List,	
  the	
  presence	
  and	
  timeliness	
  of	
  the	
  Nursing	
  Intake	
   Screening,	
  Mental	
  Health	
  Screening,	
  Physical	
  Exam,	
  Dental	
  Exam,	
  Dental	
   Treatment,	
  Oral	
  Hygiene	
  Instruction	
  and	
  Growth	
  Chart.	
  	
  Admission	
  labs	
   were	
  checked	
  for	
  completion	
  and	
  results	
  within	
  20	
  days;	
  STD	
  screening	
   for	
  Gonorrhea	
  and	
  Chlamydia;	
  Chronic	
  Care	
  and	
  Specialty	
  Care	
  Consult	
  

	
  

110.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 111 of 129 PAGEID #: 2464

documentation;	
  Transfer	
  of	
  Health	
  Records;	
  Immunizations	
  and	
   Tuberculosis	
  Screening;	
  Medication	
  Administration	
  Records;	
  Mental	
   Health	
  Documentation;	
  Progress	
  Notes	
  and	
  Physician	
  Orders	
  were	
   checked	
  in	
  each	
  health	
  record.	
  Since	
  the	
  last	
  visit,	
  the	
  health	
  records	
  now	
   contain	
  the	
  original	
  health	
  request	
  completed	
  by	
  the	
  youth,	
  which	
  are	
   addressed	
  by	
  medical	
  staff	
  in	
  the	
  progress	
  notes.	
  	
   	
   All	
  records	
  documented	
  timely	
  completion	
  of	
  intake	
  assessments	
  such	
  as	
   nurse	
  screenings	
  health	
  appraisals	
  and	
  physical	
  examinations	
  all	
  on	
  the	
   same	
  day	
  of	
  admission.	
  Growth	
  Charts	
  were	
  present	
  for	
  all	
  youth.	
  There	
   was	
  documentation	
  of	
  admission	
  labs	
  being	
  drawn	
  with	
  results	
  available	
   all	
  within	
  a	
  week.	
  STD	
  screening	
  results	
  were	
  documented	
  in	
  all	
  records.	
   Immunization	
  records	
  were	
  up	
  to	
  date	
  on	
  all	
  records	
  reviewed.	
  HPV	
   vaccine	
  is	
  now	
  being	
  administered	
  to	
  all	
  youth,	
  male	
  and	
  females,	
  as	
   available.	
  There	
  is	
  a	
  back	
  order	
  on	
  the	
  HPV	
  vaccine	
  through	
  the	
  Federal	
   Vaccines	
  for	
  Children	
  Program.	
  I	
  reviewed	
  the	
  facility’s	
  vaccine	
   accountability	
  order	
  documentation.	
  Youth	
  had	
  already	
  been	
   administered	
  influenza	
  vaccine	
  for	
  the	
  current	
  flu	
  season.	
  All	
  youth	
   received	
  tuberculosis	
  screening	
  with	
  documented	
  results.	
  	
  Dental	
   examinations	
  were	
  completed	
  within	
  a	
  week	
  of	
  admission	
  with	
   instruction	
  given	
  on	
  oral	
  hygiene.	
  Dental	
  treatment	
  was	
  provided	
  as	
  a	
   result	
  of	
  the	
  dental	
  examination	
  or	
  as	
  a	
  result	
  of	
  a	
  Health	
  Request.	
  Youth	
   are	
  being	
  recalled	
  every	
  6	
  months	
  for	
  dental	
  care.	
  	
  All	
  youth	
  allergies	
   were	
  noted	
  in	
  their	
  health	
  record.	
  	
   	
   Medication	
  administration	
  records	
  and	
  physician	
  orders	
  were	
  also	
   reviewed	
  for	
  accuracy	
  and	
  medication	
  compliance.	
  There	
  was	
   documentation	
  of	
  three	
  optometry	
  consults	
  for	
  youth	
  to	
  receive	
  glasses.	
   Youth	
  complaining	
  of	
  headaches	
  received	
  a	
  neurology	
  consult	
  and	
  CT	
   scan.	
  Diabetic	
  youth	
  appropriately	
  received	
  ophthalmology,	
  endocrine	
   and	
  podiatry	
  consults.	
  Two	
  of	
  the	
  eight	
  youth	
  records	
  reviewed	
  had	
  with	
   chronic	
  medical	
  conditions	
  (diabetes).	
  Both	
  received	
  appropriate	
   assessments	
  and	
  treatment	
  plans.	
  There	
  were	
  only	
  five	
  youth	
  at	
  the	
   facility	
  with	
  chronic	
  medical	
  diagnoses,	
  including	
  the	
  two	
  reviewed.	
  Six	
  of	
   the	
  eight	
  youth	
  records	
  reviewed	
  had	
  at	
  least	
  one	
  mental	
  health	
   diagnosis.	
  All	
  mental	
  health	
  diagnoses	
  as	
  well	
  as	
  medical	
  diagnoses	
  were	
   listed	
  on	
  the	
  problem	
  list.	
  This	
  is	
  a	
  significant	
  improvement	
  since	
  the	
  last	
   review.	
  	
   	
   Medical	
  services	
  for	
  the	
  10	
  females	
  at	
  the	
  facility	
  were	
  discussed	
  with	
   their	
  provider,	
  Dr.	
  Stein.	
  He	
  stated	
  most	
  of	
  the	
  girls	
  have	
  already	
  had	
  PAP	
   smears	
  and	
  refuse	
  the	
  pelvic	
  exam.	
  The	
  American	
  College	
  of	
  Obstetrics	
   and	
  Gynecology	
  (ACOG)	
  no	
  longer	
  recommends	
  PAP	
  smears	
  in	
  females	
   less	
  than	
  21	
  years	
  of	
  age.	
  All	
  females	
  are	
  screened	
  for	
  Gonorrhea	
  and	
   Chlamydia	
  using	
  a	
  urine	
  test.	
  There	
  were	
  no	
  pregnant	
  girls	
  at	
  the	
  facility,	
   but	
  services	
  are	
  either	
  provided	
  through	
  their	
  designated	
  Hospital	
   (Grady)	
  or	
  girls	
  are	
  transported	
  back	
  to	
  their	
  community	
  Obstetrician	
  for	
  

	
  

111.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 112 of 129 PAGEID #: 2465

continued	
  care.	
  	
  	
  

	
  

When	
  nurses	
  made	
  seclusion	
  checks,	
  they	
  were	
  documented	
  in	
  the	
  

progress	
  notes.	
  Logs	
  were	
  posted	
  on	
  the	
  unit	
  doors.	
  Some	
  youth	
  

identified	
  through	
  review	
  of	
  the	
  medical	
  records	
  spent	
  several	
  days	
  in	
  

seclusion.	
  Progress	
  notes	
  simply	
  state	
  “seclusion	
  check”	
  without	
  details	
  

of	
  the	
  youth’s	
  health	
  status.	
  A	
  full	
  progress	
  note	
  is	
  needed	
  in	
  SOAP	
  

format.	
  Youth	
  are	
  spending	
  a	
  significant	
  amount	
  of	
  time	
  in	
  seclusion	
  on	
  

the	
  Progress	
  Unit,	
  therefore	
  making	
  it	
  even	
  more	
  important	
  to	
  document	
  

the	
  details	
  of	
  their	
  health	
  status.	
  There	
  was	
  one	
  youth	
  with	
  3	
  days	
  

documented	
  since	
  his	
  arrival	
  on	
  6/14/12.	
  One	
  youth	
  had	
  24	
  days	
  of	
  

seclusion	
  checks	
  documented	
  between	
  February	
  and	
  October	
  2012.	
  

Another	
  had	
  51days	
  in	
  seclusion	
  between	
  January	
  and	
  the	
  time	
  of	
  the	
  

visit.	
  A	
  fourth	
  youth	
  had	
  69	
  days	
  of	
  documented	
  seclusion	
  checks	
  within	
  

a	
  year.	
  Many	
  of	
  the	
  days	
  in	
  seclusion	
  ran	
  in	
  continuous	
  blocks.	
  	
  At	
  least	
  

half	
  of	
  the	
  medical	
  records	
  reviewed	
  had	
  documentation	
  of	
  youth	
  having	
  

been	
  secluded.	
  	
  

	
  

	
  

Documentation	
  on	
  the	
  Youth	
  injury	
  and	
  Assessment	
  Reports	
  were	
  

reviewed	
  for	
  those	
  included	
  in	
  the	
  eight	
  health	
  records.	
  There	
  has	
  been	
  

overall	
  improvement	
  in	
  the	
  documentation	
  provided	
  by	
  nursing	
  staff	
  for	
  

youth	
  assessed	
  for	
  injuries.	
  There	
  are	
  still	
  some	
  individual	
  nurses	
  that	
  are	
  

not	
  adequately	
  documenting	
  these	
  assessments.	
  This	
  was	
  discussed	
  with	
  

the	
  Nurse	
  Manager,	
  Ms.	
  Vickie	
  Donohue,	
  who	
  was	
  already	
  aware	
  

through	
  the	
  continuous	
  quality	
  improvement	
  (CQI)	
  review	
  process.	
  These	
  

individuals	
  have	
  been	
  placed	
  on	
  a	
  performance	
  improvement	
  plans.	
  	
  

	
  

Internal	
  (CQI)	
  Quality	
  Assurance	
  documents	
  were	
  reviewed	
  that	
  were	
  

provided	
  by	
  ODYS	
  which	
  included	
  several	
  audit	
  instruments.	
  The	
  QA	
  

instruments	
  and	
  processes	
  have	
  been	
  revised	
  since	
  the	
  last	
  visit.	
  The	
  

Nurse	
  Manager	
  is	
  now	
  involving	
  more	
  staff	
  nurses	
  in	
  the	
  process	
  and	
  the	
  

documents	
  have	
  been	
  formatted	
  differently	
  for	
  easier	
  use.	
  This	
  is	
  a	
  good	
  

idea	
  and	
  helps	
  staff	
  to	
  understand	
  and	
  complete	
  the	
  process	
  better.	
  

Chronic	
  Care	
  audits	
  are	
  now	
  conducted	
  quarterly	
  due	
  to	
  the	
  small	
  

number	
  of	
  youth	
  with	
  chronic	
  medical	
  conditions.	
  Medication	
  

Administration	
  Record	
  Continuous	
  Quality	
  Improvement	
  (CQI)	
  

documents	
  for	
  April	
  10,	
  2012	
  and	
  August	
  3,	
  2012	
  was	
  reviewed.	
  Between	
  

April	
  and	
  August	
  there	
  was	
  improvement	
  from	
  60%	
  to	
  100%	
  on	
  the	
  

compliance	
  indicator	
  of	
  medication	
  frequency,	
  doses,	
  route,	
  start	
  and	
  

stop	
  date	
  documented.	
  Improvements	
  from	
  60%	
  to	
  100%	
  were	
  also	
  

shown	
  in	
  3	
  other	
  areas	
  of	
  medication	
  compliance	
  indicators.	
  The	
  CQI	
  

Problem	
  List	
  review	
  showed	
  significant	
  compliance	
  with	
  documentation	
  

of	
  all	
  chronic	
  medical	
  conditions,	
  including	
  mental	
  health	
  diagnoses.	
  This	
  

is	
  consistent	
  with	
  the	
  improvement	
  I	
  noted	
  on	
  this	
  visit	
  compared	
  to	
  the	
  

previous	
  one.	
  There	
  still	
  needs	
  to	
  be	
  improvement	
  on	
  documenting	
  acute	
  

medical	
  conditions	
  on	
  the	
  problem	
  list,	
  as	
  noted	
  in	
  the	
  CQI	
  report.	
  Vital	
  

signs	
  at	
  the	
  time	
  of	
  encounter	
  were	
  reviewed	
  on	
  June	
  5,	
  2012	
  and	
  August	
  

	
  

112.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 113 of 129 PAGEID #: 2466

Recommendations	
  
Sources	
  of	
   Information	
   	
  

7,	
  2012.	
  The	
  documentation	
  of	
  vital	
  signs	
  CQI	
  audit	
  showed	
  improvement	
   from	
  85%	
  to	
  95%.	
  The	
  CQI	
  Processing	
  of	
  Specialty	
  Consults	
  was	
  reviewed	
   from	
  June	
  2012,	
  September	
  6,	
  2012	
  and	
  October	
  9,	
  2012.	
  The	
  initial	
  June	
   review	
  identified	
  the	
  need	
  for	
  improvement	
  In	
  all	
  areas,	
  except	
  physician	
   orders	
  being	
  written	
  for	
  consultation	
  and	
  youth	
  being	
  seen	
  by	
  the	
   physician	
  at	
  the	
  next	
  clinic	
  visit.	
  The	
  September	
  audit	
  showed	
   improvement	
  to	
  90%	
  in	
  all	
  areas	
  but	
  one.	
  The	
  October	
  CQI	
  review	
   showed	
  100%	
  compliance	
  in	
  80%	
  of	
  the	
  compliance	
  indicators.	
  CQI	
   documents	
  for	
  completion	
  of	
  the	
  Youth	
  Injury	
  Assessment	
  Form	
  (YIAF)	
   were	
  reviewed	
  from	
  June	
  5,	
  2012,	
  July	
  9,	
  2012	
  and	
  October	
  5,	
  2012	
  and	
   showed	
  improvement	
  of	
  youth	
  on	
  the	
  Progress	
  Unit	
  being	
  brought	
  to	
  the	
   exam	
  room	
  for	
  evaluation.	
  The	
  Nurse	
  Manager,	
  also	
  through	
  the	
  CQI	
   process	
  was	
  able	
  to	
  identify	
  certain	
  staff	
  not	
  properly	
  conducting	
   assessments,	
  as	
  previously	
  noted.	
  What	
  is	
  most	
  important	
  is	
  the	
  process	
   and	
  that	
  medical	
  staff	
  are	
  conducting	
  self	
  assessments	
  and	
  developing	
   corrective	
  action	
  plans	
  based	
  on	
  their	
  findings	
  in	
  order	
  to	
  continuously	
   improve	
  the	
  quality	
  of	
  health	
  care.	
  During	
  this	
  site	
  visit,	
  I	
  met	
  with	
  Dr.	
   John	
  Brady,	
  Medical	
  Director	
  and	
  Pamela	
  Robbins,	
  Director	
  of	
  Nursing	
   along	
  with	
  Scioto	
  Nurse	
  Manager,	
  Vickie	
  Donohue	
  to	
  discuss	
  all	
  medical	
   findings.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  	
  	
  
1. Complete	
  satellite	
  clinic	
  and	
  medication	
  room	
  on	
  Buckeye	
  Units	
   for	
  adequate	
  injury	
  assessments	
  of	
  youth	
  and	
  medication	
   administration	
  on	
  the	
  unit.	
  	
  
2. Limit	
  time	
  of	
  youth	
  in	
  seclusion	
  and	
  improve	
  documentation	
  of	
   health	
  status	
  during	
  segregation.	
  
3. Continue	
  to	
  improve	
  Quality	
  Assurance	
  (QA)	
  activities	
  by	
   considering	
  a	
  review	
  at	
  least	
  annually	
  by	
  a	
  source	
  external	
  to	
   ODYS	
  Health	
  Services.	
  ODYS	
  should	
  also	
  consider	
  expansion	
  of	
   the	
  QA	
  process	
  to	
  include	
  some	
  additional	
  quality	
  indicators.	
   Conduct	
  Quality	
  Assurance	
  Program	
  as	
  outlined	
  in	
  the	
  National	
   Commission	
  on	
  Correctional	
  Health	
  Care	
  Juvenile	
  Health	
   Standards.	
  This	
  would	
  satisfy	
  the	
  need	
  for	
  a	
  self	
  assessment.	
  
• Site	
  visit	
  tour;	
  Review	
  of	
  eight	
  youth	
  health	
  records:	
  ID	
  #	
  217938,	
   217241,	
  217365,	
  217718,	
  215927,	
  218016,	
  218076,	
  and	
  218098;	
   CQI	
  Documentation	
  as	
  outlined	
  above.	
  	
  
	
  

	
  

113.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 114 of 129 PAGEID #: 2467

III.C.2	
  	
  Health	
  Records.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
   practices	
  to	
  ensure	
  that,	
  consistent	
  with	
  State	
  and	
  federal	
  law,	
  at	
  a	
  minimum,	
  the	
  juvenile	
   courts	
  in	
  the	
  State,	
  all	
  juvenile	
  detention	
  facilities	
  and	
  all	
  placement	
  settings	
  from	
  which	
   youth	
  are	
  committed	
  shall	
  timely	
  forward	
  to	
  Scioto,	
  or	
  to	
  the	
  facility	
  of	
  placement	
  (if	
  the	
   records	
  arrive	
  after	
  the	
  youth	
  has	
  been	
  placed),	
  all	
  pertinent	
  youth	
  records	
  regarding	
   medical	
  and	
  mental	
  health	
  care.	
  The	
  facilities	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  ensure	
  that	
  health	
  care	
  staff,	
  including	
  mental	
  health	
  care	
   staff,	
  have	
  access	
  to	
  documents	
  that	
  are	
  relevant	
  to	
  the	
  care	
  and	
  treatment	
  of	
  the	
  youth.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Ohio	
  Department	
  of	
  Youth	
  Services	
  (ODYS)	
  did	
  not	
  conduct	
  a	
   self-­‐assessment	
  for	
  the	
  level	
  of	
  medical	
  and	
  dental	
  care	
  provided	
  at	
   SJCF	
  during	
  this	
  assessment	
  period.	
  However	
  the	
  health	
  records	
  are	
   being	
  reviewed	
  as	
  a	
  part	
  of	
  the	
  CQI	
  process.	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Review	
  of	
  eight	
  youth	
  health	
  records.	
  There	
  were	
  no	
  new	
  Health	
   Policies	
  and	
  Procedures	
  or	
  Standard	
  Operating	
  Procedures	
  (SOP)	
   completed	
  by	
  ODYS	
  since	
  the	
  last	
  visit.	
  All	
  health	
  records	
  reviewed	
   contained	
  some	
  health	
  information	
  transferred	
  from	
  the	
  county	
   probation	
  offices	
  or	
  other	
  facilities.	
  I	
  still	
  have	
  a	
  concern	
  that	
  the	
   offense	
  data	
  contained	
  within	
  the	
  Disposition	
  Investigative	
  Report	
   is	
  included	
  in	
  some	
  of	
  the	
  health	
  records	
  along	
  with	
  the	
  medical	
   information	
  on	
  the	
  youth.	
  The	
  offense	
  information	
  is	
  irrelevant	
  to	
   the	
  provision	
  of	
  the	
  youth’s	
  health	
  care	
  and	
  should	
  not	
  be	
  included	
   in	
  the	
  health	
  record.	
  The	
  health	
  record	
  is	
  still	
  fragmented	
  due	
  to	
   the	
  psychological	
  and	
  counseling	
  notes	
  being	
  housed	
  separately	
  on	
   the	
  housing	
  units.	
  However,	
  two	
  weeks	
  prior	
  to	
  this	
  visit,	
  an	
  RFP	
   was	
  awarded	
  to	
  eClinical	
  Works	
  through	
  the	
  Ohio	
  Department	
  of	
   Administrative	
  Services	
  and	
  the	
  Office	
  of	
  Information	
  Technology	
   (OIT)	
  for	
  implementation	
  of	
  an	
  electronic	
  health	
  record	
  (EHR).	
  I	
   reviewed	
  the	
  Adult	
  Department	
  of	
  Rehabilitation	
  and	
  Correction	
   (DRC)	
  Electronic	
  Health	
  Record	
  (EHR)	
  workflow	
  and	
  documentation	
   requirements	
  included	
  in	
  the	
  RFP,	
  which	
  was	
  very	
  comprehensive.	
   The	
  system	
  seems	
  to	
  be	
  able	
  to	
  provide	
  adequate	
  health	
   information	
  in	
  an	
  electronic	
  format	
  at	
  the	
  facilities.	
  The	
  plan	
  is	
  for	
   the	
  EHR	
  to	
  also	
  connect	
  the	
  state	
  and	
  community	
  providers,	
   initially	
  to	
  begin	
  with	
  the	
  (DRC),	
  followed	
  by	
  ODYS,	
  KALOS	
   Pharmacy,	
  Central	
  Medical	
  Lab,	
  Franklin	
  Medical	
  Center	
  and	
  OSU	
   Hospital	
  records.	
  	
  The	
  program	
  will	
  be	
  customized	
  for	
  each	
  of	
  its	
   users	
  to	
  include	
  links	
  that	
  may	
  be	
  specific	
  to	
  DYS,	
  such	
  as	
  the	
  state	
   immunization	
  records.	
  The	
  EHR	
  is	
  to	
  be	
  piloted	
  at	
  one	
  female	
  adult	
   correctional	
  facility	
  in	
  April	
  2013.	
  The	
  electronic	
  health	
  record	
   being	
  established	
  will	
  facilitate	
  the	
  sharing	
  of	
  the	
  mental	
  health	
   and	
  medical	
  information.	
  SJCF	
  currently	
  has	
  a	
  Mental	
  Health	
   Database	
  that	
  I	
  observed	
  during	
  the	
  April	
  2012	
  visit.	
  Although	
  not	
   all-­‐inclusive,	
  this	
  database	
  includes	
  diagnosis,	
  medication	
   information	
  and	
  medication	
  compliance.	
  Psychology	
  staff	
  that	
  are	
   directly	
  involved	
  with	
  the	
  care	
  and	
  treatment	
  of	
  the	
  Youth	
  at	
  SJCF	
  

	
  

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have	
  access	
  to	
  the	
  psychiatry	
  notes.	
  This	
  system	
  can	
  continue	
  to	
  be	
   used	
  until	
  the	
  full	
  development	
  and	
  implementation	
  of	
  eClinical	
   Works.	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
   State	
  must:	
  
1. Continue	
  to	
  improve	
  the	
  process	
  for	
  sharing	
  of	
  health	
   information	
  between	
  medical	
  and	
  mental	
  health	
  to	
  include	
   psychologists	
  through	
  implementation	
  of	
  eClinical	
  Works	
   EHR.	
  ODYS	
  medical	
  management	
  staff	
  should	
  be	
  intimately	
   involved	
  in	
  the	
  process	
  of	
  customization	
  of	
  the	
  EMR	
  to	
  be	
   relevant	
  to	
  youth	
  medical	
  services.	
  
2. Redact	
  offense-­‐related	
  information	
  from	
  the	
  Disposition	
   Investigation	
  Report	
  contained	
  in	
  the	
  health	
  record.	
  	
  

Sources	
  of	
   Information	
  
	
   	
   	
   	
  

• Site	
  visit	
  tour;	
  Review	
  of	
  eight	
  youth	
  health	
  records:	
  ID	
  #	
   Site	
  visit	
  tour;	
  Review	
  of	
  ten	
  youth	
  health	
  records:	
  217938,	
   217241,	
  217635,	
  217718,	
  215927,	
  218016,	
  218076,	
  and	
   218098.	
  	
  
• Discussion	
  with	
  and	
  documentation	
  provided	
  by	
  Dr.	
  John	
   Bradley,	
  Medical	
  Director,	
  regarding	
  EHR	
  RFP	
  
	
  

	
  

115.	
  

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III.C.5	
  	
  Access	
  to	
  Health	
  Services.	
  The	
  facilities	
  shall	
  ensure	
  that	
  youth	
  can	
  request	
  to	
  be	
  seen	
  by	
   medical	
  staff	
  confidentially	
  and	
  independent	
  from	
  JCOs	
  and	
  custodial	
  staff.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Ohio	
  Department	
  of	
  Youth	
  Services	
  (ODYS)	
  did	
  not	
  conduct	
  a	
  self-­‐ assessment	
  for	
  the	
  level	
  of	
  medical	
  and	
  dental	
  care	
  provided	
  at	
  SJCF	
   during	
  this	
  assessment	
  period.	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Health	
  Request	
  call	
  drop	
  boxes	
  were	
  missing	
  on	
  some	
  of	
  the	
  living	
  units,	
   which	
  appeared	
  to	
  be	
  freshly	
  painted.	
  It	
  appeared	
  to	
  be	
  an	
  oversight	
  in	
   replacing	
  the	
  boxes	
  on	
  the	
  units.	
  Health	
  Request	
  boxes	
  were	
  present	
  in	
   the	
  Cafeteria	
  and	
  in	
  the	
  School.	
  Youth	
  interviewed	
  with	
  the	
  exception	
  of	
   one,	
  all	
  knew	
  where	
  the	
  boxes	
  were	
  located	
  and	
  all	
  could	
  verbalize	
  how	
   to	
  gain	
  access	
  to	
  health	
  services.	
  Progress	
  Notes	
  and	
  Nurse	
  Health	
   Requests	
  were	
  reviewed	
  in	
  8	
  health	
  records.	
  The	
  original	
  Health	
   Requests	
  are	
  now	
  included	
  in	
  the	
  health	
  record	
  and	
  not	
  in	
  a	
  separate	
   binder	
  as	
  on	
  the	
  previous	
  visit.	
  Health	
  requests	
  included	
  in	
  these	
  health	
   records	
  were	
  responded	
  to	
  adequately	
  and	
  documented	
  by	
  medical	
  staff	
   100%	
  of	
  the	
  time.	
  Health	
  Requests	
  were	
  reviewed	
  and	
  in	
  each	
  case	
   traced	
  back	
  to	
  a	
  corresponding	
  progress	
  note	
  to	
  determine	
  if	
  the	
   complaint	
  had	
  been	
  addressed.	
  In	
  all	
  cases,	
  the	
  requests	
  had	
  been	
   adequately	
  assessed	
  and	
  treated	
  by	
  registered	
  nursing	
  staff	
  and	
  in	
  some	
   cases	
  by	
  the	
  physician.	
  Most	
  requests	
  were	
  relatively	
  minor	
  such	
  as	
  sore	
   throat,	
  runny	
  nose	
  and	
  skin	
  complaints.	
  There	
  were	
  several	
  related	
  to	
   dental	
  complaints.	
  All	
  were	
  addressed	
  in	
  a	
  timely	
  manner	
  by	
  health	
  care	
   staff.	
  	
  	
  

Recommendations	
  

In	
  order	
  to	
  maintain	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Ensure	
  Health	
  Request	
  slips	
  and	
  boxes	
  are	
  readily	
  available	
  to	
   youth	
  on	
  all	
  housing	
  units.	
  Youth	
  should	
  not	
  have	
  to	
  rely	
  on	
   custody	
  staff	
  to	
  request	
  forms.	
  	
  	
  

Sources	
  of	
   Information	
  
	
   	
   	
   	
  

• Site	
  visit	
  tour;	
  Review	
  of	
  ten	
  youth	
  health	
  records:	
  217938,	
   217241,	
  217365,	
  217718,	
  215927,	
  218016,	
  218076,	
  and	
  218098.	
  
	
  

	
  

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SPECIAL	
  EDUCATION	
  
	
  
III.E.1	
  Provision	
  of	
  Special	
  Education.	
  The	
  State	
  shall,	
  at	
  all	
  times,	
  provide	
  all	
  youth	
  confined	
  at	
   the	
  facilities	
  with	
  adequate	
  special	
  education	
  in	
  compliance	
  with	
  the	
  Individuals	
  with	
  Disabilities	
   Education	
  Act	
  (IDEA),	
  20	
  U.S.C.	
  §	
  1400-­‐1482,	
  and	
  regulations	
  promulgated	
  thereunder,	
  and	
  this	
   Stipulation.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Prior	
  to	
  the	
  Monitor’s	
  visit	
  in	
  October	
  2012,	
  the	
  State	
  was	
  asked	
  to	
   produce	
  data	
  and	
  explanations	
  for	
  a	
  limited	
  range	
  of	
  issues	
  related	
  to	
  the	
   three	
  education-­‐related	
  provisions	
  that	
  are	
  included	
  in	
  the	
  Amended	
   Stipulation.	
  The	
  first	
  provision	
  pertains	
  to	
  the	
  delivery	
  of	
  special	
   education	
  services	
  in	
  general.	
  In	
  the	
  past,	
  the	
  key	
  compliance	
  issues	
  were	
   related	
  to	
  providing	
  education	
  services	
  to	
  youth	
  who	
  were	
  removed	
  from	
   school	
  during	
  the	
  day	
  or	
  who	
  were	
  held	
  on	
  the	
  unit	
  for	
  disciplinary	
   reasons.	
  	
   	
   School	
  Safety	
   	
   Schools	
  cannot	
  facilitate	
  learning	
  if	
  the	
  environment	
  is	
  not	
  safe.	
  Shortly	
   after	
  the	
  facility	
  converted	
  to	
  a	
  long-­‐term	
  placement	
  for	
  medium	
  and	
   close	
  custody	
  youth,	
  the	
  rates	
  of	
  youth	
  violence	
  increased	
  significantly.	
   During	
  the	
  previous	
  monitoring	
  period,	
  school	
  schedules	
  were	
  shifted	
  so	
   that	
  medium	
  custody	
  and	
  close	
  custody	
  boys	
  attended	
  school	
  in	
  different	
   buildings,	
  and	
  the	
  girls	
  attend	
  school	
  separately	
  as	
  well.	
  This	
  appears	
  to	
   have	
  created	
  a	
  safer	
  environment	
  that	
  is	
  much	
  more	
  conducive	
  to	
   learning.	
  	
   	
   With	
  many	
  of	
  the	
  staffing	
  problems	
  now	
  resolved,	
  as	
  discussed	
  below,	
   the	
  safety	
  of	
  the	
  school	
  environment	
  has	
  continued	
  to	
  improve.	
  In	
  the	
   PROGRESS	
  Unit	
  (PU)	
  school,	
  additional	
  YS	
  staff	
  have	
  been	
  deployed	
  to	
   provide	
  extra	
  security	
  during	
  school	
  hours	
  and	
  the	
  classroom	
   environments	
  have	
  been	
  “hardened”	
  (e.g.,	
  furniture	
  bolted	
  down,	
  flex	
   keyboards	
  put	
  into	
  use,	
  etc.)	
  resulting	
  in	
  greater	
  safety	
  for	
  both	
  youth	
   and	
  staff.	
  In	
  January	
  2012,	
  48	
  YBIRs	
  were	
  issued	
  in	
  the	
  PU	
  school,	
   compared	
  to	
  only	
  9	
  in	
  September	
  2012.	
  Other	
  elements	
  related	
  to	
  the	
   ability	
  to	
  of	
  students	
  to	
  access	
  and	
  teachers	
  to	
  deliver	
  the	
  special	
   education	
  program	
  are	
  discussed	
  in	
  more	
  detail	
  below.	
  	
   	
   Staffing	
  Issues	
   	
   At	
  the	
  conclusion	
  of	
  the	
  previous	
  monitoring	
  period,	
  the	
  school	
  was	
   short	
  two	
  special	
  education	
  teachers,	
  one	
  math	
  teacher	
  and	
  one	
  science	
   teacher.	
  	
  Several	
  more	
  teachers	
  were	
  out	
  on	
  disability	
  leave	
  and	
  the	
   facility	
  did	
  not	
  have	
  sufficient	
  numbers	
  of	
  substitute	
  teachers	
  to	
  cover	
  all	
   the	
  classes.	
  These	
  education	
  staffing	
  problems	
  were	
  compounded	
  by	
   direct	
  care	
  staffing	
  shortages	
  that	
  prevented	
  youth	
  from	
  being	
  

	
  

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transported	
  to	
  the	
  school	
  buildings.	
  Throughout	
  most	
  of	
  the	
  previous	
   monitoring	
  period,	
  students	
  did	
  not	
  have	
  dependable	
  access	
  to	
  the	
  daily	
   330	
  minutes	
  of	
  instruction	
  required	
  by	
  State	
  law.	
  	
   	
   During	
  the	
  current	
  monitoring	
  period,	
  these	
  staffing	
  issues	
  were	
  largely	
   resolved.	
  Many,	
  but	
  not	
  all,	
  of	
  the	
  vacant	
  teacher	
  positions	
  were	
  filled	
   and	
  nearly	
  all	
  of	
  the	
  teachers	
  on	
  disability	
  returned	
  to	
  work.	
  	
   	
   However,	
  the	
  Science	
  teacher	
  position	
  was	
  vacant	
  for	
  the	
  entire	
   monitoring	
  period.	
  The	
  attendance	
  secretary	
  position	
  was	
  vacant	
  for	
  the	
   last	
  three	
  months	
  (but	
  was	
  filled	
  just	
  prior	
  to	
  the	
  Monitor’s	
  visit	
  in	
   October	
  2012).	
  A	
  Math	
  teacher	
  position	
  became	
  vacant	
  during	
  the	
  last	
   month	
  of	
  the	
  monitoring	
  period.	
  On	
  the	
  positive	
  side,	
  all	
  of	
  the	
  special	
   education	
  teaching	
  positions	
  were	
  filled	
  throughout	
  the	
  entire	
   monitoring	
  period,	
  along	
  with	
  three	
  substitute	
  teacher	
  positions.	
  These	
   improvements	
  in	
  staffing	
  meant	
  that	
  no	
  classes	
  were	
  cancelled	
  due	
  to	
   teacher	
  shortages	
  throughout	
  the	
  entire	
  six-­‐month	
  monitoring	
  period.	
   On	
  the	
  Youth	
  Specialist	
  (YS)	
  side,	
  only	
  two	
  instructional	
  days	
  were	
   modified	
  due	
  to	
  short	
  staffing	
  during	
  the	
  current	
  monitoring	
  period	
  (one	
   in	
  April,	
  one	
  in	
  May,	
  both	
  in	
  the	
  PU	
  school).	
  Improvements	
  are	
   particularly	
  pronounced	
  in	
  the	
  PU	
  school,	
  where	
  classes	
  have	
  been	
  held	
   daily,	
  with	
  very	
  few	
  exceptions,	
  throughout	
  the	
  entire	
  monitoring	
  period.	
   [It	
  is	
  worth	
  noting	
  that	
  some	
  PU	
  students’	
  behavior	
  issues	
  result	
  in	
   frequent	
  periods	
  of	
  seclusion	
  and	
  removal	
  from	
  the	
  school	
  program.	
   Treatment	
  planning	
  and	
  behavior	
  modification	
  efforts	
  for	
  these	
  youth	
   are	
  the	
  subject	
  of	
  a	
  current	
  Dispute	
  Resolution	
  between	
  the	
  Parties.]	
  	
   	
   While	
  vacancies	
  have	
  and	
  will	
  continue	
  to	
  occur,	
  the	
  facility’s	
  staffing	
   pattern	
  has	
  returned	
  to	
  appropriate	
  levels	
  and	
  no	
  longer	
  represents	
  a	
   barrier	
  to	
  the	
  youth’s	
  ability	
  to	
  access	
  the	
  special	
  education	
  program.	
  	
   	
   ABC	
  Room	
   In	
  the	
  past,	
  youth	
  who	
  exhibited	
  non-­‐compliant	
  behavior	
  in	
  the	
   classroom	
  could	
  be	
  suspended	
  from	
  school	
  and	
  returned	
  to	
  their	
  living	
   units	
  where	
  they	
  did	
  not	
  receive	
  education	
  services	
  of	
  any	
  kind.	
  The	
   State	
  ceased	
  suspending	
  students	
  in	
  June	
  2011,	
  relying	
  more	
  heavily	
  on	
   its	
  in-­‐school	
  suspension	
  room	
  (the	
  Academic	
  Behavior	
  Center	
  (ABC))	
  and	
   its	
  procedure	
  for	
  Unit	
  Instruction.	
  	
   	
   The	
  ABC	
  room	
  provides	
  youth	
  an	
  opportunity	
  to	
  regain	
  control	
  of	
  their	
   behavior	
  and	
  to	
  return	
  to	
  the	
  classroom	
  setting	
  without	
  going	
  back	
  to	
   their	
  living	
  units.	
  Youth	
  are	
  referred	
  to	
  the	
  ABC	
  room	
  for	
  rule	
  violations	
   pertaining	
  to	
  offensive	
  or	
  threatening	
  conduct,	
  being	
  disruptive,	
   distracting	
  other	
  students	
  or	
  being	
  outside	
  an	
  authorized	
  area.	
  During	
   the	
  previous	
  monitoring	
  period,	
  staff	
  shortages	
  left	
  this	
  resource	
   unavailable	
  to	
  teachers,	
  which	
  frequently	
  resulted	
  in	
  youth	
  being	
  sent	
   back	
  to	
  their	
  units	
  during	
  the	
  school	
  day	
  and	
  the	
  loss	
  of	
  integrity	
  of	
  the	
  

	
  

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entire	
  ABC	
  intervention.	
  During	
  the	
  current	
  monitoring	
  period,	
  the	
  boys’	
   and	
  girls’	
  ABC	
  rooms	
  were	
  staffed	
  daily,	
  except	
  for	
  just	
  one	
  day	
  in	
  the	
   boys’	
  school.	
  	
   	
   The	
  number	
  of	
  youth	
  sent	
  to	
  the	
  ABC	
  room	
  during	
  the	
  current	
   monitoring	
  period	
  varied	
  significantly.	
  Nearly	
  three	
  times	
  the	
  number	
  of	
   youth	
  were	
  sent	
  in	
  April	
  (100	
  youth),	
  May	
  (148),	
  June	
  (94)	
  than	
  in	
  July	
  (32	
   youth),	
  August	
  (31)	
  and	
  September	
  (21).	
  The	
  source	
  of	
  these	
  variations	
  is	
   likely	
  the	
  significantly	
  lower	
  number	
  of	
  instructional	
  days	
  during	
  the	
  last	
   half	
  of	
  the	
  monitoring	
  period	
  and	
  the	
  stable	
  teacher	
  assignments,	
  which	
   ensured	
  that	
  the	
  ABC	
  rules	
  were	
  enforced	
  more	
  carefully.	
  	
   	
   The	
  length	
  of	
  stay	
  in	
  the	
  ABC	
  room	
  remained	
  relatively	
  constant—most	
   youth	
  stayed	
  between	
  1.5	
  to	
  2	
  hours.	
  Youth	
  may	
  earn	
  10	
  minutes	
  off	
   their	
  ABC	
  time	
  for	
  every	
  30	
  minutes	
  they	
  spend	
  focused	
  and	
  engaged	
  in	
   their	
  schoolwork.	
  	
   	
   Unit	
  Instruction	
   	
   Previously,	
  the	
  Parties	
  to	
  the	
  S.H.	
  lawsuit	
  negotiated	
  an	
  agreement	
   regarding	
  the	
  delivery	
  of	
  education	
  services	
  to	
  youth	
  who	
  are	
  confined	
  to	
   the	
  living	
  units	
  for	
  disciplinary	
  reasons.	
  Within	
  48	
  hours	
  of	
  their	
   placement	
  in	
  seclusion,	
  students	
  must	
  receive	
  instruction	
  from	
  a	
  certified	
   teacher	
  four	
  times	
  per	
  day,	
  for	
  at	
  least	
  30	
  minutes	
  per	
  visit	
  (i.e.,	
  Unit	
   Instruction).	
  	
  The	
  State	
  submitted	
  documentation	
  for	
  Unit	
  Instruction	
   provided	
  during	
  the	
  July-­‐September	
  2012	
  grading	
  period	
  and	
  described	
   the	
  process	
  for	
  providing	
  services.	
   	
   Each	
  morning,	
  the	
  Assistant	
  Principal	
  calls	
  each	
  unit	
  for	
  the	
  AOV	
  and	
  Unit	
   Restriction	
  list.	
  A	
  Unit	
  Instruction	
  list	
  is	
  compiled	
  and	
  delivered	
  to	
  all	
   teachers,	
  along	
  with	
  the	
  Unit	
  Instructor	
  schedule.	
  Teachers	
  who	
  serve	
   students	
  on	
  the	
  list	
  prepare	
  course	
  work,	
  along	
  with	
  a	
  copy	
  of	
  the	
  IEP	
  at-­‐ a-­‐glance	
  for	
  special	
  education	
  students.	
  The	
  Unit	
  Instructor	
  delivers	
  the	
   work	
  to	
  each	
  student,	
  and	
  also	
  provides	
  30-­‐minutes	
  of	
  instruction,	
  four	
   times	
  per	
  day.	
  	
   	
   Teachers	
  currently	
  provide	
  the	
  coursework	
  and	
  instruction	
  through	
  the	
   youth’s	
  door.	
  This	
  strategy	
  has	
  obvious	
  shortcomings	
  in	
  terms	
  of	
  the	
   quality	
  of	
  instruction.	
  For	
  their	
  part,	
  teachers	
  would	
  prefer	
  to	
  provide	
   face-­‐to-­‐face	
  instruction,	
  but	
  believe	
  that	
  the	
  YS	
  on	
  the	
  unit	
  (rather	
  than	
   the	
  teacher)	
  could	
  likely	
  make	
  a	
  more	
  accurate	
  assessment	
  of	
  whether	
   individual	
  youth	
  could	
  be	
  safely	
  brought	
  to	
  the	
  dayroom.	
  Procedures	
  to	
   make	
  individualized	
  decisions	
  regarding	
  whether	
  students	
  can	
  be	
  safely	
   instructed	
  in	
  the	
  day	
  room	
  need	
  to	
  be	
  established	
  and	
  implemented	
   consistently,	
  in	
  accordance	
  with	
  the	
  Court	
  Order	
  governing	
  this	
  issue	
  in	
   the	
  S.H.	
  case.	
  	
   	
  

	
  

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Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

The	
  State	
  compiled	
  monthly	
  compliance	
  data	
  regarding	
  the	
  number	
  of	
   youth	
  on	
  seclusion	
  and	
  number	
  of	
  periods	
  that	
  Unit	
  Instruction	
  was	
   required.	
  Compliance	
  rates	
  were	
  reportedly	
  96%	
  in	
  July,	
  91%	
  in	
  August,	
   and	
  96%	
  in	
  September	
  2012.	
  However,	
  the	
  State	
  cautioned	
  that	
  the	
   reliability	
  of	
  these	
  data	
  might	
  not	
  be	
  solid	
  because	
  three	
  different	
   individuals	
  were	
  managing	
  the	
  data	
  before	
  the	
  new	
  attendance	
  clerk	
  was	
   hired	
  in	
  late	
  September	
  2012.	
  Additional	
  analysis	
  was	
  undertaken	
  by	
  the	
   Monitor	
  and	
  is	
  discussed	
  below.	
  	
  	
  	
   	
   The	
  school	
  administrators	
  expend	
  significant	
  energy	
  to	
  review	
  and	
   monitor	
  Unit	
  Instruction	
  records	
  to	
  ensure	
  compliance.	
  Each	
  morning,	
   the	
  Assistant	
  Principal	
  reviews	
  records	
  from	
  the	
  prior	
  day	
  to	
  ensure	
  that	
   all	
  students	
  were	
  served.	
  In	
  addition,	
  the	
  DYS	
  Special	
  Education	
   Coordinator	
  reviews	
  these	
  records	
  on	
  a	
  monthly	
  basis.	
  The	
  Coordinator’s	
   October	
  2012	
  report	
  noted	
  significant	
  improvements	
  in	
  record	
  keeping	
   attributed	
  to	
  the	
  arrival	
  of	
  the	
  full-­‐time	
  Attendance	
  Clerk.	
  	
   	
   The	
  point	
  of	
  internal	
  efforts	
  to	
  monitor	
  performance	
  are	
  not	
  to	
   determine	
  whether	
  procedures	
  were	
  implemented	
  perfectly,	
  but	
  rather	
   to	
  develop	
  systems	
  that	
  are	
  capable	
  of	
  identifying	
  and	
  addressing	
  the	
   problems	
  that	
  will	
  inevitably	
  arise	
  with	
  the	
  complex	
  web	
  of	
  service	
   delivery	
  that	
  characterizes	
  correctional	
  facilities.	
  In	
  this	
  case,	
  the	
  internal	
   monitoring	
  efforts	
  are	
  rigorous,	
  accurately	
  identify	
  problems,	
  and	
  most	
   importantly,	
  lead	
  to	
  corrective	
  action	
  to	
  address	
  the	
  deficits.	
  	
  The	
  quality	
   assurance	
  efforts	
  are	
  a	
  tremendous	
  asset	
  to	
  the	
  State’s	
  pursuit	
  of	
   substantial	
  compliance.	
  	
  
Attendance	
   	
   Overall	
  school	
  attendance	
  rates	
  are	
  reported	
  every	
  month	
  on	
  the	
   Superintendent’s	
  report.	
  Attendance	
  rates	
  during	
  the	
  current	
  monitoring	
   period	
  ranged	
  between	
  73%	
  and	
  84%,	
  with	
  a	
  six-­‐month	
  average	
  of	
  79%.	
   Unit-­‐level	
  attendance	
  rates	
  were	
  calculated	
  based	
  on	
  data	
  submitted	
  by	
   the	
  State.	
  Three-­‐month	
  averages	
  revealed	
  that	
  the	
  boys’	
  general	
   population	
  units	
  had	
  the	
  lowest	
  attendance	
  rates	
  (Jefferson	
  66%;	
  Carver	
   77%;	
  Boone	
  79%),	
  the	
  Progress	
  Units	
  had	
  higher	
  rates	
  (Cedar	
  82%;	
   Buckeye	
  82%;	
  Sycamore	
  85%),	
  and	
  the	
  girls’	
  units	
  had	
  the	
  highest	
  rates	
   (Davey	
  88%;	
  Allman	
  94%).	
  While	
  they	
  have	
  still	
  not	
  attained	
  the	
  85%	
   threshold	
  [agreed	
  upon	
  by	
  the	
  S.H.	
  subject	
  matter	
  expert	
  and	
  DYS	
  and	
   commonly	
  used	
  by	
  the	
  Monitor	
  in	
  this	
  case]	
  consistently,	
  the	
  attendance	
   rates	
  are	
  much	
  improved	
  over	
  the	
  attendance	
  rates	
  witnessed	
  in	
  the	
   previous	
  monitoring	
  period.	
  	
   	
   According	
  to	
  school	
  administrators,	
  the	
  attendance	
  data	
  still	
  have	
   “noise”	
  from	
  inconsistent	
  data	
  entry	
  and	
  other	
  data	
  management	
   problems	
  (e.g.,	
  students	
  who	
  have	
  left	
  the	
  facility	
  remaining	
  on	
  the	
   population	
  roster	
  and	
  thus	
  being	
  counted	
  as	
  absent).	
  Until	
  these	
  data	
   issues	
  are	
  resolved,	
  the	
  true	
  rates	
  of	
  attendance	
  cannot	
  be	
  known,	
  but	
  it	
  

	
  

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appears	
  that	
  recent	
  efforts	
  to	
  improve	
  the	
  accuracy	
  with	
  which	
  data	
  are	
   entered	
  have	
  provided	
  a	
  clearer	
  and	
  more	
  positive	
  picture	
  of	
  students’	
   access	
  to	
  education	
  services.	
  	
  	
   	
   Indirectly	
  related	
  to	
  the	
  attendance	
  issue	
  is	
  a	
  recent	
  School	
  Task	
  Force	
   report	
  that	
  broadly	
  studied	
  youth’s	
  and	
  teacher’s	
  classroom	
  behaviors	
  to	
   identify	
  strategies	
  to	
  improve	
  school	
  engagement.	
  The	
  facility	
  should	
  be	
   commended	
  for	
  undertaking	
  the	
  project,	
  the	
  rigor	
  of	
  the	
  inquiry	
  (it	
   utilized	
  standardized	
  Functional	
  Behavior	
  Assessment	
  tools)	
  and	
  for	
   developing	
  a	
  comprehensive	
  set	
  of	
  recommendations	
  to	
  improve	
   classroom	
  management	
  and	
  to	
  shift	
  the	
  facility	
  culture	
  to	
  better	
  support	
   the	
  education	
  program.	
  In	
  combination,	
  these	
  strategies	
  should	
  reduce	
   the	
  absences	
  caused	
  by	
  disruptive	
  student	
  behaviors	
  and	
  exacerbated	
  by	
   the	
  staff’s	
  and	
  teachers’	
  response	
  to	
  those	
  behaviors.	
  	
   	
   Unit	
  Instruction	
   	
   As	
  discussed	
  in	
  the	
  previous	
  Monitors’	
  Report,	
  without	
  a	
  system	
  to	
  cross	
   reference	
  Unit	
  Instruction	
  data	
  with	
  the	
  AMS	
  database’s	
  seclusion	
   records,	
  it	
  would	
  be	
  impossible	
  to	
  certify	
  that	
  all	
  youth	
  on	
  seclusion	
  and	
   eligible	
  for	
  Unit	
  Instruction	
  were	
  served.	
  [In	
  the	
  court	
  order,	
  youth	
  on	
   seclusion	
  must	
  be	
  served	
  within	
  48	
  hours	
  of	
  their	
  seclusion;	
  in	
  reality,	
   youth	
  are	
  served	
  within	
  the	
  first	
  24	
  hours.]	
  To	
  assess	
  the	
  integrity	
  of	
  the	
   Unit	
  Instruction	
  procedures,	
  the	
  Unit	
  Instruction	
  records	
  maintained	
  by	
   the	
  school	
  were	
  cross-­‐referenced	
  with	
  a	
  list	
  of	
  youth	
  who	
  had	
  been	
  on	
   seclusion	
  between	
  July	
  1	
  and	
  September	
  30,	
  2012	
  generated	
  by	
  AMS.	
  	
   	
   First,	
  a	
  random	
  sample	
  of	
  14	
  youth	
  with	
  seclusion	
  stays	
  well	
  in	
  excess	
  of	
   48	
  hours	
  was	
  selected	
  from	
  the	
  AMS	
  list.	
  Instructional	
  days	
  were	
   identified	
  using	
  the	
  School	
  Calendar	
  (there	
  were	
  quite	
  a	
  few	
  non-­‐ instructional	
  days	
  during	
  the	
  period	
  of	
  inquiry,	
  e.g.,	
  intersession	
  in	
  July,	
   every	
  Friday	
  in	
  August,	
  etc.).	
  Six	
  of	
  the	
  14	
  youth	
  (43%)	
  did	
  not	
  serve	
  time	
   on	
  an	
  instructional	
  day	
  (sometimes,	
  the	
  Intervention	
  Hearing	
  officer	
  will	
   schedule	
  intervention	
  seclusion	
  to	
  be	
  served	
  on	
  the	
  weekends	
  so	
  that	
  it	
   does	
  not	
  interfere	
  with	
  the	
  youth’s	
  education).	
  Seven	
  of	
  the	
  8	
  youth	
   (88%)	
  received	
  seven	
  periods	
  worth	
  of	
  course	
  work	
  on	
  the	
  instructional	
   days	
  during	
  which	
  they	
  were	
  in	
  seclusion.	
  The	
  one	
  exception	
  did	
  not	
   receive	
  Unit	
  Instruction	
  on	
  the	
  last	
  day	
  of	
  his	
  5-­‐day	
  seclusion.	
  	
   	
   Second,	
  for	
  each	
  of	
  the	
  38	
  youth	
  on	
  the	
  Unit	
  Instruction	
  list,	
  the	
  dates	
  of	
   service	
  were	
  cross-­‐referenced	
  with	
  the	
  AMS	
  roster	
  to	
  ensure	
  that	
  youth	
   were	
  served	
  on	
  all	
  of	
  the	
  instructional	
  days	
  during	
  which	
  they	
  were	
   secluded.	
  Service	
  dates	
  were	
  verified	
  for	
  all	
  but	
  3	
  of	
  the	
  youth	
  (92%	
   compliance).	
  It	
  is	
  worth	
  noting	
  that	
  about	
  10%	
  of	
  the	
  Scioto	
  student	
  body	
   received	
  education	
  services	
  via	
  Unit	
  Instruction	
  for	
  a	
  significant	
   proportion	
  of	
  instructional	
  days	
  (between	
  17%	
  and	
  30%).	
  While	
   treatment	
  and	
  behavior	
  modification	
  efforts	
  should	
  focus	
  on	
  the	
  

	
  

121.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 122 of 129 PAGEID #: 2475

Recommendations	
  
Sources	
  of	
   Information	
  
	
   	
  

underlying	
  causes	
  of	
  the	
  youth’s	
  behavior	
  in	
  order	
  to	
  minimize	
  the	
   amount	
  of	
  time	
  youth	
  spend	
  in	
  seclusion,	
  until	
  that	
  occurs,	
  Unit	
   Instruction	
  is	
  essential	
  to	
  the	
  effort	
  to	
  maintain	
  the	
  youth’s	
  engagement	
   in	
  school.	
  	
   	
   Once	
  cross-­‐referenced	
  with	
  AMS,	
  the	
  Unit	
  Instruction	
  data	
  clearly	
   demonstrated	
  that	
  the	
  facility	
  is	
  in	
  compliance	
  with	
  its	
  obligations	
   around	
  providing	
  education	
  services	
  to	
  youth	
  who	
  are	
  in	
  seclusion.	
   Continued	
  quality	
  assurance	
  efforts	
  are	
  needed	
  to	
  ensure	
  that	
  the	
   preference	
  for	
  youth	
  to	
  receive	
  face-­‐to-­‐face	
  instruction	
  is	
  maximized,	
   and	
  that	
  students	
  receive	
  the	
  full	
  30	
  minutes	
  of	
  contact	
  on	
  each	
  of	
  the	
  4	
   visits.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Address	
  the	
  preventable	
  causes	
  of	
  absenteeism	
  and	
  address	
  data	
   entry	
  and	
  data	
  management	
  issues	
  to	
  ensure	
  that	
  average	
   attendance	
  rates	
  of	
  85%	
  or	
  better	
  are	
  achieved	
  for	
  each	
  housing	
   unit.	
  	
  
The	
  State	
  is	
  also	
  encouraged	
  to:	
   2. Continue	
  to	
  maintain	
  Youth	
  Specialist	
  and	
  teacher	
  staffing	
  levels	
   that	
  are	
  sufficient	
  to	
  ensure	
  dependable	
  access	
  to	
  school	
  for	
   youth	
  in	
  all	
  units.	
  Continue	
  to	
  ensure	
  that	
  the	
  ABC	
  rooms	
  are	
   consistently	
  staffed	
  to	
  limit	
  the	
  need	
  for	
  youth	
  to	
  return	
  to	
  the	
   unit	
  during	
  the	
  school	
  day.	
  	
   3. Continue	
  to	
  provide	
  access	
  to	
  alternative	
  education	
  services	
  for	
   youth	
  in	
  seclusion	
  through	
  the	
  use	
  of	
  Unit	
  Instruction.	
  Ensure	
   that	
  the	
  type,	
  quality	
  and	
  duration	
  of	
  instruction	
  comply	
  with	
  the	
   S.H.	
  Parties’	
  agreement.	
  Develop	
  procedures	
  to	
  serve	
  youth	
  in	
   the	
  dayroom,	
  rather	
  than	
  behind	
  their	
  doors,	
  when	
  instruction	
  in	
   the	
  dayroom	
  can	
  be	
  accomplished	
  safely.	
  	
  
• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.1,	
  prepared	
  at	
  my	
  request	
  
• Interviews	
  with	
  n=15	
  general	
  population	
  youth	
  housed	
  at	
  Scioto	
   on	
  October	
  19,	
  2012	
  
• Education	
  staffing	
  roster,	
  January	
  through	
  September	
  2012	
   • Unit	
  Instruction	
  data,	
  July	
  through	
  September	
  2012,	
  and	
  follow-­‐
up	
  discussions	
  with	
  Scioto	
  and	
  DYS	
  school	
  administrators	
  via	
   email.	
  	
   • AMS	
  Seclusion	
  Records,	
  July	
  through	
  September	
  2012	
   • Attendance	
  records,	
  by	
  unit	
  and	
  by	
  individual	
  youth,	
  July	
  through	
   September	
  2012	
   • Scioto	
  School	
  Task	
  Force	
  Report,	
  undated	
  
	
  

	
  

122.	
  

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III.E.7	
  Individual	
  Education	
  Plans.	
  (a)	
  The	
  State	
  shall	
  develop	
  an	
  IEP	
  as	
  defined	
  in	
  34	
  C.F.R.	
   §300.320	
  for	
  each	
  youth	
  who	
  qualifies	
  for	
  an	
  IEP.	
  Following	
  development	
  of	
  the	
  IEP,	
  the	
  State	
   shall	
  implement	
  the	
  IEP	
  as	
  soon	
  as	
  possible.	
  As	
  part	
  of	
  satisfying	
  this	
  requirement,	
  the	
  State	
   shall	
  conduct	
  required	
  annual	
  reviews	
  of	
  IEPs,	
  adequately	
  document	
  the	
  provision	
  of	
  special	
   education	
  services,	
  and	
  comply	
  with	
  requirements	
  regarding	
  participation	
  by	
  the	
  professional	
   staff,	
  parents	
  and	
  student	
  in	
  the	
  IEP	
  process.	
  The	
  State	
  shall,	
  if	
  necessary,	
  develop,	
  review	
  or	
   revise	
  IEPs	
  for	
  qualified	
  special	
  education	
  students;	
  (b)	
  In	
  developing	
  or	
  modifying	
  the	
  IEP,	
  the	
   State	
  shall	
  ensure	
  that:	
  the	
  IEP	
  reflects	
  the	
  individualized	
  educational	
  needs	
  of	
  the	
  youth	
  and	
   that	
  services	
  are	
  provided	
  accordingly;	
  each	
  IEP	
  includes	
  documentation	
  of	
  the	
  team’s	
   consideration	
  of	
  the	
  youth’s	
  need	
  for	
  related	
  services	
  and	
  transition	
  planning,	
  and	
  identifies	
  the	
   party	
  responsible	
  for	
  providing	
  such	
  transition	
  services;	
  the	
  student’s	
  educational	
  progress	
  is	
   monitored;	
  teachers	
  are	
  trained	
  on	
  how	
  to	
  monitor	
  progress	
  toward	
  IEP	
  goals	
  and	
  objectives;	
   and	
  teachers	
  understand	
  and	
  use	
  functional	
  behavioral	
  assessment	
  and	
  behavior	
  intervention	
   programs	
  in	
  IEP	
  planning	
  and	
  implementation.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  State	
  provided	
  data	
  on	
  the	
  35	
  special	
  education	
  students	
  in	
  custody	
   as	
  of	
  October	
  1,	
  2012	
  (approximately	
  40%	
  of	
  the	
  total	
  population).	
  Of	
   these	
  youth,	
  two	
  student’s	
  IEPs	
  were	
  expired,	
  but	
  they	
  were	
  newly	
   admitted	
  to	
  the	
  facility	
  and	
  staff	
  had	
  already	
  taken	
  steps	
  to	
  collect	
  the	
   necessary	
  information	
  and	
  schedule	
  IEP	
  meetings.	
  The	
  other	
  33	
  youth	
   (94%)	
  had	
  current	
  IEPs.	
  	
   	
   Historically,	
  the	
  State	
  has	
  struggled	
  ensure	
  that	
  IEPs	
  include	
  measurable	
   goals	
  and	
  objectives.	
  Training	
  and	
  technical	
  assistance	
  has	
  been	
  on	
   going,	
  with	
  both	
  the	
  facility’s	
  Special	
  Education	
  Administrator	
  and	
   Intervention	
  Specialist	
  reviewing	
  draft	
  IEP	
  documents	
  prior	
  to	
  the	
  IEP	
   meetings’	
  being	
  held.	
  Teachers	
  must	
  now	
  complete	
  a	
  Planning	
   Worksheet	
  for	
  each	
  IEP	
  goal	
  that	
  describes	
  how	
  and	
  when	
  the	
  goal	
  will	
   be	
  measured,	
  and	
  by	
  whom.	
  These	
  sheets	
  are	
  attached	
  to	
  every	
  IEP.	
  	
   	
   Only	
  when	
  the	
  IEP	
  goals	
  and	
  objectives	
  are	
  clearly	
  stated	
  can	
  meaningful	
   progress	
  reporting	
  be	
  accomplished.	
  Facilitating	
  students’	
  progress	
   through	
  the	
  curriculum	
  is	
  the	
  entire	
  point	
  of	
  special	
  education,	
  and	
   without	
  assessing	
  progress,	
  the	
  program	
  cannot	
  identify	
  whether	
  it	
  is	
   meeting	
  students’	
  special	
  education	
  needs.	
  	
   	
   The	
  State	
  submitted	
  IEP	
  progress	
  reports	
  for	
  each	
  of	
  the	
  40	
  special	
   education	
  students	
  (100%)	
  who	
  were	
  at	
  Scioto	
  at	
  the	
  end	
  of	
  the	
  April-­‐ June	
  2012	
  grading	
  period,	
  and	
  for	
  the	
  35	
  special	
  education	
  youth	
  (100%)	
   who	
  were	
  in	
  custody	
  at	
  the	
  end	
  of	
  the	
  July-­‐September	
  2012	
  grading	
   period.	
  That	
  progress	
  reports	
  were	
  sent	
  out	
  for	
  each	
  and	
  every	
  special	
   education	
  student	
  is	
  a	
  significant	
  improvement	
  from	
  the	
  state	
  of	
  affairs	
   when	
  the	
  Monitor	
  became	
  involved	
  with	
  this	
  case.	
  The	
  content	
  of	
  the	
   progress	
  reports	
  is	
  discussed	
  below.	
  	
   	
  

	
  

123.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 124 of 129 PAGEID #: 2477

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

DYS	
  recently	
  developed	
  and	
  implemented	
  a	
  three-­‐tiered	
  Quality	
   Assurance	
  program	
  for	
  special	
  education.	
  In	
  Tier	
  One,	
  the	
  Special	
   Education	
  Administrator	
  selects	
  a	
  sample	
  of	
  students	
  each	
  month	
  (e.g.,	
   six	
  of	
  the	
  35	
  current	
  students	
  were	
  selected	
  in	
  September	
  2012)	
  and	
   conducts	
  a	
  comprehensive	
  file	
  audit.	
  IEPs	
  are	
  evaluated	
  based	
  on	
  a	
  set	
  of	
   criteria	
  that	
  reflect	
  the	
  many	
  requirements	
  of	
  IDEA.	
  Written	
  feedback	
  is	
   provided	
  to	
  the	
  teachers	
  in	
  order	
  to	
  improve	
  teacher	
  skills.	
  In	
  Tier	
  Two,	
   each	
  quarter,	
  the	
  DYS	
  Special	
  Education	
  Director	
  reviews	
  the	
  same	
  files	
   to	
  ensure	
  that	
  all	
  deficits	
  were	
  identified	
  in	
  the	
  local	
  audit	
  and	
  that	
   teachers	
  completed	
  any	
  required	
  corrections.	
  In	
  Tier	
  Three,	
  each	
  of	
  the	
   DYS	
  schools	
  is	
  audited	
  annually	
  by	
  DYS	
  and	
  also	
  tri-­‐annually	
  by	
  the	
  Ohio	
   Department	
  of	
  Education.	
  Results	
  of	
  the	
  audits	
  will	
  be	
  reviewed	
  in	
  future	
   monitoring	
  periods.	
  	
  
Special	
  Education	
  Population	
  and	
  IEP	
  Development	
   	
   Across	
  the	
  current	
  special	
  education	
  population,	
  26	
  of	
  the	
  35	
  students	
   (74%)	
  qualified	
  under	
  the	
  Emotional	
  Disability	
  category,	
  8	
  had	
  Specific	
   Learning	
  Disabilities	
  (23%),	
  and	
  one	
  student	
  was	
  Cognitively	
  Disabled	
   (3%).	
  With	
  6	
  special	
  education	
  teachers	
  currently	
  on	
  staff,	
  the	
  caseload	
   sizes	
  are	
  well	
  below	
  the	
  state	
  limits	
  (generally,	
  12	
  for	
  ED;	
  24	
  for	
  SLD).	
   	
   A	
  sample	
  of	
  15	
  IEPs	
  were	
  reviewed.	
  The	
  sample	
  consisted	
  of	
  the	
  last	
  15	
   IEPs	
  written	
  by	
  Scioto	
  prior	
  to	
  the	
  Monitor’s	
  October	
  2012	
  site	
  visit	
   which	
  was	
  43%	
  of	
  the	
  current	
  special	
  education	
  population.	
  In	
  terms	
  of	
   the	
  prescribed	
  level	
  of	
  service,	
  2	
  of	
  the	
  15	
  students	
  in	
  the	
  IEP	
  sample	
   (13%)	
  were	
  served	
  in	
  the	
  self-­‐contained	
  classrooms	
  on	
  the	
  girls’	
  mental	
   health	
  unit;	
  10	
  students	
  (66%)	
  were	
  served	
  in	
  the	
  resource	
  room	
  for	
   between	
  one	
  and	
  four	
  class	
  periods	
  per	
  day	
  (average	
  2.3	
  periods)	
  and	
  3	
   students	
  (20%)	
  were	
  served	
  entirely	
  in	
  the	
  general	
  education	
  classrooms.	
   In	
  addition,	
  60%	
  of	
  the	
  IEPs	
  prescribed	
  bi-­‐weekly	
  consultation	
  between	
   the	
  Intervention	
  Specialist	
  and	
  student	
  to	
  discuss	
  behavior	
  and	
  40%	
  of	
   the	
  IEPs	
  prescribed	
  consultation	
  between	
  the	
  Intervention	
  Specialist	
  and	
   general	
  education	
  teachers.	
  In	
  terms	
  of	
  related	
  services,	
  13%	
  of	
  the	
   students	
  received	
  services	
  from	
  the	
  Speech-­‐Language	
  Pathologist	
  and	
   27%	
  received	
  services	
  from	
  the	
  Occupational	
  Therapist.	
  Occasionally,	
  the	
   Description	
  of	
  Specially	
  Designed	
  Instruction	
  section	
  and	
  the	
  services	
   listed	
  in	
  the	
  Least	
  Restrictive	
  Environment	
  section	
  were	
  in	
  conflict,	
  but	
   overall,	
  the	
  level	
  of	
  service	
  prescribed	
  appeared	
  to	
  be	
  individualized	
  and	
   appropriate	
  given	
  the	
  description	
  of	
  the	
  youth’s	
  academic	
  and	
  functional	
   performance	
  contained	
  in	
  the	
  IEPs.	
  	
   	
   IEP	
  Goal	
  Development	
   	
   The	
  question	
  of	
  whether	
  progress	
  can	
  be	
  accurately	
  measured	
  rests	
  on	
   the	
  quality	
  of	
  articulation	
  of	
  the	
  IEP	
  goals	
  and	
  objectives,	
  which	
  depends,	
   in	
  turn,	
  on	
  clear	
  descriptions	
  of	
  the	
  students’	
  skill	
  deficits.	
  For	
  the	
  most	
   part,	
  the	
  IEPs’	
  Student	
  Profiles	
  contained	
  excellent	
  descriptions	
  of	
  the	
  

	
  

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youth’s	
  strengths	
  and	
  weaknesses,	
  including	
  a	
  mix	
  of	
  standardized	
  test	
   scores	
  and	
  teachers’	
  observations	
  about	
  the	
  students’	
  capabilities	
  and	
   skill	
  deficits,	
  and	
  descriptions	
  of	
  the	
  youth’s	
  behavior	
  and	
  school	
   attendance.	
  The	
  Profiles	
  were	
  much	
  improved	
  compared	
  to	
  the	
   Monitor’s	
  previous	
  review.	
  	
   	
   Similarly,	
  the	
  Present	
  Level	
  of	
  Performance	
  section	
  used	
  to	
  set	
  up	
  each	
   IEP	
  goal	
  now	
  includes	
  relevant	
  test	
  scores	
  and	
  descriptions	
  of	
  the	
   students’	
  strengths	
  and	
  weaknesses	
  in	
  the	
  subject	
  matter	
  at	
  hand.	
  While	
   at	
  times	
  the	
  Present	
  Level	
  of	
  Performance	
  sections	
  and	
  Student	
  Profile	
   sections	
  were	
  redundant,	
  the	
  information	
  provided	
  necessary	
  context	
  for	
   the	
  goals	
  and	
  the	
  underlying	
  objectives.	
  Nearly	
  all	
  of	
  the	
  goals	
  reviewed	
   across	
  the	
  15	
  IEPs	
  were	
  individualized,	
  measurable	
  and	
  appeared	
  to	
   achievable	
  within	
  a	
  1-­‐year	
  period,	
  and	
  the	
  objectives	
  identified	
  the	
  skills	
   necessary	
  for	
  the	
  student	
  to	
  acquire	
  in	
  order	
  to	
  meet	
  the	
  goal.	
  Behavior	
   goals	
  are	
  now	
  individualized	
  and	
  anchored	
  in	
  a	
  description	
  of	
  problem	
   behaviors	
  and	
  the	
  situations	
  in	
  which	
  they	
  are	
  likely	
  to	
  occur.	
  Methods	
  to	
   assess	
  progress	
  on	
  behavior	
  goals	
  generally	
  include	
  a	
  combination	
  of	
   citizenship	
  scores,	
  YBIRs,	
  ABC	
  referrals,	
  attendance	
  rates	
  and	
  “working	
   behaviors.”	
  All	
  students	
  had	
  transition	
  goals	
  that	
  appeared	
  to	
  be	
  relevant	
   to	
  the	
  student’s	
  current	
  grade	
  level	
  and	
  the	
  number	
  of	
  credits	
  they’d	
   earned.	
  Goals	
  were	
  also	
  varied	
  according	
  to	
  students’	
  interests.	
  In	
   summary,	
  IEP	
  goals	
  and	
  objectives	
  were	
  much	
  improved	
  compared	
  to	
   the	
  Monitor’s	
  previous	
  review.	
   	
   Progress	
  Reporting	
   	
   As	
  noted	
  above,	
  IEP	
  Progress	
  Reports	
  are	
  now	
  created	
  reliably	
  at	
  the	
   conclusion	
  of	
  each	
  grading	
  period.	
  Measuring	
  student	
  progress	
  toward	
   IEP	
  goals	
  is	
  the	
  sole	
  mechanism	
  by	
  which	
  the	
  Parties	
  can	
  discern	
  whether	
   the	
  special	
  education	
  program	
  is	
  meeting	
  students’	
  needs.	
  Finally,	
  after	
   several	
  years	
  of	
  hard	
  work,	
  the	
  Progress	
  Reports	
  generated	
  for	
  Scioto	
   students	
  do	
  just	
  that—provide	
  a	
  tangible,	
  meaningful	
  assessment	
  of	
  the	
   extent	
  to	
  which	
  students	
  have	
  acquired	
  the	
  skills	
  needed	
  to	
  progress	
   through	
  the	
  curriculum.	
  	
  	
   	
   A	
  sample	
  of	
  10	
  Progress	
  Reports	
  was	
  selected	
  from	
  among	
  the	
  40	
   prepared	
  at	
  the	
  conclusion	
  of	
  the	
  April-­‐June	
  2012	
  grading	
  period	
  (25%	
  of	
   all	
  reports).	
  Across	
  these	
  10	
  reports,	
  most	
  of	
  them	
  offered	
  detailed,	
   comprehensive	
  descriptions	
  of	
  student	
  progress,	
  particularly	
  for	
  the	
   academic	
  goals.	
  Although	
  a	
  couple	
  of	
  the	
  reports	
  had	
  to	
  work	
  around	
   poorly	
  articulated	
  goals	
  that	
  were	
  difficult	
  to	
  measure,	
  the	
  vast	
  majority	
   had	
  a	
  logical	
  flow	
  between	
  the	
  goal,	
  how	
  it	
  was	
  supposed	
  to	
  be	
  assessed,	
   the	
  information	
  presented,	
  and	
  the	
  conclusion	
  about	
  whether	
  the	
   student	
  was	
  making	
  adequate	
  progress.	
  The	
  only	
  glaring	
  problem	
  was	
   that	
  Progress	
  Reports	
  for	
  4	
  of	
  the	
  10	
  students	
  (40%)	
  did	
  not	
  have	
  any	
   entry	
  for	
  or	
  discussion	
  about	
  the	
  students’	
  transition	
  goals.	
  	
  

	
  

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Recommendations	
   Sources	
  of	
   Information	
  
	
   	
  

	
   In	
  order	
  to	
  focus	
  on	
  that	
  particular	
  issue,	
  the	
  transition	
  goals	
  were	
   reviewed	
  for	
  each	
  of	
  the	
  35	
  Progress	
  Reports	
  generated	
  at	
  the	
   conclusion	
  of	
  the	
  July-­‐September	
  2012	
  grading	
  period.	
  The	
  fruits	
  of	
  the	
   considerable	
  technical	
  assistance	
  delivered	
  to	
  teachers	
  by	
  the	
  Special	
   Education	
  Administrator	
  were	
  easily	
  visible.	
  The	
  vast	
  majority	
  (29	
  of	
  the	
   35	
  reports;	
  83%)	
  had	
  detailed	
  entries	
  for	
  the	
  students’	
  transition	
  goals,	
   either	
  discussing	
  the	
  things	
  the	
  student’s	
  had	
  accomplished	
  or	
  discussing	
   why	
  progress	
  had	
  not	
  yet	
  been	
  witnessed	
  (most	
  often,	
  because	
  the	
   student	
  was	
  not	
  close	
  enough	
  to	
  his	
  or	
  her	
  release	
  date	
  to	
  undertake	
   some	
  of	
  the	
  late-­‐stage	
  transition	
  activities).	
  The	
  remaining	
  6	
  cases	
  simply	
   needed	
  more	
  information	
  about	
  why	
  the	
  objective	
  had	
  not	
  yet	
  been	
   undertaken	
  or	
  needed	
  to	
  provide	
  information	
  that	
  was	
  relevant	
  to	
  the	
   specific	
  goal	
  and	
  objective.	
  Together,	
  the	
  Progress	
  Reports	
  from	
  the	
   Summer	
  and	
  Fall	
  quarters	
  demonstrate	
  that	
  the	
  facility	
  is	
  now	
  fully	
   capable	
  of	
  demonstrating	
  their	
  efforts	
  to	
  deliver	
  services	
  that	
  are	
   responsive	
  to	
  students’	
  special	
  education	
  needs	
  and	
  identifying	
  whether	
   those	
  services	
  are	
  helping	
  the	
  student	
  progress	
  through	
  the	
  curriculum.	
  	
  
The	
  State	
  has	
  achieved	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  	
  
• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.7,	
  prepared	
  at	
  my	
  request	
  
• DYS	
  Education	
  Quality	
  Assurance	
  materials,	
  April	
  through	
   September	
  2012	
  
• Review	
  of	
  the	
  n=15	
  IEPs	
  development	
  most	
  recently	
  at	
  Scioto	
   (43%	
  of	
  the	
  current	
  special	
  education	
  population)	
  
• Review	
  of	
  n=10	
  Progress	
  Reports	
  from	
  the	
  April-­‐June	
  2012	
   grading	
  period	
  (25%	
  sample)	
  and	
  the	
  Transition	
  Goals	
  from	
  n=35	
   Progress	
  Reports	
  from	
  July-­‐September	
  2012	
  grading	
  period	
   (100%	
  sample)	
  	
  
	
  

	
  

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III.E.8	
  Vocational	
  Education.	
  The	
  State	
  shall	
  provide	
  appropriate	
  vocational	
  services	
  that	
  are	
   required	
  transition	
  services	
  for	
  disabled	
  youth	
  under	
  the	
  IDEA.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

Scioto	
  students	
  who	
  are	
  either	
  Juniors	
  or	
  Seniors	
  (by	
  credit)	
  are	
  eligible	
   for	
  vocational	
  programming.	
  Students	
  with	
  low	
  reading	
  or	
  math	
  levels	
   are	
  not	
  excluded	
  from	
  vocational	
  programs.	
  	
   	
   In	
  its	
  self-­‐assessment,	
  the	
  State	
  discussed	
  data	
  on	
  student	
  enrollment	
  in	
   the	
  three	
  currently	
  available	
  vocational	
  classes.	
  On	
  the	
  first	
  day	
  of	
  the	
   2012	
  school	
  year	
  (July	
  23,	
  2012),	
  of	
  the	
  63	
  students	
  enrolled	
  at	
  school:	
  
• 14	
  students	
  (22%)	
  were	
  enrolled	
  in	
  Administrative	
  Office	
   Technology	
  (a	
  course	
  that	
  teaches	
  students	
  how	
  to	
  use	
  various	
   computer	
  applications	
  to	
  prepare	
  them	
  for	
  clerical,	
  data	
  entry,	
   graphics,	
  or	
  other	
  office-­‐based	
  jobs);	
  
• 4	
  students	
  (6%)	
  were	
  enrolled	
  in	
  Career-­‐Based	
  Intervention	
  (i.e.,	
   work-­‐based	
  learning,	
  student	
  earns	
  credit);	
  and	
  	
  
• 27	
  students	
  (43%)	
  were	
  enrolled	
  in	
  Transition	
  Skills	
  (students	
   must	
  take	
  this	
  course	
  prior	
  to	
  release;	
  includes	
  job	
  skills,	
  resume	
   building,	
  interview	
  skills).	
  
Overall,	
  43	
  students	
  were	
  enrolled	
  in	
  vocational	
  programming	
  (two	
   students	
  were	
  taking	
  two	
  classes),	
  which	
  is	
  68%	
  of	
  the	
  student	
   population.	
  By	
  the	
  end	
  of	
  the	
  grading	
  period	
  (October	
  5,	
  2012),	
   enrollment	
  had	
  shrunk	
  a	
  bit	
  to	
  58%	
  of	
  the	
  student	
  population.	
  This	
  is	
  a	
   significant	
  improvement	
  over	
  the	
  previous	
  monitoring	
  period	
  where	
  less	
   than	
  half	
  the	
  students	
  were	
  involved	
  in	
  vocational	
  programming.	
  School	
   administrators	
  indicated	
  that	
  they	
  have	
  not	
  expanded	
  the	
  capacity	
  of	
  any	
   of	
  the	
  programs,	
  but	
  have	
  simply	
  emphasized	
  these	
  programs,	
   encouraging	
  teachers	
  to	
  identify	
  students	
  who	
  need	
  vocational	
   programming.	
  Each	
  of	
  the	
  three	
  courses	
  have	
  sufficient	
  capacity	
  to	
  serve	
   significantly	
  more	
  students	
  if	
  they	
  were	
  eligible	
  and	
  needed	
  vocational	
   programming.	
  	
  	
   	
   The	
  Ohio	
  DYS	
  vocational	
  programs	
  were	
  audited	
  twice	
  during	
  the	
  current	
   monitoring	
  period.	
  First,	
  the	
  ODE	
  Office	
  for	
  Exceptional	
  Children	
  audited	
   DYS’s	
  special	
  education	
  program.	
  IDEA	
  requires	
  the	
  IEPs	
  for	
  students	
  age	
   14	
  and	
  older	
  to	
  include	
  a	
  Transition	
  Plan	
  to	
  ensure	
  that	
  the	
  school	
   delivers	
  services	
  in	
  preparation	
  for	
  life	
  after	
  graduation	
  (and,	
  in	
  this	
  case,	
   after	
  they	
  return	
  to	
  the	
  community).	
  The	
  audit	
  found	
  Scioto	
  to	
  be	
  in	
   compliance	
  with	
  the	
  standard	
  related	
  to	
  Transition	
  Planning	
  (SPP	
   Indicator	
  20	
  for	
  Secondary	
  Transition	
  Plans).	
  Specifically,	
  ODE	
  found	
  that	
   Scioto’s	
  plans	
  “prescribed	
  reasonable	
  services	
  to	
  meet	
  post-­‐secondary	
   goals.”	
  In	
  other	
  words,	
  Scioto	
  youth	
  have	
  access	
  to	
  courses	
  that	
  address	
   their	
  pursuits	
  after	
  high	
  school.	
  	
   	
   In	
  addition,	
  ODE’s	
  Office	
  of	
  Career-­‐Technical	
  Education	
  conducted	
  a	
  

	
  

127.	
  

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Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

comprehensive	
  review	
  of	
  all	
  career-­‐technical	
  education	
  programs	
   offered	
  at	
  Scioto.	
  Through	
  teacher	
  surveys,	
  document	
  review	
  and	
  on-­‐site	
   program	
  observations,	
  the	
  audit	
  noted	
  significant	
  improvement	
  in	
  the	
   participation	
  rates	
  in	
  Scioto’s	
  vocational	
  programs	
  (mirroring	
  the	
   Monitor’s	
  findings	
  discussed	
  below).	
  In	
  addition,	
  the	
  audit	
  noted	
  that	
   vocational	
  textbooks	
  were	
  current	
  and	
  that	
  supplies	
  and	
  facilities	
  were	
   adequate.	
  	
   	
   The	
  report’s	
  Opportunities	
  for	
  Improvement	
  included	
  a	
  variety	
  of	
   suggestions	
  to	
  improve	
  the	
  administration	
  of	
  the	
  programs	
  (e.g.,	
   involving	
  Central	
  Office	
  in	
  vocational	
  teacher	
  hiring;	
  improving	
   communication)	
  or	
  to	
  enrich	
  the	
  curriculum	
  delivery	
  (e.g.,	
  developing	
  a	
   method	
  for	
  internet	
  access	
  with	
  appropriate	
  firewalls;	
  emphasizing	
   employability	
  skills	
  in	
  all	
  courses).	
  The	
  audit	
  also	
  recommended	
  that	
  the	
   DYS	
  formalize	
  student’s	
  course	
  completion	
  via	
  industry-­‐based	
   credentialing	
  tests	
  and	
  formal	
  graduation	
  ceremonies.	
  Notably,	
  the	
  ODE	
   did	
  not	
  require	
  or	
  advise	
  any	
  modifications	
  to	
  the	
  course	
  offerings,	
   apparently	
  finding	
  they	
  were	
  adequate	
  to	
  meet	
  the	
  needs	
  of	
  students.	
  	
  
While	
  the	
  facility	
  has	
  not	
  enhanced	
  the	
  array	
  of	
  vocational	
  options	
  since	
   the	
  Monitor’s	
  previous	
  review,	
  it	
  has	
  significantly	
  increased	
  the	
   proportion	
  of	
  youth	
  who	
  are	
  engaged	
  in	
  vocational	
  programming.	
  Some	
   of	
  Scioto’s	
  students	
  simply	
  are	
  not	
  eligible	
  (because	
  they	
  are	
  too	
  young	
   or	
  have	
  not	
  earned	
  enough	
  credits).	
  All	
  eligible	
  general	
  population	
   students	
  have	
  the	
  opportunity	
  to	
  participate	
  in	
  vocational	
  programs;	
   however,	
  some	
  students	
  choose	
  to	
  focus	
  on	
  college	
  prep	
  materials	
  and	
   may	
  not	
  choose	
  to	
  take	
  vocational	
  courses	
  as	
  a	
  result.	
  Youth	
  on	
  the	
  PU	
   may	
  not	
  enroll	
  in	
  vocational	
  courses	
  during	
  their	
  stay	
  on	
  the	
  PU.	
  The	
  CBI	
   and	
  AOT	
  courses	
  require	
  the	
  freedom	
  to	
  travel	
  throughout	
  the	
  campus	
   (which	
  PU	
  youth	
  do	
  not	
  have)	
  and	
  also	
  require	
  the	
  student	
  to	
  have	
   completed	
  all	
  16	
  credits	
  of	
  the	
  core	
  courses,	
  which	
  most	
  PU	
  students	
   have	
  not	
  yet	
  achieved.	
  All	
  youth	
  take	
  the	
  Transition	
  Course	
  at	
  some	
  point	
   3	
  to	
  6	
  months	
  before	
  their	
  scheduled	
  release	
  date.	
  	
  	
   	
   While	
  the	
  Monitor	
  would	
  prefer	
  to	
  see	
  additional	
  options	
  for	
  hands-­‐on	
   learning	
  and	
  opportunities	
  for	
  youth	
  to	
  earn	
  vocational	
  certificates	
  that	
   could	
  assist	
  in	
  their	
  future	
  job	
  searches,	
  Scioto’s	
  program	
  options	
  are	
   adequate.	
  In	
  particular,	
  these	
  services	
  can	
  fully	
  address	
  the	
  transition	
   needs	
  and	
  services	
  prescribed	
  in	
  Scioto’s	
  IEPs	
  which	
  include	
  completing	
   career	
  interest	
  inventories,	
  conducting	
  job	
  opportunity	
  searches,	
   developing	
  employability	
  skills,	
  and	
  compiling	
  transition	
  portfolios.	
  	
  The	
   improvements	
  noted	
  in	
  the	
  facility’s	
  IEP	
  goal	
  articulation	
  and	
  progress	
   reporting	
  makes	
  it	
  easier	
  for	
  the	
  Monitor	
  to	
  certify	
  the	
  compatibility	
   between	
  student	
  needs	
  and	
  the	
  transition	
  program	
  resources	
  available	
   to	
  special	
  education	
  students.	
  	
   	
   Finally,	
  particularly	
  now	
  that	
  the	
  facility	
  has	
  a	
  well-­‐developed	
  program	
   for	
  graduates,	
  the	
  opportunities	
  for	
  students	
  to	
  develop	
  job	
  and	
  

	
  

128.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 110 Filed: 02/14/13 Page: 129 of 129 PAGEID #: 2482

Recommendations	
   Sources	
  of	
   Information	
  
	
  

employability	
  skills	
  are	
  far	
  greater	
  than	
  they	
  were	
  at	
  the	
  time	
  Stipulation	
   was	
  signed.	
  	
  
The	
  State	
  has	
  reached	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  
• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.8,	
  prepared	
  at	
  my	
  request	
  
• Student	
  rosters	
  for	
  each	
  of	
  the	
  three	
  vocational	
  courses,	
  April-­‐ June	
  and	
  July-­‐September	
  2012	
  grading	
  periods.	
  	
  
• ODE	
  Office	
  of	
  Exceptional	
  Children	
  audit	
  report,	
  November,	
  2012	
   • ODE	
  Office	
  of	
  Career-­‐Technical	
  Education	
  audit	
  report,	
  
November	
  2012	
  

	
  

129.	
  

 Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 1 of 67 PAGEID #: 2495

	
   	
   	
   	
   	
   	
   	
  

U.S.	
  Department	
  of	
  Justice	
  v.	
  The	
  State	
  of	
  Ohio	
  

Civil	
  Action	
  No:	
  2:08-­‐cv-­‐475	
  

Monitor’s	
  Fourth	
  Report	
  	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

Kelly	
  Dedel,	
  Ph.D.,	
  Lead	
  Monitor	
  

Daphne	
  Glindmeyer,	
  M.D.,	
  Subject	
  Matter	
  Expert	
  

Michelle	
  Staples-­‐Horne,	
  M.D.,	
  Subject	
  Matter	
  Expert	
  

	
  

One	
  in	
  37	
  Research,	
  Inc.	
  

16	
  Rock	
  Street	
  	
  Cody,	
  WY	
  	
  82414	
  

(503)799-­‐0915	
  

kelly.dedel@gmail.com	
  

	
  

	
  

	
  

Draft	
  Submitted	
  May	
  31,	
  2013	
  

Final	
  Submitted	
  June	
  18,	
  2013	
  

	
  

	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 2 of 67 PAGEID #: 2496

TABLE	
  OF	
  CONTENTS	
  
	
   Introduction	
  ............................................................................................................................	
  3	
   Executive	
  Summary	
  .................................................................................................................	
  4	
  
Protection	
  from	
  Harm	
.   ....................................................................................................................	
  9	
   General	
  Protection	
  From	
  Harm	.
  ..................................................................................................	
  9	
   Seclusion	
 .  ..................................................................................................................................	
  20	
   Investigation	
  of	
  Serious	
  Incidents	
 .  ............................................................................................	
  27	
   Grievances	.
  ................................................................................................................................	
  33	
   Grievances	
  Explained	
  to	
  Youth	
  .................................................................................................	
  38	
   Structured	
  Programming	
  ..........................................................................................................	
  39	
   Orientation	.
  ...............................................................................................................................	
  45	
  
	
   Mental	
  Health	
  Services	
  ....................................................................................................................	
  	
  
Mental	
  Health	
  Screening	
.   .............................................................................................................	
  	
   Immediate	
  Referral	
  to	
  QMHP	
  ......................................................................................................	
  	
   Identification	
  of	
  Previously	
  Unidentified	
  Youth	
 .  ..........................................................................	
  	
   Mental	
  Health	
  Assessment	
  ..........................................................................................................	
  	
   Adequate	
  Care	
  and	
  Treatment	.
   ....................................................................................................	
  	
   Treatment	
  Planning	.
   .....................................................................................................................	
  	
   Treatment	
  Teams	
 .  ........................................................................................................................	
  	
   Integrated	
  Treatment	
  Plans	
  .........................................................................................................	
  	
   Access	
  to	
  QMHP	
 .  ..........................................................................................................................	
  	
   Mental	
  Health	
  Involvement	
  in	
  Housing	
  and	
  Placement	.
  ..............................................................	
  	
   Staffing	
  .........................................................................................................................................	
  	
   Medication	
  Notice	
.   .......................................................................................................................	
  	
   Mental	
  Health	
  Medications	.
  .........................................................................................................	
  	
   MH/DD	
  Training	
  for	
  Direct	
  Care	
  Staff	.
  ..........................................................................................	
  	
   Staff	
  Mental	
  Health	
  Training	
 .  .......................................................................................................	
  	
   Suicide	
  Prevention	.
  .......................................................................................................................	
  	
   Transition	
  Planning	.
  ......................................................................................................................	
  	
   Oversight	
  of	
  Mental	
  Health	
.   .........................................................................................................	
  	
   Documentation	.
   ................................................................................................................................	
  	
   Progress	
  Notes	
  .............................................................................................................................	
  	
   Accessibility	
  of	
  Information	.
  .........................................................................................................	
  	
   	
   Medical	
  Services	
 .  ..........................................................................................................................	
  47	
   General	
  Medical	
  Care	
.   ..............................................................................................................	
  47	
   Health	
  Records	
 .  ........................................................................................................................	
  52	
   Access	
  to	
  Health	
  Systems	
.   ........................................................................................................	
  54	
   	
   Special	
  Education	
  Services	
  ...........................................................................................................	
  55	
   Provision	
  of	
  Special	
  Education	
  .................................................................................................	
  55	
   Individual	
  Education	
  Plans	
  .......................................................................................................	
  60	
   Vocational	
  Education	
  ...............................................................................................................	
  64	
   	
   	
  

	
  

2.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 3 of 67 PAGEID #: 2497

INTRODUCTION	
  
	
  

On	
  June	
  4,	
  2008,	
  The	
  United	
  States	
  Department	
  of	
  Justice	
  (DOJ)	
  and	
  the	
  State	
  of	
  Ohio	
  (the	
  State)	
  

signed	
  a	
  stipulation	
  for	
  injunctive	
  relief	
  (the	
  Stipulation)	
  concerning	
  conditions	
  at	
  the	
  Scioto	
  

Juvenile	
  Correctional	
  Facility	
  (Scioto)	
  and	
  the	
  Marion	
  Juvenile	
  Correctional	
  Facility	
  (Marion;	
  

which	
  was	
  closed	
  shortly	
  after	
  the	
  Stipulation	
  was	
  signed).	
  Fred	
  Cohen,	
  the	
  Lead	
  Monitor	
  of	
  the	
  

concurrent	
  conditions	
  of	
  confinement	
  lawsuit,	
  S.H.	
  v	
  Reed	
  et	
  al.,	
  served	
  as	
  the	
  monitor	
  for	
  the	
  

Stipulation	
  until	
  late	
  2009.	
  At	
  that	
  point,	
  Mr.	
  Cohen	
  resigned	
  and	
  the	
  DOJ	
  assumed	
  the	
  role	
  of	
  

Monitor,	
  with	
  Dr.	
  Kelly	
  Dedel,	
  Dr.	
  Daphne	
  Glindmeyer,	
  and	
  Dr.	
  Michelle	
  Staples-­‐Horne	
  serving	
  as	
  

subject	
  matter	
  experts.	
  	
  

	
  

In	
  June	
  2011,	
  as	
  the	
  original	
  stipulation	
  expired,	
  the	
  Parties	
  recognized	
  that	
  the	
  State	
  had	
  not	
  

yet	
  reached	
  substantial	
  compliance	
  with	
  several	
  key	
  portions	
  of	
  the	
  Stipulation.	
  Thus,	
  the	
  

Stipulation	
  was	
  renegotiated	
  to	
  include	
  a	
  subset	
  of	
  the	
  original	
  provisions.	
  The	
  Amended	
  

Stipulation,	
  signed	
  June	
  28,	
  2011,	
  terminates	
  when	
  the	
  State	
  has	
  achieved	
  substantial	
  

compliance	
  with	
  each	
  provision	
  and	
  has	
  maintained	
  substantial	
  compliance	
  for	
  two	
  reporting	
  

periods	
  (i.e.,	
  12	
  months).	
  The	
  Parties	
  also	
  agreed	
  that	
  the	
  Amended	
  Stipulation	
  is	
  subject	
  to	
  the	
  

termination	
  provisions	
  of	
  the	
  Prison	
  Litigation	
  Reform	
  Act.	
  	
  

	
  

The	
  Monitor	
  for	
  the	
  Amended	
  Stipulation	
  is	
  Dr.	
  Kelly	
  Dedel,	
  who	
  evaluates	
  the	
  State’s	
  progress	
  

in	
  the	
  areas	
  of	
  Protection	
  From	
  Harm,	
  Grievances,	
  Programming	
  and	
  Special	
  Education.	
  She	
  is	
  

assisted	
  by	
  two	
  Subject	
  Matter	
  Experts,	
  Dr.	
  Daphne	
  Glindmeyer,	
  who	
  evaluates	
  the	
  State’s	
  

progress	
  on	
  provisions	
  related	
  to	
  Mental	
  Health	
  Services,	
  and	
  Dr.	
  Michelle	
  Staples-­‐Horne,	
  who	
  

evaluates	
  the	
  State’s	
  progress	
  on	
  provisions	
  related	
  to	
  Medical	
  Care.	
  	
  

	
  

As	
  the	
  Monitor,	
  Dr.	
  Dedel	
  is	
  the	
  primary	
  liaison	
  between	
  the	
  Monitoring	
  Team	
  and	
  the	
  Parties	
  

and	
  she	
  compiles	
  the	
  Monitor’s	
  Report.	
  To	
  do	
  so,	
  she	
  combines	
  Drs.	
  Glindmeyer’s	
  and	
  Staples-­‐

Horne’s	
  reports	
  with	
  her	
  own	
  to	
  form	
  a	
  coherent	
  whole,	
  but	
  does	
  not	
  change	
  the	
  substance	
  of	
  

the	
  reports	
  by	
  either	
  of	
  the	
  Subject	
  Matter	
  Experts,	
  who	
  are	
  responsible	
  for	
  forming	
  their	
  own	
  

opinions	
  about	
  the	
  level	
  of	
  compliance	
  for	
  each	
  provision	
  in	
  their	
  areas	
  of	
  expertise.	
  	
  

	
  

This	
  is	
  the	
  Monitor’s	
  fourth	
  report	
  on	
  the	
  State’s	
  progress	
  toward	
  the	
  reforms	
  required	
  by	
  the	
  

Amended	
  Stipulation.	
  The	
  monitoring	
  period	
  is	
  October	
  1,	
  2012	
  through	
  March	
  31,	
  2013.	
  

Progress	
  reports	
  are	
  issued	
  approximately	
  every	
  six	
  months.	
  This	
  report	
  includes	
  only	
  Protection	
  

from	
  Harm,	
  Medical	
  Services	
  and	
  Special	
  Education.	
  DYS	
  was	
  unavailable	
  to	
  present	
  the	
  

required	
  self-­‐assessment	
  of	
  Mental	
  Health	
  Services	
  until	
  just	
  before	
  the	
  report’s	
  due	
  date,	
  

leaving	
  Dr.	
  Glindmeyer	
  with	
  insufficient	
  time	
  to	
  integrate	
  the	
  State’s	
  assessment	
  with	
  her	
  own.	
  

The	
  draft	
  Mental	
  Health	
  report	
  was	
  submitted	
  to	
  the	
  Parties	
  for	
  review	
  and	
  comment	
  on	
  June	
  

17,	
  2013.	
  The	
  absence	
  of	
  information	
  regarding	
  Mental	
  Health	
  Services	
  in	
  this	
  report	
  should	
  not	
  

be	
  construed	
  to	
  mean	
  that	
  the	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  those	
  provisions.	
  	
  

	
  

	
  

	
  

	
  

3.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 4 of 67 PAGEID #: 2498

EXECUTIVE	
  SUMMARY	
  

	
  

The	
  Amended	
  Stipulation	
  includes	
  33	
  provisions	
  related	
  to	
  Protection	
  From	
  Harm	
  (n=3);	
  

Grievances	
  (n=2);	
  Programming	
  (n=2);	
  Mental	
  Health	
  Care	
  (n=18)	
  and	
  Documentation	
  (n=2);	
  

Medical	
  Care	
  (n=3);	
  and	
  Special	
  Education	
  (n=3).	
  Each	
  provision	
  is	
  listed	
  in	
  the	
  table	
  below,	
  

along	
  with	
  the	
  Monitor’s	
  or	
  Subject	
  Matter	
  Expert’s	
  compliance	
  rating.	
  	
  

	
  

The	
  Monitor	
  and	
  subject	
  matter	
  experts	
  use	
  a	
  three-­‐tiered	
  system	
  (substantial	
  compliance,	
  

partial	
  compliance	
  and	
  non-­‐compliance),	
  defined	
  as	
  follows:	
  

	
  

·∙	
  	
  	
  	
  	
  Substantial	
  Compliance	
  means	
  that	
  the	
  facility	
  has	
  drafted	
  relevant	
  policies	
  and	
  procedures;	
  

has	
  trained	
  the	
  staff	
  responsible	
  for	
  implementation;	
  has	
  sufficient	
  staff	
  to	
  implement	
  the	
  

required	
  reform;	
  has	
  demonstrated	
  the	
  ability	
  to	
  properly	
  implement	
  the	
  procedures	
  during	
  

the	
  majority	
  of	
  the	
  monitoring	
  period;	
  and	
  has	
  ascertained	
  that	
  the	
  procedures	
  accomplish	
  

the	
  outcome	
  envisioned	
  by	
  the	
  provision.	
  Non-­‐compliance	
  with	
  mere	
  technicalities	
  or	
  a	
  

temporary	
  failure	
  to	
  comply	
  (due	
  to	
  staff	
  vacancy	
  or	
  illness,	
  facility	
  disruptions,	
  or	
  other	
  

short-­‐term	
  events)	
  during	
  an	
  otherwise	
  sustained	
  period	
  of	
  compliance	
  do	
  not	
  constitute	
  a	
  

failure	
  to	
  achieve	
  or	
  maintain	
  substantial	
  compliance.	
  Conversely,	
  temporary	
  compliance	
  

during	
  a	
  period	
  of	
  sustained	
  non-­‐compliance	
  or	
  partial	
  compliance	
  does	
  not	
  constitute	
  

substantial	
  compliance.	
  

	
  	
  

·∙	
  	
  	
  	
  	
  	
  Partial	
  Compliance	
  means	
  that	
  the	
  facility	
  has	
  drafted	
  policies	
  and	
  procedures,	
  has	
  trained	
  

staff	
  responsible	
  for	
  implementation,	
  and	
  has	
  sufficient	
  staff	
  to	
  implement	
  the	
  required	
  

reform.	
  While	
  progress	
  has	
  been	
  made	
  toward	
  implementing	
  the	
  procedures	
  described	
  by	
  

policy,	
  performance	
  has	
  been	
  inconsistent	
  throughout	
  the	
  monitoring	
  period	
  and	
  additional	
  

modifications	
  are	
  needed	
  to	
  ensure	
  that	
  procedures	
  are	
  sufficiently	
  comprehensive	
  to	
  

translate	
  policy	
  into	
  practice.	
  	
  

	
  	
  

·∙	
  	
  	
  	
  	
  Non-­‐Compliance	
  means	
  that	
  the	
  facility	
  has	
  made	
  only	
  very	
  preliminary	
  efforts	
  to	
  implement	
  

the	
  required	
  reform,	
  but	
  significant	
  work	
  remains.	
  Policy	
  may	
  need	
  to	
  be	
  overhauled,	
  the	
  

majority	
  of	
  staff	
  may	
  need	
  to	
  be	
  trained,	
  procedures	
  may	
  not	
  have	
  been	
  developed,	
  and	
  no	
  

one	
  has	
  begun	
  to	
  ascertain	
  whether	
  the	
  procedures	
  accomplish	
  the	
  outcome	
  envisioned	
  by	
  

the	
  provision.	
  	
  

	
  

	
  

The	
  Monitor	
  wants	
  to	
  emphasize	
  that	
  the	
  substantial	
  compliance	
  rating	
  is	
  given	
  only	
  when	
  the	
  

required	
  reforms	
  address	
  all	
  of	
  the	
  issues	
  discussed	
  in	
  the	
  Provision	
  and	
  when	
  solid	
  

implementation	
  of	
  the	
  reforms	
  has	
  been	
  consistently	
  demonstrated,	
  through	
  reliable	
  data,	
  

observations	
  and	
  reports	
  from	
  staff	
  and	
  youth,	
  for	
  a	
  majority	
  of	
  the	
  monitoring	
  period.	
  Partial	
  

compliance	
  indicates	
  that	
  some	
  of	
  the	
  issues	
  addressed	
  in	
  the	
  Provision	
  have	
  been	
  resolved,	
  but	
  

that	
  problems,	
  some	
  of	
  them	
  serious,	
  still	
  remain.	
  The	
  application	
  of	
  the	
  partial	
  compliance	
  

rating	
  is	
  only	
  a	
  brief	
  indicator—the	
  entire	
  discussion	
  should	
  be	
  read	
  to	
  fully	
  understand	
  the	
  type	
  

and	
  magnitude	
  of	
  remaining	
  problems.	
  	
  

	
  

	
  

	
  

	
  

	
  

4.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 5 of 67 PAGEID #: 2499

Table	
  1.	
  Compliance	
  Ratings	
  for	
  Each	
  Provision	
  

No.	
  

Provision	
  

1st	
  Report	
  	
   2nd	
  Report	
   3rd	
  Report	
   4th	
  Report	
  

Protection	
  From	
  Harm	
  

III.A.	
  1	
   General	
  Protection	
  From	
  Harm	
  

NC	
  

PC	
  

PC	
  

PC	
  

III.A.3	
   Seclusion	
  

NC	
  

PC	
  

PC	
  

PC	
  

III.A.5	
   Investigation	
  of	
  Serious	
  Incidents	
  

SC	
  

PC	
  

PC	
  

PC	
  

III.D.1	
   Grievances	
  

PC	
  

PC	
  

PC	
  

PC	
  

III.D.2	
   Grievances	
  Explained	
  to	
  Youth	
  

PC	
  

SC	
  

SC	
  

SC	
  

III.F.1	
   Structured	
  Programming	
  

NC	
  

NC	
  

PC	
  

PC	
  

III.F.2	
   Orientation	
  

PC	
  

PC	
  

PC	
  

SC	
  

Mental	
  Health	
  Services	
  

III.B.1	
   Mental	
  Health	
  Screening	
  

PC	
  

PC	
  

SC	
  

	
  

III.B.2	
   Immediate	
  Referral	
  to	
  QMHP	
  

PC	
  

PC	
  

SC	
  

	
  

III.B.3	
   Identification	
  of	
  Unidentified	
  Youth	
  	
   NC	
  

PC	
  

PC	
  

	
  

III.B.4	
   Mental	
  Health	
  Assessment	
  

NC	
  

PC	
  

PC	
  

	
  

III.B.5	
   Adequate	
  Care	
  and	
  Treatment	
  

NC	
  

PC	
  

PC	
  

	
  

III.B.6	
   Treatment	
  Planning	
  

NC	
  

PC	
  

PC	
  

	
  

III.B.7	
   Treatment	
  Teams	
  

PC	
  

PC	
  

PC	
  

	
  

III.B.8	
   Integrated	
  Treatment	
  Plans	
  

NC	
  

PC	
  

PC	
  

	
  

III.B.9	
   Access	
  to	
  QMHP	
  

NC	
  

PC	
  

SC	
  

	
  

III.B.10	
   Involvement	
  in	
  Housing	
  and	
  Plcmt	
  

NC	
  

PC	
  

PC	
  

	
  

III.B.11	
   Staffing	
  

NC	
  

PC	
  

PC	
  

	
  

III.B.12	
   Medication	
  Notice	
  

PC	
  

PC	
  

PC	
  

	
  

III.B.13	
   Mental	
  Health	
  Medications	
  

PC	
  

PC	
  

PC	
  

	
  

III.B.14	
   MH/DD	
  Training	
  for	
  Line	
  Staff	
  

NC	
  

NC	
  

NC	
  

	
  

III.B.15	
   Staff	
  Mental	
  Health	
  Training	
  

PC	
  

PC	
  

PC	
  

	
  

III.B.16	
   Suicide	
  Prevention	
  

PC	
  

PC	
  

PC	
  

	
  

III.B.17	
   Transition	
  Planning	
  

PC	
  

PC	
  

PC	
  

	
  

III.B.18	
   Oversight	
  of	
  Mental	
  Health	
  

NC	
  

NC	
  

NC	
  

	
  

III.G.1	
   Progress	
  Notes	
  

PC	
  

PC	
  

PC	
  

	
  

III.G.2	
   Accessibility	
  of	
  Information	
  

NC	
  

NC	
  

NC	
  

	
  

	
  

	
  

	
  

5.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 6 of 67 PAGEID #: 2500

Medical	
  Services	
   No.	
  

Provision	
  

1st	
  Report	
  	
   2nd	
  Report	
   3rd	
  Report	
   4th	
  Report	
  

III.C.1	
   General	
  Medical	
  Care	
  

SC	
  

PC	
  

PC	
  

PC	
  

III.C.2	
   Health	
  Records	
  

SC	
  

PC	
  

PC	
  

PC	
  

III.C.5	
   Access	
  to	
  Health	
  Services	
  

SC	
  

SC	
  

SC	
  

SC	
  

Special	
  Education	
  Services	
  

III.E.1	
   Provision	
  of	
  Special	
  Education	
  

PC	
  

PC	
  

PC	
  

SC	
  

III.E.7	
   Individual	
  Education	
  Plans	
  

PC	
  

PC	
  

SC	
  

SC	
  

III.E.8	
   Vocational	
  Education	
  

NC	
  

NC	
  

SC	
  

SC	
  

	
   	
   Overall	
  compliance	
  rates	
  could	
  not	
  be	
  calculated	
  because	
  the	
  Mental	
  Health	
  section	
  is	
  not	
   included	
  with	
  this	
  report.	
  Individual	
  sections	
  of	
  the	
  Stipulation	
  are	
  discussed	
  below.	
  	
   	
   Protection	
  from	
  Harm	
  (includes	
  Grievances	
  and	
  Programming)	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  2	
  of	
  the	
  7	
  provisions	
  (29%)	
  related	
  to	
  protecting	
   youth	
  from	
  harm	
  and	
  is	
  in	
  partial	
  compliance	
  with	
  the	
  remaining	
  5	
  provisions	
  (71%).	
  The	
   following	
  actions	
  should	
  be	
  prioritized:	
   	
  
• Assess	
  the	
  effectiveness	
  of	
  the	
  various	
  strategies	
  that	
  have	
  been	
  recently	
  implemented	
   to	
  address	
  the	
  problem	
  of	
  youth-­‐on-­‐staff	
  violence.	
  Make	
  modifications	
  as	
  necessary	
  to	
   effect	
  substantial	
  reductions	
  in	
  the	
  rate	
  of	
  youth-­‐on-­‐staff	
  assaults.	
  	
  
• Reinforce	
  the	
  prohibition	
  against	
  provoking,	
  taunting,	
  belittling	
  and	
  otherwise	
   disrespecting	
  youth.	
  Investigate	
  complaints	
  vigorously	
  and	
  enforce	
  the	
  conduct	
   standards	
  when	
  they	
  are	
  violated.	
  	
  
• Improve	
  staff	
  accountability	
  measures	
  to	
  ensure	
  that	
  all	
  staff	
  are	
  held	
  responsible	
  not	
   just	
  for	
  maintaining	
  the	
  code	
  of	
  conduct,	
  but	
  for	
  reporting	
  concerns	
  about	
  staff	
  who	
  fail	
   to	
  do	
  so.	
  	
  
• Develop	
  a	
  robust	
  Quality	
  Assurance/Quality	
  Improvement	
  process	
  to	
  determine	
   whether	
  the	
  IRAV	
  and	
  sanctions	
  grid	
  revisions	
  are	
  properly	
  implemented	
  and	
  whether	
   they	
  have	
  significantly	
  reduced	
  the	
  reliance	
  on	
  isolation	
  to	
  control	
  and	
  respond	
  to	
  youth	
   behavior.	
  The	
  QA/QI	
  process	
  should	
  include	
  standards	
  that	
  clearly	
  articulate	
  a	
   preference	
  for	
  non-­‐seclusion	
  based	
  sanctions	
  when	
  appropriate,	
  a	
  methodology	
  for	
   auditing	
  facility	
  practices,	
  analysis	
  and	
  interpretation	
  of	
  data,	
  and	
  a	
  Quality	
   Improvement	
  Plan	
  for	
  any	
  area	
  in	
  which	
  performance	
  deficits	
  are	
  revealed.	
  	
  
• Reduce	
  the	
  number	
  of	
  individuals	
  authorized	
  to	
  conduct	
  local	
  investigations	
  and	
  ensure	
   that	
  these	
  individuals	
  have	
  the	
  requisite	
  skills	
  for	
  the	
  task.	
  Ensure	
  that	
  producing	
  timely,	
   high-­‐quality	
  investigations	
  is	
  a	
  specific	
  job	
  responsibility	
  and	
  that	
  employees	
  are	
  held	
   accountable	
  for	
  their	
  failure	
  to	
  produce	
  reports	
  that	
  meet	
  professional	
  standards.	
  	
   o The	
  lack	
  of	
  progress	
  in	
  the	
  area	
  of	
  Local	
  Investigations	
  suggests	
  that	
  additional	
   oversight	
  may	
  be	
  necessary.	
  The	
  Monitor	
  encourages	
  DYS	
  to	
  create	
  a	
  Quality	
   Improvement	
  Plan	
  that	
  determines	
  the	
  underlying	
  causes	
  of	
  the	
  delay	
  and	
  poor	
  

	
  

6.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 7 of 67 PAGEID #: 2501

quality	
  products.	
  Once	
  known,	
  specific	
  strategies	
  should	
  be	
  developed	
  to	
  target	
   each	
  underlying	
  factor	
  so	
  that	
  the	
  quality	
  of	
  the	
  product	
  is	
  significantly	
   improved.	
  The	
  effectiveness	
  of	
  these	
  strategies	
  should	
  be	
  assessed	
  frequently	
   (e.g.,	
  monthly	
  or	
  bi-­‐monthly).	
  The	
  Monitor	
  will	
  request	
  copies	
  of	
  completed	
  local	
   investigations	
  on	
  a	
  monthly	
  basis	
  in	
  order	
  to	
  provide	
  more	
  frequent	
  progress	
   reports	
  to	
  the	
  Parties	
  and	
  to	
  the	
  Court.	
  	
   • Promptly	
  notify	
  youth	
  of	
  the	
  outcome	
  of	
  any	
  grievance	
  referred	
  for	
  investigation.	
  [If	
  DYS	
   completes	
  this	
  straightforward	
  task	
  very	
  soon,	
  the	
  provision	
  may	
  be	
  rated	
  in	
  Substantial	
   Compliance	
  for	
  the	
  April-­‐October	
  2013	
  monitoring	
  period.]	
   • Create	
  and	
  implement	
  a	
  Quality	
  Improvement	
  Plan	
  to	
  improve	
  compliance	
  with	
  Quality	
   Assurance	
  standards	
  related	
  to	
  all	
  three	
  components	
  of	
  Structured	
  Programming	
  (i.e.,	
   MAV,	
  Victim	
  Awareness	
  and	
  Phoenix	
  groups;	
  recreation	
  and	
  community	
  service;	
   religious	
  and	
  volunteer-­‐led	
  programs).	
  	
   	
   Mental	
  Health	
  Services	
   	
   DYS	
  was	
  unavailable	
  to	
  present	
  the	
  required	
  self-­‐assessment	
  of	
  Mental	
  Health	
  Services	
  until	
  just	
   before	
  the	
  due	
  date,	
  leaving	
  Dr.	
  Glindmeyer	
  with	
  insufficient	
  time	
  to	
  integrate	
  the	
  State’s	
   assessment	
  with	
  her	
  own.	
  The	
  draft	
  Mental	
  Health	
  report	
  was	
  submitted	
  to	
  the	
  Parties	
  for	
   review	
  and	
  comment	
  on	
  June	
  17,	
  2013.	
  The	
  absence	
  of	
  information	
  regarding	
  Mental	
  Health	
   Services	
  in	
  this	
  report	
  should	
  not	
  be	
  construed	
  to	
  mean	
  that	
  the	
  State	
  is	
  in	
  substantial	
   compliance	
  with	
  those	
  provisions.	
  	
   	
   Medical	
  Services	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  one	
  of	
  the	
  provisions	
  (33%)	
  related	
  to	
  medical	
   services	
  and	
  in	
  partial	
  compliance	
  with	
  the	
  other	
  2	
  provisions	
  (66%).	
  The	
  following	
  actions	
   should	
  be	
  prioritized:	
   	
   • Complete	
  satellite	
  clinic	
  and	
  medication	
  room	
  on	
  Buckeye	
  Units	
  for	
  adequate	
  injury	
   assessments	
  of	
  youth	
  and	
  medication	
  administration	
  on	
  the	
  unit.	
  	
   • Continue	
  to	
  limit	
  time	
  of	
  youth	
  in	
  seclusion	
  and	
  adequately	
  document	
  health	
  status	
  in	
   during	
  segregation.	
   • Continue	
  to	
  improve	
  Quality	
  Assurance	
  (QA)	
  activities	
  by	
  continuing	
  an	
  external	
  review	
   through	
  accreditation	
  by	
  the	
  American	
  Correctional	
  Association.	
  ODYS	
  should	
  also	
   consider	
  expansion	
  of	
  the	
  QA	
  process	
  to	
  include	
  some	
  additional	
  quality	
  outcome	
   indicators.	
  	
   • Continue	
  to	
  improve	
  the	
  process	
  for	
  sharing	
  of	
  health	
  information	
  between	
  medical	
  and	
   mental	
  health	
  to	
  include	
  psychologists	
  through	
  implementation	
  of	
  eClinical	
  Works	
  EHR.	
   ODYS	
  medical	
  management	
  staff	
  should	
  be	
  intimately	
  involved	
  in	
  the	
  process	
  of	
   customization	
  of	
  the	
  EMR	
  to	
  be	
  relevant	
  to	
  youth	
  medical	
  services.	
   • Ensure	
  Health	
  Request	
  slips	
  and	
  boxes	
  are	
  readily	
  available	
  to	
  youth	
  on	
  all	
  housing	
  units.	
   Youth	
  should	
  not	
  have	
  to	
  rely	
  on	
  custody	
  staff	
  to	
  request	
  forms.	
  	
  	
   	
   Special	
  Education	
   	
   The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  all	
  3	
  of	
  the	
  education-­‐related	
  provisions	
  (100%)!	
  

	
  

7.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 8 of 67 PAGEID #: 2502

	
  

	
  

During	
  the	
  current	
  monitoring	
  period,	
  the	
  Parties	
  negotiated	
  a	
  Consent	
  Order	
  regarding	
  the	
  

operation	
  of	
  the	
  PROGRESS	
  Unit	
  (PU).	
  Signed	
  by	
  Judge	
  Marbley	
  on	
  January	
  18,	
  2013,	
  the	
  Order	
  

requires	
  specific	
  modifications	
  to	
  the	
  PU	
  that	
  are	
  monitored	
  separately	
  from	
  the	
  Amended	
  

Stipulation.	
  The	
  most	
  recent	
  Status	
  Report	
  for	
  the	
  PU	
  is	
  attached	
  to	
  this	
  report.	
  Once	
  the	
  State	
  

comes	
  into	
  substantial	
  compliance	
  with	
  all	
  of	
  the	
  provisions	
  and	
  maintains	
  that	
  level	
  of	
  

performance	
  for	
  six	
  months,	
  monitoring	
  of	
  the	
  PU	
  shifts	
  back	
  to	
  the	
  Amended	
  Stipulation	
  and	
  

will	
  be	
  reported	
  here	
  in	
  the	
  sections	
  for	
  the	
  relevant	
  provisions.	
  The	
  operation	
  of	
  the	
  PU	
  is	
  

therefore	
  not	
  discussed	
  in	
  this	
  report.	
  	
  

	
  

The	
  remainder	
  of	
  this	
  report	
  is	
  organized	
  as	
  follows:	
  1)	
  each	
  Provision	
  is	
  presented,	
  verbatim;	
  2)	
  

the	
  compliance	
  rating	
  is	
  noted;	
  3)	
  information	
  the	
  State	
  presented	
  to	
  demonstrate	
  compliance	
  

with	
  the	
  Provision	
  is	
  summarized;	
  4)	
  additional	
  activities	
  undertaken	
  by	
  the	
  Monitor	
  or	
  subject	
  

matter	
  expert	
  to	
  determine	
  the	
  level	
  of	
  compliance	
  are	
  discussed;	
  5)	
  the	
  steps	
  required	
  to	
  

achieve	
  substantial	
  compliance	
  with	
  the	
  Provision	
  are	
  listed;	
  6)	
  the	
  sources	
  of	
  information	
  the	
  

Monitor	
  or	
  subject	
  matter	
  expert	
  used	
  to	
  form	
  her	
  opinion	
  are	
  listed.	
  	
  

	
  

	
  

	
  

8.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 9 of 67 PAGEID #: 2503

PROTECTION	
  FROM	
  HARM	
  	
  
	
   	
  
III.A.1	
  General	
  Protection	
  From	
  Harm.	
  The	
  State	
  shall,	
  at	
  all	
  times,	
  provide	
  youth	
  in	
  the	
  facilities	
   with	
  safe	
  living	
  conditions.	
  As	
  part	
  of	
  this	
  requirement,	
  the	
  State	
  shall	
  take	
  appropriate	
   measures	
  to	
  ensure	
  that	
  youth	
  are	
  protected	
  from	
  abuse	
  and	
  neglect,	
  use	
  of	
  excessive	
  force,	
   undue	
  seclusion,	
  undue	
  restraint,	
  and	
  over-­‐familiarization.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Trends	
  in	
  youth	
  violence,	
  restraints,	
  and	
  allegations	
  of	
  over-­‐ familiarization	
  are	
  discussed	
  here,	
  while	
  detailed	
  discussions	
  about	
  the	
   use	
  of	
  seclusion	
  and	
  investigating	
  staff	
  misconduct	
  can	
  be	
  found	
  in	
  III.A.3	
   and	
  III.A.5	
  respectively.	
  	
   	
   Via	
  its	
  work	
  on	
  the	
  S.H.	
  case,	
  several	
  new	
  Quality	
  Assurance	
  (QA)	
   programs	
  have	
  been	
  established	
  to	
  provide	
  the	
  internal	
  capacity	
  to	
   identify	
  and	
  respond	
  to	
  problems	
  in	
  the	
  core	
  areas	
  of	
  youth	
  violence,	
   investigations,	
  and	
  seclusion.	
  These	
  join	
  pre-­‐existing	
  efforts	
  to	
  track	
   facility	
  performance	
  (youth	
  violence)	
  and	
  offer	
  technical	
  assistance	
   (restraints).	
  However,	
  the	
  QA	
  programs	
  in	
  each	
  area	
  are	
  in	
  different	
   phases	
  of	
  development.	
  Some	
  have	
  articulated	
  standards,	
  some	
  have	
  an	
   articulated	
  audit	
  methodology	
  and	
  performance	
  measures,	
  some	
  have	
   pilot	
  tested	
  the	
  methodology.	
  To	
  date,	
  a	
  “QA	
  Report”	
  on	
  the	
  success	
  with	
   which	
  the	
  facility	
  has	
  met	
  the	
  standards	
  and	
  performance	
  measures	
  in	
   each	
  area	
  has	
  not	
  been	
  produced.	
  Further,	
  structured	
  Quality	
   Improvement	
  Plans	
  have	
  not	
  yet	
  been	
  developed	
  to	
  remediate	
  identified	
   deficits.	
  DYS’	
  progress	
  in	
  sculpting	
  a	
  formal	
  QA	
  process	
  is	
  an	
  important	
   accomplishment,	
  although	
  significant	
  work	
  still	
  remains.	
  	
  	
  	
   	
   Quality	
  Assurance	
  Efforts	
  Related	
  to	
  Youth	
  Violence	
   DYS	
  has	
  leveraged	
  its	
  participation	
  in	
  the	
  Performance	
  Based	
  Standards	
   (PbS)	
  project	
  to	
  provide	
  a	
  framework	
  for	
  its	
  QA	
  process	
  in	
  this	
  area.	
  Data	
   on	
  the	
  rate	
  of	
  youth-­‐on-­‐youth	
  and	
  youth-­‐on-­‐staff	
  violence	
  is	
  collected	
   monthly	
  and	
  progress	
  is	
  measured	
  using	
  the	
  6-­‐month	
  PbS	
  cycle	
  (every	
   April	
  and	
  October).	
  Each	
  facility	
  is	
  expected	
  to	
  reduce	
  its	
  rates	
  of	
  youth	
   violence	
  by	
  at	
  least	
  10%	
  each	
  reporting	
  period.	
  	
   	
   While	
  the	
  facility	
  has	
  participated	
  in	
  PbS	
  for	
  several	
  years,	
  the	
  full	
  QA	
   framework	
  for	
  identifying	
  the	
  underlying	
  causes	
  of	
  increases	
  or	
  decreases	
   in	
  youth	
  violence	
  was	
  established	
  only	
  recently.	
  Each	
  month,	
  the	
  Bureau	
   Director	
  of	
  Facility	
  Programs	
  meets	
  with	
  each	
  Facility	
  Superintendent	
  to	
   discuss	
  the	
  various	
  influences	
  on	
  youth	
  violence	
  and	
  to	
  create	
  strategies	
   for	
  addressing	
  them.	
  During	
  the	
  first	
  two	
  months	
  that	
  the	
  QA	
  program	
   was	
  operational	
  (January	
  and	
  February,	
  2013),	
  conversations	
  with	
  the	
   Scioto	
  Superintendent	
  focused	
  on	
  the	
  two	
  youth	
  who	
  were	
  responsible	
   for	
  nearly	
  half	
  of	
  the	
  youth-­‐on-­‐staff	
  assaults.	
  These	
  two	
  youth	
  had	
  been	
   referred	
  to	
  the	
  PROGRESS	
  Unit.	
  In	
  addition,	
  the	
  agency-­‐wide	
  “Back	
  to	
  

	
  

9.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 10 of 67 PAGEID #: 2504

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Basics”	
  strategy	
  was	
  identified	
  as	
  a	
  tool	
  to	
  fortify	
  the	
  supervision	
  and	
   teamwork	
  skills	
  of	
  direct	
  care	
  staff.	
  	
   	
   Quality	
  Assurance	
  Efforts	
  Related	
  to	
  Restraints	
   As	
  discussed	
  in	
  the	
  previous	
  Monitor’s	
  Report,	
  the	
  DYS	
  has	
  a	
  system	
  for	
   both	
  internal	
  and	
  external	
  QA.	
  Scioto’s	
  Facility	
  Intervention	
  Administrator	
   (FIA)	
  is	
  responsible	
  for	
  reviewing	
  every	
  incident	
  involving	
  restraints	
  and	
   determining	
  whether	
  staff’s	
  actions	
  complied	
  with	
  policy.	
  The	
  FIA	
  has	
  the	
   option	
  to	
  approve	
  the	
  use	
  of	
  force	
  as	
  appropriate,	
  to	
  identify	
  a	
   “teachable	
  moment”	
  and	
  provide	
  specific	
  coaching	
  to	
  the	
  staff	
  involved,	
   or	
  to	
  refer	
  the	
  incident	
  for	
  investigation.	
  Each	
  month,	
  the	
  Facility	
   Resource	
  Administrator	
  (FRA)	
  from	
  DYS	
  Central	
  Office	
  reviews	
  the	
  FIA’s	
   assessment	
  and	
  decision-­‐making	
  for	
  a	
  sample	
  of	
  incidents	
  occurring	
  in	
   that	
  month.	
  	
   	
   Since	
  the	
  previous	
  monitoring	
  period,	
  the	
  FRA’s	
  reviews	
  suggest	
  that	
  the	
   detection	
  of	
  “teachable	
  moments”	
  has	
  improved.	
  The	
  FIA	
  now	
  keeps	
  a	
   log	
  of	
  these	
  opportunities,	
  which	
  both	
  documents	
  the	
  substance	
  of	
  the	
   issue	
  and	
  verifies	
  that	
  the	
  staff	
  involved	
  received	
  feedback.	
  Both	
  of	
  these	
   mechanisms	
  are	
  essential	
  for	
  the	
  ongoing	
  training	
  of	
  new	
  staff	
  and	
   refining	
  the	
  skill	
  sets	
  of	
  veteran	
  staff.	
  	
   	
   The	
  weak	
  link	
  in	
  this	
  system,	
  however,	
  is	
  the	
  poor	
  quality	
  of	
  the	
  local	
   investigations,	
  which	
  are	
  discussed	
  in	
  depth	
  in	
  III.A.5,	
  below.	
  When	
  a	
   more	
  serious	
  concern	
  about	
  the	
  use	
  of	
  restraints	
  is	
  detected	
  by	
  the	
  FIA,	
   the	
  incident	
  is	
  referred	
  for	
  investigation.	
  That	
  referral	
  is	
  a	
  sound	
  practice,	
   however,	
  the	
  poor	
  technique	
  of	
  many	
  of	
  the	
  facility-­‐based	
  investigators	
   seriously	
  undermines	
  the	
  integrity	
  of	
  this	
  process	
  and	
  offers	
  youth	
  little	
   protection	
  from	
  undue	
  restraints.	
  	
  	
  
Youth	
  Violence	
   The	
  table	
  below	
  presents	
  the	
  rate	
  of	
  youth-­‐on-­‐youth	
  and	
  youth-­‐on-­‐staff	
   violence	
  for	
  the	
  past	
  24	
  months.	
  These	
  data	
  reveal	
  a	
  steady	
  reduction	
  in	
   youth-­‐on-­‐youth	
  violence.	
  The	
  average	
  rate	
  for	
  the	
  past	
  three	
  six-­‐month	
   monitoring	
  periods	
  was	
  .24,	
  .13	
  and	
  .08.	
  The	
  average	
  rate	
  for	
  the	
  current	
   period	
  was	
  .09,	
  even	
  with	
  the	
  spike	
  in	
  violence	
  in	
  November	
  2012.	
   Overall,	
  rates	
  of	
  youth-­‐on-­‐youth	
  violence	
  have	
  been	
  low	
  for	
  a	
  little	
  over	
   one	
  year.	
  	
   	
   Unfortunately,	
  the	
  rate	
  of	
  youth-­‐on-­‐staff	
  violence	
  has	
  been	
  more	
   resistant	
  to	
  change.	
  The	
  average	
  rate	
  of	
  youth-­‐on-­‐staff	
  violence	
  increased	
   over	
  the	
  past	
  three	
  six-­‐month	
  monitoring	
  periods,	
  and	
  recently	
  leveled	
   off	
  (i.e.,	
  .15,	
  .16,	
  .20,	
  and	
  most	
  recently,	
  .17).	
  Youth-­‐on-­‐staff	
  assaults	
   occurred	
  almost	
  two	
  times	
  as	
  often	
  as	
  youth-­‐on-­‐youth	
  assaults.	
  Several	
  of	
   the	
  youth-­‐on-­‐staff	
  assaults	
  were	
  very	
  serious,	
  with	
  staff	
  admitted	
  to	
  the	
   hospital.	
  	
   	
   Conversations	
  with	
  facility	
  administrators	
  revealed	
  some	
  solid	
  problem-­‐

	
  

10.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 11 of 67 PAGEID #: 2505

solving	
  efforts	
  around	
  this	
  issue.	
  Profiles	
  of	
  staff	
  victims	
  tend	
  to	
  fall	
  into	
   three	
  categories:	
  1)	
  vulnerable	
  staff	
  who	
  are	
  new,	
  frightened,	
  and	
   inexperienced;	
  2)	
  staff	
  who	
  fail	
  to	
  identify	
  the	
  youth’s	
  immediate	
   behavioral	
  cues	
  that	
  indicate	
  a	
  heightened	
  risk	
  of	
  violence;	
  and	
  3)	
   accountability-­‐focused	
  staff	
  who	
  are	
  targeted	
  by	
  youth	
  in	
  an	
  effort	
  to	
  get	
   the	
  staff	
  removed	
  from	
  the	
  unit.	
  Efforts	
  to	
  better	
  protect	
  these	
  victims	
   are	
  underway.	
  For	
  example,	
  encouraging	
  the	
  unit	
  staff	
  to	
  function	
  as	
   team	
  so	
  that	
  all	
  staff	
  are	
  better	
  supported,	
  so	
  that	
  operational	
  practices	
   are	
  consistently	
  implemented,	
  and	
  so	
  the	
  team	
  is	
  less	
  susceptible	
  to	
   youth’s	
  efforts	
  to	
  split	
  staff	
  and	
  exploit	
  their	
  vulnerabilities.	
   	
   Other,	
  less	
  serious	
  forms	
  of	
  youth-­‐on-­‐staff	
  violence	
  have	
  been	
  addressed	
   via	
  environmental	
  strategies	
  such	
  as	
  container-­‐less	
  meals	
  (to	
  prevent	
   youth	
  from	
  being	
  able	
  to	
  collect	
  and	
  throw	
  liquids	
  at	
  staff)	
  and	
  spit	
  masks	
   (to	
  prevent	
  youth	
  from	
  being	
  able	
  to	
  spit	
  on	
  staff).	
  	
   	
   These	
  two	
  approaches—efforts	
  to	
  better	
  protect	
  victims	
  and	
   environmental	
  strategies	
  that	
  make	
  the	
  offenses	
  more	
  difficult	
  to	
   accomplish—are	
  essential	
  supplements	
  to	
  efforts	
  that	
  address	
  the	
   youth’s	
  behavior,	
  decision-­‐making,	
  empathy	
  or	
  sanctions.	
  While	
  the	
   facility	
  still	
  has	
  much	
  to	
  do	
  to	
  create	
  a	
  safer	
  environment	
  for	
  staff	
  (and	
  to	
   shield	
  youth	
  from	
  the	
  consequences	
  they	
  will	
  and	
  should	
  face	
  when	
  they	
   engage	
  in	
  that	
  type	
  of	
  violence),	
  its	
  recent	
  efforts	
  to	
  focus	
  on	
  the	
   underlying	
  causes	
  of	
  youth-­‐on-­‐staff	
  violence	
  are	
  very	
  promising.	
  	
   	
   That	
  said,	
  the	
  Monitor	
  and	
  DOJ	
  Attorney	
  continued	
  to	
  hear	
  complaints	
   from	
  youth	
  about	
  their	
  frustrations	
  with	
  certain	
  staff	
  who	
  were	
  described	
   as	
  antagonizing,	
  provoking,	
  and	
  otherwise	
  speaking	
  and	
  behaving	
  in	
  ways	
   that	
  could	
  increase	
  youth’s	
  propensity	
  for	
  violence	
  toward	
  them.	
  The	
   solution	
  to	
  this	
  problem	
  has	
  many	
  facets,	
  such	
  as	
  reiterating	
  and	
   enforcing	
  requirements	
  around	
  appropriate	
  behavior	
  and	
  demeanor	
   among	
  staff,	
  teaching	
  staff	
  skills	
  for	
  tolerating	
  their	
  frustrations	
  with	
   youth,	
  and	
  holding	
  them	
  accountable	
  for	
  failing	
  to	
  meet	
  these	
  standards.	
   On	
  the	
  other	
  hand,	
  helping	
  youth	
  to	
  develop	
  skills	
  for	
  tolerating	
   frustration,	
  making	
  requests	
  appropriately,	
  controlling	
  impulses,	
  etc.	
   should	
  also	
  contribute	
  to	
  a	
  reduction	
  in	
  the	
  rate	
  of	
  youth-­‐on-­‐staff	
   violence.	
  	
   	
   	
  

Youth	
  Violence,	
  April	
  2011	
  through	
  March	
  2013	
  

Month	
  

Youth-­‐Youth	
  

#	
  

ADP	
   Rate	
  

Youth-­‐Staff	
  

#	
  

ADP	
  

Rate	
  

Apr	
  11	
  

30	
  

128	
  

.23	
  

13	
  

128	
  

.10	
  

May	
  11	
  

40	
  

114	
  

.35	
  

14	
  

114	
  

.12	
  

June	
  11	
  

25	
  

110	
  

.23	
  

13	
  

110	
  

.12	
  

	
  

11.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 12 of 67 PAGEID #: 2506

July	
  11	
  

19	
  

101	
  

.19	
  

Aug	
  11	
  

24	
  

108	
  

.22	
  

Sept	
  11	
  

29	
  

138	
  

.21	
  

9	
  

101	
  

.09	
  

15	
  

108	
  

.14	
  

45	
  

138	
  

.33	
  

Oct	
  11	
  

31	
  

164	
  

.19	
  

Nov	
  11	
  

29	
  

161	
  

.18	
  

Dec	
  11	
  

18	
  

159	
  

.11	
  

Jan	
  12	
  

21	
  

158	
  

.13	
  

Feb	
  12	
  

10	
  

137	
  

.07	
  

Mar	
  12	
  

9	
  

125	
  

.07	
  

29	
  

164	
  

.18	
  

29	
  

161	
  

.18	
  

11	
  

159	
  

.07	
  

30	
  

158	
  

.19	
  

19	
  

137	
  

.14	
  

21	
  

125	
  

.17	
  

Apr	
  12	
  

9	
  

118	
  

.08	
  

May	
  12	
  

11	
  

101	
  

.11	
  

June	
  12	
  

4	
  

91	
  

.04	
  

July	
  12	
  

10	
  

83	
  

.12	
  

Aug	
  12	
  

11	
  

88	
  

.12	
  

Sept	
  12	
  

1	
  

86	
  

.01	
  

31	
  

118	
  

.26	
  

16	
  

101	
  

.16	
  

14	
  

91	
  

.15	
  

18	
  

83	
  

.22	
  

22	
  

88	
  

.25	
  

14	
  

86	
  

.16	
  

Oct	
  12	
  

4	
  

76	
  

.05	
  

15	
  

76	
  

.20	
  

Nov	
  12	
  

17	
  

82	
  

.21	
  

15	
  

82	
  

.18	
  

Dec	
  12	
  

9	
  

72	
  

.12	
  

11	
  

72	
  

.15	
  

Jan	
  13	
  

3	
  

62	
  

.05	
  

11	
  

62	
  

.18	
  

Feb	
  13	
  

4	
  

59	
  

.07	
  

12	
  

59	
  

.21	
  

Mar	
  13	
  

2	
  

60	
  

.03	
  

7	
  

60	
  

.12	
  

	
   	
   Use	
  of	
  Restraints	
   The	
  previous	
  Monitor’s	
  Report	
  discussed	
  the	
  decline	
  in	
  the	
  use	
  of	
   restraints	
  witnessed	
  during	
  that	
  monitoring	
  period	
  and	
  how	
  it	
  could	
  be	
   attributed	
  primarily	
  to	
  decreases	
  in	
  the	
  use	
  of	
  restraints	
  among	
  the	
   female	
  population	
  at	
  Scioto.	
  During	
  the	
  current	
  monitoring	
  period,	
  the	
   average	
  rate	
  of	
  physical	
  restraint	
  use	
  declined	
  across	
  the	
  board,	
  despite	
  a	
   spike	
  in	
  the	
  use	
  of	
  restraints	
  in	
  November	
  2012	
  that	
  mirrored	
  the	
  spike	
  in	
   youth-­‐on-­‐youth	
  violence.	
  Over	
  the	
  past	
  three	
  monitoring	
  periods,	
  the	
   average	
  rate	
  of	
  physical	
  restraint	
  use	
  for	
  the	
  total	
  population	
  was	
  .72,	
  .62	
   and,	
  most	
  recently,	
  .47.	
  This	
  represents	
  a	
  24%	
  decrease	
  from	
  the	
   previous	
  monitoring	
  period.	
  Note	
  that	
  the	
  rate	
  of	
  restraints	
  decreased	
   more	
  sharply	
  than	
  the	
  more	
  modest	
  decreases	
  in	
  youth	
  violence	
  would	
   suggest.	
  	
   	
   Separated	
  by	
  gender,	
  the	
  average	
  rate	
  of	
  physical	
  restraint	
  use	
  for	
  males	
   and	
  females	
  has	
  equalized.	
  Previously,	
  the	
  males’	
  6-­‐month	
  average	
  rates	
   were	
  .56	
  (Oct	
  11-­‐Mar	
  12),	
  .58	
  (April	
  12-­‐Sept	
  12).	
  The	
  average	
  rate	
  for	
  the	
   current	
  monitoring	
  period	
  (Oct	
  12-­‐Mar	
  13)	
  was	
  .47,	
  which	
  represents	
  a	
  

	
  

12.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 13 of 67 PAGEID #: 2507

19%	
  reduction	
  from	
  the	
  previous	
  period.	
  The	
  females’	
  6-­‐month	
  average	
   rates	
  were	
  1.31	
  (Oct	
  11-­‐Mar	
  12),	
  .73	
  (April	
  12-­‐Sept	
  12),	
  and	
  .47	
  for	
  the	
   current	
  monitoring	
  period	
  (Oct	
  12-­‐Mar	
  13),	
  which	
  represents	
  a	
  36%	
   reduction	
  from	
  the	
  previous	
  period.	
  	
   	
   These	
  statistics	
  suggest	
  positive	
  changes	
  are	
  occurring	
  at	
  the	
  facility.	
  For	
   one,	
  the	
  population	
  continues	
  to	
  decrease,	
  which	
  may	
  provide	
  staff	
  with	
   additional	
  time	
  and	
  patience	
  to	
  utilize	
  their	
  verbal	
  strategies	
  to	
  de-­‐ escalate	
  youth	
  who	
  lose	
  control.	
  In	
  addition,	
  the	
  facility’s	
  population	
  of	
   girls	
  with	
  serious	
  mental	
  health	
  issues	
  continues	
  to	
  decline	
  as	
  they	
  are	
   placed	
  in	
  alternative	
  settings.	
  Historically,	
  this	
  group	
  of	
  girls	
  was	
   restrained	
  more	
  often	
  than	
  youth	
  in	
  the	
  general	
  population.	
  	
   	
   	
  

Physical	
  Restraints,	
  October	
  2011	
  through	
  March	
  2013	
  

Month	
  

Total	
  

Males	
  

Females	
  

#	
   ADP	
   rate	
   #	
   ADP	
   rate	
   #	
   ADP	
   rate	
  

Oct	
  11	
   150	
   164	
   .91	
   103	
   128	
   .81	
   47	
   36	
   1.31	
  

Nov	
  11	
   177	
   161	
   1.10	
   111	
   128	
   .87	
   66	
   33	
   2.00	
  

Dec	
  11	
   99	
   159	
   .62	
   49	
   124	
   .40	
   50	
   35	
   1.43	
  

Jan	
  12	
   93	
   158	
   .59	
   61	
   125	
   .48	
   32	
   33	
   .97	
  

Feb	
  12	
   88	
   137	
   .64	
   50	
   106	
   .47	
   38	
   31	
   1.23	
  

Mar	
  12	
   59	
   125	
   .47	
   34	
   97	
   .35	
   25	
   28	
   .89	
  

Apr	
  12	
   94	
   118	
   .80	
   40	
   May	
  12	
   55	
   101	
   .54	
   35	
   Jun	
  12	
   52	
   91	
   .57	
   36	
   July	
  12	
   70	
   83	
   .84	
   60	
   Aug	
  12	
   51	
   88	
   .58	
   48	
   Sep	
  12	
   35	
   86	
   .41	
   34	
  

92	
   .43	
   54	
   77	
   .45	
   20	
   68	
   .53	
   16	
   64	
   .94	
   10	
   72	
   .67	
   3	
   75	
   .45	
   1	
  

26	
   2.08	
   24	
   .83	
   23	
   .70	
   20	
   .50	
   16	
   .19	
   12	
   .08	
  

Oct	
  12	
   27	
   76	
   .36	
   23	
   64	
   .36	
   4	
   12	
   .33	
  
Nov	
  12	
   63	
   82	
   .77	
   56	
   68	
   .82	
   7	
   14	
   .50	
  
Dec	
  12	
   37	
   72	
   .51	
   28	
   58	
   .48	
   9	
   15	
   .60	
  
Jan	
  13	
   36	
   62	
   .58	
   28	
   47	
   .60	
   8	
   16	
   .50	
  
Feb	
  13	
   22	
   59	
   .37	
   18	
   42	
   .43	
   4	
   16	
   .25	
  
Mar	
  13	
   16	
   60	
   .27	
   6	
   43	
   .14	
   10	
   18	
   .56	
   	
   	
   As	
  noted	
  in	
  the	
  Introduction	
  to	
  this	
  report,	
  the	
  functioning	
  and	
   operational	
  practices	
  on	
  the	
  PROGRESS	
  Unit	
  are	
  discussed	
  in	
  a	
  separate	
   document,	
  which	
  is	
  attached	
  to	
  this	
  report.	
  The	
  use	
  of	
  mechanical	
   restraints	
  with	
  Phase	
  I	
  youth	
  continues	
  to	
  be	
  a	
  concern	
  for	
  both	
  the	
  

	
  

13.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 14 of 67 PAGEID #: 2508

Monitors	
  and	
  the	
  Plaintiffs,	
  and	
  discussions	
  about	
  how	
  to	
  mitigate	
  any	
   harmful	
  effects	
  of	
  their	
  use	
  are	
  on-­‐going.	
  	
   	
   Staffing	
   Adequately	
  staffing	
  the	
  facility	
  to	
  ensure	
  youth	
  and	
  staff	
  safety	
  and	
  youth	
   access	
  to	
  programming	
  has	
  been	
  an	
  ongoing	
  challenge	
  for	
  Scioto.	
   However,	
  recently,	
  the	
  various	
  strategies	
  enacted	
  to	
  ensure	
  adequate	
   numbers	
  of	
  direct	
  care	
  staff	
  report	
  to	
  work	
  have	
  begun	
  to	
  reap	
  dividends.	
  	
   	
   As	
  noted	
  in	
  previous	
  Monitor’s	
  Reports,	
  the	
  facility	
  began	
  to	
  hold	
   Involuntary	
  Disability	
  Separation	
  (IDS)	
  hearings	
  in	
  January	
  2012.	
  These	
   hearings	
  vacated	
  positions	
  historically	
  filled	
  by	
  staff	
  who	
  had	
  exhausted	
   their	
  leave	
  benefits,	
  positions	
  which	
  could	
  then	
  be	
  filled	
  by	
  someone	
  who	
   was	
  willing	
  and	
  able	
  to	
  report	
  to	
  work.	
  The	
  commitment	
  to	
  ensure	
  that	
   direct	
  care	
  staff	
  positions	
  are	
  functionally	
  occupied	
  has	
  continued.	
  During	
   the	
  current	
  monitoring	
  period,	
  DYS	
  held	
  18	
  IDS	
  hearings	
  (and	
  won	
  16	
  of	
   those).	
  	
   	
   In	
  addition,	
  DYS	
  closed	
  one	
  girls’	
  (Hunter)	
  and	
  one	
  boys’	
  (Carver)	
  general	
   population	
  unit.	
  While	
  there	
  were	
  several	
  factors	
  underlying	
  this	
  decision,	
   one	
  of	
  them	
  was	
  to	
  alleviate	
  the	
  chronic	
  staff	
  shortages	
  that	
  had	
  plagued	
   the	
  facility	
  for	
  years.	
  Hunter	
  Unit	
  was	
  closed	
  at	
  the	
  end	
  of	
  June	
  2012,	
  and	
   more	
  recently,	
  Carver	
  Unit	
  was	
  closed	
  in	
  December	
  2012.	
  Hunter	
  staff	
  bid	
   on	
  and	
  were	
  placed	
  on	
  other	
  posts;	
  Carver	
  staff	
  were	
  placed	
  in	
  the	
  relief	
   pool	
  to	
  assist	
  with	
  staff	
  coverage	
  in	
  other	
  areas	
  of	
  the	
  facility.	
  	
  	
   	
   Both	
  Hunter	
  and	
  Carver	
  staff	
  positions	
  are	
  still	
  considered	
  in	
  the	
  facility’s	
   staffing	
  allocation,	
  which	
  makes	
  the	
  facility’s	
  data	
  on	
  staff	
  vacancies	
  and	
   overtime	
  difficult	
  to	
  interpret.	
  Furthermore,	
  the	
  facility’s	
  population	
  is	
   very	
  low,	
  but	
  the	
  number	
  of	
  mandated	
  positions	
  allocated	
  to	
  each	
  unit	
   via	
  the	
  Pick-­‐A-­‐Post	
  collective	
  bargaining	
  agreement	
  has	
  not	
  yet	
  been	
   adjusted.	
  As	
  a	
  result,	
  the	
  facility	
  is	
  required	
  to	
  call	
  staff	
  in	
  and	
  pay	
  them	
   overtime	
  to	
  cover	
  a	
  shortage,	
  even	
  though	
  the	
  staff-­‐to-­‐youth	
  ratio	
  would	
   fall	
  within	
  the	
  generally	
  accepted	
  practice.	
  	
   	
   For	
  all	
  of	
  these	
  reasons,	
  on	
  paper,	
  the	
  Scioto	
  staffing	
  situation	
  appears	
  to	
   be	
  worse	
  than	
  it	
  is.	
  Except	
  for	
  one	
  situation	
  in	
  November	
  where	
  youth	
   were	
  confined	
  to	
  their	
  rooms	
  for	
  43	
  minutes	
  during	
  the	
  normal	
  wake	
  up	
   and	
  hygiene	
  routine,	
  staff	
  shortages	
  have	
  not	
  resulted	
  in	
  a	
  lack	
  of	
  access	
   to	
  youth	
  programming	
  or	
  services.	
  As	
  discussed	
  in	
  the	
  previous	
  section,	
   youth-­‐on-­‐youth	
  violence	
  remains	
  low.	
  Perhaps	
  most	
  telling	
  are	
  the	
   statistics	
  related	
  to	
  the	
  number	
  of	
  staff	
  off	
  work—during	
  the	
  previous	
   monitoring	
  period,	
  a	
  whopping	
  47	
  staff	
  on	
  the	
  roster	
  were	
  not	
  reporting	
   to	
  work.	
  More	
  recently,	
  that	
  number	
  hovers	
  around	
  6	
  staff.	
  	
   	
   The	
  facility	
  continues	
  to	
  address	
  the	
  factors	
  that	
  result	
  in	
  the	
  abuse	
  of	
  the	
   time/attendance	
  policies.	
  Furthermore,	
  given	
  that	
  most	
  of	
  the	
  turnover	
  

	
  

14.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 15 of 67 PAGEID #: 2509

occurs	
  among	
  interim	
  staff	
  (who	
  work	
  full	
  time,	
  but	
  who	
  do	
  not	
  receive	
   benefits),	
  stabilizing	
  this	
  segment	
  of	
  the	
  workforce	
  continues	
  to	
  be	
  a	
   priority.	
  New	
  initiatives	
  to	
  recognize	
  high-­‐performing	
  staff	
  and	
  to	
  fortify	
   the	
  mentoring	
  relationships	
  created	
  via	
  On-­‐The-­‐Job	
  training	
  are	
  also	
   underway.	
  	
   	
   Investigations	
  Related	
  to	
  Use	
  of	
  Force,	
  Seclusion	
  or	
  Abusive	
  Practices	
   Over	
  the	
  past	
  six	
  months,	
  50	
  allegations	
  of	
  excessive	
  or	
  inappropriate	
   uses	
  of	
  force,	
  verbal	
  or	
  other	
  misconduct	
  were	
  investigated,	
  13	
  by	
  the	
   Chief	
  Inspector’s	
  Office	
  (CIO)	
  and	
  37	
  by	
  a	
  facility-­‐based	
  investigator.	
  This	
   is	
  a	
  significant	
  increase	
  over	
  the	
  previous	
  six-­‐month	
  period,	
  when	
  28	
   investigations	
  were	
  completed.	
  [During	
  the	
  previous	
  monitoring	
  period,	
  a	
   large	
  number	
  of	
  investigations	
  were	
  “pending”	
  which	
  may	
  account	
  for	
  the	
   difference	
  in	
  the	
  number	
  of	
  investigations	
  completed	
  and	
  available	
  for	
   review.]	
   	
   Across	
  the	
  50	
  investigations,	
  18	
  were	
  substantiated	
  (19%	
  of	
  the	
  local	
   investigations	
  and	
  85%	
  of	
  the	
  CIO	
  investigations,	
  36%	
  combined).	
  Among	
   them:	
  
• 9	
  (50%)	
  involved	
  an	
  unsanctioned	
  restraint	
  technique	
  (e.g.,	
  elbow	
   in	
  the	
  youth’s	
  face;	
  hooking	
  an	
  arm	
  around	
  the	
  youth’s	
  neck;	
   unsafe	
  take	
  down;	
  laying	
  on	
  a	
  youth	
  who	
  was	
  prone;	
  dragging	
  a	
   youth	
  by	
  his	
  shirt);	
  
• 3	
  (17%)	
  involved	
  an	
  inappropriate	
  comment	
  or	
  behavior	
  (e.g.,	
  a	
   comment	
  about	
  a	
  youth’s	
  mother;	
  using	
  gang-­‐related	
  hand	
   signals;	
  backing	
  into	
  a	
  youth’s	
  room	
  in	
  a	
  suggestive	
  manner);	
  
• 2	
  (11%)	
  involved	
  physical	
  abuse	
  or	
  an	
  abusive	
  practice	
  (e.g.,	
   exchanging	
  punches	
  with	
  a	
  youth;	
  cutting	
  off	
  a	
  youth’s	
  water	
  and	
   vent);	
  and	
  
• 4	
  (22%)	
  involved	
  improper	
  procedures	
  (e.g.,	
  failing	
  to	
  use	
  the	
   handheld	
  camera	
  and	
  notifying	
  Operations	
  about	
  a	
  youth’s	
   refusal	
  to	
  remove	
  restraints;	
  failure	
  to	
  report	
  a	
  fight	
  or	
  use	
  of	
   force;	
  leaving	
  post	
  without	
  relief;	
  bringing	
  a	
  personal	
  cell	
  phone	
   into	
  the	
  facility;	
  inappropriate	
  contact	
  with	
  youth	
  via	
  FaceBook).	
  	
   	
  
As	
  noted	
  in	
  prior	
  reports,	
  the	
  poor	
  quality	
  of	
  the	
  local	
  investigations	
   creates	
  concern	
  about	
  the	
  extent	
  to	
  which	
  staff	
  who	
  use	
  force	
  improperly	
   or	
  otherwise	
  mistreat	
  youth	
  can	
  be	
  accurately	
  identified	
  via	
  the	
   investigation	
  process.	
  These	
  concerns	
  are	
  discussed	
  in	
  detail	
  in	
  III.A.5,	
   below,	
  but	
  are	
  relevant	
  to	
  this	
  provision	
  insofar	
  as	
  a	
  poorly	
  constructed	
   investigation	
  does	
  not	
  adequately	
  protect	
  youth	
  from	
  harm	
  at	
  the	
  hands	
   of	
  staff,	
  as	
  required	
  by	
  this	
  provision.	
   	
   Allegations	
  of	
  Inappropriate	
  Relationships	
   Each	
  of	
  the	
  previous	
  Monitor’s	
  reports	
  discussed	
  the	
  problem	
  of	
   allegations	
  of	
  sexualized	
  comments	
  by	
  staff	
  and	
  inappropriate	
   relationships	
  between	
  Scioto	
  staff	
  and	
  youth.	
  Historically,	
  the	
  usual	
  tools	
  

	
  

15.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 16 of 67 PAGEID #: 2510

to	
  combat	
  this	
  type	
  of	
  problem	
  (e.g.,	
  staff	
  training,	
  a	
  robust	
  grievance	
   process,	
  and	
  procedures	
  for	
  investigating	
  allegations)	
  have	
  not	
  been	
   sufficient,	
  as	
  youth	
  continued	
  to	
  report	
  inappropriate	
  comments	
  and	
   behaviors	
  by	
  staff	
  to	
  the	
  Monitors,	
  DOJ	
  attorneys	
  and	
  facility	
  staff.	
  	
   	
   For	
  the	
  first	
  time	
  since	
  the	
  Monitor	
  became	
  involved	
  in	
  the	
  case,	
  none	
  of	
   the	
  girls	
  interviewed	
  reported	
  an	
  inappropriate	
  relationship	
  or	
  sexually	
   inappropriate	
  comments	
  or	
  conduct	
  to	
  either	
  the	
  Monitors	
  or	
  the	
  DOJ	
   Attorney	
  (all	
  but	
  two	
  of	
  the	
  girls	
  in	
  custody	
  were	
  interviewed	
  by	
  one	
  or	
   the	
  other).	
  There	
  were	
  a	
  few	
  grievances	
  about	
  sexualized	
  comments	
  by	
   female	
  staff	
  to	
  male	
  residents	
  (none	
  of	
  which	
  were	
  found	
  to	
  have	
  merit	
   by	
  the	
  facility’s	
  Grievance	
  Coordinator)	
  and	
  one	
  grievance	
  about	
   sexualized	
  behavior	
  by	
  female	
  staff	
  toward	
  a	
  male	
  resident	
  (which	
  was	
   sustained;	
  involved	
  a	
  female	
  staff	
  backing	
  into	
  a	
  youth’s	
  room	
  in	
  a	
   suggestive	
  manner).	
  Otherwise,	
  neither	
  the	
  Monitor	
  nor	
  the	
  facility	
  has	
   been	
  made	
  aware	
  of	
  continued	
  problems	
  in	
  this	
  area.	
   	
   However,	
  a	
  recent	
  report	
  by	
  the	
  Bureau	
  of	
  Justice	
  Statistics	
  (Beck,	
  A.,	
  D.	
   Cantor,	
  J.	
  Hartge	
  and	
  T.	
  Smith	
  (2013)	
  Sexual	
  Victimization	
  in	
  Juvenile	
   Facilities	
  Reported	
  by	
  Youth,	
  2012.)	
  ranked	
  Ohio,	
  and	
  Scioto	
  in	
  particular,	
   among	
  the	
  highest	
  in	
  the	
  nation	
  for	
  sexual	
  assault	
  committed	
  against	
   incarcerated	
  youth,	
  suggesting	
  that	
  serious	
  problems	
  remain.	
  At	
  the	
  time	
   this	
  report	
  was	
  issued,	
  the	
  Governor	
  Kasich	
  had	
  convened	
  an	
  interagency	
   Task	
  Force	
  to	
  develop	
  immediate,	
  short	
  and	
  long-­‐term	
  remedies	
  to	
   address	
  the	
  problem.	
  Progress	
  implementing	
  those	
  remedies	
  will	
  be	
   reviewed	
  in	
  subsequent	
  Monitor’s	
  Reports.	
  	
   	
   Verbal	
  Mistreatment	
   Although	
  no	
  new	
  allegations	
  of	
  inappropriate	
  relationships	
  or	
  sexualized	
   language	
  or	
  behaviors	
  were	
  reported	
  to	
  the	
  facility,	
  the	
  Monitor	
  or	
  the	
   DOJ	
  Attorney,	
  youth	
  continue	
  to	
  report	
  that	
  staff	
  provoke,	
  antagonize,	
   belittle	
  or	
  otherwise	
  interact	
  in	
  unprofessional,	
  counterproductive	
  and	
   hurtful	
  ways	
  with	
  youth.	
  	
   	
   Also	
  troubling	
  is	
  youth’s	
  continued	
  belief	
  that	
  neither	
  the	
  grievance	
   process	
  nor	
  the	
  investigation	
  process	
  can	
  protect	
  them	
  because	
  neither	
   will	
  result	
  in	
  staff	
  being	
  held	
  accountable	
  for	
  their	
  behavior.	
  Many	
  of	
  the	
   youth	
  interviewed	
  by	
  the	
  DOJ	
  attorney	
  reported	
  concerns	
  about	
  a	
   number	
  of	
  staff	
  who	
  appear	
  to	
  act	
  with	
  impunity,	
  who	
  treat	
  the	
  youth	
   poorly	
  and	
  then	
  taunt	
  the	
  youth	
  to	
  write	
  a	
  grievance	
  because	
  “nothing	
   will	
  happen.”	
  When	
  youth	
  gave	
  examples	
  of	
  poor	
  treatment	
  by	
  staff,	
  the	
   interviewers	
  asked	
  if	
  they	
  had	
  reported	
  the	
  incident	
  to	
  anyone	
  at	
  the	
   facility.	
  In	
  some	
  cases	
  they	
  had,	
  in	
  other	
  cases	
  they	
  hadn’t,	
  but	
  in	
  all	
  cases	
   their	
  experience	
  suggested	
  to	
  them	
  that	
  it	
  would	
  not	
  change	
  the	
   environment	
  for	
  the	
  better.	
  While	
  the	
  Monitor	
  recognizes	
  that	
  youth	
  are	
   not	
  always	
  truthful	
  when	
  interviewed,	
  the	
  similarities	
  in	
  their	
  descriptions	
   of	
  staff’s	
  bravado	
  suggest	
  that	
  the	
  facility	
  needs	
  to	
  address	
  the	
  manner	
  in	
  

	
  

16.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 17 of 67 PAGEID #: 2511

which	
  some	
  staff	
  relate	
  to	
  the	
  youth	
  in	
  their	
  care.	
  	
   	
   However,	
  from	
  the	
  discussions	
  with	
  youth,	
  it	
  appears	
  that	
  the	
  problem	
  is	
   not	
  the	
  lack	
  of	
  a	
  forum	
  to	
  voice	
  their	
  concerns	
  (all	
  of	
  the	
  youth	
  gave	
  the	
   Grievance	
  process	
  high	
  marks),	
  but	
  rather	
  in	
  their	
  belief	
  that	
  the	
  facility	
   will	
  not	
  act	
  on	
  their	
  complaints.	
  The	
  delays	
  in	
  assigning	
  and	
  completing	
   local	
  investigations	
  of	
  their	
  complaints	
  and	
  the	
  poor	
  quality	
  of	
  the	
   investigations	
  (which	
  rarely	
  lead	
  to	
  a	
  sustained	
  finding)	
  likely	
  contribute	
   to	
  this	
  perception.	
  Improving	
  the	
  quality	
  of	
  the	
  local	
  investigation	
  process	
   may	
  create	
  additional	
  opportunities	
  to	
  hold	
  staff	
  accountable	
  in	
  a	
  way	
   that	
  may	
  be	
  persuasive	
  to	
  staff	
  who	
  persist	
  in	
  acting	
  with	
  impunity,	
  and	
   may	
  help	
  youth	
  to	
  gain	
  confidence	
  in	
  the	
  system.	
  	
  	
  	
   	
   Tools	
  to	
  Ensure	
  Staff	
  Accountability	
   The	
  DOJ	
  launched	
  its	
  investigation	
  at	
  a	
  time	
  when	
  over	
  10%	
  of	
  the	
   facility’s	
  staff	
  were	
  under	
  indictment	
  for	
  physical	
  or	
  sexual	
  abuse	
  of	
   Scioto	
  youth.	
  Since	
  then,	
  the	
  DYS	
  has	
  enacted	
  a	
  number	
  of	
  measures	
   intended	
  to	
  prevent	
  the	
  reoccurrence	
  of	
  such	
  a	
  tragedy.	
  Some	
  of	
  these	
   measures	
  have	
  been	
  well	
  implemented	
  and	
  definitely	
  improve	
  the	
  State’s	
   ability	
  to	
  protect	
  youth	
  from	
  harm	
  at	
  the	
  hands	
  of	
  staff.	
  Among	
  them:	
  
• Additional	
  stationary	
  and	
  hand-­‐held	
  video	
  cameras;	
   • A	
  robust	
  grievance	
  process;	
   • Revised	
  policies	
  and	
  procedures;	
  and	
   • Investigations	
  by	
  the	
  Chief	
  Inspector’s	
  Office.	
   Other	
  measures	
  are	
  less	
  well-­‐developed,	
  but	
  if	
  fully	
  implemented,	
  could	
   add	
  additional	
  protection:	
   • Compliance	
  with	
  PREA	
  standards;	
  
o In	
  particular,	
  the	
  facility	
  should	
  develop	
  guidelines	
  to	
   prohibit	
  staff	
  from	
  being	
  alone	
  with	
  youth	
  in	
  places	
  that	
   do	
  not	
  have	
  either	
  camera	
  surveillance	
  or	
  natural	
   surveillance	
  opportunities.	
  The	
  DYS	
  has	
  already	
  made	
   substantive	
  efforts	
  to	
  move	
  toward	
  compliance	
  with	
  PREA	
   standards	
  (e.g.,	
  policy	
  review	
  and	
  revision;	
  staff	
  training;	
   youth	
  education).	
  Scioto	
  is	
  scheduled	
  for	
  a	
  “Vulnerability	
   Assessment”	
  before	
  the	
  end	
  of	
  2013,	
  which	
  should	
   indicate	
  the	
  extent	
  to	
  which	
  PREA	
  standards	
  are	
  being	
   met.	
  	
  
• “Healthy	
  Boundaries,	
  Healthy	
  Relationships”	
  group;	
  	
   o During	
  the	
  first	
  half	
  of	
  the	
  monitoring	
  period,	
  the	
  facility	
   delivered	
  the	
  second	
  cycle	
  of	
  its	
  6-­‐week	
  “Healthy	
   Boundaries	
  and	
  Relationships”	
  group,	
  co-­‐facilitated	
  by	
  a	
   contracted	
  provider	
  and	
  the	
  girls’	
  social	
  worker.	
  Progress	
   notes	
  for	
  the	
  August-­‐October	
  2012	
  group	
  revealed	
  an	
   appropriate	
  range	
  of	
  topics	
  (e.g.,	
  characteristics	
  of	
   healthy/unhealthy	
  relationships,	
  boundaries,	
   inappropriate	
  relationships	
  due	
  to	
  age	
  or	
  roles,	
  grooming	
   behaviors	
  to	
  encourage	
  girls	
  to	
  acquiesce,	
  etc.).	
  It	
  appears	
  

	
  

17.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 18 of 67 PAGEID #: 2512

this	
  group	
  is	
  held	
  only	
  twice	
  per	
  year	
  (once	
  in	
  the	
  previous	
   monitoring	
  period,	
  once	
  in	
  the	
  current	
  monitoring	
  period).	
   Positive	
  reviews	
  from	
  the	
  girls	
  who	
  have	
  attended	
  the	
   program,	
  and	
  the	
  unique	
  forum	
  for	
  identifying	
  potentially	
   inappropriate	
  relationships	
  among	
  youth	
  and	
  staff,	
   suggest	
  that	
  the	
  group	
  should	
  be	
  delivered	
  continuously.	
   • Forum	
  during	
  Interdisciplinary	
  Team	
  (IDT)	
  meetings;	
   o The	
  topics	
  of	
  over-­‐familiarization	
  and	
  boundary	
  issues	
   between	
  staff	
  and	
  youth	
  were	
  incorporated	
  into	
  the	
  staff	
   portion	
  of	
  the	
  weekly	
  Interdisciplinary	
  Team	
  (IDT)	
   meetings.	
  The	
  facility	
  provided	
  IDT	
  minutes	
  from	
  six	
   meetings	
  that	
  occurred	
  during	
  the	
  current	
  monitoring	
   period	
  to	
  demonstrate	
  the	
  extent	
  to	
  which	
  this	
  strategy	
   had	
  been	
  implemented.	
  The	
  topic	
  was	
  broadly	
  defined	
  to	
   include	
  youth	
  who	
  may	
  be	
  touching	
  each	
  other	
   inappropriately	
  and	
  youth	
  who	
  seem	
  to	
  be	
  developing	
   crushes	
  on	
  staff	
  and	
  behaving	
  inappropriately.	
  For	
  the	
   most	
  part,	
  the	
  conversations	
  revolved	
  around	
  youth	
   having	
  inappropriate	
  relationships	
  with	
  each	
  other	
  and	
   little	
  evidence	
  was	
  available	
  to	
  establish	
  that	
  staff-­‐youth	
   boundaries	
  were	
  discussed	
  with	
  staff,	
  even	
  when	
  there	
   were	
  clear	
  indicators	
  of	
  such	
  dynamics	
  (e.g.,	
  two	
  female	
   youth	
  were	
  arguing	
  because	
  they	
  both	
  had	
  a	
  crush	
  on	
  the	
   same	
  YS).	
  While	
  the	
  forum	
  for	
  these	
  discussions	
  has	
   clearly	
  been	
  established	
  (it	
  is	
  a	
  standing	
  agenda	
  item	
  on	
   the	
  IDT	
  minutes),	
  the	
  discussions	
  appear	
  to	
  lack	
  substance	
   or	
  pointed	
  conversations	
  about	
  staff’s	
  involvement	
  in	
   these	
  situations.	
  Two	
  recent	
  investigations	
  of	
   inappropriate	
  relationships	
  between	
  youth	
  and	
  staff	
   suggested	
  that	
  several	
  staff	
  had	
  concerns	
  about	
  the	
  YSs’	
   poor	
  boundaries	
  and	
  inappropriate	
  relationships	
  with	
  the	
   alleged	
  victims,	
  yet	
  none	
  of	
  them	
  addressed	
  the	
  matter	
  in	
   the	
  Unit’s	
  IDT	
  meetings	
  or	
  otherwise	
  reported	
  their	
   concerns.	
  	
   While	
  these	
  measures	
  are	
  surely	
  a	
  step	
  in	
  the	
  right	
  direction,	
  they	
   nonetheless	
  fall	
  short	
  of	
  substantial	
  compliance	
  with	
  the	
  portion	
  of	
  this	
   provision	
  related	
  to	
  protecting	
  youth	
  from	
  harm	
  at	
  the	
  hands	
  of	
  staff.	
   During	
  a	
  recent	
  conference	
  call	
  between	
  the	
  State,	
  DOJ	
  and	
  the	
  Monitor,	
   the	
  DYS	
  agreed	
  to	
  pursue	
  the	
  following	
  strategies	
  in	
  order	
  to	
  more	
  fully	
   develop	
  its	
  process	
  for	
  staff	
  accountability:	
   • Reconfiguring	
  the	
  local	
  investigations	
  process	
  by,	
  for	
  starters,	
   seeking	
  to	
  create	
  a	
  position	
  for	
  a	
  dedicated	
  facility-­‐based	
   investigator;	
  	
   o As	
  noted	
  throughout	
  this	
  report,	
  the	
  poor	
  quality	
  of	
  the	
   local	
  investigations	
  is	
  the	
  weak	
  link	
  in	
  the	
  system.	
   Without	
  a	
  solid	
  mechanism	
  to	
  determine	
  the	
  veracity	
  of	
   youth’s	
  allegations	
  and	
  to	
  hold	
  staff	
  accountable	
  for	
  

	
  

18.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 19 of 67 PAGEID #: 2513

Recommendations	
  
Sources	
  of	
   Information	
  

violating	
  policy,	
  the	
  culture	
  change	
  that	
  the	
  DYS	
  seeks	
  to	
   catalyze	
  will	
  be	
  impossible	
  to	
  achieve.	
  	
   • Fortifying	
  the	
  policy	
  language	
  and	
  enforcement	
  of	
  mandates	
  for	
   staff	
  to	
  uphold	
  the	
  standards	
  of	
  conduct	
  and	
  to	
  report	
  instances	
   when	
  they	
  observe	
  other	
  staff	
  not	
  upholding	
  those	
  standards.	
   o Once	
  established	
  in	
  policy,	
  compliance	
  with	
  these	
   standards	
  needs	
  to	
  be	
  addressed	
  through	
  the	
   investigations	
  into	
  these	
  peripheral	
  issues	
  that	
  emerge	
   while	
  investigating	
  an	
  allegation	
  of	
  staff	
  mistreatment.	
  	
   	
   Until	
  the	
  DYS	
  has	
  established	
  a	
  dependable	
  mechanism	
  to	
  investigate	
  and	
   hold	
  staff	
  accountable	
  for	
  their	
  failure	
  to	
  protect	
  youth	
  from	
  harm,	
  and	
   for	
  the	
  instances	
  in	
  which	
  they,	
  themselves,	
  are	
  the	
  source	
  of	
  harm,	
  the	
   DYS	
  will	
  not	
  be	
  able	
  to	
  achieve	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Reach	
  substantial	
  compliance	
  with	
  provisions	
  related	
  to	
   seclusion,	
  investigations	
  of	
  abuse	
  and	
  neglect,	
  grievances	
  and	
   programming.	
  	
  
2. Implement	
  and	
  assess	
  the	
  effectiveness	
  of	
  interventions	
  that	
   target	
  the	
  underlying	
  causes	
  and	
  patterns	
  of	
  youth-­‐on-­‐staff	
   violence.	
  Make	
  modifications	
  as	
  necessary	
  to	
  effect	
  substantial	
   reductions	
  in	
  the	
  rate	
  of	
  youth-­‐on-­‐staff	
  assaults.	
  	
  
3. Address	
  the	
  poor	
  quality	
  of	
  local	
  investigations	
  to	
  improve	
  the	
   ability	
  to	
  protect	
  youth	
  from	
  harm	
  related	
  to	
  inappropriate	
  uses	
   of	
  force	
  and	
  verbal	
  abuse	
  (e.g.,	
  provoking,	
  taunting,	
  belittling	
  and	
   otherwise	
  disrespecting	
  youth).	
  	
  
4. Improve	
  staff	
  accountability	
  measures	
  to	
  ensure	
  that	
  all	
  staff	
  are	
   held	
  responsible	
  not	
  just	
  for	
  maintaining	
  the	
  code	
  of	
  conduct,	
  but	
   for	
  reporting	
  their	
  concerns	
  about	
  staff	
  who	
  fail	
  to	
  do	
  so.	
  	
  
• Self-­‐assessment	
  data	
  and	
  its	
  interpretation	
  for	
  III.A.1,	
  prepared	
  at	
   my	
  request	
  
• Interviews	
  with	
  Facility	
  Superintendent	
  and	
  Deputies,	
  along	
  with	
   staff	
  from	
  DYS	
  Central	
  Office	
  
• Monthly	
  Superintendent’s	
  Reports,	
  October	
  2012	
  through	
  March	
   2013	
  
• Monitor’s	
  Monthly	
  Data,	
  Scioto	
  Male	
  and	
  Female	
  Population,	
   2012	
  and	
  2013,	
  to	
  date	
  
• CIO	
  and	
  local	
  investigation	
  log,	
  October	
  2012	
  through	
  March	
   2013	
  
• CIO	
  and	
  local	
  investigations	
  completed	
  between	
  October	
  2012	
   and	
  March	
  2013	
  
• Description	
  and	
  Group	
  Notes	
  from	
  “Healthy	
  Relationships	
  and	
   Boundaries”	
  groups,	
  August	
  through	
  October	
  2012	
  
• IDT	
  Minutes	
  from	
  October	
  2012	
  through	
  March	
  2013	
  that	
   document	
  conversations	
  surrounding	
  boundary	
  issues	
  between	
  

	
  

19.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 20 of 67 PAGEID #: 2514

youth	
  and	
  staff	
   • Interviews	
  with	
  youth	
  housed	
  at	
  Scioto	
  between	
  March	
  24-­‐26,	
  
2013,	
  in	
  consultation	
  with	
  other	
  Monitors	
  and	
  the	
  DOJ	
  attorney	
   who	
  interviewed	
  approximately	
  20	
  youth	
  housed	
  at	
  the	
  facility	
  	
   • Review	
  of	
  13	
  CIO	
  investigations	
  completed	
  since	
  October	
  2012	
   (100%	
  of	
  total)	
   • Review	
  of	
  37	
  investigations	
  conducted	
  by	
  Scioto	
  staff	
  since	
   October	
  2012	
  (100%	
  of	
  total)	
  

	
  

	
  

	
  

	
  

	
  

20.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 21 of 67 PAGEID #: 2515

III.A.3	
  Seclusion.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
  practices	
  so	
   that	
  staff	
  use	
  seclusion	
  only	
  in	
  accordance	
  with	
  policy	
  and	
  in	
  an	
  appropriate	
  manner	
  and	
  so	
  that	
   staff	
  document	
  fully	
  the	
  use	
  and	
  administrative	
  review	
  of	
  any	
  imposition	
  of	
  seclusion,	
  including	
   the	
  placing	
  of	
  youth	
  in	
  their	
  rooms	
  outside	
  normal	
  sleeping	
  hours.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Although	
  the	
  facility	
  provided	
  a	
  large	
  volume	
  of	
  data	
  on	
  the	
  use	
  of	
   seclusion	
  at	
  the	
  Monitor’s	
  request,	
  its	
  interpretation	
  was	
  challenging	
  for	
   a	
  number	
  of	
  reasons.	
  First,	
  the	
  facility	
  had	
  yet	
  another	
  change	
  in	
   Superintendent	
  and	
  thus	
  the	
  sense	
  of	
  “starting	
  over”	
  with	
  regard	
  to	
  the	
   role	
  that	
  seclusion	
  would	
  play	
  in	
  the	
  facility’s	
  disciplinary	
  process	
  was	
   predominant.	
  Second,	
  the	
  IRAV	
  policy	
  and	
  Sanctions	
  grid	
  underwent	
  a	
   major	
  transformation	
  at	
  the	
  end	
  of	
  the	
  current	
  monitoring	
  period.	
   Although	
  its	
  formal	
  implementation	
  did	
  not	
  occur	
  until	
  April	
  2013,	
  just	
   after	
  the	
  monitoring	
  period	
  ended,	
  conversations	
  with	
  DYS	
   Administrators	
  suggested	
  that	
  in	
  some	
  places,	
  the	
  reforms	
  began	
  to	
  seep	
   into	
  the	
  facility’s	
  practices	
  even	
  in	
  advance	
  of	
  the	
  policy’s	
  formal	
   implementation.	
  Both	
  of	
  these	
  changes	
  are	
  very	
  positive	
  and	
  the	
   Monitor	
  anticipates	
  significant	
  changes	
  to	
  the	
  use	
  of	
  seclusion	
  in	
  the	
   upcoming	
  monitoring	
  period	
  (April	
  through	
  September	
  2013).	
  	
   	
   In	
  terms	
  of	
  Quality	
  Assurance,	
  the	
  facility	
  has	
  multiple	
  tools	
  at	
  its	
   disposal.	
  First,	
  each	
  month,	
  the	
  Facility	
  Superintendent	
  is	
  required	
  to	
   report	
  seclusion	
  hours	
  in	
  the	
  Superintendent’s	
  Monthly	
  Report	
  and	
  must	
   explain	
  any	
  increases	
  or	
  decreases	
  in	
  the	
  various	
  categories	
  of	
  seclusion.	
   These	
  explanations	
  generally	
  connect	
  the	
  consumption	
  of	
  seclusion	
   hours	
  to	
  the	
  number	
  of	
  AOV	
  and	
  the	
  number	
  of	
  youth	
  involved,	
  but	
  do	
   not	
  look	
  at	
  whether	
  the	
  seclusion	
  procedures,	
  themselves,	
  were	
  properly	
   implemented.	
  	
   	
   Second,	
  the	
  Central	
  Office’s	
  Facility	
  Resource	
  Administrator	
  (FRA)	
   reviews	
  the	
  use	
  of	
  seclusion	
  on	
  a	
  monthly	
  basis	
  and	
  discusses	
  any	
   procedural	
  problems	
  (e.g.,	
  exceeding	
  the	
  maximum	
  length	
  of	
  stay;	
  failing	
   to	
  make	
  safety	
  and	
  welfare	
  checks	
  at	
  the	
  required	
  intervals).	
  For	
  the	
  first	
   three	
  months	
  of	
  the	
  monitoring	
  period,	
  the	
  FRA	
  noted	
  a	
  variety	
  of	
   deficiencies	
  in	
  the	
  documentation	
  (e.g.,	
  lack	
  of	
  supervisory	
  approval	
  for	
   continuation	
  or	
  release,	
  lack	
  of	
  information	
  regarding	
  the	
  reason	
  for	
   seclusion,	
  exact	
  15-­‐minute	
  increments	
  on	
  the	
  monitoring	
  logs).	
  In	
   addition,	
  the	
  FRA	
  noted	
  that	
  large	
  proportions	
  of	
  youth	
  were	
  being	
  held	
   in	
  pre-­‐hearing	
  seclusion	
  for	
  the	
  maximum	
  allowable	
  time,	
  even	
  when	
  an	
   Intervention	
  Hearing	
  was	
  not	
  utilized.	
  The	
  FRA	
  encouraged	
  the	
  facility	
  to	
   hold	
  the	
  hearings	
  more	
  quickly	
  so	
  that	
  the	
  length	
  of	
  stay	
  in	
  pre-­‐hearing	
   confinement	
  could	
  be	
  reduced.	
  By	
  February	
  2013,	
  these	
  deficiencies	
  had	
   been	
  corrected,	
  which	
  suggests	
  that	
  the	
  FRA	
  review	
  and	
  communication	
   with	
  the	
  Direct	
  Deputy,	
  and	
  others,	
  is	
  an	
  effective	
  avenue	
  for	
  program	
   improvements.	
   	
  

	
  

21.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 22 of 67 PAGEID #: 2516

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Finally,	
  via	
  the	
  S.H.	
  stipulation,	
  the	
  facility	
  designed	
  a	
  QA	
  process	
  to	
   monitor	
  the	
  implementation	
  of	
  the	
  IRAV	
  and	
  sanctions	
  grid	
  revisions.	
   Unfortunately,	
  the	
  rollout	
  of	
  the	
  policies	
  did	
  not	
  coincide	
  with	
  the	
   monitoring	
  period	
  for	
  this	
  report,	
  and	
  thus	
  complete	
  results	
  are	
  not	
   available.	
  However,	
  the	
  first	
  month	
  of	
  the	
  revised	
  IRAV’s	
  implementation	
   (April	
  2013)	
  produced	
  some	
  encouraging	
  reductions.	
  To	
  maximize	
  its	
   effectiveness,	
  the	
  QA	
  process	
  should	
  be	
  anchored	
  to	
  a	
  set	
  of	
  standards	
   that	
  clearly	
  articulate	
  DYS’	
  objectives	
  regarding	
  reducing	
  the	
  use	
  of	
   seclusion.	
  	
  

Regular	
  Seclusion	
   Regular	
  seclusion	
  is	
  a	
  time-­‐out,	
  or	
  short	
  period	
  of	
  isolation	
  imposed	
  by	
   direct	
  care	
  staff	
  in	
  response	
  to	
  mid-­‐level,	
  non-­‐violent	
  misconduct	
  such	
  as	
   throwing	
  things,	
  property	
  damage,	
  storming	
  around	
  the	
  unit,	
  etc.	
  Staff	
   must	
  obtain	
  approval	
  from	
  a	
  supervisor	
  before	
  placing	
  a	
  youth	
  in	
  regular	
   seclusion	
  and	
  again	
  at	
  the	
  one-­‐hour	
  mark.	
  If	
  the	
  youth	
  remains	
  in	
   seclusion	
  at	
  the	
  three-­‐hour	
  mark,	
  the	
  supervisor	
  must	
  document	
  in	
   writing	
  the	
  reason	
  that	
  seclusion	
  remains	
  necessary.	
   	
   During	
  the	
  2nd	
  monitoring	
  period	
  (October	
  2011-­‐March	
  2012),	
  regular	
   seclusion	
  was	
  used	
  at	
  a	
  rate	
  of	
  .43	
  (rate	
  =	
  #	
  seclusion	
  episodes/ADP).	
   This	
  rate	
  increased	
  23%	
  during	
  the	
  3rd	
  monitoring	
  period	
  to	
  .53.	
  The	
  3rd	
   Monitor’s	
  Report	
  also	
  noted	
  an	
  increase	
  in	
  the	
  length	
  of	
  stay	
  in	
  regular	
   seclusion.	
  Between	
  15%	
  and	
  20%	
  of	
  youth	
  who	
  were	
  placed	
  in	
  regular	
   seclusion	
  remained	
  there	
  for	
  longer	
  than	
  what	
  would	
  normally	
  be	
   considered	
  a	
  “cool-­‐off.”	
  [The	
  average	
  length	
  of	
  stay	
  was	
  7	
  hours.]	
   	
   During	
  the	
  current	
  monitoring	
  period,	
  these	
  problems	
  were	
  resolved.	
   The	
  rate	
  of	
  regular	
  seclusion	
  returned	
  to	
  its	
  previous	
  level,	
  .43.	
  More	
   significantly,	
  95%	
  of	
  regular	
  seclusions	
  lasted	
  4	
  hours	
  or	
  less,	
  with	
  the	
   average	
  length	
  of	
  stay	
  decreasing	
  considerably,	
  to	
  1.6	
  hours.	
  These	
   length	
  of	
  stay	
  statistics	
  reflect	
  a	
  practice	
  that	
  is	
  far	
  more	
  in	
  line	
  with	
   generally	
  accepted	
  practices	
  regarding	
  a	
  “cool-­‐off.”	
  	
  Quality	
  assurance	
   efforts,	
  particularly	
  those	
  by	
  the	
  FRA,	
  should	
  continue	
  to	
  reinforce	
  and	
   encourage	
  this	
  trend.	
  	
   	
  
Regular	
  Seclusion,	
  October	
  2012	
  through	
  March	
  2013	
  

Month	
  

#	
  

Rate	
   (#/ADP)	
  

%	
  4hrs	
  or	
   less	
  

ALOS	
   (hrs)	
  

October	
  2012	
  

42	
  

.55	
  

100%	
  

1.4	
  

November	
  2012	
  

25	
  

.30	
  

88%	
  

1.6	
  

December	
  2012	
  

28	
  

.39	
  

93%	
  

1.7	
  

January	
  2013	
  

21	
  

.34	
  

100%	
  

1.4	
  

February	
  2013	
  

28	
  

.48	
  

89%	
  

1.9	
  

March	
  2013	
  

31	
  

.51	
  

94%	
  

1.7	
  

Source:	
  Data	
  prepared	
  by	
  DYS	
  to	
  respond	
  to	
  the	
  Monitor’s	
  request	
  for	
  information	
  on	
  

	
  

22.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 23 of 67 PAGEID #: 2517

the	
  use	
  of	
  seclusion.	
  	
  
	
   Pre-­‐Hearing	
  Seclusion	
   Pre-­‐Hearing	
  Seclusion	
  (PHS)	
  is	
  a	
  period	
  of	
  isolation	
  imposed	
  following	
  an	
   act	
  of	
  violence	
  (AOV),	
  pending	
  a	
  disciplinary	
  hearing.	
  Youth	
  on	
  PHS	
   remain	
  in	
  their	
  rooms	
  except	
  for	
  showers.	
  Youth	
  must	
  receive	
  recreation	
   and	
  Unit	
  Instruction	
  (i.e.,	
  education),	
  although	
  the	
  instruction	
  is	
   delivered	
  through	
  the	
  youth’s	
  door.	
  The	
  length	
  of	
  time	
  a	
  youth	
  remains	
   on	
  PHS	
  is	
  primarily	
  determined	
  by	
  his	
  or	
  her	
  IRAV	
  score,	
  which	
  is	
  based	
   on	
  the	
  severity	
  of	
  the	
  current	
  rule	
  violation	
  and	
  the	
  youth’s	
  history	
  of	
   non-­‐compliant	
  behavior.	
  	
   	
   The	
  rate	
  of	
  PHS	
  generally	
  tracks	
  increases	
  and	
  decreases	
  in	
  the	
  rate	
  of	
   AOV	
  and	
  does	
  not	
  give	
  much	
  insight	
  into	
  the	
  facility’s	
  seclusion	
  practices.	
   Rather,	
  it	
  is	
  changes	
  to	
  the	
  youth’s	
  lengths	
  of	
  stay	
  that	
  reflect	
  whether	
   practices	
  around	
  the	
  use	
  of	
  PHS	
  are	
  being	
  reformed	
  as	
  required	
  by	
  this	
   Provision.	
  During	
  the	
  previous	
  monitoring	
  period,	
  nearly	
  all	
  PHS	
  episodes	
   exceeded	
  24	
  hours	
  and	
  the	
  average	
  length	
  of	
  stay	
  was	
  53	
  hours.	
  	
   	
   As	
  noted	
  above,	
  DYS	
  revised	
  the	
  IRAV	
  policy	
  during	
  the	
  current	
   monitoring	
  period,	
  incorporating	
  most	
  of	
  the	
  suggestions	
  discussed	
  in	
   the	
  previous	
  Monitor’s	
  Report.	
  The	
  policy	
  was	
  scheduled	
  to	
  be	
  rolled	
  out	
   in	
  April	
  2013;	
  however,	
  with	
  changes	
  on	
  the	
  horizon,	
  the	
  length	
  of	
  stay	
  in	
   PHS	
  began	
  to	
  decrease	
  even	
  before	
  the	
  policy	
  was	
  issued.	
  In	
  the	
  first	
  half	
   of	
  the	
  monitoring	
  period,	
  no	
  major	
  changes	
  were	
  evident.	
  An	
  average	
  of	
   90%	
  of	
  pre-­‐hearing	
  seclusions	
  lasted	
  more	
  than	
  24	
  hours	
  and	
  the	
  ALOS	
   was	
  54	
  hours.	
  In	
  the	
  second	
  half,	
  however,	
  the	
  proportion	
  lasting	
  more	
   than	
  24	
  hours	
  decreased	
  to	
  66%	
  and	
  the	
  average	
  length	
  of	
  stay	
   decreased	
  to	
  37	
  hours	
  (a	
  30%	
  decrease).	
  Across	
  the	
  IRAV	
  levels,	
  far	
  more	
   youth	
  were	
  released	
  prior	
  to	
  the	
  maximum	
  allowable	
  time	
  for	
  each	
  level	
   and	
  ALOS	
  also	
  decreased	
  within	
  each	
  level.	
  Once	
  the	
  new	
  IRAV	
  policy	
  is	
   implemented,	
  it	
  is	
  likely	
  that	
  these	
  decreases	
  will	
  become	
  even	
  more	
   pronounced.	
  	
   	
   Notably,	
  the	
  new	
  IRAV	
  policy	
  brings	
  additional	
  and	
  more	
  frequent	
   opportunities	
  for	
  youth	
  to	
  be	
  released	
  from	
  PHS	
  once	
  they	
  demonstrate	
   a	
  willingness	
  and	
  ability	
  to	
  return	
  to	
  the	
  general	
  population	
  safely.	
   Individualizing	
  the	
  length	
  of	
  stay	
  in	
  PHS	
  this	
  way	
  is	
  far	
  more	
  compatible	
   with	
  the	
  generally	
  accepted	
  practice	
  than	
  the	
  historical	
  reliance	
  on	
  pre-­‐ determined	
  lengths	
  of	
  stay.	
  	
  	
   	
  
Pre-­‐Hearing	
  Seclusion,	
  October	
  2012	
  through	
  March	
  2013	
  

Month	
  

#	
  

Rate	
   (#/ADP)	
  

%	
  24+	
  hours	
  

ALOS	
   (hrs)	
  

October	
  2012	
  

23	
  

.30	
  

96%	
  

61	
  

November	
  2012	
  

63	
  

.77	
  

86%	
  

52	
  

	
  

23.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 24 of 67 PAGEID #: 2518

December	
  2012	
  

28	
  

.39	
  

89%	
  

50	
  

January	
  2013	
  

24	
  

.39	
  

58%	
  

36	
  

February	
  2013	
  

20	
  

.34	
  

65%	
  

38	
  

March	
  2013	
  

12	
  

.20	
  

75%	
  

36	
  

Source:	
  Data	
  prepared	
  by	
  DYS	
  to	
  respond	
  to	
  the	
  Monitor’s	
  request	
  for	
  information	
  on	
   the	
  use	
  of	
  seclusion.	
  	
  
	
   	
   Intervention	
  Seclusion	
   Intervention	
  hearings	
  are	
  held	
  to	
  determine	
  whether	
  youth	
  are	
  culpable	
   for	
  serious	
  misconduct	
  and	
  whether	
  additional	
  time	
  in	
  seclusion	
  is	
   warranted.	
  While	
  on	
  Intervention	
  Seclusion,	
  youth	
  remain	
  in	
  their	
  rooms	
   except	
  for	
  showers.	
  Youth	
  must	
  receive	
  recreation	
  and	
  Unit	
  Instruction	
   (i.e.,	
  education)	
  outside	
  of	
  their	
  rooms.	
  By	
  policy,	
  youth	
  can	
  receive	
   Intervention	
  Seclusion	
  for	
  a	
  primary	
  rule	
  violation,	
  some	
  of	
  which	
  are	
   non-­‐violent	
  (e.g.,	
  exposure).	
  The	
  Hearing	
  Officer	
  can	
  impose	
  a	
  maximum	
   of	
  5	
  days	
  of	
  Intervention	
  Seclusion,	
  but	
  policy	
  also	
  allows	
  for	
  the	
  use	
  of	
   alternative	
  sanctions	
  to	
  respond	
  to	
  primary	
  rule	
  violations.	
  	
   	
   During	
  the	
  current	
  monitoring	
  period,	
  the	
  DYS	
  revised	
  policies	
  regarding	
   the	
  Intervention	
  Hearings	
  (requiring	
  them	
  to	
  be	
  held	
  more	
  quickly)	
  and	
   Sanctioning	
  process	
  (instituting	
  a	
  new	
  sanctions	
  grid	
  that	
  limits	
   discretion	
  and	
  significantly	
  reduces	
  the	
  amount	
  of	
  seclusion	
  that	
  can	
  be	
   imposed).	
  These	
  policies	
  are	
  scheduled	
  to	
  be	
  rolled	
  out	
  in	
  May	
  2013	
  and	
   are	
  expected	
  to	
  reduce	
  the	
  State’s	
  reliance	
  on	
  seclusion	
  as	
  a	
  sanction.	
  	
   	
   While	
  these	
  changes	
  are	
  very	
  positive	
  and	
  certainly	
  headed	
  in	
  the	
  right	
   direction,	
  it	
  is	
  worth	
  noting	
  that	
  the	
  use	
  of	
  isolation	
  as	
  a	
  disciplinary	
   sanction	
  is	
  increasingly	
  being	
  prohibited	
  by	
  juvenile	
  justice	
  systems	
   throughout	
  the	
  country.	
  Research	
  on	
  the	
  deleterious	
  effects	
  of	
  isolation	
   on	
  youth’s	
  mental	
  health	
  suggests	
  that	
  skill-­‐based,	
  restorative	
  and	
   treatment-­‐focused	
  responses	
  and	
  sanctions	
  available	
  through	
  the	
   behavior	
  management/incentive	
  system	
  are	
  less	
  harmful	
  and	
  more	
   effective	
  than	
  isolation	
  in	
  changing	
  youth’s	
  behavior.	
  The	
  Monitor	
   strongly	
  encourages	
  DYS	
  to	
  reconsider	
  its	
  use	
  of	
  disciplinary	
  isolation.	
  	
   	
   The	
  new	
  IH	
  policy	
  and	
  sanctions	
  grid	
  will	
  ensure	
  that	
  an	
  increasing	
   proportion	
  of	
  rule	
  violations	
  are	
  handled	
  by	
  the	
  IDT,	
  which	
  is	
  a	
  promising	
   practice	
  given	
  that	
  treatment	
  teams	
  tend	
  to	
  design	
  sanctions	
  that	
  are	
   more	
  responsive	
  to	
  the	
  underlying	
  causes	
  of	
  the	
  youth’s	
  behavior.	
  In	
   contrast,	
  seclusion	
  serves	
  only	
  to	
  suppress	
  a	
  youth’s	
  negative	
  behavior	
   during	
  the	
  time	
  that	
  he	
  or	
  she	
  is	
  behind	
  a	
  locked	
  door	
  and	
  also	
  denies	
   youth	
  access	
  to	
  the	
  very	
  treatment	
  programs	
  they	
  need	
  in	
  order	
  to	
   change	
  their	
  behavior.	
  	
   	
   As	
  shown	
  in	
  the	
  table	
  below,	
  the	
  use	
  of	
  intervention	
  seclusion	
  varied	
  

	
  

24.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 25 of 67 PAGEID #: 2519

across	
  the	
  monitoring	
  period,	
  with	
  rates	
  ranging	
  from	
  a	
  low	
  of	
  .18	
  to	
  a	
   high	
  of	
  .47,	
  with	
  no	
  obvious	
  patterns.	
  [Using	
  a	
  rate,	
  rather	
  than	
  the	
   number	
  of	
  youth,	
  neutralizes	
  the	
  impact	
  of	
  changes	
  in	
  the	
  size	
  of	
  the	
   population.]	
  Given	
  that	
  a	
  small	
  number	
  of	
  youth	
  are	
  involved	
  in	
  a	
   disproportionate	
  number	
  of	
  seclusion	
  events,	
  a	
  rate	
  of	
  use	
  across	
  the	
   population	
  simultaneously	
  overestimates	
  (by	
  making	
  the	
  practice	
  seem	
   more	
  widespread	
  than	
  it	
  is)	
  and	
  underestimates	
  (by	
  ignoring	
  the	
  effect	
  of	
   repeated	
  seclusion	
  experiences	
  on	
  a	
  single	
  youth)	
  the	
  impact	
  of	
  the	
   practice.	
  For	
  these	
  reasons,	
  it	
  is	
  not	
  a	
  particularly	
  useful	
  statistic.	
  	
   	
   Monthly	
  AOV	
  spreadsheets	
  track	
  the	
  disposition	
  of	
  each	
  AOV.	
  These	
  data	
   indicated	
  that,	
  on	
  average,	
  seclusion	
  was	
  used	
  to	
  sanction	
  72%	
  of	
  the	
   youth	
  who	
  committed	
  AOVs	
  (monthly	
  percentages	
  ranged	
  from	
  60%	
  to	
   88%	
  across	
  the	
  monitoring	
  period).	
  Once	
  the	
  new	
  grid	
  is	
  imposed,	
  DYS	
   should	
  monitor	
  its	
  implementation	
  and	
  encourage	
  the	
  use	
  of	
  seclusion	
   only	
  as	
  a	
  last	
  resort.	
  Quality	
  Assurance	
  efforts	
  should	
  also	
  examine	
   individual	
  cases	
  to	
  determine	
  whether	
  the	
  full	
  range	
  of	
  non-­‐seclusion	
   sanctions	
  have	
  been	
  exhausted	
  prior	
  to	
  imposing	
  seclusion.	
  	
   	
   The	
  total	
  number	
  of	
  Intervention	
  Seclusion	
  hours	
  varied	
  widely	
  across	
   the	
  monitoring	
  period,	
  driven	
  by	
  the	
  number	
  of	
  youth	
  who	
  received	
  it	
  as	
   a	
  sanction	
  (e.g.,	
  the	
  spike	
  in	
  youth	
  violence	
  that	
  occurred	
  in	
  November	
   2012	
  doubled	
  the	
  number	
  of	
  youth	
  who	
  were	
  placed	
  in	
  seclusion,	
  and	
   led	
  to	
  longer	
  lengths	
  of	
  stay,	
  which	
  drastically	
  increased	
  the	
  total	
   number	
  of	
  hours).	
  Similarly,	
  the	
  ALOS	
  varied	
  throughout	
  the	
  monitoring	
   period,	
  with	
  no	
  obvious	
  patterns.	
  Except	
  for	
  those	
  who	
  received	
  IS	
  in	
   November	
  2012,	
  the	
  average	
  youth	
  spent	
  approximately	
  two	
  days	
  in	
   Intervention	
  Seclusion	
  (which	
  followed	
  a	
  period	
  of	
  Pre-­‐Hearing	
   Seclusion).	
  	
   	
  
Intervention	
  Seclusion	
  Hours,	
  October	
  2012	
  through	
  March	
  2013	
  

Month	
  

#	
  Y	
  who	
   received	
  IS	
  

Rate	
  	
   (#	
  Y/ADP)	
  

Total	
  IS	
   hours	
  

ALOS	
  

Oct	
  2012	
  

14	
  

.18	
  

595	
  

42.5	
  

Nov	
  2012	
  

39	
  

.47	
  

3,312	
  

84.9	
  

Dec	
  2012	
  

17	
  

.23	
  

657	
  

38.6	
  

Jan	
  2013	
  

20	
  

.32	
  

1,001	
  

50.5	
  

Feb	
  2013	
  

20	
  

.34	
  

881	
  

44.0	
  

March	
  2013	
  

15	
  

.24	
  

733	
  

48.9	
  

Source:	
  Data	
  prepared	
  by	
  DYS	
  to	
  respond	
  to	
  the	
  Monitor’s	
  request	
  for	
  information	
  on	
   the	
  use	
  of	
  seclusion.	
  
	
   	
   Although	
  aggregate	
  data	
  is	
  useful	
  for	
  identifying	
  trends	
  and	
  overall	
  

	
  

25.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 26 of 67 PAGEID #: 2520

Recommendations	
  

increases	
  and	
  decreases	
  in	
  the	
  use	
  of	
  seclusion,	
  it	
  can	
  mask	
  the	
  impact	
  of	
   the	
  facility’s	
  disciplinary	
  strategy	
  on	
  individual	
  youth.	
  A	
  review	
  of	
  AMS	
   Seclusion	
  records	
  for	
  the	
  Special	
  Education	
  provisions	
  of	
  the	
  Stipulation	
   casts	
  this	
  problem	
  in	
  sharp	
  relief.	
  One	
  youth,	
  CC,	
  spent	
  16	
  consecutive	
   days	
  in	
  seclusion,	
  with	
  only	
  one	
  24-­‐hour	
  period	
  in	
  the	
  general	
   population.	
  Another	
  youth,	
  TB,	
  spent	
  8	
  consecutive	
  days	
  in	
  seclusion.	
   While	
  these	
  youth	
  committed	
  serious	
  acts	
  of	
  violence,	
  their	
  long	
  stays	
  in	
   seclusion	
  likely	
  exacerbated	
  their	
  anger	
  and	
  frustration	
  and	
  did	
  nothing	
   to	
  help	
  them	
  develop	
  the	
  anger	
  management	
  skills,	
  impulse	
  control,	
   empathy,	
  etc.	
  they	
  so	
  desperately	
  needed.	
  In	
  this	
  way,	
  the	
  use	
  of	
   seclusion	
  may	
  very	
  well	
  exacerbate	
  the	
  exact	
  problems	
  that	
  the	
  facility	
  is	
   trying	
  to	
  solve.	
  The	
  Monitor	
  strongly	
  encourages	
  the	
  State	
  to	
  seek	
  other	
   ways	
  to	
  manage	
  and	
  respond	
  to	
  youth’s	
  behavior.	
  	
   	
   Quality	
  Assurance	
   Pilot	
  testing	
  of	
  the	
  Quality	
  Assurance	
  process	
  developed	
  via	
  the	
  S.H.	
  case	
   was	
  limited	
  due	
  to	
  the	
  mismatch	
  between	
  the	
  Order’s	
  termination	
  date	
   and	
  the	
  date	
  on	
  which	
  the	
  policy	
  revisions	
  were	
  implemented.	
  While	
   early	
  returns	
  on	
  the	
  IRAV	
  policy	
  suggest	
  that	
  revisions	
  will	
  produce	
  some	
   decreases	
  in	
  the	
  length	
  of	
  stay	
  in	
  PHS,	
  DYS	
  is	
  encouraged	
  to	
  revisit	
  the	
   task	
  of	
  developing	
  a	
  QA	
  procedure	
  for	
  the	
  use	
  of	
  seclusion	
  to	
  ensure	
  it	
  is	
   anchored	
  to	
  specific	
  standards	
  (i.e.,	
  What	
  are	
  the	
  agency’s	
  expectations	
   regarding	
  the	
  length	
  of	
  stay	
  in	
  PHS?	
  What	
  are	
  the	
  agency’s	
  expectations	
   surrounding	
  the	
  use	
  of	
  seclusion	
  as	
  a	
  sanction	
  versus	
  the	
  use	
  of	
   alternatives	
  to	
  seclusion?).	
  Once	
  anchored	
  to	
  clear	
  standards,	
  the	
  mass	
   of	
  QA	
  data	
  regarding	
  PHS	
  and	
  Intervention	
  Seclusion	
  can	
  be	
  more	
  easily	
   interpreted.	
  Setting	
  specific	
  targets	
  will	
  permit	
  the	
  agency	
  to	
  evaluate	
  its	
   facilities’	
  performance	
  in	
  context	
  and	
  will	
  permit	
  the	
  agency	
  to	
   substantiate,	
  with	
  objective	
  data,	
  whether	
  it	
  has	
  complied	
  with	
  the	
   requirements	
  of	
  this	
  provision.	
  Historically,	
  the	
  Monitor	
  has	
  interpreted	
   data	
  related	
  to	
  seclusion—moving	
  forward,	
  the	
  DYS	
  should	
  assume	
  this	
   responsibility.	
  The	
  Monitor	
  is	
  available	
  to	
  provide	
  technical	
  assistance	
  on	
   setting	
  standards,	
  collecting,	
  analyzing,	
  and	
  interpreting	
  data,	
  if	
  desired.	
  	
   	
   Seclusion	
  among	
  Youth	
  on	
  the	
  Progress	
  Units	
  (PU)	
   As	
  noted	
  in	
  the	
  Introduction,	
  the	
  conditions	
  of	
  confinement	
  on	
  the	
  PU	
   are	
  discussed	
  in	
  a	
  Status	
  Report	
  that	
  is	
  attached	
  to	
  this	
  report.	
  Once	
  the	
   State	
  reaches	
  substantial	
  compliance	
  with	
  all	
  of	
  the	
  provisions	
  of	
  the	
   Court	
  Order	
  governing	
  the	
  PU,	
  the	
  use	
  of	
  seclusion	
  on	
  the	
  PU	
  will	
  again	
   be	
  discussed	
  in	
  this	
  section	
  of	
  the	
  report.	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Develop	
  robust	
  Quality	
  Assurance/Quality	
  Improvement	
   processes	
  to	
  determine	
  whether	
  the	
  IRAV	
  and	
  Sanction	
  Grid	
   revisions	
  are	
  properly	
  implemented	
  and	
  whether	
  they	
  have	
   significantly	
  reduced	
  the	
  reliance	
  on	
  isolation	
  to	
  control	
  and	
   respond	
  to	
  youth’s	
  behavior.	
  These	
  processes	
  should	
  include:	
  

	
  

26.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 27 of 67 PAGEID #: 2521

Sources	
  of	
   Information	
  
	
   	
  

a. 	
  Standards	
  that	
  indicate	
  the	
  benchmarks	
  against	
  which	
   performance	
  will	
  be	
  measured,	
  which	
  should	
  clearly	
   indicate	
  a	
  preference	
  for	
  non-­‐seclusion	
  based	
  sanctions	
   and	
  methods	
  for	
  de-­‐escalating	
  youth’s	
  behavior.	
  	
  
b. Audit	
  methodologies;	
   c. Analysis	
  and	
  interpretation	
  of	
  data;	
   d. Development	
  of	
  a	
  Quality	
  Improvement	
  Plan	
  for	
  each	
  
area	
  in	
  which	
  performance	
  deficits	
  are	
  identified.	
  	
   2. Once	
  the	
  Consent	
  Order	
  for	
  the	
  PROGRESS	
  Unit	
  has	
  been	
  
satisfied,	
  maintain	
  the	
  current	
  procedures	
  for	
  out-­‐of-­‐room	
  time	
   on	
  the	
  PROGRESS	
  Unit.	
  	
  
• Self-­‐assessment	
  data	
  for	
  III.A.3,	
  prepared	
  at	
  my	
  request	
   • Monthly	
  Superintendent’s	
  Reports,	
  October	
  2012	
  through	
  March	
  
2013	
   • Consultation	
  with	
  Steve	
  Martin,	
  subject	
  matter	
  expert	
  for	
  S.H.	
  v.	
  
Reed	
  et	
  al.,	
  and	
  various	
  DYS	
  personnel	
  regarding	
  modifications	
  to	
   IRAV	
  and	
  Sanctions	
  Grid	
   • AMS	
  Seclusion	
  Log,	
  February	
  and	
  March	
  2013	
  
	
  

	
  

27.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 28 of 67 PAGEID #: 2522

	
  
III.A.5	
  Investigation	
  of	
  Serious	
  Incidents.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  so	
  that	
  appropriate	
  investigations	
  are	
  conducted	
  of	
  all	
  incidents	
  of:	
   use	
  of	
  force;	
  staff-­‐on-­‐youth	
  violence;	
  serious	
  youth-­‐on-­‐youth	
  violence;	
  inappropriate	
   relationships	
  with	
  youth;	
  sexual	
  misconduct	
  between	
  youth;	
  and	
  abusive	
  institutional	
  practices.	
   Investigations	
  shall	
  be	
  conducted	
  by	
  persons	
  who	
  do	
  not	
  have	
  direct	
  or	
  immediate	
  indirect	
   responsibility	
  for	
  the	
  employee	
  being	
  investigated.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  State	
  submitted	
  a	
  log	
  of	
  all	
  investigations	
  related	
  to	
  excessive	
  uses	
  of	
   force,	
  allegations	
  of	
  abuse,	
  allegations	
  of	
  verbal	
  abuse,	
  and	
  inappropriate	
   relationships	
  completed	
  during	
  the	
  current	
  monitoring	
  period.	
  The	
  Chief	
   Inspector’s	
  Office	
  (CIO)	
  investigated	
  the	
  more	
  serious	
  allegations,	
  while	
   facility-­‐based	
  investigators	
  addressed	
  the	
  less	
  serious	
  allegations.	
  	
   	
   Between	
  October	
  2012	
  and	
  March	
  2013,	
  a	
  total	
  of	
  50	
  investigations	
  were	
   completed	
  related	
  to	
  the	
  topics	
  covered	
  by	
  this	
  provision	
  (37	
  of	
  these	
   were	
  completed	
  by	
  facility-­‐based	
  investigators	
  and	
  13	
  were	
  completed	
   by	
  the	
  CIO).	
  Of	
  these,	
  7	
  of	
  the	
  local	
  investigations	
  (19%)	
  were	
   substantiated	
  and	
  11	
  of	
  the	
  CIO	
  investigations	
  were	
  substantiated	
  (85%),	
   or	
  36%	
  overall.	
  As	
  noted	
  in	
  previous	
  Monitors’	
  Reports,	
  the	
  low	
   proportion	
  of	
  substantiated	
  allegations	
  is	
  likely	
  due	
  to	
  the	
  poor	
  quality	
  of	
   the	
  local	
  investigations.	
  	
   	
   Among	
  the	
  substantiated	
  investigations:	
  
• 9	
  (50%)	
  involved	
  an	
  unsanctioned	
  restraint	
  technique	
  (e.g.,	
   elbow	
  in	
  the	
  youth’s	
  face;	
  hooking	
  an	
  arm	
  around	
  the	
  youth’s	
   neck;	
  unsafe	
  take	
  down;	
  laying	
  on	
  a	
  youth	
  who	
  was	
  prone;	
   dragging	
  a	
  youth	
  by	
  his	
  shirt);	
  
• 3	
  (17%)	
  involved	
  an	
  inappropriate	
  comment	
  or	
  behavior	
  (e.g.,	
  a	
   comment	
  about	
  a	
  youth’s	
  mother;	
  using	
  gang-­‐related	
  hand	
   signals;	
  backing	
  into	
  a	
  youth’s	
  room	
  in	
  a	
  suggestive	
  manner);	
  
• 2	
  (11%)	
  involved	
  physical	
  abuse	
  or	
  an	
  abusive	
  practice	
  (e.g.,	
   exchanging	
  punches	
  with	
  a	
  youth;	
  cutting	
  off	
  a	
  youth’s	
  water	
  and	
   vent);	
  and	
  
• 4	
  (22%)	
  involved	
  improper	
  procedures	
  (e.g.,	
  failing	
  to	
  use	
  the	
   handheld	
  camera	
  and	
  notifying	
  about	
  a	
  youth’s	
  refusal	
  to	
   remove	
  restraints;	
  failure	
  to	
  report	
  a	
  fight	
  or	
  use	
  of	
  force;	
  leaving	
   post	
  without	
  relief;	
  bringing	
  in	
  a	
  personal	
  cell	
  phone;	
   inappropriate	
  contact	
  with	
  youth	
  via	
  FaceBook).	
  	
  
	
   Quality	
  Assurance	
   The	
  CIO	
  conducts	
  an	
  audit	
  of	
  the	
  facility’s	
  investigations	
  every	
  four	
   months.	
  The	
  audit	
  process	
  was	
  recently	
  enhanced	
  to	
  include	
  a	
  variety	
  of	
   performance	
  indicators.	
  The	
  most	
  recent	
  CIO	
  report,	
  covering	
  September	
   through	
  December	
  2012,	
  uses	
  these	
  performance	
  indicators	
  to	
  assess	
   the	
  quality	
  of	
  a	
  random	
  sample	
  of	
  12	
  local	
  investigations.	
  Several	
  

	
  

28.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 29 of 67 PAGEID #: 2523

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

performance	
  indicators	
  were	
  met:	
   • 90%	
  appropriately	
  documented	
  the	
  allegation	
   • 80%	
  included	
  a	
  narrative	
  summary	
  of	
  each	
  interview	
   • 90%	
  used	
  correct	
  terminology	
  in	
  the	
  conclusion	
   • 100%	
  included	
  all	
  attachments	
   • All	
  of	
  the	
  investigators	
  had	
  been	
  trained	
   • 83%	
  of	
  the	
  investigations	
  were	
  properly	
  scanned	
  into	
  AMS	
   • 100%	
  issued	
  Notification	
  Letters	
  to	
  youth	
  whose	
  allegations	
  were	
   reported	
  via	
  the	
  Grievance	
  System.	
  	
   	
  
However,	
  the	
  CIO	
  report	
  identified	
  that	
  a	
  large	
  number	
  of	
  performance	
   indicators,	
  arguably	
  the	
  more	
  substantive	
  of	
  the	
  lot	
  and	
  those	
  that	
   reflect	
  the	
  quality	
  of	
  the	
  investigation,	
  were	
  not	
  met:	
  
• Only	
  40%	
  included	
  a	
  review	
  of	
  all	
  relevant	
  documents	
  and	
  video;	
   • Only	
  10%	
  were	
  started	
  in	
  a	
  timely	
  manner;	
   • Only	
  40%	
  interviewed	
  all	
  relevant	
  staff	
  and	
  youth;	
   • Only	
  60%	
  notified	
  staff	
  of	
  their	
  status	
  (as	
  a	
  witness	
  or	
  the	
  
subject)	
  during	
  the	
  interview;	
   • Only	
  50%	
  noted	
  the	
  time	
  and	
  date	
  of	
  the	
  interview;	
   • Only	
  30%	
  asked	
  all	
  of	
  the	
  necessary	
  questions	
  required	
  to	
  
respond	
  to	
  the	
  allegation;	
   • Only	
  60%	
  came	
  to	
  a	
  conclusion	
  that	
  was	
  supported	
  by	
  the	
  
evidence;	
  	
   • Only	
  17%	
  met	
  all	
  required	
  timelines.	
  	
   	
   These	
  results	
  mirror	
  the	
  Monitor’s	
  and,	
  obviously,	
  create	
  serious	
  concern	
   about	
  the	
  ability	
  of	
  the	
  investigation	
  process	
  undertaken	
  at	
  the	
  facility	
   level	
  to	
  adequately	
  protect	
  youth	
  from	
  harm	
  at	
  the	
  hands	
  of	
  staff.	
  On	
  a	
   positive	
  note,	
  however,	
  the	
  revised	
  audit	
  methodology	
  and	
  performance	
   indicators	
  add	
  a	
  great	
  deal	
  of	
  integrity	
  to	
  the	
  investigation	
  process.	
   Hopefully,	
  the	
  CIO’s	
  new	
  process	
  will	
  catalyze	
  much	
  needed	
   improvements	
  to	
  the	
  local	
  investigation	
  protocol	
  and	
  product.	
  	
  	
  
Chief	
  Inspectors	
  Office	
  (CIO)	
  Investigations	
   Timeliness.	
  Of	
  the	
  13	
  investigations	
  reviewed,	
  12	
  (92%)	
  were	
  completed	
   within	
  the	
  timelines	
  prescribed	
  by	
  policy	
  (i.e.,	
  14	
  business	
  days	
  for	
  use	
  of	
   force	
  investigations;	
  30	
  calendar	
  days	
  for	
  all	
  others)	
  or	
  were	
  granted	
  an	
   extension	
  for	
  cause	
  (e.g.,	
  key	
  witness	
  was	
  unavailable;	
  delay	
  in	
  obtaining	
   permission	
  to	
  proceed	
  from	
  the	
  OSHP).	
  At	
  the	
  time	
  of	
  the	
  Monitor’s	
  site	
   visit,	
  the	
  CIO	
  also	
  had	
  2	
  pending	
  investigations,	
  neither	
  of	
  which	
  had	
  yet	
   reached	
  their	
  due	
  dates.	
  The	
  timeliness	
  of	
  CIO	
  investigations	
  has	
   improved	
  significantly	
  since	
  the	
  previous	
  Monitor’s	
  report.	
  	
   	
   Quality.	
  Each	
  of	
  the	
  13	
  CIO	
  investigations	
  completed	
  during	
  the	
   Monitoring	
  period	
  was	
  reviewed.	
  As	
  in	
  the	
  past,	
  the	
  investigations	
  were	
   very	
  well	
  done.	
  They	
  featured	
  comprehensive	
  interviews	
  with	
  all	
  key	
   witnesses,	
  utilized	
  videotaped	
  footage	
  effectively,	
  and	
  pursued	
  

	
  

29.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 30 of 67 PAGEID #: 2524

peripheral	
  issues	
  that	
  emerged	
  during	
  the	
  course	
  of	
  the	
  initial	
  inquiry.	
   Across	
  the	
  sample,	
  the	
  findings	
  appeared	
  to	
  be	
  reasonable	
  and	
  the	
  basis	
   for	
  the	
  conclusions	
  was	
  clearly	
  identified	
  among	
  the	
  evidence.	
  	
   	
   Local	
  Investigations	
   Timeliness.	
  Of	
  the	
  37	
  investigations	
  completed	
  by	
  Scioto	
  staff	
  during	
  the	
   current	
  monitoring	
  period,	
  only	
  18	
  (49%)	
  were	
  completed	
  within	
  the	
   timelines	
  prescribed	
  by	
  policy.	
  While	
  this	
  is	
  an	
  improvement	
  over	
  the	
  last	
   monitoring	
  period,	
  where	
  only	
  23%	
  were	
  on-­‐time,	
  the	
  timeliness	
  of	
   investigations	
  conducted	
  at	
  the	
  facility	
  level	
  is	
  a	
  major	
  concern.	
  The	
   remaining	
  19	
  investigations	
  (51%)	
  were	
  late	
  (an	
  average	
  of	
  61	
  calendar	
   days!).	
  In	
  addition,	
  at	
  the	
  time	
  of	
  the	
  Monitor’s	
  site	
  visit,	
  2	
  local	
   investigations	
  were	
  pending	
  and	
  both	
  were	
  significantly	
  overdue.	
   	
   As	
  discussed	
  in	
  each	
  of	
  the	
  previous	
  Monitor’s	
  Reports,	
  the	
  investigation	
   process	
  is	
  a	
  critical	
  feature	
  of	
  the	
  State’s	
  ability	
  to	
  protect	
  youth	
  from	
   harm.	
  The	
  continued	
  and	
  widespread	
  delays	
  in	
  completing	
  investigations	
   have	
  deleterious	
  consequences	
  across	
  the	
  board:	
  	
  
• Delays	
  greatly	
  compromise	
  the	
  ability	
  to	
  accurately	
  assess	
  the	
   veracity	
  of	
  the	
  allegation;	
  
• Delays	
  prevent	
  guilty	
  staff	
  from	
  receiving	
  necessary	
  re-­‐training,	
   discipline	
  or	
  termination,	
  which	
  perpetuates	
  the	
  risk	
  to	
  youth;	
  
• Delays	
  unfairly	
  stress	
  innocent	
  staff	
  who	
  may	
  be	
  placed	
  on	
   modified	
  duty	
  awaiting	
  the	
  outcome	
  of	
  the	
  investigation;	
  and	
  
• Delays	
  exacerbate	
  the	
  already	
  prevalent	
  sense	
  among	
  youth	
  that	
   the	
  facility	
  does	
  not	
  take	
  their	
  complaints	
  seriously	
  or	
  that	
   “nothing	
  will	
  be	
  done”	
  about	
  the	
  concerns	
  they	
  have	
  regarding	
   their	
  treatment.	
  	
  	
  
	
   This	
  problem	
  has	
  been	
  at	
  the	
  forefront	
  of	
  the	
  Monitor’s	
  concerns	
  since	
   the	
  inception	
  of	
  this	
  case.	
   	
   Quality.	
  Even	
  after	
  the	
  Monitor	
  downgraded	
  the	
  compliance	
  level	
  for	
  this	
   provision	
  in	
  the	
  2nd	
  Monitor’s	
  Report	
  and	
  commented	
  extensively	
  on	
  the	
   various	
  inadequacies	
  identified	
  among	
  the	
  reports	
  for	
  the	
  past	
  two	
   monitoring	
  periods,	
  the	
  quality	
  of	
  the	
  investigations	
  has	
  not	
  improved	
   and	
  remains	
  far	
  below	
  professional	
  standards.	
  	
   	
   As	
  in	
  the	
  previous	
  monitoring	
  period,	
  the	
  Monitor	
  provided	
  detailed	
   feedback	
  on	
  each	
  of	
  the	
  37	
  cases	
  to	
  develop	
  consensus	
  around	
  the	
   essential	
  elements	
  of	
  a	
  quality	
  investigation	
  and	
  to	
  highlight	
  the	
  many	
   features	
  that	
  were	
  lacking	
  from	
  the	
  most	
  recent	
  set	
  of	
  investigations.	
   Among	
  the	
  most	
  serious	
  problems:	
  
• Everyone	
  who	
  can	
  contribute	
  to	
  the	
  understanding	
  of	
  what	
   occurred	
  should	
  be	
  interviewed.	
  In	
  several	
  cases,	
  the	
   investigator	
  identified	
  a	
  very	
  limited	
  set	
  of	
  witnesses	
  (e.g.,	
  the	
   accused	
  staff,	
  the	
  victim	
  and	
  possibly	
  one	
  other	
  staff	
  witness)	
  

	
  

30.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 31 of 67 PAGEID #: 2525

even	
  though	
  other	
  people	
  were	
  in	
  the	
  vicinity	
  when	
  the	
  incident	
   allegedly	
  occurred.	
  	
   • Witnesses	
  should	
  be	
  asked	
  to	
  describe	
  what	
  happened	
  in	
  their	
   own	
  words,	
  and	
  the	
  investigator	
  should	
  seek	
  clarification	
  or	
   additional	
  detail	
  through	
  appropriate	
  follow-­‐up	
  questions.	
  Many	
   times,	
  it	
  appeared	
  that	
  the	
  witness	
  was	
  simply	
  asked	
  to	
  respond	
   to	
  a	
  set	
  of	
  yes/no	
  questions.	
  The	
  absence	
  of	
  follow-­‐up	
  questions	
   from	
  many	
  of	
  the	
  investigators	
  suggested	
  that	
  the	
  investigators	
   were	
  simply	
  going	
  through	
  the	
  motions	
  without	
  a	
  particular	
   drive	
  to	
  determine	
  what	
  actually	
  occurred.	
  	
  	
   • The	
  sequence	
  of	
  the	
  interviews	
  is	
  important.	
  The	
  alleged	
  victim	
   should	
  be	
  interviewed	
  first	
  in	
  order	
  to	
  obtain	
  a	
  complete	
   accounting	
  of	
  the	
  youth’s	
  concerns	
  and	
  to	
  obtain	
  details	
  that	
   can	
  be	
  used	
  to	
  construct	
  questions	
  with	
  the	
  witnesses	
  and	
  the	
   accused	
  staff.	
  The	
  accused	
  staff	
  should	
  be	
  interviewed	
  last,	
  so	
   that	
  he	
  or	
  she	
  can	
  be	
  asked	
  to	
  respond	
  to	
  the	
  specific	
  allegations	
   discovered	
  during	
  the	
  previous	
  interviews.	
  In	
  several	
  cases,	
   sequence	
  was	
  off,	
  which	
  meant	
  that	
  the	
  investigator	
  could	
  not	
   conduct	
  the	
  subsequent	
  interviews	
  effectively.	
   • The	
  investigator	
  should	
  follow-­‐up	
  on	
  peripheral	
  issues	
  that	
   emerge,	
  such	
  as	
  staff	
  witnesses’	
  failure	
  to	
  report	
  misconduct	
   that	
  they	
  observe	
  or	
  failing	
  to	
  write	
  an	
  accurate	
  incident	
  report.	
  	
   • The	
  basis	
  for	
  the	
  conclusions	
  must	
  be	
  clearly	
  articulated	
  and	
   must	
  rest	
  upon	
  facts	
  that	
  were	
  gathered	
  during	
  the	
   investigation.	
  Many	
  of	
  the	
  investigators	
  did	
  not	
  write	
  coherent	
   narratives	
  and	
  did	
  not	
  summarize	
  the	
  facts	
  that	
  supported	
  the	
   conclusion,	
  and	
  did	
  not	
  explain	
  why	
  they	
  discounted	
  facts	
  that	
   didn’t	
  fit.	
  In	
  one	
  case	
  (#5501120122),	
  the	
  Monitor	
  had	
  the	
   opportunity	
  to	
  review	
  videotaped	
  footage	
  of	
  the	
  incident	
  in	
   question.	
  The	
  investigator	
  left	
  out	
  many	
  relevant	
  details,	
  did	
  not	
   confront	
  witnesses	
  with	
  various	
  omissions	
  and	
  contradictions	
  in	
   their	
  written	
  statements,	
  and	
  ultimately	
  came	
  to	
  a	
  conclusion	
   that	
  the	
  allegation	
  was	
  not	
  substantiated,	
  despite,	
  in	
  the	
   Monitor’s	
  opinion,	
  rather	
  clear	
  evidence	
  that	
  the	
  subject	
  of	
  the	
   investigation	
  used	
  excessive/improper	
  force.	
  The	
  Monitor	
   strongly	
  recommends	
  that	
  the	
  CIO	
  re-­‐open	
  this	
  case	
  and	
  re-­‐ examine	
  the	
  evidence.	
  One	
  wonders	
  how	
  often	
  this	
  occurs— that	
  the	
  investigation	
  is	
  so	
  shoddily	
  done	
  that	
  true	
  allegations	
   do	
  not	
  get	
  substantiated.	
  	
   	
   It	
  is	
  worth	
  noting	
  that	
  these	
  same	
  problems	
  were	
  articulated	
  in	
  the	
   previous	
  two	
  Monitors’	
  Reports,	
  and	
  more	
  recently,	
  by	
  the	
  CIO’s	
  Quality	
   Assurance	
  process.	
  The	
  shoddy	
  investigation	
  protocol	
  is	
  insufficient	
  to	
   produce	
  accurate	
  findings	
  of	
  an	
  allegation’s	
  veracity	
  and,	
  as	
  a	
  result,	
   places	
  youth	
  at	
  significant	
  risk	
  of	
  harm.	
  When	
  an	
  investigation	
  fails	
  to	
   substantiate	
  a	
  true	
  allegation:	
  	
   • Youth	
  lose	
  faith	
  in	
  the	
  processes	
  designed	
  to	
  protect	
  them	
  (i.e.,	
  

	
  

31.	
  

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“the	
  grievance	
  process	
  doesn’t	
  work”)	
  and	
  may	
  be	
  even	
  less	
   likely	
  to	
  report	
  mistreatment	
  in	
  the	
  future;	
   • Staff	
  are	
  not	
  held	
  accountable	
  and	
  thus	
  are	
  not	
  subjected	
  to	
  the	
   retraining	
  or	
  discipline	
  designed	
  to	
  modify	
  their	
  behavior,	
  which	
   increases	
  the	
  likelihood	
  they	
  will	
  repeat	
  the	
  behavior	
  in	
  the	
   future;	
  	
   • A	
  culture	
  in	
  which	
  staff	
  behave	
  with	
  impunity	
  and	
  believe	
  that	
   “nothing	
  will	
  happen”	
  if	
  a	
  youth	
  reports	
  mistreatment	
  is	
  allowed	
   to	
  perpetuate,	
  which	
  creates	
  a	
  risk	
  that	
  staff	
  will	
  continue	
  to	
   violate	
  the	
  boundaries	
  of	
  acceptable	
  behavior	
  because	
  they	
  do	
   not	
  fear	
  the	
  consequences.	
  	
   	
   The	
  State	
  has	
  made	
  no	
  progress	
  in	
  improving	
  the	
  quality	
  of	
  this	
  essential	
   function.	
  The	
  primary	
  contributor	
  to	
  this	
  problem	
  appears	
  to	
  be	
  the	
   continued	
  practice	
  of	
  distributing	
  the	
  investigations	
  across	
  a	
  large	
   number	
  of	
  staff.	
  Dispersing	
  the	
  responsibility	
  so	
  broadly	
  will	
  inevitably	
   lead	
  to	
  inconsistency,	
  and	
  because	
  each	
  staff	
  person	
  may	
  only	
  do	
  one	
  or	
   two	
  investigations	
  per	
  year,	
  their	
  opportunities	
  to	
  develop	
  the	
   appropriate	
  skill	
  set	
  are	
  very	
  limited.	
  	
   	
   In	
  order	
  to	
  accelerate	
  the	
  State’s	
  progress	
  toward	
  compliance	
  with	
  this	
   provision,	
  the	
  Monitor	
  strongly	
  recommends	
  that	
  the	
  State	
  significantly	
   reduce	
  the	
  number	
  of	
  people	
  who	
  are	
  authorized	
  to	
  conduct	
  a	
  local	
   investigation	
  and	
  that	
  this	
  responsibility	
  is	
  assigned	
  only	
  to	
  individuals	
   who	
  have	
  demonstrated	
  that	
  they	
  have	
  the	
  requisite	
  skill	
  set.	
  In	
  a	
   conference	
  call	
  between	
  DYS,	
  the	
  DOJ,	
  and	
  the	
  Monitor	
  just	
  prior	
  to	
  this	
   report	
  being	
  issued,	
  DYS	
  agreed	
  to	
  pursue	
  this	
  strategy,	
  if	
  funding	
   permits.	
  	
   	
   The	
  poor	
  quality	
  of	
  these	
  reports	
  cannot	
  continue.	
  Although	
  the	
   allegations	
  investigated	
  at	
  the	
  facility-­‐level	
  are	
  generally	
  less	
  serious,	
  the	
   nature	
  of	
  the	
  allegations	
  are	
  at	
  the	
  heart	
  of	
  the	
  facility’s	
  staff	
  culture	
  that	
   has	
  been	
  labeled	
  as	
  problematic	
  by	
  past	
  administrations	
  and	
  that	
  was	
   the	
  chief	
  complaint	
  among	
  the	
  youth	
  interviewed	
  during	
  the	
  current	
   monitoring	
  period.	
  Youth	
  often	
  described	
  staff	
  behaving	
  with	
  impunity,	
   boasting	
  that	
  “nothing	
  will	
  happen”	
  if	
  the	
  youth	
  filed	
  a	
  compliant.	
  The	
   lack	
  of	
  accountability	
  brought	
  to	
  bear	
  by	
  the	
  shoddy	
  local	
  investigation	
   process	
  is	
  a	
  major	
  contributing	
  factor	
  to	
  this	
  problem.	
  	
   	
   The	
  lack	
  of	
  progress	
  in	
  this	
  area	
  suggests	
  that	
  additional	
  oversight	
  may	
   be	
  necessary.	
  The	
  Monitor	
  recommends	
  that	
  the	
  DYS	
  create	
  a	
  specific	
   Corrective	
  Action	
  Plan/Quality	
  Improvement	
  Plan	
  (perhaps	
  via	
  the	
  Quality	
   Assurance	
  process	
  that	
  the	
  CIO	
  has	
  recently	
  implemented)	
  to	
  determine	
   the	
  underlying	
  causes	
  of	
  the	
  delays	
  and	
  poor	
  quality	
  products,	
  and	
  to	
   enact	
  specific	
  strategies	
  to	
  target	
  each	
  of	
  the	
  underlying	
  factors	
  in	
  order	
   to	
  significantly	
  improve	
  performance	
  in	
  this	
  area.	
  The	
  Monitor	
  will	
  also	
   request	
  copies	
  of	
  all	
  completed	
  local	
  investigations	
  on	
  a	
  monthly	
  basis	
  so	
  

	
  

32.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 33 of 67 PAGEID #: 2527

Recommendations	
  
Sources	
  of	
   Information	
  
	
   	
  

that	
  more	
  frequent	
  status	
  reports	
  can	
  be	
  made	
  to	
  the	
  Parties	
  and	
  the	
   Court.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Reduce	
  the	
  number	
  of	
  individuals	
  authorized	
  to	
  conduct	
  local	
   investigations	
  and	
  ensure	
  that	
  these	
  individuals	
  have	
  the	
   requisite	
  skills	
  for	
  the	
  task.	
  Ensure	
  that	
  producing	
  timely,	
  high-­‐ quality	
  investigations	
  is	
  a	
  specific	
  job	
  responsibility	
  and	
  that	
   employees	
  are	
  held	
  accountable	
  for	
  their	
  failure	
  to	
  produce	
   reports	
  that	
  meet	
  professional	
  standards.	
  	
  	
  
2. Produce	
  high-­‐quality	
  investigations	
  of	
  all	
  allegations	
  of	
   misconduct	
  by	
  staff.	
  The	
  investigations	
  must	
  reflect	
  timely,	
   comprehensive	
  interviews	
  with	
  all	
  key	
  witnesses,	
  must	
  address	
   peripheral	
  issues	
  (e.g.,	
  witnesses’	
  failure	
  to	
  report)	
  and	
  must	
   arrive	
  at	
  reasonable	
  conclusions	
  based	
  on	
  the	
  facts	
  in	
  evidence.	
   Enact	
  accountability	
  measures	
  to	
  address	
  poor	
  performance	
  by	
   staff	
  tasked	
  with	
  the	
  responsibility	
  to	
  investigate	
  allegations	
  of	
   all	
  types.	
  	
  	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.A.5,	
  prepared	
  at	
  my	
  request	
  	
  
• “Scioto	
  Juvenile	
  Correctional	
  Facility	
  Coaching	
  and	
  Monitoring	
   Report,”	
  by	
  the	
  Chief	
  Inspector’s	
  Office,	
  January	
  2013	
  
• Log,	
  “Investigation	
  Tracking	
  Log,	
  October	
  2012	
  through	
  March	
   2013”	
  
• Email	
  communication	
  with	
  J.	
  Fears,	
  CIO,	
  and	
  C.	
  Price,	
  Scioto	
   Correctional	
  Facility,	
  to	
  verify	
  dates	
  of	
  submission	
  of	
  various	
   reports	
  
• Review	
  of	
  13	
  CIO	
  investigations	
  completed	
  since	
  October	
  2012	
   (100%	
  of	
  total)	
  
• Review	
  of	
  37	
  investigations	
  conducted	
  by	
  Scioto	
  staff	
  since	
   October	
  2012	
  (100%	
  of	
  total)	
  
• Conference	
  call	
  with	
  Ohio	
  Attorney	
  General’s	
  office,	
  DYS	
  Chiefs	
   of	
  Staff,	
  Department	
  of	
  Justice	
  and	
  the	
  Monitor,	
  May	
  29,	
  2013.	
  
	
  

	
  

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III.D.1	
  Grievances.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
  practices	
  to	
   ensure	
  that	
  the	
  facility	
  has	
  an	
  adequate	
  grievance	
  system	
  including:	
  no	
  formal	
  or	
  informal	
   preconditions	
  to	
  the	
  completion	
  and	
  submission	
  of	
  a	
  grievance;	
  review	
  of	
  grievances	
  by	
  the	
   Chief	
  Inspector;	
  timely	
  initiation	
  and	
  resolution	
  of	
  grievances;	
  appropriate	
  corrective	
  action;	
  and	
   written	
  notification	
  provided	
  to	
  the	
  youth	
  of	
  the	
  final	
  resolution	
  of	
  the	
  grievance.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  previous	
  Monitor’s	
  Report	
  noted	
  that	
  the	
  Scioto	
  Grievance	
   Coordinator	
  hired	
  in	
  May	
  2012	
  had	
  largely	
  resolved	
  the	
  systemic	
   deficiencies	
  with	
  the	
  process.	
  	
   	
   Quality	
  Assurance	
   As	
  before,	
  the	
  CIO	
  reviews	
  all	
  grievances	
  on	
  an	
  on-­‐going	
  basis.	
  If	
  the	
   grievance	
  response	
  includes	
  all	
  the	
  necessary	
  actions	
  and	
   documentation,	
  it	
  is	
  “closed”	
  by	
  the	
  CIO.	
  If	
  additional	
  documentation	
  or	
   information	
  is	
  needed,	
  “follow-­‐up	
  action”	
  is	
  requested.	
  Once	
  the	
   grievance	
  coordinator	
  provides	
  the	
  necessary	
  information,	
  the	
  grievance	
   is	
  then	
  closed.	
  [For	
  statistical	
  purposes,	
  “follow-­‐up	
  action”	
  is	
  a	
  fluid	
  status	
   and	
  it	
  can	
  only	
  provide	
  a	
  snapshot	
  of	
  the	
  grievance	
  process	
  on	
  any	
  given	
   day.]	
  If	
  the	
  CIO	
  finds	
  that	
  the	
  resolution	
  of	
  the	
  grievance	
  is	
  at	
  odds	
  with	
   facility	
  procedure,	
  “corrective	
  action”	
  is	
  required	
  and	
  the	
  grievance	
   coordinator	
  must	
  revisit	
  the	
  issue	
  with	
  the	
  youth	
  and	
  explain	
  how	
  the	
   grievance	
  was	
  resolved	
  in	
  error.	
  Only	
  4	
  of	
  142	
  grievances	
  (3%)	
  required	
   corrective	
  action	
  during	
  the	
  current	
  monitoring	
  period:	
  
• A	
  grievance	
  was	
  marked	
  “closed	
  by	
  investigation,”	
  but	
  the	
  CIO	
   investigated	
  a	
  different	
  part	
  of	
  the	
  issue	
  (fight)	
  and	
  not	
  what	
  was	
   the	
  substance	
  of	
  the	
  grievance	
  (commissary).	
  The	
  Grievance	
   Coordinator	
  corrected	
  the	
  notification	
  letter	
  and	
  also	
  refunded	
   the	
  youth’s	
  commissary	
  funds.	
  	
  
• A	
  youth	
  complained	
  that	
  the	
  clean	
  clothing	
  still	
  smelled.	
  The	
   Grievance	
  Coordinator	
  didn’t	
  actually	
  smell	
  the	
  clothing	
  and	
  the	
   UM	
  had	
  indicated	
  there	
  had	
  been	
  problems	
  with	
  the	
  unit’s	
  dryer.	
   The	
  grievance	
  coordinator	
  was	
  encouraged	
  to	
  conduct	
  a	
  broader	
   inquiry	
  should	
  a	
  similar	
  complaint	
  occur	
  in	
  the	
  future.	
  	
  
• A	
  youth	
  alleged	
  that	
  a	
  staff	
  called	
  her	
  a	
  “dumb	
  ass.”	
  The	
  staff	
  was	
   never	
  asked	
  to	
  make	
  a	
  statement.	
  Upon	
  re-­‐opening	
  the	
  issue	
  at	
   the	
  request	
  of	
  the	
  CIO,	
  the	
  staff	
  refused	
  to	
  make	
  a	
  statement,	
  so	
   the	
  matter	
  was	
  referred	
  for	
  investigation.	
  	
  
• A	
  youth	
  alleged	
  physical	
  mistreatment	
  during	
  a	
  restraint.	
  The	
   matter	
  should	
  have	
  been	
  immediately	
  referred	
  for	
  investigation,	
   but	
  instead	
  the	
  grievance	
  coordinator	
  took	
  additional	
  steps	
  to	
   investigate	
  the	
  matter	
  on	
  his	
  own.	
  The	
  CIO	
  admonished	
  him	
  from	
   doing	
  so	
  in	
  the	
  future.	
  	
  
	
   The	
  Grievance	
  Coordinator	
  also	
  prepares	
  a	
  monthly	
  report	
  for	
  review	
  by	
   the	
  CIO,	
  and	
  grievance	
  data	
  (number	
  and	
  type)	
  are	
  part	
  of	
  the	
  weekly	
   Management	
  by	
  Measurement	
  (MBM)	
  data	
  that	
  the	
  facility	
  

	
  

34.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 35 of 67 PAGEID #: 2529

Superintendent	
  receives.	
   	
   In	
  addition	
  to	
  this	
  on-­‐going	
  Quality	
  Assurance,	
  the	
  CIO	
  also	
  audits	
  the	
   grievance	
  process	
  every	
  four	
  months.	
  This	
  process	
  includes	
  observations	
   of	
  the	
  interaction	
  between	
  the	
  grievance	
  coordinator	
  and	
  youth;	
  visual	
   verification	
  that	
  the	
  grievance	
  boxes	
  and	
  necessary	
  supplies	
  are	
  available	
   to	
  youth;	
  and	
  checks	
  to	
  ensure	
  that	
  the	
  general	
  procedures	
  are	
  in	
  place.	
   Scioto’s	
  most	
  recent	
  QA	
  audit	
  covered	
  October	
  2012	
  through	
  January	
   2013.	
  The	
  auditor	
  reported	
  that	
  the	
  grievance	
  coordinator	
  knew	
  the	
   youth	
  and	
  the	
  youth	
  knew	
  him;	
  comprehensive	
  monthly	
  reports	
  were	
   being	
  produced;	
  and	
  all	
  supplies	
  were	
  accessible.	
  In	
  addition,	
  a	
  random	
   sample	
  of	
  10	
  grievances	
  was	
  reviewed	
  to	
  determine	
  their	
  compliance	
   with	
  policy.	
  In	
  all	
  cases,	
  the	
  grievance	
  coordinator	
  met	
  with	
  the	
  youth	
   face-­‐to-­‐face,	
  medical	
  issues	
  and	
  abuse	
  allegations	
  were	
  handled	
  per	
   policy,	
  follow-­‐up	
  occurred	
  as	
  needed,	
  and	
  all	
  	
  youth	
  were	
  given	
  a	
  copy	
  of	
   the	
  grievance	
  and	
  its	
  resolution.	
  The	
  only	
  point	
  of	
  development	
  was	
  to	
   ensure	
  that	
  the	
  new	
  lesson	
  plan	
  for	
  Orientation,	
  created	
  by	
  the	
  CIO	
  to	
   standardize	
  the	
  information	
  presented	
  across	
  the	
  facilities,	
  was	
  used.	
  	
   	
   Clearly,	
  the	
  grievance	
  process	
  benefits	
  from	
  a	
  great	
  deal	
  of	
  oversight	
  to	
   ensure	
  that	
  grievances	
  are	
  resolved	
  timely	
  and	
  that	
  youth	
  are	
  provided	
   with	
  a	
  solid	
  mechanism	
  to	
  voice	
  their	
  concerns	
  and	
  to	
  ensure	
  they	
  are	
   treated	
  fairly.	
  	
   	
   Other	
  performance	
  indicators	
  continued	
  to	
  improve	
  throughout	
  the	
   current	
  monitoring	
  period,	
  as	
  compared	
  to	
  the	
  systemic	
  problems	
  noted	
   in	
  previous	
  reports.	
  In	
  Q4	
  2012	
  (October-­‐December),	
  100%	
  of	
  the	
   grievances	
  were	
  resolved	
  within	
  required	
  timelines,	
  and	
  in	
  Q1	
  2013	
   (January-­‐March),	
  98%	
  of	
  grievances	
  were	
  resolved	
  timely.	
  In	
  terms	
  of	
   substance,	
  in	
  Q4	
  2012,	
  32	
  of	
  80	
  (40%)	
  grievances	
  required	
  follow-­‐up	
   action,	
  generally,	
  questions	
  about	
  how	
  the	
  incident	
  was	
  coded	
  or	
  to	
   clarify	
  how	
  the	
  issue	
  was	
  framed.	
  As	
  noted	
  above,	
  “follow-­‐up	
  required”	
  is	
   a	
  status	
  that	
  can	
  be	
  quickly	
  remediated	
  with	
  additional	
  information	
  or	
   documentation.	
  The	
  CIO	
  did	
  not	
  report	
  this	
  statistic	
  for	
  Q1	
  2013.	
  	
   	
   A	
  total	
  of	
  80	
  grievances	
  were	
  submitted	
  in	
  Q4	
  2012	
  and	
  62	
  were	
   submitted	
  in	
  Q1	
  2013.	
  The	
  rate	
  of	
  grievances	
  per	
  youth	
  has	
  remained	
   stable	
  for	
  quite	
  some	
  time,	
  save	
  for	
  a	
  spike	
  in	
  Q2	
  2012.	
  The	
  youth’s	
  chief	
   concerns	
  included	
  complaints	
  about	
  staff’s	
  decisions	
  (18%	
  of	
  the	
  142	
   grievances	
  submitted),	
  program	
  concerns	
  (10%),	
  physical	
  abuse	
  (9%),	
   verbal	
  abuse	
  (8%),	
  and	
  medical	
  concerns	
  (8%).	
  More	
  specifically,	
   examples	
  include:	
  
• Alleged	
  Verbal	
  Abuse:	
  “staff	
  threatened	
  to	
  extend	
  my	
  stay,”	
   “staff	
  called	
  me	
  ‘a	
  joke’,”	
  “social	
  worker	
  has	
  an	
  attitude,”	
  “staff	
   said	
  ‘Wake	
  your	
  fat	
  ass	
  up!’,”	
  “staff	
  threatened	
  to	
  write	
  me	
  up,”	
   “staff	
  called	
  me	
  a	
  ‘fag’	
  and	
  said	
  he’d	
  get	
  my	
  sister	
  pregnant,”	
  “	
   social	
  worker	
  made	
  sexual	
  comments	
  to	
  me,”	
  and	
  “YS	
  is	
  bragging	
  

	
  

35.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 36 of 67 PAGEID #: 2530

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

that	
  he’s	
  going	
  to	
  fight	
  me.”	
  [These	
  last	
  two	
  were	
  referred	
  for	
   investigation.]	
   • Alleged	
  Physical	
  Abuse:	
  “staff	
  put	
  her	
  hand	
  on	
  my	
  back,”	
  “staff	
   smacked	
  my	
  hand	
  when	
  I	
  grabbed	
  a	
  tray,”	
  “	
  staff	
  pushed	
  me	
   when	
  I	
  hit	
  him	
  with	
  a	
  basketball,”	
  “staff	
  squeezed	
  my	
  wrist	
  to	
  get	
   a	
  bag	
  of	
  chips,”	
  “staff	
  pulled	
  hard	
  on	
  my	
  gators,”	
  “staff	
  choked	
   me	
  and	
  banged	
  my	
  head	
  on	
  the	
  wall,”	
  “staff	
  hit	
  me	
  on	
  the	
  neck,	
   lays	
  hands	
  on	
  us	
  a	
  lot.”	
  [The	
  last	
  four	
  were	
  referred	
  for	
   investigation.]	
   	
   In	
  terms	
  of	
  the	
  grievances’	
  resolution,	
  69%	
  had	
  no	
  merit,	
  20%	
  had	
  merit,	
   7%	
  were	
  referred	
  for	
  investigation,	
  and	
  4%	
  were	
  pending	
  at	
  the	
  time	
  of	
   the	
  CIO’s	
  report.	
  	
  	
   	
   Not	
  only	
  does	
  the	
  DYS	
  have	
  a	
  robust	
  system	
  for	
  monitoring	
  the	
  grievance	
   process,	
  but	
  the	
  results	
  of	
  those	
  audits	
  reveal	
  fidelity	
  to	
  the	
  design	
  and	
  a	
   clear	
  commitment	
  to	
  ensure	
  that	
  youth	
  have	
  ready	
  access	
  to	
  a	
   confidential	
  grievance	
  process.	
  	
  
The	
  DYS	
  has	
  done	
  such	
  an	
  exceptional	
  job	
  of	
  auditing	
  its	
  grievance	
   process	
  that	
  the	
  Monitor	
  had	
  little	
  to	
  add.	
  	
   	
   Youth	
  Survey	
   The	
  CIO	
  re-­‐administered	
  its	
  Youth	
  Survey	
  in	
  Q4	
  2012.	
  The	
  results	
  largely	
   paralleled	
  the	
  previous	
  survey—30%	
  reported	
  they’d	
  been	
  told	
  they	
   could	
  not	
  use	
  the	
  grievance	
  process	
  to	
  report	
  staff	
  misconduct,	
  39%	
   reported	
  they	
  were	
  treated	
  “differently”	
  after	
  filing	
  a	
  grievance,	
  and	
  62%	
   said	
  that	
  staff	
  told	
  them	
  nothing	
  would	
  happen	
  if	
  they	
  filed	
  a	
  grievance.	
   On	
  the	
  surface	
  these	
  results	
  would	
  appear	
  to	
  conflict	
  with	
  what	
  the	
  	
   Monitor	
  and	
  the	
  DOJ	
  Attorney	
  heard	
  in	
  their	
  interviews	
  with	
  youth,	
  who	
   listed	
  the	
  grievance	
  process	
  among	
  the	
  facility’s	
  strengths,	
  and	
  reported	
   that	
  they	
  knew	
  and	
  appreciated	
  the	
  Grievance	
  Coordinator’s	
  accessibility	
   and	
  approach	
  to	
  dealing	
  with	
  their	
  issues.	
  However,	
  the	
  responses	
  to	
  the	
   CIO’s	
  survey	
  suggest	
  that	
  the	
  youth’s	
  concerns	
  about	
  the	
  process	
  lie	
  not	
   with	
  the	
  Grievance	
  Coordinator	
  but	
  with	
  the	
  direct	
  care	
  staff’s	
  attempts	
   to	
  undermine	
  the	
  process.	
  	
   	
   In	
  response	
  to	
  this	
  survey,	
  the	
  Facility	
  Superintendent	
  has	
  attended	
  Roll	
   Call	
  for	
  each	
  shift	
  and	
  reinforced	
  the	
  importance	
  of	
  supporting,	
  and	
   warned	
  against	
  undermining,	
  the	
  grievance	
  process.	
  	
  	
   	
   Notification	
  to	
  Youth	
  about	
  the	
  Outcome	
  of	
  Investigations	
   In	
  March	
  2012,	
  the	
  Grievance	
  Policy	
  (#	
  304.03)	
  was	
  revised	
  to	
  include	
   written	
  notification	
  to	
  the	
  youth	
  of	
  the	
  outcome	
  of	
  investigations	
  that	
   were	
  triggered	
  by	
  a	
  youth’s	
  grievance.	
  A	
  letter	
  to	
  the	
  youth	
  from	
  the	
   facility’s	
  Labor	
  Relations	
  Officer	
  (LRO)	
  refers	
  to	
  the	
  investigation	
  number	
   and	
  indicates	
  whether	
  the	
  allegation	
  was	
  substantiated	
  or	
   unsubstantiated.	
  The	
  Investigation	
  Policy	
  (#101.15)	
  and	
  the	
  Youth	
  

	
  

36.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 37 of 67 PAGEID #: 2531

Handbook	
  were	
  also	
  updated	
  to	
  reflect	
  this	
  change	
  in	
  procedure.	
   	
   During	
  the	
  current	
  monitoring	
  period,	
  a	
  total	
  of	
  8	
  investigations	
  were	
   closed	
  that	
  were	
  initiated	
  via	
  a	
  youth	
  grievance.	
  Letters	
  to	
  youth	
   notifying	
  them	
  of	
  the	
  outcome	
  of	
  the	
  investigation	
  were	
  presented	
  to	
  all	
   youth	
  (100%).	
  However,	
  as	
  noted	
  in	
  the	
  previous	
  Monitor’s	
  Report,	
   although	
  letters	
  were	
  sent	
  out	
  in	
  every	
  case,	
  some	
  of	
  the	
  cases	
  had	
  a	
   significant	
  delay	
  between	
  the	
  date	
  the	
  investigation	
  was	
  completed	
  and	
   the	
  day	
  the	
  letter	
  was	
  drafted.	
  The	
  table	
  below	
  summarizes	
  the	
  key	
  dates	
   for	
  each	
  case:	
   	
  
Timeliness	
  of	
  Youth	
  Notification	
  Letters	
  

Investigation	
  #	
  

Date	
  Case	
  Closed	
  

Date	
  of	
  Letter	
   (business	
  days	
  from	
  
completion)	
  

Date	
  Signed	
  by	
   Youth	
  (business	
   days	
  from	
  letter	
  
being	
  sent)	
  

5501120080	
  

10/15/12	
  

11/21/12	
  (22	
  days)	
   11/26/12	
  (3	
  days)	
  

5501120098	
  

10/11/12	
  

11/6/12	
  (17	
  days)	
   11/7/12	
  (1	
  day)	
  

1001120087	
   (youth	
  1)	
  

10/13/12	
  

11/6/12	
  (17	
  days)	
   11/6/12	
  (~)	
  

1001120087	
   (youth	
  2)	
  

10/13/12	
  

11/6/12	
  (17	
  days)	
   11/6/12	
  (~)	
  

5501120105	
  

10/29/12**	
  

11/6/12	
  (6	
  days)	
  

11/6/12	
  (~)	
  

5501120110	
  

11/6/12**	
  

11/15/12	
  (7	
  days)	
   11/15/12	
  (~)	
  

5501120117	
  

11/30/12**	
  

12/6/12	
  (4	
  days)	
  

12/7/12	
  (1	
  day)	
  

5501120132	
  

1/4/12	
  

1/23/12	
  (13	
  days)	
   2/8/12	
  (12	
  days)	
  

**These	
  investigations	
  did	
  not	
  have	
  a	
  closure	
  date	
  on	
  the	
  log	
  submitted	
  to	
  the	
  Monitor,	
  so	
  the	
   date	
  the	
  investigation	
  was	
  completed	
  was	
  used.	
  Given	
  that	
  the	
  closure	
  occurs	
  after	
  the	
  report	
  is	
   submitted,	
  the	
  closure	
  date	
  would	
  not	
  change	
  the	
  outcome	
  of	
  this	
  analysis.	
  	
  
	
   Current	
  DYS	
  policy	
  does	
  not	
  set	
  a	
  specific	
  timeline	
  for	
  sending	
  out	
   notification	
  letters,	
  although	
  an	
  upcoming	
  revision	
  will	
  require	
  the	
  letters	
   to	
  be	
  sent	
  within	
  5	
  or	
  10	
  business	
  days.	
  Using	
  10	
  business	
  days	
  from	
  the	
   date	
  of	
  case	
  closure	
  as	
  an	
  outside	
  limit,	
  the	
  table	
  above	
  illustrates	
  that	
   letters	
  are	
  generally	
  not	
  sent	
  out	
  timely.	
  Across	
  the	
  8	
  investigations,	
  only	
   3	
  were	
  sent	
  out	
  timely	
  (38%;	
  range	
  4	
  to	
  22	
  business	
  days;	
  average	
  13	
   business	
  days).	
  It	
  is	
  also	
  worth	
  noting	
  that	
  the	
  Notification	
  Letter	
  for	
  one	
   of	
  these	
  investigations	
  (1101120087)	
  erroneously	
  indicated	
  that	
  the	
   allegation	
  was	
  unsubstantiated,	
  when	
  in	
  fact,	
  it	
  was	
  found	
  to	
  be	
  true.	
   Youth	
  generally	
  sign	
  the	
  Notification	
  Letters	
  in	
  a	
  timely	
  manner.	
  Although	
   the	
  situation	
  did	
  not	
  occur	
  during	
  the	
  current	
  monitoring	
  period,	
  in	
  the	
   past,	
  DYS	
  has	
  delivered	
  the	
  Notification	
  Letters	
  to	
  youth	
  who	
  were	
   released	
  prior	
  to	
  the	
  investigation’s	
  completion.	
   	
   Thus,	
  youth	
  are	
  being	
  notified	
  of	
  the	
  outcome	
  of	
  the	
  investigations,	
  but	
   the	
  notification	
  needs	
  to	
  be	
  timely	
  in	
  order	
  to	
  meet	
  the	
  spirit	
  of	
  the	
  

	
  

37.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 38 of 67 PAGEID #: 2532

Recommendations	
   Sources	
  of	
   Information	
  
	
   	
  

requirement	
  and	
  to	
  address	
  youth’s	
  persistent	
  belief	
  that	
  staff	
  are	
  not	
   held	
  accountable	
  for	
  their	
  behavior	
  in	
  any	
  meaningful	
  way.	
  	
  Prompt	
   notification	
  could	
  help	
  to	
  counteract	
  this	
  belief.	
  	
  The	
  CIO	
  plans	
  to	
   monitor	
  the	
  timeliness	
  of	
  the	
  Notification	
  Letters	
  in	
  the	
  future,	
  which	
   should	
  accelerate	
  progress	
  toward	
  compliance.	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Promptly	
  notify	
  youth	
  of	
  the	
  outcome	
  of	
  any	
  investigation	
   referred	
  via	
  the	
  grievance	
  process.	
  	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.D.1,	
  prepared	
  at	
  my	
  request	
  
• Q4	
  2012	
  and	
  Q1	
  2013	
  Grievance	
  Audits	
  completed	
  by	
  the	
  Chief	
   Inspector’s	
  Office	
  
• Grievance	
  Monthly	
  Reports,	
  October	
  2012	
  through	
  March	
  2013	
   • AMS	
  Grievance	
  Summary	
  for	
  grievances	
  submitted	
  October	
  2012	
  
through	
  March	
  2012	
   • List	
  of	
  Grievances	
  requiring	
  “follow-­‐up	
  action”	
  and	
  the	
  substance	
  
of	
  that	
  action,	
  Q1	
  2013	
   • List	
  of	
  Grievances	
  requiring	
  “corrective	
  action”	
  and	
  the	
  substance	
  
of	
  that	
  action,	
  Q4	
  2012	
  and	
  Q1	
  2013	
   • List	
  of	
  completed	
  investigations	
  that	
  were	
  triggered	
  by	
  a	
  
grievance,	
  October	
  2012	
  through	
  March	
  2013	
   • Copies	
  of	
  Youth	
  notification	
  letters	
  for	
  grievances	
  referred	
  for	
  
investigation,	
  October	
  2012	
  though	
  March	
  2013	
  
	
  

	
  

38.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 39 of 67 PAGEID #: 2533

	
  
III.D.2	
  Grievances	
  Explained	
  to	
  Youth.	
  A	
  clear	
  explanation	
  of	
  the	
  grievance	
  process	
  shall	
  be	
   provided	
  to	
  each	
  youth	
  upon	
  admission	
  to	
  the	
  facilities	
  during	
  orientation	
  and	
  to	
  their	
  parents	
   or	
  guardians,	
  and	
  the	
  youth’s	
  understanding	
  of	
  the	
  process	
  shall	
  be	
  at	
  least	
  verbally	
  verified.	
  	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Orientation	
  process	
  includes	
  two	
  videos—one	
  is	
  a	
  general	
   Orientation	
  video	
  covering	
  several	
  topics	
  including	
  Youth	
  Rights	
  and	
  the	
   purpose	
  of	
  the	
  grievance	
  system.	
  The	
  second	
  video	
  focuses	
  on	
  the	
   grievance	
  process	
  and	
  includes	
  information	
  about	
  what	
  to	
  do	
  if	
  the	
  youth	
   has	
  a	
  problem	
  with	
  living	
  conditions,	
  medical	
  care,	
  staff	
  treatment,	
   education	
  services,	
  etc.	
  The	
  video	
  describes	
  the	
  differing	
  roles	
  of	
  the	
   Grievance	
  Coordinator,	
  the	
  Chief	
  Inspector’s	
  Office,	
  and	
  the	
  Legal	
   Assistance	
  Program	
  attorneys.	
  Finally,	
  youth	
  are	
  provided	
  step-­‐by-­‐step	
   instructions	
  for	
  navigating	
  the	
  grievance	
  system.	
  The	
  information	
  in	
  the	
   video	
  is	
  reinforced	
  by	
  a	
  written	
  Youth	
  Grievance	
  Handbook,	
  which	
  an	
   intake	
  staff	
  member	
  discusses	
  with	
  the	
  youth.	
  Youth	
  are	
  also	
  provided	
   in-­‐depth	
  information	
  about	
  sexual	
  abuse	
  and	
  sexual	
  assault	
  in	
  the	
   correctional	
  setting,	
  and	
  how	
  to	
  handle	
  situations	
  in	
  which	
  they	
  may	
  feel	
   threatened	
  or	
  that	
  the	
  staff	
  is	
  being	
  inappropriate.	
  	
   	
   The	
  CIO	
  has	
  developed	
  a	
  formal	
  Lesson	
  Plan	
  for	
  each	
  DYS	
  facility’s	
   orientation	
  in	
  order	
  to	
  ensure	
  that	
  consistent,	
  accurate	
  information	
  is	
   delivered	
  to	
  all	
  DYS	
  youth.	
  The	
  most	
  recent	
  QA	
  report,	
  issued	
  February	
   2013,	
  found	
  that	
  Scioto	
  had	
  yet	
  to	
  implement	
  the	
  new	
  lesson	
  plan,	
  and	
   were	
  still	
  using	
  they	
  one	
  they	
  had	
  developed	
  internally.	
  	
   	
   All	
  youth	
  are	
  required	
  to	
  sign	
  several	
  forms	
  indicating	
  that	
  they	
  received	
   and	
  understand	
  information	
  about	
  the	
  grievance	
  process.	
  The	
  facility	
   audits	
  a	
  random	
  sample	
  of	
  admissions	
  files	
  every	
  month	
  to	
  ensure	
   compliance	
  with	
  policy	
  and	
  procedure.	
  Each	
  month,	
  October	
  2012	
   through	
  March	
  2013,	
  100%	
  of	
  the	
  youth	
  sampled	
  (30	
  total	
  youth;	
  10%	
  of	
   all	
  admissions)	
  received	
  a	
  complete	
  orientation	
  to	
  the	
  facility,	
  which	
   included	
  information	
  on	
  how	
  to	
  access	
  the	
  grievance	
  system.	
  Signed	
   Orientation	
  Acknowledgement	
  Forms	
  were	
  submitted	
  for	
  the	
  Monitor’s	
   verification.	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

The	
  State	
  continues	
  to	
  conduct	
  rigorous	
  audits	
  of	
  facility	
  records	
  to	
   ensure	
  that	
  the	
  Orientation	
  to	
  the	
  grievance	
  process	
  is	
  delivered	
  upon	
   admission.	
  All	
  of	
  the	
  underlying	
  documentation	
  submitted	
  to	
  the	
   Monitor	
  verified	
  the	
  reported	
  results—that	
  100%	
  of	
  the	
  sample	
  received	
   a	
  proper	
  introduction	
  to	
  the	
  grievance	
  process.	
  	
  

Recommendations	
   The	
  State	
  remains	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  	
  

Sources	
  of	
   Information	
  
	
  

• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.D.2,	
  prepared	
  at	
  my	
  request	
  
	
  

	
  

39.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 40 of 67 PAGEID #: 2534

III.F.1	
  Structured	
  Programming.	
  The	
  State	
  shall	
  provide	
  adequate	
  structured	
  rehabilitative	
   services,	
  including	
  an	
  appropriate	
  mix	
  of	
  physical,	
  recreational	
  or	
  leisure	
  activities	
  during	
  non-­‐ school	
  hours	
  and	
  days.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  structured	
  programming	
  from	
   the	
  end	
  of	
  the	
  school	
  day	
  until	
  youth	
  go	
  to	
  bed,	
  and	
  on	
  weekends.	
  	
   	
   For	
  youth	
  housed	
  in	
  closed-­‐cell	
  environments,	
  programming	
  shall	
  be	
  designed	
  to	
  ensure	
  that	
   youth	
  are	
  not	
  confined	
  in	
  locked	
  cells	
  except:	
  a)	
  from	
  after	
  programming	
  to	
  wake	
  up;	
  b)	
  as	
   necessary	
  where	
  youth	
  pose	
  an	
  immediate	
  risk	
  of	
  harm	
  to	
  self	
  or	
  others;	
  c)	
  following	
  an	
   adequate	
  disciplinary	
  hearing,	
  pursuant	
  to	
  an	
  appropriate	
  disciplinary	
  sanctions.	
  	
   	
   The	
  programming	
  shall	
  be	
  designed	
  to	
  modify	
  behaviors,	
  provide	
  rehabilitation	
  to	
  the	
  types	
  of	
   youth	
  committed	
  at	
  the	
  facility,	
  address	
  general	
  health	
  and	
  mental	
  health	
  needs,	
  and	
  be	
   coordinated	
  with	
  the	
  youth’s	
  individual	
  behavioral	
  and	
  treatment	
  plans.	
  The	
  State	
  shall	
  use	
   teachers,	
  school	
  administrators,	
  correctional	
  officers,	
  caseworkers,	
  school	
  counselors,	
  cottage	
   staff,	
  and	
  any	
  other	
  qualified	
  assistance	
  to	
  develop	
  and	
  implement	
  structured	
  programming.	
   The	
  State	
  shall	
  provide	
  youth	
  with	
  access	
  to	
  programming	
  activities	
  that	
  are	
  required	
  for	
  parole	
   eligibility.	
  	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

Structured	
  Programming	
   Via	
  the	
  S.H.	
  litigation,	
  the	
  DYS	
  developed	
  and	
  implemented	
  a	
  Quality	
   Assurance	
  Protocol	
  for	
  structured	
  programming	
  during	
  the	
  current	
   monitoring	
  period.	
  Over	
  the	
  years,	
  DYS	
  has	
  struggled	
  to	
  assemble	
  and	
   interpret	
  the	
  large	
  volume	
  of	
  data	
  regarding	
  program	
  participation.	
  The	
   QA	
  protocol	
  is	
  a	
  tremendous	
  breakthrough.	
  	
   	
   DYS	
  developed	
  a	
  full	
  set	
  of	
  standards	
  from	
  which	
  performance	
  can	
  be	
   measured.	
  Given	
  how	
  many	
  different	
  activities	
  comprise	
  Structured	
   Programming,	
  the	
  area	
  was	
  broken	
  into	
  component	
  parts.	
  Programming	
   includes	
  the	
  Managing	
  Anger	
  and	
  Violence	
  (MAV)	
  groups,	
  Victim	
   Awareness	
  groups	
  and	
  the	
  Phoenix	
  Program.	
  Standards	
  for	
  this	
   component	
  include:	
  
• All	
  youth	
  admitted	
  to	
  DYS	
  shall	
  participate	
  in	
  all	
  50	
  Core	
  B	
  (MAV)	
   sessions,	
  until	
  completed	
  or	
  released.	
  A	
  minimum	
  of	
  12	
  MAV	
   groups	
  shall	
  be	
  facilitated	
  monthly	
  by	
  staff	
  on	
  each	
  unit.	
  Unless	
   attending	
  a	
  priority	
  treatment	
  program,	
  youth	
  shall	
  attend	
  no	
   less	
  than	
  10	
  MAV	
  sessions	
  per	
  month	
  until	
  completion.	
  	
  
• Youth	
  identified	
  at	
  Intake	
  as	
  needing	
  victim	
  awareness	
  shall	
   attend	
  and	
  complete	
  the	
  Victim	
  Awareness	
  Education	
  Program	
   prior	
  to	
  release	
  from	
  the	
  facility.	
  A	
  minimum	
  of	
  4	
  Victim	
   Awareness	
  sessions	
  shall	
  be	
  facilitated	
  monthly	
  by	
  qualified	
  staff.	
   Until	
  completion,	
  identified	
  youth	
  shall	
  attend	
  no	
  less	
  than	
  4	
   Victim	
  Awareness	
  sessions	
  per	
  month.	
  Due	
  to	
  the	
  Victim	
   Awareness	
  Education	
  Program	
  being	
  a	
  closed	
  group,	
  a	
  waiting	
   list	
  shall	
  be	
  developed	
  and	
  available.	
  	
  
• If	
  appropriate,	
  youth	
  identified	
  as	
  active	
  Security	
  Threat	
  Group	
   (STG)	
  members	
  upon	
  admission,	
  or	
  at	
  any	
  point	
  during	
  their	
  

	
  

40.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 41 of 67 PAGEID #: 2535

incarceration,	
  shall	
  participate	
  in	
  the	
  Phoenix	
  Program.	
  A	
   minimum	
  of	
  4	
  Phoenix	
  Program	
  sessions	
  shall	
  be	
  facilitated	
   monthly	
  by	
  qualified	
  staff.	
  Until	
  completion,	
  identified	
  youth	
   shall	
  attend	
  no	
  less	
  than	
  4	
  Phoenix	
  sessions	
  per	
  month.	
  Due	
  to	
   the	
  Phoenix	
  Program	
  being	
  a	
  closed	
  group,	
  a	
  waiting	
  list	
  shall	
  be	
   developed	
  and	
  available.	
  	
   With	
  regard	
  to	
  Recreation	
  and	
  Community	
  Service,	
  the	
  following	
   standard	
  was	
  developed:	
   • Youth	
  shall	
  receive	
  at	
  least	
  one	
  hour	
  of	
  large	
  muscle	
  activity	
  per	
   day.	
  The	
  program	
  involves	
  a	
  wide	
  variety	
  of	
  physical	
  activities	
   and	
  intends	
  to	
  produce	
  physical	
  skill	
  building	
  and	
  personal	
   fitness.	
  At	
  least	
  70%	
  of	
  youth	
  are	
  expected	
  to	
  participate	
  in	
  the	
   Presidential	
  Fitness	
  Test	
  each	
  quarter.	
  Recreation	
  staff	
  provide	
   input	
  into	
  youth’s	
  treatment	
  reviews	
  by	
  attending	
  the	
  IDT	
   meetings	
  each	
  week.	
  Total	
  community	
  service	
  hours	
  should	
   equal	
  twice	
  the	
  ADP.	
  	
   With	
  regard	
  to	
  Religious	
  and	
  Volunteer	
  Programming,	
  the	
  following	
   standard	
  was	
  developed:	
   • In	
  order	
  to	
  reduce	
  idleness	
  and	
  advance	
  the	
  goal	
  of	
   rehabilitation,	
  the	
  facility	
  maintains	
  an	
  array	
  of	
  religious	
  and	
   volunteer-­‐led	
  programing	
  for	
  youth.	
  Each	
  facility	
  will	
  provide	
  a	
   minimum	
  of	
  350	
  hours	
  of	
  volunteer-­‐led	
  programming	
  each	
   month.	
  The	
  Chaplain	
  at	
  each	
  facility	
  will	
  offer,	
  at	
  a	
  minimum,	
  one	
   congregate	
  worship	
  service	
  each	
  week	
  for	
  eligible	
  youth.	
  	
   	
   Together,	
  these	
  five	
  Standards	
  cover	
  the	
  full	
  range	
  of	
  structured	
   programming	
  for	
  youth	
  and	
  provide	
  clear,	
  measurable	
  goals	
  for	
  youth’s	
   participation.	
  	
   	
   Using	
  these	
  standards	
  and	
  a	
  rigorous	
  methodology,	
  DYS	
  conducted	
  an	
   audit	
  of	
  the	
  facility’s	
  performance	
  in	
  March	
  2013.	
  The	
  findings	
  were	
   discouraging:	
   • Programming	
  results	
  were	
  mixed.	
  With	
  regard	
  to	
  MAV,	
  the	
  girls’	
   units	
  met	
  the	
  standard	
  related	
  to	
  the	
  groups,	
  but	
  did	
  not	
  meet	
   the	
  threshold	
  for	
  individual	
  participation	
  rates.	
  None	
  of	
  the	
  boys’	
   units	
  met	
  the	
  standards	
  for	
  groups,	
  and	
  only	
  one	
  youth	
  attended	
   the	
  minimum	
  number	
  of	
  MAV	
  sessions.	
  The	
  facility	
  met	
  the	
   standard	
  related	
  to	
  the	
  Phoenix	
  Program,	
  but	
  did	
  not	
  meet	
  the	
   standard	
  related	
  to	
  Victim	
  Awareness	
  programming.	
  	
   • With	
  regard	
  to	
  Recreation	
  and	
  Community	
  Service,	
  all	
  of	
  the	
   units	
  held	
  the	
  required	
  number	
  of	
  recreation	
  sessions,	
  and	
  all	
   but	
  1	
  had	
  sufficient	
  attendance	
  rates.	
  Participation	
  rates	
  were	
   high	
  in	
  6	
  of	
  the	
  7	
  units	
  (and	
  the	
  other	
  unit	
  only	
  missed	
  the	
   benchmark	
  by	
  2	
  percentage	
  points).	
  The	
  President’s	
  Physical	
   Fitness	
  Challenge	
  is	
  not	
  scheduled	
  until	
  June	
  2013,	
  so	
   participation	
  could	
  not	
  be	
  audited.	
  Only	
  12%	
  of	
  youth	
  in	
   seclusion	
  participated	
  in	
  recreation.	
  A	
  lack	
  of	
  detail	
  in	
  unit	
  

	
  

41.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 42 of 67 PAGEID #: 2536

records	
  prevented	
  the	
  auditor	
  from	
  assessing	
  GAT	
   presence/input	
  at	
  IDT	
  meetings.	
  The	
  facility	
  did	
  meet	
  the	
   standard	
  related	
  to	
  Community	
  Service,	
  with	
  each	
  youth	
  given	
  at	
   least	
  two	
  opportunities	
  to	
  participate	
  per	
  month.	
  	
   • With	
  regard	
  to	
  Religious	
  and	
  Volunteer-­‐Led	
  programming,	
  the	
   facility	
  exceeded	
  the	
  requirements	
  with	
  460	
  hours	
  of	
  Volunteer	
   Programming,	
  although	
  the	
  auditors	
  did	
  not	
  collect	
  the	
  required	
   information	
  on	
  youth	
  participation	
  levels.	
  The	
  facility	
  also	
  far	
   exceeded	
  the	
  requirements	
  around	
  Congregate	
  Services,	
  with	
  24	
   services	
  offered.	
  	
   	
   While	
  the	
  audit	
  results	
  are	
  concerning,	
  the	
  fact	
  that	
  DYS	
  is	
  now	
  capable	
   of	
  auditing	
  and	
  reporting	
  on	
  the	
  quality	
  of	
  youth	
  programming	
  in	
  an	
   integrated	
  and	
  coherent	
  fashion	
  is	
  a	
  tremendous	
  accomplishment.	
   Hopefully,	
  the	
  innovations	
  surrounding	
  the	
  auditing	
  process	
  will	
  lead	
  to	
   substantive	
  Quality	
  Improvement	
  Plans	
  that	
  will	
  accelerate	
  the	
  facility’s	
   movement	
  toward	
  substantial	
  compliance.	
  	
  	
   	
   Recently,	
  the	
  facility	
  changed	
  the	
  location	
  where	
  groups	
  (MAV,	
  Victim	
   Awareness,	
  Phoenix,	
  etc.)	
  are	
  held	
  to	
  ensure	
  that	
  groups	
  occur	
  as	
   scheduled.	
  Due	
  to	
  the	
  facility’s	
  low	
  population,	
  the	
  Annex	
  of	
  the	
  school	
   building	
  has	
  sufficient	
  capacity	
  to	
  house	
  groups	
  for	
  the	
  general	
   population	
  in	
  the	
  afternoons	
  and	
  on	
  weekends.	
  More	
  consistent	
   oversight	
  by	
  the	
  Unit	
  Managers,	
  improved	
  supervision	
  by	
  the	
  Youth	
   Specialists	
  and	
  focused	
  attention	
  from	
  the	
  Deputy	
  who	
  oversees	
   programming	
  should	
  ameliorate	
  the	
  problems	
  related	
  to	
  scheduling	
   revealed	
  by	
  the	
  QA	
  audit.	
  Problems	
  related	
  to	
  documentation	
  and	
  data	
   entry	
  were	
  also	
  identified	
  during	
  the	
  audit.	
  	
   	
   Programming	
  for	
  Graduates	
   During	
  the	
  previous	
  monitoring	
  period,	
  the	
  facility	
  made	
  significant	
   progress	
  in	
  developing	
  programming	
  for	
  youth	
  who	
  have	
  graduated	
  from	
   high	
  school	
  or	
  obtained	
  their	
  GED.	
  These	
  programs	
  have	
  all	
  been	
   sustained.	
  Graduates	
  are	
  engaged	
  throughout	
  the	
  day	
  in	
  a	
  combination	
   of	
  post-­‐secondary	
  education	
  and	
  employment.	
  	
   • The	
  primary	
  academic	
  program	
  is	
  delivered	
  by	
  Ashland	
  College,	
   which	
  provides	
  coursework	
  for	
  students	
  in	
  English	
  101,	
  Basic	
   Finance,	
  Entrepreneurship,	
  and	
  Accounting.	
  Courses	
  are	
  offered	
   on	
  a	
  rotating	
  basis	
  and	
  classes	
  are	
  held	
  twice	
  per	
  week	
  for	
  4.5	
   hours.	
  On	
  the	
  “off	
  days,”	
  study	
  hall	
  is	
  held.	
  	
   • An	
  additional	
  academic	
  program	
  is	
  delivered	
  by	
  Henkles	
  &	
   McCoy.	
  TechBridges/Employability	
  Skills	
  is	
  an	
  intensive	
  one-­‐ week	
  class,	
  held	
  from	
  8a	
  to	
  4:30p	
  each	
  day	
  and	
  offered	
  once	
  per	
   grading	
  period.	
  Youth	
  learn	
  how	
  to	
  disassemble	
  and	
  rebuild	
   computers,	
  and	
  also	
  learn	
  essential	
  employability	
  skills	
  to	
   prepare	
  them	
  for	
  release.	
  Upon	
  release,	
  students	
  are	
  connected	
   to	
  Henkels	
  &	
  McCoy’s	
  community	
  facility	
  where	
  they	
  may	
  

	
  

42.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 43 of 67 PAGEID #: 2537

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

continue	
  the	
  academic	
  instruction	
  and	
  also	
  receive	
  assistance	
   with	
  job	
  preparation	
  and	
  interview	
  skills.	
  	
   • The	
  Youth	
  Work	
  Program	
  was	
  designed	
  to	
  provide	
  jobs	
  for	
   graduates.	
  [Note:	
  non-­‐graduates	
  may	
  still	
  obtain	
  employment	
   through	
  Career	
  Based	
  Intervention.]	
  Graduates	
  must	
  under	
  go	
  an	
   application	
  and	
  interview	
  process	
  and	
  once	
  hired,	
  are	
  paid	
  $0.50	
   per	
  hour.	
  The	
  work	
  supervisor	
  communicates	
  regularly	
  with	
  the	
   youth’s	
  treatment	
  team	
  to	
  ensure	
  that	
  youth	
  are	
  maintaining	
  a	
   high	
  standard	
  of	
  behavior	
  and	
  performance	
  on	
  the	
  job.	
  Available	
   jobs	
  include:	
  cafeteria,	
  storeroom,	
  maintenance,	
  porters	
  for	
  the	
   living	
  units,	
  religious	
  services,	
  program	
  services,	
  school,	
   recreation	
  and	
  cosmetology	
  aides.	
  An	
  academic	
  tutor	
  is	
  paid	
   $0.90	
  per	
  hour.	
  Hours	
  vary	
  according	
  to	
  the	
  Department’s	
  need	
   and	
  the	
  youth’s	
  availability.	
  Graduates	
  may	
  work	
  up	
  to	
  35	
  hours	
   per	
  week	
  but	
  must	
  also	
  ensure	
  that	
  they	
  attend	
  all	
  required	
   treatment	
  programs.	
  There	
  are	
  enough	
  jobs	
  available	
  to	
  support	
   all	
  youth	
  who	
  desire	
  to	
  have	
  one.	
  	
  
Structured	
  Programming	
   The	
  DYS’	
  new	
  Quality	
  Assurance	
  protocol	
  provides	
  all	
  of	
  the	
  data	
   necessary	
  to	
  determine	
  whether	
  the	
  State	
  is	
  in	
  substantial	
  compliance	
   with	
  this	
  part	
  of	
  the	
  provision—the	
  Monitor	
  did	
  not	
  need	
  to	
  conduct	
  any	
   subsequent	
  audits.	
  As	
  noted	
  above,	
  the	
  March	
  2013	
  audit	
  revealed	
  some	
   serious	
  performance	
  deficits	
  that	
  must	
  be	
  rectified	
  in	
  order	
  to	
  reach	
   substantial	
  compliance	
  with	
  this	
  provision.	
  Once	
  the	
  scheduling	
  and	
   documentation/data	
  entry	
  issues	
  are	
  addressed,	
  another	
  audit	
  should	
  be	
   conducted	
  to	
  determine	
  whether	
  problems	
  remain.	
  The	
  Monitor	
  will	
   then	
  validate/confirm	
  the	
  QA	
  audit’s	
  findings	
  with	
  her	
  subsequent	
   audits.	
  	
   	
   Although	
  additional	
  data	
  collection	
  and	
  analysis	
  was	
  not	
  required	
  to	
   assess	
  compliance,	
  interviews	
  with	
  staff	
  and	
  the	
  Deputy	
  responsible	
  for	
   programming	
  suggested	
  that	
  the	
  facility	
  continues	
  to	
  evolve,	
  pushing	
   forward	
  to	
  ensure	
  that	
  youth’s	
  idle	
  time	
  is	
  limited.	
  A	
  Game	
  Room	
  and	
  a	
   Small	
  Muscle	
  Activity	
  area	
  equipped	
  with	
  board	
  games,	
  video	
  games,	
   foosball,	
  Ping-­‐Pong,	
  etc.	
  were	
  created.	
  Some	
  of	
  the	
  units	
  have	
  time	
   scheduled	
  into	
  these	
  rooms,	
  while	
  other	
  youth	
  are	
  permitted	
  to	
   purchase	
  admission	
  using	
  SBBMS	
  points.	
  In	
  addition,	
  the	
  facility	
  is	
   looking	
  to	
  bolster	
  the	
  volunteer	
  programming	
  available	
  to	
  males	
  in	
  the	
   general	
  population.	
  [During	
  the	
  time	
  that	
  Scioto	
  was	
  a	
  male	
  reception	
   center,	
  the	
  volunteer	
  programs	
  catered	
  to	
  the	
  female	
  population	
   because	
  of	
  their	
  longer	
  length	
  of	
  stays.]	
   	
   Programming	
  for	
  Graduates	
   At	
  the	
  time	
  of	
  the	
  Monitor’s	
  site	
  visit,	
  10	
  youth	
  housed	
  at	
  Scioto	
  had	
   graduated	
  from	
  High	
  School	
  or	
  obtained	
  a	
  GED.	
  Of	
  these,	
  90%	
  of	
  those	
   eligible	
  had	
  jobs	
  (one	
  youth	
  is	
  on	
  the	
  PU	
  and	
  is	
  not	
  eligible	
  to	
  have	
  a	
   job—the	
  UM	
  is	
  responsible	
  for	
  developing	
  a	
  daily	
  schedule	
  for	
  all	
  

	
  

43.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 44 of 67 PAGEID #: 2538

Recommendations	
  

graduate	
  youth;	
  the	
  other	
  youth	
  did	
  not	
  want	
  to	
  work).	
  Seven	
  of	
  the	
  10	
   youth	
  were	
  enrolled	
  in	
  the	
  Accounting	
  course	
  (those	
  not	
  attending	
  either	
   arrived	
  at	
  Scioto	
  after	
  the	
  class	
  began,	
  or	
  were	
  not	
  accepted	
  to	
  the	
   program).	
  A	
  female	
  youth	
  with	
  very	
  high	
  ACT	
  scores	
  was	
  also	
  taking	
  on-­‐ line	
  classes	
  at	
  Columbus	
  State.	
  Finally,	
  a	
  new	
  Job	
  Readiness	
  course	
  is	
   available	
  to	
  graduate	
  boys	
  in	
  the	
  general	
  population	
  (all	
  were	
  attending).	
   In	
  the	
  near	
  future,	
  an	
  11-­‐week	
  Barbering	
  class	
  that	
  offers	
  certification	
   will	
  be	
  available	
  as	
  well.	
  	
   	
   Attendance	
  records	
  for	
  the	
  graduate	
  academic	
  program	
  revealed	
  that	
  a	
   total	
  of	
  14	
  youth	
  participated	
  in	
  at	
  least	
  one	
  of	
  the	
  four	
  courses	
  offered	
   during	
  the	
  current	
  monitoring	
  period.	
  Youth	
  attendance	
  was	
  extremely	
   high,	
  with	
  few	
  class	
  periods	
  missed	
  by	
  any	
  youth.	
  Occasionally,	
  youth	
   were	
  removed	
  from	
  the	
  classes	
  due	
  to	
  on-­‐going,	
  serious	
  behavior	
  issues	
   that	
  disrupted	
  the	
  learning	
  environment.	
  	
   	
   The	
  facility	
  keeps	
  monthly	
  data	
  showing	
  the	
  proportion	
  of	
  graduates	
   who	
  are	
  employed.	
  Throughout	
  the	
  monitoring	
  period,	
  the	
  rate	
  of	
   employment	
  for	
  male	
  graduates	
  averaged	
  86%	
  (range	
  64%	
  to	
  100%)	
  and	
   the	
  rate	
  of	
  employment	
  for	
  female	
  graduates	
  averaged	
  94%	
  (range	
  66%	
   to	
  100%).	
  Each	
  month,	
  the	
  facility	
  had	
  a	
  surplus	
  of	
  available	
  jobs	
  and	
   clearly	
  has	
  the	
  capacity	
  to	
  accommodate	
  more	
  graduates	
  with	
  jobs,	
  if	
   needed.	
  	
  	
  	
   	
   When	
  interviewed,	
  graduate	
  youth	
  reported	
  there	
  was	
  “more	
  to	
  do	
  at	
   the	
  facility	
  than	
  there	
  used	
  to	
  be,”	
  although	
  also	
  noted	
  that	
  they	
  had	
   more	
  free	
  time	
  than	
  the	
  non-­‐graduate	
  youth	
  when	
  their	
  jobs	
  ended	
  for	
   the	
  day.	
  Overall,	
  the	
  facility	
  continues	
  to	
  operate	
  a	
  solid	
  program	
  for	
   graduates	
  that	
  constructively	
  occupies	
  the	
  portion	
  of	
  the	
  day	
  that	
  non-­‐ graduate	
  youth	
  spend	
  in	
  school.	
  	
   	
   PROGRESS	
  Unit	
  (PU)	
   Improvements	
  to	
  the	
  programming	
  schedule	
  for	
  youth	
  housed	
  on	
  the	
  PU	
   are	
  discussed	
  in	
  the	
  attached	
  Status	
  Report.	
  Once	
  DYS	
  achieves	
   substantial	
  compliance	
  with	
  the	
  Consent	
  Order,	
  information	
  on	
   programming	
  for	
  youth	
  on	
  the	
  PU	
  will	
  again	
  be	
  reported	
  here.	
  	
  	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Create	
  a	
  Quality	
  Improvement	
  Plan	
  to	
  improve	
  compliance	
  with	
   QA	
  standards	
  related	
  to	
  all	
  three	
  components	
  of	
  Structured	
   Programming.	
  Implement	
  strategies	
  directed	
  at	
  each	
  of	
  the	
   underlying	
  causes	
  of	
  the	
  failure	
  to	
  meet	
  performance	
  standards.	
   Track	
  the	
  effectiveness	
  of	
  these	
  strategies	
  on	
  a	
  monthly	
  basis	
   until	
  the	
  problems	
  are	
  rectified.	
  	
  
2. Once	
  the	
  Consent	
  Order	
  related	
  to	
  the	
  PROGRESS	
  Unit	
  has	
  been	
   satisfied,	
  continue	
  to	
  implement	
  structured	
  programming	
   opportunities	
  for	
  youth	
  housed	
  on	
  the	
  PROGRESS	
  Unit,	
  as	
  

	
  

44.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 45 of 67 PAGEID #: 2539

Sources	
  of	
   Information	
  
	
   	
  

required	
  by	
  this	
  provision.	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.F.1,	
  prepared	
  at	
  my	
  request	
  
• Interview	
  with	
  Deputy	
  Superintendent	
  for	
  Programming	
   • Quality	
  Assurance	
  audit	
  for	
  Structured	
  Programming,	
  March	
  
2013	
   • Work	
  schedules	
  for	
  graduates	
  housed	
  at	
  Scioto	
  as	
  of	
  October	
  1,	
  
2012	
   • Course	
  attendance	
  records	
  for	
  all	
  post-­‐secondary	
  courses	
  held	
  
since	
  October	
  1,	
  2012	
  
	
  

	
  

45.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 46 of 67 PAGEID #: 2540

	
  
III.F.2	
  Orientation.	
  	
   a) Admissions	
  Intake	
  and	
  Orientation.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  establish	
  a	
  consistent,	
  orderly	
  admissions	
  intake	
  system,	
   conducive	
  to	
  gathering	
  necessary	
  information	
  about	
  youth,	
  disseminating	
  information	
   to	
  staff	
  providing	
  services	
  and	
  care	
  for	
  youth,	
  and	
  maintaining	
  youth	
  safety.	
  The	
   orientation	
  shall	
  also	
  clearly	
  set	
  forth	
  the	
  rules	
  youth	
  must	
  follow	
  at	
  the	
  facility,	
  explain	
   how	
  to	
  access	
  medical	
  and	
  mental	
  health	
  care	
  and	
  the	
  grievance	
  system,	
  and	
  provide	
   other	
  information	
  pertinent	
  to	
  the	
  youth’s	
  participation	
  in	
  facility	
  programs.	
   b) Notice	
  to	
  Youth	
  of	
  Facility	
  Rules	
  and	
  Incentives/Consequences	
  for	
  Compliance.	
  The	
  State	
   shall	
  explain	
  the	
  structured	
  programming	
  to	
  all	
  youth	
  during	
  an	
  orientation	
  session	
  that	
   shall	
  set	
  forth	
  the	
  facility	
  rules,	
  the	
  positive	
  incentives	
  for	
  compliance	
  and	
  good	
  behavior	
   and	
  the	
  sanctions	
  for	
  rule	
  violations.	
  The	
  State	
  shall	
  provide	
  the	
  facility	
  rules	
  in	
  writing.	
  	
  	
   c) Introductory	
  Handbook,	
  Orientation	
  and	
  Reporting	
  Abuse.	
  Each	
  youth	
  entering	
  the	
   facilities	
  shall	
  be	
  given	
  an	
  orientation	
  that	
  shall	
  include	
  simple	
  directions	
  for	
  reporting	
   abuse	
  and	
  assuring	
  youth	
  of	
  his/her	
  right	
  to	
  be	
  protected	
  from	
  retaliation	
  for	
  reporting	
   allegations	
  of	
  abuse.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  facility	
  continues	
  to	
  audit	
  a	
  random	
  10%	
  sample	
  of	
  admissions	
  files	
   every	
  month	
  to	
  ensure	
  compliance	
  with	
  policy	
  and	
  procedure.	
  Between	
   October	
  2012	
  and	
  March	
  2013,	
  approximately	
  300	
  youth	
  were	
  admitted	
   to	
  the	
  facility;	
  10%,	
  or	
  30	
  youth,	
  were	
  included	
  in	
  the	
  audit.	
  Each	
  month,	
   the	
  audits	
  found	
  that	
  100%	
  of	
  the	
  youth	
  sampled	
  received	
  a	
  complete	
   orientation	
  to	
  the	
  facility	
  which	
  included,	
  among	
  other	
  things:	
  
• Youth	
  Handbook	
   • Orientation	
  Video	
   • Facility	
  rules	
  and	
  consequences	
  (IRAV)	
   • Strength	
  Based	
  Behavior	
  Management	
  System	
  (SBBMS)	
   • Obtaining	
  legal	
  assistance	
   • Accessing	
  medical	
  and	
  mental	
  health	
  care	
   • Sexual	
  abuse	
  and	
  sexual	
  assault	
  information	
   • Grievance	
  system	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Religious	
  Accommodations	
   With	
  the	
  update	
  of	
  the	
  Youth	
  Handbook	
  and	
  appropriate	
  response	
  to	
   grievances	
  pertaining	
  to	
  religious	
  freedom,	
  the	
  DYS	
  satisfied	
  the	
   requirements	
  of	
  this	
  provision	
  during	
  the	
  previous	
  monitoring	
  period.	
   During	
  the	
  current	
  monitoring	
  period,	
  three	
  youth	
  submitted	
  grievances	
   pertaining	
  to	
  religious	
  freedom.	
  Two	
  of	
  these	
  were	
  found	
  to	
  have	
  no	
   merit:	
  
• A	
  youth	
  requested	
  information	
  about	
  Wicca.	
  He	
  had	
  already	
   received	
  all	
  of	
  the	
  information,	
  and	
  had	
  met	
  with	
  both	
  the	
   librarian	
  and	
  the	
  Chaplain.	
  	
  
• A	
  youth	
  complained	
  that	
  he’d	
  received	
  a	
  YBIR	
  for	
  wearing	
  a	
  kufi.	
   The	
  YBIR	
  was	
  issued	
  because	
  the	
  kufi	
  did	
  not	
  belong	
  to	
  the	
   youth.	
  	
  

	
  

46.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 47 of 67 PAGEID #: 2541

Recommendations	
   Sources	
  of	
   Information	
  
	
   	
  
	
  

One	
  of	
  the	
  grievances	
  was	
  found	
  to	
  have	
  merit:	
   • A	
  youth	
  did	
  not	
  want	
  to	
  shave	
  because	
  it	
  violated	
  his	
  religious	
   beliefs.	
  [The	
  youth	
  is	
  Muslim.]	
  His	
  request	
  was	
  granted.	
  	
  
	
   The	
  Youth	
  Handbook	
  clearly	
  articulates	
  that	
  youth	
  are	
  free	
  to	
  practice	
   their	
  religion	
  of	
  choice	
  and	
  the	
  facility	
  continues	
  to	
  demonstrate	
  its	
   willingness	
  to	
  make	
  religious	
  accommodations	
  when	
  the	
  issue	
  has	
  arisen.	
  	
   	
   PROGRESS	
  Unit	
  Orientation	
   While	
  most	
  of	
  the	
  youth	
  at	
  Scioto	
  undergo	
  an	
  orientation	
  to	
  the	
  general	
   population,	
  youth	
  can	
  also	
  be	
  admitted	
  directly	
  to	
  the	
  PROGRESS	
  Unit	
   (PU),	
  and	
  thus	
  the	
  orientation	
  for	
  that	
  program	
  is	
  relevant	
  to	
  this	
   provision.	
  SOP	
  303.01.07	
  “Unit	
  PROGRESS”	
  requires	
  the	
  Unit	
  Manager	
  to	
   ensure	
  that	
  the	
  PU	
  Youth	
  Handbook	
  is	
  available	
  to	
  all	
  youth	
  and	
  that	
  a	
   staff	
  member	
  provides	
  a	
  thorough	
  orientation	
  to	
  youth	
  upon	
  their	
   admission	
  to	
  the	
  Unit.	
  Youth	
  must	
  sign	
  the	
  Handbook’s	
  signature	
  page	
  to	
   acknowledge	
  receipt	
  of	
  the	
  information.	
  Both	
  the	
  policy	
  and	
  handbook	
   (now	
  final	
  and	
  signed	
  into	
  effect!)	
  are	
  the	
  subject	
  of	
  the	
  Consent	
  Order	
   covering	
  the	
  Unit’s	
  operation	
  and	
  thus	
  are	
  not	
  discussed	
  here.	
  However,	
   given	
  that	
  some	
  youth	
  enter	
  the	
  facility	
  via	
  the	
  PU,	
  their	
  timely	
   orientation	
  is	
  discussed	
  in	
  this	
  report.	
  	
   	
   During	
  the	
  current	
  monitoring	
  period,	
  14	
  youth	
  were	
  admitted	
  to	
  the	
  PU	
   (some	
  youth	
  had	
  multiple	
  admissions,	
  but	
  are	
  counted	
  separately	
  given	
   that	
  they	
  must	
  receive	
  an	
  orientation	
  on	
  each	
  admission).	
  Signed	
   “Handbook	
  Signature	
  Sheets”	
  were	
  submitted	
  for	
  all	
  youth	
  and	
  verified	
   that	
  all	
  youth	
  received	
  a	
  timely	
  Orientation	
  (usually	
  on	
  the	
  same	
  day	
  of	
   transfer,	
  occasionally	
  on	
  the	
  next	
  day).	
  	
  	
  	
  
The	
  State	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  	
  
• Self-­‐assessment	
  data	
  and	
  oral	
  presentation	
  of	
  its	
  interpretation	
   for	
  III.F.2,	
  prepared	
  at	
  my	
  request	
  
• Intake	
  Audit	
  Report,	
  October	
  2012	
  through	
  March	
  2013	
   • Scioto	
  Youth	
  Handbook,	
  last	
  modified	
  March	
  16,	
  2012	
   • Grievances	
  related	
  to	
  religious	
  accommodation	
  (n=3),	
  submitted	
  
between	
  October	
  2012	
  and	
  March	
  2013	
   • Admission	
  dates	
  and	
  orientation	
  records	
  for	
  youth	
  admitted	
  to	
  
the	
  PROGRESS	
  Unit	
  since	
  October	
  1,	
  2012	
  	
  
	
  

	
  

47.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 48 of 67 PAGEID #: 2542

MEDICAL	
  SERVICES	
   	
  
	
  
III.C.1	
  	
  General.	
  The	
  facilities	
  shall	
  ensure	
  that	
  the	
  individuals	
  they	
  serve	
  receive	
  routine,	
   preventive,	
  and	
  emergency	
  medical	
  and	
  dental	
  care	
  consistent	
  with	
  current,	
  generally	
  accepted	
   professional	
  standards.	
  The	
  facilities	
  shall	
  ensure	
  that	
  individuals	
  with	
  health	
  problems	
  are	
   identified,	
  assessed,	
  diagnosed,	
  and	
  treated	
  consistent	
  with	
  current,	
  generally	
  accepted	
   professional	
  standards	
  of	
  care.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Ohio	
  Department	
  of	
  Youth	
  Services	
  (ODYS)	
  does	
  not	
  conduct	
  a	
  self-­‐ assessment	
  for	
  the	
  level	
  of	
  medical	
  and	
  dental	
  care	
  provided	
  at	
  SJCF.	
   However,	
  there	
  continues	
  to	
  be	
  improvement	
  in	
  their	
  quality	
  assurance	
   processes,	
  which	
  in	
  essence	
  completes	
  the	
  task	
  of	
  self-­‐assessment	
  for	
  the	
   purpose	
  of	
  this	
  report.	
  Also,	
  the	
  facility	
  was	
  accredited	
  through	
  the	
   American	
  Correctional	
  Association	
  (ACA)	
  in	
  September	
  2012	
  to	
  include	
   health	
  care	
  standards.	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

An	
  onsite	
  visit	
  was	
  conducted	
  at	
  the	
  Scioto	
  Juvenile	
  Correctional	
  Facility	
   on	
  April	
  23-­‐25,	
  2013.	
  It	
  was	
  this	
  monitor’s	
  third	
  visit	
  to	
  the	
  facility.	
  All	
   previous	
  reviews	
  of	
  health	
  information	
  and	
  other	
  related	
  documents	
  had	
   been	
  conducted	
  off	
  site	
  from	
  records	
  provided	
  by	
  ODYS.	
  	
  All	
  living	
  units	
   where	
  youth	
  were	
  being	
  housed	
  were	
  visited.	
  The	
  Hunter	
  and	
  Carver	
   Units	
  had	
  been	
  closed.	
  There	
  has	
  been	
  a	
  continuing	
  decrease	
  in	
  the	
   facility’s	
  population	
  over	
  the	
  last	
  several	
  visits,	
  down	
  to	
  37	
  males	
  and	
  17	
   females	
  on	
  this	
  site	
  visit.	
  The	
  location	
  of	
  the	
  sick	
  call	
  health	
  request	
  boxes	
   and	
  availability	
  of	
  the	
  health	
  request	
  slips	
  were	
  observed	
  on	
  each	
  living	
   unit.	
  Slips	
  were	
  not	
  in	
  place	
  outside	
  the	
  box	
  on	
  two	
  units.	
  Youth	
  were	
   interviewed	
  on	
  the	
  units	
  as	
  to	
  how	
  to	
  access	
  health	
  services	
  and	
  if	
  they	
   had	
  any	
  complaints	
  regarding	
  their	
  medical	
  care.	
  All	
  the	
  youth	
  I	
   interviewed	
  knew	
  the	
  correct	
  process	
  to	
  obtain	
  health	
  services	
  and	
  had	
   no	
  complaints	
  about	
  the	
  health	
  services.	
  There	
  was	
  one	
  complaint	
  made	
   to	
  a	
  member	
  of	
  the	
  team	
  by	
  one	
  of	
  the	
  females	
  that	
  she	
  had	
  been	
   ignored	
  by	
  the	
  medical	
  staff	
  while	
  in	
  labor.	
  	
   	
   The	
  food	
  service	
  area	
  was	
  toured	
  and	
  the	
  medication	
  room	
  located	
  there	
   observed.	
  The	
  satellite	
  clinics	
  for	
  Buckeye	
  have	
  not	
  been	
  completed.	
  The	
   population	
  housed	
  on	
  those	
  Progress	
  units	
  has	
  been	
  significantly	
   reduced.	
  The	
  main	
  clinic	
  was	
  still	
  found	
  to	
  be	
  adequate,	
  with	
  appropriate	
   space,	
  medical	
  supplies	
  and	
  equipment	
  for	
  medical	
  and	
  dental	
  care	
  of	
   the	
  youth.	
   	
  	
   A	
  review	
  of	
  seven	
  youth	
  health	
  records	
  housed	
  at	
  the	
  Scioto	
  Facility	
  was	
   conducted.	
  This	
  included	
  three	
  females	
  and	
  four	
  males.	
  The	
  health	
   record	
  review	
  included	
  assessing	
  completeness	
  of	
  the	
  Problem	
  List,	
  the	
   presence	
  and	
  timeliness	
  of	
  the	
  Nursing	
  Intake	
  Screening,	
  Mental	
  Health	
   Screening,	
  Physical	
  Exam,	
  Dental	
  Exam,	
  Dental	
  Treatment,	
  Oral	
  Hygiene	
  

	
  

48.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 49 of 67 PAGEID #: 2543

Instruction	
  and	
  Growth	
  Chart.	
  	
  Admission	
  labs	
  were	
  checked	
  for	
   completion	
  and	
  results	
  within	
  20	
  days;	
  STD	
  screening	
  for	
  Gonorrhea	
  and	
   Chlamydia;	
  Chronic	
  Care	
  and	
  Specialty	
  Care	
  Consult	
  documentation;	
   Transfer	
  of	
  Health	
  Records;	
  Immunizations	
  and	
  Tuberculosis	
  Screening;	
   Medication	
  Administration	
  Records;	
  Mental	
  Health	
  Documentation;	
   Youth	
  Injury	
  and	
  Assessment	
  Forms;	
  Youth	
  Health	
  Requests	
  and	
  medical	
   staff	
  responses;	
  Progress	
  Notes	
  including	
  seclusion	
  checks	
  and	
  Physician	
   Orders	
  were	
  identified	
  in	
  each	
  health	
  record.	
  	
   	
   All	
  health	
  records	
  documented	
  timely	
  completion	
  of	
  intake	
  assessments.	
  	
   Nurse	
  screening	
  health	
  appraisals	
  were	
  completed	
  on	
  the	
  same	
  day	
  of	
   admission.	
  Physical	
  examinations,	
  including	
  gynecological	
  exams	
  for	
   females	
  were	
  completed	
  the	
  following	
  day.	
  Problem	
  lists	
  were	
  inclusive	
   of	
  medical,	
  mental	
  health	
  and	
  dental	
  conditions.	
  Growth	
  charts	
  were	
   present	
  in	
  the	
  health	
  records	
  of	
  all	
  youth.	
  All	
  youth	
  allergies	
  were	
  noted	
   on	
  their	
  health	
  record.	
  	
  	
   	
   There	
  was	
  documentation	
  of	
  admission	
  labs	
  being	
  drawn	
  with	
  results	
   available	
  all	
  within	
  a	
  week.	
  Specialized	
  laboratory	
  testing	
  was	
   documented	
  such	
  as	
  Strep	
  testing,	
  Hemoglobin	
  A1C	
  for	
  diabetes,	
  and	
   Beta	
  HCG	
  for	
  pregnancy	
  confirmation.	
  STD	
  (Gonorrhea	
  and	
  Chlamydia)	
   urine	
  screening	
  test	
  results	
  were	
  documented	
  in	
  all	
  records.	
  One	
  youth	
   identified	
  in	
  the	
  screening	
  process	
  to	
  be	
  positive	
  for	
  a	
  Chlamydia	
  STD	
   received	
  treatment.	
  Immunization	
  records	
  were	
  present	
  in	
  all	
  records	
   reviewed.	
  HPV	
  vaccine	
  is	
  now	
  being	
  administered	
  to	
  youth,	
  male	
  and	
   female	
  (43	
  in	
  the	
  last	
  quarter).	
  The	
  previous	
  back	
  order	
  on	
  the	
   HPV	
  vaccine	
  through	
  the	
  Federal	
  Vaccines	
  for	
  Children	
  Program	
  has	
  been	
   resolved	
  with	
  only	
  one	
  youth	
  of	
  seven	
  reviewed	
  not	
  receiving	
  that	
   vaccine.	
  All	
  youth	
  reviewed	
  received	
  tuberculosis	
  screening	
  with	
   documented	
  results.	
  One	
  youth	
  with	
  a	
  previous	
  history	
  of	
  a	
  positive	
  TB	
   skin	
  test	
  appropriately	
  received	
  a	
  chest	
  x-­‐ray	
  upon	
  admission,	
  rather	
  than	
   another	
  skin	
  test	
  being	
  administered.	
  	
   	
   Dental	
  examinations	
  were	
  completed	
  within	
  three	
  days	
  of	
  admission	
  with	
   instruction	
  given	
  on	
  oral	
  hygiene	
  and	
  prophylaxis	
  completed.	
  Dental	
   treatment	
  was	
  provided	
  as	
  a	
  result	
  of	
  the	
  dental	
  examination	
  or	
  as	
  a	
   result	
  of	
  a	
  health	
  request	
  in	
  a	
  timely	
  manner.	
  Two	
  long	
  term	
  youth	
  were	
   recalled	
  for	
  routine	
  dental	
  care	
  annually.	
  The	
  latest	
  recommendation	
   from	
  the	
  American	
  Dental	
  Association	
  is	
  for	
  dental	
  prophylaxis	
  to	
  be	
   completed	
  every	
  6	
  months.	
  	
  	
  	
   	
   Medication	
  administration	
  records	
  (MAR)	
  and	
  physician	
  orders	
  were	
  also	
   reviewed	
  for	
  accuracy	
  and	
  medication	
  compliance.	
  Nurses	
  are	
   documenting	
  medication	
  administration	
  as	
  well	
  as	
  when	
  youth	
  refuse	
   medications.	
  In	
  two	
  cases,	
  the	
  MAR	
  was	
  also	
  utilized	
  to	
  document	
  blood	
   pressure	
  checks.	
  Special	
  diets	
  were	
  ordered	
  appropriately.	
   	
  

	
  

49.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 50 of 67 PAGEID #: 2544

Few	
  youth	
  with	
  chronic	
  medical	
  conditions	
  were	
  housed	
  at	
  Scioto.	
  Of	
  the	
   records	
  reviewed,	
  there	
  was	
  one	
  diabetic	
  and	
  two	
  hypertensive	
  youth	
   housed	
  at	
  Scioto.	
  All	
  received	
  appropriate	
  assessments	
  and	
  treatment	
   plans.	
  The	
  diabetic	
  youth	
  that	
  also	
  had	
  a	
  history	
  of	
  asthma,	
  received	
  a	
   special	
  diet,	
  proper	
  medication	
  management,	
  blood	
  glucose	
  monitoring,	
   appropriate	
  laboratory	
  testing,	
  and	
  ophthalmology	
  and	
  endocrine	
   specialty	
  consults.	
  One	
  youth	
  was	
  pregnant	
  when	
  admitted	
  on	
  11/2/12	
   to	
  the	
  facility	
  and	
  delivered	
  during	
  her	
  stay.	
  Her	
  obstetrical	
  care	
  provided	
   during	
  her	
  stay	
  was	
  reviewed	
  based	
  on	
  her	
  statement	
  to	
  a	
  member	
  of	
   the	
  monitoring	
  team	
  that	
  her	
  complaint	
  of	
  labor	
  pain	
  was	
  ignored	
  by	
   medical	
  staff.	
  She	
  had	
  been	
  seen	
  by	
  Dr.	
  Stein	
  at	
  the	
  facility	
  and	
  received	
   9	
  regular	
  visits	
  to	
  Dr.	
  Koffler,	
  Obstetrician	
  for	
  Central	
  Ohio	
  OBGYN,	
  the	
   last	
  of	
  which	
  was	
  the	
  day	
  before	
  she	
  delivered	
  on	
  4/17/13.	
  At	
  that	
  time	
   there	
  was	
  no	
  indication	
  of	
  her	
  being	
  in	
  active	
  labor	
  at	
  39	
  weeks	
  pregnant.	
   On	
  4/18/13,	
  youth	
  began	
  complaining	
  of	
  back	
  and	
  stomach	
  pain	
  at	
  7:15	
   AM.	
  She	
  was	
  seen	
  by	
  medical	
  staff	
  at	
  that	
  time	
  and	
  again	
  at	
  10:05	
  AM	
   complaining	
  of	
  pain	
  and	
  wanting	
  a	
  tranquilizer.	
  Medical	
  explained	
  the	
   labor	
  process	
  and	
  encouraged	
  walking	
  and	
  fluid	
  intake.	
  Contractions	
   were	
  irregular	
  at	
  that	
  time.	
  Youth	
  was	
  brought	
  from	
  school	
  on	
  the	
  golf	
   cart	
  to	
  medical	
  and	
  seen	
  at	
  12:47	
  PM	
  with	
  continuing	
  irregular	
   contractions,	
  having	
  vomited	
  a	
  small	
  amount	
  after	
  eating	
  lunch.	
  Her	
   baby’s	
  heart	
  rate	
  was	
  documented	
  on	
  the	
  exam.	
  Youth	
  was	
  instructed	
  to	
   return	
  to	
  the	
  unit	
  and	
  rest	
  with	
  increased	
  fluids.	
  The	
  facility	
  nurse	
   contacted	
  Dr.	
  Koffler’s	
  office	
  and	
  informed	
  their	
  nurse	
  practitioner	
  of	
  the	
   situation	
  and	
  asked	
  for	
  any	
  further	
  instructions.	
  At	
  3:15	
  PM,	
  medical	
  was	
   called	
  and	
  unit	
  staff	
  reported	
  passage	
  of	
  the	
  mucous	
  plug.	
  Youth	
  was	
   assessed	
  in	
  medical	
  with	
  regular	
  contractions	
  2-­‐3	
  minutes	
  apart	
  and	
  fetal	
   heart	
  tones	
  present.	
  Youth	
  was	
  then	
  transported	
  to	
  Grady	
  Memorial	
   Hospital	
  and	
  delivered	
  without	
  complications	
  at	
  5:15	
  PM,	
  progressing	
   faster	
  than	
  usual	
  for	
  a	
  first	
  delivery.	
   	
   Three	
  of	
  the	
  seven	
  youth	
  records	
  reviewed	
  had	
  at	
  least	
  one	
  mental	
   health	
  diagnosis.	
  	
  Mental	
  health	
  diagnoses	
  have	
  continued	
  to	
  be	
   consistently	
  listed	
  on	
  the	
  problem	
  list	
  along	
  with	
  the	
  medical	
  diagnoses.	
   None	
  of	
  the	
  psychological	
  documentation	
  for	
  the	
  youth	
  in	
  included	
  in	
  the	
   health	
  record.	
   	
   When	
  nurses	
  made	
  seclusion	
  checks,	
  they	
  were	
  documented	
  in	
  the	
   progress	
  notes.	
  Logs	
  were	
  posted	
  on	
  the	
  unit	
  doors.	
  There	
  appears	
  to	
  be	
   some	
  reduction	
  in	
  the	
  use	
  of	
  room	
  seclusion	
  based	
  on	
  documentation	
  in	
   the	
  health	
  record.	
  One	
  youth	
  housed	
  on	
  the	
  Progress	
  Unit	
  averaged	
   about	
  four	
  episodes	
  of	
  room	
  seclusion	
  a	
  month	
  between	
  November	
  13th	
   and	
  February	
  1st.	
  	
  For	
  the	
  remainder	
  of	
  February	
  and	
  March	
  there	
  were	
   still	
  about	
  the	
  same	
  number	
  of	
  room	
  seclusions,	
  but	
  the	
  number	
  of	
  days	
   in	
  each	
  episode	
  grew	
  shorter.	
  	
  The	
  medical	
  progress	
  notes	
  state	
   “seclusion	
  check”	
  and	
  now	
  include	
  details	
  of	
  the	
  youth’s	
  health	
  status	
  in	
   SOAP	
  format.	
  This	
  is	
  an	
  improvement	
  over	
  the	
  last	
  site	
  visit.	
  	
  

	
  

50.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 51 of 67 PAGEID #: 2545

	
  

	
  

Documentation	
  on	
  the	
  Youth	
  injury	
  and	
  Assessment	
  Reports	
  were	
  

reviewed	
  for	
  those	
  included	
  in	
  the	
  seven	
  health	
  records.	
  The	
  

documentation	
  provided	
  by	
  nursing	
  staff	
  for	
  youth	
  assessed	
  for	
  injuries	
  

has	
  significantly	
  improved.	
  The	
  Nurse	
  Manager,	
  Ms.	
  Vickie	
  Donohue	
  has	
  

continued	
  to	
  monitor	
  these	
  assessments	
  through	
  the	
  continuous	
  quality	
  

improvement	
  (CQI)	
  review	
  process.	
  There	
  was	
  one	
  Youth	
  Injury	
  and	
  

Assessment	
  form	
  reviewed	
  secondary	
  to	
  an	
  allegation	
  of	
  staff	
  abuse.	
  

Medical	
  was	
  called	
  on	
  3/23/13	
  to	
  the	
  Cedar	
  Unit	
  to	
  assess	
  youth	
  after	
  he	
  

had	
  assaulted	
  a	
  staff	
  member.	
  At	
  5:55	
  PM,	
  a	
  visual	
  check	
  was	
  made	
  by	
  

the	
  nurse	
  and	
  no	
  injuries	
  noted.	
  The	
  youth	
  had	
  no	
  complaints	
  and	
  was	
  

told	
  he	
  would	
  be	
  further	
  assessed	
  in	
  the	
  exam	
  room	
  when	
  he	
  calmed	
  

down.	
  At	
  approximately	
  6:15	
  PM,	
  youth	
  was	
  escorted	
  by	
  unit	
  staff	
  cuffed	
  

from	
  behind	
  to	
  the	
  exam	
  room.	
  No	
  visible	
  injuries	
  to	
  the	
  face	
  or	
  hands	
  

were	
  noted.	
  Youth	
  denied	
  having	
  any	
  injuries	
  twice	
  to	
  medical	
  staff.	
  

Youth	
  was	
  taken	
  to	
  Sycamore	
  Unit	
  by	
  staff.	
  Youth	
  requested	
  to	
  see	
  nurse	
  

and	
  was	
  taken	
  to	
  exam	
  room	
  on	
  unit	
  at	
  approximately	
  6:40	
  PM.	
  	
  Youth	
  

then	
  made	
  an	
  allegation	
  to	
  the	
  nurse	
  that	
  staff	
  beat	
  him	
  up.	
  The	
  medical	
  

exam	
  at	
  that	
  time	
  documented	
  that	
  the	
  left	
  side	
  of	
  his	
  face	
  was	
  swollen	
  

and	
  tender,	
  his	
  left	
  forearm	
  and	
  wrist	
  were	
  swollen	
  with	
  deformity	
  and	
  

his	
  left	
  ankle	
  swollen.	
  He	
  complained	
  of	
  pain	
  upon	
  touching	
  his	
  face,	
  arm	
  

and	
  wrist.	
  He	
  had	
  visual	
  complaints	
  that	
  had	
  resolved	
  by	
  the	
  time	
  of	
  the	
  

exam.	
  	
  

	
  

Internal	
  Continuous	
  Quality	
  Improvement	
  (CQI)	
  documents	
  were	
  

reviewed	
  that	
  were	
  provided	
  by	
  the	
  Scioto	
  nurse	
  manager.	
  The	
  nurse	
  

manager	
  and	
  staff	
  nurses	
  continue	
  to	
  participate	
  in	
  the	
  CQI	
  process.	
  The	
  

Medication	
  Administration	
  Record	
  CQI	
  document	
  for	
  January	
  2013	
  

averaged	
  87%	
  based	
  on	
  the	
  10	
  compliance	
  indicators	
  reviewed.	
  The	
  CQI	
  

Intra-­‐system	
  Transfer	
  tool	
  of	
  January	
  2013	
  showed	
  100%	
  compliance	
  for	
  

nine	
  of	
  ten	
  quality	
  indicators	
  with	
  75%	
  for	
  one	
  indicators	
  regarding	
  

documentation	
  in	
  the	
  progress	
  notes.	
  Four	
  charts	
  in	
  January	
  and	
  five	
  

charts	
  in	
  April	
  were	
  selected	
  for	
  a	
  CQI	
  audit	
  of	
  the	
  processing	
  of	
  specialty	
  

consults.	
  There	
  was	
  90	
  -­‐100%	
  compliance	
  for	
  six	
  of	
  nine	
  quality	
  

indicators.	
  Low	
  compliance	
  percentages	
  occurred	
  for	
  documentation	
  that	
  

a	
  parent	
  or	
  guardian	
  had	
  been	
  notified	
  and	
  with	
  scheduling	
  follow	
  up	
  

physician	
  appointments.	
  The	
  nurse	
  health	
  call	
  CQI	
  audit	
  of	
  March	
  2013	
  

showed	
  100%	
  compliance	
  on	
  8	
  of	
  10	
  compliance	
  indicators.	
  

Improvement	
  was	
  needed	
  on	
  documenting	
  vital	
  signs	
  on	
  each	
  encounter.	
  

The	
  Nurse	
  Charting	
  Review	
  CQI	
  audit	
  of	
  March	
  3013	
  showed	
  9	
  of	
  10	
  

quality	
  indicators	
  at	
  100%	
  and	
  one	
  at	
  90%.	
  Vital	
  signs	
  at	
  the	
  time	
  of	
  each	
  

encounter	
  were	
  reviewed	
  on	
  March	
  5,	
  2013.	
  The	
  documentation	
  of	
  vital	
  

signs	
  CQI	
  audit	
  showed	
  100%	
  compliance	
  with	
  the	
  4	
  quality	
  indicators.	
  

The	
  CQI	
  audit	
  tool	
  for	
  Laboratory	
  and	
  Diagnostic	
  Tests	
  was	
  reviewed	
  for	
  

January	
  and	
  March	
  2013.	
  The	
  two	
  lowest	
  compliance	
  indicators	
  at	
  60%	
  

were	
  for	
  lack	
  of	
  documentation	
  that	
  youth	
  were	
  informed	
  of	
  normal	
  or	
  

abnormal	
  test	
  results.	
  Since	
  the	
  last	
  visit,	
  the	
  CQI	
  audits	
  for	
  completion	
  of	
  

	
  

51.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 52 of 67 PAGEID #: 2546

Recommendations	
  
Sources	
  of	
   Information	
   	
  

the	
  Youth	
  Injury	
  Assessment	
  Form	
  (YIAF)	
  have	
  been	
  reviewed	
  monthly	
   since	
  January	
  2013	
  due	
  to	
  deficiencies	
  identified	
  from	
  the	
  previous	
   report.	
  	
  Over	
  those	
  months	
  the	
  documentation	
  and	
  compliance	
   indicators	
  continued	
  to	
  improve.	
  Lack	
  of	
  documentation	
  of	
  youth	
   education	
  was	
  noted	
  as	
  a	
  particular	
  area	
  of	
  weakness.	
  The	
  last	
  audit	
  of	
   3/29/13	
  had	
  100%	
  compliance	
  in	
  9	
  of	
  10	
  quality	
  indicators	
  with	
  90%	
  in	
   that	
  one	
  indicator.	
  This	
  outcome	
  demonstrates	
  the	
  true	
  benefit	
  of	
  a	
  self-­‐	
   auditing	
  process.	
  Medical	
  staff	
  also	
  identified	
  through	
  this	
  process	
  the	
   need	
  to	
  modify	
  the	
  CQI	
  instrument	
  to	
  monitor	
  discharge	
  planning.	
  	
   Medical	
  findings	
  were	
  discussed	
  with	
  Dr.	
  John	
  Brady,	
  Medical	
  Director	
   and	
  Scioto	
  Nurse	
  Manager,	
  Vickie	
  Donohue.	
  
In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  	
  	
  
1. Complete	
  satellite	
  clinic	
  and	
  medication	
  room	
  on	
  Buckeye	
  Units	
   for	
  adequate	
  injury	
  assessments	
  of	
  youth	
  and	
  medication	
   administration	
  on	
  the	
  unit.	
  	
  
2. Continue	
  to	
  limit	
  time	
  of	
  youth	
  in	
  seclusion	
  with	
  documentation	
   of	
  health	
  status	
  during	
  segregation.	
  
3. Continue	
  to	
  improve	
  Quality	
  Assurance	
  (QA)	
  activities	
  to	
  include	
   some	
  additional	
  quality	
  outcome	
  indicators.	
  	
  
4. Continue	
  accreditation	
  through	
  the	
  American	
  Correctional	
   Association	
  as	
  an	
  external	
  auditing	
  process.	
  
• Site	
  visit	
  tour;	
  Review	
  of	
  seven	
  youth	
  health	
  records:	
  ID	
  #	
   218418,	
  217757,	
  218277,	
  218393,	
  217113,	
  218312,	
  216642;	
  CQI	
   Documentation	
  as	
  outlined	
  above.	
  	
  
	
  

	
  

52.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 53 of 67 PAGEID #: 2547

III.C.2	
  	
  Health	
  Records.	
  The	
  State	
  shall	
  develop	
  and	
  implement	
  policies,	
  procedures	
  and	
   practices	
  to	
  ensure	
  that,	
  consistent	
  with	
  State	
  and	
  federal	
  law,	
  at	
  a	
  minimum,	
  the	
  juvenile	
   courts	
  in	
  the	
  State,	
  all	
  juvenile	
  detention	
  facilities	
  and	
  all	
  placement	
  settings	
  from	
  which	
   youth	
  are	
  committed	
  shall	
  timely	
  forward	
  to	
  Scioto,	
  or	
  to	
  the	
  facility	
  of	
  placement	
  (if	
  the	
   records	
  arrive	
  after	
  the	
  youth	
  has	
  been	
  placed),	
  all	
  pertinent	
  youth	
  records	
  regarding	
   medical	
  and	
  mental	
  health	
  care.	
  The	
  facilities	
  shall	
  develop	
  and	
  implement	
  policies,	
   procedures	
  and	
  practices	
  to	
  ensure	
  that	
  health	
  care	
  staff,	
  including	
  mental	
  health	
  care	
   staff,	
  have	
  access	
  to	
  documents	
  that	
  are	
  relevant	
  to	
  the	
  care	
  and	
  treatment	
  of	
  the	
  youth.	
  	
  

Compliance	
  Rating	
   Partial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Ohio	
  Department	
  of	
  Youth	
  Services	
  (ODYS)	
  does	
  not	
  conduct	
  a	
   self-­‐assessment	
  for	
  the	
  level	
  of	
  medical	
  and	
  dental	
  care	
  provided	
  at	
   SJCF.	
  However	
  the	
  health	
  records	
  are	
  being	
  reviewed	
  as	
  a	
  part	
  of	
   the	
  CQI	
  process.	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Review	
  of	
  seven	
  youth	
  health	
  records.	
  There	
  were	
  no	
  new	
  Health	
   Policies	
  and	
  Procedures	
  or	
  Standard	
  Operating	
  Procedures	
  (SOP)	
   completed	
  by	
  ODYS	
  since	
  the	
  last	
  visit.	
  Three	
  of	
  seven	
  youth	
  had	
   been	
  transferred	
  from	
  other	
  facilities.	
  These	
  youth	
  health	
  records	
   contained	
  health	
  information	
  from	
  the	
  transferring	
  facility.	
  The	
   offense	
  information	
  was	
  not	
  present	
  in	
  the	
  health	
  records	
  reviewed	
   at	
  this	
  visit.	
  The	
  health	
  record	
  is	
  still	
  incomplete,	
  due	
  to	
  the	
   psychological	
  and	
  counseling	
  notes	
  being	
  housed	
  separately	
  on	
  the	
   housing	
  units.	
  The	
  RFP	
  awarded	
  to	
  eClinical	
  Works	
  for	
  an	
  electronic	
   health	
  record	
  (EHR)	
  through	
  the	
  Ohio	
  Department	
  of	
   Administrative	
  Services	
  and	
  the	
  Office	
  of	
  Information	
  Technology	
   (OIT)	
  was	
  in	
  the	
  implementation	
  phase	
  during	
  this	
  visit.	
  	
  The	
   eClinical	
  Works	
  EHR	
  correctional	
  module	
  has	
  been	
  used	
   successfully	
  in	
  other	
  correctional	
  settings.	
  	
  I	
  attended	
  the	
   presentation	
  to	
  demonstrate	
  how	
  the	
  adult	
  Department	
  of	
   Rehabilitation	
  and	
  Correction	
  (DRC)	
  had	
  structured	
  the	
  use	
  of	
  the	
   EHR	
  in	
  their	
  system.	
  In	
  attendance	
  were	
  Dr.	
  John	
  Bradley	
  (Medical	
   Director),	
  Jacqueline	
  Carter	
  (Nursing	
  Director)	
  and	
  other	
  DYS	
   central	
  office	
  health	
  staff	
  in	
  order	
  to	
  review	
  the	
  system	
  and	
   determine	
  how	
  best	
  to	
  utilize	
  it	
  to	
  meet	
  the	
  needs	
  of	
  DYS.	
  Certified	
   trainers	
  are	
  being	
  used	
  to	
  train	
  certified	
  users	
  for	
  current	
  field	
   testing	
  in	
  DRC.	
  The	
  same	
  process	
  will	
  be	
  required	
  in	
  order	
  to	
   adequately	
  train	
  DYS	
  medical	
  staff	
  in	
  the	
  use	
  of	
  the	
  system.	
  The	
   plan	
  is	
  for	
  the	
  EHR	
  to	
  also	
  connect	
  the	
  state	
  and	
  community	
   providers,	
  initially	
  to	
  begin	
  with	
  the	
  (DRC),	
  followed	
  by	
  ODYS,	
   KALOS	
  Pharmacy,	
  Central	
  Medical	
  Lab,	
  Immunization	
  database,	
   Franklin	
  Medical	
  Center	
  and	
  OSU	
  Hospital	
  records.	
  	
  Of	
  great	
   significance,	
  the	
  youth	
  mental	
  health	
  records	
  will	
  interface	
  with	
  the	
   new	
  EHR.	
  The	
  eClinical	
  Works	
  electronic	
  health	
  record	
  being	
   established	
  will	
  facilitate	
  the	
  sharing	
  of	
  the	
  mental	
  health	
  and	
   medical	
  information	
  into	
  one	
  combined	
  health	
  record.	
  The	
  system	
   is	
  web	
  based	
  will	
  be	
  able	
  to	
  interface	
  with	
  community	
  providers	
   and	
  pharmacies	
  and	
  improve	
  continuity	
  of	
  health	
  care	
  for	
  youth	
  

	
  

53.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 54 of 67 PAGEID #: 2548

upon	
  release.	
  	
  	
  

Recommendations	
  

In	
  order	
  to	
  reach	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
   State	
  must:	
  
1. Continue	
  to	
  improve	
  the	
  process	
  for	
  sharing	
  of	
  health	
   information	
  between	
  medical	
  and	
  mental	
  health	
  to	
  include	
   psychologists	
  and	
  counselors	
  through	
  implementation	
  of	
   eClinical	
  Works	
  EHR.	
  	
  
2. ODYS	
  medical	
  management	
  staff	
  should	
  continue	
  to	
  be	
   intimately	
  involved	
  in	
  the	
  process	
  of	
  customization	
  of	
  the	
   EHR	
  to	
  be	
  relevant	
  to	
  youth	
  medical	
  services.	
  

Sources	
  of	
   Information	
  
	
   	
   	
   	
  

• Site	
  visit	
  tour;	
  Review	
  of	
  seven	
  youth	
  health	
  records:	
  ID	
  #	
   218418,	
  217757,	
  218277,	
  218393,	
  217113,	
  218312,	
  and	
   216642.	
  	
  
• Presentation	
  on	
  eClinical	
  Works	
  electronic	
  health	
  record	
  
	
  

	
  

54.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 55 of 67 PAGEID #: 2549

III.C.5	
  	
  Access	
  to	
  Health	
  Services.	
  The	
  facilities	
  shall	
  ensure	
  that	
  youth	
  can	
  request	
  to	
  be	
  seen	
  by	
   medical	
  staff	
  confidentially	
  and	
  independent	
  from	
  JCOs	
  and	
  custodial	
  staff.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  Ohio	
  Department	
  of	
  Youth	
  Services	
  (ODYS)	
  does	
  not	
  conduct	
  a	
  self-­‐ assessment	
  for	
  the	
  level	
  of	
  medical	
  and	
  dental	
  care	
  provided	
  at	
  SJCF.	
  	
  	
  

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Health	
  Request	
  drop	
  boxes	
  were	
  present	
  on	
  all	
  the	
  units	
  where	
  youth	
   were	
  housed.	
  	
  Health	
  Request	
  boxes	
  were	
  present	
  in	
  the	
  cafeteria	
  and	
  in	
   the	
  school.	
  Of	
  the	
  7	
  housing	
  units	
  toured,	
  slips	
  were	
  outside	
  the	
  boxes	
   and	
  readily	
  available	
  to	
  youth	
  on	
  all	
  but	
  2	
  units.	
  On	
  one	
  unit,	
  the	
  staff	
   immediately	
  located	
  the	
  slips	
  and	
  refilled	
  the	
  box	
  ;	
  on	
  the	
  other,	
  staff	
   could	
  not	
  locate	
  the	
  blank	
  health	
  request	
  slips.	
  One	
  youth	
  when	
   questioned	
  on	
  that	
  same	
  unit	
  stated	
  that	
  the	
  slips	
  were	
  not	
  always	
   available.	
  This	
  is	
  an	
  acceptable	
  rate	
  of	
  error.	
  	
   	
   Youth	
  were	
  interviewed	
  on	
  the	
  units	
  as	
  to	
  how	
  to	
  access	
  confidential	
   health	
  services.	
  Youth	
  interviewed	
  knew	
  where	
  the	
  boxes	
  were	
  located	
   and	
  all	
  could	
  verbalize	
  how	
  to	
  gain	
  access	
  to	
  health	
  services.	
  Nurse	
   Health	
  Requests	
  submitted	
  by	
  the	
  youth	
  were	
  reviewed	
  in	
  7	
  health	
   records.	
  Most	
  health	
  requests	
  were	
  related	
  to	
  skin	
  complaints	
  such	
  as	
   acne	
  and	
  rashes,	
  musculoskeletal	
  pains	
  and	
  dental	
  complaints.	
  Each	
   Health	
  Request	
  was	
  reviewed	
  and	
  traced	
  back	
  to	
  a	
  corresponding	
   progress	
  note	
  to	
  determine	
  if	
  the	
  complaint	
  had	
  been	
  addressed.	
  Health	
   requests	
  included	
  in	
  these	
  health	
  records	
  were	
  responded	
  to	
  adequately	
   and	
  documented	
  by	
  medical	
  staff	
  100%	
  of	
  the	
  time.	
  In	
  all	
  cases,	
  the	
   requests	
  had	
  been	
  adequately	
  assessed	
  and	
  treated	
  in	
  a	
  timely	
  manner	
   by	
  registered	
  nursing	
  staff,	
  physician	
  or	
  dentist.	
  	
  	
  

Recommendations	
  

In	
  order	
  to	
  maintain	
  substantial	
  compliance	
  with	
  this	
  provision,	
  the	
  State	
   must:	
  
1. Ensure	
  Health	
  Request	
  slips	
  and	
  boxes	
  are	
  readily	
  available	
  to	
   youth	
  on	
  all	
  housing	
  units.	
  Youth	
  should	
  not	
  have	
  to	
  rely	
  on	
   custody	
  staff	
  to	
  request	
  forms.	
  	
  	
  

Sources	
  of	
   Information	
  
	
   	
   	
  
	
  

• Site	
  visit	
  tour;	
  Review	
  of	
  seven	
  youth	
  health	
  records:	
  ID	
  #218418,	
   217757,	
  218277,	
  218393,	
  217113,	
  218312,	
  and	
  216642.	
  
	
  

	
  

55.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 56 of 67 PAGEID #: 2550

SPECIAL	
  EDUCATION	
  
	
  
III.E.1	
  Provision	
  of	
  Special	
  Education.	
  The	
  State	
  shall,	
  at	
  all	
  times,	
  provide	
  all	
  youth	
  confined	
  at	
   the	
  facilities	
  with	
  adequate	
  special	
  education	
  in	
  compliance	
  with	
  the	
  Individuals	
  with	
  Disabilities	
   Education	
  Act	
  (IDEA),	
  20	
  U.S.C.	
  §	
  1400-­‐1482,	
  and	
  regulations	
  promulgated	
  thereunder,	
  and	
  this	
   Stipulation.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

This	
  provision	
  pertains	
  to	
  the	
  facility’s	
  ability	
  to	
  deliver	
  the	
  special	
   education	
  program.	
  Certain	
  foundations	
  need	
  to	
  be	
  in	
  place—adequate	
   safety,	
  sufficient	
  numbers	
  of	
  qualified	
  teachers,	
  and	
  dependable	
  access	
   to	
  the	
  education	
  program	
  that	
  is	
  not	
  interrupted	
  by	
  disciplinary	
   procedures	
  that	
  remove	
  students	
  from	
  school	
  for	
  long	
  periods	
  of	
  time.	
   The	
  State	
  was	
  asked	
  to	
  comment	
  on	
  each	
  of	
  these	
  issues	
  (summarized	
   here)	
  and	
  to	
  provide	
  quantitative	
  data	
  to	
  demonstrate	
  their	
  level	
  of	
   compliance	
  (analyzed	
  below).	
  	
   	
   School	
  Safety	
   Although	
  at	
  times	
  in	
  the	
  past	
  the	
  school	
  was	
  a	
  hotspot	
  for	
  youth	
   violence,	
  changes	
  were	
  made	
  to	
  the	
  way	
  students	
  cycled	
  through	
  the	
   school	
  facility,	
  the	
  number	
  of	
  staff	
  posted	
  in	
  the	
  school	
  buildings,	
  and	
  to	
   the	
  physical	
  features	
  of	
  the	
  classrooms.	
  These	
  modifications,	
  coupled	
   with	
  the	
  stabilizing	
  influence	
  of	
  a	
  highly	
  competent	
  set	
  of	
  school	
   administrators,	
  have	
  transformed	
  the	
  school	
  into	
  a	
  relatively	
  safe	
   environment	
  where	
  learning	
  can	
  occur.	
  	
   	
   Education	
  has	
  also	
  become	
  better	
  integrated	
  with	
  the	
  rest	
  of	
  the	
   facility’s	
  programming.	
  The	
  Superintendent,	
  Direct	
  Deputy	
  and	
   Programming	
  Deputy	
  all	
  attend	
  the	
  school’s	
  morning	
  meeting,	
  allowing	
   for	
  the	
  free	
  exchange	
  of	
  information	
  across	
  disciplines.	
  Even	
  though	
  the	
   youth	
  violence	
  problem	
  in	
  school	
  has	
  improved,	
  school	
  administrators	
   continue	
  to	
  develop	
  new	
  strategies	
  to	
  improve	
  the	
  school	
  environment	
   and	
  increase	
  student’s	
  engagement.	
   	
   A	
  school	
  incentive	
  program	
  was	
  introduced	
  to	
  supplement	
  the	
  SBBMS.	
   When	
  students	
  meet	
  a	
  set	
  of	
  education-­‐related	
  behavioral	
  expectations	
   (e.g.,	
  perfect	
  attendance,	
  no	
  YBIRs,	
  no	
  ABC	
  referrals,	
  good	
  hallway	
   movement)	
  and	
  performance	
  measures	
  (e.g.,	
  effort	
  in	
  class,	
  complete	
   assignments),	
  they	
  earn	
  tokens	
  (i.e.,	
  “apples”)	
  that	
  can	
  be	
  used	
  to	
   purchase	
  admission	
  to	
  a	
  Friday	
  assembly	
  along	
  with	
  a	
  variety	
  of	
  snacks	
   and	
  drinks.	
  This	
  program	
  has	
  reportedly	
  improved	
  student	
  behavior	
  and	
   performance	
  in	
  the	
  classroom.	
  	
   	
   Staffing	
  Issues	
   Although	
  the	
  teaching	
  roster	
  still	
  has	
  a	
  few	
  vacancies	
  (science,	
  math,	
   special	
  education	
  and	
  substitutes),	
  the	
  facility’s	
  low	
  population	
  means	
   that	
  the	
  current	
  complement	
  of	
  staff	
  is	
  sufficient	
  to	
  provide	
  all	
  core	
  

	
  

56.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 57 of 67 PAGEID #: 2551

subjects,	
  vocational	
  courses,	
  and	
  electives	
  without	
  interruption.	
  Students	
   in	
  all	
  of	
  Scioto’s	
  programs	
  now	
  have	
  dependable	
  access	
  to	
  the	
  330	
   minutes	
  of	
  education	
  required	
  by	
  State	
  law.	
  	
   	
   ABC	
  Room	
   In	
  the	
  past,	
  youth	
  who	
  exhibited	
  non-­‐compliant	
  behavior	
  in	
  the	
   classroom	
  could	
  be	
  suspended	
  from	
  school	
  and	
  returned	
  to	
  their	
  living	
   units	
  where	
  they	
  did	
  not	
  receive	
  education	
  services	
  of	
  any	
  kind.	
  While	
   youth	
  may	
  be	
  sent	
  back	
  to	
  the	
  unit	
  in	
  emergency	
  situations	
  (i.e.,	
  out	
  of	
   control	
  behavior,	
  fights,	
  etc.),	
  the	
  State	
  ceased	
  suspending	
  students	
  in	
   June	
  2011,	
  relying	
  instead	
  on	
  its	
  in-­‐school	
  suspension	
  room	
  (the	
   Academic	
  Behavior	
  Center	
  (ABC))	
  and	
  its	
  procedure	
  for	
  Unit	
  Instruction.	
  	
   	
   The	
  ABC	
  room	
  provides	
  youth	
  an	
  opportunity	
  to	
  regain	
  control	
  of	
  their	
   behavior	
  and	
  to	
  return	
  to	
  the	
  classroom	
  setting	
  without	
  going	
  back	
  to	
   their	
  living	
  units.	
  Youth	
  are	
  referred	
  to	
  the	
  ABC	
  room	
  for	
  rule	
  violations	
   pertaining	
  to	
  offensive	
  or	
  threatening	
  conduct,	
  being	
  disruptive,	
   distracting	
  other	
  students	
  or	
  being	
  outside	
  an	
  authorized	
  area.	
  Most	
   youth	
  stay	
  between	
  1.5	
  to	
  2	
  hours—they	
  may	
  earn	
  10	
  minutes	
  off	
  their	
   ABC	
  time	
  for	
  every	
  30	
  minutes	
  they	
  spend	
  focused	
  and	
  engaged	
  in	
  their	
   classwork.	
  In	
  the	
  past,	
  staffing	
  shortages	
  left	
  this	
  resource	
  unavailable	
  to	
   teachers,	
  which	
  frequently	
  resulted	
  in	
  youth	
  being	
  sent	
  back	
  to	
  their	
   units	
  during	
  the	
  school	
  day	
  and	
  the	
  loss	
  of	
  integrity	
  of	
  the	
  entire	
  ABC	
   intervention.	
  The	
  staffing	
  problems	
  have	
  been	
  resolved,	
  and	
  the	
  ABC	
   room	
  has	
  been	
  available	
  on	
  a	
  daily	
  basis	
  for	
  over	
  a	
  year.	
  	
   	
   The	
  number	
  of	
  youth	
  sent	
  to	
  the	
  ABC	
  room	
  during	
  the	
  current	
   monitoring	
  period	
  fluctuated.	
  During	
  the	
  2nd	
  grading	
  period,	
  26	
  youth	
   were	
  referred	
  to	
  the	
  ABC	
  room,	
  as	
  compared	
  to	
  76	
  referrals	
  during	
  the	
   3rd	
  grading	
  period.	
  However,	
  across	
  this	
  same	
  time	
  period,	
  there	
  were	
   193	
  and	
  106	
  emergency	
  removals	
  (i.e.,	
  youth	
  returned	
  directly	
  to	
  the	
   housing	
  units,	
  bypassing	
  the	
  ABC	
  room).	
  These	
  data	
  suggest	
  that	
  youth’s	
   classroom	
  behavior	
  is	
  being	
  managed	
  more	
  effectively—teachers	
  are	
   intervening	
  earlier	
  and	
  sending	
  youth	
  to	
  the	
  ABC	
  room	
  rather	
  than	
   sending	
  them	
  directly	
  to	
  the	
  unit.	
  This	
  effort	
  to	
  maintain	
  the	
  youth	
  in	
  the	
   classroom	
  is	
  fully	
  aligned	
  with	
  the	
  intent	
  of	
  this	
  provision.	
  	
   	
   Unit	
  Instruction	
   Previously,	
  the	
  Parties	
  to	
  the	
  S.H.	
  lawsuit	
  negotiated	
  an	
  agreement	
   regarding	
  the	
  delivery	
  of	
  education	
  services	
  to	
  youth	
  who	
  are	
  confined	
  to	
   the	
  living	
  units	
  for	
  disciplinary	
  reasons.	
  Within	
  48	
  hours	
  of	
  their	
   placement	
  in	
  seclusion,	
  students	
  must	
  receive	
  instruction	
  from	
  a	
  certified	
   teacher	
  four	
  times	
  per	
  day,	
  for	
  at	
  least	
  30	
  minutes	
  per	
  visit	
  (i.e.,	
  Unit	
   Instruction).	
  	
  	
   	
   Each	
  morning,	
  the	
  attendance	
  clerk	
  calls	
  each	
  unit	
  for	
  the	
  AOV	
  and	
  Unit	
   Restriction	
  list.	
  A	
  Unit	
  Instruction	
  list	
  is	
  compiled	
  and	
  delivered	
  to	
  all	
  

	
  

57.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 58 of 67 PAGEID #: 2552

teachers,	
  along	
  with	
  the	
  Unit	
  Instructor	
  schedule.	
  Teachers	
  who	
  serve	
   students	
  on	
  the	
  list	
  prepare	
  course	
  work,	
  along	
  with	
  a	
  copy	
  of	
  the	
  IEP	
  at-­‐ a-­‐glance	
  for	
  special	
  education	
  students.	
  The	
  Unit	
  Instructor	
  (which	
   rotates	
  throughout	
  the	
  day)	
  delivers	
  the	
  work	
  to	
  each	
  student,	
  and	
  also	
   provides	
  30-­‐minutes	
  of	
  instruction,	
  four	
  times	
  per	
  day.	
  	
   	
   Classwork	
  for	
  youth	
  on	
  Pre-­‐Hearing	
  Seclusion	
  (PHS)	
  for	
  an	
  act	
  of	
  violence	
   is	
  delivered	
  underneath	
  the	
  youth’s	
  door.	
  For	
  most	
  youth,	
  PHS	
  lasts	
  less	
   than	
  2	
  days	
  (see	
  the	
  discussion	
  for	
  III.A.3,	
  above).	
  If	
  a	
  youth	
  receives	
   additional	
  seclusion	
  time	
  as	
  a	
  sanction,	
  they	
  are	
  brought	
  out	
  to	
  the	
  table	
   in	
  the	
  dayroom,	
  unless	
  their	
  behavior	
  suggests	
  a	
  risk	
  of	
  violence.	
  The	
   Operations	
  staff	
  makes	
  these	
  determinations,	
  and	
  the	
  assumption	
  is	
  that	
   youth	
  on	
  Intervention	
  Seclusion	
  will	
  be	
  served	
  in	
  the	
  dayroom,	
  unless	
   otherwise	
  indicated.	
  	
   	
   The	
  school’s	
  clerical	
  staff	
  and	
  administrators	
  expend	
  significant	
  time	
  and	
   energy	
  reviewing	
  and	
  monitoring	
  Unit	
  Instruction	
  records	
  to	
  ensure	
   compliance.	
  A	
  teacher	
  reviews	
  each	
  youth’s	
  folder	
  every	
  afternoon,	
   makes	
  sure	
  the	
  documents	
  are	
  filled	
  out	
  correctly	
  and	
  enters	
  the	
   information	
  in	
  to	
  the	
  database.	
  The	
  attendance	
  officer	
  double	
  checks	
  the	
   paperwork	
  and	
  the	
  entry	
  into	
  the	
  database	
  and	
  files	
  the	
  student’s	
   paperwork.	
  On	
  a	
  monthly	
  basis,	
  the	
  Unit	
  Instruction	
  log	
  is	
  compared	
  to	
   the	
  AMS	
  seclusion	
  list	
  by	
  at	
  least	
  two	
  school	
  administrators.	
  Finally,	
   Central	
  Office	
  reviews	
  the	
  information	
  every	
  couple	
  of	
  months	
  and	
  sends	
   written	
  feedback	
  to	
  the	
  facility.	
  Reviews	
  during	
  the	
  current	
  monitoring	
   period	
  found	
  high	
  rates	
  of	
  compliance.	
  	
   	
   Progress	
  Unit	
  School	
   As	
  noted	
  in	
  the	
  previous	
  Monitor’s	
  Reports,	
  the	
  PROGRESS	
  Unit	
  (PU)	
   school	
  was	
  the	
  site	
  of	
  numerous	
  staff	
  and	
  youth	
  assaults.	
  Enhancements	
   to	
  the	
  direct	
  care	
  staffing	
  levels	
  and	
  the	
  physical	
  “hardening”	
  of	
  the	
   environment	
  (different	
  furniture,	
  bolting	
  down	
  monitors,	
  flex	
  keyboards,	
   etc.)	
  reported	
  in	
  the	
  previous	
  Monitor’s	
  Reports	
  have	
  largely	
  solved	
  this	
   problem.	
  While	
  misconduct	
  still	
  occurs	
  among	
  these	
  high-­‐security	
  youth,	
   the	
  environment	
  has	
  settled,	
  teachers	
  are	
  becoming	
  more	
  creative	
  and	
   youth	
  are	
  becoming	
  more	
  engaged	
  in	
  the	
  program.	
  PU	
  students	
  have	
   made	
  important	
  academic	
  achievements	
  (one	
  earned	
  a	
  GED,	
  one	
  earned	
   a	
  diploma,	
  several	
  made	
  the	
  Honor	
  Roll	
  and	
  Merit	
  Roll,	
  and	
  one	
  of	
  the	
   students	
  had	
  the	
  highest	
  GPA	
  on	
  campus).	
  New	
  course	
  offerings	
  (PE	
  for	
   Phase	
  2	
  youth	
  and	
  Health	
  for	
  Phase	
  1	
  youth)	
  will	
  help	
  to	
  ensure	
  that	
  PU	
   students	
  continue	
  to	
  earn	
  needed	
  credits	
  during	
  their	
  stay	
  on	
  the	
  PU.	
  	
   	
   Overall,	
  the	
  school	
  administrators	
  are	
  vigilant	
  about	
  the	
  school	
   environment	
  and	
  the	
  various	
  barriers	
  that	
  could	
  impede	
  access	
  to	
  the	
   education	
  program.	
  The	
  system	
  of	
  internal	
  review	
  and	
  monitoring	
  is	
  fully	
   capable	
  of	
  identifying	
  and	
  responding	
  to	
  any	
  problems	
  that	
  may	
  arise	
   over	
  time.	
  	
  	
  

	
  

58.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 59 of 67 PAGEID #: 2553

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

Attendance	
   Overall	
  school	
  attendance	
  rates	
  are	
  reported	
  every	
  month	
  on	
  the	
   Superintendent’s	
  report,	
  and	
  the	
  DYS	
  also	
  provided	
  these	
  data	
   disaggregated	
  by	
  housing	
  unit.	
  Across	
  the	
  six-­‐month	
  monitoring	
  period	
   (October	
  2012	
  through	
  March	
  2013)	
  average	
  unit	
  attendance	
  rates	
   ranged	
  between	
  83%	
  (Sycamore)	
  and	
  95%	
  (Allman)	
  with	
  an	
  overall	
   average	
  of	
  89%.	
  Importantly,	
  only	
  one	
  of	
  the	
  units	
  (Sycamore)	
  was	
  below	
   the	
  85%	
  benchmark,	
  and	
  only	
  by	
  two	
  percentage	
  points.	
  The	
  attendance	
   rates	
  consistently	
  met	
  or	
  exceeded	
  the	
  85%	
  threshold	
  across	
  the	
  rest	
  of	
   the	
  housing	
  units.	
  	
   	
   Unit	
  Instruction	
   To	
  assess	
  the	
  integrity	
  of	
  the	
  Unit	
  Instruction	
  procedures,	
  the	
  Unit	
   Instruction	
  records	
  maintained	
  by	
  the	
  school	
  were	
  cross-­‐referenced	
  with	
   a	
  list	
  of	
  youth	
  who	
  had	
  been	
  on	
  seclusion	
  between	
  February	
  1	
  and	
  March	
   31,	
  2013	
  generated	
  by	
  AMS.	
  	
   	
   First,	
  a	
  random	
  sample	
  of	
  23	
  youth	
  with	
  seclusion	
  stays	
  in	
  excess	
  of	
  48	
   hours	
  was	
  selected	
  from	
  the	
  AMS	
  list.	
  A	
  surprising	
  number	
  of	
  youth	
  had	
   to	
  be	
  excluded	
  from	
  the	
  analysis	
  because	
  they	
  were	
  in	
  seclusion	
  only	
   over	
  the	
  weekend	
  or	
  on	
  a	
  non-­‐instructional	
  day.	
  [This	
  is	
  positive	
  given	
   that,	
  in	
  these	
  cases,	
  seclusion	
  does	
  not	
  obstruct	
  student’s	
  access	
  to	
   school.	
  However,	
  separating	
  in	
  time	
  the	
  sanction	
  from	
  the	
  behavior	
  one	
   is	
  trying	
  to	
  address	
  is	
  not	
  a	
  particularly	
  effective	
  behavior	
  modification	
   strategy.]	
  Once	
  the	
  non-­‐instructional	
  days	
  were	
  filtered	
  out,	
  a	
  sample	
  of	
   9	
  youth	
  remained.	
  In	
  each	
  case,	
  students	
  were	
  provided	
  with	
  education	
   services	
  in	
  accordance	
  with	
  DYS	
  Policy	
  #303.01.05	
  “School	
   Interventions.”	
  In	
  most	
  cases,	
  youth	
  received	
  education	
  services	
  on	
  the	
   next	
  school	
  day	
  following	
  their	
  seclusion,	
  though	
  in	
  a	
  couple	
  cases,	
  they	
   received	
  work	
  toward	
  the	
  end	
  of	
  the	
  48-­‐hour	
  timeline.	
  The	
  Unit	
   Instruction	
  log	
  recorded	
  whether	
  the	
  work	
  was	
  received	
  or	
  declined	
   (most	
  youth	
  accepted	
  the	
  work)	
  and	
  whether	
  the	
  instruction	
  was	
   provided	
  in	
  or	
  out	
  of	
  the	
  room	
  (youth	
  on	
  intervention	
  seclusion	
  were	
   served	
  out	
  of	
  their	
  rooms;	
  youth	
  on	
  pre-­‐hearing	
  seclusion	
  were	
  served	
  in	
   their	
  rooms).	
  	
   	
   Second,	
  for	
  each	
  of	
  the	
  14	
  youth	
  on	
  the	
  Unit	
  Instruction	
  list,	
  the	
  dates	
  of	
   service	
  were	
  cross-­‐referenced	
  with	
  the	
  AMS	
  roster	
  to	
  ensure	
  that	
  youth	
   were	
  served	
  on	
  all	
  of	
  the	
  instructional	
  days	
  during	
  which	
  they	
  were	
   secluded.	
  Service	
  dates	
  were	
  verified	
  for	
  all	
  but	
  2	
  of	
  the	
  youth	
  (86%	
   compliance),	
  each	
  of	
  whom	
  appeared	
  to	
  be	
  in	
  seclusion	
  on	
  a	
  given	
  day	
   but	
  did	
  not	
  have	
  service	
  recorded	
  in	
  the	
  Unit	
  Instruction	
  Log.	
  This	
  is	
  an	
   acceptable	
  rate	
  of	
  error,	
  particularly	
  given	
  the	
  complexity	
  of	
  the	
  AMS	
   seclusion	
  logs.	
  	
   	
   In	
  summary,	
  once	
  cross-­‐referenced	
  with	
  AMS,	
  the	
  Unit	
  Instruction	
  data	
   demonstrated	
  that	
  the	
  facility	
  is	
  in	
  compliance	
  with	
  its	
  obligations	
  

	
  

59.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 60 of 67 PAGEID #: 2554

Recommendations	
   Sources	
  of	
   Information	
  
	
   	
  

around	
  providing	
  education	
  services	
  to	
  youth	
  who	
  are	
  in	
  seclusion.	
   However,	
  it	
  is	
  worth	
  noting	
  that	
  several	
  youth	
  spent	
  an	
  extraordinary	
   amount	
  of	
  time	
  in	
  seclusion	
  (a	
  commentary	
  on	
  the	
  facility’s	
  disciplinary	
   practices,	
  not	
  on	
  the	
  education	
  program).	
  For	
  example,	
  youth	
  CC	
  spent	
   16	
  days	
  in	
  a	
  row	
  in	
  seclusion	
  with	
  only	
  one	
  day	
  out	
  in	
  the	
  general	
   population.	
  Another	
  youth,	
  TB,	
  spent	
  8	
  days	
  in	
  a	
  row	
  in	
  seclusion.	
  The	
   facility’s	
  reliance	
  on	
  seclusion	
  to	
  address	
  violent	
  misconduct	
  is	
  discussed	
   in	
  provision	
  III.A.3,	
  above.	
  Revisions	
  to	
  the	
  sanctioning	
  grid,	
  to	
  be	
   implemented	
  in	
  the	
  very	
  near	
  future,	
  should	
  decrease	
  the	
  amount	
  of	
   time	
  youth	
  spend	
  in	
  seclusion,	
  and	
  by	
  extension,	
  the	
  need	
  for	
  Unit	
   Instruction.	
  Unit	
  Instruction	
  is	
  an	
  essential	
  tool	
  to	
  ensure	
  that	
  education	
   services	
  are	
  not	
  disrupted	
  by	
  the	
  disciplinary	
  system	
  chosen	
  by	
  the	
   facility.	
  	
  
The	
  facility	
  is	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  	
  
• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.1,	
  prepared	
  at	
  my	
  request	
  
• Education	
  staffing	
  roster,	
  October	
  2012	
  through	
  March	
  2013	
   • Unit	
  Instruction	
  data,	
  February	
  and	
  March	
  2013,	
  and	
  follow-­‐up	
  
discussions	
  with	
  Scioto	
  and	
  DYS	
  school	
  administrators	
  via	
  email.	
  	
   • AMS	
  Seclusion	
  Records,	
  February	
  and	
  March	
  2013	
   • Attendance	
  records,	
  by	
  unit,	
  October	
  2012	
  through	
  March	
  2013	
  
	
  

	
  

60.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 61 of 67 PAGEID #: 2555

	
  
III.E.7	
  Individual	
  Education	
  Plans.	
  (a)	
  The	
  State	
  shall	
  develop	
  an	
  IEP	
  as	
  defined	
  in	
  34	
  C.F.R.	
   §300.320	
  for	
  each	
  youth	
  who	
  qualifies	
  for	
  an	
  IEP.	
  Following	
  development	
  of	
  the	
  IEP,	
  the	
  State	
   shall	
  implement	
  the	
  IEP	
  as	
  soon	
  as	
  possible.	
  As	
  part	
  of	
  satisfying	
  this	
  requirement,	
  the	
  State	
   shall	
  conduct	
  required	
  annual	
  reviews	
  of	
  IEPs,	
  adequately	
  document	
  the	
  provision	
  of	
  special	
   education	
  services,	
  and	
  comply	
  with	
  requirements	
  regarding	
  participation	
  by	
  the	
  professional	
   staff,	
  parents	
  and	
  student	
  in	
  the	
  IEP	
  process.	
  The	
  State	
  shall,	
  if	
  necessary,	
  develop,	
  review	
  or	
   revise	
  IEPs	
  for	
  qualified	
  special	
  education	
  students;	
  (b)	
  In	
  developing	
  or	
  modifying	
  the	
  IEP,	
  the	
   State	
  shall	
  ensure	
  that:	
  the	
  IEP	
  reflects	
  the	
  individualized	
  educational	
  needs	
  of	
  the	
  youth	
  and	
   that	
  services	
  are	
  provided	
  accordingly;	
  each	
  IEP	
  includes	
  documentation	
  of	
  the	
  team’s	
   consideration	
  of	
  the	
  youth’s	
  need	
  for	
  related	
  services	
  and	
  transition	
  planning,	
  and	
  identifies	
  the	
   party	
  responsible	
  for	
  providing	
  such	
  transition	
  services;	
  the	
  student’s	
  educational	
  progress	
  is	
   monitored;	
  teachers	
  are	
  trained	
  on	
  how	
  to	
  monitor	
  progress	
  toward	
  IEP	
  goals	
  and	
  objectives;	
   and	
  teachers	
  understand	
  and	
  use	
  functional	
  behavioral	
  assessment	
  and	
  behavior	
  intervention	
   programs	
  in	
  IEP	
  planning	
  and	
  implementation.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

The	
  State	
  provided	
  data	
  on	
  the	
  19	
  special	
  education	
  students	
  in	
  custody	
   as	
  of	
  April	
  19,	
  2013	
  (approximately	
  41%	
  of	
  the	
  total	
  population;	
  59%	
  of	
   the	
  females	
  and	
  31%	
  of	
  the	
  males).	
  Of	
  these	
  youth,	
  three	
  student’s	
  IEPs	
   were	
  expired,	
  but	
  staff	
  had	
  taken	
  steps	
  to	
  collect	
  the	
  necessary	
   information	
  and	
  schedule	
  IEP	
  meetings	
  during	
  the	
  month	
  of	
  April	
  2013.	
   The	
  other	
  16	
  youth	
  had	
  current	
  IEPs	
  and	
  current	
  eligibility.	
  	
   	
   The	
  State	
  has	
  implemented	
  a	
  solid,	
  multi-­‐level	
  process	
  to	
  ensure	
  the	
   quality	
  of	
  the	
  IEPs	
  written	
  at	
  Scioto.	
  For	
  teachers,	
  a	
  variety	
  of	
  tools	
  have	
   been	
  created:	
  
• IEP	
  Documentation	
  Guidelines	
  Checklist:	
  discusses	
  the	
   procedures	
  for	
  submitting	
  draft	
  IEPs	
  for	
  review,	
  what	
  needs	
  to	
   be	
  completed	
  during	
  the	
  IEP	
  meeting,	
  and	
  what	
  documents	
  need	
   to	
  be	
  submitted	
  once	
  the	
  IEP	
  meeting	
  has	
  been	
  held.	
  	
  
• IEP	
  Goal	
  Planning	
  Worksheet:	
  requires	
  teachers	
  to	
  articulate	
  the	
   various	
  components	
  of	
  a	
  well-­‐written	
  IEP	
  goal	
  and	
  to	
  devise	
  a	
   plan	
  for	
  how	
  progress	
  will	
  be	
  measured.	
  	
  
• Goal	
  Tracking	
  Sheet:	
  for	
  each	
  IEP	
  goal,	
  asks	
  whether	
  the	
  goal	
  was	
   met	
  or	
  not	
  met,	
  and	
  whether	
  a	
  problem	
  with	
  how	
  the	
  goal	
  was	
   articulated	
  made	
  it	
  difficult	
  to	
  measure.	
  [Recommendation:	
  it	
   might	
  also	
  be	
  useful	
  to	
  ask	
  the	
  teacher	
  to	
  indicate	
  the	
  basis	
  for	
   determining	
  whether	
  the	
  goal	
  was	
  met	
  or	
  not,	
  although	
  the	
   review	
  of	
  Progress	
  Reports	
  may	
  address	
  quality	
  assurance	
  needs	
   in	
  this	
  area.]	
  
The	
  Special	
  Education	
  Administrator	
  at	
  the	
  facility	
  also	
  reviews	
  IEPs	
  each	
   month.	
  The	
  following	
  documents	
  are	
  used	
  to	
  guide	
  this	
  review:	
  
• Continuous	
  IEP	
  Compliance	
  Monitoring	
  Checklist:	
  assesses,	
  in	
   detail,	
  whether	
  the	
  required	
  content	
  is	
  present	
  within	
  each	
  of	
   the	
  14	
  sections	
  of	
  the	
  IEP	
  document.	
  Written	
  feedback	
  is	
   provided	
  to	
  the	
  teachers	
  in	
  order	
  to	
  improve	
  their	
  skills.	
  

	
  

61.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 62 of 67 PAGEID #: 2556

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

• On-­‐Site	
  Monthly	
  Monitoring	
  Form:	
  used	
  to	
  rate	
  a	
  sample	
  of	
  10	
   IEPs	
  on	
  12	
  performance	
  measures	
  (e.g.,	
  whether	
  the	
  IEP	
  is	
   current,	
  whether	
  the	
  ETR	
  is	
  current,	
  whether	
  the	
  goals	
  and	
   objectives	
  are	
  appropriate,	
  whether	
  progress	
  notes	
  have	
  been	
   updated,	
  whether	
  school	
  refusals	
  are	
  being	
  addressed,	
  if	
  parents	
   have	
  been	
  properly	
  notified,	
  etc.).	
  	
  
• Monthly	
  Local	
  Special	
  Education	
  Accountability	
  and	
  Compliance	
   Review:	
  provides	
  summary	
  statistics	
  for	
  each	
  of	
  the	
  various	
   indicators	
  measured	
  using	
  the	
  Monthly	
  Monitoring	
  Form.	
  	
  
These	
  monthly	
  reviews	
  are	
  “Tier	
  One”	
  of	
  the	
  QA	
  program.	
  In	
  Tier	
  Two,	
   each	
  quarter,	
  the	
  DYS	
  Special	
  Education	
  Director	
  reviews	
  the	
  same	
  files	
   to	
  ensure	
  that	
  all	
  deficits	
  were	
  identified	
  in	
  the	
  local	
  audit	
  and	
  that	
   teachers	
  completed	
  any	
  required	
  corrections.	
  Sadly,	
  the	
  extremely	
   talented	
  DYS	
  Special	
  Education	
  Director	
  retired	
  during	
  the	
  current	
   monitoring	
  period.	
  She	
  has	
  not	
  yet	
  been	
  replaced	
  and	
  thus	
  Tier	
  Two	
  was	
   not	
  completed	
  during	
  the	
  current	
  monitoring	
  period.	
  However,	
  the	
   excellent	
  results	
  obtained	
  via	
  the	
  Tier	
  One	
  process	
  (at	
  least	
  90%	
   compliance	
  in	
  January,	
  February,	
  and	
  March)	
  make	
  this	
  hiatus	
  less	
  of	
  a	
   concern.	
  Tier	
  Two	
  should	
  be	
  reinstated	
  as	
  soon	
  as	
  possible	
  to	
  maintain	
   the	
  integrity	
  of	
  the	
  QA	
  system.	
  	
   	
   In	
  Tier	
  Three,	
  each	
  of	
  the	
  DYS	
  schools	
  is	
  audited	
  annually	
  by	
  DYS	
  and	
  also	
   tri-­‐annually	
  by	
  the	
  Ohio	
  Department	
  of	
  Education.	
  Neither	
  of	
  these	
   audits	
  was	
  scheduled	
  during	
  the	
  current	
  monitoring	
  period.	
  	
  	
  
Special	
  Education	
  Population	
  and	
  IEP	
  Development	
   Across	
  the	
  current	
  special	
  education	
  population,	
  16	
  of	
  the	
  19	
  students	
   (84%)	
  qualified	
  under	
  the	
  Emotional	
  Disability	
  category,	
  one	
  student	
  had	
   a	
  Specific	
  Learning	
  Disabilities	
  (5%),	
  one	
  student	
  was	
  Cognitively	
  Disabled	
   (5%),	
  and	
  one	
  student	
  was	
  Other	
  Health	
  Impaired	
  (5%).	
  With	
  4	
  special	
   education	
  teachers	
  currently	
  on	
  staff,	
  the	
  caseload	
  sizes	
  are	
  well	
  below	
   the	
  state	
  limits	
  (generally,	
  12	
  for	
  ED;	
  24	
  for	
  SLD).	
   	
   The	
  Monitor	
  reviewed	
  a	
  sample	
  of	
  the	
  last	
  10	
  IEPs	
  written	
  by	
  Scioto	
  staff	
   prior	
  to	
  the	
  Monitor’s	
  April	
  2013	
  site	
  visit	
  (53%	
  of	
  the	
  current	
  special	
   education	
  population).	
  As	
  expected	
  after	
  reviewing	
  the	
  QA	
  results,	
  all	
  of	
   the	
  procedural	
  requirements	
  were	
  met	
  and	
  the	
  content	
  of	
  each	
  section	
   of	
  the	
  IEP	
  conformed	
  to	
  the	
  IDEA’s	
  requirements.	
  What	
  was	
  particularly	
   impressive	
  was	
  the	
  level	
  of	
  consideration	
  given	
  to	
  the	
  constellation	
  of	
   services	
  that	
  was	
  prescribed	
  for	
  each	
  student.	
  The	
  student’s	
  response	
  to	
   the	
  previous	
  level	
  of	
  service	
  was	
  discussed	
  and	
  reconsidered	
  to	
   determine	
  whether	
  a	
  different	
  arrangement	
  might	
  better	
  fit	
  the	
   student’s	
  needs.	
  In	
  some	
  cases,	
  the	
  service	
  was	
  delivery	
  was	
  modified	
   with	
  the	
  hope	
  that	
  the	
  student	
  would	
  become	
  more	
  engaged	
  in	
  the	
   program.	
  For	
  example,	
  one	
  student	
  had	
  previously	
  received	
  Occupational	
   Therapy	
  (OT)	
  services	
  in	
  the	
  general	
  education	
  classroom,	
  but	
  the	
   therapist	
  noted	
  that	
  the	
  youth	
  did	
  better	
  when	
  she	
  worked	
  with	
  him	
  1:1.	
   The	
  team	
  modified	
  the	
  service	
  delivery	
  accordingly.	
  	
  

	
  

62.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 63 of 67 PAGEID #: 2557

	
   IEP	
  Goal	
  Development	
   The	
  quality	
  of	
  articulation	
  of	
  the	
  IEP	
  goals	
  and	
  objectives	
  is	
  paramount	
  to	
   ensure	
  that	
  students	
  progress	
  through	
  the	
  curriculum.	
  This	
  task	
  is	
  much	
   easier	
  when	
  the	
  teacher/team	
  can	
  relay	
  on	
  clear	
  descriptions	
  of	
  the	
   students’	
  skill	
  deficits.	
  For	
  the	
  most	
  part,	
  the	
  IEPs’	
  Student	
  Profiles	
   contained	
  excellent	
  descriptions	
  of	
  the	
  youth’s	
  strengths	
  and	
   weaknesses,	
  including	
  a	
  mix	
  of	
  standardized	
  test	
  scores	
  and	
  teachers’	
   observations	
  about	
  the	
  students’	
  capabilities	
  and	
  skill	
  deficits,	
  and	
   descriptions	
  of	
  the	
  student’s	
  behavior	
  and	
  school	
  attendance.	
  	
   	
   Similarly,	
  the	
  Present	
  Level	
  of	
  Performance	
  section	
  used	
  to	
  set	
  up	
  each	
   IEP	
  goal	
  includes	
  relevant	
  test	
  scores	
  and	
  descriptions	
  of	
  the	
  students’	
   strengths	
  and	
  weaknesses	
  in	
  the	
  subject	
  matter	
  at	
  hand.	
  This	
   information	
  provided	
  necessary	
  context	
  for	
  the	
  goals	
  and	
  the	
  underlying	
   objectives.	
  Nearly	
  all	
  of	
  the	
  goals	
  reviewed	
  across	
  the	
  10	
  IEPs	
  were	
   individualized,	
  measurable	
  and	
  appeared	
  to	
  be	
  achievable	
  within	
  a	
  1-­‐ year	
  period,	
  and	
  the	
  objectives	
  identified	
  the	
  skills	
  necessary	
  to	
  meet	
  the	
   goal.	
  Behavior	
  goals	
  were	
  individualized	
  and	
  anchored	
  in	
  a	
  description	
  of	
   problem	
  behaviors	
  and	
  the	
  situations	
  in	
  which	
  they	
  are	
  likely	
  to	
  occur.	
   Methods	
  to	
  assess	
  progress	
  on	
  behavior	
  goals	
  generally	
  include	
  a	
   combination	
  of	
  citizenship	
  scores,	
  YBIRs,	
  ABC	
  referrals,	
  attendance	
  rates	
   and	
  “working	
  behaviors.”	
  All	
  students	
  had	
  transition	
  goals	
  that	
  appeared	
   to	
  be	
  relevant	
  to	
  the	
  student’s	
  current	
  grade	
  level	
  and	
  the	
  number	
  of	
   credits	
  they’d	
  earned.	
  These	
  goals	
  and	
  objectives	
  provide	
  a	
  solid	
   platform	
  from	
  which	
  student	
  progress	
  can	
  be	
  measured.	
  	
   	
   Progress	
  Reporting	
   Meaningful	
  progress	
  reporting	
  is	
  essential	
  to	
  ensuring	
  compliance	
  with	
   IDEA.	
  Facilitating	
  students’	
  progress	
  through	
  the	
  curriculum	
  is	
  the	
  entire	
   point	
  of	
  special	
  education,	
  and	
  without	
  assessing	
  progress,	
  the	
  program	
   cannot	
  identify	
  whether	
  it	
  is	
  meeting	
  students’	
  special	
  education	
  needs.	
  	
   	
   The	
  State	
  submitted	
  IEP	
  progress	
  reports	
  for	
  the	
  15	
  special	
  education	
   students	
  (100%)	
  who	
  were	
  at	
  Scioto	
  at	
  the	
  end	
  of	
  the	
  Jan-­‐March	
  2013	
   grading	
  period	
  (the	
  other	
  four	
  were	
  admitted	
  just	
  before	
  the	
  grading	
   period	
  ended,	
  or	
  their	
  IEPs	
  had	
  just	
  been	
  developed).	
  As	
  noted	
  in	
  the	
   previous	
  Monitor’s	
  Report,	
  DYS	
  has	
  a	
  dependable	
  procedure	
  for	
  ensuring	
   that	
  progress	
  reports	
  are	
  issued	
  each	
  grading	
  period.	
  Further,	
  the	
   content	
  of	
  the	
  progress	
  reports	
  continues	
  to	
  provide	
  tangible,	
   meaningful	
  assessments	
  of	
  the	
  extent	
  to	
  which	
  students	
  have	
  acquired	
   the	
  skills	
  needed	
  to	
  progress	
  through	
  the	
  curriculum.	
  	
  	
   	
   Most	
  of	
  the	
  15	
  progress	
  reports	
  offered	
  detailed,	
  comprehensive	
   descriptions	
  of	
  students’	
  progress	
  on	
  behavior,	
  academic	
  and	
  transition	
   goals.	
  Most	
  flowed	
  logically	
  from	
  the	
  goal,	
  to	
  the	
  assessment	
   information,	
  to	
  a	
  conclusion	
  about	
  the	
  extent	
  to	
  which	
  the	
  student	
  was	
  

	
  

63.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 64 of 67 PAGEID #: 2558

Recommendations	
   Sources	
  of	
   Information	
  
	
   	
  

progressing.	
  The	
  best	
  of	
  the	
  reports	
  offered	
  both	
  specific	
  assessments	
   (e.g.,	
  “In	
  a	
  108	
  word	
  essay,	
  there	
  were	
  10	
  capitalization	
  errors	
  and	
  half	
  a	
   dozen	
  punctuation	
  errors…”)	
  and	
  general	
  conclusions	
  about	
  the	
   student’s	
  progress	
  (e.g.,	
  “While	
  he	
  can	
  express	
  his	
  thoughts	
  fairly	
  clearly	
   in	
  writing,	
  it	
  is	
  full	
  of	
  errors	
  and	
  lacks	
  proper	
  structure.”).	
   	
   Occasionally,	
  specific	
  objectives	
  were	
  listed	
  (e.g.,	
  remain	
  in	
  the	
   designated	
  area,	
  complete	
  assignments,	
  respect	
  personal	
  space),	
  but	
   only	
  a	
  general	
  indicator	
  of	
  progress	
  was	
  given	
  (e.g.,	
  “the	
  youth	
  received	
  8	
   YBIRs.”).	
  While	
  this	
  may	
  be	
  a	
  good	
  starting	
  place,	
  the	
  assessment	
  of	
   progress	
  would	
  be	
  more	
  precise	
  if	
  the	
  teacher	
  discussed	
  the	
  nature	
  of	
   those	
  8	
  YBIRs	
  and	
  their	
  relationship	
  to	
  the	
  objectives.	
  Similarly,	
  a	
  couple	
   of	
  reports	
  contained	
  reasonable	
  goals	
  (e.g.,	
  “Explore	
  job	
  opportunities”)	
   but	
  contained	
  assessments	
  that	
  were	
  non-­‐responsive	
  (e.g.,	
  “student	
  is	
   passing	
  all	
  classes…studying	
  for	
  the	
  GED…had	
  8	
  unexcused	
  absences”).	
   These	
  examples	
  refer	
  to	
  a	
  very	
  small	
  minority	
  of	
  IEP	
  Progress	
  Reports— most	
  of	
  those	
  reviewed	
  gave	
  sufficient	
  information	
  about	
  the	
  youth’s	
   classroom	
  performance.	
  	
   	
   Together,	
  the	
  IEPs,	
  goals	
  and	
  objectives	
  and	
  progress	
  reports	
  document	
   the	
  planning	
  and	
  delivery	
  of	
  special	
  education	
  services	
  that	
  are	
   responsive	
  to	
  individual	
  student’s	
  needs.	
  Most	
  importantly,	
  the	
  progress	
   reports	
  reveal	
  that	
  most	
  of	
  Scioto’s	
  students	
  are	
  making	
  progress	
  toward	
   their	
  behavior,	
  academic	
  and	
  transition	
  goals	
  via	
  the	
  services	
  they	
   receive	
  in	
  the	
  special	
  education	
  program.	
  	
  	
  
The	
  State	
  remains	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  	
  
• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.7,	
  prepared	
  at	
  my	
  request	
  
• DYS	
  Education	
  Quality	
  Assurance	
  materials,	
  January	
  through	
   March	
  2013	
  
• Review	
  of	
  the	
  n=10	
  IEPs	
  development	
  most	
  recently	
  at	
  Scioto	
   (53%	
  of	
  the	
  current	
  special	
  education	
  population)	
  
• Review	
  15	
  Progress	
  Reports	
  from	
  the	
  January-­‐March	
  2013	
   grading	
  period	
  	
  
	
  

	
  

64.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 65 of 67 PAGEID #: 2559

	
  
III.E.8	
  Vocational	
  Education.	
  The	
  State	
  shall	
  provide	
  appropriate	
  vocational	
  services	
  that	
  are	
   required	
  transition	
  services	
  for	
  disabled	
  youth	
  under	
  the	
  IDEA.	
  	
  

Compliance	
  Rating	
   Substantial	
  Compliance	
  

Self	
  Assessment	
  

Although	
  vocational	
  eligibility	
  criteria	
  normally	
  require	
  students	
  to	
  be	
   either	
  Juniors	
  or	
  Seniors	
  (by	
  credit),	
  Scioto	
  obtained	
  a	
  waiver	
  from	
  the	
   ODE	
  to	
  serve	
  a	
  larger	
  segment	
  of	
  its	
  student	
  population.	
  Many	
  of	
  Scioto’s	
   9th	
  and	
  10th	
  graders	
  are	
  between	
  17	
  and	
  19	
  years	
  old,	
  are	
  behind	
  in	
   credits	
  and	
  may	
  not	
  graduate.	
  They	
  would	
  benefit	
  greatly	
  from	
   opportunities	
  to	
  develop	
  vocational	
  skills	
  and	
  thus	
  the	
  ODE	
  granted	
  the	
   facility	
  the	
  flexibility	
  to	
  allow	
  such	
  youth	
  to	
  participate	
  in	
  the	
   programming.	
  	
   	
   In	
  its	
  self-­‐assessment,	
  the	
  State	
  discussed	
  data	
  on	
  student	
  enrollment	
  in	
   the	
  three	
  currently	
  available	
  vocational	
  classes.	
  As	
  of	
  April	
  22,	
  2013,	
   there	
  were	
  47	
  youth	
  on	
  the	
  school	
  roster.	
  Ten	
  of	
  these	
  were	
  graduates,	
   and	
  ten	
  were	
  housed	
  on	
  the	
  PROGRESS	
  Unit,	
  leaving	
  27	
  students	
  in	
  the	
   general	
  population.	
  Of	
  these:	
  
• 7	
  students	
  (26%)	
  were	
  enrolled	
  in	
  Administrative	
  Office	
   Technology	
  (a	
  course	
  that	
  teaches	
  students	
  how	
  to	
  use	
  various	
   computer	
  applications	
  to	
  prepare	
  them	
  for	
  clerical,	
  data	
  entry,	
   graphics,	
  or	
  other	
  office-­‐based	
  jobs);	
  
• 5	
  students	
  (19%)	
  were	
  enrolled	
  in	
  Career-­‐Based	
  Intervention	
   (i.e.,	
  work-­‐based	
  learning,	
  student	
  earns	
  credit);	
  and	
  	
  
• 7	
  students	
  (26%)	
  were	
  enrolled	
  in	
  Transition	
  Skills	
  (students	
  must	
   take	
  this	
  course	
  prior	
  to	
  release;	
  includes	
  job	
  skills,	
  resume	
   building,	
  interview	
  skills).	
  
Overall,	
  71%	
  of	
  the	
  students	
  in	
  the	
  general	
  population	
  were	
  involved	
  in	
   vocational	
  courses,	
  along	
  with	
  one	
  or	
  two	
  graduates	
  who	
  were	
  simply	
   interested	
  in	
  the	
  course	
  offerings.	
  Even	
  with	
  the	
  expansion	
  of	
  the	
   “eligibility	
  criteria,”	
  each	
  of	
  the	
  three	
  courses	
  has	
  sufficient	
  capacity	
  to	
   serve	
  significantly	
  more	
  students	
  if	
  needed.	
  	
   	
   The	
  Ohio	
  DYS	
  vocational	
  programs	
  were	
  audited	
  twice	
  during	
  the	
   previous	
  monitoring	
  period.	
  First,	
  the	
  ODE	
  Office	
  for	
  Exceptional	
  Children	
   audited	
  DYS’s	
  special	
  education	
  program.	
  IDEA	
  requires	
  the	
  IEPs	
  for	
   students	
  age	
  14	
  and	
  older	
  to	
  include	
  a	
  Transition	
  Plan	
  to	
  ensure	
  that	
  the	
   school	
  delivers	
  services	
  in	
  preparation	
  for	
  life	
  after	
  graduation	
  (and,	
  in	
   this	
  case,	
  after	
  they	
  return	
  to	
  the	
  community).	
  The	
  audit	
  found	
  Scioto	
  to	
   be	
  in	
  compliance	
  with	
  the	
  standard	
  related	
  to	
  Transition	
  Planning	
  (SPP	
   Indicator	
  20	
  for	
  Secondary	
  Transition	
  Plans).	
  Specifically,	
  ODE	
  found	
  that	
   Scioto’s	
  plans	
  “prescribed	
  reasonable	
  services	
  to	
  meet	
  post-­‐secondary	
   goals.”	
  In	
  other	
  words,	
  Scioto	
  youth	
  have	
  access	
  to	
  courses	
  that	
  address	
   their	
  pursuits	
  after	
  high	
  school.	
  	
   	
   In	
  addition,	
  ODE’s	
  Office	
  of	
  Career-­‐Technical	
  Education	
  conducted	
  a	
  

	
  

65.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 66 of 67 PAGEID #: 2560

Steps	
  Taken	
  to	
   Assess	
  Compliance	
  

comprehensive	
  review	
  of	
  all	
  career-­‐technical	
  education	
  programs	
  offered	
   at	
  Scioto.	
  Through	
  teacher	
  surveys,	
  document	
  review	
  and	
  on-­‐site	
   program	
  observations,	
  the	
  audit	
  noted	
  significant	
  improvement	
  in	
  the	
   participation	
  rates	
  in	
  Scioto’s	
  vocational	
  programs	
  (mirroring	
  the	
   Monitor’s	
  findings	
  discussed	
  below).	
  In	
  addition,	
  the	
  audit	
  noted	
  that	
   vocational	
  textbooks	
  were	
  current	
  and	
  that	
  supplies	
  and	
  facilities	
  were	
   adequate.	
  	
   	
   The	
  report’s	
  Opportunities	
  for	
  Improvement	
  included	
  a	
  variety	
  of	
   suggestions	
  to	
  improve	
  the	
  administration	
  of	
  the	
  programs	
  (e.g.,	
   involving	
  Central	
  Office	
  in	
  vocational	
  teacher	
  hiring;	
  improving	
   communication)	
  or	
  to	
  enrich	
  the	
  curriculum	
  delivery	
  (e.g.,	
  developing	
  a	
   method	
  for	
  internet	
  access	
  with	
  appropriate	
  firewalls;	
  emphasizing	
   employability	
  skills	
  in	
  all	
  courses).	
  The	
  audit	
  also	
  recommended	
  that	
  the	
   DYS	
  formalize	
  student’s	
  course	
  completion	
  via	
  industry-­‐based	
   credentialing	
  tests	
  and	
  formal	
  graduation	
  ceremonies.	
  Notably,	
  the	
  ODE	
   did	
  not	
  require	
  or	
  advise	
  any	
  modifications	
  to	
  the	
  course	
  offerings,	
   apparently	
  finding	
  they	
  were	
  adequate	
  to	
  meet	
  the	
  needs	
  of	
  students.	
  	
  
The	
  State	
  has	
  continued	
  its	
  efforts	
  to	
  increase	
  the	
  proportion	
  of	
  youth	
   who	
  are	
  engaged	
  in	
  vocational	
  programming.	
  All	
  students	
  in	
  the	
  general	
   population	
  have	
  the	
  opportunity	
  to	
  participate	
  in	
  vocational	
  programs;	
   however,	
  some	
  students	
  choose	
  to	
  focus	
  on	
  college	
  prep	
  materials	
  and	
   may	
  not	
  choose	
  to	
  take	
  vocational	
  courses	
  as	
  a	
  result.	
  Some	
  of	
  Scioto’s	
   students	
  simply	
  are	
  not	
  eligible	
  (because	
  they	
  are	
  too	
  young	
  and	
  are	
  on	
   track	
  to	
  graduate).	
  Further,	
  a	
  significant	
  portion	
  of	
  Scioto’s	
  students	
  is	
   housed	
  on	
  the	
  PROGRESS	
  Unit	
  (i.e.,	
  21%	
  of	
  the	
  students	
  included	
  in	
  this	
   review).	
  These	
  students	
  do	
  not	
  have	
  access	
  to	
  the	
  AOT	
  classroom	
  and	
  are	
   not	
  permitted	
  to	
  have	
  jobs	
  (CBI).	
  However,	
  once	
  they	
  are	
  transferred	
  to	
   the	
  Transition	
  Unit,	
  where	
  they	
  attend	
  school	
  with	
  the	
  general	
   population,	
  they	
  are	
  enrolled	
  in	
  the	
  courses	
  they	
  need.	
  The	
  State	
   provided	
  documentation	
  showing	
  such	
  enrollments	
  for	
  two	
  youth	
  who	
   recently	
  transferred	
  from	
  the	
  PU.	
  All	
  youth	
  take	
  the	
  Transition	
  Course	
  at	
   some	
  point	
  3	
  to	
  6	
  months	
  before	
  their	
  scheduled	
  release	
  date.	
  	
  	
   	
   The	
  Monitor	
  has	
  expressed	
  a	
  preference	
  for	
  hands-­‐on	
  learning	
   opportunities	
  and	
  the	
  facility	
  has	
  been	
  vigilant	
  about	
  identifying	
  new	
   opportunities.	
  As	
  noted	
  in	
  the	
  Programming	
  provision	
  (III.F.1),	
  an	
  11-­‐ week	
  Barbering	
  class	
  offering	
  certification	
  will	
  soon	
  be	
  available.	
  In	
   addition,	
  a	
  few	
  of	
  the	
  facility’s	
  volunteers	
  are	
  employed	
  in	
  various	
  trades	
   (e.g.,	
  construction,	
  landscaping)	
  and	
  have	
  agreed	
  to	
  provide	
  hands-­‐on	
   programming	
  to	
  students.	
  Currently,	
  8	
  students	
  are	
  formulating	
  ideas	
  for	
   a	
  cabinet-­‐making	
  project.	
  	
   	
   In	
  summary,	
  the	
  opportunities	
  for	
  students	
  to	
  develop	
  job	
  and	
   employability	
  skills	
  are	
  far	
  greater	
  than	
  they	
  were	
  at	
  the	
  time	
  Stipulation	
   was	
  signed.	
  Scioto’s	
  available	
  services	
  can	
  fully	
  address	
  the	
  transition	
   needs	
  and	
  services	
  prescribed	
  in	
  Scioto’s	
  IEPs	
  which	
  include	
  completing	
  

	
  

66.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 114 Filed: 06/18/13 Page: 67 of 67 PAGEID #: 2561

Recommendations	
   Sources	
  of	
   Information	
  
	
  

career	
  interest	
  inventories,	
  conducting	
  job	
  opportunity	
  searches,	
   developing	
  employability	
  skills,	
  and	
  compiling	
  transition	
  portfolios.	
  
The	
  State	
  remains	
  in	
  substantial	
  compliance	
  with	
  this	
  provision.	
  	
  
• Oral	
  presentation	
  and	
  underlying	
  documentation	
  for	
  provision	
   III.E.8,	
  prepared	
  at	
  my	
  request	
  
• Student	
  rosters	
  for	
  each	
  of	
  the	
  three	
  vocational	
  courses,	
  January-­‐ March	
  2013	
  grading	
  period	
  
• Documentation	
  of	
  vocational	
  enrollment	
  for	
  two	
  former	
  PU	
   students	
  
• ODE	
  Office	
  of	
  Exceptional	
  Children	
  audit	
  report,	
  November,	
  2012	
   • ODE	
  Office	
  of	
  Career-­‐Technical	
  Education	
  audit	
  report,	
  
November	
  2012	
  

	
  

67.	
  

 Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 1 of 34 PAGEID #: 2562

	
   	
   	
   	
   	
   	
   	
   	
  
PROGRESS	
  Unit	
  at	
  the	
  Scioto	
  Juvenile	
  Correctional	
  Facility	
  
1st	
  Status	
  Report	
   Civil	
  Actions	
  2:08-­‐cv-­‐00475	
  and	
  2:04-­‐cv-­‐01206	
  
	
   	
   	
   	
   	
   Submitted	
  by:	
   	
   Kelly	
  Dedel,	
  Ph.D.	
   One	
  in	
  37	
  Research,	
  Inc.	
   16	
  Rock	
  Street	
  	
  Cody,	
  WY	
  	
  82414	
   (503)799-­‐0915	
  	
  kelly.dedel@gmail.com	
   	
   Daphne	
  Glindmeyer,	
  M.D.	
   229	
  Bellemeade	
  Boulevard	
  Suite	
  420	
   Gretna,	
  Louisiana	
  70056	
   (504)666-­‐1600	
  	
  	
  dglindmeyer@gmail.com	
  	
   	
   	
   Reviewed	
  by:	
   	
   Will	
  Harrell,	
  J.D.,	
  LL.M	
   1221	
  Kerlerec	
   New	
  Orleans,	
  LA	
  	
  70117	
   (512)695-­‐7519	
  	
  shmonitor.harrell@gmail.com	
  	
   	
   Terry	
  Schuster,	
  J.D.	
   1037	
  Neil	
  Ave.,	
  Apt.	
  C	
   Columbus,	
  Oh	
  43201	
   (512)468-­‐4486	
  	
  shmonitor.schuster@gmail.com	
  	
   	
   	
   	
   Draft	
  submitted	
  March	
  15,	
  2013	
   Final	
  submitted	
  March	
  27,	
  2013	
   	
  

	
  

1.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 2 of 34 PAGEID #: 2563

TABLE	
  OF	
  CONTENTS	
   	
   	
  
Introduction	
  .................................................................................................................................................	
 3  	
  	
  

Purpose	
  and	
  Structure	
  of	
  the	
  Report	
.   ..........................................................................................................	
 3  	
  

	
  
II.14	
  Policies,	
  Procedures	
  and	
  Handbooks	
  ...................................................................................................	
 7  	
  

	
  
II.9	
  Admissions	
  Screening	.
  ............................................................................................................................	
 8  	
  

	
  
II.10	
  Daily	
  Schedule	
 .  ...................................................................................................................................	
 1  1	
  

Out	
  of	
  Room	
  Time	
.   ........................................................................................................................	
 1  1	
  

Daily	
  Activities	
.   ..............................................................................................................................	
 1  2	
  

Graduate	
  Programming	.
  ................................................................................................................	
 1  3	
  

	
  
II.11	
  Staffing	
 .  ..............................................................................................................................................	
 1  5	
  

Staff	
  Numbers	
  and	
  Training	
  ..........................................................................................................	
 1  5	
  

Impact	
  on	
  Safety	
  ...........................................................................................................................	
 1  7	
  

	
  
II.12	
  Treatment	
  Planning	.
  ...........................................................................................................................	
 1  9	
  

Clinical	
  Staffing	
.   .............................................................................................................................	
 1  9	
  

Treatment	
  Planning	.
  ......................................................................................................................	
 1  9	
  

Progress	
  Reporting	
  and	
  Promotion	
.   ..............................................................................................	
 2  2	
  

InterDisciplinary	
  Team	
  (IDT)	.
  .........................................................................................................	
 2  3	
  

IDT	
  Substance	.
  ...............................................................................................................................	
 2  4	
  

Length	
  of	
  Stay	
  ...............................................................................................................................	
 2  5	
  

Central	
  Office	
  Review	
  Board	
  (CORB)	
  Composition	
  and	
  Timelines	
  ................................................	
 2  7	
  

CORB	
  Substance	
 .  ...........................................................................................................................	
 2  8	
  

	
  
II.13	
  Phase	
  Demotions	
  ...............................................................................................................................	
 3  0	
  

	
  
III.C.3	
  Quality	
  Assurance	
  ............................................................................................................................	
 3  2	
  

	
  

	
  

	
  

2.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 3 of 34 PAGEID #: 2564

INTRODUCTION	
  
	
   In	
  October	
  and	
  November	
  2012,	
  pursuant	
  to	
  the	
  United	
  States	
  v.	
  Ohio	
  and	
  S.H.	
  v.	
  Reed	
   Stipulations,	
  the	
  U.S.	
  Department	
  of	
  Justice	
  (DOJ)	
  and	
  the	
  S.H.	
  plaintiff	
  class	
  each	
  initiated	
  a	
   process	
  for	
  dispute	
  resolution	
  to	
  address	
  concerns	
  regarding	
  the	
  purpose,	
  structure,	
  and	
   operation	
  of	
  the	
  PROGRESS	
  and	
  Transition	
  Units	
  at	
  the	
  Scioto	
  Juvenile	
  Correctional	
  Facility	
  (the	
   PU).	
  	
  The	
  Monitors	
  and	
  Plaintiffs	
  in	
  both	
  cases	
  have	
  expressed	
  on-­‐going	
  concerns	
  about	
  DYS’	
   operation	
  of	
  special	
  management	
  units	
  since	
  at	
  least	
  2007.	
  The	
  Ohio	
  Department	
  of	
  Youth	
   Services	
  (DYS)	
  and	
  DOJ	
  negotiated	
  and	
  agreed	
  upon	
  a	
  proposed	
  Consent	
  Order,	
  filed	
  with	
  the	
   Court	
  on	
  December	
  19,	
  2012.	
  	
  The	
  Court	
  did	
  not	
  sign	
  the	
  Order	
  until	
  January	
  18,	
  2013	
  when	
  it	
   was	
  also	
  incorporated	
  into	
  a	
  broader	
  settlement	
  between	
  DYS	
  and	
  the	
  S.H.	
  plaintiff	
  class.	
  	
  The	
   Consent	
  Order	
  sets	
  standards	
  related	
  to	
  PU	
  policies,	
  admissions	
  screening,	
  programming,	
  out-­‐ of-­‐room	
  time,	
  staffing,	
  treatment	
  planning,	
  length	
  of	
  stay,	
  and	
  promotion	
  and	
  demotion	
   between	
  phases.	
  	
  The	
  S.H.	
  settlement	
  supplements	
  the	
  Consent	
  Order	
  with	
  additional	
  standards	
   related	
  to	
  PU	
  behavioral	
  health	
  staffing	
  and	
  quality	
  assurance.	
  	
  	
   	
  
PURPOSE	
  AND	
  STRUCTURE	
  OF	
  THE	
  REPORT	
  
	
   Although	
  the	
  DOJ	
  monitoring	
  team	
  issues	
  reports	
  every	
  six	
  months,	
  Drs.	
  Dedel	
  and	
  Glindmeyer	
   feel	
  strongly	
  that	
  progress	
  can	
  be	
  facilitated	
  by	
  more	
  frequent	
  feedback	
  to	
  the	
  Parties.	
  The	
  PU	
   program	
  is	
  changing	
  quickly,	
  and	
  more	
  frequent	
  feedback	
  will	
  both	
  recognize	
  the	
  State’s	
   progress	
  and	
  also	
  provide	
  sufficient	
  guidance	
  to	
  keep	
  the	
  program	
  development	
  on	
  track	
  with	
   what	
  is	
  required	
  in	
  the	
  Order.	
  The	
  Parties	
  and	
  Monitors	
  agreed	
  that	
  Drs.	
  Dedel	
  and	
  Glindmeyer	
   would	
  write	
  this	
  first	
  status	
  report,	
  covering	
  the	
  period	
  January	
  18,	
  2013	
  (the	
  date	
  the	
  order	
  was	
   signed)	
  through	
  February	
  28,	
  2013.	
  While	
  January	
  18,	
  2013	
  is	
  the	
  official	
  “start	
  date,”	
  it	
  is	
   important	
  to	
  recognize	
  that	
  the	
  PU	
  reform	
  effort	
  predates	
  the	
  Order.	
  The	
  State,	
  DOJ	
  and	
   Monitors	
  began	
  sketching	
  out	
  a	
  new	
  vision	
  for	
  the	
  PU	
  in	
  early	
  November	
  2012,	
  and	
  the	
  State	
   began	
  submitting	
  data	
  documenting	
  these	
  changes	
  in	
  late	
  November	
  2012.	
  Status	
  Reports	
  will	
   be	
  issued	
  every	
  three	
  months	
  hereafter.	
  The	
  next	
  one	
  will	
  cover	
  the	
  period	
  March	
  1	
  through	
   May	
  31,	
  2013	
  and	
  will	
  be	
  issued	
  sometime	
  in	
  June	
  2013.	
  	
   	
   In	
  order	
  to	
  facilitate	
  progress,	
  this	
  report	
  is	
  formatted	
  as	
  a	
  Quality	
  Assurance	
  (QA)	
  report.	
  When	
   the	
  Order	
  was	
  incorporated	
  into	
  the	
  S.H.	
  settlement,	
  a	
  requirement	
  for	
  a	
  QA	
  plan	
  to	
  be	
   developed	
  and	
  implemented	
  was	
  imposed.	
  While	
  there	
  are	
  many	
  ways	
  to	
  accomplish	
  this	
  task,	
   Drs.	
  Dedel	
  and	
  Glindmeyer	
  believe	
  that	
  structuring	
  feedback	
  using	
  a	
  QA	
  model	
  will	
  provide	
  a	
   clearer	
  sense	
  of	
  our	
  expectations	
  of	
  the	
  State	
  toward	
  this	
  end,	
  and	
  will	
  advance	
  the	
  State’s	
   understanding	
  of	
  Quality	
  Assurance	
  and	
  Quality	
  Improvement	
  (QA/QI)	
  by	
  using	
  concrete,	
  real-­‐ time	
  examples.	
  We	
  hope	
  that	
  this	
  format	
  is	
  helpful	
  to	
  the	
  Plaintiffs	
  in	
  their	
  effort	
  to	
  assess	
  the	
   current	
  conditions	
  of	
  the	
  PU	
  and	
  to	
  the	
  State	
  in	
  their	
  efforts	
  to	
  adopt	
  a	
  QA/QI	
  system	
  that	
   creates	
  the	
  internal	
  capacity	
  to	
  identify	
  and	
  solve	
  problems.	
  	
  	
   	
   Technical	
  assistance	
  notes	
  are	
  offered	
  throughout	
  the	
  report.	
  These	
  are	
  designed	
  to	
  improve	
   the	
  DYS’	
  ability	
  to	
  monitor	
  program	
  performance	
  (and,	
  concurrently,	
  assist	
  the	
  Monitors	
  in	
   providing	
  a	
  comprehensive	
  review	
  of	
  the	
  program).	
  Generally,	
  these	
  issues	
  cluster	
  around	
  data	
   collection	
  issues	
  and	
  documentation	
  needed	
  to	
  substantiate	
  program	
  performance.	
  	
   	
  

	
  

3.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 4 of 34 PAGEID #: 2565

For	
  each	
  of	
  the	
  seven	
  substantive	
  areas	
  in	
  the	
  Order	
  [identified	
  by	
  the	
  Consent	
  Order’s	
   paragraph	
  number	
  in	
  brackets],	
  the	
  report	
  includes	
  the	
  following:	
   	
  
• Standard:	
  A	
  statement	
  of	
  what	
  the	
  State	
  is	
  trying	
  to	
  achieve	
  in	
  the	
  particular	
  substantive	
   area.	
  Multiple	
  standards	
  may	
  apply	
  to	
  a	
  single	
  substantive	
  area.	
  The	
  standards	
  are	
   based	
  on	
  the	
  requirements	
  of	
  the	
  Court	
  Order.	
  However,	
  they	
  are	
  a	
  statement	
  of	
  what	
   “should	
  be,”	
  not	
  necessarily	
  a	
  description	
  of	
  what	
  currently	
  exists	
  at	
  this	
  point	
  in	
  time.	
  	
   	
  
• Status:	
  For	
  the	
  purpose	
  of	
  the	
  status	
  report,	
  the	
  Monitors	
  use	
  a	
  two-­‐level	
  system	
  for	
   each	
  substantive	
  area:	
  the	
  area	
  is	
  either	
  in	
  substantial	
  compliance	
  or	
  it	
  is	
  not.	
  [Once	
  the	
   DYS	
  adopts	
  a	
  comprehensive	
  QA	
  program,	
  it	
  is	
  encouraged	
  to	
  adopt	
  non-­‐legal	
  language	
   for	
  these	
  categories.	
  For	
  example,	
  “Exemplary	
  Performance,”	
  “Adequate	
  Performance”	
   and	
  “Performance	
  Needs	
  Remediation.”	
  Further,	
  under	
  the	
  QA	
  program,	
  each	
  standard	
   within	
  the	
  substantive	
  area	
  should	
  be	
  rated	
  individually	
  to	
  provide	
  a	
  more	
  precise	
   measure	
  of	
  the	
  PU’s	
  performance.]	
  	
  
	
   • Methodology:	
  The	
  data	
  that	
  should	
  be	
  used	
  to	
  assess	
  performance	
  toward	
  the	
  standard.	
   In	
  some	
  cases,	
  this	
  goes	
  beyond	
  the	
  data	
  that	
  have	
  been	
  sent	
  to	
  the	
  Monitors.	
  
	
  	
   • Analysis	
  and	
  Interpretation:	
  A	
  presentation	
  of	
  the	
  data	
  collected	
  for	
  the	
  timeframe,	
   January	
  18-­‐February	
  28,	
  2013,	
  and	
  an	
  interpretation	
  of	
  what	
  it	
  says	
  about	
  the	
  extent	
  to	
   which	
  the	
  standard	
  is	
  being	
  achieved.	
  [At	
  times,	
  this	
  report	
  relies	
  on	
  older	
  data	
  to	
   provide	
  a	
  better	
  context	
  for	
  the	
  discussion	
  or	
  to	
  better	
  illustrate	
  patterns	
  that	
  have	
   emerged.]	
  
	
   • Recommendations:	
  Statements	
  regarding	
  what	
  must	
  occur	
  in	
  order	
  for	
  the	
  standard	
  to	
   be	
  achieved.	
  The	
  Monitors	
  also	
  provide	
  technical	
  assistance	
  throughout	
  this	
  document,	
   intended	
  to	
  solidify	
  quality	
  assurance	
  procedures	
  or	
  ensure	
  the	
  integrity	
  of	
  the	
  program	
   design.	
  	
   	
  
The	
  recommendations	
  refer	
  to	
  a	
  Quality	
  Improvement	
  Plan	
  (QIP).	
  This	
  structure	
  is	
  utilized	
  to	
   shift	
  responsibility	
  for	
  the	
  ongoing	
  monitoring	
  of	
  the	
  PU	
  to	
  the	
  DYS,	
  in	
  order	
  to	
  make	
  external	
   monitoring	
  unnecessary.	
  A	
  QIP	
  is	
  recommended	
  for	
  each	
  area	
  in	
  which	
  the	
  Monitors	
  have	
   identified	
  areas	
  of	
  concern.	
  A	
  multidisciplinary	
  team	
  should	
  be	
  involved	
  in	
  analyzing	
  the	
   problems	
  to	
  understand	
  the	
  reasons	
  they	
  occur,	
  and	
  then	
  drafting	
  a	
  QIP	
  to	
  address	
  the	
   underlying	
  causes	
  of	
  the	
  problem.	
  	
   	
   Subsequent	
  status	
  reports	
  will	
  ask	
  for	
  the	
  State’s	
  analysis	
  and	
  interpretation	
  of	
  current	
  data,	
   which	
  will	
  be	
  validated	
  by	
  the	
  Monitors.	
  From	
  there,	
  the	
  Monitors	
  will	
  review	
  the	
  progress	
   made	
  on	
  QIPs	
  developed	
  in	
  response	
  to	
  this	
  report.	
  As	
  substantial	
  compliance	
  is	
  reached	
  with	
  all	
   of	
  the	
  standards,	
  the	
  State	
  should	
  begin	
  to	
  produce	
  both	
  the	
  QA	
  and	
  QI	
  portions	
  of	
  the	
  report.	
  	
   	
   Although	
  DYS	
  is	
  not	
  yet	
  in	
  substantial	
  compliance	
  with	
  any	
  of	
  the	
  standards,	
  it	
  is	
  essential	
  to	
   recognize	
  that	
  less	
  than	
  two	
  months	
  have	
  elapsed	
  since	
  the	
  Order	
  was	
  signed.	
  In	
  several	
  cases,	
   DYS	
  has	
  addressed	
  most	
  of	
  the	
  requirements	
  of	
  the	
  subsection	
  and	
  must	
  refine	
  only	
  a	
  small	
  part	
   of	
  the	
  required	
  procedures.	
  	
   	
  

	
  

4.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 5 of 34 PAGEID #: 2566

The	
  Order	
  is	
  very	
  specific.	
  Dissecting	
  the	
  PU	
  at	
  this	
  level	
  risks	
  “missing	
  the	
  forest	
  for	
  the	
  trees.”	
   The	
  PU	
  is	
  a	
  radically	
  different	
  program	
  than	
  it	
  was	
  a	
  year	
  ago,	
  when	
  the	
  Plaintiffs	
  for	
  both	
   lawsuits	
  raised	
  serious	
  concerns	
  about	
  the	
  amount	
  of	
  isolation	
  and	
  lack	
  of	
  treatment	
  that	
   characterized	
  the	
  youths’	
  experience.	
  Today,	
  all	
  youth	
  on	
  the	
  PU	
  are	
  out	
  of	
  their	
  rooms	
  during	
   waking	
  hours	
  and	
  are	
  engaged	
  in	
  a	
  full	
  range	
  of	
  education	
  and	
  rehabilitative	
  programming.	
  This	
   change	
  represents	
  a	
  massive	
  cultural	
  shift	
  for	
  DYS	
  and	
  the	
  PU	
  staff.	
  From	
  here,	
  DYS	
  must	
  tie	
  up	
   some	
  procedural	
  loose	
  ends	
  and	
  must	
  advance	
  the	
  substance	
  and	
  quality	
  of	
  the	
  treatment	
   offered	
  to	
  youth	
  on	
  the	
  PU	
  so	
  that	
  they	
  can	
  return	
  to	
  the	
  general	
  population	
  more	
  quickly.	
  Even	
   in	
  the	
  short	
  time	
  since	
  the	
  PU	
  reform	
  effort	
  began,	
  the	
  DYS	
  has	
  made	
  significant	
  positive	
   changes	
  to	
  the	
  quality	
  of	
  the	
  youth’s	
  living	
  conditions.	
   	
   Furthermore,	
  DYS	
  has	
  been	
  dutiful	
  in	
  its	
  submission	
  of	
  required	
  data	
  and	
  information	
  and	
  has	
   supported	
  the	
  monitoring	
  team’s	
  efforts	
  to	
  obtain	
  current,	
  accurate	
  descriptions	
  of	
  the	
  PU’s	
   functioning.	
  In	
  late	
  February	
  2013,	
  the	
  S.H.	
  Lead	
  Monitor	
  and	
  his	
  Assistant	
  made	
  an	
   unannounced	
  visit	
  to	
  the	
  PU.	
  DYS	
  cooperated	
  fully	
  and	
  the	
  Monitors’	
  observations	
  largely	
   validated	
  the	
  data	
  that	
  DYS	
  had	
  been	
  submitting.	
  Not	
  only	
  were	
  all	
  youth	
  out	
  of	
  their	
  rooms	
   during	
  waking	
  hours,	
  but	
  they	
  also	
  remained	
  out	
  of	
  their	
  rooms	
  even	
  after	
  a	
  youth	
  engaged	
  in	
  a	
   serious	
  incident.	
  Such	
  observations	
  are	
  very	
  encouraging.	
  	
   	
   While	
  there	
  has	
  been	
  significant	
  progress,	
  much	
  work	
  remains.	
  One	
  of	
  the	
  key	
  findings	
  of	
  this	
   status	
  report	
  is	
  the	
  frequency	
  with	
  which	
  youth	
  are	
  recycled	
  back	
  through	
  the	
  phases,	
  resulting	
   in	
  prolonged	
  lengths	
  of	
  stay	
  on	
  the	
  PU	
  for	
  most	
  youth.	
  While	
  most	
  of	
  the	
  procedures	
  designed	
   to	
  ensure	
  prompt	
  promotion	
  have	
  been	
  properly	
  implemented,	
  many	
  youth	
  continue	
  to	
  engage	
   in	
  problematic	
  behaviors	
  even	
  after	
  they	
  are	
  promoted	
  toward	
  the	
  general	
  population.	
  While	
   some	
  of	
  these	
  youth	
  may	
  persist	
  in	
  problem	
  behaviors	
  no	
  matter	
  what	
  treatment	
  interventions	
   and	
  behavior	
  management	
  strategies	
  are	
  attempted,	
  the	
  deficits	
  in	
  treatment	
  planning	
  suggest	
   that	
  improvements	
  in	
  this	
  area	
  may	
  produce	
  better	
  outcomes,	
  and	
  shorter	
  lengths	
  of	
  stay,	
  for	
   many	
  of	
  the	
  PU	
  youth.	
  DYS	
  is	
  strongly	
  encouraged	
  to	
  focus	
  on	
  the	
  reasons	
  that	
  youth	
  are	
  not	
   moving	
  through	
  the	
  program	
  back	
  to	
  the	
  general	
  population	
  within	
  the	
  basic	
  prescribed	
   timelines	
  (i.e.,	
  not	
  the	
  behavior,	
  but	
  rather	
  the	
  skill	
  deficits).	
  	
  Questions	
  about	
  whether	
  youth	
   are	
  receiving	
  the	
  type	
  and	
  intensity	
  of	
  treatment	
  prescribed	
  by	
  their	
  treatment	
  plans	
  are	
  also	
   still	
  pending,	
  given	
  the	
  difficulties	
  experienced	
  in	
  matching	
  current	
  ITPs	
  to	
  the	
  CaseNotes	
  data.	
  	
   	
   The	
  monitoring	
  team	
  sincerely	
  hopes	
  that	
  this	
  report	
  brings	
  greater	
  clarity	
  to	
  the	
  work	
  that	
  lies	
   ahead	
  and	
  provides	
  a	
  useful	
  template	
  for	
  the	
  DYS	
  Quality	
  Assurance/Quality	
  Improvement	
   program.	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  Data	
  Analysis	
  and	
  Interpretation	
  
The	
  Court	
  Order	
  requires	
  DYS	
  to	
  provide	
  a	
  broad	
  range	
  of	
  data	
  to	
  substantiate	
  compliance	
  with	
  the	
   various	
  requirements.	
  Simply	
  providing	
  the	
  data	
  is	
  only	
  the	
  first	
  step—these	
  data	
  must	
  demonstrate	
  that	
   the	
  PU	
  is	
  functioning	
  in	
  a	
  manner	
  that	
  cures	
  concerns	
  about	
  the	
  program’s	
  design,	
  the	
  treatment	
  and	
   services	
  provided	
  to	
  youth,	
  whether	
  youth	
  develop	
  the	
  skills	
  necessary	
  to	
  meet	
  behavioral	
  expectations	
   and	
  treatment	
  goals,	
  and	
  the	
  youth’s	
  length	
  of	
  stay	
  on	
  the	
  unit.	
  In	
  order	
  to	
  do	
  so,	
  the	
  data	
  must	
  be	
  specific	
   and	
  must	
  be	
  structured	
  to	
  reveal	
  the	
  dynamics	
  of	
  the	
  care	
  provided	
  to	
  youth.	
   	
   Toward	
  that	
  end,	
  the	
  Monitors	
  provided	
  feedback	
  to	
  DYS	
  designed	
  to	
  improve	
  the	
  quality	
  of	
  the	
  data.	
  DYS	
   began	
  submitting	
  data	
  to	
  the	
  Monitors	
  well	
  before	
  the	
  Order	
  was	
  signed.	
  Since	
  early	
  December	
  2012,	
  the	
  

	
  

5.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 6 of 34 PAGEID #: 2567

Monitors	
  provided	
  feedback	
  to	
  address	
  the	
  following	
  issues:	
   • Categorization	
  and	
  completeness	
  of	
  data	
  contained	
  in	
  the	
  CaseNotes	
  database	
  to	
  accurately	
   depict	
  the	
  amount	
  of	
  CBT	
  group	
  therapy,	
  other	
  treatment,	
  and	
  various	
  contacts	
  with	
  youth.	
   • Accuracy	
  of	
  the	
  data	
  contained	
  in	
  the	
  Youth	
  Activity	
  Tracking	
  data	
  to	
  ensure	
  that	
  it	
  can	
  be	
  used	
   to	
  troubleshoot	
  issues	
  that	
  became	
  evident	
  with	
  leisure	
  time,	
  delivery	
  of	
  MAV	
  groups	
  by	
  the	
   Youth	
  Specialists,	
  meals	
  being	
  eaten	
  in	
  rooms,	
  and	
  opportunities	
  for	
  recreation.	
  	
   • Methods	
  for	
  validating	
  the	
  activities	
  categorized	
  as	
  “Structured	
  Programming.”	
   • Functioning	
  of	
  the	
  Central	
  Office	
  Review	
  Board.	
   • Tracking	
  youth’s	
  progress	
  toward	
  behavioral	
  expectations	
  and	
  treatment	
  goals	
  and	
  how	
  these	
   could	
  be	
  captured	
  in	
  the	
  IDT	
  minutes	
  rather	
  than	
  continuing	
  to	
  utilize	
  the	
  Behavioral	
  Tracking	
   Sheets	
  that	
  were	
  originally	
  designed	
  for	
  this	
  purpose.	
  	
   • Capturing	
  the	
  youth’s	
  length	
  of	
  stay	
  on	
  each	
  phase,	
  and	
  cycling	
  back	
  through	
  the	
  phases	
  when	
  it	
   occurred.	
  	
   • Analyzing	
  and	
  interpreting	
  the	
  data	
  in-­‐house	
  so	
  that	
  program	
  modifications	
  can	
  be	
  made	
  more	
   quickly	
  and	
  without	
  needing	
  the	
  Monitors	
  to	
  direct	
  these	
  improvements.	
  	
  
	
   In	
  mid-­‐February,	
  DYS	
  requested	
  a	
  hiatus	
  in	
  providing	
  data	
  so	
  that	
  the	
  bugs	
  in	
  the	
  various	
  databases	
  could	
   be	
  addressed	
  and	
  an	
  internal	
  effort	
  to	
  review	
  and	
  interpret	
  data	
  could	
  be	
  launched.	
  As	
  of	
  the	
  writing	
  of	
   this	
  report,	
  fixes	
  to	
  the	
  databases	
  are	
  underway	
  but	
  the	
  facility	
  has	
  yet	
  to	
  undertake	
  the	
  task	
  of	
  analyzing	
   and	
  interpreting	
  the	
  large	
  volume	
  of	
  data	
  submitted.	
  The	
  Monitors	
  requested	
  that	
  the	
  data	
  submission	
   resume	
  in	
  order	
  to	
  ensure	
  that	
  current	
  data	
  are	
  immediately	
  available	
  and	
  to	
  ensure	
  that	
  progress	
  toward	
   meeting	
  the	
  performance	
  objectives	
  envisioned	
  in	
  the	
  Order	
  does	
  not	
  stall.	
  All	
  historical	
  data,	
  albeit	
   unanalyzed	
  was	
  submitted	
  prior	
  to	
  the	
  drafting	
  of	
  this	
  report.	
  Hopefully,	
  the	
  format	
  of	
  this	
  report	
  will	
  help	
   DYS	
  to	
  conceptualize	
  the	
  type	
  of	
  internal	
  review	
  that	
  is	
  still	
  needed	
  to	
  demonstrate	
  that	
  this	
  type	
  of	
   intensive,	
  external	
  oversight	
  is	
  no	
  longer	
  necessary.	
  	
  

	
  

	
  

	
  

	
  

	
  

	
  

6.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 7 of 34 PAGEID #: 2568

[II.14]	
  	
  Policies,	
  Procedures	
  and	
  Handbooks	
  [monitored	
  by	
  Dr.	
  Dedel]	
  

Status:	
  Not	
  in	
  Substantial	
  Compliance	
  

	
  

(1)	
  Standard:	
  Policies	
  and	
  Procedures	
  

Policies	
  and	
  procedural	
  manuals	
  are	
  current,	
  accurately	
  describe	
  the	
  operation	
  of	
  the	
  PU,	
  and	
  

provide	
  guidance	
  to	
  staff	
  in	
  implementing	
  the	
  standards	
  for	
  the	
  Unit.	
  The	
  Youth	
  Handbook	
  

accurately	
  describes	
  the	
  operation	
  of	
  the	
  PU	
  so	
  youth	
  know	
  what	
  to	
  expect	
  from	
  the	
  program	
  

and	
  what	
  is	
  expected	
  of	
  them.	
  	
  

	
  

Methodology.	
  	
  

The	
  following	
  information	
  is	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  

• PU	
  Policy	
  	
  

• PU	
  Procedural	
  Manuals	
  

• PU	
  Youth	
  Handbook	
  

	
  

Analysis	
  and	
  Interpretation.	
  	
  

The	
  Court	
  Order	
  grants	
  DYS	
  60	
  days	
  from	
  the	
  day	
  of	
  signing	
  to	
  submit	
  policies,	
  procedures	
  and	
  

Handbooks	
  that	
  accurately	
  describe	
  the	
  operation	
  of	
  the	
  PU.	
  DYS	
  submitted	
  these	
  materials	
  to	
  

the	
  Monitor	
  within	
  the	
  required	
  timelines.	
  Because	
  the	
  timeline	
  fell	
  outside	
  of	
  the	
  review	
  period	
  

and	
  because	
  both	
  documents	
  will	
  require	
  some	
  revision	
  to	
  ensure	
  they	
  capture	
  all	
  of	
  the	
  

information	
  required	
  by	
  the	
  Court	
  Order,	
  the	
  adequacy	
  of	
  the	
  documents	
  will	
  be	
  discussed	
  in	
  

the	
  next	
  Status	
  Report.	
  	
  

	
  

Recommendations.	
  	
  

In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Policies	
  and	
  Procedures,	
  the	
  DYS	
  should	
  develop	
  a	
  

Quality	
  Improvement	
  Plan	
  to	
  address	
  the	
  following	
  issues:	
  

1. Creating	
  written	
  policies,	
  procedures	
  and	
  a	
  Youth	
  Handbook	
  that	
  accurately	
  describe	
  

the	
  operation	
  of	
  the	
  PU.	
  Reviewing	
  and	
  revising	
  the	
  documents	
  as	
  needed	
  to	
  keep	
  pace	
  

with	
  the	
  evolution	
  of	
  the	
  program.	
  	
  

	
  	
  

	
  

	
  

	
  

	
  

	
  

7.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 8 of 34 PAGEID #: 2569

II.9	
  	
  Admission	
  Screening	
  [monitored	
  by	
  Dr.	
  Glindmeyer]	
   Status:	
  Not	
  in	
  Substantial	
  Compliance	
  
	
   (1)	
  Standard:	
  Admissions	
  Screening.	
  	
   The	
  PU	
  accepts	
  only	
  those	
  youth	
  who	
  can	
  be	
  reasonably	
  expected	
  to	
  respond	
  positively	
  to	
  the	
   type	
  of	
  program	
  and	
  treatment	
  services	
  on	
  the	
  Unit.	
  As	
  such,	
  their	
  behavior	
  and	
  mental	
  health	
   history	
  is	
  reviewed	
  to	
  ensure	
  that	
  the	
  behaviors	
  are	
  not	
  the	
  symptoms	
  of	
  mental	
  illness	
   (including	
  undiagnosed	
  or	
  untreated	
  mental	
  illness).	
  	
  Youth	
  with	
  the	
  following	
  DSM-­‐IV	
  diagnoses	
   or	
  conditions	
  are	
  excluded	
  from	
  placement	
  on	
  the	
  PU:	
  
• Thought	
  Disorders	
   • Mood	
  Disorders	
   • Developmental	
  Disorders	
   • Recurring	
  self-­‐injurious	
  behavior	
  or	
  suicidal	
  ideation.	
   	
   Methodology:	
  The	
  following	
  information	
  is	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
   • “Requests	
  for	
  PROGRESS	
  Placement”	
  table	
   	
   	
  
Technical	
  Assistance	
  Note:	
  Admissions	
  Screening	
  
The	
  methodology	
  for	
  auditing	
  the	
  PU	
  admissions	
  process	
  needs	
  to	
  be	
  fortified	
  in	
  order	
  to	
  gain	
  a	
  more	
   complete	
  picture	
  of	
  the	
  characteristics	
  of	
  youth	
  who	
  are	
  admitted	
  to	
  the	
  PU	
  and	
  the	
  screening	
  process	
   itself	
  (e.g.,	
  whether	
  the	
  admissions	
  protocol	
  was	
  followed,	
  whether	
  youth	
  with	
  disqualifying	
  diagnoses	
   were	
  denied	
  admission).	
  This	
  information	
  would	
  also	
  be	
  useful	
  to	
  determine	
  whether	
  certain	
  diagnoses	
   may	
  be	
  harbingers	
  for	
  poor	
  adjustment	
  to	
  the	
  PU.	
  Future	
  submissions	
  to	
  the	
  Monitor	
  should	
  include:	
  
• Notes	
  from	
  the	
  Administrative	
  Psychiatrists’	
  documenting	
  the	
  pre-­‐admission	
  review	
   • Mental	
  health	
  files	
  of	
  youth	
  who	
  are	
  admitted	
  to	
  the	
  PU.	
  [Note:	
  During	
  a	
  conference	
  call	
  in	
  
February	
  2013,	
  Dr.	
  Glindmeyer	
  requested	
  mental	
  health	
  files	
  for	
  all	
  youth	
  admitted	
  to	
  the	
  PU,	
  but	
   was	
  directed	
  to	
  request	
  them	
  individually.	
  Only	
  three	
  youth	
  had	
  been	
  admitted	
  at	
  that	
  point	
  and	
   so	
  it	
  was	
  unclear	
  why	
  this	
  request	
  could	
  not	
  be	
  fulfilled.]	
   The	
  DYS	
  QA	
  team	
  should	
  review	
  these	
  same	
  documents,	
  once	
  comprehensive	
  internal	
  audits	
  of	
  the	
  PU	
  are	
   established.	
  	
  
	
   	
   Analysis	
  and	
  Interpretation.	
  	
   The	
  “Requests	
  for	
  PROGRESS	
  Placement”	
  grid	
  included	
  the	
  following	
  information:	
  youth’s	
  name;	
   identification	
  number;	
  facility;	
  date	
  the	
  PU	
  packet	
  was	
  received;	
  adjudicated	
  offense;	
  mental	
   health	
  caseload	
  status;	
  educational	
  program	
  (e.g.	
  regular	
  or	
  special	
  education);	
  DSM	
  diagnoses;	
   reason	
  for	
  request	
  for	
  PU	
  placement;	
  outcome	
  of	
  request	
  (e.g.	
  either	
  approved	
  or	
  denied);	
  the	
   rationale	
  for	
  the	
  approval/denial	
  of	
  placement;	
  and	
  the	
  date	
  of	
  transfer	
  to	
  the	
  unit.	
   	
   Per	
  a	
  review	
  of	
  the	
  grids	
  for	
  December	
  2012	
  and	
  January	
  2013,	
  there	
  were	
  a	
  total	
  of	
  five	
  youth	
   referred	
  for	
  PU	
  placement.	
  Of	
  those	
  five	
  youth,	
  two	
  were	
  declined	
  for	
  PU	
  placement.	
  The	
  first,	
   JH,	
  was	
  declined,	
  as	
  “youth	
  had	
  not	
  been	
  placed	
  on	
  any	
  special	
  management	
  plans	
  to	
  address	
   his	
  behavior.”	
  TH,	
  the	
  second	
  youth,	
  was	
  declined	
  as	
  “the	
  youth’s	
  ITP	
  had	
  not	
  been	
  updated	
  to	
   reflect	
  the	
  youth’s	
  current	
  behaviors	
  so	
  that	
  they	
  could	
  be	
  addressed…the	
  youth	
  had	
  not	
  been	
   placed	
  on	
  a	
  behavior	
  contract.”	
  Both	
  of	
  these	
  cases	
  revealed	
  the	
  recognition	
  of	
  the	
  need	
  for	
  the	
  

	
  

8.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 9 of 34 PAGEID #: 2570

implementation	
  of	
  intermediate	
  steps	
  to	
  address	
  the	
  youth’s	
  behavioral	
  challenges	
  prior	
  to	
   resorting	
  to	
  PU	
  placement.	
   	
   Of	
  the	
  remaining	
  three	
  youth	
  approved	
  for	
  PU	
  placement,	
  all	
  had	
  DSM-­‐IV-­‐TR	
  diagnoses	
  listed;	
   however,	
  only	
  two	
  youth	
  were	
  assigned	
  to	
  the	
  mental	
  health	
  caseload.	
  	
  The	
  third	
  youth,	
  KD,	
  had	
   diagnoses	
  including	
  ADHD	
  and	
  Borderline	
  Intellectual	
  Functioning.	
  	
  There	
  was	
  a	
  notation	
  of	
   previous	
  diagnoses	
  including	
  Conduct	
  Disorder;	
  Bipolar	
  Mood	
  Disorder,	
  not	
  otherwise	
  specified;	
   Alcohol	
  Abuse;	
  Cannabis	
  Abuse;	
  and	
  Antisocial	
  Personality	
  Disorder.	
  	
  Given	
  these	
  significant	
   mental	
  health	
  diagnoses,	
  it	
  would	
  be	
  expected	
  that	
  this	
  youth	
  would	
  be	
  assigned	
  to	
  the	
  mental	
   health	
  caseload.	
  	
  It	
  is	
  also	
  concerning	
  that	
  this	
  youth	
  had	
  a	
  previous	
  diagnosis	
  of	
  a	
  mood	
   disorder,	
  which	
  would	
  be	
  an	
  automatic	
  exclusion	
  to	
  PU	
  acceptance.	
  	
  It	
  is	
  recognized	
  that	
  this	
   diagnosis	
  may	
  have	
  been	
  revised	
  prior	
  to	
  his	
  PU	
  referral;	
  however,	
  a	
  review	
  of	
  medical	
  records	
   would	
  be	
  necessary	
  to	
  determine	
  this.	
   	
   There	
  was	
  a	
  notation	
  in	
  the	
  “Central	
  Office	
  Progress/Transition	
  Unit	
  Review	
  Board”	
   documentation	
  dated	
  1.30.13	
  that	
  youth	
  KD	
  “requested	
  to	
  see	
  the	
  psychiatrist	
  and	
  restart	
  his	
   medication.”	
  It	
  was	
  noted	
  that	
  Depakote	
  ER	
  (a	
  mood	
  stabilizing	
  medication)	
  was	
  prescribed,	
   with	
  the	
  dosage	
  increased	
  on	
  January	
  23,	
  2013	
  to	
  a	
  total	
  of	
  1000	
  mg	
  daily.	
  	
  This	
  document	
   indicated	
  that	
  KD’s	
  diagnosis	
  included	
  “rule	
  out	
  Bipolar	
  Disorder,	
  not	
  otherwise	
  specified;”	
   however,	
  the	
  utilization	
  of	
  this	
  medication	
  was	
  suspicious	
  for	
  an	
  actual	
  diagnosis	
  of	
  Bipolar	
   Mood	
  Disorder.	
  There	
  was	
  also	
  documentation	
  of	
  this	
  youth	
  engaging	
  in	
  assaultive	
  behaviors	
   and	
  sexually	
  inappropriate	
  behaviors.	
  Moreover,	
  the	
  document	
  provided	
  recommendations	
  to	
   the	
  Interdisciplinary	
  Team	
  (IDT)	
  which	
  included,	
  “the	
  youth’s	
  psychological	
  services	
  summary	
   does	
  not	
  include	
  a	
  case	
  formulation,	
  treatment	
  progress,	
  or	
  the	
  youth’s	
  response	
  to	
  treatment”	
   indicating	
  the	
  likelihood	
  that	
  the	
  youth’s	
  diagnoses	
  had	
  not	
  been	
  formulated	
  in	
  a	
  collaborative	
   manner	
  prior	
  to	
  his	
  referral	
  to	
  the	
  PU	
  or	
  for	
  the	
  period	
  between	
  his	
  acceptance	
  to	
  the	
  PU	
  on	
   12.31.12	
  and	
  the	
  review	
  board	
  documentation	
  dated	
  1.30.13	
  and	
  signed	
  2.5.13.	
  	
  Regardless,	
  this	
   youth’s	
  record,	
  inclusive	
  of	
  the	
  documentation	
  of	
  the	
  Administrative	
  Psychiatrist’s	
  review,	
   should	
  be	
  reviewed	
  closely	
  given	
  his	
  admission	
  to	
  the	
  PU	
  with	
  a	
  potential	
  mood	
  disorder,	
  which	
   should	
  have	
  been	
  ruled	
  out	
  prior	
  to	
  admission.	
   	
   Of	
  the	
  three	
  youth	
  accepted	
  for	
  the	
  PU,	
  two	
  were	
  receiving	
  special	
  education	
  services.	
  	
  One	
   youth,	
  TB,	
  was	
  noted	
  as	
  receiving	
  special	
  education	
  services	
  due	
  to	
  “ED”	
  indicating	
  “emotional	
   disturbance.”	
  	
  This	
  youth	
  also	
  had	
  mental	
  health	
  diagnoses	
  including	
  Cannabis	
  Dependence;	
   Oppositional	
  Defiant	
  Disorder;	
  Conduct	
  Disorder;	
  and	
  rule	
  out	
  Psychotic	
  Disorder,	
  not	
  otherwise	
   specified.	
  	
  This	
  youth	
  was	
  accepted	
  to	
  the	
  PU	
  “due	
  to	
  the	
  youth’s	
  continued	
  assaultive	
  behaviors	
   despite	
  staff’s	
  efforts.”	
  	
  This	
  case	
  is	
  concerning	
  as	
  the	
  potential	
  presence	
  of	
  a	
  thought	
  disorder	
  is	
   an	
  automatic	
  exclusion	
  to	
  PU	
  acceptance.	
  	
  At	
  the	
  time	
  this	
  report	
  was	
  authored,	
  documentation	
   indicated	
  that	
  this	
  youth	
  had	
  transferred	
  to	
  the	
  PU	
  on	
  2/1/13	
  and	
  remained	
  on	
  Phase	
  1	
  as	
  of	
   3/8/13.	
  	
  Over	
  time,	
  ODYS	
  should	
  monitor	
  the	
  length	
  of	
  stay	
  on	
  the	
  phases	
  for	
  youth	
  with	
  mental	
   health	
  disorders.	
  	
  Regardless,	
  this	
  youth’s	
  record,	
  inclusive	
  of	
  the	
  Administrative	
  Psychiatrist’s	
   review,	
  should	
  be	
  reviewed	
  closely	
  given	
  his	
  admission	
  to	
  the	
  PU	
  with	
  a	
  potential	
  thought	
   disorder,	
  which	
  should	
  have	
  been	
  ruled	
  out	
  prior	
  to	
  admission.	
   	
   	
   	
   	
  

	
  

9.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 10 of 34 PAGEID #: 2571

Youth	
  	
   Diagnoses	
  

Phase	
  One	
  

Phase	
  Two	
  

TB	
   Rule	
  out	
  psychotic	
  disorder,	
  NOS;	
  Conduct	
   Transfer	
  2.1.13	
  

	
  

Disorder;	
  Oppositional	
  Defiant	
  Disorder;	
   Per	
  roster	
  of	
  3.8.13	
  

Cannabis	
  Dependence	
  

youth	
  remains	
  on	
  P1	
  

	
  

35	
  days	
  

KD	
   Current	
  Diagnoses:	
  	
  ADHD	
  and	
  BIF.	
  	
  

Transfer	
  12.31.12	
  

	
  

Prior	
  diagnoses:	
  	
  Rule	
  out	
  Bipolar	
  Mood	
   Last	
  documentation	
  on	
  

disorder,	
  NOS;	
  Conduct	
  Disorder;	
  

unit	
  2.16.13	
  and	
  youth	
  

Oppositional	
  Defiant	
  Disorder;	
  Alcohol	
  

remained	
  on	
  P1	
  

Abuse;	
  Cannabis	
  Abuse;	
  Antisocial	
  

	
  

Personality	
  Disorder	
  

	
  

47	
  days	
  (minimum,	
  stay	
  

may	
  have	
  been	
  longer,	
  

do	
  not	
  have	
  record	
  of	
  

date	
  of	
  transfer	
  to	
  

another	
  facility)	
  

DG	
   Adjustment	
  Disorder;	
  PTSD;	
  Conduct	
   Disorder;	
  Cannabis	
  Abuse	
  

Transfer	
  2.1.13.	
   Promoted	
  2.20.13	
   	
   19	
  days	
  

Promoted	
  2.20.13	
  

	
   	
   The	
  table	
  above	
  suggests	
  that	
  youth	
  with	
  certain	
  mental	
  health	
  diagnoses	
  (e.g.,	
  TB	
  and	
  KD)	
   require	
  an	
  increased	
  amount	
  of	
  time	
  to	
  progress	
  through	
  the	
  phases.	
  	
  This	
  should	
  be	
  reviewed	
   by	
  ODYS	
  on	
  a	
  continuous	
  basis.	
   	
   While	
  the	
  facility	
  has	
  a	
  process	
  for	
  reviewing	
  and	
  screening	
  youth	
  prior	
  to	
  admission,	
  a	
  few	
   youth	
  were	
  admitted	
  with	
  “rule	
  out”	
  diagnoses.	
  If	
  these	
  diagnoses	
  were	
  finalized	
  and	
  “ruled	
  in,”	
   they	
  would	
  have	
  precluded	
  the	
  youth	
  from	
  admission.	
  Youth	
  should	
  not	
  be	
  admitted	
  to	
  the	
  PU	
   with	
  these	
  pending	
  diagnoses.	
  	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Admissions	
  Screening,	
  a	
  Quality	
  Improvement	
   Plan	
  should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issues:	
  
1. Expanding	
  the	
  scope	
  of	
  data	
  that	
  are	
  available	
  for	
  review	
  by	
  the	
  QA	
  auditor	
  (e.g.,	
   youth’s	
  complete	
  mental	
  health	
  record;	
  Administrative	
  Psychiatrist’s	
  notes).	
  	
  
2. Ensuring	
  that	
  youth	
  referred	
  for	
  admission	
  to	
  the	
  PU	
  are	
  screened	
  with	
  regard	
  to	
  the	
   presence	
  or	
  absence	
  of	
  a	
  mental	
  health	
  condition	
  that	
  would	
  preclude	
  admission.	
  	
  For	
   these	
  youth,	
  alternate	
  placements	
  should	
  be	
  considered	
  (e.g.,	
  a	
  referral	
  to	
  the	
  mental	
   health	
  unit).	
  
3. For	
  youth	
  with	
  mental	
  health	
  conditions	
  who	
  are	
  accepted	
  to	
  the	
  PU,	
  reviewing	
  their	
   length	
  of	
  stay	
  on	
  each	
  level	
  to	
  determine	
  whether	
  youth	
  with	
  mental	
  health	
  conditions	
   experience	
  difficulty	
  progressing	
  through	
  the	
  stages	
  on	
  the	
  PU,	
  further	
  informing	
  the	
   referral	
  and	
  screening	
  process.	
  	
  	
  
	
  
	
  

	
  

10.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 11 of 34 PAGEID #: 2572

[II.10]	
  	
  Daily	
  Schedule	
  [reviewed	
  by	
  Dr.	
  Dedel]	
   Status:	
  Not	
  in	
  Substantial	
  Compliance	
  [Note:	
  see	
  issues	
  regarding	
  large	
  muscle	
  activity	
   while	
  in	
  restraints	
  and	
  a	
  written	
  plan	
  for	
  graduate	
  programming	
  during	
  school	
  hours.]	
  
	
   (1)	
  Standard:	
  Out-­‐of-­‐Room	
  Time.	
  	
  	
   Youth	
  on	
  the	
  PU	
  have	
  as	
  much	
  out-­‐of-­‐room	
  time	
  as	
  youth	
  in	
  the	
  general	
  population,	
  which	
   ensures	
  their	
  access	
  to	
  the	
  rehabilitative	
  treatment	
  necessary	
  to	
  address	
  the	
  behaviors	
  and	
  skill	
   deficits	
  that	
  resulted	
  in	
  their	
  placement	
  on	
  the	
  PU.	
  In	
  general,	
  PU	
  youth	
  are	
  out	
  of	
  their	
  rooms	
   from	
  7am	
  to	
  7pm,	
  except	
  during	
  shift	
  change	
  (40	
  minutes	
  daily),	
  medication	
  pass	
  (30	
  minutes	
   daily),	
  Treatment	
  Team	
  (3	
  to	
  4	
  hours	
  per	
  week),	
  and	
  seclusion	
  time	
  that	
  is	
  ordered	
  as	
  a	
  sanction	
   for	
  major	
  rule	
  violations.	
  The	
  PU	
  is	
  not	
  a	
  lock-­‐down	
  unit	
  that	
  relies	
  on	
  isolation	
  to	
  suppress	
   youth	
  behaviors.	
   	
   Methodology.	
  	
   The	
  following	
  information	
  is	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• Youth	
  Activity	
  Tracking	
  sheets	
  that	
  indicate	
  the	
  youth’s	
  activities	
  throughout	
  each	
  day,	
   separated	
  according	
  to	
  whether	
  the	
  youth	
  is	
  in	
  his	
  room	
  or	
  out	
  of	
  his	
  room.	
  	
  
• Youth	
  and	
  staff	
  interviews	
   	
   Analysis	
  and	
  Interpretation.	
  	
   The	
  DYS	
  provided	
  Youth	
  Activity	
  Tracking	
  (YAT)	
  logs	
  for	
  the	
  4-­‐week	
  period	
  from	
  January	
  20	
   through	
  February	
  16,	
  2013.	
  Each	
  week,	
  a	
  random	
  sample	
  of	
  4	
  youth	
  was	
  selected	
  for	
  a	
  total	
  of	
   16	
  youth	
  and	
  107	
  days.	
  Of	
  the	
  107	
  days	
  reviewed,	
  youth	
  were	
  in	
  seclusion	
  for	
  8	
  of	
  them.	
  In	
   other	
  words,	
  on	
  92%	
  of	
  the	
  days	
  reviewed,	
  the	
  youth	
  were	
  out	
  of	
  their	
  rooms	
  and	
  engaged	
  in	
   the	
  program.	
  About	
  half	
  of	
  the	
  youth	
  spent	
  one	
  day	
  in	
  seclusion	
  during	
  the	
  week	
  reviewed.	
  	
   	
   The	
  Order	
  requires	
  youth	
  to	
  be	
  out	
  of	
  their	
  rooms	
  on	
  non-­‐IDT	
  days	
  for	
  at	
  least	
  10	
  hours	
  and	
  50	
   minutes	
  (allowing	
  70	
  minutes	
  for	
  shift	
  change	
  and	
  med	
  passes	
  during	
  the	
  12	
  waking	
  hours).	
  This	
   minimum	
  was	
  exceeded	
  for	
  approximately	
  90%	
  of	
  the	
  non-­‐IDT	
  days	
  in	
  the	
  sample.	
  On	
  11	
  of	
  the	
   107	
  days	
  (10%),	
  times	
  in	
  excess	
  of	
  70	
  minutes	
  were	
  recorded	
  for	
  shift	
  change/med	
  pass.	
  This	
  is	
  a	
   reasonable	
  rate	
  of	
  exception.	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  Activity	
  Tracking	
  
Until	
  very	
  recently,	
  the	
  days	
  on	
  which	
  IDT	
  meetings	
  were	
  held	
  were	
  not	
  identified	
  in	
  the	
  YAT.	
  While	
  there	
   are	
  other	
  ways	
  to	
  verify	
  that	
  IDT	
  meetings	
  are	
  held	
  as	
  required	
  (and	
  the	
  data	
  confirm	
  that	
  they	
  are),	
  it	
  is	
  of	
   concern	
  that	
  the	
  YAT	
  data	
  reflected	
  that	
  youth	
  were	
  out	
  of	
  their	
  rooms	
  during	
  times	
  when	
  they	
  were	
  not.	
  
	
   It	
  is	
  worth	
  highlighting	
  the	
  significant	
  change	
  in	
  practice	
  that	
  has	
  occurred	
  over	
  the	
  past	
  few	
   months.	
  Previously,	
  youth	
  spent	
  most	
  of	
  their	
  waking	
  hours	
  locked	
  inside	
  their	
  rooms.	
  Now,	
   they	
  have	
  similar	
  out-­‐of-­‐cell	
  time	
  to	
  the	
  general	
  population,	
  which	
  creates	
  the	
  opportunity	
  to	
   provide	
  the	
  intensive	
  programing	
  that	
  these	
  youth	
  sorely	
  need.	
   	
   Recommendations.	
  	
   A	
  Quality	
  Improvement	
  Plan	
  is	
  not	
  necessary	
  to	
  meet	
  the	
  standard	
  regarding	
  out-­‐of-­‐room	
  time	
   on	
  the	
  Daily	
  Schedule.	
  	
   	
  

	
  

11.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 12 of 34 PAGEID #: 2573

(2)	
  Standard:	
  Daily	
  Activities.	
  	
   Each	
  day,	
  youth	
  on	
  the	
  PU	
  participate	
  in	
  the	
  following	
  activities,	
  out	
  of	
  their	
  rooms:	
  	
  
• Meals;	
   • 330	
  minutes	
  of	
  education,	
  except	
  during	
  intersession;	
   • One	
  hour	
  of	
  large	
  muscle	
  activity	
  (without	
  restraints);	
   • Individual	
  and	
  group	
  treatment	
  conducted	
  by	
  Behavioral	
  Health	
  Staff;	
   • Structured	
  activities	
  led	
  by	
  Youth	
  Specialists	
  or	
  Volunteers;	
   • Leisure	
  time	
  (one	
  hour	
  on	
  school	
  days,	
  two	
  hours	
  on	
  non-­‐school	
  days).	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  is	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
   • Youth	
  Activity	
  Tracking	
  sheets	
  that	
  indicate	
  the	
  youth’s	
  activities	
  throughout	
  each	
  day,	
  
separated	
  according	
  to	
  whether	
  the	
  youth	
  is	
  in	
  his	
  room	
  or	
  out	
  of	
  his	
  room.	
  	
   • Observations	
  of	
  PU	
  activities	
   • Youth	
  and	
  staff	
  interviews	
   	
   Analysis	
  and	
  Interpretation.	
  	
   The	
  DYS	
  provided	
  Youth	
  Activity	
  Tracking	
  (YAT)	
  logs	
  for	
  the	
  4-­‐week	
  period	
  from	
  January	
  20	
   through	
  February	
  16,	
  2013.	
  Each	
  week,	
  a	
  random	
  sample	
  of	
  4	
  youth	
  was	
  selected	
  for	
  a	
  total	
  of	
   16	
  youth	
  and	
  107	
  days.	
  Across	
  the	
  days:	
   • Three	
  meals	
  were	
  provided	
  to	
  each	
  youth,	
  each	
  day	
  (100%).	
  Youth	
  who	
  were	
  not	
  in	
  
seclusion	
  ate	
  outside	
  of	
  their	
  rooms.	
   • A	
  full	
  day	
  of	
  education	
  was	
  provided	
  to	
  youth	
  who	
  were	
  not	
  in	
  seclusion	
  (100%)	
  
[Chancery	
  attendance	
  records	
  should	
  be	
  used	
  to	
  verify	
  these	
  data.].	
  	
   • Recreation	
  was	
  provided	
  on	
  all	
  but	
  12	
  days	
  (89%;	
  4	
  non-­‐seclusion	
  and	
  8	
  seclusion	
  days).	
  
Although	
  recreation	
  was	
  provided	
  consistently,	
  the	
  PU	
  practice	
  continues	
  to	
  require	
  P1	
   youth	
  to	
  attend	
  recreation	
  while	
  wearing	
  restraints	
  if	
  they	
  choose	
  to	
  go	
  to	
  the	
   gymnasium	
  or	
  the	
  outdoor	
  recreation	
  area.	
  True	
  large	
  muscle	
  activity	
  is	
  nearly	
   impossible	
  while	
  wearing	
  these	
  devices,	
  particularly	
  for	
  taller	
  youth.	
  Furthermore,	
  youth	
   in	
  seclusion	
  do	
  not	
  receive	
  recreation,	
  which	
  goes	
  against	
  the	
  generally	
  accepted	
   practice	
  in	
  the	
  field.	
  	
   • Group	
  and	
  individual	
  treatment	
  was	
  recorded	
  for	
  all	
  but	
  12	
  of	
  the	
  99	
  non-­‐seclusion	
  days	
   (88%).	
  It	
  is	
  likely	
  that	
  IDTs	
  were	
  held	
  on	
  these	
  days	
  but	
  were	
  not	
  recorded.	
  On	
  most	
   days,	
  multiple	
  treatment	
  activities	
  were	
  recorded.	
  	
   • Structured	
  activities	
  were	
  recorded	
  on	
  all	
  of	
  the	
  non-­‐seclusion	
  days	
  (100%).	
   • Leisure	
  time	
  was	
  recorded	
  for	
  only	
  6	
  of	
  the	
  99	
  non-­‐seclusion	
  days	
  (6%).	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  Activity	
  Tracking	
  
“Structured	
  activity”	
  and	
  “leisure	
  time”	
  appear	
  to	
  be	
  used	
  somewhat	
  interchangeably.	
  In	
  November	
  2012,	
   youth	
  had	
  a	
  large	
  amount	
  of	
  leisure	
  time	
  recorded,	
  about	
  which	
  the	
  Monitor	
  expressed	
  concern.	
  Since	
   then,	
  the	
  pattern	
  in	
  the	
  data	
  has	
  shifted	
  to	
  register	
  a	
  high	
  volume	
  of	
  “structured	
  activity”	
  and	
  relatively	
  no	
   “leisure	
  time.”	
  This	
  issue	
  should	
  not	
  be	
  one	
  of	
  semantics;	
  the	
  distinguishing	
  feature	
  should	
  be	
  one	
  of	
   interaction	
  with	
  staff.	
  The	
  precise	
  term	
  used	
  does	
  not	
  concern	
  the	
  Monitor,	
  but	
  DYS	
  should	
  construct	
  a	
   way	
  to	
  verify	
  that	
  staff	
  and	
  youth	
  are	
  interacting	
  during	
  the	
  majority	
  of	
  time	
  when	
  youth	
  are	
  not	
  in	
  school	
   or	
  participating	
  in	
  a	
  treatment	
  activity.	
  Experience	
  has	
  shown	
  that	
  excessive,	
  unstructured	
  leisure	
  time	
   leads	
  to	
  increases	
  in	
  misconduct.	
  	
  

	
  

12.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 13 of 34 PAGEID #: 2574

	
   Overall,	
  the	
  Monitor	
  is	
  concerned	
  that	
  the	
  amount	
  of	
  staff	
  time	
  and	
  effort	
  used	
  to	
  construct	
  the	
  daily	
   activity	
  records	
  may	
  be	
  overkill	
  and	
  thus	
  not	
  sustainable	
  for	
  the	
  purposes	
  of	
  QA.	
  There	
  may	
  be	
  a	
  simpler	
   way	
  to	
  verify	
  that	
  youth	
  are	
  out	
  of	
  their	
  rooms	
  and	
  engaged	
  in	
  the	
  required	
  activities.	
  Some	
  combination	
   of	
  tracking	
  in-­‐room	
  time	
  (which	
  is	
  far	
  less	
  voluminous),	
  structured	
  questioning	
  during	
  IDT	
  meetings	
  (e.g.,	
   “did	
  you	
  get	
  meals/shower/rec	
  every	
  day	
  this	
  week?”),	
  and	
  a	
  targeted	
  effort	
  to	
  document	
  structured	
   programming	
  and	
  leisure	
  time	
  activities	
  may	
  be	
  more	
  practical.	
  	
   	
   Finally,	
  the	
  on-­‐site	
  visit	
  conducted	
  by	
  the	
  S.H.	
  Lead	
  Monitor	
  and	
  his	
  Assistant	
  reinforced	
  the	
  importance	
  of	
   posting	
  a	
  current	
  daily	
  schedule	
  on	
  each	
  Unit.	
  The	
  schedule	
  for	
  the	
  Transition	
  Unit	
  was	
  outdated,	
  which	
   led	
  to	
  complaints	
  from	
  youth	
  that	
  staff	
  were	
  not	
  following	
  the	
  program	
  with	
  regard	
  to	
  bedtime.	
  Not	
  only	
   are	
  current	
  schedules	
  essential	
  to	
  inform	
  youth	
  expectations,	
  but	
  are	
  also	
  important	
  to	
  ensure	
  that	
  relief	
   staff	
  properly	
  implement	
  the	
  program.	
  On	
  a	
  positive	
  note,	
  both	
  youth	
  and	
  staff	
  were	
  very	
  cognizant	
  of	
  the	
   schedule—they	
  know	
  what	
  should	
  be	
  happening	
  at	
  all	
  times	
  and	
  youth	
  could	
  recite	
  the	
  schedule	
  without	
   looking	
  at	
  it.	
  	
  
	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  activity	
  component	
  of	
  the	
  Daily	
  Schedule,	
  a	
   Quality	
  Improvement	
  Plan	
  should	
  be	
  constructed	
  to	
  address	
  the	
  following	
  issues:	
  
1. Identifying	
  ways	
  to	
  engage	
  youth	
  in	
  large	
  muscle	
  activities	
  without	
  the	
  use	
  of	
  restraints.	
   DYS	
  contends	
  that	
  youth	
  are	
  offered	
  indoor	
  recreational	
  opportunities	
  that	
  do	
  not	
   require	
  restraints,	
  but	
  that	
  youth	
  choose	
  options	
  in	
  which	
  DYS	
  has	
  determined	
  restraints	
   must	
  be	
  worn.	
  Setting	
  up	
  situations	
  in	
  which	
  youth	
  cannot	
  actually	
  participate	
  in	
   meaningful	
  activity	
  seems	
  contrary	
  to	
  the	
  agency’s	
  commitment	
  to	
  recreation.	
  	
  	
  	
  	
  
2. Providing	
  daily	
  large	
  muscle	
  recreation	
  to	
  youth	
  in	
  seclusion.	
  	
   3. Efficient	
  methods	
  for	
  tracking	
  out	
  of	
  room	
  time,	
  receipt	
  of	
  basic	
  services	
  (meals,	
  
showers,	
  recreation)	
  and	
  engagement	
  in	
  structured	
  activities.	
  Any	
  new	
  methods	
  should	
   provide	
  sufficient	
  details	
  to	
  substantiate	
  compliance	
  with	
  the	
  standard,	
  but	
  should	
  also	
   be	
  simple	
  enough	
  to	
  ensure	
  DYS	
  continues	
  to	
  utilize	
  them	
  for	
  the	
  purpose	
  of	
  Quality	
   Assurance.	
  	
   	
   	
   (3)	
  Standard:	
  Graduate	
  Programming.	
  	
   Youth	
  on	
  the	
  PU	
  who	
  have	
  graduated	
  from	
  high	
  school	
  participate	
  in	
  out-­‐of-­‐room	
  structured	
   activities	
  throughout	
  the	
  time	
  that	
  non-­‐graduates	
  are	
  in	
  school.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  is	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
   • List	
  of	
  youth	
  who	
  have	
  graduated	
  from	
  high	
  school	
   • Youth	
  Activity	
  Tracking	
  sheets	
  that	
  indicate	
  the	
  youth’s	
  activities	
  throughout	
  each	
  day,	
   separated	
  according	
  to	
  whether	
  the	
  youth	
  is	
  in	
  his	
  room	
  or	
  out	
  of	
  his	
  room.	
  	
   • Youth	
  and	
  staff	
  interviews	
   	
   Analysis	
  and	
  Interpretation.	
  	
   The	
  DYS	
  submits	
  weekly	
  Youth	
  Activity	
  Tracking	
  logs	
  that	
  record	
  how	
  youth	
  spend	
  their	
  waking	
   hours.	
  A	
  specific	
  data	
  collection	
  and	
  analysis	
  protocol	
  has	
  not	
  been	
  established	
  for	
  youth	
  who	
   have	
  graduated	
  from	
  high	
  school	
  or	
  obtained	
  their	
  GEDs.	
  One	
  such	
  youth	
  was	
  identified	
  via	
  the	
  

	
  

13.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 14 of 34 PAGEID #: 2575

IDT	
  minutes,	
  and	
  his	
  YAT	
  consistently	
  revealed	
  that	
  he	
  spent	
  the	
  hours	
  when	
  other	
  youth	
  were	
  

in	
  school	
  outside	
  of	
  his	
  room	
  in	
  “structured	
  activities.”	
  The	
  specific	
  activities	
  in	
  which	
  the	
  youth	
  

engaged	
  are	
  unknown.	
  Youth	
  in	
  the	
  general	
  population	
  have	
  access	
  to	
  college	
  courses,	
  

vocational	
  programming	
  and	
  campus	
  jobs.	
  Given	
  that	
  PU	
  youth	
  cannot	
  travel	
  around	
  campus,	
  

the	
  traditional	
  options	
  are	
  not	
  available.	
  However,	
  a	
  plan	
  should	
  be	
  developed	
  to	
  advance	
  the	
  

youth’s	
  career	
  interest	
  and	
  job	
  readiness	
  while	
  on	
  the	
  PU,	
  but	
  that	
  also	
  addresses	
  the	
  legitimate	
  

safety	
  concerns	
  posed	
  by	
  these	
  youth.	
  The	
  Order	
  allows	
  DYS	
  60	
  days	
  from	
  the	
  date	
  of	
  signing	
  to	
  

develop	
  such	
  a	
  plan,	
  which	
  expires	
  on	
  March	
  18,	
  2013.	
  DYS	
  submitted	
  the	
  Unit	
  Handbook	
  within	
  

the	
  required	
  timeline,	
  but	
  outside	
  of	
  the	
  period	
  of	
  review	
  for	
  this	
  report.	
  The	
  substance	
  and	
  

outcomes	
  associated	
  with	
  graduate	
  programming	
  will	
  be	
  discussed	
  in	
  the	
  next	
  status	
  report.	
  	
  

	
  

Recommendations.	
  	
  

In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  graduate	
  programming	
  on	
  the	
  Daily	
  Schedule,	
  a	
  

Quality	
  Improvement	
  Plan	
  should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issue:	
  

1. Occupying	
  graduates’	
  time	
  when	
  other	
  youth	
  are	
  in	
  school.	
  While	
  they	
  are	
  currently	
  

able	
  to	
  spend	
  this	
  time	
  outside	
  their	
  rooms,	
  structured	
  activities	
  that	
  promote	
  career	
  

interest	
  or	
  job	
  readiness	
  should	
  be	
  considered.	
  At	
  a	
  minimum,	
  the	
  plan	
  should	
  include	
  a	
  

mechanism	
  to	
  identify	
  graduates	
  housed	
  on	
  the	
  PU	
  and	
  should	
  indicate	
  how	
  the	
  hours	
  

that	
  other	
  youth	
  spend	
  in	
  school	
  will	
  be	
  occupied.	
  	
  

	
  

	
  

	
  

	
  

	
  

	
  

14.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 15 of 34 PAGEID #: 2576
[II.11]	
  Staffing	
  [monitored	
  by	
  Dr.	
  Dedel]	
   Status:	
  Not	
  in	
  Substantial	
  Compliance	
  [see	
  issues	
  related	
  to	
  identifying	
  which	
  staff	
  are	
   permanent	
  versus	
  relief	
  and	
  staff	
  training]	
  
	
   (1)	
  Standard:	
  Staff	
  Numbers	
  and	
  Training.	
  	
   A	
  sufficient	
  number	
  of	
  adequately	
  trained	
  supervisory	
  and	
  line	
  staff	
  are	
  available	
  to	
  implement	
   the	
  PU	
  program	
  as	
  designed.	
  	
  
• A	
  Unit	
  Manager	
  (UM)	
  works	
  during	
  all	
  waking	
  hours,	
  seven	
  days	
  per	
  week.	
  	
   • All	
  assigned	
  PU	
  Youth	
  Specialists	
  have	
  completed	
  required	
  training	
  within	
  three	
  months	
  
of	
  their	
  assignment.	
   • All	
  Youth	
  Specialists	
  (whether	
  assigned	
  or	
  relief)	
  read	
  and	
  sign	
  the	
  relevant	
  Post	
  Orders.	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
   • Average	
  daily	
  populations	
  for	
  Sycamore,	
  Cedar	
  and	
  Buckeye	
   • UM	
  schedule	
   • Youth	
  Specialist	
  staffing	
  reports	
   • Youth	
  Specialist	
  training	
  records	
   • PU	
  Post	
  Orders	
  and	
  signature	
  pages	
   • Staff	
  interviews	
   	
   Analysis	
  and	
  Interpretation.	
  	
   The	
  DYS	
  submitted	
  work	
  schedules	
  for	
  the	
  four	
  Unit	
  Mangers	
  (UM)	
  assigned	
  to	
  the	
  PU	
  for	
  the	
   months	
  of	
  January	
  and	
  February	
  2013.	
  Throughout	
  the	
  two-­‐month	
  period,	
  UM	
  coverage	
  met	
   the	
  requirements	
  of	
  the	
  Order	
  (i.e.,	
  UM	
  available	
  during	
  all	
  waking	
  hours,	
  7	
  days	
  per	
  week).	
  On	
   Monday,	
  Tuesday	
  and	
  Thursday,	
  all	
  four	
  UMs	
  were	
  on	
  duty	
  with	
  staggered	
  start	
  times	
  which	
   provided	
  extensive	
  UM	
  coverage	
  throughout	
  waking	
  hours.	
  On	
  Wednesdays,	
  Fridays	
  and	
   weekend	
  days,	
  two	
  unit	
  managers	
  were	
  on	
  duty	
  with	
  staggered	
  schedules	
  that	
  provided	
  for	
   overlap	
  between	
  11a	
  and	
  3:30p	
  and	
  one	
  UM	
  on	
  duty	
  during	
  the	
  remaining	
  waking	
  hours.	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  Unit	
  Manager	
  Schedules	
  
A	
  review	
  of	
  each	
  individual	
  UM’s	
  schedule	
  indicated	
  that	
  all	
  of	
  the	
  UMs	
  rotate	
  days	
  off	
  (either	
   Sunday/Friday	
  or	
  Wednesday/Saturday).	
  While	
  this	
  provides	
  everyone	
  with	
  one	
  weekend	
  day	
  off	
  per	
  week,	
   the	
  UMs	
  never	
  have	
  two	
  days	
  off	
  in	
  a	
  row.	
  This	
  may	
  be	
  entirely	
  to	
  the	
  preference	
  of	
  currently	
  assigned	
   UMs.	
  But,	
  if	
  problems	
  with	
  morale	
  or	
  retention	
  develop,	
  re-­‐examining	
  the	
  schedule	
  is	
  advised.	
  Experience	
   with	
  other	
  positions	
  at	
  DYS	
  (e.g.,	
  social	
  workers)	
  indicates	
  that	
  scheduling	
  is	
  an	
  essential	
  component	
  of	
  the	
   ability	
  to	
  attract	
  and	
  retain	
  highly	
  qualified	
  staff.	
  	
  
	
   The	
  Youth	
  Specialists’	
  (YS)	
  schedule	
  was	
  provided	
  at	
  the	
  end	
  of	
  February	
  2013	
  for	
  the	
  Sycamore	
   and	
  Cedar	
  Units.	
  [Staffing	
  data	
  were	
  not	
  provided	
  for	
  the	
  Transition	
  Unit.]	
  The	
  YS	
  shift	
   assignments	
  are	
  as	
  follows:	
  5	
  staff	
  on	
  1st	
  shift,	
  4	
  staff	
  on	
  2nd	
  shift,	
  and	
  3	
  staff	
  on	
  3rd	
  shift	
  on	
  each	
   unit,	
  for	
  a	
  total	
  of	
  24	
  positions.	
  There	
  is	
  currently	
  one	
  vacancy	
  on	
  Cedar,	
  1st	
  shift.	
  Each	
  of	
  the	
  24	
   staff	
  is	
  assigned	
  to	
  1st,	
  2nd,	
  or	
  3rd	
  shift	
  and	
  has	
  two	
  days	
  off	
  per	
  week.	
  In	
  all	
  cases,	
  the	
  staff	
  have	
   two	
  days	
  off	
  in	
  a	
  row.	
  As	
  stated	
  in	
  the	
  Technical	
  Assistance	
  Note,	
  above,	
  this	
  may	
  be	
  preferable	
  

	
  

15.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 16 of 34 PAGEID #: 2577

to	
  currently	
  assigned	
  staff,	
  but	
  DYS	
  should	
  consider	
  how	
  the	
  staff’s	
  days	
  off	
  are	
  sequenced	
  if	
   problems	
  with	
  morale	
  or	
  retention	
  are	
  encountered.	
  	
   	
   DYS	
  also	
  provided	
  weekly	
  staffing	
  reports	
  for	
  November	
  and	
  December	
  2012,	
  which	
  show	
  the	
   number	
  of	
  staff	
  who	
  actually	
  reported	
  to	
  work	
  each	
  day.	
  [YS	
  staffing	
  data	
  were	
  not	
  submitted	
   for	
  January	
  2013.]	
  This	
  report	
  does	
  not	
  list	
  the	
  names	
  of	
  the	
  staff,	
  so	
  it	
  was	
  not	
  possible	
  to	
   determine	
  whether	
  the	
  staff	
  who	
  reported	
  were	
  those	
  who	
  were	
  regularly	
  assigned	
  to	
  the	
  PU,	
   or	
  if	
  relief	
  staff	
  were	
  utilized.	
  	
   	
   The	
  Order	
  requires	
  staff	
  assigned	
  to	
  the	
  PU	
  to	
  complete	
  training	
  “specifically	
  relating	
  to	
  working	
   with	
  youth	
  on	
  the	
  PU	
  and	
  implementing	
  the	
  PU	
  as	
  designed”	
  within	
  3-­‐months	
  of	
  their	
   assignment.	
  DYS	
  is	
  required	
  to	
  submit	
  training	
  records	
  for	
  staff	
  assigned	
  to	
  the	
  PU	
  within	
  three	
   months	
  of	
  the	
  date	
  the	
  Order	
  was	
  signed.	
  These	
  records	
  are	
  due	
  on	
  April	
  18,	
  2013	
  and	
  will	
  be	
   discussed	
  in	
  the	
  subsequent	
  Status	
  Report.	
  	
   	
   Staff	
  who	
  are	
  not	
  regularly	
  assigned	
  to	
  the	
  unit	
  (i.e.,	
  relief	
  staff)	
  are	
  required	
  to	
  read	
  and	
  initial	
   the	
  PU	
  Post	
  Orders	
  whenever	
  they	
  are	
  scheduled	
  to	
  work	
  the	
  unit.	
  The	
  PU’s	
  Post	
  Orders	
  are	
   severely	
  outdated	
  (last	
  revised	
  in	
  March	
  2012,	
  prior	
  to	
  the	
  significant	
  program	
  changes	
   described	
  in	
  this	
  report).	
  In	
  order	
  to	
  maintain	
  the	
  integrity	
  of	
  the	
  reforms,	
  even	
  when	
  regular	
   staff	
  are	
  on	
  vacation,	
  out	
  sick	
  or	
  otherwise	
  unavailable	
  to	
  work,	
  these	
  Post	
  Orders	
  need	
  to	
  be	
   updated	
  to	
  accurately	
  reflect	
  the	
  job	
  responsibilities	
  of	
  a	
  YS	
  assigned	
  to	
  the	
  PU.	
  	
   	
   Determining	
  whether	
  staffing	
  levels	
  are	
  “adequate”	
  requires	
  knowledge	
  of	
  the	
  size	
  of	
  the	
   population	
  the	
  staff	
  are	
  supervising	
  on	
  any	
  given	
  day.	
  Average	
  daily	
  populations	
  (ADP)	
  are	
   normally	
  calculated	
  by	
  adding	
  the	
  number	
  of	
  youth	
  on	
  a	
  unit	
  each	
  day,	
  and	
  dividing	
  the	
  sum	
  by	
   the	
  number	
  of	
  days	
  in	
  the	
  month.	
  Daily	
  population	
  levels	
  were	
  not	
  available	
  to	
  the	
  Monitor,	
  but	
   weekly	
  unit	
  rosters	
  provided	
  a	
  snapshot	
  of	
  population	
  levels	
  that	
  could	
  be	
  used	
  to	
  estimate	
  the	
   ADP.	
  	
   	
  
Population	
  Averages,	
  per	
  unit	
  

Unit	
  

Nov/Dec	
  

Jan/Feb	
   Average	
  

Sycamore	
  (P1)	
  

7.0	
  

5.75	
  

6.375	
  

Cedar	
  (P2)	
  

8.0*	
  

4.5	
  

6.25	
  

Buckeye	
  (Transition)	
  

6.4	
  

8.25	
  

7.325	
  

Total	
  PU	
  

21.4	
  

18.5	
  

19.95	
  

*Note:	
  There	
  were	
  several	
  days	
  in	
  December	
  when	
  P2	
  boys	
  were	
  housed	
  on	
   Buckeye	
  with	
  the	
  Transition	
  youth.	
  They	
  are	
  included	
  in	
  the	
  P2	
  count.	
  	
  
	
   As	
  shown	
  in	
  the	
  table	
  above,	
  the	
  average	
  number	
  of	
  youth	
  assigned	
  to	
  the	
  PU	
  decreased	
  by	
   approximately	
  14%	
  over	
  the	
  4-­‐month	
  period.	
  Within	
  the	
  PU	
  as	
  a	
  whole,	
  the	
  population	
  across	
   the	
  three	
  units	
  fluctuated	
  (decreasing	
  on	
  Sycamore	
  and	
  Cedar,	
  but	
  increasing	
  on	
  Buckeye).	
  In	
   real	
  numbers,	
  the	
  average	
  PU	
  population	
  decreased	
  by	
  about	
  3	
  youth	
  over	
  the	
  4-­‐month	
  period.	
  	
   	
   	
  

	
  

16.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 17 of 34 PAGEID #: 2578

The	
  weekly	
  staffing	
  reports,	
  coupled	
  with	
  the	
  estimated	
  ADP	
  permit	
  an	
  assessment	
  of	
  the	
   typical	
  staff—youth	
  ratio	
  on	
  Sycamore	
  and	
  Cedar.	
  1st	
  and	
  2nd	
  shifts	
  normally	
  had	
  3	
  staff	
  on	
  each	
   unit,	
  while	
  3rd	
  shift	
  normally	
  had	
  2	
  staff.	
  About	
  10%	
  of	
  the	
  time,	
  1st	
  and	
  2nd	
  shifts	
  had	
  4	
  or	
  5	
  staff	
   and	
  3rd	
  shift	
  had	
  3	
  staff.	
  	
   	
   A	
  staff-­‐youth	
  ratio	
  was	
  calculated	
  for	
  all	
  three	
  shifts	
  on	
  each	
  unit	
  for	
  each	
  of	
  the	
  66	
  days	
   reviewed.	
  On	
  Sycamore,	
  1st	
  and	
  2nd	
  shifts	
  were	
  staffed	
  at	
  1:2.33	
  or	
  better	
  every	
  day,	
  and	
  3rd	
  shift	
   was	
  staffed	
  at	
  1:3.5	
  or	
  better	
  every	
  day.	
  On	
  Cedar,	
  1st	
  and	
  2nd	
  shifts	
  were	
  staffed	
  at	
  1:2.66	
  or	
   better	
  every	
  day,	
  and	
  3rd	
  shift	
  was	
  staffed	
  at	
  1:4	
  or	
  better	
  every	
  day.	
  These	
  staffing	
  levels	
  are	
   appropriate	
  for	
  an	
  intensive	
  programming	
  unit	
  with	
  high-­‐risk	
  youth,	
  such	
  as	
  the	
  PU.	
  As	
  noted,	
   staffing	
  data	
  were	
  not	
  submitted	
  for	
  the	
  Transition	
  Unit,	
  so	
  staff—youth	
  ratios	
  could	
  not	
  be	
   calculated.	
  	
   	
  
Technical	
  Assistance	
  Note:	
  Staffing	
  
DYS	
  data	
  submissions	
  have	
  not	
  included	
  staffing	
  levels	
  on	
  the	
  Transition	
  Unit.	
  Being	
  as	
  the	
  Transition	
  Unit	
   is	
  part	
  of	
  the	
  PU,	
  these	
  data	
  are	
  required	
  by	
  the	
  Court	
  Order.	
  Furthermore,	
  staffing	
  data	
  for	
  January	
  and	
   February	
  has	
  not	
  yet	
  been	
  submitted.	
  	
  
	
   	
   Recommendations.	
  	
   While	
  the	
  DYS	
  meets	
  some	
  of	
  the	
  requirements	
  related	
  to	
  staffing	
  (e.g.,	
  UM	
  scheduling,	
  staff— youth	
  ratio)	
  a	
  few	
  issues	
  remain.	
  The	
  DYS	
  should	
  develop	
  a	
  Quality	
  Improvement	
  Plan	
  related	
  to	
   the	
  following	
  issues:	
  
1. Calculating	
  a	
  monthly	
  ADP	
  for	
  each	
  unit	
  so	
  that	
  staff	
  ratios	
  can	
  be	
  tracked	
  easily.	
   2. Including	
  Transition	
  staff	
  in	
  the	
  Quality	
  Assurance	
  process	
  surrounding	
  staffing	
  (e.g.,	
  
schedules,	
  daily	
  staffing	
  levels,	
  training,	
  etc.).	
   3. Amending	
  staffing	
  reports	
  to	
  identify	
  whether	
  any	
  of	
  the	
  staff	
  who	
  worked	
  on	
  a	
  given	
  
day/shift	
  were	
  relief	
  staff.	
   4. Developing	
  a	
  mechanism	
  to	
  certify	
  that	
  all	
  assigned	
  staff	
  have	
  completed	
  PU-­‐specific	
  
training	
  within	
  3	
  months	
  of	
  their	
  assignment.	
  	
   5. Updating	
  the	
  Post	
  Orders	
  for	
  the	
  PU	
  to	
  reflect	
  current	
  procedures.	
  	
  
	
   	
   (2)	
  Standard:	
  Impact	
  on	
  Safety.	
  	
   Recognizing	
  there	
  are	
  many	
  contributing	
  factors	
  to	
  youth	
  violence,	
  staffing	
  levels	
  on	
  the	
  PU	
  are	
   sufficient	
  to	
  ensure	
  that	
  a	
  lack	
  of	
  supervision	
  does	
  not	
  contribute	
  to	
  the	
  opportunity	
  for	
  youth	
   to	
  commit	
  violence	
  against	
  other	
  youth	
  or	
  staff.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• Rate	
  of	
  youth-­‐on-­‐youth	
  violence	
  for	
  past	
  12	
  months	
   • Rate	
  of	
  youth-­‐on-­‐staff	
  violence	
  for	
  past	
  12	
  months	
   • Disaggregated	
  list	
  of	
  AOVs	
  committed	
  by	
  youth	
  that	
  includes	
  the	
  youth’s	
  name,	
  date	
  
and	
  type	
  of	
  violence.	
  	
   	
   	
   	
  

	
  

17.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 18 of 34 PAGEID #: 2579

Analysis	
  and	
  Interpretation.	
  	
   The	
  DYS	
  has	
  provided	
  a	
  spreadsheet	
  each	
  month	
  since	
  November	
  2012	
  listing	
  the	
  youth	
  who	
   have	
  been	
  involved	
  in	
  AOV	
  during	
  the	
  month.	
  Spreadsheets	
  from	
  November	
  2012	
  through	
   January	
  2013	
  (the	
  last	
  month	
  for	
  which	
  data	
  are	
  available)	
  were	
  analyzed	
  to	
  identify	
  the	
  number	
   of	
  youth	
  involved	
  in	
  AOV	
  against	
  staff	
  and	
  other	
  youth.	
  The	
  table	
  below	
  presents	
  the	
  number	
  of	
   youth-­‐staff	
  assaults	
  and	
  youth-­‐youth	
  assaults.	
  In	
  the	
  future,	
  the	
  DYS	
  should	
  include	
  data	
  on	
  the	
   ADP	
  each	
  month	
  and	
  calculate	
  a	
  rate	
  for	
  each	
  type	
  of	
  violence	
  (rate	
  =	
  number	
  of	
  incidents/ADP).	
   Using	
  a	
  rate	
  will	
  neutralize	
  the	
  impact	
  of	
  the	
  fluctuating	
  population	
  on	
  the	
  units	
  and	
  will	
  permit	
   long-­‐term	
  comparisons.	
  While	
  it	
  appears	
  that	
  the	
  rate	
  of	
  violence	
  is	
  decreasing	
  in	
  the	
  PU,	
  the	
   population	
  of	
  the	
  PU	
  has	
  also	
  decreased	
  during	
  this	
  same	
  time	
  period.	
  This	
  makes	
  the	
  need	
  to	
   use	
  a	
  rate	
  particularly	
  pronounced.	
  	
   	
   The	
  estimated	
  unit-­‐level	
  ADP	
  used	
  in	
  the	
  staffing	
  discussion	
  above	
  is	
  not	
  sensitive	
  enough	
  for	
   these	
  calculations	
  given	
  that	
  a	
  complete	
  set	
  of	
  weekly	
  data	
  were	
  not	
  available	
  for	
  each	
  month.	
   However,	
  ADPs	
  of	
  21	
  (Nov),	
  20	
  (Dec)	
  and	
  19	
  (Jan)	
  are	
  reasonable	
  estimates	
  and	
  are	
  used	
  for	
   illustrative	
  purposes.	
  These	
  rates	
  should	
  be	
  recalculated	
  when	
  the	
  actual	
  ADP	
  is	
  known.	
  	
   	
  
Rates	
  of	
  Violence	
  on	
  the	
  PU	
  

Month	
  

Youth—Staff	
  

Youth—Youth	
  

Number	
   ADP	
   Rate	
   Number	
   ADP	
   Rate	
  

Nov	
  12	
  

8	
  

21	
  

.381	
  

5	
  

21	
   .238	
  

Dec	
  12	
  

6	
  

20	
  

.285	
  

1	
  

21	
   .048	
  

Jan	
  12	
  

5	
  

19	
  

.263	
  

1	
  

19	
   .053	
  

	
   The	
  same	
  youth	
  was	
  involved	
  in	
  early	
  all	
  of	
  the	
  youth-­‐youth	
  assaults.	
  This	
  youth’s	
  treatment	
   plan	
  should	
  be	
  reviewed	
  to	
  determine	
  whether	
  there	
  are	
  sufficient	
  therapeutic	
  and	
   environmental	
  supports	
  to	
  help	
  him	
  to	
  refrain	
  from	
  violent	
  behavior.	
  	
   	
   Clearly,	
  the	
  rate	
  of	
  youth-­‐staff	
  assaults	
  is	
  much	
  higher	
  than	
  the	
  rate	
  of	
  youth-­‐youth	
  assaults.	
  In	
   order	
  to	
  ensure	
  a	
  safe	
  environment	
  for	
  the	
  staff	
  posted	
  to	
  the	
  PU,	
  the	
  types	
  of	
  violence	
  and	
  the	
   underlying	
  causes	
  of	
  these	
  assaults	
  should	
  be	
  further	
  analyzed	
  and	
  addressed.	
  As	
  noted	
  in	
   subsequent	
  sections	
  of	
  this	
  report,	
  reducing	
  the	
  rate	
  of	
  youth-­‐staff	
  assaults	
  will	
  also	
  shorten	
   youth’s	
  length	
  of	
  stay	
  and	
  shrink	
  the	
  PU’s	
  population,	
  as	
  youth-­‐staff	
  assault	
  is	
  one	
  of	
  the	
  main	
   reasons	
  why	
  youth	
  are	
  recycled	
  through	
  the	
  phases.	
  	
   	
  

Technical	
  Assistance	
  Note:	
  Rates	
  of	
  Violence	
  

While	
  DYS	
  has	
  invested	
  considerable	
  resources	
  in	
  creating	
  a	
  robust	
  staffing	
  plan	
  for	
  the	
  PU,	
  the	
   ability	
  to	
  demonstrate	
  that	
  the	
  enhanced	
  staffing	
  levels	
  translate	
  to	
  a	
  safer	
  environment	
  for	
   youth	
  and	
  staff	
  (as	
  required	
  by	
  the	
  Order)	
  is	
  hampered	
  by	
  the	
  lack	
  of	
  unit-­‐specific	
  data	
  on	
  AOV	
   and	
  ADPs.	
  The	
  safe	
  environment	
  may	
  be	
  easy	
  to	
  substantiate	
  once	
  the	
  data	
  are	
  in	
  order.	
  	
  	
  
	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  the	
  Impact	
  of	
  Staffing	
  on	
  Safety,	
  the	
  DYS	
  should	
   create	
  a	
  Quality	
  Improvement	
  Plan	
  to	
  address	
  the	
  following	
  issues:	
  

	
  

18.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 19 of 34 PAGEID #: 2580

1. Developing	
  the	
  ability	
  to	
  track	
  rates	
  of	
  violence	
  by	
  collecting	
  the	
  number	
  of	
  AOVs	
  and	
  

the	
  ADP	
  each	
  month	
  for	
  the	
  PU,	
  specifically.	
  	
  

2. Analyzing	
  the	
  incidents	
  involving	
  violence	
  against	
  youth	
  to	
  identify	
  any	
  patterns	
  in	
  unit,	
  

location,	
  youth	
  involved,	
  etc.	
  Enact	
  specific	
  strategies	
  to	
  address	
  these	
  patterns.	
  	
  

3. Analyzing	
  the	
  types	
  of	
  violence	
  perpetrated	
  against	
  staff,	
  their	
  underlying	
  causes	
  and	
  

any	
  environmental	
  conditions	
  that	
  create	
  the	
  opportunity	
  for	
  violence	
  to	
  occur	
  (e.g.,	
  

sufficient	
  staff	
  support	
  during	
  restraints?	
  Ability	
  to	
  collect	
  liquids	
  and	
  throw	
  them?	
  

Tensions	
  between	
  individuals	
  that	
  should	
  be	
  mitigated?).	
  Develop	
  and	
  implement	
  

specific	
  strategies	
  to	
  address	
  these	
  issues.	
  	
  

	
  

	
  

	
  

	
  

19.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 20 of 34 PAGEID #: 2581

[II.12]	
  Treatment	
  Planning	
  [monitored	
  by	
  Dr.	
  Glindmeyer]	
   Status:	
  Not	
  in	
  Substantial	
  Compliance	
   	
  
(1)	
  Standard:	
  Clinical	
  Staffing	
  [this	
  standard	
  is	
  derived	
  from	
  paragraph	
  II.C.3	
  of	
  the	
  SH	
  Order]	
   Clinical	
  staffing	
  is	
  sufficient	
  to	
  implement	
  youth’s	
  treatment	
  plans	
  and	
  to	
  conduct	
  Inter-­‐ Disciplinary	
  Team	
  (IDT)	
  meetings	
  (e.g.,	
  with	
  20	
  youth	
  on	
  the	
  PU,	
  “sufficient	
  staffing”	
  is	
  three	
   psychologists,	
  one	
  psychiatrist,	
  one	
  psychiatric	
  nurse	
  and	
  three	
  social	
  workers).	
  The	
  staffing	
   levels	
  are	
  adjusted	
  when	
  the	
  population	
  fluctuates	
  or	
  upon	
  reasonable	
  professional	
  judgment.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• PU	
  clinical	
  staffing	
  plan	
   	
   Analysis	
  and	
  Interpretation.	
  	
   Sufficient	
  data	
  were	
  not	
  submitted	
  in	
  order	
  to	
  demonstrate	
  compliance	
  with	
  this	
  standard.	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  Clinical	
  Staffing	
  
The	
  clinical	
  staffing	
  plan	
  was	
  not	
  submitted	
  for	
  review	
  at	
  the	
  time	
  this	
  report	
  was	
  authored.	
  DYS	
  needs	
  to	
   develop	
  a	
  mechanism	
  to	
  track	
  the	
  number	
  and	
  type	
  of	
  clinical	
  staff	
  and	
  the	
  ratio	
  to	
  the	
  PU	
  population	
  for	
   each	
  position.	
  	
  
	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Clinical	
  Staffing,	
  a	
  Quality	
  Improvement	
  Plan	
   should	
  be	
  created	
  to	
  address	
  the	
  following	
  issues:	
  
1. Reporting	
  the	
  clinical	
  staffing	
  levels	
  and	
  hours	
  of	
  clinical	
  activity	
  on	
  a	
  periodic	
  basis.	
   2. If	
  ratios	
  are	
  found	
  to	
  be	
  insufficient	
  once	
  the	
  data	
  have	
  been	
  assembled,	
  ensuring	
  
appropriate	
  staff	
  to	
  meet	
  the	
  clinical	
  needs	
  of	
  youth	
  on	
  the	
  PU.	
   	
   	
   (2)	
  Standard:	
  Treatment	
  Planning.	
  	
   Treatment	
  plans	
  are	
  individualized	
  and	
  include	
  concrete,	
  realistic,	
  measurable	
  goals	
  and	
   objectives	
  that	
  are	
  designed	
  to	
  address	
  the	
  specific	
  behaviors	
  that	
  led	
  to	
  the	
  youth’s	
  placement	
   on	
  the	
  PU.	
  Specific	
  interventions	
  are	
  prescribed	
  in	
  order	
  to	
  assist	
  youth	
  in	
  accomplishing	
   treatment	
  goals.	
  Progress	
  toward	
  treatment	
  goals	
  results	
  in	
  promotion	
  through	
  the	
  PU’s	
  phases	
   and,	
  ultimately,	
  back	
  to	
  the	
  general	
  population.	
  	
  
• Phase	
  1	
  (P1)	
  goals	
  focus	
  on	
  acquiring	
  skills	
  to	
  move	
  safely	
  about	
  the	
  unit	
  without	
  the	
  use	
   of	
  restraints	
  once	
  promoted.	
  Skill	
  acquisition	
  is	
  demonstrated	
  by	
  meeting	
  behavioral	
   expectations.	
  	
  	
  
• Phase	
  2	
  (P2)	
  goals	
  focus	
  on	
  acquiring	
  skills	
  needed	
  to	
  refrain	
  from	
  aggressive	
  behavior	
   once	
  returned	
  to	
  the	
  general	
  population.	
  	
  
	
   	
   	
   	
  

	
  

20.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 21 of 34 PAGEID #: 2582

Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• Content	
  analysis	
  of	
  Treatment	
  Plans	
  for	
  youth	
  on	
  P1	
  and	
  P2	
  including	
  the	
  presence	
  of	
   measurable	
  goals	
  and	
  objectives	
  with	
  targeted	
  interventions.	
  
• Data	
  on	
  the	
  frequency	
  and	
  type	
  of	
  treatment	
  services	
  provided,	
  via	
  the	
  CaseNotes	
   database.	
  
• Progress	
  notes	
  to	
  demonstrate	
  how	
  treatment	
  goals	
  are	
  addressed	
  within	
  each	
   treatment	
  activity.	
  
	
   Analysis	
  and	
  Interpretation.	
  	
   ITP	
  documents	
  were	
  available	
  for	
  five	
  youth	
  (AE,	
  DS,	
  DS2,	
  BD,	
  and	
  WH).	
  	
  These	
  ITP	
  documents	
   were	
  provided	
  in	
  early	
  January	
  2013.	
  More	
  recent	
  documents	
  were	
  not	
  made	
  available	
  for	
   review,	
  so,	
  in	
  the	
  interest	
  of	
  providing	
  guidance	
  and	
  feedback,	
  the	
  early	
  January	
  documents	
   were	
  audited.	
  Improvements	
  were	
  noted	
  in	
  the	
  goals	
  and	
  objectives	
  recorded	
  in	
  the	
  ITPs	
   compared	
  to	
  those	
  reviewed	
  in	
  October	
  2012	
  during	
  the	
  most	
  recent	
  DOJ	
  site	
  visit,	
  but	
  the	
  lack	
   of	
  focus	
  on	
  skill	
  building	
  continues	
  to	
  be	
  problematic	
  (and,	
  encouragingly,	
  has	
  been	
  a	
  focus	
  of	
   the	
  feedback	
  from	
  the	
  Central	
  Office	
  Review	
  Board).	
   	
   Furthermore,	
  the	
  prescribed	
  type	
  and	
  frequency	
  of	
  treatment	
  was	
  not	
  always	
  clear	
  in	
  the	
   description	
  of	
  the	
  intervention.	
  This	
  lack	
  of	
  specificity	
  precluded	
  an	
  assessment	
  of	
  the	
  extent	
  to	
   which	
  treatment	
  services	
  were	
  provided	
  (per	
  the	
  CaseNotes	
  data)	
  as	
  prescribed	
  on	
  the	
  ITP.	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  Treatment	
  Planning	
  
The	
  Court	
  Order	
  requires	
  ITP	
  documents	
  to	
  be	
  provided	
  within	
  30	
  days	
  of	
  the	
  youth’s	
  admission	
  to	
  the	
   facility	
  and	
  subsequently	
  upon	
  any	
  changes	
  to	
  the	
  ITP.	
  	
  Documentation	
  showed	
  that	
  a	
  number	
  of	
  youth	
   were	
  admitted	
  to	
  the	
  unit	
  in	
  late	
  December	
  2012	
  and	
  early	
  February	
  2013;	
  however,	
  initial	
  ITP	
   documentation	
  was	
  not	
  received.	
  In	
  the	
  future,	
  timely	
  submission	
  of	
  initial	
  and	
  subsequent	
  ITPs	
  is	
  essential	
   for	
  comprehensive	
  monitoring	
  and	
  quality	
  assurance.	
   	
   CaseNotes	
  data	
  are	
  regularly	
  submitted	
  and,	
  despite	
  some	
  mis-­‐categorization	
  of	
  activities,	
  appear	
   sufficient	
  to	
  identify	
  the	
  type	
  and	
  amount	
  of	
  treatment	
  youth	
  receive.	
  However,	
  without	
  current	
  ITPs,	
  the	
   CaseNotes	
  data	
  cannot	
  be	
  cross-­‐referenced	
  with	
  the	
  ITP	
  prescription.	
  Finally,	
  the	
  QA	
  process	
  should	
  also	
   include	
  a	
  review	
  of	
  Progress	
  Notes	
  to	
  ascertain	
  whether	
  treatment	
  sessions	
  are	
  appropriately	
  anchored	
  to	
   the	
  youth’s	
  treatment	
  goals.	
  These	
  data	
  should	
  all	
  be	
  submitted	
  to	
  the	
  Monitor.	
  	
   	
   ODYS	
  has	
  conducted	
  several	
  audits	
  to	
  improve	
  the	
  quality	
  of	
  treatment	
  planning.	
  These	
  reviews	
  provided	
   excellent	
  feedback	
  and	
  will	
  be	
  an	
  essential	
  component	
  of	
  DYS’	
  Quality	
  Improvement	
  Plan.	
  
	
   	
   Whether	
  youth	
  were	
  prescribed	
  psychotropic	
  medication	
  was	
  difficult	
  to	
  determine	
  given	
  the	
   content	
  of	
  the	
  treatment	
  plans.	
  Youth	
  who	
  are	
  prescribed	
  medication	
  must	
  have	
  an	
  ITP	
  goal	
   referring	
  to	
  this	
  treatment	
  intervention.	
   	
   Other	
  goals,	
  while	
  appropriate,	
  were	
  variable	
  with	
  regard	
  to	
  appropriate	
  interventions	
   indicated.	
  	
  Two	
  specific	
  examples	
  are	
  discussed	
  here,	
  but	
  the	
  pattern	
  was	
  evident	
  throughout	
   the	
  IDT	
  documents.	
  In	
  the	
  case	
  of	
  BD,	
  one	
  of	
  his	
  treatment	
  goals	
  was	
  “I	
  will	
  not	
  expose	
  my	
  penis	
   to	
  any	
  female	
  for	
  the	
  next	
  14	
  days.	
  	
  This	
  will	
  be	
  monitored	
  by	
  not	
  receiving	
  any	
  YBIR’s	
  for	
  sexual	
  

	
  

21.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 22 of 34 PAGEID #: 2583

conduct	
  within	
  that	
  14	
  days.”	
  	
  The	
  intervention	
  indicated,	
  “If	
  I	
  feel	
  the	
  urge	
  to	
  expose	
  myself	
  or	
   masturbate	
  in	
  front	
  of	
  a	
  female…I	
  will	
  complete	
  a	
  Decisional	
  Balance	
  worksheet	
  and	
  process	
  the	
   information	
  with	
  my	
  social	
  worker	
  during	
  individual	
  sessions.	
  	
  I	
  will	
  talk	
  to	
  my	
  behavioral	
  health	
   [staff]	
  at	
  least	
  one	
  time	
  per	
  week	
  regarding	
  my	
  sexual	
  misconduct	
  urges.”	
  This	
  youth	
  had	
   diagnoses	
  documented	
  as	
  ADHD	
  and	
  Conduct	
  Disorder.	
  	
  There	
  was	
  no	
  IDT	
  goal	
  regarding	
   psychotropic	
  medication,	
  and	
  therefore,	
  it	
  was	
  unclear	
  if	
  he	
  was	
  prescribed	
  medication	
  at	
  the	
   time	
  this	
  ITP	
  was	
  authored.	
   	
   In	
  this	
  case,	
  a	
  more	
  appropriate	
  treatment	
  protocol	
  would	
  be	
  to	
  consider	
  the	
  youth’s	
  motivation	
   for	
  exposing	
  himself	
  (e.g.	
  anxiety,	
  sexual	
  aggression,	
  impulsivity,	
  to	
  repel	
  others,	
  hypersexuality,	
   control	
  of	
  his	
  environment,	
  attention	
  seeking,	
  etc.)	
  or	
  specific	
  triggers,	
  which	
  precipitated	
  his	
   self-­‐exposure.	
  	
  Then,	
  treatment	
  interventions	
  should	
  be	
  developed	
  focusing	
  on	
  specific	
  skills	
  the	
   youth	
  will	
  need	
  to	
  acquire	
  in	
  order	
  to	
  address	
  the	
  underlying	
  cause	
  of	
  the	
  maladaptive	
  behavior.	
   	
   Documentation	
  provided	
  revealed	
  a	
  review	
  of	
  this	
  youth’s	
  treatment	
  plan	
  performed	
  by	
  ODYS	
   central	
  office	
  2/15/13.	
  	
  There	
  were	
  excellent	
  suggestions	
  provided	
  via	
  this	
  review	
  document.	
  	
   Unfortunately,	
  the	
  ITP	
  revisions	
  performed	
  as	
  a	
  result	
  of	
  this	
  review	
  were	
  not	
  provided	
  prior	
  to	
   the	
  completion	
  of	
  this	
  status	
  report.	
   	
   Other	
  examples	
  included	
  the	
  case	
  of	
  RB.	
  	
  Per	
  the	
  IDT	
  minutes	
  dated	
  2.26.12,	
  his	
  treatment	
  goals	
   included,	
  “I	
  will	
  reduce	
  acts	
  of	
  violence	
  or	
  cruelty	
  towards	
  people.”	
  	
  IDT	
  documentation	
   indicated,	
  “this	
  is…weakest	
  area…he	
  earned	
  two	
  primary	
  YBIR’s	
  for	
  fighting…peers	
  target	
  him	
   and	
  taunt	
  him…he	
  appeared	
  to	
  allow	
  these	
  insults	
  to	
  fester	
  to	
  the	
  point	
  where	
  he	
  would	
   fight…shows	
  an	
  increased	
  ability	
  to	
  ignore	
  and	
  control	
  his	
  temper,	
  but	
  he	
  is	
  still	
  fighting…not	
   meeting	
  this	
  behavioral	
  requirement.”	
  	
  The	
  document	
  further	
  stated,	
  “in	
  light	
  of	
  the	
  fights,	
   there	
  may	
  be	
  a	
  recommendation	
  to	
  return	
  to	
  the	
  PU	
  where	
  he	
  does	
  well	
  because	
  of	
  the	
   structure	
  on	
  the	
  unit	
  and	
  in	
  school…another	
  option	
  is	
  that	
  …earn	
  his	
  way	
  to	
  general	
  population	
   and	
  possibly	
  transfer	
  to	
  another	
  facility.	
  	
  	
  Youth	
  Specialists	
  expressed	
  concern	
  for…safety	
   because	
  of	
  the	
  behaviors	
  of	
  his	
  peers.”	
  	
  	
   	
   This	
  documentation	
  is	
  concerning	
  as	
  there	
  are	
  apparently	
  concerns	
  for	
  this	
  youth’s	
  safety,	
  he	
  is	
   being	
  targeted	
  and	
  taunted,	
  and	
  then	
  penalized	
  for	
  fighting.	
  	
  The	
  IDT	
  must	
  explore	
  ways	
  to	
   ensure	
  this	
  youth	
  is	
  safe	
  and	
  not	
  provoked	
  by	
  other	
  youth.	
  	
  In	
  addition,	
  there	
  were	
  no	
  notations	
   regarding	
  skills	
  he	
  may	
  need	
  to	
  develop.	
  	
  The	
  document	
  indicated,	
  “team	
  members	
  encouraged	
   him	
  to	
  stop	
  fighting,	
  continue	
  to	
  work	
  on	
  expressing	
  his	
  anger	
  differently	
  and	
  asked	
  if	
  they	
  could	
   assist	
  him	
  to	
  reach	
  these	
  goals.	
  	
  [He]	
  did	
  not	
  identify	
  any	
  needs	
  from	
  the	
  team.	
  	
  It	
  was	
   considered	
  that	
  the	
  youth’s	
  primary	
  need	
  is	
  safety.”	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Treatment	
  Planning,	
  a	
  Quality	
  Improvement	
  Plan	
   should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issues:	
  
1. Ensuring	
  that	
  ITP	
  goals	
  and	
  objectives	
  are	
  measurable,	
  strength-­‐based	
  and	
  include	
  the	
   specific	
  skill	
  development	
  needed.	
  	
  
2. Ensuring	
  that	
  ITP	
  interventions	
  are	
  documented	
  and	
  appropriate	
  to	
  the	
  stated	
  goals	
  and	
   objectives,	
  via	
  clinicians’	
  Progress	
  Notes.	
  
3. Verifying	
  that	
  youth	
  receive	
  the	
  type	
  and	
  intensity	
  of	
  the	
  services	
  prescribed	
  on	
  the	
  ITP.	
  	
   	
   	
  

	
  

22.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 23 of 34 PAGEID #: 2584

	
   (3)	
  Standard:	
  Progress	
  Reporting	
  and	
  Promotion.	
   Progress	
  toward	
  treatment	
  goals	
  and	
  behavioral	
  expectations	
  is	
  assessed	
  on	
  a	
  weekly	
  basis.	
   Youth	
  are	
  promoted	
  to	
  the	
  next	
  higher	
  phase	
  when	
  they	
  have	
  met	
  their	
  treatment	
  goals	
  and	
   behavioral	
  expectations.	
  Behavior	
  not	
  related	
  to	
  AOV,	
  serious	
  STG	
  activity,	
  possession	
  of	
  major	
   contraband,	
  or	
  repeated	
  verbal	
  threats	
  to	
  cause	
  serious	
  harm	
  are	
  not	
  used	
  as	
  a	
  basis	
  to	
   withhold	
  promotion.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• Behavior	
  Expectation	
  Tracking	
  Sheets	
   • Treatment	
  Plans,	
  and	
  updates	
   • Progress	
  Note	
  entries	
  in	
  the	
  CaseNotes	
  database	
   • IDT	
  Minutes	
   	
   Analysis	
  and	
  Interpretation.	
  	
   IDT	
  minutes	
  were	
  received	
  throughout	
  the	
  monitoring	
  period,	
  clearly	
  demonstrating	
  that	
  the	
   IDTs	
  on	
  all	
  three	
  units	
  meet	
  weekly	
  as	
  required.	
  Youth	
  are	
  regularly	
  promoted	
  when	
  they	
  have	
   accomplished	
  the	
  behavioral	
  objectives.	
  However,	
  the	
  discussion	
  surrounding	
  why	
  Phase	
  1	
   youth	
  did	
  not	
  or	
  could	
  not	
  meet	
  the	
  behavioral	
  objectives	
  often	
  lacked	
  substance.	
  Furthermore,	
   progress	
  toward	
  treatment	
  goals	
  was	
  not	
  discussed	
  with	
  enough	
  detail	
  to	
  determine	
  which	
   objectives	
  may	
  have	
  been	
  met	
  and	
  which	
  remained	
  incomplete.	
  	
   	
   In	
  general,	
  the	
  discussion	
  surrounding	
  treatment	
  plans	
  (ITPs)	
  during	
  the	
  2/26/13	
  IDT	
  meetings	
   were	
  much	
  improved	
  over	
  previous	
  submissions.	
  	
  The	
  revised	
  format	
  reviews	
  the	
  youth’s	
  ITP	
   goals	
  and	
  a	
  brief	
  summary	
  of	
  his	
  progress	
  toward	
  said	
  goals.	
  However,	
  it	
  was	
  difficult	
  to	
  discern	
   the	
  skills	
  that	
  the	
  team	
  believed	
  were	
  necessary	
  for	
  the	
  youth	
  to	
  develop	
  in	
  order	
  to	
  meet	
  their	
   goals.	
   	
   For	
  example,	
  in	
  the	
  case	
  of	
  youth	
  CC,	
  the	
  IDT	
  minutes	
  revealed	
  the	
  youth	
  “received	
  a	
  primary	
   violation	
  for	
  sexual	
  misconduct…last	
  week…since	
  this,	
  he	
  has	
  had	
  three	
  secondary	
   violations…has	
  not	
  met	
  his	
  behavioral	
  expectations…team	
  members	
  reported	
  youth’s	
  positive	
   participation	
  in	
  group	
  and	
  in	
  school…[but]	
  he	
  continues	
  to	
  sit	
  alone	
  in	
  the	
  corner…observing	
  unit	
   activity.	
  [Psychology	
  staff]…continues	
  to	
  process	
  his	
  feelings	
  of	
  dissonance.”	
  This	
  IDT	
  case	
   summary	
  lacks	
  clarity	
  with	
  regard	
  to	
  specific	
  skills	
  this	
  youth	
  needs	
  to	
  develop	
  in	
  order	
  to	
  avoid	
   behavioral	
  challenges,	
  including	
  sexual	
  misconduct.	
  This	
  youth	
  was	
  noted	
  to	
  have	
  strengths	
  with	
   regard	
  to	
  participation	
  in	
  group	
  and	
  in	
  school,	
  but	
  was	
  reported	
  to	
  isolate	
  on	
  the	
  unit.	
  While	
  it	
   was	
  suggested	
  that	
  the	
  youth’s	
  observation	
  served	
  a	
  purpose,	
  it	
  is	
  unclear	
  what	
  this	
  purpose	
  is	
   and	
  how	
  it	
  will	
  be	
  addressed	
  with	
  regard	
  to	
  skill	
  acquisition.	
  This	
  discussion	
  was	
  not	
  anchored	
  to	
   the	
  youth’s	
  treatment	
  goals,	
  and	
  thus	
  the	
  youth’s	
  progress	
  toward	
  them	
  was	
  never	
  quite	
   articulated.	
  	
   	
   In	
  the	
  case	
  of	
  youth	
  RB,	
  it	
  was	
  noted	
  that	
  acts	
  of	
  violence	
  toward	
  others	
  was	
  this	
  youth’s	
   “weakest	
  area.”	
  There	
  was	
  information	
  that	
  “peers	
  target	
  him	
  and	
  taunt	
  him…shows	
  an	
   increased	
  ability	
  to	
  ignore	
  and	
  control	
  his	
  temper,	
  but	
  he	
  is	
  still	
  fighting…not	
  meeting	
  this	
   behavioral	
  requirement.”	
  	
  There	
  was	
  a	
  notation	
  that	
  the	
  team	
  encouraged	
  this	
  youth	
  to	
  “stop	
   fighting”	
  but	
  it	
  was	
  unclear	
  what	
  skills	
  this	
  youth	
  needed	
  to	
  develop	
  in	
  order	
  to	
  achieve	
  this	
   goal.	
  

	
  

23.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 24 of 34 PAGEID #: 2585

	
   With	
  regard	
  to	
  youth	
  TB,	
  the	
  lack	
  of	
  progress	
  toward	
  treatment	
  goals	
  may	
  be	
  due	
  to	
  a	
  potential	
   psychiatric	
  illness.	
  This	
  youth	
  had	
  diagnoses	
  on	
  admission	
  to	
  the	
  PU	
  of:	
  	
  Rule	
  out	
  psychotic	
   disorder,	
  NOS;	
  Conduct	
  Disorder;	
  Oppositional	
  Defiant	
  Disorder;	
  Cannabis	
  Dependence.	
  	
  His	
   family	
  reportedly	
  refuses	
  to	
  consent	
  to	
  psychotropic	
  medication,	
  and	
  his	
  behavior	
  has	
  been	
   “odd”	
  and	
  included	
  the	
  requirement	
  for	
  suicide	
  watch	
  due	
  to	
  his	
  tying	
  “	
  jumpsuit	
  around	
  his	
   neck”	
  covering	
  “himself	
  with	
  his	
  mattress	
  and	
  was	
  unresponsive	
  to	
  staff.”	
  This	
  youth	
  has	
   reportedly	
  not	
  met	
  any	
  of	
  his	
  treatment	
  goals	
  and	
  has	
  not	
  been	
  promoted.	
  Given	
  what	
  appear	
   to	
  be	
  significant	
  mental	
  health	
  symptoms,	
  consideration	
  of	
  a	
  transfer	
  to	
  the	
  mental	
  health	
  unit	
   would	
  be	
  expected.	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Progress	
  Reporting	
  and	
  Promotion,	
  a	
  Quality	
   Improvement	
  Plan	
  should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issues:	
  
1. Ensuring	
  that	
  ITP	
  and	
  IDT	
  documentation	
  clearly	
  outlines	
  the	
  skills	
  that	
  the	
  youth	
  needs	
   to	
  develop	
  in	
  order	
  to	
  meet	
  identified	
  treatment	
  goals.	
  
2. Ensure	
  that	
  the	
  ITP	
  clearly	
  outlines	
  the	
  steps	
  that	
  will	
  be	
  utilized	
  to	
  assist	
  the	
  youth	
  in	
   skill	
  development.	
  
3. Documenting	
  the	
  progress,	
  or	
  the	
  lack	
  thereof,	
  on	
  the	
  ITP	
  goals	
  and	
  how	
  the	
   interventions	
  will	
  be	
  adjusted	
  in	
  order	
  to	
  assist	
  the	
  youth	
  in	
  achieving	
  said	
  goals	
  (note:	
   this	
  may	
  be	
  documented	
  in	
  weekly	
  IDT	
  minutes).	
   	
  
	
   (4)	
  Standard:	
  Inter-­‐Disciplinary	
  Team.	
  [Note:	
  this	
  standard	
  applies	
  only	
  to	
  the	
  S.H.	
  Agreement.]	
   A	
  psychiatrist	
  or	
  psychologist	
  facilitates	
  an	
  Inter-­‐Disciplinary	
  Team	
  (IDT)	
  meeting.	
  Attendees	
   include	
  social	
  workers,	
  psychologists,	
  occupational	
  therapists,	
  medical	
  staff,	
  educators,	
   recreation	
  staff,	
  Unit	
  Managers	
  and	
  Youth	
  Specialists.	
  If	
  a	
  member	
  of	
  the	
  IDT	
  cannot	
  attend,	
   written	
  input	
  is	
  provided	
  to	
  the	
  IDT	
  Chair.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• IDT	
  Minutes	
   	
   	
  
Technical	
  Assistance	
  Note:	
  IDT	
  
While	
  the	
  Monitors	
  have	
  not	
  yet	
  engaged	
  in	
  this	
  type	
  of	
  monitoring,	
  any	
  Quality	
  Assurance	
  protocol	
   should	
  include	
  direct	
  observation	
  of	
  IDT	
  meetings	
  in	
  order	
  to	
  form	
  conclusions	
  about	
  whether	
  they	
  meet	
   the	
  relevant	
  standards.	
  	
  
	
   	
   Analysis	
  and	
  Interpretation.	
  	
   The	
  IDT	
  minutes	
  available	
  for	
  the	
  majority	
  of	
  the	
  monitoring	
  period	
  did	
  not	
  include	
  the	
  names	
  or	
   positions	
  of	
  the	
  staff	
  members	
  present.	
  	
  The	
  one	
  exception	
  to	
  this	
  was	
  the	
  IDT	
  documentation	
   from	
  2/26/13.	
  These	
  minutes	
  revealed	
  an	
  improvement	
  in	
  documentation	
  surrounding	
  the	
   participants	
  in	
  the	
  meetings,	
  although	
  it	
  did	
  not	
  always	
  specify	
  the	
  individual’s	
  role.	
  The	
  contract	
   psychiatrist	
  was	
  present	
  for	
  IDT	
  on	
  Phase	
  1	
  and	
  Phase	
  2,	
  and	
  the	
  psychologist	
  was	
  present	
  for	
   the	
  IDT	
  on	
  the	
  Transition	
  Unit.	
  Prior	
  to	
  these	
  minutes,	
  it	
  was	
  not	
  possible	
  to	
  verify	
  whether	
  the	
  

	
  

24.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 25 of 34 PAGEID #: 2586

required	
  participants	
  attended	
  or	
  not,	
  and	
  it	
  did	
  not	
  appear	
  that	
  non-­‐attending	
  members	
   submitted	
  written	
  input	
  for	
  consideration	
  by	
  the	
  team.	
  	
  	
  	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  the	
  Inter-­‐Disciplinary	
  Team,	
  a	
  Quality	
   Improvement	
  Plan	
  should	
  be	
  created	
  to	
  address	
  the	
  following	
  issues:	
  	
  
1. Documenting	
  staff	
  attendance	
  (i.e.,	
  name	
  and	
  role)	
  at	
  IDT	
  via	
  the	
  IDT	
  minutes.	
   2. Ensuring	
  an	
  appropriate	
  complement	
  of	
  staff	
  at	
  the	
  IDT	
  meetings.	
   3. If	
  staff	
  are	
  not	
  in	
  attendance,	
  providing	
  written	
  input	
  to	
  the	
  IDT	
  chair	
  for	
  review.	
   	
   	
   (5)	
  Standard:	
  IDT	
  Substance.	
  	
   Youth	
  appear	
  before	
  an	
  Inter-­‐Disciplinary	
  Team	
  (IDT)	
  at	
  least	
  bi-­‐weekly.	
  IDT	
  meetings	
  for	
  each	
   youth	
  involve	
  a	
  structured	
  and	
  specific	
  discussion	
  of	
  each	
  youth’s	
  goals	
  and	
  objectives,	
   behavioral	
  expectations	
  and	
  progress	
  toward	
  meeting	
  them.	
  	
   • When	
  goals	
  and	
  expectations	
  are	
  met,	
  the	
  youth	
  is	
  promoted.	
  	
   • If	
  goals	
  and	
  expectations	
  are	
  not	
  met,	
  the	
  IDT	
  identifies	
  the	
  areas	
  in	
  need	
  of	
  
improvement	
  so	
  the	
  youth	
  know	
  what	
  is	
  required	
  for	
  promotion.	
  The	
  IDT	
  also	
  revises	
   the	
  treatment	
  plan	
  or	
  its	
  implementation	
  to	
  better	
  address	
  the	
  underlying	
  causes	
  of	
  the	
   youth’s	
  unwanted	
  behaviors.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
   • IDT	
  Minutes	
   • Treatment	
  Plans,	
  and	
  updates	
   	
   	
  
Technical	
  Assistance	
  Note:	
  IDT	
  
While	
  the	
  Monitors	
  have	
  not	
  yet	
  engaged	
  in	
  this	
  type	
  of	
  monitoring,	
  any	
  Quality	
  Assurance	
  protocol	
   should	
  include	
  direct	
  observation	
  of	
  IDT	
  meetings	
  in	
  order	
  to	
  form	
  conclusions	
  about	
  whether	
  they	
  meet	
   the	
  relevant	
  standards.	
  	
  
	
   	
   Analysis	
  and	
  Interpretation.	
  	
   IDT	
  minutes	
  reviewed	
  for	
  this	
  status	
  report	
  revealed	
  documentation	
  that	
  youth	
  meet	
  with	
  the	
   IDT	
  bi-­‐weekly	
  as	
  required.	
  There	
  was	
  notation	
  that	
  the	
  youth	
  were	
  engaged	
  in	
  the	
  treatment	
   planning	
  process	
  and	
  that	
  treatment	
  interventions	
  were	
  discussed	
  with	
  them.	
  	
  As	
  noted	
  in	
  the	
   discussions	
  above,	
  there	
  needs	
  to	
  be	
  increased	
  attention	
  to	
  skill	
  development	
  with	
  regard	
  to	
   those	
  skills	
  needed	
  to	
  meet	
  specific	
  treatment	
  goals.	
  Furthermore,	
  only	
  some	
  of	
  the	
  youth	
   reviewed	
  in	
  the	
  most	
  recent	
  set	
  of	
  IDT	
  Minutes	
  includes	
  a	
  structured	
  review	
  of	
  the	
  youth’s	
  ITP	
   goals	
  and	
  objectives.	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  IDT	
  
The	
  Court	
  Order	
  requires	
  youth	
  to	
  attend	
  the	
  IDT	
  only	
  every	
  other	
  week.	
  It	
  is	
  likely	
  that	
  feedback	
  on	
  the	
   youth’s	
  performance	
  is	
  more	
  powerful	
  when	
  delivered	
  to	
  the	
  youth	
  by	
  the	
  team.	
  	
  In	
  order	
  to	
  facilitate	
  

	
  

25.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 26 of 34 PAGEID #: 2587

progress	
  through	
  the	
  program,	
  as	
  is	
  the	
  goal,	
  DYS	
  should	
  consider	
  reviewing	
  each	
  youth	
  in	
  person	
  every	
   week.	
  This	
  may	
  be	
  feasible	
  given	
  that	
  the	
  PU	
  population	
  is	
  lower	
  than	
  it	
  has	
  been	
  in	
  the	
  past.	
  	
  
	
   	
   There	
  was	
  documentation	
  of	
  the	
  IDT’s	
  awareness	
  of	
  the	
  need	
  to	
  be	
  clear	
  and	
  consistent	
  with	
   youth	
  when	
  discussing	
  promotions	
  (or	
  retention	
  on	
  a	
  specific	
  level).	
  	
  For	
  example,	
  in	
  the	
  case	
  of	
   DS	
  reviewed	
  in	
  IDT	
  on	
  2/26/13,	
  “it	
  was	
  suggested	
  that	
  in	
  the	
  future,	
  the	
  team	
  needs	
  to	
  be	
  clear	
   with	
  youth	
  that	
  they	
  need	
  to	
  complete	
  all	
  ITP	
  goals	
  for	
  a	
  youth	
  on	
  Phase	
  2	
  to	
  qualify	
  for	
   transition,	
  and	
  if	
  behavioral	
  expectations	
  need	
  to	
  be	
  carried	
  over	
  from	
  Phase	
  1,	
  that	
  they	
  need	
   to	
  be	
  put	
  in	
  the	
  form	
  of	
  a	
  measurable	
  objective	
  on	
  their	
  ITP…Phase	
  2	
  youth	
  move	
  to	
  transition	
   based	
  strictly	
  on	
  their	
  ITP	
  goals.”	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  the	
  IDT	
  Substance,	
  a	
  Quality	
  Improvement	
  Plan	
   should	
  be	
  crafted	
  to	
  address	
  the	
  following	
  issues:	
  
1. Ensuring	
  that	
  IDT	
  documentation	
  reveals	
  a	
  structured	
  and	
  specific	
  discussion	
  of	
  each	
   youth’s	
  goals	
  and	
  objectives.	
  
2. Ensuring	
  that	
  IDT	
  documentation	
  includes	
  discussion	
  of	
  behavioral	
  expectations	
  and	
   progress	
  toward	
  meeting	
  expectations.	
  
3. If	
  goals	
  and	
  expectations	
  are	
  not	
  met,	
  identifying	
  the	
  areas	
  in	
  need	
  of	
  improvement	
  so	
   the	
  youth	
  know	
  what	
  is	
  required	
  for	
  promotion.	
  
	
   	
   (6)	
  Standard:	
  Length	
  of	
  Stay	
  [this	
  standard	
  is	
  monitored	
  by	
  Dr.	
  Dedel;	
  the	
  other	
  standards	
  in	
  the	
   Treatment	
  Planning	
  section	
  are	
  monitored	
  by	
  Dr.	
  Glindmeyer]	
   	
   A	
  Length	
  of	
  Stay	
  (LOS)	
  record	
  is	
  maintained	
  for	
  each	
  youth	
  to	
  document	
  the	
  date	
  placed	
  on	
   Phase	
  1,	
  promoted	
  to	
  Phase	
  2,	
  promoted	
  to	
  Transition,	
  and	
  transferred	
  to	
  the	
  general	
   population.	
  Youth	
  are	
  expected	
  to	
  promote	
  to	
  the	
  next	
  phase	
  within	
  30	
  days	
  (or	
  be	
  referred	
  for	
   review,	
  as	
  described	
  by	
  Standards	
  7-­‐8,	
  below).	
  Across	
  the	
  three	
  phases,	
  the	
  outer	
  limit	
  is	
  90	
   days.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• LOS	
  Records	
  which	
  are	
  currently	
  captured	
  on	
  the	
  Youth	
  Activity	
  Tracking	
  form	
   	
   Although	
  21	
  youth	
  spent	
  time	
  on	
  the	
  PU	
  during	
  the	
  period	
  of	
  review,	
  LOS	
  data	
  were	
  available	
   for	
  only	
  the	
  17	
  youth	
  housed	
  on	
  the	
  unit	
  as	
  of	
  February	
  25,	
  2013	
  (see	
  Technical	
  Assistance	
  note,	
   below).	
  Each	
  youth’s	
  Youth	
  Activity	
  Tracking	
  (YAT)	
  record	
  begins	
  with	
  a	
  synopsis	
  of	
  their	
   movement	
  across	
  the	
  phases.	
  [Note:	
  DYS	
  began	
  capturing	
  LOS	
  data	
  on	
  October	
  1,	
  2012.	
  As	
  a	
   result,	
  LOS	
  data	
  for	
  youth	
  who	
  entered	
  the	
  PU	
  prior	
  to	
  that	
  date	
  will	
  underestimate	
  their	
  actual	
   LOS.]	
  Data	
  on	
  overall	
  LOS	
  and	
  LOS	
  within	
  each	
  phase	
  were	
  calculated	
  for	
  each	
  youth,	
  and	
  then	
   aggregated	
  across	
  the	
  17	
  youth	
  in	
  the	
  sample.	
  	
   	
   	
   	
   	
  

	
  

26.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 27 of 34 PAGEID #: 2588

Technical	
  Assistance	
  Note:	
  
Given	
  that	
  DYS	
  does	
  not	
  capture	
  YAT	
  data	
  for	
  youth	
  on	
  in	
  Transition,	
  it	
  may	
  not	
  be	
  prudent	
  to	
  house	
  LOS	
   data	
  within	
  these	
  records.	
  End	
  dates	
  for	
  Transition	
  are	
  not	
  included	
  among	
  the	
  data	
  provided	
  to	
  the	
   Monitor	
  and	
  so	
  the	
  LOS	
  could	
  not	
  be	
  calculated	
  for	
  the	
  four	
  youth	
  who	
  returned	
  to	
  the	
  general	
  population	
   during	
  the	
  sampling	
  timeframe.	
  DYS	
  should	
  develop	
  the	
  ability	
  to	
  compile	
  stand-­‐alone	
  LOS	
  records	
  that	
   capture	
  the	
  beginning	
  and	
  end	
  date	
  for	
  all	
  phases.	
  
	
   	
   Analysis	
  and	
  Interpretation.	
  	
   The	
  youth	
  housed	
  on	
  the	
  PU	
  as	
  of	
  February	
  25,	
  2013	
  had	
  been	
  there	
  for	
  an	
  average	
  of	
  118	
  days	
   (about	
  4	
  months).	
  Because	
  outliers	
  (i.e.,	
  youth	
  who	
  have	
  a	
  very	
  short	
  LOS	
  or	
  a	
  very	
  long	
  LOS)	
   distort	
  a	
  mathematical	
  average,	
  the	
  median	
  was	
  also	
  calculated.	
  The	
  median	
  was	
  142	
  days	
   (about	
  5	
  months),	
  which	
  means	
  50%	
  of	
  the	
  youth	
  on	
  the	
  PU	
  had	
  been	
  there	
  for	
  less	
  than	
  142	
   days	
  and	
  50%	
  of	
  the	
  youth	
  on	
  the	
  PU	
  had	
  been	
  there	
  for	
  more	
  than	
  142	
  days.	
  Put	
  simply,	
  the	
   average	
  youth	
  currently	
  on	
  the	
  PU	
  has	
  been	
  there	
  for	
  about	
  4	
  or	
  5	
  months.	
  Note	
  that	
  these	
   youth	
  have	
  not	
  yet	
  completed	
  the	
  program—this	
  statistic	
  refers	
  only	
  to	
  the	
  length	
  of	
  time	
  they	
   have	
  currently	
  been	
  on	
  the	
  PU.	
  	
  	
   	
   The	
  LOS	
  on	
  Phases	
  1	
  (P1)	
  and	
  2	
  (P2)	
  were	
  also	
  calculated.	
  These	
  calculations	
  used	
  only	
  stays	
  that	
   had	
  been	
  completed—if	
  a	
  youth	
  is	
  currently	
  on	
  a	
  phase,	
  that	
  data	
  was	
  not	
  used	
  because	
  there	
  is	
   no	
  end	
  date.	
  Across	
  the	
  20	
  P1	
  stays,	
  the	
  average	
  LOS	
  was	
  35	
  days,	
  and	
  the	
  median	
  was	
  19.5	
   days.	
  For	
  the	
  17	
  stays	
  on	
  P2,	
  the	
  average	
  was	
  22	
  days	
  and	
  the	
  median	
  was	
  16	
  days.	
  The	
  median	
   for	
  both	
  P1	
  and	
  P2	
  was	
  significantly	
  shorter	
  than	
  the	
  average,	
  which	
  means	
  that	
  the	
  average	
   was	
  distorted	
  by	
  a	
  small	
  number	
  of	
  youth	
  who	
  spent	
  an	
  extraordinarily	
  long	
  time	
  on	
  the	
  phase	
   (e.g.	
  one	
  youth	
  spent	
  134	
  days	
  on	
  P1,	
  another	
  spent	
  64	
  days	
  on	
  P2).	
  	
   	
   The	
  number	
  of	
  times	
  the	
  30-­‐day	
  benchmark	
  for	
  external	
  review	
  was	
  exceeded	
  was	
  also	
   calculated.	
  Across	
  the	
  20	
  completed	
  stays	
  on	
  P1,	
  7	
  exceeded	
  the	
  30-­‐day	
  maximum	
  limit	
  (35%).	
   Across	
  the	
  17	
  completed	
  stays	
  on	
  P2,	
  3	
  exceeded	
  the	
  30-­‐day	
  maximum	
  limit	
  (18%).	
  In	
  other	
   words,	
  65%	
  of	
  the	
  P1	
  episodes	
  were	
  completed	
  within	
  30	
  days	
  and	
  82%	
  of	
  the	
  P2	
  episodes	
  were	
   completed	
  within	
  30	
  days.	
  	
   	
   Finally,	
  the	
  frequency	
  with	
  which	
  youth	
  recycled	
  through	
  the	
  phases	
  was	
  calculated.	
  Across	
  the	
   17	
  youth,	
  all	
  but	
  5	
  youth	
  had	
  repeated	
  the	
  P1-­‐P2-­‐T	
  cycle	
  (or	
  part	
  of	
  it)	
  at	
  least	
  once.	
  In	
  other	
   words,	
  70%	
  of	
  the	
  youth	
  currently	
  on	
  the	
  PU	
  have	
  not	
  progressed	
  cleanly	
  from	
  P1	
  to	
  P2	
  to	
   Transition,	
  but	
  rather	
  have	
  recycled	
  through	
  the	
  phases,	
  sometimes	
  more	
  than	
  once.	
  	
   	
   Thus,	
  while	
  many	
  of	
  the	
  individual	
  LOS	
  on	
  P1	
  (65%)	
  and	
  P2	
  (82%)	
  fall	
  within	
  the	
  30-­‐day	
   maximum	
  limit,	
  the	
  fact	
  that	
  youth	
  often	
  cycle	
  back	
  through	
  the	
  phases	
  accounts	
  for	
  the	
   significantly	
  longer	
  LOS	
  than	
  these	
  data	
  would	
  suggest.	
  In	
  fact,	
  all	
  but	
  three	
  of	
  the	
  17	
  youth	
   currently	
  housed	
  on	
  the	
  unit	
  	
  (82%)	
  have	
  already	
  exceeded	
  the	
  90-­‐day	
  maximum	
  limit,	
  and	
  they	
   have	
  yet	
  to	
  complete	
  the	
  PU	
  program.	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Length	
  of	
  Stay,	
  the	
  DYS	
  should	
  develop	
  a	
  Quality	
   Improvement	
  Plan	
  to	
  address	
  the	
  following	
  issues:	
  

	
  

27.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 28 of 34 PAGEID #: 2589

1. Develop	
  stand-­‐alone	
  LOS	
  records	
  that	
  provide	
  definitive	
  end	
  dates	
  for	
  all	
  phases,	
   including	
  the	
  Transition	
  phase.	
  Consider	
  divorcing	
  the	
  LOS	
  record	
  from	
  the	
  YAT	
  records.	
  	
  
2. Investigate	
  the	
  reasons	
  that	
  youth	
  are	
  being	
  returned	
  to	
  lower	
  phases	
  at	
  such	
  high	
   frequencies.	
  While	
  the	
  obvious	
  reason	
  is	
  that	
  they	
  have	
  displayed	
  behavior	
  that	
   warrants	
  demotion	
  (i.e.,	
  AOV,	
  using	
  STG	
  to	
  direct	
  the	
  harm	
  of	
  another	
  person,	
  major	
   contraband,	
  repeated	
  verbal	
  threats),	
  the	
  QIP	
  should	
  look	
  for	
  the	
  underlying	
  reason	
  that	
   these	
  youth	
  have	
  not	
  adopted	
  or	
  are	
  not	
  displaying	
  the	
  skills	
  needed	
  to	
  control	
  their	
   impulses,	
  manage	
  anger,	
  improve	
  decision-­‐making	
  etc.	
  	
  
	
   	
   (7)	
  Standard:	
  Central	
  Office	
  Review	
  Board	
  Composition	
  and	
  Timelines.	
  	
   A	
  Central	
  Office	
  Review	
  Board	
  (CORB)	
  conducts	
  a	
  review	
  of	
  any	
  youth	
  who	
  has	
  been	
  on	
  any	
   phase	
  of	
  the	
  PU	
  for	
  more	
  than	
  28	
  days.	
  At	
  a	
  minimum,	
  the	
  CORB	
  consists	
  of	
  an	
  Administrative	
   Psychiatrist,	
  the	
  Bureau	
  Chief	
  of	
  Facility	
  Programs,	
  and	
  Behavioral	
  Health	
  Administrator.	
  The	
   CORB	
  review	
  is	
  completed	
  by	
  the	
  42nd	
  /35th	
  day	
  on	
  the	
  phase.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• CORB	
  review	
  packets	
   	
   Analysis	
  and	
  Interpretation.	
  	
   Of	
  a	
  total	
  of	
  seven	
  CORB	
  review	
  documents,	
  six	
  included	
  signatures	
  of	
  a	
  minimum	
  of	
  three	
  staff	
   members,	
  including	
  the	
  Administrative	
  Psychiatrist.	
  	
  One	
  did	
  not	
  include	
  the	
  signature	
  of	
  the	
   Administrative	
  Psychiatrist.	
  	
  For	
  other	
  members	
  present,	
  it	
  was	
  difficult	
  to	
  determine	
  the	
   individual	
  and	
  their	
  role,	
  as	
  in	
  some	
  cases,	
  the	
  signatures	
  were	
  illegible,	
  and	
  there	
  was	
  no	
   notation	
  included.	
   	
   A	
  review	
  of	
  the	
  documents	
  revealed	
  inconsistencies	
  with	
  regard	
  to	
  the	
  required	
  timelines	
  for	
   review.	
  For	
  example,	
  BD	
  was	
  admitted	
  to	
  the	
  PU	
  11/9/12,	
  he	
  was	
  placed	
  on	
  his	
  current	
  phase	
   1/2/13,	
  and	
  the	
  date	
  of	
  the	
  review	
  was	
  2/15/13,	
  however	
  two	
  board	
  members	
  signatures	
  were	
   dated	
  2/19/13.	
  There	
  was	
  notation	
  of	
  a	
  previous	
  review	
  12/21/12,	
  but	
  documentation	
  of	
  this	
   meeting	
  was	
  not	
  reviewed	
  given	
  the	
  timeframe	
  for	
  this	
  status	
  report.	
  This	
  timeline	
  was	
   confusing:	
  this	
  youth	
  had	
  a	
  period	
  of	
  56	
  days	
  between	
  the	
  first	
  and	
  second	
  review;	
  however,	
   documentation	
  did	
  not	
  clarify	
  the	
  reason	
  for	
  this	
  delay.	
  Review	
  of	
  other	
  cases	
  revealed	
  similar	
   issues	
  with	
  regard	
  to	
  timelines.	
  	
  Documentation	
  should	
  provide	
  a	
  clear	
  history	
  of	
  the	
  youth’s	
  PU	
   stay	
  including	
  the	
  number	
  of	
  days	
  on	
  a	
  particular	
  level,	
  promotions	
  and	
  demotions.	
  Special	
   attention	
  should	
  be	
  given	
  to	
  youth	
  who	
  “recycle”	
  through	
  the	
  system.	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  the	
  CORB	
  Composition	
  and	
  Timelines,	
  a	
  Quality	
   Improvement	
  Plan	
  should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issues:	
   1. Ensuring	
  that	
  the	
  full	
  complement	
  of	
  CORB	
  staff	
  participate	
  in	
  the	
  review	
  and	
  sign	
  the	
  
document.	
  Clearly	
  indicate	
  the	
  individual’s	
  title.	
  	
   2. Ensuring	
  documentation	
  of	
  the	
  youth’s	
  history	
  on	
  the	
  PU	
  including	
  the	
  number	
  of	
  days	
  
on	
  a	
  particular	
  level,	
  promotions	
  and	
  demotions,	
  and	
  ensuring	
  that	
  the	
  CORB	
  review	
  is	
   performed	
  within	
  the	
  required	
  timelines.	
   	
   	
  

	
  

28.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 29 of 34 PAGEID #: 2590

	
   	
   (8)	
  Standard:	
  Central	
  Office	
  Review	
  Board	
  Substance.	
  	
   The	
  CORB	
  utilizes	
  a	
  comprehensive	
  summary	
  of	
  the	
  youth’s	
  clinical	
  formulation,	
  treatment,	
   progress	
  and	
  challenges	
  to	
  date.	
  The	
  summary	
  is	
  reviewed	
  by	
  each	
  CORB	
  team	
  member	
  prior	
  to	
   the	
  case	
  review.	
  The	
  CORB	
  issues	
  specific	
  recommendations	
  for	
  refocusing	
  the	
  youth’s	
   treatment	
  and	
  sets	
  specific	
  timelines	
  for	
  subsequent	
  reviews.	
  Recommendations	
  are	
   communicated	
  to	
  the	
  IDT,	
  which	
  notifies	
  the	
  youth	
  if	
  the	
  treatment	
  plan	
  has	
  been	
  modified.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• CORB	
  review	
  packets	
   • IDT	
  Minutes	
   	
   Analysis	
  and	
  Interpretation.	
  	
   A	
  review	
  of	
  seven	
  examples	
  of	
  CORB	
  documentation	
  revealed	
  that	
  in	
  most	
  cases,	
  all	
  of	
  the	
   required	
  documentation	
  was	
  not	
  reviewed.	
  For	
  example,	
  in	
  the	
  case	
  of	
  BD,	
  the	
  psychological	
   services	
  summary	
  and	
  the	
  IDT	
  monthly	
  progress	
  report	
  were	
  not	
  reviewed.	
  In	
  the	
  case	
  of	
  RB,	
   the	
  IDT	
  monthly	
  progress	
  report	
  was	
  not	
  reviewed.	
  In	
  the	
  case	
  of	
  DH,	
  the	
  psychological	
   summary	
  was	
  not	
  reviewed,	
  nor	
  were	
  behavioral	
  health	
  assessments.	
  In	
  the	
  case	
  of	
  KD,	
  the	
  IDT	
   monthly	
  progress	
  report	
  was	
  not	
  reviewed.	
  In	
  the	
  case	
  of	
  JC,	
  behavioral	
  health	
  assessments	
   were	
  not	
  reviewed.	
  In	
  only	
  two	
  cases	
  was	
  there	
  indication	
  that	
  all	
  data	
  were	
  reviewed.	
   	
   	
  
Technical	
  Assistance	
  Note:	
  
The	
  CORB	
  review	
  should	
  not	
  proceed	
  without	
  a	
  comprehensive	
  packet	
  of	
  information	
  for	
  the	
  youth.	
   Reviewing	
  a	
  youth’s	
  progress	
  with	
  incomplete	
  information	
  is	
  counterproductive.	
  Furthermore,	
  the	
  fact	
   that	
  treatment	
  has	
  been	
  ongoing	
  without	
  some	
  of	
  these	
  essential	
  treatment	
  documents	
  raises	
  serious	
   concern	
  about	
  the	
  quality	
  of	
  treatment	
  provided.	
  	
  
	
   	
   It	
  was	
  concerning	
  that	
  in	
  some	
  cases,	
  there	
  was	
  a	
  failure	
  on	
  the	
  part	
  of	
  the	
  IDT	
  to	
  follow	
  through	
   with	
  recommendations	
  in	
  a	
  timely	
  manner.	
  For	
  example,	
  in	
  the	
  case	
  of	
  KA,	
  documentation	
   indicated	
  that	
  during	
  a	
  previous	
  review	
  dated	
  11/19/12,	
  the	
  CORB	
  recommended	
  an	
  increase	
  in	
   the	
  frequency	
  of	
  sessions	
  to	
  focus	
  on	
  the	
  youth’s	
  anger	
  management	
  and	
  plans	
  for	
  additional	
   psychological	
  testing.	
  	
  With	
  regard	
  to	
  the	
  increase	
  in	
  frequency	
  of	
  sessions,	
  there	
  was	
   documentation	
  of	
  the	
  sessions	
  with	
  the	
  youth,	
  specifically,	
  four	
  individual	
  psychotherapy	
   sessions	
  in	
  January	
  2013,	
  but	
  overall,	
  this	
  was	
  a	
  decrease	
  over	
  the	
  number	
  of	
  individual	
  sessions	
   in	
  the	
  month	
  of	
  December	
  2012,	
  where	
  there	
  were	
  six	
  noted.	
   	
   It	
  was	
  noted	
  that	
  although	
  the	
  focus	
  of	
  the	
  sessions	
  was	
  “to	
  explore	
  the	
  youth	
  becoming	
  more	
   open	
  with	
  the	
  psychologist	
  and	
  to	
  exercise	
  better	
  methods	
  of	
  self	
  control”	
  and	
  the	
  CORB	
  had	
   recommended	
  anger	
  management,	
  it	
  was	
  not	
  documented	
  that	
  anger	
  management	
  techniques	
   were	
  being	
  addressed	
  with	
  this	
  youth.	
  Moreover,	
  psychological	
  testing	
  remained	
  pending,	
   almost	
  three	
  months	
  after	
  it	
  was	
  recommended.	
  	
  	
   	
  

	
  

29.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 30 of 34 PAGEID #: 2591

In	
  general,	
  documentation	
  did	
  not	
  indicate	
  specific	
  skills	
  that	
  the	
  youth	
  would	
  need	
  to	
  develop	
  

in	
  order	
  to	
  progress.	
  For	
  example,	
  in	
  the	
  case	
  of	
  KA,	
  the	
  CORB	
  noted,	
  “will	
  connect	
  his	
  thoughts	
  

regarding	
  being	
  aggressive	
  towards	
  others	
  by	
  completing	
  a	
  decisional	
  balance	
  worksheet.”	
  	
  	
  

Assaultive	
  behavior	
  has	
  been	
  a	
  significant	
  issue	
  for	
  this	
  youth.	
  The	
  CORB	
  document	
  does	
  not	
  

opine	
  regarding	
  the	
  reason	
  the	
  youth	
  has	
  not	
  been	
  able	
  to	
  acquire	
  the	
  necessary	
  skills	
  to	
  

address	
  his	
  impulsivity	
  (outside	
  of	
  the	
  recent	
  prescription	
  of	
  psychotropic	
  medication).	
  	
  

	
  

In	
  the	
  case	
  of	
  RB,	
  the	
  CORB	
  indicated	
  that	
  the	
  youth	
  had	
  routine	
  contact	
  with	
  social	
  work,	
  

psychology,	
  OT,	
  nursing,	
  and	
  psychiatry.	
  Information	
  regarding	
  the	
  content	
  of	
  these	
  contacts	
  

and	
  the	
  need	
  to	
  alter	
  treatment	
  modalities	
  in	
  order	
  for	
  this	
  youth	
  meet	
  his	
  treatment	
  goals	
  was	
  

not	
  included.	
  	
  In	
  addition,	
  recommendations	
  to	
  the	
  IDT	
  were	
  vague,	
  for	
  example,	
  “continue	
  to	
  

focus	
  on	
  managing	
  anger	
  and	
  teaching	
  positive	
  coping	
  skills.”	
  As	
  this	
  youth	
  apparently	
  cycled	
  

from	
  P1	
  to	
  P2	
  on	
  several	
  occasions,	
  more	
  focus	
  should	
  have	
  been	
  placed	
  on	
  what	
  skills	
  the	
  

youth	
  needed	
  to	
  progress	
  and	
  the	
  manner	
  in	
  which	
  these	
  skills	
  were	
  being	
  

taught/modeled/reinforced	
  with	
  the	
  youth.	
  	
  

	
  

	
  

Recommendations.	
  	
  

In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  the	
  CORB	
  Substance,	
  a	
  Quality	
  Improvement	
  Plan	
  

should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issues:	
  

1. Ensuring	
  that	
  all	
  information	
  is	
  available	
  to	
  the	
  CORB	
  so	
  that	
  the	
  members	
  can	
  perform	
  

a	
  quality	
  review	
  and	
  make	
  appropriate	
  recommendations.	
  

2. Ensuring	
  that	
  specific	
  recommendations	
  for	
  refocusing	
  the	
  youth’s	
  treatment	
  are	
  

provided.	
  Consider	
  soliciting	
  feedback	
  from	
  the	
  IDT	
  on	
  the	
  utility	
  of	
  the	
  CORB	
  

document.	
  

3. Ensuring	
  that	
  ITP	
  documentation	
  addresses	
  specific	
  recommendations	
  of	
  the	
  CORB.	
  

	
  

	
  

	
  

	
  

	
  

30.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 31 of 34 PAGEID #: 2592

[II.13]	
  	
  Phase	
  Demotions	
  [monitored	
  by	
  Dr.	
  Dedel]	
   Status:	
  Not	
  in	
  Substantial	
  Compliance	
  
	
   (1)	
  Standard:	
  Phase	
  Demotion.	
  	
   A	
  deliberative	
  process	
  is	
  utilized	
  to	
  demote	
  youth	
  to	
  a	
  lower	
  phase.	
  Demotions	
  are	
  imposed	
  only	
   for	
  the	
  following	
  reasons:	
  an	
  act	
  of	
  violence,	
  STG	
  activity	
  that	
  promotes	
  or	
  directs	
  an	
  individual	
   to	
  carry	
  out	
  an	
  act	
  of	
  violence,	
  possession	
  of	
  major	
  contraband,	
  repeated	
  verbal	
  threats	
  to	
   cause	
  serious	
  physical	
  harm	
  to	
  staff	
  or	
  other	
  youth.	
  All	
  demotions	
  are	
  approved	
  by	
  the	
  facility	
   Superintendent.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• AMS	
  reports	
   • IDT	
  Meeting	
  minutes	
   • IH	
  documentation,	
  including	
  appeals	
   • Interviews	
  with	
  youth,	
  DYS	
  and	
  Scioto	
  administrators	
   • Phase	
  Demotion	
  Summary	
  Form	
  (currently	
  under	
  development)	
   	
   DYS	
  submitted	
  a	
  list	
  of	
  four	
  youth	
  in	
  response	
  to	
  a	
  request	
  for	
  “a	
  list	
  of	
  youth	
  who	
  were	
   demoted	
  between	
  January	
  18	
  and	
  February	
  28,	
  2013.”	
  Three	
  of	
  these	
  demotions	
  were	
   overturned	
  just	
  before	
  this	
  report	
  was	
  issued.	
  Four	
  additional	
  demotions	
  (one	
  of	
  which	
  was	
   overturned)	
  were	
  identified	
  via	
  the	
  IDT	
  minutes.	
  	
   	
   IDT	
  minutes	
  and	
  other	
  documents	
  were	
  reviewed	
  to	
  ascertain	
  the	
  reason	
  for	
  demotion	
  and	
  how	
   the	
  decision	
  to	
  demote	
  was	
  deliberated.	
  IDT	
  Minutes	
  were	
  also	
  reviewed	
  to	
  ascertain	
  whether	
   the	
  teams	
  use	
  alternative	
  consequences	
  to	
  sanction	
  youth,	
  even	
  when	
  their	
  behavior	
  may	
  have	
   qualified	
  them	
  for	
  a	
  demotion.	
  	
   	
   	
  
Technical	
  Assistance	
  Note:	
  
Although	
  the	
  Monitor	
  was	
  provided	
  with	
  data	
  regarding	
  youth	
  who	
  were	
  demoted,	
  the	
  data	
  were	
  often	
   incomplete	
  and	
  required	
  additional	
  follow-­‐up	
  questions,	
  memos	
  and	
  conference	
  calls.	
  Moving	
  forward,	
   DYS	
  should	
  develop	
  a	
  form	
  for	
  the	
  Superintendent’s	
  signature	
  that	
  clearly	
  delineates	
  1)	
  whether	
  the	
   youth’s	
  behavior	
  fits	
  into	
  the	
  four	
  criteria	
  listed	
  in	
  the	
  standard;	
  2)	
  the	
  evidence	
  that	
  is	
  available	
  to	
  support	
   that	
  conclusion;	
  and	
  3)	
  why	
  phase	
  demotion	
  is	
  considered	
  the	
  best	
  response	
  (i.e.,	
  why	
  a	
  less	
  severe	
   sanction	
  is	
  considered	
  to	
  be	
  inadequate;	
  why	
  Phase	
  1	
  and	
  not	
  Phase	
  2;	
  what	
  skills	
  the	
  youth	
  needs	
  in	
  order	
   to	
  prevent	
  similar	
  behavior	
  from	
  re-­‐occurring	
  and	
  how	
  to	
  best	
  teach	
  him	
  those	
  skills).	
  Such	
  a	
  document	
   would	
  likely	
  reduce	
  the	
  need	
  for	
  DYS	
  to	
  respond	
  to	
  follow-­‐up	
  questions	
  from	
  Monitors,	
  public	
  defenders,	
   and	
  other	
  interested	
  parties.	
  At	
  the	
  time	
  this	
  report	
  was	
  drafted,	
  DYS	
  had	
  begun	
  to	
  create	
  this	
  form.	
  It	
   should	
  be	
  completed	
  for	
  all	
  youth	
  who	
  are	
  demoted,	
  whether	
  or	
  not	
  their	
  demotions	
  are	
  later	
  rescinded	
  or	
   overturned.	
  The	
  extent	
  to	
  which	
  this	
  form	
  provides	
  the	
  required	
  information	
  will	
  be	
  discussed	
  in	
   subsequent	
  Status	
  Reports.	
  	
  
	
   	
   Analysis	
  and	
  Interpretation.	
  	
   During	
  the	
  period	
  of	
  review,	
  eight	
  youth	
  were	
  slated	
  for	
  demotion	
  to	
  a	
  lower	
  phase.	
  The	
   demotion	
  was	
  overturned	
  for	
  one	
  of	
  these	
  youth	
  due	
  to	
  a	
  technical	
  violation	
  of	
  his	
  due	
  process	
  

	
  

31.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 32 of 34 PAGEID #: 2593

rights	
  (the	
  YBIR	
  was	
  not	
  served	
  within	
  24	
  hours;	
  he	
  was	
  accused	
  of	
  using	
  his	
  position	
  within	
  an	
  

STG	
  to	
  direct	
  other	
  members	
  to	
  harm	
  a	
  female	
  staff	
  if	
  she	
  refused	
  to	
  bring	
  in	
  contraband).	
  

Among	
  the	
  other	
  seven	
  youth,	
  one	
  assaulted	
  a	
  Unit	
  Manager	
  on	
  the	
  Transition	
  Unit;	
  one	
  

engaged	
  in	
  an	
  AOV	
  (details	
  were	
  not	
  provided);	
  one	
  had	
  a	
  promotion	
  rescinded	
  because	
  he	
  was	
  

found	
  in	
  possession	
  of	
  tobacco	
  during	
  the	
  unit	
  transfer;	
  one	
  sexually	
  assaulted	
  a	
  Youth	
  Specialist	
  

by	
  grabbing	
  her	
  crotch;	
  and	
  the	
  other	
  three	
  allegedly	
  engaged	
  in	
  verbal	
  threatening	
  and	
  

intimidation	
  of	
  medical	
  staff	
  during	
  an	
  emergency	
  response	
  (although	
  this	
  was	
  reported	
  by	
  

medical	
  staff	
  only	
  after	
  the	
  fact,	
  not	
  in	
  their	
  written	
  witness	
  statements).	
  After	
  several	
  weeks,	
  

the	
  phase	
  demotions	
  for	
  these	
  last	
  three	
  youth	
  were	
  overturned	
  via	
  the	
  IH	
  Appeal	
  process,	
  just	
  

prior	
  to	
  this	
  report	
  being	
  issued.	
  The	
  IH	
  ruling	
  stated	
  that	
  “the	
  youth’s	
  behavior	
  did	
  not	
  amount	
  

to	
  a	
  primary	
  rule	
  violation.”	
  	
  

	
  

While	
  on	
  the	
  surface,	
  some	
  of	
  these	
  youths’	
  behaviors	
  may	
  meet	
  the	
  requirements	
  of	
  the	
  Court	
  

Order,	
  documentation	
  of	
  the	
  deliberative	
  process	
  (whether	
  an	
  Intervention	
  Hearing,	
  IDT	
  

meeting	
  or	
  other	
  group	
  decision-­‐making	
  process)	
  was	
  not	
  provided	
  to	
  identify	
  the	
  relevant	
  facts	
  

and	
  whether	
  they	
  supported	
  the	
  youth’s	
  eligibility	
  for	
  demotion.	
  The	
  youth’s	
  perspective	
  is	
  also	
  

not	
  represented	
  anywhere.	
  Similarly,	
  no	
  information	
  was	
  provided	
  to	
  indicate	
  why	
  the	
  group	
  

believed	
  demotion	
  to	
  Phase	
  1	
  to	
  be	
  the	
  most	
  appropriate	
  response.	
  In	
  one	
  case,	
  the	
  IDT	
  had	
  

recommended	
  a	
  demotion	
  from	
  Transition	
  to	
  P2,	
  but	
  the	
  Superintendent	
  overrode	
  the	
  IDT	
  

decision	
  and	
  demoted	
  the	
  youth	
  to	
  P1.	
  The	
  reason	
  for	
  this	
  override	
  was	
  not	
  provided.	
  The	
  Court	
  

Order	
  requires	
  active	
  deliberation	
  to	
  ensure	
  that	
  phase	
  demotions	
  are	
  used	
  only	
  in	
  response	
  to	
  

egregious	
  behavior	
  and	
  to	
  ensure	
  that	
  other,	
  less	
  severe	
  sanctions	
  have	
  been	
  considered.	
  	
  

	
  

IDT	
  minutes	
  from	
  January	
  18	
  through	
  February	
  28,	
  2013	
  were	
  reviewed	
  to	
  identify	
  instances	
  in	
  

which	
  alternative	
  sanctions	
  were	
  imposed,	
  even	
  when	
  a	
  youth’s	
  behavior	
  may	
  have	
  met	
  the	
  

demotion	
  criteria.	
  During	
  the	
  review	
  period,	
  three	
  instances	
  were	
  noted	
  where	
  youth	
  engaged	
  

in	
  behavior	
  that	
  appeared	
  to	
  qualify	
  them	
  for	
  demotion,	
  but	
  a	
  less	
  punitive	
  sanction	
  was	
  

imposed.	
  These	
  included:	
  two	
  Transition	
  youth	
  who	
  engaged	
  in	
  a	
  fight	
  in	
  school	
  (both	
  were	
  put	
  

on	
  extended	
  Behavior	
  Contracts	
  on	
  the	
  Transition	
  Unit)	
  and	
  a	
  youth	
  who	
  was	
  put	
  on	
  a	
  Behavior	
  

Contract	
  for	
  serious	
  threatening	
  behavior	
  (although	
  he	
  was	
  later	
  demoted	
  for	
  an	
  AOV).	
  

	
  

Moving	
  forward,	
  DYS	
  needs	
  to	
  provide	
  additional	
  information	
  regarding	
  the	
  nature	
  of	
  the	
  

youth’s	
  misconduct	
  and	
  evidence	
  of	
  a	
  deliberative	
  process	
  to	
  determine	
  the	
  most	
  appropriate	
  

sanction.	
  Though	
  not	
  required	
  by	
  the	
  Court	
  Order,	
  it	
  would	
  be	
  helpful	
  for	
  the	
  DYS	
  to	
  assess	
  the	
  

extent	
  to	
  which	
  youth	
  who	
  engage	
  in	
  serious	
  misconduct	
  are	
  sanctioned	
  without	
  the	
  use	
  of	
  

phase	
  demotion.	
  	
  

	
  

Recommendations.	
  	
  

In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Phase	
  Demotions,	
  a	
  Quality	
  Improvement	
  Plan	
  

should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issues:	
  

1. Ensuring	
  that	
  documentation	
  supports	
  the	
  requirement	
  that	
  a	
  deliberative	
  process	
  was	
  

used	
  to	
  determine	
  whether	
  the	
  facts	
  of	
  the	
  incident	
  support	
  the	
  youth’s	
  eligibility	
  for	
  

demotion	
  and	
  why	
  phase	
  demotion	
  was	
  selected	
  from	
  among	
  the	
  other	
  available	
  

sanctions.	
  	
  

	
  

	
  

	
  

	
  

32.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 33 of 34 PAGEID #: 2594

[II.C.3]	
  Quality	
  Assurance	
  [monitored	
  by	
  both	
  Dr.	
  Dedel	
  and	
  Dr.	
  Glindmeyer;	
  this	
  standard	
   applies	
  only	
  to	
  the	
  S.H.	
  Agreement]	
   Status:	
  Not	
  in	
  Substantial	
  Compliance	
  
	
   (1)	
  Standard:	
  Quality	
  Assurance	
  Process.	
  	
   The	
  Quality	
  Assurance	
  (QA)	
  program	
  establishes	
  specific	
  standards	
  for	
  the	
  operation	
  of	
  the	
  unit	
   and	
  a	
  specific	
  methodology	
  for	
  measuring	
  the	
  level	
  of	
  performance	
  on	
  each	
  standard.	
  When	
   deficits	
  are	
  identified,	
  a	
  Quality	
  Improvement	
  (QI)	
  plan	
  is	
  created	
  to	
  identify	
  the	
  underlying	
   causes	
  of	
  the	
  problem	
  and	
  to	
  construct	
  specific	
  strategies	
  designed	
  to	
  remediate	
  the	
  deficit.	
  The	
   QI	
  plan’s	
  effectiveness	
  is	
  measure	
  on	
  a	
  monthly	
  basis.	
  Findings	
  from	
  the	
  QA/QI	
  process	
  are	
   articulated	
  in	
  a	
  written	
  document	
  at	
  least	
  twice	
  per	
  year.	
  	
   	
   Methodology.	
  	
   The	
  following	
  information	
  should	
  be	
  used	
  to	
  determine	
  compliance	
  with	
  the	
  standard:	
  
• Written	
  reports	
  that	
  include	
  QA	
  standards,	
  methodologies	
  and	
  results	
   • Written	
  QI	
  plans	
  and	
  monthly	
  progress	
  reports	
   	
   Analysis	
  and	
  Interpretation.	
  	
   While	
  the	
  DYS	
  has	
  amassed	
  a	
  large	
  volume	
  of	
  data	
  relevant	
  to	
  the	
  daily	
  operation	
  of	
  the	
  unit	
   and	
  the	
  substance	
  of	
  the	
  treatment	
  delivered	
  on	
  the	
  PU,	
  it	
  has	
  yet	
  to	
  organize	
  these	
  data	
  in	
  any	
   meaningful	
  way.	
  To	
  date,	
  the	
  Monitors	
  have	
  borne	
  the	
  responsibility	
  of	
  analyzing	
  and	
   interpreting	
  the	
  data,	
  and	
  making	
  recommendations	
  for	
  program	
  improvements.	
  While	
  this	
   ensures	
  that	
  the	
  Monitors	
  are	
  fully	
  informed	
  about	
  the	
  PU’s	
  operation,	
  it	
  comes	
  at	
  significant	
   expense	
  to	
  the	
  State.	
  Perhaps	
  more	
  importantly,	
  it	
  does	
  not	
  carry	
  an	
  exit	
  strategy.	
  DYS	
  needs	
  to	
   develop	
  a	
  rigorous	
  Quality	
  Assurance/Quality	
  Improvement	
  process	
  that	
  is	
  capable	
  of	
   identifying,	
  analyzing	
  and	
  solving	
  problems	
  that	
  will	
  inevitably	
  occur	
  in	
  the	
  operation	
  of	
  a	
   complicated	
  program	
  with	
  very	
  challenging	
  youth.	
  Only	
  when	
  this	
  occurs	
  will	
  external	
   monitoring	
  by	
  the	
  Monitors	
  become	
  unnecessary.	
  	
   	
   Recommendations.	
  	
   In	
  order	
  to	
  meet	
  the	
  standard	
  associated	
  with	
  Quality	
  Assurance,	
  a	
  Quality	
  Improvement	
  Plan	
   should	
  be	
  developed	
  to	
  address	
  the	
  following	
  issues:	
   1. Developing	
  a	
  set	
  of	
  standards	
  or	
  performance	
  objectives	
  that	
  describe	
  what	
  each	
  
component	
  of	
  the	
  program	
  aspires	
  to	
  do.	
  To	
  assist	
  in	
  this	
  effort,	
  the	
  Monitors	
  drafted	
   the	
  standards	
  used	
  in	
  this	
  report	
  to	
  reflect	
  the	
  various	
  subsections	
  of	
  the	
  Court	
  Order.	
   These	
  should	
  be	
  considered,	
  modified	
  if	
  necessary,	
  and	
  supplemented	
  with	
  standards	
   that	
  address	
  important	
  issues	
  that	
  may	
  not	
  be	
  adequately	
  addressed	
  in	
  the	
  Court	
  Order	
   (e.g.,	
  SBBMS).	
  	
   2. Developing	
  an	
  audit	
  methodology	
  for	
  each	
  standard.	
  Identify	
  existing	
  data	
  that	
  speak	
  to	
   the	
  performance	
  on	
  each	
  standard.	
  DYS	
  appears	
  to	
  possess	
  most	
  of	
  the	
  data	
  it	
  needs	
  to	
   assess	
  the	
  unit’s	
  performance	
  (exceptions	
  are	
  noted	
  throughout	
  this	
  status	
  report).	
   Develop	
  a	
  schedule	
  for	
  audits	
  (e.g.,	
  quarterly,	
  semi-­‐annually)	
  and	
  a	
  sampling	
  strategy	
   (i.e.,	
  what	
  proportion	
  of	
  the	
  cases/days/occurrences/incidents	
  will	
  be	
  reviewed?	
  For	
   things	
  that	
  don’t	
  happen	
  often	
  (e.g.,	
  phase	
  demotions),	
  all	
  cases	
  should	
  be	
  reviewed.	
   For	
  things	
  that	
  occur	
  regularly	
  (e.g.,	
  daily	
  activities),	
  a	
  random	
  sample	
  should	
  be	
   identified).	
  	
  

	
  

33.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 115 Filed: 06/18/13 Page: 34 of 34 PAGEID #: 2595
3. Analyzing	
  and	
  interpreting	
  the	
  data	
  that	
  is	
  produced	
  by	
  the	
  audits.	
  Identify	
  patterns	
  that	
   speak	
  to	
  the	
  challenges	
  in	
  meeting	
  a	
  particular	
  standard.	
  Memorialize	
  these	
  efforts	
  in	
   writing,	
  in	
  the	
  form	
  of	
  a	
  written	
  Quality	
  Assurance	
  Report	
  that	
  includes	
  the	
  standard,	
   the	
  methodology	
  used	
  to	
  audit	
  performance,	
  and	
  the	
  analysis	
  and	
  interpretation	
  of	
  the	
   data	
  that	
  was	
  collected.	
  	
  
4. Developing	
  a	
  Quality	
  Improvement	
  Plan	
  for	
  each	
  area	
  in	
  which	
  the	
  standard	
  is	
  not	
  met.	
   An	
  interdisciplinary	
  team	
  of	
  staff	
  who	
  can	
  dissect	
  the	
  problem	
  to	
  determine	
  its	
   underlying	
  causes	
  should	
  develop	
  this	
  plan.	
  Once	
  known,	
  specific	
  strategies	
  to	
  address	
   the	
  underlying	
  causes	
  need	
  to	
  be	
  developed.	
  The	
  strategies	
  should	
  be	
  fleshed	
  out	
  into	
   specific	
  tasks,	
  responsible	
  parties,	
  and	
  timelines.	
  	
  
5. Conducting	
  targeted	
  reviews	
  for	
  each	
  QIP	
  to	
  determine	
  whether	
  the	
  strategies	
  are	
   working	
  to	
  improve	
  performance	
  toward	
  a	
  specific	
  standard.	
  These	
  should	
  be	
  in	
   addition	
  to	
  regularly	
  scheduled,	
  comprehensive	
  audits.	
  Document	
  the	
  results	
  of	
  the	
   targeted	
  reviews	
  on	
  the	
  QIP	
  and	
  make	
  adjustments	
  to	
  the	
  strategies	
  if	
  the	
  desired	
   results	
  are	
  not	
  being	
  obtained.	
  	
  
	
   	
   	
   	
  

	
  

34.	
  

 U.S. Department of Justice Civil Rights Division

Assistant Attorney General 950 Pennsylvania Avenue, NW - RFK Washington, DC 20530
May 9, 2007
The Honorable Ted Strickland Governor State of Ohio 30th Floor 77 South High Street Columbus, OH 43215-6117
Re: Investigation of the Scioto Juvenile Correctional Facility, Delaware, Ohio
Dear Governor Strickland:
I am writing to report the findings of the Civil Rights Division’s investigation of conditions at the Scioto Juvenile Correctional Facility (“Scioto”), located in Delaware, Ohio. On March 16, 2005, we notified you of our intent to conduct an investigation of Scioto, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 (“CRIPA”), and the pattern or practice provision of the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141”). We informed you that our investigation of Scioto would focus on protecting residents from harm, medical care, mental health care, grievances, and provision of special education.1 As we noted, both CRIPA and Section 14141 give the Department of Justice authority to seek a remedy for a pattern or practice of conduct that violates the constitutional or federal statutory rights of children in juvenile justice institutions.
We note that the State has worked cooperatively and, under the leadership of Director of Ohio Youth Services Thomas Stickrath, has unequivocally indicated its clear desire to improve both facilities since being placed on notice of possible constitutional deficiencies. Prior to the Department of Justice investigations of Scioto and Marion, the State hired a team of expert consultants, led by Mr. Fred Cohen, to evaluate the

1

Shortly thereafter, on April 15, 2005, we notified you

of our intent to conduct an investigation of the Marion Juvenile

Correctional Facility in Marion, Ohio (“Marion”) regarding

similar issues. Our findings regarding Marion are addressed in a

separate letter.

- 2 -
constitutional conditions at the girls’ section of the Scioto facility.2 Mr. Cohen issued an Interim Report on August 16, 2004 and an Action Plan on September 28, 2004. In each of these documents, Mr. Cohen found constitutional deficiencies in the areas of protection from harm, medical care, mental health care, grievances, and provision of special education. The State agreed to adopt and stipulate to Mr. Cohen’s findings, for the purpose of our investigation, and to apply those findings to the entire Scioto facility and the Marion facility.
Given the State’s stipulation that the conditions identified in our March 16, 2005 notice letter are constitutionally deficient, we agreed to conduct limited facility tours.3 On June 29-July 1, 2005, we conducted an on-site inspection of Scioto, accompanied by expert consultants in mental health care and medical care. During our inspections, we interviewed mental health providers, medical providers, other staff, youth residents, and facility administrators. Before, during, and after our visit, we reviewed an extensive number of documents, including policies and procedures, mental health records, youth detention records, unit logs, and orientation materials. Consistent with our commitment to provide technical assistance and conduct a transparent investigation, we conducted an exit conference with facility staff and Ohio Department of Youth Services officials upon the conclusion of the tour, during which our expert consultants conveyed their initial impressions and concerns.

2

Although the main Scioto facility houses female youth,

a separate section of the facility acts as state-wide intake for

all male youth.

3

This investigation is anomalous because Mr. Cohen's

2004 factual findings regarding the conditions of confinement at

Scioto revealed significant deficiencies in each of the areas

that were the subject of our investigation and because the State

has stipulated to all of Mr. Cohen's generally well-supported

findings. Together, these factors created the unusual

circumstance in which it was not necessary for the Department to

conduct a facility tour regarding each of the specific subject

areas of our investigation. However, we did tour Scioto

regarding areas in which we required additional factual

information to make a thorough and complete finding or to frame

appropriate corrective measures. For example, as Mr. Cohen's

2004 report is admittedly not thorough regarding its assessment

of medical and mental health care, we reviewed these subjects on-

site with expert consultants before issuing our findings.

- 3 -
We commend the Scioto staff for their helpful, courteous, and professional conduct throughout the course of this investigation. We also wish to express our appreciation for the cooperation of Ohio Department of Youth Services officials and staff.
Consistent with our statutory obligation under CRIPA, we set forth below the findings of our investigation, the facts supporting them, and the minimum remedial steps that are necessary to address the deficiencies we have identified. As described below, we conclude that youth confined at Scioto suffer harm or the risk of harm from constitutional deficiencies as to: protecting residents from harm; certain discrete elements of medical care; mental health care; grievances; and special education services. Notwithstanding the foregoing, we are pleased to report that our review indicates that Scioto’s general medical programs are, for the most part, good. In particular we find that Scioto’s medical quality improvement program, environmental conditions, and management of special dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
I. BACKGROUND
The State of Ohio, through its Department of Youth Services, owns and operates Scioto, located approximately 15 miles north of Columbus, Ohio. Scioto is the reception center for all juvenile males entering Department of Youth Services’ juvenile justice facilities and serves as Ohio’s sole facility for girls adjudicated, of felony-level crimes, in juvenile courts. Reportedly, many of these girls were in the State’s foster care system before being confined. The facility has a rated capacity of 192 and currently houses approximately 185 males and 120 females, aged 12 to 21.
II. FINDINGS
As a general matter, States must provide confined juveniles with reasonably safe conditions of confinement. Youngberg v. Romeo, 457 U.S. 307 (1982); Nelson v. Heyne, 491 F.2d 352 (7th Cir. 1974); see also Miletic v. Natalucci-Persichetti, No. C-3-89-299, 1992 WL 1258522, *2, *4 (S.D. Ohio Feb. 6, 1992) (holding, in a case against the Ohio Department of Youth Services, that “a juvenile who is involuntarily committed to a correctional as opposed to mental health facility has a right to treatment under the Fourteenth Amendment similar to that which was recognized in Youngberg . . . .”).

- 4 -
A. PROTECTION FROM HARM
Juveniles in state custody have a constitutional right to reasonable safety. See Youngberg, 457 U.S. at 315-16 (“personal security constitutes a historic liberty interest protected substantively by the Due Process Clause”) (internal quotation omitted).
Our review of conditions of confinement at Scioto reveals significant constitutional deficiencies regarding use of physical force, grievance investigation and processing, and use of seclusion. For purposes of our investigation, the State has stipulated to Mr. Cohen’s August 2004 findings, agreeing to the applicability to Scioto’s intake program of Mr. Cohen’s findings for each of the above-mentioned subject areas. In addition, our experts concur with Mr. Cohen's findings and suggested remedies.
1. Use of Physical Force
Juveniles at Scioto have a right to be free from unnecessary restraint and the use of excessive force. Youngberg, 457 U.S. at 315-16. Since 2003, 14 Scioto staff have been indicted on charges relating to physical and sexual abuse of youth at Scioto. In response to this crisis, the State hired Mr. Cohen and a team of experts in 2004 to review protection from harm issues in Scioto’s Girls’ Program. For purposes of our investigation, the State has stipulated to Mr. Cohen’s August 2004 findings, agreeing to the applicability of Mr. Cohen’s findings to Scioto’s intake section.
In his report, Mr. Cohen concludes that “there has been (and remains) a culture of violence among the uniformed staff, that verbal and physical abuse are common, [and] sexual misconduct by staff occurs . . . .” Mr. Cohen indicates that he and his team of experts “have the most serious reservations as to whether [the State’s] investigators are presently able to produce the quality of investigative work required to identify those use of force incidents that merit corrective actions for staff who violate the [Department of Youth Services’] use of force policy.” Finally, Mr. Cohen concludes that “there can be no debate on the constitutional obligation under the Fourteenth Amendment to provide a safe environment. Scioto has not met its obligations to provide such an environment . . . .”
In reviewing Scioto’s use of force incidents, Mr. Cohen reported that “verbal and physical abuse are common” at Scioto. Since 2003, five defendants have been convicted of various charges such as sexual battery, attempted sexual battery,

- 5 -
assault, falsification, and dereliction of duty. In addition, as of July 2006, one defendant awaits trial on charges of assault, child endangerment, falsification, dereliction of duty, and tampering with evidence.4
One officer was convicted of attempted sexual battery as a result of allegations that he ordered a female youth to undress while he watched and engaged in inappropriate sexual touching. Another officer pled guilty to misdemeanor assault for slapping and punching a youth, and then kicking the youth after she fell to the floor. A female officer pled guilty to dereliction of duty as a result of allegations that she ordered a male youth to expose himself and engage in inappropriate sexual touching. Another officer tendered an Alford plea5 to misdemeanor assault and falsification charges for striking a youth during an altercation, puncturing her eardrum. Finally, an officer was convicted of sexual battery and attempted sexual battery for forcing one youth to perform sex acts on him and for inappropriately sexually touching another female youth.
In his report, Mr. Cohen stated that he and his team “found countless examples of situations where no force at all should have been used and others where the force used was excessive.” Further, according to Mr. Cohen, verbal abuse is rampant and often serves, perhaps intentionally, to precipitate physical confrontations with juveniles.
Finally, we note that Scioto currently allows use of a physical restraint technique directing staff to place an arm across a youth’s chest below the neck and push on the cheek with the back of the hand. As our medical expert observed during the tour, use of any technique calling for an arm to be placed across the neck during a physical altercation or other incident exposes the youth to a significant risk of harm. This practice is especially problematic in light of allegations that we have received that youth have been choked by staff during altercations.
Based on these assessments and the State’s stipulation as to the applicability of Mr. Cohen’s findings, we agreed that it was

4

One defendant was acquitted and seven other defendants

were indicted, but the charges were later dismissed.

5

In an Alford plea a defendant does not admit the act,

but admits that sufficient evidence exists with which the

prosecution could likely convince a judge or jury to find the

defendant guilty. North Carolina v. Alford, 400 U.S. 25, 38

(1970).

- 6 -
not necessary to perform additional fact-finding regarding use of force at Scioto and we conclude that youth at Scioto are subject to use of excessive physical force and physical abuse.
2. Grievances (Investigations and Processing)
Just as prisoners and juvenile detainees have a constitutional right of access to the courts, they have a right to a grievance system that does not carry risk of punishment as a price for using it. See Thaddeus-X v. Blatter, 175 F.3d 378, 394 (6th Cir. 1999); see also Bounds v. Smith, 430 U.S. 817, 822 n.17 (1977) (“Our main concern here is protecting the ability of an inmate to prepare a petition or complaint.”) (internal quotation marks and citations omitted).
We adopt the following findings by the State’s experts. As part of Mr. Cohen’s assessment, the State’s experts conducted a review of Scioto’s incident investigation and grievance process,6 finding that several factors contribute to its inadequacy. In particular, Mr. Cohen’s report finds that Scioto investigations are “pedestrian, time consuming, and full of errors or oversights.” The State’s experts also determined that, with the exception of a few cases, investigators rarely attempt to determine if officers followed existing protocol.
In his report, Mr. Cohen found that investigations contain few facts other than repetition of the complaint and denials by involved individuals. The investigations reveal a trend of repetitive questioning of involved youth, as though questioning was to continue until the youth provided the “correct” answer. Incidents involving physical aggression contained no evaluation of events preceding the incident, nor questions regarding use or attempted use of lesser physical interventions.
Although Scioto grievances contain serious allegations, such as verbal harassment and abuse, use of physical force, loss of programs and privileges, sexual harassment, and medical issues, such investigations rarely result in corrective action for staff or youth or any attempt to recognize or identify patterns of behavior requiring intervention.
Finally, given the facility’s population, the number of grievances filed appears low and, when examined in conjunction with the above, supports the conclusion that Scioto youth view the grievance process as ineffective. We note that some investigations completed by the Department of Youth Services'

6

Mr. Cohen’s team reviewed the 984 incidents filed from

January 1, 2003 through August 18, 2004.

- 7 -
Bureau of Chief Inspector contained more facts than those completed by Scioto personnel. However, these investigations varied widely in quality and accuracy and were not completed in a timely manner necessary to sustain a proper incident review and grievance system and implement warranted corrective actions.
The dysfunctional grievance system at Scioto contributes to the State’s failure to ensure a reasonably safe environment. An adequately functioning grievance system ensures that youth have an avenue for bringing serious allegations of abuse and other complaints to the attention of the administration. It also provides an important tool in evaluating the culture at the facility, and alerting the administration about dangers and other problems in the facility’s operations.
3. Seclusion
The State's experts reviewed over 200 seclusion reports regarding Scioto girls from May 2004 to June 2004. In his report, Mr. Cohen concluded that staff use seclusion as a “knee-jerk, prolonged first response” and often hold youth in seclusion for hours even though they do not pose an imminent threat. For example, many Scioto youth are held in seclusion for lengthy periods for refusing breakfast, cursing, and talking in class. In one instance, Scioto held a youth in seclusion for 14 hours for being “argumentative” and using a racial epitaph. Additionally, the State's expert found that Scioto's routine use of seclusion as immediate punishment is often accompanied by use of force. We adopt Mr. Cohen's findings.
B. MEDICAL AND MENTAL HEALTH CARE
Juveniles in state custody have a due process right to adequate mental health care. The Supreme Court in Youngberg broadly labeled health care as “medical care,” but recognized that this would include care provided by various disciplines, including persons with appropriate training in psychology. See id., 457 U.S. at 322-323, n.30. The Sixth Circuit also has recognized that medical care encompasses mental health care. See Horn v. Madison County Fiscal Court, 22 F.3d 653, 660 (6th Cir. 1994) (“A detainee’s psychological needs may constitute serious medical needs, especially when they result in suicidal tendencies.”).
1. Medical
We are pleased to report that our review indicates that Scioto’s general medical programs are, for the most part, good. In particular we find that Scioto’s medical quality improvement program, environmental conditions, and management of special

- 8 -
dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
a. Identification of Health Problems and Initial Health Assessments
Based on our review, Scioto’s health records are inadequate insofar as they do not contain problem lists identifying all active health problems. Problem lists are necessary tools in monitoring youth health status and providing adequate health care. Scioto’s initial health assessments are similarly inadequate, due to the absence of problem lists. These lists and plans of care should be reviewed and approved by a physician after reviewing all relevant assessment information.
b. Evaluation and Treatment of Sick Residents
Scioto’s sick call procedures make youth access to medical care dependent upon line staff and force youth to submit requests through line staff in a non-confidential manner. It is a generally accepted professional standard of care that youth should be able to submit sick call requests confidentially and independent of the line staff.
c. Dental Care
Scioto’s dental program fails to meet the dental needs of its youth. We found numerous instances of youth with significant, untreated, dental health needs.
We find that Scioto dentists' practice of not providing crowns and rarely replacing missing or damaged front teeth conflicts with Department of Youth Services policies and generally accepted professional standards of care requiring that such services are to be provided, as needed, upon the dentist's recommendation. We also note that Scioto’s dental program for the girls’ section of the facility fails to provide timely restorative care for youth with cavities. As a general matter, Scioto must develop a system for tracking the dental needs of its youth and providing services in a timely manner. The treating dentist should determine the necessity of dental care on a patient-by-patient basis.
We also found that documentation of oral surgery procedures and recommendations of post-operative management of youth was missing in the files we reviewed.

- 9 -
Finally, Scioto has no dental assistant or dental hygienist. Consequently, its dentists are forced to choose between foregoing basic dental care that such practitioners provide, or delaying or ignoring more significant dental needs.
d. Special Services for Chronically Ill and Disabled Youth
We find Scioto’s care provided to patients with asthma substantially departs from generally accepted professional standards. The facility must acquire peak flow meters to properly assess patients when healthy and ill, to determine the effectiveness of treatment. Scioto nurses also do not clinically assess youth when administering rescue inhalers, and youth who use such inhalers frequently are not referred to the physician for more intense treatment. Scioto’s current treatment approach results in preventable asthma hospitalizations due to inadequate treatment of active asthma.
e. Disease Prevention and Health Promotion
Fifteen percent of Scioto’s youth had incomplete immunizations, and youth are not fully immunized for their age. This is a substantial departure from generally accepted professional standards.
In addition, Scioto’s blanket discontinuation of all oral contraception for youth entering the facility and Scioto’s failure to offer emergency contraception conflict with applicable standards of care, exposing female youth to harm.
f. Medical Quality Improvement Program
While we find that Scioto’s current medical quality improvement program is adequate, we suggest that Scioto begin to place more emphasis on health outcomes and use the topics identified in this section to establish such a system.
g. Environmental Conditions
As a matter of technical assistance, Scioto youth should be provided opportunities to practice appropriate hygiene in order to reduce transmission of communicable diseases.
h. Special Dietary Needs for Youth
Scioto adequately manages food allergies and special medical diets.

- 10 -
i. Abuse Reported By Medical Professionals
While nurses at Scioto assess youth after a use of physical restraint, they only report suspected abuse to the facility administration, rather than to State child abuse authorities. This reporting scheme is a substantial departure from generally accepted standards of practice and, in light of the State’s stipulation regarding use of excessive force, is especially problematic.
2. Mental Health Care
The Constitution requires that youth in juvenile justice institutions receive adequate mental health care. Youngberg, 457 U.S. at 323, n.30; Nelson, 491 F.2d at 360; see also K.H. v. Morgan, 914 F.2d 846, 851 (7th Cir. 1990); A.M. v. Luzerne County Juvenile Detention Center, 372 F.3d 572, 585 n.3 (3d Cir. 2004). We find that mental health care at Scioto’s intake facility and girls’ facility is constitutionally inadequate.
As a threshold matter, we note the assessment of the State’s expert that the girls’ mental health unit “is little more than a residence for girls with mental disorders” and that “[m]ental health care is so deficient” that it was not feasible to comment on the various elements of such care, indicating that “[a] more refined analysis must await another day – a day when constitutionally required, minimally acceptable care is instituted.” Given this assessment, we conducted an independent review of mental health care at the facility and found significant deficiencies in almost every aspect of mental health care encompassed within screening and assessment services and the provision of treatment.
a. Scioto Intake
1. Screening and Assessment Services
Upon arrival at Scioto, all male juveniles receive an assessment in the reception area. The assessment includes a review of the youth’s offense history, his behavior in the reception facility, his scores on various assessments, and a social worker’s recommendations for specific programming. We found that assessments were implemented in a consistent manner and often contained an impressive range of information collected from sources outside the facility (i.e., court records, previous mental health records). Nevertheless, we conclude that there are a number of constitutional deficiencies with respect to the assessment of youth for mental illness.

- 11 -
(i) Reception Assessments: We found that many reception assessments were incomplete, failing to address numerous factors important to an accurate and complete assessment of a youth’s mental condition. In addition, the assessments are primarily deficit oriented, focusing little on strengths or family functioning. As a result, they fail to identify important bases for treatment interventions. We also note that assessment records are poorly integrated and that there is no reliable system of communication among various contributors to the assessment. Furthermore, the assessments do not include structured consideration of data to determine placement or appropriate programming. In this regard, placement and planning recommendations are often made with no justification. As a result of these weaknesses, placement decisions and specific treatment plans for youth are arbitrary in important respects and are otherwise excessively generic.
(ii) Mental Health Assessments: In addition to the reception assessment, youth entering Scioto receive a mental health assessment. A social worker administers the Massachusetts Youth Screening Instrument (“MAYSI”) checklist to each youth and the MAYSI is scored by a psychologist. Youth answering positive to questions regarding suicidal thinking or behavior on the MAYSI, or on medical screening questions, meet with a psychologist or psychologist assistant for a mental health assessment. Youth receiving psychiatric medication upon arrival at Scioto and youth whose psychological assessment reveals serious acute psychopathology are referred to a psychiatrist for psychopharmacological assessment and treatment.
Like the reception assessment, the mental health assessment follows a consistent, reliable format. Nevertheless, the process suffers from poor data gathering and recording. In this regard, we note that assessments often fail to address important considerations such as cognition problems, impact of trauma, school history, past treatment experiences, past treatment responses, and dysphoric (i.e., anxious or despairing) moods. Moreover, we found that data collection regarding positive adaptions, peer relationships, developmental information, and family history and functioning is completely inadequate. As a result, the assessment lacks information that is fundamental to making appropriate recommendations.
In addition, Scioto’s mental health assessments do not employ validated structured instruments for diagnosis or functional assessment. Without such instruments, assessments tend to be arbitrary as to identifying clinical disorders and appropriate treatment. Additionally, the assessments rely heavily on a structured interview of the youth, which provides questionable information and fails to make use of information

- 12 -
regarding current behavior adaption or school functioning. Lastly, Scioto’s use of checklists to be read and completed by youth is problematic, because these checklists are used without establishing that the youth can read and comprehend them.
Scioto’s psychological assessments are also inadequate. Most assessments we reviewed rarely include specific treatment recommendations or consider multiple concurrent conditions, despite the prevalence of such conditions among the facility’s population. The assessments fail to contain differential diagnoses (considering alternative diagnostic hypotheses) and do not link the diagnoses to likely functional problems, such as socialization problems and aggressiveness. As a result, Scioto’s assessments do not provide information and opinions adequate for coherent treatment planning.
We found similar problems with Scioto’s psychiatric assessments, in that the assessments appeared perfunctory, with little follow-up. Also, we noted that a number of obvious candidates for psychiatric care were not referred for psychiatric assessment.
Finally, we found that Scioto’s overall mental health staffing is inadequate, allowing for only superficial assessment without any routine follow-up. We also could not find any explicit criteria used for determining who should receive ongoing mental health treatment while in reception.
As a consequence of these deficiencies, youths’ mental health needs are often untreated or inappropriately treated, resulting, among other things, in no treatment, counterproductive treatment, exposure to inappropriate or unnecessary medications posing serious physical and other side effects, longer periods of confinement, and needlessly greater potential for recidivism.
b. Scioto Girls’ Program
Girls come to Scioto only after failing to complete a number of other, less restrictive, state-sponsored juvenile programs. Given the Scioto girls’ prior programming failures, and that our consultants have estimated the prevalence of mental disorders among female juvenile offenders to be as high as 87 percent, a female youth at Scioto without significant mental health problems would be in the minority. Nevertheless, it was evident from our expert’s review of randomly selected files that Scioto’s current process for identifying youth with mental illness is inadequate, and that girls’ significant mental disorders often go unidentified and untreated. For example, in three randomly selected cases our consultant reviewed, each youth showed clear signs of mental health issues. Two of the youth were identified

- 13 -
as having mental health issues within nine months (one was only identified after undergoing multiple risk assessments in response to several instances of self-injurious behavior and reports of hallucinations instructing her to hang herself).7 The third youth showed clear signs of mental distress but did not complain of specific symptoms, and she received no mental health followup. Scioto’s failure to reliably identify girls in its custody with significant mental health concerns is a substantial departure from generally accepted standards of practice that exposes girls to risk of significant harm, in the form of serious, untreated mental disorders.
1. Provision of Treatment
Scioto’s attempt to establish and implement individual treatment plans for its residents is clearly in its beginning stages. We noted that few records of girls with identified mental disorders included a treatment plan. Records containing such plans provided no indication that the treatment services provided to the girl were linked to a specific plan. In addition, we found no regularly scheduled treatment meetings involving clinicians and residents with clearly identified treatment needs. In fact, apparently because of current inadequate staffing, most Scioto youth with mental health disorders do not receive regular, scheduled treatment sessions, allowing these disorders to go neglected. As a result, the quality and effectiveness of the treatment provided is deficient, resulting in an ongoing risk of self harm and disruptive behavior, and lack of progress in rehabilitation, which, in turn, can lead to an extended period of confinement.
While we note that Scioto provides psychopharmacological treatment in a more consistent manner, our record review indicates underutilization of applicable medications for attention problems and impulse control disorders. In addition, we noted a lack of collaboration between psychiatry and psychology regarding psychopharmacological treatment. Such lack of collaboration causes the psychiatrist to be less informed regarding youth behavior, thus reducing the effectiveness of psychiatric treatment regarding attention and impulse control problems.

7

Although these two youth were eventually identified as

having mental health problems, the significant delay was a factor

causing each youth to spend additional time in the program, to

suffer behavioral and emotional instability over a longer period

of time resulting in impairment in their growth and

rehabilitation, to remain at increased risk for self harm, and to

create considerable disruption in the program.

- 14 -
Indicative of many of these problems, Scioto’s Special Needs Unit for girls with heightened mental health or behavioral needs provides no improvement in the intensity, specificity, or consistency of mental health care in comparison to other units, other than having a better youth-to-social worker ratio and a dialectical behavioral therapy skills group. In this regard, we note that the State’s expert determined that Scioto’s Special Needs Unit “is little more than a residence for girls with mental disorders.”
We do note that Scioto’s risk assessment procedures have resulted in preventing self-harm among its population. However, as implemented, these procedures contribute to Scioto’s current crisis atmosphere (teaching youth that the way to get attention is to engage in, or to threaten, self-harm) and divert psychologists from providing consistent treatment to other youth.
In summary, Scioto does not provide supports and services adequate to meet the needs of its population, in contravention of generally accepted professional standards, exposing girls to harm or a significant risk of harm in the form of significant, untreated mental health disorders, and leading to heightened emotional distress, longer periods of confinement, and greater potential for recidivism.
C. SPECIAL EDUCATION SERVICES
Students with disabilities have federal statutory rights to special education services under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006).8 As part of the review conducted by the State’s expert, Mr. Cohen, the Ohio Department of Youth Services retained Ms. Ava Crow to review special education services at Scioto.9 Ms. Crow conducted an exhaustive study, including two three-day site visits, numerous interviews, classroom observation, and document review. In her August 31, 2004 report, Ms. Crow concluded that Scioto’s special education program suffers from systemic failure and violates residents’ rights under the IDEA by failing to provide adequate special

8

We note that the IDEA was reauthorized and amended by

the Individuals with Disabilities Education Improvement Act of

2004, Pub. L. No. 108-446, 118 Stat. 2647 (2004), effective

July 1, 2005.

9

The IDEA provisions cited herein are substantively the

same as those in force at the time of Ava Crow’s review. At the

time of Ms. Crow’s tour, slightly less than half of Scioto

residents had been identified as qualifying for special education

services under the IDEA.

- 15 -
education.10 As indicated earlier, the State has stipulated, for the purpose of resolving this investigation, to the following deficiencies identified in Ms. Crow’s report. In addition, our expert consultant concurs with Ms. Crow's findings and recommendations.
1. Child Find
The IDEA requires that states implement systems to identify all students who are eligible for special education services and provide such services to all those identified as having disabilities. 20 U.S.C. § 1412. The State’s expert determined that Scioto does not meet “Child Find” requirements of the IDEA. In this regard, school guidance counselors acknowledge that Scioto does not comply with “Child Find.”
2. Parental Involvement
Parental involvement is an essential element of the IDEA, which requires parental consent for decisions about eligibility, evaluation, and placement. 20 U.S.C. § 1414.
However, based on the State expert’s review of a sample of youth files, Scioto often fails to contact parents, sometimes sending parental notices and consent forms to social services agencies. In one instance, a consent form was signed by a “former social worker.” In the same manner, two additional files revealed students whose placements were restricted in scope without parental consent or notification, in clear violation of the IDEA.
3. Provision of Transition Services
The IDEA requires schools to actively attempt to involve outside agencies in transition plan meetings to help students progress from school to adult life. The State’s expert found that Scioto’s transition plans are inadequate: students do not have written transition plans, and there is no indication of any outside agency involvement or any evidence of sustained efforts to involve outside agencies.
4. Implementation and Monitoring of Individualized Education Plans
The IDEA requires that each student with a disability have an IEP (“Individual Education Plan”), and describes the IEP components required to ensure that each student receives adequate special education services. The State’s expert determined that
10 Scioto's school program is called the William K. Willis School.

- 16 -
IEPs developed at Scioto do not ensure that students with disabilities receive required special education services.
For example, all Scioto IEPs reviewed by Mr. Cohen’s team contain an identical, barely exploratory list of services. Document review also revealed a pattern in which Scioto adopts IEPs from local education authorities but fails to implement them. In addition, while the IDEA requires consideration of positive behavioral interventions for students whose behaviors interfere with their learning or that of other students, document review revealed almost no individualized interventions for any Scioto student. Given the makeup of the Scioto population, lack of such clearly relevant interventions is telling. Finally, classroom observations indicate that there is substantially no difference in Scioto regular education classrooms versus special education classrooms and no indication that special education students were expected to perform less work or offered extended time to complete projects.
Separately, the IDEA requires a multidisciplinary team reevaluation of the information included in a youth’s multifactored evaluation, which is the basis for the IEP, every three years. We find that Scioto failed to update its multifactored evaluations for more than one-third of its special education population within the required three-year period.
The IDEA also requires that all IEPs are to be reviewed periodically and at least annually. The State’s expert found that Scioto failed to complete the required reviews and that 60 percent of Scioto’s IEPs had expired.
Lastly, the State’s expert found that Scioto has no appropriate system to monitor specific IEP goals. Document review indicated that some teachers at Scioto use weekly reporting forms to attempt compliance with IDEA monitoring requirements. However, such forms appear inadequate to document specific IDEA goals and fail to inform parents of students’ progress as required by the IDEA. Even if Scioto’s current forms were adequate, they are not sent to parents for review as required.
In light of these findings by the State’s expert and of the State’s stipulation, we find that the State fails to comply with the IDEA in the areas set forth above.
III. REMEDIAL MEASURES
In order to rectify the identified deficiencies and protect the constitutional and statutory rights of the youth confined at Scioto, the facility should implement, at a minimum, the following measures:

- 17 -
A. Protection from Harm
1. Ensure that youth are provided with safe living conditions and are protected from abuse, use of excessive force, undue seclusion, and undue restraint.
2. Develop appropriate policies and procedures that govern the use of force, requiring reliable documentation and limiting use of force to situations where a youth is physically violent and poses an immediate danger to himself and/or others or the youth is physically resisting institutional rules and the institution has attempted a hierarchy of nonphysical alternatives.
3. Prohibit verbal and physical punishment, and use of force practices that are incompatible with minimum actions necessary to prevent harm or obtain compliance with reasonable orders, including practices such as shoving, pushing, kicking, striking, or using inappropriate holds on youth.
4. Monitor and supervise staff, maintaining appropriate staff ratios and holding staff accountable for the use of excessive force or abuse.
5. Develop policies and procedures to ensure that seclusion and restraint are only used in appropriate, documented, instances by trained staff.
6. Provide youth with an effective and reliable process to raise grievances, without exposing them to retribution from staff, ensuring that all grievances are reviewed and addressed in a timely matter that provides youth with notification of the final resolution.
7. Employ sufficiently trained and independent investigators to ensure that all incidents of violence, use of force, or serious injury are adequately investigated, and documented, and that appropriate personnel actions are taken in response to substantiated findings.
B. Medical and Mental Health Care
1. Ensure that youth receive routine, preventative, and emergency medical and dental care consistent with current, generally accepted professional standards, including identification, assessment, diagnosis, and treatment of health problems.
2. Develop policies and procedures to ensure that youth are provided with: complete and accurate health records, access to confidential health care, a complete initial health

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assessment, appropriate access to health services, appropriate medications and care to manage chronic illness, access to specialty consults, proper immunizations, and female reproductive health care managed according to generally accepted medical standards.
3. Maintain appropriate dental staffing and require that generally accepted professional standards are followed to ensure that: youths’ restorative needs are met in a timely manner, youth are not denied appropriate pain medication, needed prosthetic dental services are provided, and health records contain adequate documentation of outside dental consults.
4. Provide mental health and rehabilitative treatment consistent with generally accepted professional standards and ensure that there are an adequate number of qualified mental health professionals to provide mental health and rehabilitative services in a timely manner to all youth who require such services.
5. Develop and implement policies, procedures, and practices to ensure that, consistent with generally accepted professional standards of care, youth are: (1) comprehensively screened by appropriately trained personnel for mental disorders, including substance abuse, depression, and serious mental illness within 24 hours of admission; (2) systematically evaluated in response to problem indicators to address potential manifestations of mental or behavioral disorders in youth who have not been previously identified as requiring treatment; and (3) provided appropriate mental health care, substance abuse care, and treatment services.
6. Ensure that any youth determined at screening to be at immediate risk is immediately referred to a qualified mental health treatment professional for: assessment, treatment, and other appropriate actions, including facility transfer when necessary.
7. Implement policies, procedures, and practices according to generally accepted professional standards to ensure that: mental health assessments, including health, risks, strengths, and needs are performed within two weeks of a youth’s arrival at Scioto; youth identified in screening receive timely, comprehensive, and accurate assessments by qualified mental health professionals; and assessments are designed to incorporate data necessary to identify youth with mental disorders and contribute to a plan for managing the youth’s risk.
8. Develop and implement policies and procedures consistent with generally accepted professional standards of care to:

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(1) ensure that treatment determinations are made by an interdisciplinary team through integrated treatment planning; (2) create and implement treatment plans that are current and individualized; (3) maintain readily accessible records containing meaningful, accurate and coherent assessments of the individual’s treatment plan progress, goals, and objectives.
9. Develop and implement a system to ensure that mental health issues are adequately considered in making housing decisions and that mentally ill youth receive appropriate housing.
10. Prior to administration of prescribed psychoactive medication, Scioto must: (1) ensure that youth and their parents (or guardians, if parents have lost custody due to abuse or neglect) are provided with goals, risks, benefits, and potential side effects of the medication, along with the potential consequences of not treating with the medication; (2) follow state law in order to administer such medication without consent.
11. Develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, consistent with generally accepted professional standards of care.
12. Provide training to all staff who interact directly with youth regarding mental health information, developmental disabilities, recognition of signs and symptoms of trauma, teenage development, strength-based treatment strategies, suicide risks, and (for staff working with female youth) female development.
13. Develop and implement policies and procedures that comply with generally accepted professional standards for the management of suicidal youth.
14. Create transition plans for youth leaving the facility that are consistent with generally accepted practice standards.
15. Develop and implement polices and procedures to maintain oversight of mental health services and ensure that such services are provided consistent with generally accepted professional standards of care.
C. Special Education
1. Provide prompt and adequate screening, and ongoing rescreening and referral, of youth for special education needs and ensure that all students requiring special education services receive services in compliance with the IDEA within a reasonable time following intake.

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2. Ensure that all eligible youth have current, accurate IEPs that are developed and implemented consistent with IDEA requirements.
3. Create and implement a system to routinely develop, implement, and monitor youths' IEPs, with involvement of parents and guardians, as required by the IDEA.
4. Develop and implement a staffing plan that allows for a sufficient number of certified special education teachers and staff to provide all youth with the opportunity to attend school full-time and to obtain adequate educational services while providing teachers with sufficient time to plan lessons, grade assignments, and participate in special education meetings.
5. Develop a quality assurance program to ensure the quality of IEPs, compliance with the IDEA, and monitoring of teaching staff on compliance issues.
6. Ensure that special education staff receive in-service training and maintain current educator licenses appropriate to the courses they teach.
* * *
As stated above, we appreciate the cooperation we have received from Ohio Department of Youth Services officials and facility staff throughout this investigation. We hope to be able to continue working with the State in an amicable and cooperative fashion to resolve the deficiencies found at Scioto. Provided that our cooperative relationship continues, we will forward our expert consultant reports under separate cover. Although this report is our consultants’ work – and does not necessarily reflect the official conclusions of the Department of Justice – the observations, analyses, and recommendations contained in the reports provide further elaboration of the issues discussed in this letter and offer practical assistance in addressing them.
In the unexpected event that we are unable to reach a resolution regarding our concerns, the Attorney General is empowered to institute a lawsuit pursuant to CRIPA to correct the deficiencies of the kind identified in this letter 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working cooperatively with you. We have every confidence that we will be able to do so in this case. The lawyers assigned to this matter will be contacting your attorneys to discuss this matter in further detail. If you have any questions regarding this letter,

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please contact Shanetta Y. Cutlar, Chief of the Civil Rights Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/s/ Wan J. Kim Wan J. Kim Assistant Attorney General
cc: The Honorable Marc Dann Ohio Attorney General Department of the Attorney General
Thomas J. Stickrath Director Ohio Department of Youth Services
Amy Ast Superintendent Scioto Juvenile Correctional Facility
The Honorable Gregory G. Lockhart United States Attorney Southern District of Ohio

 Case: 2:08-cv-00475-ALM-MRA Doc #: 161 Filed: 12/09/15 Page: 1 of 5 PAGEID #: 3271

IN THE UNITED STATES DISTRICT COURT
 FOR THE SOUTHERN DISTRICT OF OHIO 

EASTERN DIVISION 


S.H., a minor child and all others similarly situated, et al., Plaintiffs, v.
HARVEY J. REED, Defendant.
UNITED STATES OF AMERICA, Plaintiff,
v. THE STATE OF OHIO, et al.,
Defendants.

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Case No. 2:04-CV-1206

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JUDGE ALGENON L. MARBLEY

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Magistrate Judge Kemp

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:

Case No. 2:08-CV-00475

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JUDGE ALGENON L. MARBLEY

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ORDER This matter is before the Court on the Parties’ Joint Motion to Terminate the Consent Decree. (Doc. 410.) The Court-appointed monitors, Will Harrell and Kelly Dedel (“the Monitors”), have submitted final reports on the Department of Youth Services’ (“DYS”) facilities for boys and DYS-contracted facilities for girls, finding DYS in substantial compliance with the remaining quality assurance measures under monitoring. All parties now agree that this case should be terminated. The Monitors have also submitted a final report entitled “The Ohio Model: A Report on the Transformation of the Ohio Department of Youth Services, 2007-2015,” which details the remarkable improvement in conditions of confinement in DYS juvenile
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facilities over the last seven years. They hope to use this report in part to “memorialize the agency’s major policy and practice decisions for the benefit of others in the field.” (Doc. 411.) The Court will briefly summarize the history of the litigation and highlight some of the remarkable improvements at DYS facilities since this case began.
I. HISTORY OF THIS LITIGATION On December 20, 2004, Plaintiffs in S.H. v. Reed, No. 2:04-cv-1206, filed a complaint challenging conditions at DYS juvenile correctional facilities. The Court later entered an order certifying the S.H. case as a class action. (Doc. 67.) The S.H. plaintiffs challenged the application by staff of unnecessary force; arbitrary and excessive use of isolation and seclusion, arbitrary and excessive discipline; inadequate mental health, medical, and dental care; inadequate educational services; inadequate structured programming; broadly inadequate training of staff; an unsafe living environment; and a dysfunctional grievance system. (Doc. 76 at 6.) On May 16, 2008, the United States filed a similar complaint in the companion case United States v. Ohio, No. 2:08-cv-475. On May 18, 2007, the Court approved a case management plan under which the parties agreed to a joint fact finding team, and that team’s report was filed on December 31, 2007. On May 21, 2008, the parties agreed to a Stipulation of Injunctive Relief which incorporated that Report and established that the conditions of confinement for youth in DYS facilities violated the constitutional and statutory rights of those youth. (Doc. 108.) The Stipulation provided for a period of oversight by a Court-appointed monitor for five years. (Id. at 87.) On February 18, 2014, the S.H. Plaintiffs filed a motion for specific performance and alleged a failure to provide adequate treatment to youth who are or have been on the mental health caseload, in particular faulting the excessive periods of seclusion to which these youth
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were subjected. The United States also filed a supplemental complaint renewing its motion for a temporary restraining order. Through settlement negotiations, the parties reached an agreement on the resolution of Plaintiffs’ claims, which the Court approved. (Doc. 401.)
This settlement established a Grid that detailed the actions Defendants committed to undertake to improve mental health services and reduce seclusion of youth on the mental health caseload. (Doc. 401-1.) The remaining areas to be monitored included quality assurance and peer review for mental health and psychiatry, case formulation, fidelity of treatment provided to treatment model, treatment planning and treatment terms, behavior contracts, suicide prevention, and discipline for youth on the mental health caseload through the intervention hearing process. (Doc. 400 at 3.) Starting on July 31, 2014, DYS agreed to provide to the Monitors quarterly reports on its seclusion practices. The parties agreed that Defendants’ compliance with the Grid would be monitored by Mr. Harrell and Dr. Dedel until DYS maintained substantial compliance with all provisions and performance measures for six months. Although the order indicated that the Grid applies only to youth at facilities directly managed by DYS, it also specified that “youth at other facilities shall receive mental health services consistent with those described [in the Grid] but appropriately tailored for such non-DYS managed facilities.” (Doc. 401-1 at 9.) These other facilities include the contracted facilities which house girls.
II. CURRENT CONDITIONS AT DYS FACILITIES In June 2015, the Monitors filed a Compliance Report for the DYS boys’ facilities (“Boys Report”). (Doc. 407.) In November 2015, the Monitors also filed a review of the DYS contracted programs for girls (“Girls Report”). The Boys Report, and the memos that followed it in August 2015, concluded that DYS is now in substantial compliance with all of the provisions and performance measures incorporated in the Grid. The Girls Report concluded that the
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practices at the contracted girls’ facilities were functionally equivalent to services prescribed by
the Grid for boys at DYS facilities, including significant progress in quality of treatment and
further restrictions on the use of seclusion. The improvements documented by the Ohio Model
Report include the following:
 The video recording and review of all applications of the use of force, and intensive staff training and oversight for compliance with the use-of-force policy
 A meaningful grievance system and easy access to attorneys to address concerns related to fact, duration, and conditions of confinement
 Abolition of the practice of disciplinary seclusion and dramatic reductions in pre-hearing seclusion
 Fully staffed and well-managed educational programming and the elimination of school suspensions and school-day reductions
 Improved systems for health assessments, physical exams, maintenance of medical records, and more thorough documentation, as well as chronic care and medication administration that is now consistent with national guidelines
 New Program Administrator positions at each facility; expanded access to work programs (for high school graduates); Youth Councils that offer youth a meaningful role in decision-making; positive behavior incentive programs for youth; cognitive behavioral therapy program to target youth at risk of reoffending or gang involvement
 Video conferencing technology and bus transportation to increase family visitation and a policy of seven-day-a-week visitation
 Vastly improved mental health treatment including group treatment sessions; quality oversight of staff; easy accessibility of treatment professionals; and the replacement of punitive Special Management Plans that relied excessively on seclusion with Behavior Contracts, tailored plans with incentives and consequences
 Development of standardized criteria to deny a youth’s release rather than making such decisions without any criteria, as well as a meaningful process to appeal a release denial
 Reducing the incarcerated population from over 2000 youth several years ago to less than 500 today through the initiative RECLAIM, whereby DYS partnered with juvenile courts throughout the state to increase their capacity effectively to supervise and serve youth at the county level, which has led to less school interruption, more family engagement, and better behavioral outcomes for youth.
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III. CONCLUSION 


The Court concludes that the Defendants have complied with the terms and modifications

of the Stipulation for Injunctive Relief in Case No. 2:04-cv-1206 and the consent decree in Case

No. 2:08-cv-475. The Joint Motion to Terminate the Consent Decree is GRANTED. The

consent decree is hereby TERMINATED.

IT IS SO ORDERED.

DATED: December 9, 2015

s/ Algenon L. Marbley ALGENON L. MARBLEY UNITED STATES DISTRICT JUDGE

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 Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 1 of 39 PAGEID #: 3200
The Ohio Model 

A Report on the Transformational Reform of the 
 Ohio Department of Youth Services, 2007 ‐ 2015 

Will Harrell, J.D., LL.M. & Kelly Dedel, Ph.D, Federal Court Monitors and Terry Schuster, J.D., Special Assistant to the Monitors 12/7/2015

Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 2 of 39 PAGEID #: 3201
The Ohio Model
A Report on the Transformational Reform of the
 Ohio Department of Youth Services, 2007 ‐ 2015

By Will Harrell, Kelly Dedel, and Terry Schuster
 Video footage recorded and produced by Roger Cohen

Introduction
Ohio is well known among juvenile justice practitioners for its RECLAIM and Targeted RECLAIM initiatives, which have reduced the population of youth placed in the state’s juvenile facilities through financial incentives and significant advanced planning with the counties. Less well known is the story of how, with a reduced population, Ohio has transformed the conditions and culture inside the state’s juvenile facilities. This report tells that story. Comparing conditions today with those found unconstitutional in 2008, this report describes how the focused efforts of the state juvenile corrections agency, spurred by litigation, have resulted in what is in many ways a model system – and what we are calling The Ohio Model.
All juvenile correctional agencies have areas in which they can improve, and Ohio’s Department of Youth Services (DYS) is no exception. Higher concentrations of youth with serious behavioral challenges and mental health disorders remain in DYS facilities after downsizing, as they have in other states. This group of youth often includes those who have exhausted county resources and placement options, and most if not all juvenile corrections agencies struggle to provide them with appropriate programming and behavioral interventions. We have reported over the last several years on areas of progress and ongoing deficiencies. We continue to find that DYS’s leaders are vested in examining and improving their practices. The purpose of this report is not to make the case that DYS is a perfect agency. Rather, it is to applaud their significant improvement in conditions of confinement, and memorialize the agency’s major policy and practice decisions for the benefit of others in the field. All findings in this report reflect the Department’s practices at the time monitoring of the relevant subject matter was terminated.
Authors
Will Harrell, J.D., LL.M. was appointed Lead Monitor for the remedy stage of the S.H. v. Reed litigation by Federal District Judge Algenon Marbley. Mr. Harrell is the Founder and Director of the Justice Collaborative, a consulting firm on criminal and juvenile justice reform initiatives. He also serves as Ombudsman for the New Orleans juvenile detention center, and Southern Regional Policy Director for the ACLU doing criminal justice reform work throughout the South. As Director of the Justice Collaborative, he provides technical assistance to jurisdictions around the country to strengthen justice reform initiatives, improve conditions of confinement, and expand alternatives to confinement. He has previously served as Public Policy Director for the Southern Poverty Law Center; the Independent Ombudsman for the Texas Youth Commission; the Executive Director of the ACLU of Texas; and the Executive Director of the National Police Accountability
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Project. As Legal Director for the Centro Para La Accion Legal En Derechos Humanos, he developed and managed an international human rights law clinic in Guatemala; investigated Guatemalan jails and prisons for the United Nations Human Rights Verification Mission; and brought litigation against the Ecuadoran prison system before the Inter‐American Commission on Human Rights. Mr. Harrell began his legal career in criminal justice reform as a Thurgood Marshall Law Fellow at the ACLU National Prison Project in 1991 under the wings of the late Al Bronstein.
Kelly Dedel, Ph.D was appointed Lead Monitor in the U.S. v. Ohio litigation. She is an independent consultant and Director of One in 37 Research, Inc. For the past 17 years, she has worked as a monitor and investigator in juvenile conditions of confinement litigation, with subject matter expertise in protection from harm, use of seclusion, special education, and quality assurance. While litigation is rarely a pleasant experience for those involved, Dr. Dedel embraces the opportunity to help defendants accomplish the reforms in a way that best suits their philosophy, resources, and staff and youth cultures. Her monitoring strategy comes with a commitment to technical assistance and to helping systems develop an internal capacity to identify and respond to their problems so that oversight becomes unnecessary.
Terry Schuster, J.D., was Special Assistant to Monitor Will Harrell from 2011 to early 2014. He is a senior associate at The Pew Charitable Trusts’ Public Safety Performance Project, where he has provided technical assistance on sentencing and corrections reform efforts in Utah, Arkansas, and Alaska. He has previously worked as an attorney for Juvenile Law Center; and as a law clerk for the Special Master in the juvenile conditions of confinement case Farrell v. Cate, the Ombudsman for the Texas Youth Commission, the Travis County Juvenile Court, and the Texas RioGrande Legal Aid Public Defender’s Office.
The collaborative monitoring model
Our monitoring model has created a framework to shift from an adversarial process to a more collaborative remedy process. We have aimed to be efficient and cost‐effective, empowering to the parties and community stakeholders, and focused on collaborative resolutions to the problems identified through the litigation. We have streamlined site visits and information requests, and created shared electronic filing systems for the parties and monitoring team. We developed a fact‐finding and reporting protocol to ensure timely comprehensive monitoring, to avoid conflicting findings regarding compliance with the stipulated agreements, and to triage concerns and recommendations for change. We worked with the Department and interested parties to outline a plan to achieve compliance and reach closure of the case in a short period of time. We moderated disputes and made every effort to resolve them informally and collaboratively. We also provided quick and thorough national research to guide the parties toward resolution.
We believe in transparency, and have gone out of our way to keep the parties and the Court informed of the monitoring team’s work. Understanding the overlapping, but sometimes differing perspectives of private counsel and the Department of Justice, we have been cautious to approach our work with those perspectives in mind, and to regularly seek input and consensus.
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This monitoring model is a coaching model that has included a heavy emphasis on quality assurance and continuous quality improvement. The subject matter experts on the team have worked with DYS to develop and continually revise internal monitoring tools, to ensure that as DYS has achieved compliance with the stipulated agreements, they are also prepared to take over the work of monitoring conditions of confinement themselves – monitoring that will continue long after the remedial phase of the cases have ended. DYS has taken ownership of the reforms, and we applaud their outstanding accomplishments.
A note on the multi‐media content of this report
Throughout this report we have included video segments of youth describing changes they have witnessed and benefitted from during the term of their confinement in DYS facilities. Video footage was recorded and produced by Roger Cohen as one among many measures of DYS’s progress over time. Youth who were interviewed were asked general, non‐leading questions about subject matters under Court supervision (use of force, education, mental health care, etc.), and were not promised any rewards for saying favorable things about the agency. All of those portrayed in this report have given written legal permission for their words and images to be shared publicly. To view the video segments, click on the hyperlinks in the body of the report or in the Table of Contents.
Acknowledgements
The class of youth placed in DYS secure facilities has benefitted from extraordinarily skilled counsel since 2004. The S.H. case was filed by Kim Tandy, Director of the Children’s Law Center. Along with Al Gerhardstein of Gerhardstein & Branch, LPA, Kim led the legal team through the negotiations in 2004 and through implementation of the decree during the reform years until 2015. They were ably assisted at various times by Jennifer Kinsley, Marc Schindler, Maria Ramiu, Mark Soler, Joseph Scantlebury, David Singleton, Janet Moore, Jessica Gingold, and Angelina Jackson. They have represented the S.H. class in federal court hearings and negotiations, and secured among other things a Stipulated Consent Order unique in scope and specificity. Over the same period of time, DYS has received outstanding representation from several Assistant Attorneys General, including Judy Goldstein, Tom Anger, Mindy Worly, Rich Cholar, Eric Holloway, Joseph Mancini, Philip King, Sharon Jennings, Frank Strigari, Janet Hill Arbogast, Brian Laliberte, Lisa Eschbacher, and Zachary Swisher; as well as in‐house counsel Kelly Castle, Anthony Pierson, Marla Burton, and Dustin Calhoun; and private counsel Geoffrey Moul, James Burnes and Laura Anthony.
Presiding over the S.H. v. Reed (previously S.H. v. Stickrath) case, the Honorable Algenon Marbley has overseen both the litigation and eight years of efforts to remedy the unconstitutional conditions found in 2008. His attention to this case, his guidance to the monitoring team, and his compassion for system‐ involved youth have helped mold and strengthen the reforms. Judge Marbley has inspired movement and momentum at times when reform efforts were stalled. He has served the parties as a mediator, a problem‐ solver, and an agent for change. His judicial clerks, Natalie McGlaughlin, Soren Aandahl, Sara Belton, Elizabeth Gerber, Lauren Hilsheimer, Rob Szykowny, and Adam Rusnak have also contributed immensely to the S.H. reforms.
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Above all, the authors and drivers of reform in DYS facilities have been the Department’s staff and administrators. Their leadership, innovation, experimentation, and tireless work have dramatically improved the environment for youth in state custody, and altered the course of many youths’ lives. While there are far too many individuals to name here, the reforms were brought about under the leadership of Directors Harvey Reed, Tom Stickrath, Christine Money, Martha Spohn, and Geno Natalucci‐Persichetti, each of whom worked closely with Governors Bob Taft, Ted Strickland, and John Kasich. In the final years of monitoring, Governor Kasich’s engagement with the Department and active support helped sustain and build on the previous years’ efforts. Significant credit must also be paid to Assistant Directors Linda Janes, Damita Peery, Bonnie Sweeney, and Brenda Cronin; Bureau Chiefs Amy Ast, Laura Dolan, Ginine Trim, MT Schwartz, Wendi Faulkner, Ryan Gies, Linda Modry, and Kevin Shepherd; Chief Inspector Jennifer Fears; Superintendents Katie Neeham, Jim Darnell, Ron Edwards, Andrea Jones, Gwen Randall, Chris Baker, Dave Blackburn, Earl Myles, Marci Sutherland, Dave Pigman, Dion Norman, Thomas Teague, and Fred Nelson; central office administrators Jodi Slagle, Shelly Fitzhugh, Christy Hauck, Kim Kehl, Jeff Spears, Tony Panzino, Cedric Collins, Rochele Jones, Joan Olivieri, Shari Wolf, Brandon Strange, Edward Dachowski, John Bradley, Jacqueline Carter, Pam Robbins, Pam Gulley, Latoya Gregory, Mike Gordon, Peter Huling, Ernie Moore, Maryalice Turner, Jerry McGlone, Jennifer Sanders, Cynthie McIntosh, Connie Blair, Burger Penrod, Mark Thompson, Dave Dutton, Kim Parsell, Andrea Kruse, Nan Hoff, Aaron Bauer, Shannon Komisarek, Pat Hurley, Chris Freeman, Jim Ferrell, Keith Willliams, Clifford Smith, and countless others both in central office and at the facilities.
An exceptionally talented group of experts and consultants have served as members of the court‐appointed monitoring team. They have each played a dual role – part fact‐finder for the Court and part coach and consultant for their counterparts at DYS. Our monitoring model has been very hands‐on and collaborative. Over the last three years, we have focused intensively on helping the agency develop internal quality assurance tools, ensuring that DYS could conduct systematic internal monitoring as a step toward phasing out our external monitoring. The expertise and guidance of these monitoring team members have been invaluable for the Court and the parties, and the legacy of The Ohio Model is, in part, their legacy. In addition to ourselves, members of the S.H. monitoring team have included Monitors Fred Cohen and Vince Nathan; and subject matter experts Ava Crow, Anne Flynn, Ron Shansky, Barb Peterson, Shay Bilchik, Steve Martin, Daphne Glindmeyer, Andi Weisman, Orlando Martinez, David Roush, Cheryl Wills, Don Sauter, and Nick Makrides. Two of these experts as well as Michelle Staples Horne also served as members of the monitoring team for U.S. v. Ohio, a parallel suit brought by the U.S. Department of Justice regarding conditions at two DYS facilities. We would like to acknowledge their outstanding work and also recognize the attorneys for the United States who have played a vital role in system reforms, Bo Tayloe, Silvia Dominguez Reese, Rashida Ogletree, Jackie Cuncannan, Grace Chung Becker, Shanetta Cutlar, Gregory Gonzalez, and Vincent Herman.
A number of other consultants, including many leading national experts, contributed to the S.H. remedial efforts. We owe a debt of gratitude to the Vera Institute of Justice, the Juvenile Detention Alternatives Initiative, the Center for Juvenile Justice Reform at Georgetown University, Ed Latessa, Brian Lovins, Larry Travis and other researchers at the University of Cincinnati School of Criminal Justice, the Schubert Center for Child Studies at Case Western Reserve University, the PREA Resource Center, the Moss Group, the Project Addressing Prison Rape at the American University Washington College of Law, Leta Smith, Kathy Burns, Ned Loughran, Robert Prentky, Jim Austin, John Boston, Julian Ford, Amanda Yurick, Lindsay Hayes, Stuart
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Grassian, Patrick Canary, and Lisa Boesky. Juvenile justice stakeholders and other state and county agencies in Ohio have influenced DYS policy and practice through participation in the Ohio Interagency Task Force on Mental Health and Juvenile Justice, the Interagency Task Force on Sexual Misconduct, the RECLAIM Ohio and Targeted RECLAIM initiatives, and the Behavioral Health / Juvenile Justice Initiative. Ohio also benefits from a uniquely robust community of youth advocates and external oversight bodies that will remain long after the S.H. case ends. The Office of the Ohio Public Defender provides legal assistance to youth housed in DYS facilities on matters relating to the fact, duration, or conditions of their confinement. For several years, legal services were also provided by Emma Setta and the law office of Marc Mezibov. The state’s Correctional Institution Inspection Committee regularly audits each facility and reports its findings to the legislature. Disability Rights Ohio serves as the state’s Protection and Advocacy organization for youth with mental health disorders and other disabilities. Facilities are also monitored by a citizen oversight group, the Juvenile Justice Coalition. Additionally, the Children’s Law Center, Voices for Ohio’s Children, Children’s Defense Fund, the ACLU of Ohio, and the National Campaign to Reform State Juvenile Justice Systems continue to advocate for the rights and protection of youth in DYS facilities.
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Table of Contents
Executive Summary……………………………………………………………………………………………………………………………….……8 Protection from Harm………………………………………………………………………………………………………………………….……13
Dangerous conditions and practices in 2007…………………………………………………………………………………………..13 Changes to use‐of‐force practices…………………………………………………………………………………………………………..13 Improved documentation and video recording of applications of force ……………………………..………………….14 Better oversight and investigations…………………………………………………………………………………………………………14 Improved grievance system and access to attorneys ……………………………………………………………………………..15 Enhanced efforts to prevent and address sexual victimization.…………………………………………………………….…15 Development of a youth classification and housing system…………………………………………………………………….16 Development of internal quality assurance practices………………………………………………………………………………17 Video segment: Click here to hear from youth about improvements in protection from harm………….….17 Discipline and Seclusion……………………………………………………………………………………………………………………………17 Dangerous conditions and practices in 2007…………………………………………………………………………………………..17 Reduced reliance on pre‐hearing seclusion…………………………………………………………………………………………….17 Abolishing seclusion as a disciplinary sanction………………………………………………………………………………………..18 Alternatives to formal discipline……………………………………………………………………………………………………………..18 Increased oversight of seclusion practices………………………………………………………………………………………………18 Creation of a new Youth Advocate program……………………………………………………………………………………………19 Elimination of Special Management Units………………………………………………………………………………………………19 Education………………………………………………………………………………………………………………………………………………….19 Conditions in 2007………………………………………………………………………………………………………………………………….19 Better collaboration between school and facility staff………………………………………………………………………….…20 Meeting the needs of youth who can’t read……………………………………………………………………………………………20 Improvements in staffing and classroom space………………………………………………………………………………………20 Improvements in classroom management and school safety………………………………………………………………….21 Compliance with Special Education law………………………………………………………………………………………………….22 Providing education to youth on specialty housing units and youth in seclusion…………………………………….22 More vocational training, college courses, and transition planning…………………………………………………………23 Internal quality assurance monitoring for education………………………………………………………………………………24 Video segment: Click here to hear from youth about improvements in educational services………………..24 Video segment: Click here to learn more about the Inside‐Out program…………………………………………….…24 Medical and Dental Care…………………………….…………………………………………………………………………………………….24 Conditions in 2007………………………………….………………………………………………………………………………………………24 Improvements in medical assessments...………………………………………………………………………………………………..25 Improvements in medication, chronic care, and emergency care.…………………………………………………………..25 Improvements in medical records………………………………………………..…………………………………………………………26 Continuous Quality Improvement and peer review of doctors and nurses……………………………………………..26 Improvements in dental care………………………………………………………………………………………………………………….26 Cultural and Environmental Changes………………………………………………………………………………………………………..27 Conditions in 2007………………………………………………………………………………………………………………………………….27 Changing the role of direct care staff………………………………………………………………………………………………………27
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More activities, more staff, and fewer youth………………………………………………………………………………………….27 Identifying and addressing youths’ criminogenic needs……………………………………………………………………….…28 Family Engagement…………………………………………………………………………………………………………………………………..29 Finding new and innovative ways to engage family members during a youth’s stay at DYS…………………….29 Video segment: Click here to hear from youth about improvements in family engagement..……………….30 Mental Health and Psychiatry Services……………………………………………………………………………………………………..30 Conditions in 2007………………………………………………………………………………………………………………………………….30 Providing proactive rather than reactive mental health services…………………………………………………………….31 Improved care for youth with the most serious mental health symptoms………………………………………………31 Treatment‐based interventions for youth with disruptive behavior……………………………………………………..…32 Improved psychiatry services……………………………………………………………………………………………………….…………32 Quality assurance monitoring and peer review……………………………………………………………………………………….33 More continuity of care for youth returning home…………………………………………………………………………………33 Video segment: Click here to hear from youth about improvement in mental health services..…………….33 Release from Secure Custody……………………………………………………………………………………………………………………33 Release practices in 2007………………………………………………………………………………………………………………….…….33 Clear‐cut criteria for denying release……………………………………………………………………………………………..……….34 Conducting internal quality assurance monitoring……………………………………………………………………………..…..34 Reducing the Incarcerated Population………………………………………………………………………………………………………35 Downsizing the juvenile prison system by increasing effective local alternatives……………………………………35 Risk assessment tools used to inform placement decisions…………………………………………………………………….35 JDAI and DMC initiatives…………………………………………………………………………………………………………………………35 Improvements to parole and reentry efforts…………………………………………………………………………………………..36 Dramatically improved outcomes and cost savings…………………………………………………………………………………36 Additional Accomplishments…………………………………………………………………………………………………………………….36 Conclusion………………………………………………………………………………………………………………………………………………..37
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Executive Summary
Protection from Harm
The Ohio Department of Youth Services (DYS) put in place several measures to protect youth in their custody from harm. DYS intensified staff training and oversight, responding to findings that use of force in the facilities was excessive and reckless. Today, staff members consistently engage in verbal strategies to deescalate violent and threatening behavior among youth, and use minimal amounts of force when necessary, only as a last resort. Every application of force is now recorded on video and reviewed by administrators for compliance with policy. The staff members engaged in incidents get immediate, detailed feedback from those administrators. DYS now also has a state of the art process for investigating allegations of excessive force.
Youth have a meaningful grievance system, and have easy access to attorneys who help them address concerns related to the fact, duration, or conditions of their confinement. An improved security classification system and quality assurance system have contributed to a steady decline in youth‐on‐youth violence. With assistance from a wide range of national experts, DYS has also greatly expanded its efforts to prevent and address sexual victimization of youth in its facilities.
Discipline and seclusion
Excessively punitive consequences for youth who violated facility rules have been revised. Rather than utilizing a formal disciplinary system, interventions to respond to rule violations are constructed by youths’ treatment teams. DYS has abolished the practice of disciplinary seclusion, has achieved dramatic reductions in the use of pre‐hearing seclusion, and has put in place a robust oversight process to monitor placement in seclusion, length of stay, and frequency of staff contacts with youth. Youth report that the disciplinary process is more fair, in part due to the agency’s placement of a Youth Advocate at each facility who assists youth during hearings.
DYS has removed all youth from Special Management Units, which previously relied excessively on seclusion and restraints. They revised the program so that, if utilized in the future, those housed on the unit will be out of their rooms and engaged in programming for the entire day.
Education
Education has vastly improved in DYS facilities. Schools that were plagued by violence, teacher shortages, lack of instruction, and ineffective classroom management, are now fully staffed, safe, and well‐managed. Teachers receive professional development and mentoring to better manage challenging student behavior and engage more effectively with youth. Students are no longer suspended from school. Those housed on mental health units are no longer deprived of a
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full school day. Special Education services are now compliant with federal and state law, and responsive to individual student needs. Additionally, DYS now has a unique quality assurance system for Special Education that should serve as a model for other schools around the country.
Medical and dental care
Medical and dental services in DYS facilities are now closely monitored through clinician peer review and Continuous Quality Improvement systems. DYS hired a Dental Director whose oversight and guidance have significantly improved the quality and timeliness of dental care. Dental staffing has improved, as have exams, cleanings, and restorative dental care. Medical services, which previously lacked adequate assessments and documentation, and which provided no systematic care for youth with chronic diseases, are now significantly improved. Health assessments are timely and complete. Chronic care and medication administration are consistent with national guidelines. Nurses who assess youth for injuries after fights or applications of force now take appropriate histories. They conduct physical exams in a clinical space rather than through the youth’s door. Central office also closely monitors practices related to intake, lab and diagnostic services, vital sign monitoring, sick call, emergency services, and family engagement in treatment.
Medical records are up‐to‐date and chronological. They contain thorough notes on clinical findings, treatment plans, patient encounters, and responses to treatment. At the time monitoring of medical care terminated, DYS was working toward the roll‐out of an electronic medical record system that would combine medical, dental, mental health, psychiatry, and social work files into a single fully‐integrated record.
Cultural and environmental changes
Much of DYS’s reform efforts have focused on changing the culture and environment in the institutions. A 2007 investigation found that direct care staff in the facilities were overly confrontational and violent. Their approach created a hostile environment, and negatively affected youths’ behavioral outcomes. DYS expanded the job duties of direct care staff, ensuring that they would be highly involved in programming, treatment teams, and mentoring of youth, rather than just acting as guards. Each facility now has a core group of staff who have good relationships with a wide range of youth, and whose approaches to problem behaviors are based on a positive rapport that they have built over time with the youth.
The creation of new Program Administrator positions at each facility has increased the quantity and quality of programming and activities. High school graduates now benefit from an expanded work program to constructively occupy the portion of their day that other youth spend in school. Each facility also has a Youth Council, which offers youth a meaningful role in facility decision‐ making.
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All youth earn points through a positive behavior incentive program, and spend those points on commissary items, additional phone calls, and entry into special events. The reduced population has allowed staff more time to interact with youth and engage them in programming. These changes have helped improve perceptions of safety among both youth and staff. Because fewer staff members call off work due to stress and injuries, these cultural changes have also helped alleviate chronic staffing shortages.
DYS adopted the Ohio Youth Assessment System (OYAS), which helps staff determine the types of interventions that will be most effective with youth, based on their risk to reoffend and their criminogenic treatment needs. The agency also adopted a Cognitive Behavioral Therapy modality that targets these criminogenic factors, and helps teach and reinforce pro‐social ways to cope with stressful situations. DYS changed their approach to gang intervention as well. Rather than attempting to simply sanction all gang‐related behavior, which has not been successful in the past, DYS’s new approach aims to disengage youth from gang activity by understanding why they are getting involved in the first place. They manage gang problems by creating a safe place for youth to talk about them; and providing alternatives, incentives, and supports for youth who want to disengage. These approaches have helped to shift staff responses away from labelling youth as troublemakers, and toward interventions that are based on meeting their criminogenic needs.
Family engagement
DYS now uses video conferencing technology and provides bus transportation to increase family visitation, which in turn has improved youth behavioral and educational outcomes. They have also implemented a policy that facilitates family visitation seven days a week. Through a partnership with the Vera Institute of Justice, DYS has developed staff members’ abilities to find and engage family members and supportive community members in youths’ treatment, and plan for reentry back to the youth’s home community.
Mental health and psychiatry services
In the area of mental health care, DYS’s efforts transformed a profoundly understaffed and disorganized system in which mental health needs went largely undiagnosed and untreated, into a proactive system that provides individualized treatment planning and progress monitoring for each youth in their custody. A 2007 investigation found grossly inadequate services for youth with the most serious mental health needs, and barriers to inpatient hospitalization for those in acute crisis. Today, specially trained staff provide intensive treatment services on Mental Health Units, and all youth have access to inpatient care when needed. The agency has drafted and revised a comprehensive set of policies and procedures governing mental health and psychiatry services. Social workers, psychologists, occupational therapists, and psychiatric nurses work as an integrated behavioral health team, are easily accessible to youth on all housing units, and provide more than adequate clinical coverage.
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Treatment teams meet monthly to review each youth’s progress toward their goals. Group treatment sessions are provided nearly every day and individual sessions are provided as needed. Psychiatrists meet regularly with youth who are treated with psychotropic medications to monitor treatment efficacy and side effects. The agency has begun monitoring services and staff performance through quality assurance measures and clinician peer review. They have also improved continuity of care for youth returning home, by securing a policy change that makes youth presumptively eligible for Medicaid coverage upon release from the institution.
Behavior management for youth whose disruptive behavior stems from underlying mental health disorders has also changed. DYS stopped using punitive Special Management Plans that relied excessively on seclusion, and replaced them with Behavior Contracts. These contracts offer incentives and consequences tailored for each youth to incrementally improve behavior. Mental health clinicians review incidents in which youth on the mental health caseload engage in violent or disruptive behavior. This process allows them to divert youth away from formal disciplinary hearings or offer guidance to hearing officers regarding appropriate interventions.
Release from secure custody
The release process, which youth and staff previously found confusing and exasperating, has become much more fair and consistent. The 2007 investigation found release decisions being made without clear‐cut criteria. At times, youth were denied release due to staff members’ failure to complete paperwork or due to other factors beyond the youth’s control. Not knowing when they were going home or how that decision was being made caused youth act out, which undermined the agency’s behavior incentive program. DYS has since defined a limited set of barriers that would warrant denying a youth’s release. These barriers are invoked sparingly, and each quarter between 70 and 90 percent of youth reviewed are released by their minimum sentence expiration date. Youth now also have a meaningful process to appeal a release denial. Additionally, DYS reviews the performance of Release Authority panel members and facility staff members involved in release reviews through an internal quality assurance system.
Reducing the incarcerated population
Finally, DYS is best known for its extraordinary success in downsizing the juvenile prison population. The agency partnered with juvenile courts throughout the state to increase capacity to effectively supervise and serve youth at the county level. They provided financial incentives to use those dispositional alternatives rather than commit youth to state‐run correctional facilities. This initiative, called RECLAIM Ohio, was bolstered by the Targeted RECLAIM initiative that expanded evidence‐based alternatives in the state’s six largest counties. Both this initiative and a similar project focused on increasing local mental health resources at the county level have since been expanded to many more counties. DYS reduced its juvenile prison population from over 2000 youth several years ago to less than 500 today. These downsizing efforts
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resulted in enormous cost savings for the state, and were supported by studies showing that low‐ and moderate‐risk youth had lower recidivism rates if they were not placed in the state’s secure facilities. Youth diverted from confinement in DYS facilities also had less school interruption, more family engagement in treatment, and better behavioral outcomes. DYS also closed its girls’ unit at the Scioto Juvenile Correctional Facility, and transitioned the youth housed there to the community with aftercare plans or to one of three small contract placements, two of which are licensed to provide mental health and addiction services.
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Protection from Harm
Dangerous conditions and practices in 2007. An investigation conducted in 2007, with findings reported in January 2008, revealed a pattern and practice of excessive staff use of force in DYS facilities. Direct care staff engaged in reckless and malicious practices, disregarding obvious risks of harm to youth.1 The degree of force applied was unnecessary and often life‐threatening. The investigation report described several examples of chokeholds and other restraints that created extreme risks of asphyxia to youth in DYS custody.2 Staff were untrained, confrontational, quick to apply physical restraints and excessive force, and often strategic in the location of incidents in order to avoid cameras. Staff supervisors became directly and unnecessarily involved in applications of force rather than managing the incidents and overseeing the involved staff.3
Staff documentation regarding applications of force lacked detail sufficient to determine the nature of the force used. Staff often used terms such as “fight break‐up” without fully describing the actions they took. Other reports were incomplete or entirely false. The investigation report included examples of incidents in which many staff members witnessed (and video captured) youth being choked for extended periods of time or kicked in the head multiple times, but where none of the witness reports documented these details.4 Most administrative reviews of incidents did not involve viewing video footage, and both staff and youth described abuse of youth in areas without video coverage.5 Facility administrators had no reliable set of criteria to review the propriety of applications of force or the need for an abuse investigation by the Chief Inspector’s Office. Abuse investigations at the facility level were of very questionable quality, often resulting in facially unreliable findings. Moreover, employee disciplinary sanctions for engaging in abusive practices were often too lenient compared with the seriousness of the violation, or were not imposed at all.6
Youth also reported being scared of peer violence. Psychology staff reported dramatic numbers of youth making suicidal gestures or statements in order to be placed in protective custody.7 Youth grievances related to peer violence (as well as sexual harassment, staff retaliation, and unmet medical needs) often received no response. Youth with low levels of literacy were not provided any assistance in writing grievances. Furthermore, the Grievance Coordinators at each facility had no clearly defined role or special training.8
Changes to use‐of‐force practices. Staff now receive quarterly training on appropriate techniques for de‐escalation and managing youth resistance. Throughout DYS facilities, staff members engage in verbal strategies to de‐escalate violent and threatening behavior among youth, and resort to force only
1 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 24‐25.
 2 Id. at pp. 35‐37.
 3 Id. at pp. 37‐38, 133.
 4 Id. at pp. 33‐38, 41.
 5 Id. at pp. 26‐27, 37‐38, 82.
 6 Id. at pp. 26‐27, 37‐38.
 7 Id. at pp. 76‐77.
 8 Id. at pp. 186‐191.

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as a last resort.9 The rates of physical restraints have declined. When they do occur, they are planned and captured by hand‐held video cameras. The levels and intensity of force now applied are minimal with very few injuries occurring to youth and staff.10 Mechanical restraints occur at very modest levels, and for minimal lengths of time.11 Supervisory staff at the facilities are also effectively managing incidents of force rather than becoming directly involved.12
Improved documentation and video recording of applications of force. Staff members’ written documentation of use of force incidents has significantly improved. Staff record applications of force on hand‐held video cameras, and preserve the videos for review by supervisors and investigators. In recent months, an additional 40‐70 stationary cameras were installed at each facility to increase DYS’s surveillance capabilities in vulnerable areas. The video camera coverage enhances the monitoring of use of force and other potential abuse.13
Better oversight and investigations. DYS created a new administrative position at each facility called the Facility Intervention Administrator (FIA), who is responsible for reviewing every incident involving physical or mechanical restraints, and determining whether the staff members’ actions complied with policy. The FIA provides staff with immediate, detailed feedback to refine their skills and improve incident management. The facility FIAs are diligent in taking corrective action. They are not hesitant to refer incidents to the Chief Inspector’s Office (CIO) for investigation into potential abuse. Where policy violations fall short of abuse, they address staff performance through “teachable moments” or direct coaching.14 DYS is unique among juvenile corrections agencies for creating a role like the FIA. The position has had a dramatic impact on use of force practices, and serves as a model for agencies struggling with violent conditions. Each month, a Facility Resource Administrator (FRA) from Central Office reviews the FIA’s decision‐making for a sample of incidents. The FRA provides comprehensive assessments, and meets with facility officials to improve the use‐of‐force review process.15 When abuse has been alleged, the CIO conducts thorough and timely investigations, sustains the allegations when supported by the evidence, and imposes appropriate staff disciplinary action.16
9 See Steve Martin, CJCF site visit report (Jan. 2013), pp. 3‐4; Steve Martin SJCF site visit report (Jan. 2013), p. 4;
 Steve Martin, CHJCF site visit report (Sept. 2012), p. 3.
 10 Id.; Kelly Dedel, et al., Monitor’s Fourth Report, U.S. Department of Justice v. The State of Ohio (June 2013), p. 12
 (Hereinafter “Monitor’s Fourth Report”).
 11 See Steve Martin, CJCF site visit report (Mar. 2012), p. 7.
 12 See Steve Martin, CJCF site visit report (Jan. 2013), pp. 3‐4; Steve Martin & Amy Ast, Fifth Year Plan for Bureau of
 Facility Operations (Nov. 2012), p. 2.
 13 Steve Martin, IRJCF site visit report (Sept. 2012), p. 3; Steve Martin, CJCF site visit report (Jan. 2013), p.4;
 Message from DYS Director Harvey Reed, Facility Developments (Sept. 6, 2013).
 14 Steve Martin, CJCF site visit report (Jan. 2013), pp. 3‐4; Steve Martin, CHJCF site visit report (Sept. 2012), p. 3;
 Steve Martin, IRJCF site visit report (Sept. 2012), pp. 3‐4; Steve Martin, CJCF site visit report (Mar. 2012), p. 5; Kelly
 Dedel, et al., Monitor’s Fourth Report (June 2013), p. 10.
 15 Steve Martin, SJCF site visit report (Jan. 2013), p. 4; Steve Martin, IRJCF site visit report (Sept. 2012), pp. 3‐4;
 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 10.
 16 Steve Martin, CJCF site visit report (Jan. 2013), pp. 4‐5; Steve Martin, CHJCF site visit report (Sept. 2012), p. 3.

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Improved grievance system and access to attorneys. Youth receive a handbook and a thorough orientation covering the grievance system and their legal rights.17 Grievance Coordinators at each facility are easily accessible to youth. They respond to grievances in a timely and substantive manner, and effectively resolve youth complaints.18 The CIO reviews all grievances on an ongoing basis, requesting follow‐up action from the Grievance Coordinators if additional information is needed, and imposing corrective action when grievances are not resolved appropriately. The CIO audits the grievance process, directly observing interaction between the Grievance Coordinator and youth. The CIO also regularly surveys youth to identify ways in which the grievance system could be improved. As a result of these surveys, youth now receive a notification letter advising them of the outcomes of abuse investigations triggered by one of their grievances.19 Youth now have easy access to attorneys through the Ohio Public Defender’s office, which helps youth address concerns related to the fact or duration of their confinement; and which also operates the Legal Assistance Program, focused on resolving or litigating youth concerns related to their living conditions. The Public Defender’s degree of access to youth in custody and their ability to troubleshoot problems largely without litigation is rare in the United States, and should serve as a model for independent ombudsman offices nationwide.20
Enhanced efforts to prevent and address sexual victimization. In response to a Bureau of Justice Statistics report listing DYS among the juvenile corrections agencies with the highest reported incidence of sexual victimization, Governor Kasich convened an Interagency Task Force on Sexual Misconduct. The Task Force made unannounced visits to each facility, and developed recommendations related to implementation of the Prison Rape Elimination Act (PREA) regulations, improving reporting and investigation protocols, and data collection and analysis related to sexual misconduct. DYS received a two‐year grant to enhance training efforts and modify the facility physical plants, with technical assistance from the National PREA Resource Center. They identified areas in the facilities vulnerable to sexual misconduct, completed restroom and shower renovations to provide youth with more privacy, installed locks on school restrooms to eliminate the opportunity for youth to enter without staff knowledge, rearranged furniture to improve visibility and safety, and installed over 200 additional cameras. They developed a new more sophisticated system for daily rounds and random security checks at multiple levels to deter misconduct, and enhanced the protocols for monitoring camera footage. Cultural assessments lasting four days and nights at each facility were conducted to identify factors contributing to victimization and reporting problems. DYS reviewed its training for current staff and new hires with assistance from the PREA Resource Center and the Project Addressing Prison Rape at the Washington College of Law. They developed a four‐hour training for all staff based on evidence‐based practices and strategies to address sexual misconduct, with materials provided by the National Institute of Corrections, Washington College of Law, Just Detention
17 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 39.
 18 See Steve Martin, CHJCF site visit report (Sept. 2012), pp. 5‐6; Steve Martin, IRJCF site visit report (Sept. 2012),
 pp. 3, 7; Steve Martin, SJCF site visit report (June 2011), p. 8; Kelly Dedel, et al., Monitor’s Fourth Report (June
 2013), p. 35.
 19 Steve Martin, CJCF site visit report (Jan. 2013), p. 7; Steve Martin, CJCF site visit report (Mar. 2012), pp. 9‐10;
 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 36.
 20 See 51 Ohio Rev. Code § 5139.04(H); Memorandum of Understanding between Ohio Public Defender and Ohio
 Department of Youth Services (Jan. 2006); State of Ohio Inter‐Departmental Agreement, Department of Youth
 Services and Ohio Public Defender (Aug. 2013).

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International, and the Center for Children’s Law and Policy. Investigators of sexual misconduct and harassment incidents participated in a training provided by The Moss Group and the PREA Resource Center on conducting quality investigations, and additional training was provided to behavioral health staff on identifying warning signs and behavioral indicators of abuse. DYS also developed an excellent policy to protect and provide for the special needs of lesbian, gay, bisexual, transgender, and intersex youth.21
DYS put in place a Tip Line, a direct line to central office, for staff, youth, and family members to report any issues related to sexual harassment or abuse. Messages left on the Tip Line can be anonymous, and are reviewed within 24 hours by DYS’s new Youth Ombudsman at central office. The Tip Line number is posted in all housing units, and has been delivered to the families of youth currently in DYS facilities and on parole. DYS conducted interviews with staff and youth to collect input on how to address sexual victimization issues. Town hall meetings and labor‐management meetings were held with staff in which all staff were encouraged to read the BJS report, and asked to provide input through suggestion boxes and a special email account for suggestions. House meetings were conducted on every housing unit to discuss the desire to keep youth safe and to review with youth the ways they can report incidents of misconduct through the grievance process, trusted staff members, the Chief Inspector’s Office, the Legal Assistance Program, or the Correctional Institution Inspection Committee. All youth received a letter from the Director and a special training on their rights to be free from sexual abuse, harassment, and retaliation, DYS’s zero tolerance policy, and their avenues for reporting. Youth are interviewed upon leaving DYS and reentering the community, and youth on parole have been encouraged to report any sexual activity or abuse that they experienced or witnessed while in custody. Youth and staff surveys are also being developed to assess whether new interventions are working.22
Development of a youth classification and housing system. In collaboration with the University of Cincinnati, DYS developed and validated an assessment tool that designates youth as appropriate for minimum, medium, or close security housing; and that allows for reclassification of youth based on their demonstrated behavior while in custody. This security classification system has contributed to a steady decline in youth‐on‐youth violence.23
21 Ohio Department of Youth Services, Message from DYS Director Harvey Reed (Dec. 17, 2013); Ohio Department
 of Youth Services, Message from DYS Director Harvey Reed (Oct. 3, 2013); Ohio Department of Youth Services,
 Message from DYS Director Harvey Reed (Sept. 6, 2013); Ohio Department of Youth Services, Message from DYS
 Director Harvey Reed (Aug. 12, 2013); Ohio Department of Youth Services, Message from DYS Director Harvey
 Reed (July 17, 2013); Ohio Department of Youth Services, Message from DYS Director Harvey Reed (June 18, 2013);
 ODYS Standard Operating Procedure 304.02.01; Memorandum from Will Harrell and Terry Schuster to Gwen
 Randle, Linda Janes, Laura Dolan, and Jodi Slagle re: Comments on ODYS SOP 304.02.01 regarding LGBTI youth
 (July 17, 2013).
 22 Email from Kim Parsell to DYS Stakeholders (Oct. 15, 2013); Ohio Department of Youth Services, Message from
 DYS Director Harvey Reed (Sept. 6, 2013); Memorandum from Director Reed to All Youth (July 11, 2013);
 Memorandum from Director Reed to All Youth on Parole (July 11, 2013); Ohio Department of Youth Services,
 Message from DYS Director Harvey Reed (July 10, 2013); Email from Danny Turek, DYS Training Academy, to Dustin
 Calhoun, DYS General Counsel (Sept. 30, 2013).
 23 See Steve Martin, Report on Stipulation Paragraph 47 re: Classification and Housing (Mar. 2011), pp. 1‐4;
 Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), p. 11; Kelly Dedel, et al., Monitor’s Fourth
 Report (June 2013), p. 10.

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Development of internal quality assurance practices. Each facility collects and analyzes extensive data on youth violence and applications of force. DYS created a quality assurance system to identify increases or decreases in youth violence and to respond thoughtfully to those trends. Local monitoring of force is reviewed regularly by central office, and the Bureau Chief over facility operations meets monthly with the facility Superintendents to discuss the influences on youth violence and strategies to improve safety and security outcomes.24
Video segment: Click here to hear from youth about improvements in protection from harm.
Discipline and Seclusion
Dangerous conditions and practices in 2007. The 2007 investigation found that consequences for youth who violated facility rules were excessively punitive and not effective at making the facility safer for youth and staff. DYS placed youth in seclusion too frequently and for far too long.25 DYS was not using oversight tools to monitor youth placed in seclusion or trends in seclusion data, allowing excessive stays to go unchecked. The agency’s Youth Advocate had no clear job description, and did not have the resources or staff to assist youth during the disciplinary process, which meant youth were routinely exposed to harsh disciplinary sanctions with no one to assist them, to explain the potential consequences, or to assess whether underlying mental health conditions contributed to their rule‐ breaking behavior.26
DYS also operated special management housing units (SMUs) that held youth in lockdown 23‐hours a day, 7‐days a week. Monitor Fred Cohen reported that they resembled “supermax” housing units found in adult prisons. Youth on the SMUs were held for weeks or months at a time in prolonged isolation under stark conditions, without any substantive treatment or programming.27
Reduced reliance on pre‐hearing seclusion. Prior to the Consent Order, DYS utilized a structured decision‐making tool to determine the severity of the rule violation and the resulting length of stay in pre‐hearing seclusion. Youth accused of serious rule violations were held in pre‐hearing seclusion for between 56‐72 hours. Following the Consent Order, DYS implemented its new seclusion policy, which required all youth to be assessed for release no later than 4 hours following their placement in pre‐ hearing confinement, and every 3 hours thereafter if continued seclusion was justified based on the youth’s current behavior. The “safe‐to‐release” check involves a structured interview designed to help youth identify the circumstances that led to his misconduct and opportunities to respond differently in
24 Steve Martin & Amy Ast, Fifth Year Plan for Bureau of Facility Operations (Nov. 2012), p. 1; Kelly Dedel,
 Compliance Review, Quality Assurance for Safe Living Conditions and Structured Programming (May 2013), p. 7;
 Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 9.
 25 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 28, 39, 84.
 26 Id., at pp. 39, 192‐195.
 27 Id., at pp. 32‐33.

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the future. Between March and July 2015, over 90 percent of the pre‐hearing seclusion episodes were terminated within 4 hours, with an average length of stay of just 2.83 hours.28
Abolishing seclusion as a disciplinary sanction. Prior to the Consent Order regarding the use of seclusion, DYS conducted Intervention Hearings to determine whether youth were culpable for serious misconduct and whether to impose Intervention Seclusion as a sanction for the youth’s behavior, which could last up to five days for serious rule violations. Youth who engaged in frequent misconduct accumulated time in seclusion that represented a significant portion of their time in custody.29 On January 1, 2015, DYS issued a policy that abolished the use of seclusion as a disciplinary sanction. Rather than placing youth in isolation and increasing the risk of self‐harm and decompensation of their mental health, disciplinary sanctions now rely on restricting youth’s access to privileges available through its behavior management system and, in some cases, adding days to their time in custody (i.e. Intervention Time). Changes to practices regarding the imposition of Intervention Time were also reformed, resulting in significant reductions to historically excessive time‐adds. In the six months prior to the new seclusion policy taking effect, a total of 38,203 days of Intervention Time were imposed. During the six months following the implementation of the new policy, only 4,100 days were imposed, for a decrease of 89 percent.30 Not only does DYS’s new policy for responding to youth misconduct prohibit the harmful practice of seclusion, but it also protects against the imposition of excessive Intervention Time.
Alternatives to formal discipline. DYS facilities now screen incident reports in an effort to identify those infractions that can be addressed by treatment teams rather than by formal disciplinary hearings. This referral process has led to a significant decrease in hearings and, as a result, in seclusion hours. Treatment teams generally design alternative interventions that are more responsive to the underlying causes of the youth’s behavior. These include treatment assignments and Behavior Contracts, combined with sanctions like commissary restrictions and suspension of other privileges.31 DYS has also implemented a process to divert youth away from the formal disciplinary process when their rule‐breaking behavior is related to underlying mental health conditions. [This process is described in more detail under the section of this report titled Mental Health and Psychiatry Services.]
Increased oversight of seclusion practices. DYS has developed several quality assurance practices to internally identify and respond to problems related to seclusion of youth. The Superintendent at each facility reports seclusion hours monthly and must explain any increase or decrease in the various categories of seclusion. Every month, facility administrators compile monthly statistical summaries and a Facility Resource Administrator (FRA) from central office analyzes seclusion events at each facility. The FRA provides a compliance score and when that score falls below 80%, also provides recommendations for a performance improvement plan. With regard to pre‐hearing seclusion, for example, the FRA reviews the initial placement decision, the frequency of contacts while a youth is in seclusion, and the continued justification for seclusion. Deficiencies noted by the FRA in the past have
28 Kelly Dedel, Memorandum (Aug. 16, 2015).
 29 Kelly Dedel, et al., Monitors’ 6‐Month Report on Compliance with The Grid (June 2015).
 30 Id.
 31 Steve Martin, CJCF site visit report (Jan. 2013), pp. 7‐8; Steve Martin, IRJCF site visit report (Sept. 2012), p. 8; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 24.
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Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 20 of 39 PAGEID #: 3219
been corrected, suggesting that the internal compliance monitoring has been effective at improving practices at the facilities.32
Creation of a new Youth Advocate program. DYS reinvented the Youth Advocate position, and placed one Youth Advocate at each facility. The new position is tasked with assisting youth who are charged with rule violations that may result in serious disciplinary sanctions. They ensure that youths’ rights are protected throughout the disciplinary process. They explain to the youth what his rights are, help write a statement, call witnesses, and use the avenues available to the youth to tell his or her side of the story during the hearing. They also help with appeals. Youth have overwhelmingly reported that the disciplinary process is fair, due in large part to the assistance they get from their Youth Advocate. Rather than being intimidated during the hearing, youth are more likely to defend or explain themselves, and are often able to help the Hearing Officer see a bigger picture of what happened during a particular incident. The Youth Advocate also acts as a check on the Hearing Officer, and may push back against a potential sanction that seems too harsh in relation to the youth’s behavior.33
Elimination of Special Management Units. No youth have been housed on a Special Management Unit (SMU) since July of 2013. These housing units have existed in various forms and under various names over the last several years. They have relied excessively on seclusion and restraints to manage disruptive behavior among youth. Initially, in place of SMUs, DYS created a two‐phase program (“PROGRESS”) that offers intensive clinical intervention for the most challenging youth, along with separation from the general population in the first phase of the program. When this program was in place, youth on PROGRESS were out of their rooms for the entire day, engaged in programming, and were not subjected to seclusion or restraints any more than youth are in the general population. The program benefits from intensive oversight, data collection, and quality assurance measures, and those youth who did not transition quickly through the phases were provided with a review from central office administrators. The PROGRESS program is no longer utilized at any DYS facility. Instead, DYS now manages all youth either in the general population or on mental health units.34
Education
Conditions in 2007. The investigation report found that students with the most severe need for remedial reading assistance received no services to help them learn to read.35 Chronic shortages in
32 Steve Martin, Final Report on Seclusion and IRAV Quality Assurance Monitoring (May 2013), pp. 1‐3; Steve
 Martin & Amy Ast, Fifth Year Plan for Bureau of Facility Operations (Nov. 2012), pp. 1‐2; Kelly Dedel, et al,
 Monitor’s Fourth Report (June 2013), p. 9, 21‐22.
 33 Terry Schuster & Will Harrell, S.H. v. Reed Youth Advocate Program (July 2012), pp. 1‐3, 10‐11.
 34 See Ohio Department of Youth Services Standard Operating Procedure 303.01.07 (effective date Oct. 7, 2013);
 Consent Order, S.H. v. Reed (Dkt. 359‐2) (Jan. 18, 2013); Ohio Department of Youth Services, Second PROGRESS
 Unit Status Report (Sept. 2013); Kelly Dedel & Daphne Glindmeyer, Monitor’s PROGRESS Unit Compliance Report
 (Dec. 2013); Terry Schuster, 13 Good Ideas from Other Jurisdictions That May Help Improve Outcomes on the
 PROGRESS Units (Aug. 2012); Terry Schuster, Chart of Special Management Unit Models from other Jurisdictions
 (Aug. 2012) (on file with author).
 35 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 101, 120.

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Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 21 of 39 PAGEID #: 3220
teaching and substitute teaching staff as well as limited classroom space caused youth to receive less than a full day of school. Students and faculty expressed high levels of fear for their personal safety in the school buildings, and teachers regularly took extended leave due to stress, fear, and injuries from assaults.36 Classroom management and discipline were not consistent, and too many classrooms were found to have little or no instruction occurring at all.37
The 2007 investigation revealed that DYS was also not complying with federal Special Education law. Faculty did not develop appropriate Individualized Education Programs (IEPs) for Special Ed students. They did not teach to the youth’s IEP goals or monitor the youth’s progress toward meeting those goals. Agency and facility administrators often made decisions limiting youths’ access to education based on security concerns without consulting the school principals or faculty. Students were disciplined and suspended from school for behavior related to their disabilities in violation of the law. Youth who were housed on mental health units received only three hours of education per day, and those in protective custody or in seclusion for acts of violence received no education at all.38
Better collaboration between school and facility staff. The schools are now far more integrated into the identity and purpose of DYS facilities. Communication between the school principals and the facility superintendents is excellent, as is communication between the principals and central office. Teachers integrate the concepts and language of the agency’s Cognitive Behavioral Therapy program into their lesson plans and classroom activities. Facility social workers participate in IEP meetings for Special Ed students and teachers attend inter‐disciplinary treatment teams along with clinical and direct care staff. Youth Specialists who are posted in the school building attend meetings with the school staff. The school’s transition coordinator also works closely with facility social workers, the Release Authority, and the regional parole offices to assure that students’ educational needs are met when they return to their home communities.39
Meeting the needs of youth who can’t read. DYS adopted a computerized software program called My Reading Coach to teach reading to students with pre‐literacy skills. The program has an established record with non‐readers and students who have very low literacy levels. It is now available in all DYS facilities on computers in Special Education, English, and Title I classrooms, and is also used by speech therapists providing services to Special Ed students.40
Improvements in staffing and classroom space. Students are no longer missing classes because of teacher absenteeism and vacancies. DYS’s staffing plan provides for a principal and assistant principal
36 Id., at pp. 101, 105‐107, 121‐122, 129.
 37 Id., at pp. 113‐114, 131‐132.
 38 Id., at pp. 101, 103‐105, 108‐113.
 39 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), pp. 1‐2; Ava Crow & Anne
 Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 2; Ava Crow & Anne Flynn, site visit report,
 Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 7‐9; Ava Crow & Anne
 Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School (Sept. 2012), pp. 5, 21,
 34‐35; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 56.
 40 See Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), p. 19; Ava Crow &
 Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 15.

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at each school, two guidance counselors, three administrative assistants, a librarian, two teachers in each of the four core classes, an art teacher, a teacher for P.E. and health, a permanent substitute and five intermittent substitutes, a Title I teacher, as well as career tech positions. Because of the smaller youth population, the current complement of staff is sufficient to provide all core subjects, vocational courses, and electives even when vacancies arise. Virtually all students are now receiving a full school day with no repeating classes due to short staffing. Sufficient space now also exists at all DYS facilities to ensure that no students are deprived of a full school day due to lack of classroom space.41
Improvements in classroom management and school safety. Teachers in DYS schools now receive professional development in classroom management and behavioral intervention with challenging students. DYS has contracted with a behavioral analyst to mentor and provide one‐to‐one modeling with teachers who are having difficulty. School principals also now conduct frequent walk‐throughs to observe teaching staff and become familiar with their strengths and weaknesses. They utilize improvement plans and face‐to‐face conferences as part of their efforts to supervise faculty and improve teacher performance. In the past, youth who exhibited non‐compliant behavior in the classroom could be suspended from school and returned to their living units where they did not receive education services of any kind. DYS stopped this practice in June 2011, and now relies instead on its in‐school suspension room, the Academic Behavior Classroom (the ABC room), where youth have an opportunity to regain control of their behavior, work on an assignment, and return to their regular classroom after a short period of time. Assistant principals have placed increased emphasis on following appropriate protocol for referring students to the ABC room. Moreover, teachers across the board have shown marked improvement in classroom management. Students are more actively engaged in learning activities, more youth are remaining in the classroom, and fewer youth are being sent to the ABC room. Teachers differentiate their instruction so that some students may be working on a computer‐generated assignment while others in the same classroom are engaged in a teacher‐ generated assignment. They provide instruction and walk around assisting students both on the computer and on other assignments. Student achievement and good behavior is also recognized in the classrooms, and in special assemblies and award ceremonies.42
Each school is well‐staffed with Youth Specialists and an Operations Manager who work with teachers to anticipate and prevent gang activity in the school, and who respond to any fights quickly and with little or no disruption to the normal course of the day. On a monthly basis, the school principals also analyze violence reduction data and develop plans to address increases in violence. At Scioto JCF, for example, cooperative efforts between school staff and facility staff to adjust the school schedule,
41 Ava Crow & Anne Flynn, CHJCF site visit repot, Luther E. Ball High School (June 2011), pp. 3, 5; Ava Crow & Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 3; Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 10, 12, 15; Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (Sept. 2012), pp. 8‐9; Ava Crow & Anne Flynn, CJCF site visit report, Ralph E. Starkey High School (Aug. 2011); Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012); Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 56‐57. 42 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), pp. 12, 16, 19‐20; Ava Crow & Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), pp. 2, 13‐14; Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 8‐9, 18‐20; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School (Sept. 2012), pp. 18, 20‐23; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 56‐57.
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increase the number of staff posted in the school building, and change some physical features of the classrooms reduced violence and disruption in the school building.43
Compliance with Special Education law. DYS now provides Special Education services that are responsive to individual student’s needs and that are compliant with the IDEA. The Special Education program is overseen by well‐qualified assistant principals at each facility and by central office. DYS has implemented Special Ed policies and procedures, developed an excellent Special Ed manual, and provided teaching staff with relevant professional development. DYS’s “child find” process is conducted by Intervention Assistance Teams at each facility that meet regularly and seek out students in need of additional interventions related to behavioral, academic, and attendance issues. These teams make referrals for special education evaluations as needed.44
All Individualized Education Programs (IEPs) are developed and implemented in a timely manner, and appropriate representatives attend IEP meetings. DYS has created checklists and tools for teaching staff that assist with drafting IEP goals and measuring progress toward those goals. Students’ IEPs are individualized, and contain measurable, achievable goals. IEP teams consider a broad range of services and arrangements to meet the students’ needs. Teachers have also made significant improvements in using data to track students’ progress toward IEP goals. All Special Ed teachers are Highly Qualified Teachers, and all teachers’ caseloads are under the state‐mandated cap of 12. Vocational programs are available to all Special Ed students, and related services are provided by occupational therapists, speech therapists, and school psychologists.45
Providing education to youth on specialty housing units and youth in seclusion. Special Education teachers serve all specialty units, and unit classrooms are wired for computer learning. These teachers also get weekly reports from medical staff on any medication changes that may affect the students’ behavior or alertness during school hours. Educational placement decisions for Special Ed students housed on specialty units are dictated by the terms of their IEPs, and even students with the most severe impairments and disabilities are provided with at least one class in the school building.46
43 Ava Crow & Anne Flynn, Status of Quality Assurance Program, Buckeye United School District (May 2013), p. 3;
 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), pp. 8‐9, 18; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), pp. 7, 21; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 56.
 44 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), p. 10; Ava Crow & Anne
 Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), pp. 7‐8; Ava Crow & Anne Flynn, site visit report,
 Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan, 2013), pp. 28‐29; Kelly Dedel, et
 al., Monitor’s Fourth Report (June 2013), pp. 63‐64.
 45 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), pp. 9, 12; Ava Crow &
 Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), pp. 7‐8; Ava Crow & Anne Flynn, site visit
 report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 28, 30‐33; Ava
 Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School (Sept. 2012), pp. 17‐18; Kelly Dedel,
 et al., Monitor’s Fourth Report (June 2013), pp. 61‐64.
 46 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), pp. 17, 25; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), pp. 17, 35.

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Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 24 of 39 PAGEID #: 3223
DYS no longer suspends students from school. Students who commit acts of violence and are placed in seclusion are provided with education on the unit. At the time that monitoring of education was terminated, hearing officers who imposed seclusion as a disciplinary sanction for violent behavior often limited seclusion hours to the weekend in order to minimize the impact of the sanction on the student’s education. For those secluded during the week, teachers visited them on the housing units four times per day and offered unit instruction for at least 30 minutes during each visit. They were also available to assist students on the unit during all six school periods. These students got individualized assignments from their regular teachers, were counted as present, and receive credit for completed work. Instruction for students on the housing units was closely monitored by the school’s administrators for compliance with agency policy.47
More vocational training, college courses, and transition planning. Each DYS school has a transition team that guides every student through an array of reentry skills, beginning at least six weeks before they return to their home communities. The team consists of the transition coordinator, the transition class teacher, the Career Based Instruction (CBI) teacher, and teachers to supervise online college classes or industry certification classes. CBI students spend two hours each day doing class work on job skills and career exploration. This is followed by work experience on campus for which the youth interviews. The transition coordinator continues reentry services after release by working with the parole officer, home schools and potential employers. The program tracks the transition of DYS youth at 30, 60, and 90 day intervals after release.48
Youth are given a career interest assessment and allowed to transfer to other DYS facilities that have vocational programming of interest to them. These programs include graphic design; horticulture; auto technology; healthy living, which offers a ServSafe certificate recognized by the restaurant industry; and administrative office technology, which offers an industry‐recognized Microsoft Office certificate. DYS secured a grant that offers off‐campus training and work experience for students returning to Franklin County. This initiative is focused on solar energy, and computer and electrical skills. Students in all grade levels are allowed to participate in and receive credit for vocational programming, and a very large percentage of students do in fact participate. At Scioto JCF, for example, more than 70 percent of students participated in vocational education.49
Through a partnership with Ashland University, DYS offers college courses in English, History, Business, Financial Literacy, Entrepreneurship, Sociology, and Psychology. These online courses are team‐taught
47 Ava Crow & Anne Flynn, CHJCF site visit report, Luther E. Ball High School (June 2011), p. 3; Ava Crow & Anne
 Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 3, n. 4; Ava Crow & Anne Flynn, site visit
 report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), pp. 9, 11‐12, 17,
 25; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School
 (Sept. 2012), pp. 9‐11; 17‐18, 35; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 57‐58.
 48 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), pp. 21‐22; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), p. 25.
 49 Ava Crow & Anne Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High
 School (Jan. 2013), p. 24; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School &
 Indian River High School (Sept. 2012), pp. 8, 26‐28, 30; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp.
 65‐67.

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by DYS teachers and Ashland professors. DYS has also taken youth off campus for visits to colleges and for community service projects.50 Another course provided intermittently through a partnership with Wooster college combines DYS students and free world college students in a criminal justice course taught on‐site at Indian River JCF.51 Students and teachers involved in this course, called the Inside‐ Out Program, are featured in the video segment below.
Internal quality assurance monitoring for education. The quality assurance system developed by DYS to review their Special Education program is unique and impressive. Because there are few, if any, national models or tools that measure the quality and effectiveness of Special Education services, DYS’s practices now serve as a model for schools both in correctional facilities and in the community. The individual schools and central office conduct monthly and quarterly reviews of Individualized Education Programs (IEPs) to identify whether the goals and objectives are appropriate for the student and whether they incorporate positive behavioral strategies to assist the student. The schools and central office also conduct monthly and quarterly compliance reviews to monitor a host of other Special Education issues, identifying problems that might otherwise be missed and remedying those concerns both for individual students and systemically. Teachers whose paperwork requires frequent correction are placed on performance improvement plans and provided with coaching. Principals also submit monthly reports to central office that address staffing, violence reduction, and other administrative issues. Each school is also audited annually by DYS and by the Ohio Standards Committee, as well as tri‐annually by the Ohio Department of Education.52
Video segment: Click here to hear from youth about improvements in educational services.
Video segment: Click here to learn more about the Inside‐Out program.
Medical and Dental Care
Conditions in 2007. Initial medical assessments for youth coming into DYS facilities were incomplete, lacked any conclusions about the health or medical problems of the youth, and contained no documentation of follow‐up by a physician. The 2007 investigation found abnormal vital signs that were not reported to or assessed by the physician, and lab results that were delayed and inaccurate. The problems with health assessments and documentation resulted in delays in treatment and delays in recognizing chronic disease. In 2007, there was no chronic care program at all. Youth with chronic
50 Ava Crow & Anne Flynn, IRJCF site visit report, Indian River High School (Feb. 2011), p. 14; Ava Crow & Anne
 Flynn, site visit report, Scioto William K. Willis High School & Circleville Ralph C. Starkey High School (Jan. 2013), p.
 22; Ava Crow & Anne Flynn, site visit report, Cuyahoga Hills Luther E. Ball High School & Indian River High School
 (Sept. 2012), pp. 25, 27‐28.
 51 See Anne M. Nurse, Juveniles and College: Inside Out as a Way Forward 93 The Prison Journal 234‐247 (Jan.
 2013), available at http://tpj.sagepub.com/content/93/2/234.full.pdf+html; Orlando Martinez & David Roush,
 IRJCF site visit report (Dec. 2011), pp. 20‐21; Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), p.
 17.
 52 Ava Crow & Anne Flynn, Status of Quality Assurance Program, Buckeye United School District (May 2013), pp .1‐ 6; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 62.

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Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 26 of 39 PAGEID #: 3225
diseases were not seen regularly for status checks, which led to episodic treatment at higher levels than might otherwise have been avoided. Medical information was not shared when youth were transferred between facilities or sent off‐site for scheduled or emergency medical treatment. Youth were also not properly assessed for injuries following fights or applications of force by staff. Medical and mental health information was not integrated. This, plus incomplete medical documentation generally compromised the quality of care being provided to youth. DYS did not monitor medical records and data for quality or completeness. There was no tracking of clinical outcomes or peer review process to ensure that doctors and nurses were meeting medical practice standards. There was also no peer review process for dentists providing services to DYS youth. Youth with dental pain were not being seen and stabilized in a timely manner. Cavities were not always treated and documented, and there was no system for triaging care. Dental staffing was inadequate, as was dental treatment planning, documentation, x‐rays, and infection control.53
Improvements in medical assessments. Initial health screens, physical exams, hearing and vision exams, lab testing, and review of immunization status are now timely and complete. Parents are contacted to provide information relevant to initial medical assessments. Intake information is integrated by care providers into a comprehensive assessment and plan, and physicians now follow up on problems and abnormal findings in a timely manner. Care providers respond appropriately to abnormal vital signs. They provide information to youth in a manner that the youth can understand, and have increased efforts to involve family members throughout the youth’s stay in the provision of care.54
Improvements in medication, chronic care, and emergency care. DYS’s administering of medications has improved. Meds come in pharmacy‐prepared blister packs, are checked against the doctor’s order and the pharmacy manifest, and are checked again when given to the youth. The medication is recorded as given only after the youth has taken it, or it is recorded as refused or missed. “As needed” medications are available at meal times and at other times if directed by the physician. DYS has developed chronic care clinics consistent with national guidelines. Patients enrolled in the chronic care clinics receive timely, appropriate care. A database has also been developed that allows tracking of chronic disease encounters. Nurses assessing youth for injuries following fights or applications of force are now taking appropriate histories, and performing complete physical exams in the clinic rather than through the youth’s door. Additionally, the transfer of information and the continuity of care for youth receiving off‐site medical services are much improved.55
53 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 139‐173. 54 Barb Peterson & Ron Shansky, CJCF site visit report (Jan. 2013), pp. 2, 4, 6; Barb Peterson & Ron Shansky, SJCF site visit report (Jan. 2013), pp. 3‐4; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), p. 11; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), p. 10; Barb Peterson & Ron Shansky, SJCF site visit report (Dec. 2010), p. 2; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011); Michelle Staples‐Horne, et al., Monitor’s Fourth Report, U.S. Department of Justice v. The State of Ohio (June 2013), p. 49 [hereinafter referred to as “Monitor’s Fourth Report”]. 55 Barb Peterson & Ron Shansky, CJCF site visit report (Jan. 2013), pp. 1, 7; Barb Peterson & Ron Shansky, SJCF site visit repot (Jan. 2013), p. 4; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), pp. 1, 4, 6‐7; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), pp. 1, 5; Barb Peterson & Ron Shansky, CJCF site visit report (Aug. 2011), p. 1; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011), Michelle Staples‐Horne, et al., Monitor’s Fourth Report (June 2013), pp. 49‐50, 53.
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Improvements in medical records. Medical records are now chronological, organized into clearly identified sections, have easy‐to‐find and up‐to‐date problem lists, and thorough notes on clinical findings, treatment plans, patient encounters, and responses to treatment. Medical records contain both medical and mental health diagnoses. Physical plant renovations in the medical and mental health service areas have improved collaboration and access to information among providers. At the time monitoring of medical services was terminated, DYS was also rolling out an electronic medical record that would combine medical and dental files, mental health and psychiatry files, and social work files into a single integrated system. This would allow for more collaborative treatment planning. It would also be able to interface with community providers and pharmacies, which will improve continuity of health care for youth upon release.56
Continuous Quality Improvement and peer review of doctors and nurses. Both the on‐site Health Services Administrator and the central office Medical and Nursing Directors now monitor a variety of health services provided. The Continuous Quality Improvement (CQI) system includes paper monitoring tools and an electronic database. It gathers both quantitative and qualitative information on patient intake, lab and diagnostic services, vital sign monitoring, chronic care programs, medication management, sick call, youth injury assessments, specialty and emergency services, intra‐system transfers, and parental notifications. Data is analyzed for trends at the institution level and across institutions. The central office Nursing Director also meets with the on‐site Health Services Administrator at each facility to ensure consistency in compliance monitoring. Peer review is now routinely conducted for nurses and physicians. This process identifies areas in need of improvement and provides action plans and increased monitoring until the provider’s performance has improved.57
Improvements in dental care. Dental staffing has improved, and all DYS youth now have complete dental exams, initial cleanings, routine preventative and restorative dental care, and oral hygiene instruction. Youth receive radiographs adequate to diagnose carious lesions (cavities), and are provided with individualized treatment plans for sealants and other services. Youth who have complaints of dental pain are assessed and stabilized within one day. Youth in need of crowns, dentures, or oral surgery all have access to these services as well. DYS has hired a Dental Director who has implemented a Continuous Quality Improvement (CQI) program, and who conducts peer review of
56 Barb Peterson & Ron Shansky, SJCF site visit report (Jan. 2013), p. 6; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), pp. 1‐2, 8; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), pp. 5, 7; Barb Peterson & Ron Shansky, SJCF site visit report (Dec. 2010), p. 5; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011), p. 9; John Bradley, Jacqueline Carter, Barb Peterson & Ron Shansky, ODYS Fifth Year Plan for Medical Care (Oct. 2012), pp. 1‐2; Email from John Bradley to Terry Schuster (Dec. 20, 2013); Michelle Staples‐Horne, et al., Monitor’s Fourth Report (June 2013), pp. 49, 53. 57 John Bradley, Medical Program Compliance Progress Report (April 2013); Jacqueline Carter, Quality Assurance Review / Report (April 2013), pp. 1‐8; John Bradley, Jacqueline Carter, Barb Peterson & Ron Shansky, ODYS Fifth Year Plan for Medical Care (Oct. 2012), p. 1; Barb Peterson & Ron Shansky, CJCF site visit report (Jan. 2013), pp. 4, 6; Barb Peterson & Ron Shansky, SJCF site visit report (Jan. 2013), pp. 4, 9; Barb Peterson & Ron Shansky, CHJCF site visit report (Sept. 2012), pp. 3, 5; Barb Peterson & Ron Shansky, IRJCF site visit report (Sept. 2012), pp. 1‐2, 4, 7‐9; Barb Peterson & Ron Shansky, IRJCF site visit report (Dec. 2011), p. 6.
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the facility dentists. His oversight and guidance have significantly improved the quality and timeliness of dental care in DYS facilities.58
Cultural and Environmental Changes
Conditions in 2007. The 2007 investigation found that direct care staff, at the time called Juvenile Correctional Officers (JCOs), functioned almost exclusively as guards. They did not participate in or lead youth programming or activities, and there was no mention in their performance objectives of encouraging youth, reinforcing behavior, or being a role model for youth in DYS custody. Rather staff were trained to find problems and to sanction them. This confrontational approach created a hostile and violent culture in the facilities and negatively affected youth behavioral outcomes.59
Changing the role of direct care staff. In 2009, DYS changed the title of the direct care staff position to Youth Specialist. The agency expanded Youth Specialist job duties to include participating in and leading recreation activities, group discussions and treatment sessions; mentoring youth; mediating conflicts; acting as a member of the youth’s treatment team; implementing a strength‐based behavior management system; and serving as a pro‐social role model for youth. DYS expanded and improved training for Youth Specialists. These staff members are now highly involved in programming and treatment teams. At each facility, there are a core group of Youth Specialists who have good relationships with a wide range of youth. Youth are enthusiastic about naming and describing those staff members who they like and respect, and who they believe are genuinely trying to help them. Youth perceptions of safety in the facilities are also significantly improved, in large part because they believe there are people on staff who listen to them, look out for their best interests, and take action to protect them from harm. Each facility has implemented mentoring programs in which staff members adopt a youth as a mentee and meet with that youth regularly for informal and structured activities. These mentoring programs have provided an opportunity for youth to build a relationship with a special adult, which improves their confidence and helps them aim for and achieve higher aspirations. Importantly, mentor relationships have also helped change the attitudes and approaches of staff toward youth who are exhibiting problem behavior. Their interventions, framed within trusting relationships and an understanding of what motivates the youth, are more likely to de‐escalate volatile situations than those based solely on correctional security and control.60
More activities, more staff, and fewer youth. A new Program Administrator position was created at each facility to expand the range of programs and services for youth. The facilities have seen a marked
58 Don Sauter, CJCF site visit report (June 2011), pp. 2‐4, 7‐10, 12, 14; Don Sauter & Nick Makrides, CJCF site visit
 report (Apr. 2012), pp. 2‐9; Don Sauter & Nick Makrides, IRJCF site visit report (Apr. 2012), pp. 2, 4, 9; Don Sauter &
 Nick Makrides, CHJCF site visit report (Dec. 2011), pp. 2, 4, 6.
 59 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 25, 38, 73, 96‐97, 133‐135.
 60 Orlando Martinez, CJCF & SJCF site visit report (Jan. 2013), pp. 3, 6; Orlando Martinez & David Roush, IRJCF site
 visit report (Aug. 2012), pp. 7, 14, 16‐17, 19, 23; Orlando Martinez & David Roush, CHJCF site visit report (Aug.
 2012), pp. 13‐14, 18, 20; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), pp. 13, 16, 18, 28‐29,
 37‐38; David Roush, Report on DYS Bureau of Professional and Organizational Excellence and Human Resources
 (Sept. 2011), pp. 5‐6.

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increase in the quantity and quality of programming and activities, particularly on weekends and during school intersessions. In addition to programming focused on anger management and victim awareness, DYS facilities now offer a wide range of recreational activities (fitness activities, gardening, movie nights, concerts, game rooms, etc.), youth empowerment activities (Youth Council, house meetings, etc.), and community service activities. The Youth Council, which offers youth a meaningful role in facility decision‐making, is particularly noteworthy. DYS has implemented an outstanding teen‐ parenting program (the Baby Elmo project) designed to help incarcerated youth develop parenting skills and bond with their infants and toddlers. DYS has also expanded the work program for youth who have graduated from high school to constructively occupy the portion of their day that other youth spend in school. Youth interview for positions in the cafeteria, school, storeroom, with the maintenance staff, or with programming and recreation staff, and are paid by the hour. The ability to participate in activities and work opportunities incentivizes positive behavior. The reduction in youths’ idle time has also helped curtail gang activity. DYS sets benchmarks for participation in programming and recreation, and has recently begun auditing facilities to measure the quality and quantity of activities measured against those performance benchmarks.61
The increase in activities is paired with an incentive program in which youth earn points for engaging in positive behavior. They can spend those points on commissary items, additional phone calls, or entry into special events. The reduction in DYS’s youth population has allowed staff more time to interact with youth, and has made it easier for staff to engage youth in programming. It has also allowed for greater surveillance of youth, a safer climate on the housing units, and better opportunities to address gang‐related issues before they escalate. Fewer staff call off work due to stress or injuries. The reduced population and more positive environment have thus helped alleviate the chronic staffing shortages experienced by DYS in the past.62
Identifying and addressing youths’ criminogenic needs. The Ohio Youth Assessment System (OYAS), which the State has used to divert low‐ and moderate‐risk youth away from secure confinement, also provides a tool for use inside DYS facilities. The facility‐based OYAS tool helps DYS staff determine the types of interventions that will be most effective with youth, based on their risk to reoffend and their criminogenic treatment needs. This assessment along with various others (educational, medical, psychological, etc.) provide staff with the information needed to develop individualized treatment plans for youth. Cognitive Behavioral Therapy (CBT), DYS’s treatment modality, targets these criminogenic factors and helps to restructure or change the way youth think and respond in various situations. This is accomplished through learning and practicing pro‐social skills and behaviors. The introduction of CBT has provided a uniform language for Youth Specialists and behavioral health staff, and has helped to increase positive interactions between staff and youth. DYS has also adopted a promising gang intervention program and created a Security Threat Group Coordinator staff position at
61 Kelly Dedel, Compliance Review, Quality Assurance for Safe Living Conditions and Structured Programming (May 2013), pp. 2, 4‐5, 8‐11; Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), p. 16; Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), pp. 15‐16; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), pp. 19‐20, 28; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), pp. 40‐44. 62 Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), pp. 10, 14, 16, 22; Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), pp. 14, 19; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), pp. 13, 24, 27, 29; Kelly Dedel, et al., Monitor’s Fourth Report (June 2013), p. 14.
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each facility. The program creates a major shift in approach to gang‐involved youth. Rather than attempting to simply sanction all gang‐related behavior, which has not been successful in the past, the program aims to disengage youth from gang activity by understanding why they are getting involved in the first place. The program and the coordinator manage gang problems by creating a safe place for youth to talk about them; and providing alternatives, incentives, and supports for youth who want to disengage. At one DYS facility a survey to assess the perceived needs of gang members has gone even further to shift staff responses away from labelling these youth as troublemakers, and toward interventions that are based on their criminogenic needs.63
Family Engagement
Finding new and innovative ways to engage family members during a youth’s stay at DYS. In February 2010, DYS began the Families as Partners program with the Vera Institute of Justice. The project sought to promote better outcomes for youth in DYS custody by encouraging visits and correspondence between youth and their families and increasing family involvement in youth’s treatment and reentry plans. Staff have been trained in using the Vera Institute’s Juvenile Relational Inquiry Tool (JRIT) to recognize and reinforce the connections youth have to family members, mentors, and other supportive people in their social networks during and after incarceration. The State now provides free bus transportation every month to DYS facilities to promote family visitation. This is a remarkable development that has helped families overcome distance and transportation barriers that previously prevented them from visiting. In Ohio, increased family visitation led to improved youth outcomes. A study conducted by the Vera Institute, for example, found that more frequent family visitation was associated with fewer rule violation incidents and improved grade point average (controlling for race, age, school attendance and other variables). Facility staff members and juvenile parole officers (JPOs) also use video conferencing technology to conduct family visits, reentry conferences, and inter‐agency staffings. Video conferencing capability has expanded to all parole regions in the state and has helped youth stay in more frequent contact with supportive family and community members. Additionally, family members often participate by phone in youths’ monthly treatment team meetings. DYS has trained JPOs to conduct family coaching sessions, and continues to contract with monitoring team member Shay Bilchik to enhance JPOs’ family engagement efforts. The agency also adopted a Family Finder tool that has vastly increased the agency’s ability to identify family members who may serve as post‐release placement alternatives for youth, or as supportive individuals to help youth transition back into the community.64
63 Orlando Martinez, CJCF & SJCF site visit report (Jan. 2013), pp. 2, 4; Orlando Martinez & David Roush, IRJCF site visit report (Aug. 2012), pp. 9, 14, 18, 24‐26; Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), pp. 13, 21; Orlando Martinez & David Roush, CJCF site visit report (Feb. 2012), p. 11; Orlando Martinez & David Roush, SJCF site visit report (Jan. 2012), p. 8. 64 Shay Bilchik, Regionalization and Reentry Monitoring Report (Jan. 2012), p. 5; Shay Bilchik, Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 7‐9; see also Orlando Martinez & David Roush, CHJCF site visit report (Aug. 2012), p. 13; Vera Institute of Justice, Tools and Methods Used by the Family Justice Program, available at http://www.vera.org/centers/family‐justice‐program/tools‐and‐methods‐used‐family‐justice‐program; Vera Institute of Justice, Issue Brief, The Impact of Family Visitation on Incarcerated Youth’s Behavior and School
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Video segment: Click here to hear from youth about improvements in family engagement.
Mental Health and Psychiatry Services
Conditions in 2007. The 2007 investigation found that DYS facilities lacked even rudimentary mental health care and basic rehabilitation efforts. In most major areas of mental health service delivery, DYS lacked adequate policies and protocols. The agency had no core curriculum, no special training for clinical staff, and no unifying model of psychotherapeutic intervention. Mental health services were profoundly understaffed given the prevalence and severity of mental health disorders present in the youth population. Staffing levels did not permit opportunities for adequate assessment or regular group and individual therapy because of the frequency and urgency of crisis interventions. Mental health needs went largely undiagnosed and untreated, and related risks (preventable deterioration, self‐harm, etc.) increased due to the understaffing. The investigation found virtually no proactive mental health services. Treatment was essentially “on demand” through verbalizing intent to harm oneself or actually engaging in self‐injurious behavior. Youth used the threat of suicide simply to get an opportunity to speak with a psychologist, and the relatively few clinical staff members spent most of their time responding to crises.65
Access to inpatient psychiatric care was not available for youth under the age of 18, meaning those who experienced acute psychiatric symptoms were managed in DYS facilities rather than in the hospital. In the facilities, youth remained on suicide watch for unreasonably long periods of time (weeks or months) without clear behavioral plans to intensify or modify treatment interventions in order to get them off watch and back to routine activities. The agency’s intensive Mental Health Units were little more than housing units. There was essentially no mental health program above that available to any other youth housed in the general population. Staff on those specialty units had no additional mental health training, and services for those with the most serious levels of mental health need were grossly inadequate.66
Staff members of the various disciplines (social work, psychology, psychiatry) did not function as a team or provide consistent direction for youth treatment. There was no single mental health clinical treatment plan. Fragmented documentation and communication impeded the sharing of information needed to address youths’ symptoms and behaviors. Psychiatric services were extremely limited and did not include much more than medication monitoring every 30 days. Youth were subjected to inappropriate and harmful punishments for behaviors driven by mental health disorders. Special Management Plans for youth exhibiting disruptive behavior were not developed or approved by clinical staff, and involved excessive seclusion. The plans provided no defined goals that the youth should
Performance: Findings from the Families as Partners Project (Apr. 2013), available at
 http://www.vera.org/pubs/impact‐of‐family‐visitation‐on‐incarcerated‐youth.
 65 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 44‐45, 47‐52, 54, 58‐59, 61, 64, 66‐68, 74,
 76, 84, 97‐99, 152, 155‐156.
 66 Id., at pp. 50, 52, 55, 57‐58, 62, 65, 76, 83.

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work toward, or acceptable behaviors the youth should engage in as alternatives to disruptive behaviors. The quality of mental health care and psychiatry was not monitored internally. DYS did not have the capacity to identify and address problems with service delivery in a systematic manner, nor did they assess the performance of clinical staff members.67
Providing proactive rather than reactive mental health services. Since 2007, DYS has drafted and revised a comprehensive set of policies and procedures governing mental health and psychiatry services. The reduced youth population and increased clinical staffing has allowed for more than adequate behavioral health coverage. Clinical staff‐to‐youth ratios at the remaining DYS facilities range from 1:9 to 1:11. Clinical staff also work evenings and weekends, and psychologists are available after hours when necessary. Social workers, psychologists, occupational therapists, and psychiatric nurses now work as an integrated behavioral health team at each facility. Both social workers and psychologists work out of offices on the housing units, which has dramatically increased youths’ access to treatment providers. Youth are also now thoroughly screened and assessed at intake for treatment needs related to mental health and trauma symptoms. An individualized treatment plan is developed for each youth in DYS custody, and clinical staff meet monthly with Unit Managers, direct care staff, and the youth to review the youth’s progress in meeting treatment goals. The agency has also increased efforts to involve family members and other staff disciplines (medical, education, recreation) in these treatment team meetings. Clinical staff and direct care staff now engage youth in group sessions nearly every day (cognitive behavioral therapy, substance abuse treatment, sexual behavior treatment, occupational therapy, victim awareness, managing anger and violence, etc.), and have improved over time in their group facilitation skills. Social workers, psychologists, and psychiatrists also meet individually with youth as needed.68
Improved care for youth with the most serious mental health symptoms. DYS adopted appropriate suicide prevention policies and practices, and developed a plan to conduct relevant quality assurance monitoring and data analysis around suicidal incidents. The Mental Health Units now provide intensive treatment services for youth according to a well‐articulated trauma informed program. The roles and responsibilities of direct care staff and clinical staff are clearly defined, and all staff working on these units as well as the Life Skills Units (for youth with developmental disabilities) receive additional training to work with these special needs populations. The program includes meaningful leadership roles for youth, including the opportunity to serve as peer mentors. The efforts of staff and administrators overseeing services on the Mental Health and Life Skills Units have resulted in fewer fights and assaults, and dramatically less disciplinary seclusion. Youth on these specialty units also show improvement in symptoms related to trauma and depression, as measured by pre‐ and post‐tests on various assessment tools. Any youth needing inpatient psychiatric care can now be hospitalized and
67 Id., at pp. 29, 31, 45, 53, 61, 66‐67, 74‐75, 78, 153.
 68 Andi Weisman, CJCF site visit report (Jan. 2013), pp. 2, 4; Andi Weisman, SJCF site visit report (Jan. 2013), pp. 14,
 18; Daphne Glindmeyer, Monitor’s Fourth Report, Addendum – Mental Health Provisions, U.S. Department of
 Justice v. The State of Ohio (June 2013), pp. 5, 7, 9, 11, 13‐14, 18‐22, 25 [hereinafter “Monitor’s Fourth Report,
 Addendum”]; Andi Weisman, CHJCF & IRJCF site visit report (Sept. 2012), pp. 26‐27, 32, 36, 43, 45‐46.

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treated for acute symptoms, and DYS is exploring alternative placement options for youth who need long‐term residential treatment.69
Treatment‐based interventions for youth with disruptive behavior. Having determined that the use of seclusion as a disciplinary sanction was ineffective and harmful to both youth and staff, DYS created a more intensive clinical process for youth who engage in acts of violence (AOVs). In collaboration with the subject matter experts and other stakeholders, DYS committed to two essential clinical requirements following AOVs. The first was a review and potential revision of the individual treatment plan following each AOV. The second requirement was a formalized process to address the mental health needs of youth who engage in repeated AOVs. Within DYS secure facilities for boys, youth who engage in repeated AOVs are managed by Special Review Teams (SRTs) consisting of the youth, his primary clinician, Unit Manager, and social worker. The purpose of the SRT is to identify the causes and functions of the AOVs, to prescribe more intensive interventions aimed at addressing the root causes of the behavior, and to recommend updates to the Individualized Treatment Plan (ISP). The SRT meets with the youth until his challenges have been resolved.70
The girls’ contract facilities are not enjoined in the lawsuit and their practices and documentation are not obligated to mirror the processes in place in facilities operated by DYS. However the subject matter experts’ review of practice and documentation for the contract facilities makes clear that they are all functionally equivalent to what is provided within DYS. The partnership DYS has established with the girls’ contract programs is exemplary. Girls are now served in softer, more resource‐rich environments. The collaboration among the facilities and with the Department’s central office has led to robust clinical oversight of the treatment girls are receiving.71
Improved psychiatry services. Psychiatrists in DYS facilities conduct extensive reviews of available clinical information in preparation for psychiatry clinic. They meet regularly with youth who are treated with psychotropic medications and monitor for treatment efficacy and side effects. The clinicians appropriately document the plan and rationale for treatment interventions. Youth who require treatment with psychotropic medications are identified, with medications prescribed as necessary. Medication regimens are appropriate and do not include excessive dosing or polypharmacy. The psychiatrists are supported by psychiatric nurses at each facility who assist with the informed consent process, and who conduct chronic care monitoring (weight, body mass index, vital signs, lab results, etc.) for prescribed psychotropic medications.72
69 Daphne Glindmeyer, CJCF site visit report (Jan. 2013), p. 5; Daphne Glindmeyer, Monitor’s Fourth Report,
 Addendum (June 2013), p. 7; Andi Weisman, CHJCF & IRJCF sit visit report (Sept. 2012), pp. 16, 18‐21, 28, 34;
 Daphne Glindmeyer, Report on DYS Compliance with Psychiatry Provisions of S.H. Consent Order (Dec. 2013), pp.
 4, 6.
 70 Kelly Dedel, et al., Monitors’ 6‐Month Report on Compliance with The Grid (June 2015).
 71 Kelly Dedel, et al., Monitors’ Review of DYS’ Contracted Programs for Girls (Nov. 2015).
 72 Daphne Glindmeyer, CJCF site visit report (Jan. 2013), pp. 1‐3, 6, 9‐10, 13; Daphne Glindmeyer, IRJCF site visit
 report (Sept. 2012), pp. 1‐4, 6‐7, 10; Daphne Glindmeyer, Monitor’s Fourth Report, Addendum (June 2013), p. 32;
 Daphne Glindmeyer, Report on DYS Compliance with Psychiatry Provisions of S.H. Consent Order (Dec. 2013), p. 8
 (revised Jan. 2014).

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Quality assurance monitoring and peer review. DYS has improved its internal quality assurance monitoring since the 2007 fact‐finding investigation. Supervisors now observe behavioral health staff leading group sessions and conducting treatment team meetings. They provide feedback based on their observations and reviews of clinical documentation. Psychologists now conduct peer review for one another, and DYS’s administrative psychiatrist conducts peer review for facility psychiatrists. DYS has used this quality assurance monitoring and peer review system to place clinical staff on Performance Improvement Plans and to terminate staff when appropriate.73
DYS is now able to identify and respond to issues within the system, determining whether additional staff training, alterations to policy, or increased clinical supervision for a provider is necessary. Their quality assurance monitoring creates a structure to assure and maintain the clinical quality of mental health services provided to the youth in their care, and has been expanded to include reviews of the mental health treatment provided to girls in contract facilities. The contract facilities have been open to the quality assurance monitoring by DYS and receptive to technical assistance when necessary. Their collaborative relationship has been evidenced by improvements in documentation of the treatment occurring at contract facilities. Mental health services for girls in the contracted facilities are commensurate with those services provided to boys in DYS facilities.74
More continuity of care for youth returning home. For youth returning to their home communities, DYS now provides documentation summarizing their diagnoses, course of treatment while in custody, medications and dosages, and any notes on need for follow‐up treatment in the community. Youth return home with a 30‐day supply of medications, and are now presumptively eligible for Medicaid coverage, because of a policy change recommended by Ohio’s Interagency Task Force on Mental Health and Juvenile Justice. This change in state Medicaid law has helped countless youth overcome financial barriers to treatment upon reentry, which in turn has contributed to lower recidivism rates.75
Video segment: Click here to hear from youth about improvement in mental health services.
Release from Secure Custody
Release practices in 2007. Youth and staff in 2007 expressed confusion and exasperation over the release decision process. Decisions made by the Release Authority were inconsistent with one another. They were made without clear‐cut criteria for releasing youth back to their communities or extending their stays in DYS custody. The fact that youth did not know when they were going home or how that decision was being made undermined the effectiveness of DYS’s behavioral incentive system and rehabilitative efforts. Youth stays were also extended because of factors beyond their control, like
73 Andi Weisman, SJCF site visit report (Jan. 2013), pp. 17‐18; Andi Weisman, CHJCF & IRJCF site visit report (Sept.
 2012), pp. 48‐50; Daphne Glindmeyer, CJCF site visit report (Jan. 2013), p. 15; Daphne Glindmeyer, Report on DYS
 Compliance with Psychiatry Provisions of S.H. Consent Order (Dec. 2013), p. 3 (revised Jan. 2014).
 74 Kelly Dedel, et al., Monitors’ Review of DYS’ Contracted Programs for Girls (Nov. 2015).
 75 Daphne Glindmeyer, Monitor’s Fourth Report, Addendum (June 2013), p. 43; Ohio Interagency Task Force on
 Mental Health and Juvenile Justice, Report and Recommendations (Sept. 2012), p. 8.

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delays in programming or staff members’ failure to complete paperwork. Extensions like these made the release process seem not only arbitrary, but unfair.76
Clear‐cut criteria for denying release. DYS developed a Standard Operating Procedure that directs the Release Authority to release youth at their minimum sentence or parole eligibility date unless the panel members determine that one or more barriers to release exist. The procedure narrowly defines three specific barriers. Youth may be denied release when a clinical assessment and risk assessment provide sufficient evidence that the youth, if released, will present a risk to public safety. They may be denied release if they have recently engaged in serious (usually violent) rule violations in the institution. And they may be denied release if they have not completed necessary treatment. This third barrier may only be applied if the treatment is known to be effective, is available in the institution, and cannot be provided safely in the community. For situations that do not fit into one of the defined barriers, but that do warrant denial of release (for example, an alleged assault on a staff member without sufficient time to investigate before a youth’s release date), the procedure allows for the rare use of administrative overrides. Some problems persisted with implementation of this release procedure into 2011. For example, the Release Authority continued to deny release without sufficient facts to support any of the defined barriers, or concluded that there was a treatment barrier to release even though alternative treatment was available in the community. These problems have since been corrected, and the Release Authority now consistently follows the Standard Operating Procedure. Barriers to release are invoked sparingly, and each quarter between 70 and 90 percent of youth reviewed are released on their minimum sentence expiration date. Both youth and staff now increasingly report that the release process is fair and consistent. Youth also have a meaningful process now to appeal denials of release.77
Conducting internal quality assurance monitoring. DYS collects and analyzes a significant amount of data related to the activities of the Release Authority. This monitoring ensures that release plans are developed in a timely manner, that release reviews are timely and follow procedural requirements, that youth and their family members are present for reviews, and that the panel complies with the rules regarding release denials. Decisions of the Release Authority are monitored monthly to identify and correct problems with individual panel members and to address systemic issues. Panel members have received training on communicating with youth who have mental health disorders. DYS facilities and the youth’s treatment team are assessed for their compliance with procedures, their assistance to youth during release reviews, and the quality of their documentation. DYS also monitors treatment teams to ensure that they offer youth assistance with appeals.78
76 Fred Cohen, Final Fact‐Finding Report, S.H. v. Stickrath (Jan. 2008), pp. 19‐20, 98, 174‐176, 178‐179, 183.
 77 Vince Nathan, First Report on Requirements Relating to the Release Authority (June 2011), pp. 17‐18, 22‐23, 28,
 40, 55; Vince Nathan, Supplemental Report on Requirements Relating to the Release Authority (Aug. 2011), pp. 2,
 6; Vince Nathan, Third Report on Requirements Relating to the Release Authority (Jan. 2013), pp. 4‐5, 8‐12, 16‐17;
 ODYS Standard Operating Procedure 704.01.04.
 78 Vince Nathan, Report on the Quality Assurance Plan for the Release Authority (Apr. 2013), pp. 3‐4; ODYS Release
 Authority Quality Assurance Plan Narrative (Apr. 2013), pp. 1‐4.

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Reducing the Incarcerated Population
Downsizing the juvenile prison system by increasing effective local alternatives. Drawing significant national attention for its efforts, Ohio safely downsized its juvenile prison population from over 2000 youth several years ago to less than 500 today. DYS partnered with juvenile courts throughout the state to increase the capacity at the county level to effectively supervise and serve youth. The project expanded the availability of local treatment options (residential and non‐residential) and the use of small (12‐24 bed) community‐based facilities. The state provided counties with financial incentives to use those dispositional alternatives rather than commit youth to state‐run correctional facilities. This initiative, called RECLAIM Ohio, was bolstered by the Targeted RECLAIM initiative, which expanded evidence‐based disposition alternatives in the state’s six largest counties. Targeted RECLAIM has been extremely successful, and has since been broadened to include an additional eight counties. DYS also partnered with the largest counties on a similar project – the Behavioral Health / Juvenile Justice Initiative – focused on increasing local mental health resources for youth whose involvement in the juvenile justice system stems from underlying mental health disorders. This initiative has recently been expanded to six additional counties. Ohio’s downsizing efforts have succeeded in large part due to extensive advanced planning between DYS and local courts, a level of collaboration which is unique among states with bifurcated (local and state) juvenile justice authority.79
Risk assessment tools used to inform placement decisions. DYS and the University of Cincinnati developed and implemented a risk assessment tool (the Ohio Youth Assessment System) state‐wide, dividing youth into low‐, moderate‐, and high‐risk categories. Tracking outcomes for each category of youth, DYS and its partners found that placement in secure facilities increased recidivism rates for low‐ and moderate‐risk youth. These youth reoffended at far lower rates when they were served in evidence‐based community alternatives. Armed with this data, juvenile justice practitioners in Ohio have been better able to push for deinstitutionalization of low‐ and moderate‐risk youth as a public safety measure.80
JDAI and DMC initiatives. DYS has provided support to five of the state’s biggest counties as they have become involved in the Juvenile Detention Alternatives Initiative (JDAI). The JDAI methodology has been proven to reduce the unnecessary detention of youth without increasing pre‐trial offending, and has also helped reduce commitments to DYS facilities. Additionally, with the support of federal funding, DYS joined forces with 24 county courts to address the over‐representation of minority youth in the state’s juvenile justice system. Working in concert with the Ohio State University, DYS assisted with the planning and implementation of strategies to reduce disproportionate minority confinement
79 Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), pp. 1‐3, 6; Shay Bilchik, Regionalization and Reentry Monitoring Report (Jan. 2012), pp. 2, 4; Shay Bilchik, Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 2‐4, 13; Ohio Department of Youth Services, Message from Director Harvey Reed (Jan. 22, 2014). 80 See Comments of Ed Latessa, Director of the University of Cincinnati School of Criminal Justice, at the DYS Annual Stakeholder Retreat (Sept. 25, 2013); Ed Latessa, et al., The Ohio Youth Assessment System, Final Report (July 2009), available at http://www.uc.edu/content/dam/uc/ccjr/docs/reports/project_reports/OYAS_final_report.pdf.
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(DMC). Independent evaluations confirm that these projects have been effective at reducing disparities, diverting youth away from the juvenile justice system, and lowering rates of re‐offending.81
Improvements to parole and reentry efforts. In response to data analyses showing that low‐ and moderate‐risk youth were not benefitting from lengthy periods of parole, DYS shortened parole terms. This left the agency adequate time to help youth transition back to the community, while not keeping youth on parole for such long periods that they would likely incur technical violations. This change, plus the reduced facility population, has led to a decline in Juvenile Parole Officer (JPO) caseloads. DYS continues to contract with subject matter expert Shay Bilchik to ensure that with these smaller caseloads, JPOs engage more productively with youth and their families before and after release, spend more time in joint case management with facility staff, and partner with community resources to improve reentry services.82
Dramatically improved outcomes and cost savings. Formal program evaluations found that youth who were diverted away from state‐run juvenile facilities had lower recidivism rates, less school interruption, more family engagement in treatment, and better behavioral health outcomes. Numerous S.H. monitoring reports support the assertion that the lower institutional population has helped to decrease violence in the facilities. One cost‐benefit analysis found that every dollar spent on RECLAIM Ohio saved the state between $11 and $45 in confinement and recidivism costs (depending on youth risk levels). Additionally, the closure of five state‐operated facilities saves the state millions of dollars each year in operational costs.83
Additional Accomplishments
Despite its length, this report cannot and has not captured all of the Department’s accomplishments during the last eight years. Whether outside the scope of monitoring, or occurring after the termination of monitoring in a particular subject area, these additional accomplishments are part of the Department’s culture, operations, and legacy, and are worthy of special mention. They include: providing apprenticeships that combine work‐based learning with related classroom instruction, as well as other advancements in educational and employment programs;84 establishing the Office of
81 Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), p. 5; Shay Bilchik,
 Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 15‐16.
 82 Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), p. 3; Shay Bildhik,
 Regionalization and Reentry Monitoring Report (Dec. 2012), pp. 9‐10.
 83 See Shay Bilchik, Report on Stipulations 13, 14, and 15 of the S.H. Stipulation (May 2011), p. 2; Shay Bilchik,
 Regionalization and Reentry Monitoring Report (Dec. 2012), p. 3; Ohio Department of Youth Services, Targeted
 RECLAIM, available at http://www.dys.ohio.gov/dnn/Community/TargetedRECLAIM/tabid/211/Default.aspx.
 84 See Ohio Department of Youth Services Fiscal Year 2015 Annual Report, available at
 http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=F%2bdUC7IbbIw%3d&tabid=102&mid=544; Ohio
 Department of Youth Services, Message from DYS Director Harvey Reed, Apprenticeships Prepare Youth for
 Workforce (Nov. 2015), available at
 http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=pFVSDl%2bySgE%3d&tabid=176&mid=897.

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Quality Assurance & Improvement to increase accountability and improve processes and outcomes;85 adopting the performance‐driven grant program, Competitive RECLAIM, to incentivize local communities in Ohio to develop evidence‐based services to meet the needs of youth and their families;86 expanding the Juvenile Detention Alternatives Initiative to additional counties to create alternatives to the use of secure detention and reduce the disproportionate confinement of youth of color;87 implementing the Baby Elmo Visitation Program to help youth who have children of their own build relationships with, and learn to care for, those children;88 participating in new violence prevention efforts, including the 40‐day Power of Peace Project;89 creating virtual tour videos to allow youth and families to see facilities prior to a youth’s arrival, and expanding efforts to encourage family involvement in youth’s treatment and programming;90 establishing core values for the Department through a series of town hall meetings with Department staff on all shifts;91 and many more.
Conclusion
The State of Ohio has accomplished a transformational change in the culture and daily operations of their juvenile corrections system. The toxic conditions that once existed in DYS facilities are not uncommon in juvenile corrections systems across the country. But they should be. This model system – the Ohio Model – came about because state leaders and stakeholders committed to reinventing a system based on the best research and practices in the field. The Department’s administration and line staff could have become trapped in the whirlpool of fears about abandoning old practices, particularly the use of disciplinary seclusion and notions about punishing juvenile offenders. Instead they demonstrated courage, resolve, and compassion to create a more humane and safe environment for both youth and staff. Furthermore, the monitoring model that offered up technical assistance from national experts opened up the possibility of tracking progress and outcomes across a variety of measures. As the Court withdraws its oversight, the Department is well equipped to monitor itself through quality assurance processes and to work with
85 See Ohio Department of Youth Services Fiscal Year 2014 Annual Report, available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=RcOcYya1FM8%3d&tabid=102&mid=544; Department of Youth Services Office of Quality Assurance and Improvement, http://www.dys.ohio.gov/dnn/InsideDYS/OfficeofQualityAssuranceandImprovement/tabid/219/Default.aspx. 86 See Ohio Department of Youth Services, Director’s Monthly Brief (Feb. 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=QRzTgx6ignw%3d&tabid=80&mid=540. 87 See Ohio Department of Youth Services, Director’s Monthly Brief, Juvenile Detention Alternatives Initiative Expands (Mar. 2014), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=1UeYmDu7zkQ%3d&tabid=80&mid=540. 88 See Incarcerated Fathers Learn How To Be Better Parents, WKYC (June 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=s9Va3pukgYQ%3d&tabid=78&mid=542. 89 See Ohio Department of Youth Services, Director’s Monthly Brief, Teaching Youth to Pursue Peace (Apr. 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=o9YKpfBH1L0%3d&tabid=80&mid=540. 90 See Ohio Department of Youth Services, Message from DYS Director Harvey Reed, Virtual Tour of DYS Facilities (Nov. 12, 2014), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=WJhHYwlpL8c%3d&tabid=176&mid=897. 91 See Ohio Department of Youth Services, Director’s Monthly Brief, Rising to the Next Level with DYS Core Values (May 2015), available at http://www.dys.ohio.gov/DNN/LinkClick.aspx?fileticket=eTwHNJRJ0Mo%3d&tabid=80&mid=540.
37


Case: 2:08-cv-00475-ALM-MRA Doc #: 159 Filed: 12/07/15 Page: 39 of 39 PAGEID #: 3238
stakeholders, youths’ families, and advocates to continually improve. Ohio is now a model not just for other states facing litigation, but for all jurisdictions examining the best practices in the field of juvenile corrections. To those who have put years of hard work into these systemic reforms, we applaud you. You’ve accomplished an immense change. Sustaining this change – this legacy – will require your ongoing commitment. We know you take great pride in this work. On behalf of the Court, we take great pride in this work too. Thank you and congratulations.
38


 Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 1 of 6 PAGEID #: 3130

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

S.H., et aIl.,
Plainttiffs,
v.
HARVEY J. REED, Defeennddant.

) ) ) ) ) CIVIL ACTION NO. 2:04-cv-1206 ) ) )

UNITED STATES OF AMERICA, Plaintiff,
v.
THE STATE OF OHIO, etaaL, Defenndants.

)

)

)

)

)

CIVIL ACTION NO. 2:08-cv-475

)

)

)

JUDGE ALGENON L. MARBLEY

)

)

AGREED ORDER On February 18,,22014, Plaintiffs in S.H v. Reed filed a motion for specific performance (Doc 389), and alleged a failure "to provide adequate treatment to youth who are or have been on the mental health caseload. As a result many of these youth are experiencing excessive periods of seclusion ...." lId at p. 1L. On March 12, 2014, the United States filed a motion for a temporary restraining order in United States v. Ohio raising concerns about Defendants' use of seclusion for all youth with an identified mental health disorder. (Doc 1311). The United States also filed a supplemental complaint. (Doc 140). Shortly thereafter, the parties engaged in settlement negotiations aimed at addressing the issues raised in those filings. The Court hereby consolidates these actions under Fed R. Civ. Proc. 42. They shall retain their separate status but be consolidated for the purpose of case

- - - ---- ------

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 2 of 6 PAGEID #: 3131

management and monitoring. The terms of this Order are intended to be implemented consistent with Docs 108 and 359 in S.H v. Reed and with Doc 85 in United States v. Ohio.
Attached as Exhibit A to this Order is the agreed grid that details the actions Defendants will undertake to improve mental health services and reduce seclusion of youth who are on the mental health caseload. The actions and deadlines included in the attached grid are hereby incorporated into this Order. Defendants' compliance with those terms will be co-monitored by Mr. Will Harrell and Dr. Kelly Dedel under the Court's jurisdiction, and monitoring will continue until Defendants have maintained substantial compliance with all provisions and performance measures for six months.
Upon entry of this Order, Plaintiffs in S.H v. Reed agree to withdraw their pending motions (Docs 389 and 390) without prejudice. The United States agrees to withdraw without prejudice its renewed motion for a temporary restraining order. (Doc 145). Because Defendants have committed to the eventual elimination of disciplinary seclusion for all youth housed in a DYS facility and to engage with the monitors and subject matter experts within six months hereof to formulate steps to reach that goal, the United States also agrees to withdraw without prejudice the claims in its supplemental complaint concerning youth who are not on the mental health caseload. (Doc 140). The United States agrees that it may not renew those claims until one month after the effective date of a request that this Court conduct a conference with the United States and the Defendants regarding a resolution oftthe United States' claims and that the effective date for a conference request shall be no sooner than seven months from the date of this Order.
On a quarterly basis starting July 31, 2014, DYS will provide AMS reports for youth not on the MHCL, but who were held in seclusion for an act of violence, that will contain a narrative
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 3 of 6 PAGEID #: 3132

of the incident resulting in seclusion, the AMS number, the date and time the youth went into seclusion and the date and time the youth was released from seclusion, the date the youth entered DYS, the date the youth was released from DYS (if youth has been released) and the type of seclusion. On July 31, 2014, DYS shall send the monitors such documents from May 1, 2014 to July 30, 2014. These documents will be provided quarterly until DYS reaches substantial compliance with regard to seclusion, or the lawsuit terminates, whichever occurs first. The monitors may share this information with counsel for the United States and S.HH. Plaintiffs.
The following areas are hereby removed from monitoring: psychotropic medication, sufficiency of psychiatric resources, and equitable treatment. The remaining areas of monitoring (QAl/QI and peer review for mental health and psychiatry, case formulation, fidelity of treatment provided to treatment model, treatment planning and treatment teams, behavior contracts, suicide prevention, and discipline for youth on the mental health caseload through the intervention hearing process) are addressed by the grid and will be monitored in accordance therewith.
This Order is necessary to address and redress ongoing constitutional violations already found, and the relief set forth herein is narrowly drawn, extends no further than necessary, and is the least intrusive means to do so. Defendants may seek to terminate this Order no earlier than July 15,,2015 at which time the SS.HH. Plaintiffs and United States shall bear the burden of proof to demonstrate the existence of an ongoing violation of federal law and that the current order reflects narrowly drawn relief which extends no further than necessary and is the least intrusive means to remedy that violation.
IT IS SO STIPULATED AND AGREED FOR S.H. PLAINTIFFS:
DATE: May 20,2014
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 4 of 6 PAGEID #: 3133


sfAlphonse A. Gerhardstein ALPHONSE A. GERHARDSTEIN (Ohio Bar No. 0032053) Trial Attorney for Plaintiffs Gerhardstein && Branch Co. LPA 432 Walnut Street, Suite 400 Cincinnati, Ohio 45202 (513) 621-9100 (513) 345-5543 fax agerhardstein@gbfIirm.com

s/fKim Brooks Tandy KIM BROOKS TANDY (Ohio Bar No. 0076173) Attorney for Plaintiffs Children's Law Center, Inc. 104 East 7th Street Covington, Kentucky 41011 (859) 431-3313 ktandy@childrenslawky.org
Attorneys for Plaintiffs

4

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 5 of 6 PAGEID #: 3134


IT IS SO STIPULATED AND AGREED FOR THE UNITED STATES:

DATE: May 20,,220014
CARTER STEWART United States Attorney Southern District of Ohio

JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice

lIsi/ Deborah F. Sanders
DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 {(T) (614) 469-5653 (F) Deborah. Sanders@usdoj. gov

EVE HILL Deputy Assistant Attorney General Civil Rights Division
JONATHHAANNM. SMITH Chief Special Litigation Section
lIsi/ Benjamin 0O. Tayloe., Jr. BENJAMIN 0O. TAYLOE, JR. Deputy Chief Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 514-8103 (T) (202) 514-4883 (F) Benjamin.Tayloe@usdoj.gov SILVIA J. DOMINGUEZ-REESE CYNTHIACOE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
Attorneys for Plaintiff

5

Case: 2:08-cv-00475-ALM-MRA Doc #: 148 Filed: 05/21/14 Page: 6 of 6 PAGEID #: 3135

IT IS SO STIPULATED AND AGREED FOR DEFENDANTS REED AND THE STATE OF OHIO, ET AL.:

DATE: May 20,2014

/Is/ Judith Goldstein JUDITH GOLDSTEIN (Ohio Bar No. 0069655) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-7233 Fax: (614) 728-9327 Judith. goldstein@ohioattorneygeneral. gov

/Isl/ Thomas Anger THOMAS ANGER (Ohio Bar No. 0088577) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-8742 (877) 584-2041 Thomas.anger@ohioattorneygeneral. gov

Attorneys for Defendants

:bL WHEREFORE, for good cause shown, this ORDER shall be entered this ~ day of
~2014

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 1 of 9 PAGEID #: 3136
EXIDBIT A
YOUTH ON THE MENTAL HEALTH CASE LOAD: PROPOSAL TO REDUCE VIOLENCE AND IMPROVE THE RESPONSE TO VIOLENCE IN DYS FACILITIES

A..1l1l Vrcrrlfy Trcqtmcot 'lnfmfty

eCLLJlIJ Reduce RcIlIlqnq po SuullI1ll1liippo

• Quality Assurance (QOA) will be put in place to ensure that individual treatment is aligned with

• No intervention seclusion {(IS) for High Severity (e.g., fight, consensual sexual activity), unless the victim requires off­

treatment goals. Each month, the PsyycchhoololoBgYy Supervisor will sample 2 files per clinician. Monitors will review the cases sampled and the completed QOA audit tools.
• Timel;jne: o Tools are developed; o Will be implemented by May 1, 2014.

grounds emergency medical treatment (and then up to 24 hours can be imposed).
• Interdisciplinary Team {(lIODT) determines sanction.
• Timelines: o Policy changes to be completed by June 30, 2014. o OQA for Performance Measure by July 15, 2014. o Training Completed by August 31, 2014.

• OQA will be put in place to verify that group treatment displays fidelity to design. Each month,

o Implementation by September 1, 2014.

a sample of groups {(MManaging Anger and

Violence, Cognitive Behavioral Therapies overlays,

etc.) will be audited using a OQA tool that has been drafted. Monitors will review the completed OQA

tools.

• Timeline: o Tools are under development, will be sent to

Monitors immediately for input; o Will be implemented by May 1, 2014.
Perdformanccee MMeeasure A.l

I Pediforrmmoance MMeeasure B8..1l • Proportion of youth who commit High Severity infractions
who were given intervention seclusion (should be 0%,

• 90% of all cases reviewed showed correspondence between content of individual sessions and treatment goals.

unless victim required off-grounds emergency medical treatment).

• 90% of all groups included in the sample score 80% or better on a measure of treatment fidelity.

'C1111 TmzJmmt Plgqn RBmmCcWw
• Within 2 days of every AOV, the treating clinician/lOT will review the treatment plan to identify antecedents and function of the behavior; review treatment goals and interventions. If implementation of existing plan has not been sufficient, it will be fortified. If existing plan was propertly implemented yet ineffective, it will be revised to include additional skill-development or environmental changes. May use Behavior Contract if appropriate.
• Intensity of treatment will be increased to 3x/week individual sessions for two weeks; daily homework will be assigned.
• Timeline: Implemented by July 1, 2014.
Perforcmmqqnncce MMeeasure (C,1.l • 90% of youth involved in AOV have Treatment
Plan Review within 2 days of the incident. o % of cases in which implementation was
fortified. o % of cases in which interventions were
revised. o These should total 100%, not an option to
do nothing.

1

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 2 of 9 PAGEID #: 3137

A. Prevention S5ttt:att..a.t.e.s
A.lIl OQmmllOqRp 8Sl1o0PPsmycbbpSSqqcdlql Assmmvmncnt that
lnduda Qalfanflcma'l qgand Qlqqn9oSstfk fEqqaannuullqqrrllooan • Initial BioPsychoSocial Assessment includes a
broad range of informational sources and culminates in a clinical formulation and diagnostic formulation, which is reflected in the youth's treatment plan.
• Tjmeljone:
o Guidance on the formulation concept for Department of Youth Services (DYS) staff will be fully developed ASAP, with input from DYS clinicians and Monitors;
o TraininB for all clinicians will occur within 60 days of entry of this Order;
o QA tools will be developed and implemented by May 1, 2014.

8:tmmediate lnterverati~·strateates

8S..2l1l fRkedduuq" DyrpptIlon qpfS,dusslqo • Interim Measure: Effective no later than July 15, 2014, and
ending on September 1, 2014, any youth on seclusion (intervention or pre-hearing) for over 72 hours in a rolling 30-day period must be reviewed by the Treatment Teearmn and any continued seclusion must first receive approval from the Bureau Chief for Facilities or the Deputy Director before the seclusion continues past 72 hours in a rolling 3O0--day period. • TDImmeelijne for ijnterijm measure: Effective July 15, 2014.
• DYS will decrease the minimum length of stay (LOS) for youth engaged in AOVs to two to four hours, not to exceed 24 hours.
• The Safe to Release (STR) process will be initiated between two and four hours and if the youth refuses to engage or the suitability of the climate indicates safety concerns, staff will attempt to engage the youth every two to three hours thereafter, up to the 24 hour period.
• If the 24 hour period is reached and the youth continues to refuse or the suitability of the climate indicates safety concerns, the Superintendent must approve any further seclusion.
• TDImmeellines: o Poljicy changes to be completed by June 30, 2014. o QA for Performance Measure by July 15, 2014. o Training Completed by August 31, 2014. o Implementation by September 1, 2014.

C.ll SRCddgqll8Rccyy1fcw Tcqm (CSSSRD • Within 2 days of a youth's 2rnwdJ Severe or 3rnd1
High Severity AOV, he will be referred to the SRT for a clinical staffing, led by the psychologist and specifically focused on understanding and addressing the AOV behavior. • The SRT will function as the lIODT until the youth's behavior improves.
• The SRT will explore the causes and functions of the behavior and will prescribe interventions designed to address those causes and functions (e.g., Intensive Behavior Contract; staff mentor; change unit; skill building work; referral to Mental Health faciljity).
• Tijmeljine: Implemented by July 1, 2014.

• Decrease intervention seclusion time imposed for Severe AOVs (e.g., assault, sexual exposure/assault; imposed by Hearing Officer, not consecutive to pre-hearing seclusion (PHS)). o 1sstt gets Credit for TIime Served.
o 2trwwJJ gets up to 4 hours.
o 3nn1l gets up to 8 hours. o 4th gets up to 12 hours. o 5Sth+ gets up to 24 hours. o Unless victim requires off-grounds emergency medical
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 3 of 9 PAGEID #: 3138

;:-·:·-- ,;·~\.'.:!-'

-~; -~~j

A. ·Prevention Stri~;

Pedocrmgqnce MMeqsure A 2 • 90% of initial assessments include a solid
clinical/diagnostic formulation. Every month, a sample of cases will be reviewed by the Monitor andQQAA. • 90% of treatment plans reflect information from the formulation. Every month, a sample of cases will be reviewed by the Monitor and QA.

treatment, then up to 24 hours. o For the purposes of calculating how many previous
"Severe" rule violations youth have committed, the number of "Severe" rule violations is considered zero if a youth goes 30 days without a "•Severe" rule violation unless the superintendent decides otherwise; and, if so, the youth will be reviewed again in 30ddaays. o Served on Saturday and Sunday. o The State shall not substitute physical restraints for seclusion. • IDimmelijnes: o Policy changes to be completed by June 30, 2014. o QA for Performance Measure by July 15, 2014. o Training Completed by August 31, 2014. o Implementation by September 1, 2014.
Pedormoance MMeasure 8B.2 • Proportion of youth released at 4 hours or less. • 100% of youth were sanctioned according to the IS
graduated scheme. • 0% of youth spent more than 72 hours in seclusion in a
rolling 3£0k-dtay period (except in rare circumstances with approval from the Bureau Chief for Facilities or the Deputy Director).

Perforrmmance MMeasure C.2 • Number of youth involved in 2 Severe or 3 High
AOVs (descriptive). o SRT was convened within 2 days for 100%. o 90% of the SRTs explored the causes and
functions of the behavior. o 90% of the SRTs prescribed interventions
that addressed those causes and functions.

3

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 4 of 9 PAGEID #: 3139
8..331' Rnlusc Hqpcamn Apqclqtcd with Seudfustlqo
• Intervention seclusion is imposed only on Saturday & Sunday, to reduce interference with core programming.
• For IS, provide 1 hour out for every 4 hours in seclusion, during waking hours.
• Youth in IS participate in treatment activities, school and recreation out of their room and time counts toward seclusion hours if behavior is appropriate.
• Timelines: o Policy changes to be completed by June 30, 2014.
o OA for Performance Measure by July 15, 2014.
o Training Completed by August 31, 220014. o Implementation by September 1, 2014.
Performance Measure 8.3
• 90% of youth in intervention seclusion spent 4 inn//1loouut during waking hours.
• 90% of youth in intervention seclusion participated in all programming (e.g., recreation, treatment) that was scheduled during seclusion time.
8.441. Rnlusc Amulmnulqgtiqo qfSSeudfUwllqo
• To apply more than 72 hours of seclusion in a 30-day period: o Conduct Treatment Plan Review (see Strategy C.l1)). o Obtain approval from Bureau Chief for Facilities or the Deputy Director. o Monitors/Plaintiffs will be provided with information on youth reviewed on a monthly basis.
• UTImmeeljnes:
o Policy changes to be completed by June 30, 2014.
o OA for Performance Measure by July 15, 2014.
o Training Completed by August 31, 2014. o Implementation by September 1, 2014.
Performance Measure 8.4
• Number of youth secluded each month and number of
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 5 of 9 PAGEID #: 3140

A. PPrreveevnteionntStirloifnt!Sl~~.·

hours in seclusion (Monthly-for all youth on MHCL, provide date, type of AOV, PHS and IS). • Number of youth who spent more than 72 hours in 30day period (descriptive). o 90% received Treatment Plan Review. o 90% receive approval for exception to the 72 hour
rule. • TDImelipe:
o To be implemented by July 15,,22014.
8..551' Pcpyffddc, Cd"R, lntf!YYcotfqo Whlile In PHS • STR process will be initiated with every youth engaged in
an AOV between two and four hours. • STR process will include a structured interview by Social
Worker/Unit Manager/Operations Manager that discusses triggers, decision-making, external influences on behavior. • Timeline: o Obtain input from Monitor on STR interview guide by
Aprriill1, 2014. Completed. • Timelines:
o STR Interview Form developed and Policy changes to be completed by June 30, 2014.
o QA for Performance Measure by July 15, 2014. o Training Completed by August 31, 220014. o Implementation by September 1, 2014.
PPedorrmmaannce MMeeaasure 8.5 • STR process was initiated with 90% of youth within 4
hours. • 90% of STR checks examine the underlying causes of the
youth's behavior, both internal and external.
8.61J EEYRCantu_qtltvv Elllimmfianqatec Usc ofSu/lusilon
• DYS is committed to the eventual elimination of disciplinary seclusion for all youth housed in a DOYS facility. Thus, six months from the acceptance of this proposed settlement, DYS will engage the monitors and subject matter experts in formulating steps to take, and the timeline for completing those steps, to eliminate disciplinary seclusion.
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 6 of 9 PAGEID #: 3141

Stnlteltft"''
Omqll Pcdppccmmqqnnwq MMAgsuvCrCc;i Vlolcnq Rd"'ucctf1lqp • Increase proportion of youth who do not engage
in Acts of Violence (AOV) (baseline: February 14, 2014, 83% system-wide). • Decrease number and proportion of Mental Health Case load (MHCl) youth who engage in 3 or more AOVs each month (any severity). • A 10% reduction goal each month based upon the previous month's total.

• Timeline: o Six (6) months from the entry of this Order.
0OmvmqIf1l Pcdpnnqq"m" MMuawwt,!,;i W BcruJW uq Tfq*tq#f Su/luslop Hours
• Reduce the number of youth who serve 72+ seclusion hours per month by 10% each month, compared to previous month. o DYS to calculate pre-policy change total.

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 7 of 9 PAGEID #: 3142
DEFINITIONS "AOV" means act of violence.
"BioPsychoSocial Assessment" means an assessment of all biological, psychological, and social factors present for an individual in order to inform that individual's treatment.
"Disciplinary Seclusion," also known as "Intervention Seclusion," means a period of confinement in a locked room that is used as a disciplinary sanction following a Severe Rule Violation.
"DOJ" means the United States Department of Justice, which represents the United States in this matter.
"DYS" means the Ohio Department of Youth Services.
"Effective Date" means the date by which this Agreed Order has been signed by representatives for each of the parties to this Agreed Order and issued as this Court's Order.
"Facilities" or "Facility" means Scioto Juvenile Correctional Facility, Circleville Juvenile Correctional Facility, Cuyahoga Hills Juvenile Correctional Facility and Indian River Juvenile Correctional Facility, including any DYS facility that replaces or supplements any of those named facilities.
"High Rule Violation" means actions that create immediate and direct threats to the security, safe and order of the facility, its staff, visitors or youth.
"IlODT" means Interdisciplinary Team.
"Implement" means to give practical effect and ensure actual fulfillment by concrete measures, including appropriate training of relevant staff.
"Intervention Grid" means a DYS.grid of sanctions for rule violations ranging in severity from Low, to Moderate, High and Severe.
"Intervention Hearing" means a disciplinary hearing that is conducted, consistent with due process, to determine by a preponderance of the evidence whether a Severe Rule Violation has been proven or not proven.
"Intervention Seclusion," also known as "Disciplinary Seclusion," means a period of confinement in a locked room that is used as a disciplinary sanction following a Severe Rule Violation.
"LOS" means Length of Stay.
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 8 of 9 PAGEID #: 3143
"Mental Health Caseload" or "MHCL" means all youth with an identified mental health disorder, including those youth who have a psychiatric disorder, including but not limited to psychoses, schizophrenia, bipolar with psychotic features, depression with psychotic features, severe post-traumatic stress disorder, or schizoaffective disorders and who, consistent with reasonable professional judgment, DYS believes require psychiatric or psychological care.
"Monitor" means Will Harrell and Dr. Kelly Dedel, including anyone else the court or parties by agreement may designate as their replacements.
"Monitoring" at facilities other than Indian River, Circleville, Cuyahoga Hills, and Scioto means a review of youth files or other materials requested by the monitor or subject-matter experts. The parties agree to meet and confer should additional access be requested and a good faith effort will be made to resolve any such requests. Monitoring at Indian River, Circleville, Cuyahoga Hills, and Scioto shall otherwise be conducted in accordance with Doc 359 in SH v. Taft 04 cv 1206 and with Doc 85 in United States v. Ohio..
"Order" means this agreed order.
"Pre-hearing Seclusion" means placement of an out-of-control youth or a youth whose behavior poses an immediate threat to himself or others, in a locked room for a period of time until he or she regains control of his or her behavior and can be safely returned to the general population
"Quality Assurance/Improvement Program" or "QA" means a system of self-auditing and improvement to assess the implementation and effectiveness of all remedies instituted pursuant to this Order, to identify deficits that may exist, and to effectuate new measures to cure deficits identified.
"Restraints" means any chemical or mechanical device used to control the behavior of a youth.
"Safe to Release" means a determination pursuant to DYS guidelines that a youth should be released from Pre-hearing Seclusion.
"Seclusion," "seclude," and "secluding" mean isolating a youth in a room from which the youth's ability to egress is blocked. The term seclusion does not apply to locking a youth in a room during normal hours of sleep.
"Severe Rule Violation" means actions that have potential to create immediate and direct harm to the security, safety and order of the Facility, its Staff, visitors or youth, including assault, escape, sexual assault or riot/disturbance.
"Staff' means employees who work at any of the Facilities.
"Subject Matter Experts" means Dr. Daphne Glindmeyer, Dr. Andi Weisman, and anyone else the court or parties by agreement may designate as their replacements.
8

Case: 2:08-cv-00475-ALM-MRA Doc #: 148-1 Filed: 05/21/14 Page: 9 of 9 PAGEID #: 3144
"State" means the State of Ohio, Harvey Reed, Director of the Ohio Department of Youth Services, the Ohio Department of Youth Services, and their successors, contractors and agents.
"Treatment Fidelity" means strategies that monitor the implementation of a behavioral health intervention (e.g., group treatment) to ensure it is delivered according to design/curriculum/theory and that it is delivered in a comparable manner across all youth.
"Youth" means any juvenile or juveniles committed by a court to, and residing at, the Facilities during the pendency of this Agreed Order. The specific terms set out in the grid only apply to youth at facilities directly managed by DYS. Youth at other facilities shall receive mental health services consistent with those described herein but appropriately tailored for the such non-DYS managed facilities.
9

 Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 1 of 6 PAGEID #: 12833

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

S.H., et al.,

)

)

Plaintiffs,

)

)

v.

)

)

HARVEY J. REED,

)

Defendant.

)

____________________________________

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

CIVIL ACTION NO. 2:04-cv-1206
CIVIL ACTION NO. 2:08-cv-475 JUDGE ALGENON L. MARBLEY

JOINT MOTION FOR ENTRY OF AGREED ORDER The Parties in the above-entitled cases jointly move this Court to enter as its Order the attached Agreed Order and Exhibit A thereto, which embody the Parties’ agreement for a resolution of the Plaintiffs’ claims in these actions. In support of this motion, the Parties state as follows: 1. On December 20, 2004, the S.H. Plaintiffs filed a complaint (Doc 1 in S.H. v. Reed, 2:04-cv-1206) challenging conditions at Defendants’ juvenile correctional facilities. On May 16, 2008, the United States also filed a complaint (Doc 2 in U.S. v. Ohio, 2:08-cv-475) challenging conditions at Defendants’ juvenile correctional facilities. 2. On February 18, 2014, the S.H. Plaintiffs filed a motion for specific performance (Doc 389) and alleged a failure “to provide adequate treatment to youth who are or have been on

Case: 2:04-cv-01206-ALM-TPK Doc #: 400 Filed: 05/20/14 Page: 2 of 6 PAGEID #: 12834
the mental health caseload. As a result many of these youth are experiencing excessive periods of seclusion . . . .” Id at p. 1.
3. On March 31, 2014, the United States filed a supplemental complaint to include claims relating to Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility, and Cuyahoga Hills Juvenile Correctional Facility. (Doc 140). On April 29, 2014, the United States renewed its motion for a temporary restraining order in United States v. Ohio, raising concerns about Defendants’ use of seclusion for all youth with an identified mental health disorder (Doc 145).
4. Thereafter, the Parties engaged in settlement negotiations aimed at addressing the issues raised in those filings, and the parties have now reached agreement on a resolution of Plaintiffs’ claims. The Parties’ agreement is embodied in the Joint Proposed Order and Exhibit A thereto, which is attached to this motion.
ACCORDINGLY, the Parties request that the Court enter the attached Joint Proposed Order and Exhibit A thereto as its Order. Subject to the conditions in the Joint Proposed Order, the S.H. Plaintiffs request that the Court dismiss without prejudice their motion for specific performance, and the United States requests that the Court dismiss without prejudice the United States’ renewed motion for a temporary restraining order and the claims in the United States’ supplemental complaint concerning youth who are not on the mental health caseload.
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DATE: May 20, 2014
s/ Alphonse A. Gerhardstein ALPHONSE A. GERHARDSTEIN (Ohio Bar No. 0032053) Trial Attorney for Plaintiffs Gerhardstein & Branch Co. LPA 432 Walnut Street, Suite 400 Cincinnati, Ohio 45202 (513) 621-9100 (513) 345-5543 fax agerhardstein@gbfirm.com

s/Kim Brooks Tandy KIM BROOKS TANDY (Ohio Bar No. 0076173) Attorney for Plaintiffs Children’s Law Center, Inc. 104 East 7th Street Covington, Kentucky 41011 (859) 431-3313 ktandy@childrenslawky.org
Attorneys for Plaintiffs

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DATE: May 20, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov

JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
EVE HILL Deputy Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Chief Special Litigation Section
/s/ Benjamin O. Tayloe, Jr. BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 514-8103 (T) (202) 514-4883 (F) Benjamin.Tayloe@usdoj.gov SILVIA J. DOMINGUEZ-REESE CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
Attorneys for Plaintiff

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DATE: May 20, 2014
/s/ Judith Goldstein JUDITH GOLDSTEIN (Ohio Bar No. 0069655) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-7233 Fax: (614) 728-9327 Judith.goldstein@ohioattorneygeneral.gov

/s/ Thomas Anger THOMAS ANGER (Ohio Bar No. 0088577) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-8742 (877) 584-2041 Thomas.anger@ohioattorneygeneral.gov

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Certificate of Service I HEREBY CERTIFY that this date, May 20, 2014, I caused the foregoing to be electronically filed with the Clerk of the Court using the CM/ECF system, which will simultaneously serve notice of such filing to counsel of record and the Court Monitor to their registered electronic mail addresses.
/s/ Thomas Anger THOMAS ANGER (Ohio Bar No. 0088577) Assistant Attorney General Criminal Justice Section 150 East Gay Street, 16th Floor Columbus, Ohio 43215 (614) 644-8742 (877) 584-2041 Thomas.anger@ohioattorneygeneral.gov
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 Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 1 of 18 PAGEID #: 2898

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, Plaintiff, v.
THE STATE OF OHIO, et al., Defendants.

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CIVIL ACTION NO:

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2:08-cv-475

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UNITED STATES’ MOTION FOR LEAVE TO FILE SUPPLEMENTAL COMPLAINT The United States moves the Court for leave to file a Supplemental Complaint in this
matter, under Fed. R. Civ. P. 15(d). The grounds for this motion are set forth in the attached Memorandum of Points and Authorities. The United States requests an expedited ruling on this motion in order to expedite consideration of the accompanying Motion for a Temporary Restraining Order.
Respectfully Submitted,

s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorney for Plaintiff

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 2 of 18 PAGEID #: 2899
MEMORANDUM OF POINTS AND AUTHORITIES IN SUPPORT OF THE UNITED STATES’ MOTION FOR LEAVE TO FILE SUPPLEMENTAL COMPLAINT
The United States seeks to supplement its Complaint in this case under Fed. R. Civ. P. 15(d) to enforce the constitutional and federal statutory rights of youth confined in Ohio’s juvenile justice facilities, including youth in Circleville Juvenile Correctional Facility (“Circleville”), Cuyahoga Hills Juvenile Correctional Facility (“Cuyahoga”), Indian River Correctional Facility (“Indian River”), and Scioto Juvenile Correctional Facility (“Scioto”) (collectively, the “DYS Facilities”). The United States alleges that the State of Ohio (the “State”) is engaging in a pattern or practice of harming youth in its custody through its unnecessary use of seclusion. The United States also alleges that the State is engaging in a pattern or practice of denying adequate mental health care and rehabilitative treatment to youth in its custody, particularly youth the State has harmed through unwarranted seclusion. Finally, the United States alleges that the State’s use of seclusion exceeds the point that the use is reasonably related to a legitimate governmental objective and is tantamount to punishment and a violation of youths’ due process rights. See U.S. Supplemental Compl. (Attach. A). The United States discovered this conduct recently, and subsequent attempts to resolve the violations without litigation have failed. The United States notified the State of its intention to seek leave to file a Supplemental Complaint on March 7, 2014. On March 10, 2014, the United States contacted the State to ascertain whether it would consent to the motion, and the State replied that it would object to this motion.
I. INTRODUCTION The United States has pursued reform of unlawful conditions at the DYS Facilities since May 2007, when it issued findings of unlawful conditions at Scioto and the since-closed Marion
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Juvenile Correctional Facility (“Marion”). The United States entered into a stipulation with the
State regarding Scioto and Marion in June 2008 in this case, U.S .v. Ohio, ECF No. 8, and has
participated as an interested party in the related case, S.H. v. Reed, No. 2:04-cv-1206 (S.D.
Ohio), since that time. Thereafter, the parties and the monitoring teams in each case worked
toward resolving the unconstitutional conditions, and the United States understood that the
litigation was working its way toward a final resolution.
That understanding changed beginning in November 2013. Recent developments have
made it increasingly clear that certain unconstitutional conditions exist at Scioto as well as the
other DYS Facilities, placing Scioto boys and other youth at risk of continued harm, with no
signs from the State that it intends to remedy these conditions. In particular, these developments
include: • The discovery in November 2013 that the State is excessively secluding youth at Scioto who have significant mental health needs, see K. Dedel, Results of Seclusion Analysis (Nov. 8, 2013) (Attach. B); • The State’s announcement in November 2013 that it is closing Scioto and moving the 20 boys there to other DYS Facilities by May 2014, see Letter from Harvey Reed, DYS Director, to Stakeholders (Nov. 21, 2013) (Attach. C); • The State’s attempt on December 18, 2013, to end the stipulation in U.S. v. Ohio via the Prison Litigation Reform Act (“PLRA”) rather than correct its unlawful practices, see U.S. v.Ohio, ECF No. 121; • The discovery on January 17, 2014, that the State is also excessively secluding youth with mental health needs at its other DYS Facilities, as reflected in records the State produced that day, see United States’ Seclusion Hours Summary Table (Attach. D); • The failure of mediation in January 2014 to resolve concerns about the State’s seclusion of, and provision of mental health services to, youth with mental health needs; and • The S.H. plaintiffs’ filing on February 18, 2014, of a motion for specific performance on these issues, see id. at ECF No. 389.
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It is thus appropriate for the United States to supplement its Complaint in this matter in order to ensure full and appropriate relief for Scioto boys and other youth in all DYS Facilities. The United States seeks to supplement its Complaint to include these new events: the State’s closure of Scioto, the State’s transfer of boys subject to excessive seclusion at Scioto to other DYS Facilities where the same unconstitutional conditions exist, and the State’s pattern and practice of harming Scioto boys and other youth through excessive seclusion and insufficient mental health treatment at the other DYS Facilities. As discussed below, the United States’ motion to supplement its Complaint should be granted because the inclusion of the new facts will avoid piecemeal litigation, allow a prompt and efficient resolution of the entire controversy between the parties, and impose no prejudice on the State. In particular, the State will not be prejudiced by allowing the United States to add the new facts because they are timely filed, relate to the same legal theories underlying the original Complaint, will not impose undue delay or trial inconvenience, and the State has received ample notice of its constitutional violations. More fundamentally, this Court should grant the United States’ motion to supplement its Complaint so that the United States can promptly vindicate the federal rights of youth that the State is violating by excessively isolating them and denying them access to mental health care.1
1 The United States Attorney General is tasked with protecting the rights of juveniles in custody pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141. A national enforcement priority of the United States is preventing the use of unlawful seclusion on persons in custody who have significant mental health needs. The United States can best fulfill these responsibilities to protect the public interest by resolving the unconstitutional conditions at all DYS Facilities in a single action.
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II. BACKGROUND A. The State Has Inflicted Extraordinary Levels of Seclusion on Scioto Youth. On November 8, 2013, the United States learned that the State was inflicting extraordinary rates of seclusion on youth, particularly youth with mental health needs. On that day, the monitor in this case2, Dr. Kelly Dedel, reported that the State had secluded a number of youth for over 10 percent of their total time in custody over a recent six-month period. See Attach. B. She noted “that there are a number of [Scioto] youth who spent a considerable amount of time (20, 30, 40, nearly 50 days) in seclusion.” Id. at 1. All of the youth identified in her report also suffered mental health issues. Id. at 2. The monitor also reported that the State was denying mental and behavioral health treatment to the same Scioto youth with mental health disorders whom it was secluding, thereby effectively withholding the interventions these youth needed to address the causes of the behaviors triggering their seclusion. See Fifth Compliance Report, U.S. v. Ohio, ECF No. 127. The monitor’s subject matter expert reviewed the mental health records of the youth identified in the monitor’s report, and this review revealed that these youth were not receiving mental health treatment via group during their seclusion period. Instead, they received visits by mental health staff limited to “brief checks per protocol, [that] were not treatment oriented.” Id. at 60.
2 The Consent Order addresses violations of federal rights including, but not limited to, failures to protect youth from harm, inadequate provision of mental health care, and the excessive use of seclusion. U.S. v. Ohio, ECF No. 8.
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B. The Other Three DYS Facilities Similarly Impose Seclusion and Withhold Mental Health Care.
The State’s unconstitutional treatment of youth in its custody is not limited to Scioto youth. In January 2014, the State provided the United States and S.H. plaintiffs with seclusion data for youth with mental health disorders at all four DYS Facilities for the period July 1, 2013December 31, 2013. The State’s data were clear: It imposed 59,865 seclusion hours on 229 youth with mental health disorders during this six month period. See Attach. D.
In December 2013, Dr. Andrea Weisman, a member of the S.H. monitoring team, confirmed that the excessive use of seclusion at Scioto was present at the other DYS Facilities. Specifically, Dr. Weisman explained:
It is clear to me that the deficiencies in behavioral health care led to the high rates of seclusion for youth at Scioto, and that the same deficiencies exist at the other three DYS facilities. . . . Given the recent closure of the [Scioto special management unit] and Scioto JCF, plaintiffs’ question regarding whether youth with behavioral challenges at other facilities spend a significant portion of their DYS stays in seclusion is a valid one. See Report by Andrea Weisman, S.H. “Compliance with Consent Order Provisions Regarding Mental Health” (Dec. 16, 2013) (Attach. E). In early January 2014, Dr. Weisman reviewed the mental health records for youth at Circleville, Indian River, and Cuyahoga and found that youth with mental health disorders were disproportionately engaging in behaviors likely to result in their being secluded. S.H. v. Reed, ECF No. 388. C. The State Has Refused to Address the Seclusion and Mental Health Care
Problems at the Facilities. The parties have been unable to resolve the problems Dr. Dedel identified. Following her November 8, 2013, seclusion report, both the United States and Dr. Dedel invited the State to engage in substantive discussions about its seclusion practices. Instead, the State filed a PLRA
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motion on December 18, 2013, to terminate this case. U.S. v. Ohio, ECF No. 121. Settlement discussions broke down at a joint January 29, 2014 court-mediated settlement conference. The S.H. plaintiffs moved for specific performance on February 18, 2014, and the United States promptly sought leave to supplement its Complaint.
D. The Proposed Supplemental Complaint. The proposed Supplemental Complaint is attached for the Court’s review. Attach. A. As with the allegations in the United States’ original Complaint, the Supplemental Complaint includes allegations concerning newly discovered events involving Defendants’ pattern or practice of harming youth through unnecessary seclusion and the denial of adequate mental health care and rehabilitative treatment. Specifically, the new events detailed in the Supplemental Complaint include the State’s closure of Scioto, the State’s transfer of boys subjected to excessive seclusion at Scioto to other DYS Facilities where the same unconstitutional conditions exist, and the State’s pattern and practice of harming Scioto boys and other youth through excessive seclusion and insufficient mental health treatment at the other DYS Facilities. These new allegations are based upon information revealed by the monitors in this case and the S.H. case. Despite significant efforts to reach a resolution outside of litigation, it has become evident that the State has not remedied these violations. Consequently, the United States seeks to supplement its Complaint to vindicate the rights of Scioto youth who have been, or will be transferred to the State’s other Facilities, and the rights of other youth at these Facilities whom the State has excessively secluded and prevented from receiving adequate mental health care.
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E. The United States’ Dismissal Without Prejudice. On May 16, 2008, the United States moved to intervene in S.H. v. Reed. See S.H. v. Reed, ECF No. 99. On June 5, 2008, the United States entered into a stipulation with the State to remedy the conditions at Scioto and Marion and stipulated to the conditional dismissal of its original Complaint as to the other DYS Facilities. See U.S. v. Ohio, ECF No. 6. The S.H. plaintiffs separately entered into a consent decree with the State to remedy conditions at all DYS Facilities. The order conditionally dismissing the United States’ Complaint in intervention was without prejudice. U.S. v. Ohio, ECF No. 7. Federal Rule of Civil Procedure 41(a)(2) instructs that a court-ordered voluntary dismissal is without prejudice unless the order of dismissal states otherwise. Following the conditional dismissal, the United States participated in S.H. as an interested party. On February 18, 2014, the S.H. plaintiffs moved for specific performance to secure compliance with the S.H. consent decree. S.H. v. Reed, ECF No. 388. The S.H. plaintiffs argue that the State must provide adequate mental health treatment to address youth’s misconduct and respond in a manner that reduces recurrence – not simply resort to seclusion again and again. Id. The S.H. plaintiffs allege that the conditions for youth on the DYS Facilities’ mental health caseload violate both the S.H. consent decree and the Eighth and Fourteenth Amendments to the Constitution. Id.
III. ARGUMENT The United States seeks leave to supplement its Complaint pursuant to Fed. R. Civ. P. 15(d), which provides that “the [C]ourt may, on just terms, permit a party to serve a
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supplemental pleading setting out any transaction, occurrence, or event that happened after the date of the pleading to be supplemented.” Fed. R. Civ. P. 15(d). The Sixth Circuit has instructed that Rule 15(d) should be given a “liberal construction,” so as “to permit amendments freely.” McHenry v. Ford Motor Co., 269 F.2d 18, 24, 25 (6th Cir. 1959).
“The purpose of Rule 15(d) is to promote as complete an adjudication of the dispute between the parties as possible by allowing the addition of claims which arise after the initial pleadings are filed.” William Inglis & Sons Baking Co. v. ITT Cont’l Baking Co., 668 F.2d 1014, 1057 (9th Cir. 1981) (citing Case-Swayne Co. v. Sunkist Growers, Inc., 369 F.2d 449, 462 (9th Cir. 1966); 6 C. Wright & A. Miller, Federal Practice and Procedure § 1504 (1971)). Rule 15(d) allows a party to seek additional relief where, as here, events occurring subsequent to the original complaint justify such relief. See Griffin v. Cnty. Sch. Bd., 377 U.S. 218, 226-27 (1964) (finding grant of leave to file supplemental complaint proper where original complaint challenged racial segregation in public schools and, ten years later, supplemental complaint challenged the same county’s subsequent funding of segregated private schools in a “continued, persistent effort[]” to avoid desegregation). Courts normally grant leave to file a supplemental complaint if there is no substantial showing of prejudice to the defendant. See McHenry, 269 F.2d at 25.
Consistent with this lenient standard, the Court should grant the United States leave to file a supplemental complaint under Fed. R. Civ. P. Rule 15(d) because it would avoid piecemeal litigation and allow a prompt and efficient resolution of the entire controversy between the parties without prejudice to the State.
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A. Supplementation Will Allow a Prompt and Efficient Resolution of the Entire Controversy Between the Parties and Will Avoid Piecemeal Litigation.
Consistent with the purpose of Rule 15(d), the United States’ Supplemental Complaint will promote the prompt, efficient, and full resolution of all of the claims at issue here regarding excessive seclusion of youth with mental health disorders. This Court has stated that “[a]s a matter of judicial economy, and for the sake of providing a complete and adequate remedy, if plaintiff prevails on the merits, the plaintiff should present any and all additional allegations concerning the defendants’ illegal conduct, occurring subsequent to the filing of the . . . [c]omplaint.” Selelyo v. Drury, 508 F. Supp. 122, 128 (S.D. Ohio 1980) (urging plaintiff to file a supplemental complaint). The alternative is for the United States to initiate a separate action, which would involve needless expense, delay, and waste of judicial resources. This would also result in piecemeal litigation in which the parties would litigate the issue of excessive seclusion at Scioto in this case while separately litigating the same issues at the other DYS Facilities in another case. “[P]iecemeal litigation should be discouraged, not only because it is antagonistic to the goals of public policy, but also because it is prejudicial to the rights of individual litigants.” Troxel Mfg. Co. v. Schwinn Bicycle Co., 489 F.2d 968, 970 (6th Cir. 1973). Allowing the United States to file a supplemental complaint would avoid piecemeal litigation between the same parties on substantially similar issues.
Hearing the additional violations now – rather than in new litigation – is particularly appropriate because of the public interest at stake. The United States seeks to supplement its Complaint in order to fully protect the federal rights of youth confined in the DYS Facilities, especially youth who have been, or will be, moved to other DYS Facilities from Scioto. This interest arises out of the United States’ efforts in this case to safeguard the federal rights of youth
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who have experienced unlawful conditions at Scioto. Those youth are now being transferred to
other DYS Facilities where they are experiencing harm resulting from the same type of unlawful
conditions. The State cannot avoid its obligations in this suit to the Scioto youth simply by
transferring them to other DYS Facilities. Cf. Griffin, 377 U.S. at 226-27 (explaining that grant
of leave to file supplemental complaint was proper to address a “continued, persistent effort[]” to
avoid court-mandated desegregation). It is vital that these issues be resolved in the most
expeditious manner available to the parties and the Court. Until then, the State will continue to
harm youth in its custody by subjecting them to excessive seclusion and denying them adequate mental health care.3
B. Supplementation Will Not Prejudice the State.
The Court should freely grant leave to supplement the Complaint where, as here, there is
no substantial showing of prejudice to the State. See McHenry, 269 F.2d at 25. In the similar context of a motion to amend a complaint, 4 the opposing party must make a “significant
showing of prejudice to prevail.” Sec. Ins. Co. v. Tucker & Assocs., 64 F.3d 1001, 1009 (6th Cir.
1995). The State cannot show it will be prejudiced, because it has received ample notice of the
3 For this reason, the United States intends to seek a temporary restraining order when its motion to supplement is granted, to stop the most egregious aspects of the State’s unlawful conduct. 4 Courts have recognized that the same factors and rationale may apply to motions to supplement pleadings under Fed. R. Civ. P. 15(d) as to motions to amend under Fed. R. Civ. P. 15(a). See Marshall v. Columbus, No. 2:05-cv-484, 2008 WL 4334616, at *2 (S.D. Ohio Sept. 17, 2008) (citing Spies v. Voinovich, No. 00-4015, 48 Fed. Appx. 520, 527 (6th Cir. Sept. 20, 2002)). Factors to be considered in deciding a motion to amend include “[u]ndue delay in filing, lack of notice to the opposing party, bad faith or dilatory motive on the part of the moving party, repeated failure to cure deficiencies by previous amendments, undue prejudice to the opposing party by virtue of allowance of the amendment, and futility of the amendment.” Foman v. Davis, 371 U.S. 178, 182 (1962). As discussed herein, the United States has timely filed this motion, the State received sufficient notice of the violations, and the State will not be prejudiced by any delay or impairment of discovery or trial preparation. The other factors – bad faith, repeated failure to cure deficiencies by previous amendments, and futility – are plainly not at issue here.
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unconstitutional conditions at the DYS Facilities, the United States has acted in a timely manner in filing its Supplemental Complaint, and the litigation will not be unduly delayed or otherwise impaired.
1. The State Has Been on Notice of its Constitutional Violations and the United States’ Supplemental Complaint Is Timely.
The State has had ample notice that the conditions in the DYS Facilities are unconstitutional and that the United States would seek to remedy these conditions. The United States’ initial Complaint put the State on notice that unnecessary and excessive seclusion and failure to provide adequate mental health treatment to youth in custody constituted constitutional violations for which the United States could seek relief. U.S.v. Ohio, ECF No. 2. Thus, the State has known since 2007 that the United States could bring claims for these types of conditions. The State itself has been in the best position to know whether these conditions actually existed at the DYS Facilities.
As soon as the United States became aware of the present unconstitutional conditions, it contacted the State and subsequently made several attempts to resolve its concerns outside of litigation. Following calls and email exchanges in which the United States attempted to discuss the State’s use of seclusion at Scioto, the State responded to these concerns by moving to terminate the parties’ Stipulation under the PLRA on December 18, 2013. U.S. v. Ohio, ECF No. 121. At a December 19, 2013 status conference, the Court encouraged the parties to negotiate a settlement of these issues, and the parties agreed to temporarily refrain from litigating. S.H. v. Reed, ECF No. 387. Throughout this entire period, the United States – and the S.H. plaintiffs – sought to negotiate with the State to resolve their concerns regarding seclusion and mental health care. On January 29, 2014, the parties engaged in court-directed mediation, at
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which the United States raised all of its concerns regarding the use of excessive seclusion at Scioto, the closure of Scioto, the transfer of the Scioto boys to other DYS Facilities, and the existence of unconstitutional conditions in the form of excessive seclusion at the other DYS Facilities and denial of mental health care to youth there, particularly youth subjected to seclusion. All attempts to resolve these issues ended without success.
On March 7, 2014, the United States notified the State that, in light of the failed settlement negotiations, it intended to seek leave to file a supplemental complaint regarding these issues. On March 10, 2014, the United States contacted the State in an attempt to ascertain its position and, when the State did not consent, the United States promptly filed this motion. Thus, the State has received sufficient notice of the unconstitutional conditions at DYS Facilities and the United States has timely sought to supplement its Complaint in this matter.
2. The Allegations in the Supplemental Complaint Are Related and Substantially Similar to the United States’ Original Complaint.
“[W]here facts set forth in the original complaint relate to and support the new cause of action in the amended complaint, the amended cause of action ‘is not so different as to cause prejudice to the defendant.’” Belle v. Ross Prods. Div., No. 2:01-CV-677, 2003 WL 133242, at *3 (S.D. Ohio Jan. 2, 2003) (quoting Tefft v. Seward, 689 F.2d 637, 639 (6th Cir. 1982)). Here, the United States seeks to advance new facts that are related and substantially similar to the claims presented against the State in the United States’ original Complaint.5 The allegations in
5 Courts have found supplementation appropriate where the supplemental complaint alleges new facts that relate to the cause of action in the original complaint, and where the supplemental complaint alleges a course of conduct that has continued from the filing of the original complaint. See, e.g., Griffin, 377 U.S. at 226-27 (explaining that the supplemental pleading added new parties and relied on events that occurred since the action began, which were “alleged to have occurred as a part of continued, persistent efforts” to circumvent the Court’s prior holding requiring desegregation of public schools); McHenry, 269 F.2d at 25 (finding that where
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the Supplemental Complaint relate to facts that the United States has recently discovered,
regarding violations of youths’ federal rights at all four DYS Facilities. But these allegations are
factually similar and related to the claims in the original Complaint. Moreover, the
Supplemental Complaint arises out of the United States’ continued interest in protecting the
rights of former Scioto youth.
The original Complaint and the proposed Supplemental Complaint share core questions
of law and fact:
• Whether the State has deprived youth in DYS Facilities of their rights under the Fourteenth Amendment to the Constitution, Compl. at ¶ 20; Supplemental Compl. at ¶ 24;
• Whether the State fails to provide adequate mental health care and rehabilitative treatment to youth with mental health needs at the DYS Facilities, Compl. at ¶ 24; Supplemental Compl. at ¶ 20; and
• Whether the State fails to ensure that youth at the DYS Facilities are adequately protected from harm and from undue risk of harm, especially harm due to unnecessary and excessive seclusion, Compl. at ¶ 22; Supplemental Compl. at ¶ 21.
Accordingly, the State cannot show prejudice, because the Supplemental Complaint is related
and substantially similar to the claims and facts in the original Complaint.
3. Supplementation Will Not Cause Undue Delay or Impair the State’s Trial Preparation.
The State cannot show that any delay will ensue if the United States’ motion is granted,
nor can the State show that its ability to litigate these issues will be impaired. “[P]rejudice is
demonstrated when a party has insufficient time to conduct discovery on a new issue raised in an
untimely manner. Allowance of the amendment would then force that party to go to trial without
new allegations described a continuing trespass, supplementation “should be allowed almost as a matter of course”). Moreover, “a change in legal theory of the action is not the test of propriety of an amendment to a pleading, particularly in view of the prevailing practice of making final disposition of actions on the evidence rather than the pleadings.” McHenry, 269 F.2d at 25 (allowing supplementation where supplemental complaint stated a new cause of action).
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adequate preparation on the new issue.” Estes v. Ky. Utils. Co., 636 F.2d 1131, 1134 (6th Cir. 1980) (quoting Garrison v. Balt. & Ohio R.R. Co., 20 F.R.D. 190 (W.D. Pa. 1957)); see also Hageman v. Signal L.P. Gas, Inc., 486 F.2d 479, 484-85 (6th Cir. 1973) (quoting Green v. Wolf Corp., 50 F.R.D. 220, 223 (S.D.N.Y. 1970)). Here, the dispute over the State’s use of seclusion and provision of mental health care at the DYS Facilities has just begun. There is presently no discovery schedule or trial date set. There has been no litigation taking place because parties have been working to resolve the issues outside of court. With the filing of the Supplemental Complaint, the parties and the Court will have the opportunity to set a schedule for discovery on these issues, providing the State sufficient time to conduct any discovery and trial preparation it deems necessary. Discovery will be followed by a full hearing and decision by the Court. See McHenry, 269 F.2d at 25 (“A full hearing and decision on the merits can do injustice to neither party.”). The State thus cannot show that it will be prejudiced by any delay or inability to conduct discovery or prepare for trial.
IV. CONCLUSION Supplementation of the United States’ Complaint, rather than prejudice the State, will advance judicial economy for the benefit of the parties and the Court. More fundamentally, it will accelerate the adjudication of the United States’ claims that the State is currently violating the most basic federal rights of youth in its custody by excessively secluding them and withholding mental health care from them. These claims warrant this Court’s immediate attention. Accordingly, the Court should grant the United States’ Motion for Leave to File a Supplemental Complaint.
14

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 16 of 18 PAGEID #: 2913

DATE: March 12, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders____________ DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov
STEVEN M. DETTLEBACH United States Attorney Northern District of Ohio
/s/ Michelle L. Heyer___________ MICHELLE L. HEYER, Reg. No. 0065723 Assistant United States Attorney Northern District of Ohio 801 West Superior Avenue, Suite 400 Cleveland, Ohio 44113 (216) 622-3686/(216) 622-3781 (T) (216) 522-2404 (F) michelle.heyer@usdoj.gov

Respectfully submitted,
JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
JONATHAN M. SMITH Chief Special Litigation Section
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section
CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
/s/ Silvia J. Dominguez-Reese________ SILVIA J. DOMINGUEZ-REESE Trial Attorney Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorneys for Plaintiff

15

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 17 of 18 PAGEID #: 2914
CERTIFICATE OF SERVICE I HEREBY CERTIFY that this date, March 12, 2014, I caused the foregoing to be electronically filed with the Clerk of the Court using the CM/ECF system, which will simultaneously serve notice of such filing to counsel of record and the Court Monitor to their registered electronic mail addresses.
/s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547 (T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov Attorney for Plaintiff
16

Case: 2:08-cv-00475-ALM-MRA Doc #: 130 Filed: 03/12/14 Page: 18 of 18 PAGEID #: 2915

UNITED STATES OF AMERICA, Plaintiff, v.
THE STATE OF OHIO, et al., Defendants.

)

)

)

)

)

)

CIVIL ACTION NO:

)

2:08-cv-475

)

)

)

)

[PROPOSED] ORDER GRANTING UNITED STATES’ MOTION FOR LEAVE TO FILE SUPPLEMENTAL COMPLAINT

Upon consideration of the parties’ submissions and the applicable law, the Court hereby grants the United States’ Motion for Leave to File Supplemental Complaint. It is so ordered.

Signed this ____ day of ____________, 2014

___________________________________ HONORABLE ALGENON MARBLEY UNITED STATES DISTRICT JUDGE

17

 Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 1 of 5 PAGEID #: 23

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

THE UNITED STATES OF AMERICA, Plaintiff, v.
THE STATE OF OHIO, et al., Defendants.

) ) CIVIL ACTION NO: ) 2:08-cv-475 ) ) JUDGE ALGENON L. MARBLEY ) ) ) ) )

JOINT MOTION AND [PROPOSED] ORDER FOR ENTRY OF STIPULATION AND FOR CONDITIONAL DISMISSAL OF COMPLAINT
The Parties jointly move this Court to enter as its Order the attached Stipulation resolving the United States’ claims in this matter as to Scioto Juvenile Correctional Facility (“Scioto”) and Marion Juvenile Correctional Facility (“Marion”) and, separately, to conditionally dismiss the United States’ complaint in this matter (Docket (“Dkt.”) # 2) as to the remaining six state-operated juvenile correctional facilities that are subject to this litigation (collectively, “State-Operated Juvenile Correctional Facilities”).1 In support of this motion, the Parties state as follows: 1. On May 16, 2008, the United States filed a complaint alleging the existence of ongoing
violations of federal law regarding conditions of confinement in all eight State-Operated Juvenile Correctional Facilities.

1

The six remaining facilities are: Circleville Juvenile Correctional Facility; Indian

River Juvenile Correctional Facility; Cuyahoga Hills Juvenile Correctional Facility; Mohican

Juvenile Correctional Facility; Ohio River Valley Juvenile Correctional Facility; and the

Freedom Center.

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 2 of 5 PAGEID #: 24
-22. Also on May 16, 2008, in the related case of S.H. v. Taft, No. 2:04-cv-1206, also pending
before this Court, the United States filed a Motion to Intervene and Request for Continuance of the May 21, 2008 Fairness Hearing (“Intervention Motion”). On May 18, 2008, plaintiffs in S.H. filed Plaintiffs’ Response to Department of Justice Motion to Intervene (“Plaintiffs’ Response”), (S.H. Dkt # 102) stating that plaintiffs did not oppose the United States’ intervention in S.H. but did oppose a continuance of the fairness hearing. Plaintiffs’ Response at 1. On May 20, 2008, plaintiffs in S.H. amended their position and filed a Supplemental Memorandum, in which plaintiffs opposed the United States’ Intervention Motion (S.H. Dkt # 107). Also on May 20, 2008, the defendant in S.H. filed its Memorandum in Opposition to the United States of America’s Motion to Intervene & Motion to Continue Fairness Hearing (S.H. Dkt # 106). 3. Before the filing of the complaint herein, the United States and Defendants had engaged in negotiations to resolve the United States’ claims. After the filing of the complaint in this matter and the Intervention Motion in S.H., the Parties, assisted by class counsel in S.H., engaged in Court-facilitated negotiations that led to the Parties’ agreement resolving the complaint herein and the Intervention Motion in S.H. Pursuant to that agreement, the United States withdrew its Intervention Motion on May 21, 2008, during the fairness hearing in S.H., subject to the following terms, which were confirmed at the fairness hearing by the Defendants: A. The Court approve and enter as its Order the attached Stipulation, resolving the
United States’ claims herein as to Scioto and Marion; and

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 3 of 5 PAGEID #: 25
-3B. The Court conditionally dismiss the United States’ complaint as to the remaining
State-Operated Juvenile Correctional Facilities, subject to the following terms: i. The Defendants shall provide the United States, for review and comment,
all DYS policies associated with conditions of confinement at the StateOperated Juvenile Correctional Facilities; ii. The United States shall have unfettered access to the Monitor and to the DYS Compliance Coordinator in S.H.; iii. The Defendants shall provide the United States with copies of all performance data gathered by the Monitor in S.H.; and iv. The Defendants shall provide the United States with copies of any reports prepared by the Monitor in S.H. ACCORDINGLY, the Parties request that the Court enter the attached Stipulation as its Order and, subject to the foregoing terms, conditionally dismiss the United States’ complaint as to Circleville Juvenile Correctional Facility, Indian River Juvenile Correctional Facility, Cuyahoga Hills Juvenile Correctional Facility, Mohican Juvenile Correctional Facility, Ohio River Valley Juvenile Correctional Facility, and the Freedom Center.

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 4 of 5 PAGEID #: 26

FOR THE UNITED STATES:

-4DATE:

June 5, 2008

GREGORY G. LOCKHART United States Attorney Southern District of Ohio
MARK T. D’ALESSANDRO Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard Suite 200 Columbus, OH 43215
FOR THE DEFENDANTS S/ J. Eric Holloway J. ERIC HOLLOWAY Assistant Attorney General Corrections Litigation Section 150 East Gay Street, 16th Floor Columbus, OH 43215 Telephone: (614) 644-7233 Facsimile: (614) 728-9327

GRACE CHUNG BECKER Acting Assistant Attorney General Civil Rights Division
SHANETTA Y. CUTLAR Chief Special Litigation Section
S/ Gregory Gonzalez BENJAMIN O. TAYLOE, JR. Special Counsel Special Litigation Section GREGORY GONZALEZ STACEY K. GRIGSBY Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 Telephone: (202) 514-6255 Facsimile: (202) 514-0212 Email: Gregory.Gonzalez@usdoj.gov

Case: 2:08-cv-00475-ALM-MRA Doc #: 6 Filed: 06/05/08 Page: 5 of 5 PAGEID #: 27
-5WHEREFORE, for good cause shown, it is SO ORDERED.
ALGENON L. MARBLEY United States District Court Judge

 Compliance Report Regarding DYS’ PROGRESS Unit at the Scioto Juvenile Correctional Facility
Civil Actions 2:08‐cv‐00475 and 2:04‐cv‐01206
Submitted by:
 Kelly Dedel, Ph.D., Lead Monitor, U.S. v State of Ohio, and Subject Matter Expert
 One in 37 Research, Inc.
 16 Rock Street Cody, WY 82414
 (503) 799‐0915 kelly.dedel@gmail.com
Daphne Glindmeyer, M.D., Subject Matter Expert 229 Bellemeade Boulevard Suite 420 Gretna, Louisiana 70056 (504)666‐1600 dglindmeyer@gmail.com
Reviewed by: Will Harrell, J.D., LL.M, Lead Monitor, S.H. v Reed 1221 Kerlerec New Orleans, LA 70117 (512)695‐7519 shmonitor.harrell@gmail.com
Terry Schuster, J.D., Assistant to the Monitor 1037 Neil Ave., Apt. C Columbus, Oh 43201 (512)468‐4486 shmonitor.schuster@gmail.com
September 22, 2013

Introduction
In October and November 2012, pursuant to the United States v. Ohio and S.H. v. Reed Stipulations, the U.S. Department of Justice (DOJ) and the S.H. plaintiff class each initiated a process for dispute resolution to address concerns regarding the purpose, structure, and operation of the PROGRESS Unit at the Scioto Juvenile Correctional Facility (the PU). The Monitors and Plaintiffs in both cases have expressed on‐going concerns about DYS’ operation of special management units since at least 2007. The Ohio Department of Youth Services (DYS) and DOJ negotiated and agreed upon a proposed Consent Order, filed with the Court on December 19, 2012. The Court did not sign the Order until January 18, 2013 when it was also incorporated into a broader settlement between DYS and the S.H. plaintiff class. The Consent Order sets standards related to PU policies, admissions screening, programming, out‐of‐room time, staffing, treatment planning, length of stay, and promotion and demotion between phases. The S.H. settlement supplements the Consent Order with additional standards related to PU behavioral health staffing and quality assurance.
Drs. Kelly Dedel and Daphne Glindmeyer were tasked with monitoring DYS’ compliance with the Consent Order. In order to facilitate compliance in a more efficient manner than the standard 6‐ month monitoring period, the Monitors decided to issue status reports on a more frequent basis. The 1st Status Report, covering the period November 2012 through February 2013, was issued to the Parties on March 27, 2013 and filed with the Court simultaneously with the DOJ Monitor’s Fourth Monitor’s Report on June 18, 2013.
In response to the 1st Status Report, the Parties made some agreements designed to facilitate DYS’ progress toward compliance, while also ensuring that the integrity of the monitoring process. Subsequent status reports would assign compliance ratings to each of the 17 subsections of the seven core areas of the Consent Order so that progress with component parts could be better recognized and deficits in other areas could be highlighted for additional attention. In addition, the requirements for satisfying the Consent Order were clarified. In order to reach substantial compliance with the Consent Order, DYS must first come into compliance with all of the core areas and subsections and then must maintain that level of performance for an additional six months. Once this threshold is obtained, monitoring of the PU’s operation will once again be subsumed under the larger DOJ Agreement.
The Consent Order requires DYS to develop a Quality Assurance mechanism, designed to rigorously examine each of the PU’s component parts using multiple sources of data so that program areas not meeting the requirements of the Order can quickly be identified and remediated. In March 2013, DYS took a major step toward meeting this requirement by agreeing to produce the 2nd Status Report internally. For the March through June 2013 reporting period, using the same data submitted to the Monitors for review as required by the Consent Order, DYS constructed its first quality assurance report regarding the operation of the PU. [DYS’ Status Report is attached to this Compliance Report.]
A draft was submitted to the Monitors and Plaintiffs for review and feedback. The Monitors reviewed the relevant data on their own to determine whether DYS’ analysis and interpretation met generally accepted practices for quality assurance. Extensive feedback was provided to DYS
2.


to improve the clarity, rigor and coherence of the Status Report. In nearly all cases, DYS accepted the Monitors’ and Plaintiffs suggestions.
The assignment of compliance ratings remains the Monitor’s responsibility, and thus is the purpose of this Compliance Report. For each of the 17 subsections, the Monitors indicate whether they agree or disagree with DYS’ assessment of its level of compliance. In areas of disagreement, the Monitors explain the rationale for their compliance ratings.
Overall, DYS has made significant progress complying with the requirements of the Consent Order. Of the 17 subsections, 8 are in substantial compliance (47%) and 9 (53%) are in partial compliance. Many of the changes required to bring other parts into substantial compliance should be relatively simple to address.
Recent changes to DYS’ use of the PU have brought into question whether the Consent Order still applies. Although DYS is currently using only the least restrictive of the PROGRESS units, the structure for the more restrictive units remains active in DYS policy and procedure. Absent a written commitment to decommission the entire Unit, or to remove the more restrictive units with the attendant permission to use programmatic restraints in a self‐contained program environment, the Monitor will continue to conduct periodic reviews of DYS’ compliance with the Consent Order, as it pertains to whichever of the PROGRESS Units are currently in use.
Over the next couple of months, for each component in partial compliance, DYS should craft a written Quality Improvement Plan (QIP) that addresses the underlying causes of the subpar performance. For example, youth in seclusion are not receiving the required one‐hour of daily recreation. This could occur for many reasons—insufficient numbers of recreation staff; insufficient space; lack of interest or incentives among youth; etc. DYS’ challenge is to accurately identify what is driving the problem and to craft strategies to address these contributing factors. The Monitor expects to receive QIPs for the following subparts rated in partial compliance:
 Daily Activities  Graduate Programming  Staff Numbers  Treatment Planning  IDT Composition  IDT Substance  Length of Stay  CORB Substance Technical assistance with crafting and implementing the QIPs is available from the Monitors if desired. Once the QIPs have been implemented, the 3rd Status Report can be drafted to determine whether the problems identified in the current report have been remediated.
What follows is a list of the 17 subsections and the compliance rating assigned to each one. In any area where the Monitors do not agree with DYS’ self‐assessment, the rationale for the Monitor’s compliance rating is provided. Even where agreement exists, key issues related to each partial compliance rating are briefly summarized. The reader is referred to the attached 2nd Status Report for details surrounding the program’s operation in areas where DYS and the Monitor agree on the level of compliance.
3.


II.9 Admissions Screening
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.10(1) Daily Schedule: Out of Room Time
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.10(2) Daily Schedule: Daily Activities
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In order to reach substantial compliance, DYS needs to ensure that structured activities are led by an adult; that leisure time is provided each day; and that youth in seclusion are afforded the opportunity for one‐hour of recreation per day. [Note: this last component, regarding recreation for youth in seclusion, was not included among DYS’ list of issues in need of remediation.]
In addition, the Monitor noted a calculation error regarding the “structured activities” component of the analysis. The report should read that “in the first group of cases sampled, 54% of activities were not led by an adult” and “in the second group of cases, 43% of the activities were not led by an adult.”
II.10(3) Daily Schedule: Graduate Programming
The Monitor agrees with DYS’s assessment that it is in partial compliance with this provision. While there was only one graduate on the PROGRESS Unit during the period of review, his schedule was followed only 65% of the time.
II.11(1) Staffing: Staff Numbers and Training
The Monitor does not agree with DYS’ assessment that it is in substantial compliance with this provision; rather, the Monitor believes the DYS is in partial compliance with this provision, absent additional data analysis. DYS asserted that time Unit Managers spend in training should be included in the calculation of Unit Manager coverage because, since they are on campus, “they can respond if needed.” The Monitor disagrees. Presumably focused on the content of the training session, Unit Managers cannot provide active supervision of the Youth Specialist (YS) staff assigned to the Unit. While they may be able to respond to a call for assistance, the negotiations surrounding the Consent Order emphasized the need for hands‐on mentoring and oversight of YS staff, which clearly cannot occur if the Unit Manager is not physically present. It is possible that DYS’ Unit Manager coverage exceeds the 80% minimum threshold for substantial compliance even once the training hours are subtracted out, but DYS did not provide these data and so compliance cannot be substantiated at this time.
4.


The Monitor does agree that the level of YS staffing meets the requirements of the provision, though recommends that in future Status Reports, DYS should combine the ADP data with the staffing data to calculate a specific YS—youth ratio for each unit, each shift.
II.11(2) Staffing: Impact on Safety
The Monitor agrees that DYS is in substantial compliance with this provision. While the level of youth‐on‐staff violence remains a concern, it does not appear to be related to insufficient numbers of staff, which was the key caution behind this section of the Order.
II.12(1) Treatment Planning: Clinical Staffing
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.12(2) Treatment Planning: Treatment Planning
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In the data analysis, DYS reviewed youth treatment planning goals and objectives. While goals and objectives were appropriately measurable and realistic, there were marked deficits in strengths based and skills focused objectives. In addition, a review of treatment documentation indicated that treatment (and its documentation) needed to utilize interventions that were more focused on the goals and objectives outlined in the treatment plan. In order to reach substantial compliance, these areas must be addressed.
Throughout the 2nd Status Report, skills acquisition is discussed. The Monitors acknowledge that deficits in skill acquisition are likely the precipitating factor in youth recycling through the PU phases. Skills acquisition must be addressed via a process that includes:
 Identifying skills that a particular youth requires;  Outlining necessary skill development via treatment planning (i.e., goals, objectives,
interventions);  Implementing interventions that addresses the development of these skills in
treatment;  Documenting the interventions and the youth’s progress with regard to skill
development; and  Addressing a lack of progress toward skill development via the treatment planning
process in order to identify alternate interventions that may be beneficial.
II.12(3) Treatment Planning: Progress Reporting and Promotion
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
5.


II.12(4) Treatment Planning: Interdisciplinary Treatment Team
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In their review of the data, DYS recognized issues with staff attendance at Interdisciplinary Treatment Team (IDT) meetings. In order to reach substantial compliance, the facility plans to develop a Program Improvement Plan to address issues of attendance at IDT meetings. Furthermore, representatives from all disciplines must consistently attend and provide input on all Progress Units.
II.12(5) Treatment Planning: IDT Substance
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In order to achieve substantial compliance, DYS must ensure that the IDT appropriately and regularly reviews the youth’s behavioral expectations and treatment goals, focusing on skill acquisition. Both the IDT and the youth must be aware of the youth’s progress (or lack thereof) toward meeting the treatment goals. When youth are not meeting treatment goals or are not acquiring necessary skills, the IDT must recommend alternate strategies for consideration.
II.12(6) Treatment Planning: Length of Stay
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. Using a 30‐day maximum threshold for each of the three phases, 22% of the stays across all of the phases lasted longer than 30 days. Furthermore, 10 of the 16 youth reviewed (63%) had a total length of stay in excess of 90 days. Finally, “recycling” (being demoted to a lower phase) continues to be prevalent and brings into question whether youth are acquiring the skills they need to refrain from violent behavior.
II.12(7) Treatment Planning: Central Office Review Board (CORB)
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
Several months ago, the Monitors’ gave their approval for DYS to cease completing CORB reviews for youth on the Transition Unit so that they could prioritize the reviews of Phase 1 and Phase 2 youth and complete them in a timely manner. However, the Monitors gave this permission without first consulting the Plaintiffs, who feel strongly that youth on the Transition Unit should be reviewed if they have not been promoted within 30 days. Moving forward, in order to maintain substantial compliance, the CORB will need to review Transition youth, as described in the Consent Order.
6.


II.12(8) Treatment Planning: CORB Substance
The Monitor agrees with DYS’ assessment that it is in partial compliance with this provision. In order to achieve substantial compliance, DYS must ensure that the IDT reviews with the youth the results of the CORB review and that CORB recommendations are implemented at the facility level.
II.13 Phase Demotions
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
II.14 Policies and Procedures
The Monitor agrees with DYS’ assessment that it is in substantial compliance with this provision.
In order to maintain substantial compliance, DYS must update the SOP and Youth Handbooks to keep pace with the recent evolution of the program (i.e., a narrowing of the program that utilizes only the least restrictive of the PROGRESS Units, the Transition Unit). If, as DYS asserts, youth will no longer be admitted or demoted to the more restrictive units (i.e., Phase 1 on Cedar or Phase 2 on Sycamore), the written documentation for the program must be updated to reflect this significant change. As of the writing of this report, the policy and handbook revisions are in progress.
III.C.3 Quality Assurance
As noted in the Introduction, DYS took a major step toward complying with the consent order when it agreed to produce the 2nd Status Report internally. For this reason, DYS is in partial compliance with this provision. While the Monitor had feedback and suggestions about the content of the report, most of the comments were stylistic and intended to better communicate the information rather than to correct a misleading analysis. Moving forward, DYS should strive to improve the organization of the report (e.g., ensuring that all component parts are included and eventually synthesized into a single document that will provide the reader with a concise assessment of the PU’s operation).
In order to reach substantial compliance with this subsection, DYS needs to actively engage in the process of remediating the identified deficits, via the Quality Improvement Planning (QIP) process. As noted in the Introduction, within the next couple months, the Monitor expects to receive written QIPs that address the underlying causes of the performance problems. QIPs need to be developed for the following subparts rated in partial compliance:
7.


 Daily Activities  Graduate Programming  Staff Numbers  Treatment Planning  IDT Composition  IDT Substance  Length of Stay  CORB Substance Technical assistance with crafting and implementing the QIPs is available from the Monitors if desired. Once the QIPs have been implemented, the 3rd Status Report can be drafted to determine whether the problems identified in the current report have been remediated.
8.


 Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 1 of 26 PAGEID #: 2939

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

CIVIL ACTION NO: 2:08-cv-475 JUDGE ALGENON L. MARBLEY

UNITED STATES’ MOTION FOR A TEMPORARY RESTRAINING ORDER
Plaintiff, the United States, moves the Court for a temporary restraining order against
Defendants, the State of Ohio, et al. (the “State”), and requests a hearing. The grounds for this
motion are set forth in the attached Memorandum of Points and Authorities.
The United States notified the State on March 12, 2014, that it planned to file this motion.
Respectfully Submitted,
_s/Silvia J. Dominguez-Reese_ SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorney for Plaintiff

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 2 of 26 PAGEID #: 2940
MEMORANDUM OF POINTS AND AUTHORITIES IN SUPPORT OF THE UNITED STATES’ MOTION FOR A TEMPORARY RESTRAINING ORDER
The State has systematically violated the substantive due process rights of boys with mental health disorders at four of its juvenile correctional facilities (the “Facilities”)1, and this Court must act immediately to protect these boys from mounting and irreparable harm. The State punishes the boys with seclusion (i.e., solitary confinement) for days on end, often also depriving them of education, exercise, programming and crucial mental health care. When the State returns them to the general population, the State often does not adjust their mental health care treatment to address the harm from seclusion or the misconduct that led to seclusion in the first place. Even when the boys are not secluded, the State deprives them of appropriate mental health care, instead providing cut-and-paste treatment plans that bear little relationship to the mental health needs of a particular boy.
Seclusion has become the State’s modus operandi for handling boys with mental illness. In the second half of 2013, the State imposed almost 60,000 hours of seclusion on boys at the Facilities. Ten boys at Circleville and Indian River spent over 1,000 hours in seclusion over a six month period, and another 17 boys spent over 500 hours in seclusion. At least ten boys at Scioto spent over 10 percent of their time in custody in seclusion from April to September 2013.
Those statistics are disturbing, but the youth at the Facilities are not statistics. They are troubled boys coping with mental health disorders who are suffering real, irreparable harm from tremendous time in seclusion. A few examples from just six months of the State’s records:
1 The Facilities are Cuyahoga Juvenile Correctional Facility, Circleville Juvenile Correctional Facility, Indian River Juvenile Correctional Facility and Scioto Juvenile Correctional Facility.
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 3 of 26 PAGEID #: 2941
• K.R. (218520) at Circleville is taking significant psychiatric medications. He bangs his head frequently, and he had fresh head injuries during a recent visit.2 Yet K.R. spent 1,964 hours in seclusion over six months. His longest episode of seclusion was about 19 days. Eleven times, he was secluded for five or more days at a time. Three times, he received a five-day penalty of extra seclusion during a time when he was already serving seven days in seclusion. While secluded, he was on “Suicide Watch,” had “Suicide [Ideation],” and displayed “Self Injurious Behavior.”
• A.E. (217241) at Circleville spent 1,504 hours in seclusion over six months. At one point, he was given 21 consecutive days in seclusion, with five of those days tacked on while he was already in seclusion.
• J.H. (218144) at Circleville spent 1,146 hours in seclusion over six months. In September 2013, he received 120 hours of seclusion, and then an additional 179 hours that same day, for over 12 days of seclusion. On November 17, 2013, he received 143 hours of seclusion; the next day the State tacked on 108 more.
• N.H. (217322) at Indian River spent 90 hours in seclusion, followed by an additional 120 hours. A week later, he received 92.5 hours. The day after that, the State imposed another 144 hours. One observation during his seclusion was “Self Injurious Behavior.”
• M.L. (218660) at Cuyahoga spent 164.58 hours in seclusion over three months, culminating in “Suicidal Ideation.”
• N.O. (218428) at Indian River spent 752 hours in seclusion. During 158 hours of seclusion, he demonstrated “Self Injurious Behavior.” Another 81 hours yielded a notation of “Suicide Watch”; two days later, he received 91.5 hours of seclusion and another notation of “Suicide Watch.”
• J.S. (218396) at Circleville spent 1,585 hours in seclusion. “Self Injurious Behavior” marred his last 48 hours of seclusion.3
The State has had every opportunity to address the rampant use of seclusion on boys with
mental health disorders, but it has made little or no improvement and may actually be losing
2 See Email from Alphonse Gerhardstein to Thomas Anger (Jan. 11, 2014) (Attach. A). 3 Monitor Dr. Dedel found additional instances of lengthy seclusion at Scioto from April through September 2013. C.C. spent 16 consecutive days in seclusion with only one 24-hour period in the general population. T.B. spent eight consecutive days in seclusion. Fifth Compliance Report at 29-30, U.S. v. Ohio, ECF No. 127.
2

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ground. Indeed, the State does not view seclusion at the Facilities as a problem at all. At one
point, counsel for the State brushed aside a boy’s seclusion of 142 hours in a single month as “not alarming.”4 When the State was advised that K.R. (1,964 seclusion hours in six months)
was in immediate and extreme distress, the State’s lawyers responded with a demand for the
resignation of the subject matter expert who tried to look into K.R.’s situation at the monitor’s request.5 One thing is certain: The State will continue the excessive seclusion of boys with
mental health disorders unless this Court steps in.
The United States requests an immediate temporary restraining order to stop the seclusion
of boys with mental health disorders and to avoid the irreparable harm these boys are suffering
and will continue to suffer absent Court protection. Specifically, the United States seeks a
temporary restraining order as follows:
I. This Court, as an interim response to the State’s infliction of unlawful and irreparable harm on boys through its seclusion and mental health practices, should immediately issue a temporary restraining order that the State:
A. Stop secluding any boy with an identified mental health disorder for more than 24 hours without providing him, outside of his confinement area and during normal facility programming times, at least four hours of programming, exercise, education, or combinations thereof;
B. Stop imposing more than three consecutive days of seclusion in any form (e.g., prehearing seclusion and intervention seclusion) on any boy with an identified mental health disorder;
C. Stop imposing more than three days of seclusion in any form within a 30-day period on any boy with an identified mental health disorder without first:
1. Conducting a comprehensive mental health treatment review of the boy that
4 See Email from Dustin Calhoun to Silvia Dominguez and Benjamin Tayloe (Dec. 4, 2013) (Attach. B). 5 See Email from Will Harrell to Alphonse Gerhardstein (Jan. 15, 2014) (Attach. C).
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includes the treatment team meeting and reviewing the boy’s mental health treatment plan to consider and address potential problems with the plan and its implementation;
2. Obtaining the prior written approval of the Deputy Director of the Department of Youth Services (“DYS”) responsible for Facility programming; and
3. Providing written notice to the United States and monitor within 24 hours of a youth exceeding three days of seclusion within a single month, describing the amount of seclusion, reason for seclusion, treatment provided in response to seclusion, whether the youth’s behavior intervention plan was modified or created, and alternatives to seclusion that were rejected.
D. Provide monthly to the monitor an AMS printout of monthly seclusion hours for boys at the Facilities; and
E. Refrain from substituting restraints for seclusion.
II. The Court should hold an expedited hearing to determine the United States’ entitlement to a preliminary injunction.
III. The Court should set an expedited schedule for discovery and further briefing in preparation for a hearing on a permanent injunction. At the permanent injunction hearing, the Court should determine the circumstances and limitations governing the use of seclusion (or restraints as a substitute for seclusion) on boys with mental health disorders at the Facilities, particularly given that the proposed temporary restraining order’s terms do not extend far enough to address the extent of the State’s violations;
IV. Such other and further relief as the Court deems necessary to prevent the boys with mental health disorders at the Facilities from suffering additional irreparable harm.6
BACKGROUND
A. U.S. v. Ohio.
Following an investigation of the Scioto Juvenile Correctional Facility (“Scioto”) in
Delaware, Ohio, the United States found “significant constitutional deficiencies regarding use of
6 The United States seeks a temporary restraining order permitting the State to use up to three days of seclusion as an interim measure only, until the State implements reasonable programmatic changes enabling it to constrain further its seclusion use and comply with constitutional standards. The United States will delineate those programmatic changes in a subsequent request for relief, after conducting discovery with its experts.
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physical force, grievance investigation and processing, and use of seclusion.” See Letter from Wan J. Kim, Assistant Att’y Gen., Ohio Att’y Gen., to Ted Strickland, Governor, State of Ohio, “Investigation of the Scioto Juvenile Correctional Facility, Delaware, Ohio” (May 9, 2007) (on file with author). Thereafter, on May 16, 2008, the United States filed suit against the State (including the Governor, DYS, and various officials associated with DYS), alleging among other things that the State engaged in a pattern or practice of failing adequately to protect boys from undue risk of harm by failing to “protect[] from the unwarranted use of seclusion” and failing to provide adequate mental health care and rehabilitative treatment to boys through “the provision of adequate screening and assessments . . . adequate treatment planning . . . and adequate psychological services.” Compl., ¶¶ 22, 24, U.S. v. Ohio, ECF No. 2.
On June 28, 2008, the United States and the State entered into a Consent Order to resolve the identified violations of federal rights. U.S. v. Ohio, ECF No. 8. Three years later, the United States and the State negotiated an Amended Stipulation for Injunctive Relief, reflecting that progress had occurred in certain areas but violations related to seclusion and mental health care continued. U.S. v. Ohio, ECF No. 85. In January 2012, this Court issued as its order a proposed stipulation between the United States and the State intended to resolve the State’s use of excessive seclusion on Scioto youth housed on special management units. U.S. v. Ohio, ECF No. 109 (the “Progress Unit Consent Order”).
Less than six months after the Progress Unit Consent Order was filed, it became apparent the State was forcing Progress Unit boys to wear restraints for an average of 12-14 hours per day. Essentially, the boys in the Progress Unit who had been subjected to prolonged periods of seclusion were now being forced to wear restraints virtually every waking moment. Only after an exchange of letters and the threat of litigation did the State, on August 22, 2013, announce
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that it would discontinue use of programmatic restraints. See Letter from Thomas Anger, Ohio Asst. Att’y Gen., to Benjamin Tayloe (Aug. 22, 2013) (Attach. D).

1. The Monitor’s Discovery of Excessive Seclusion at Scioto. On November 8, 2013, Dr. Kelly Dedel, the monitor, investigated the accumulation of seclusion hours among some Scioto boys. She found the State had secluded ten boys for over 10 percent of their time in custody and that one boy spent almost 40 percent of his time in seclusion:

Youth
O.J. B.D. A.F. T.R. D.H. J.A. T.H. M.G. R.B. K.A. D.S.

Days in Custody during Monitoring Period (max 184)
74 184 184 184 184 141 109 137 184 184 184

Days in Seclusion during Monitoring Period 28.54 49.56 43.83 35.36 33.59 24.56 16.27 17.55 23.24 20.57 17.62

% days spent in Seclusion
38.57% 26.93% 23.82% 19.21% 18.25% 17.42% 14.92% 12.81% 12.63% 11.18% 9.6%

See Memorandum from Kelly Dedel, Lead Monitor, U.S. v. Ohio, to Tom Anger, Ohio Asst. Att’y Gen., “Results of Seclusion Analysis” (Nov. 8, 2013) (Attach. E) (“Seclusion Report”).

Faced with this evidence of seclusion, Dr. Dedel expressed her “serious concerns.” She

invited the State to consider “how to mitigate these risks for the youth who have chronic,

aggressive misconduct.” She urged the State to participate in a “problem-solving discussion.”

She proposed that the State consult the mental health subject matter expert for recommendations.

Id. at 1-2.

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All of this fell upon deaf ears. The State has not identified any policy change or other course of action to mitigate the harm of seclusion for the boys named in the Seclusion Report or any other boys at the Facilities. On the contrary, counsel for the State cited the November seclusion hours for B.D. (142.3 hours) and A.F. (80.93 hours) and stated, “As you can see, the seclusion hours are not alarming for these youth.” Attach. B.
2. The Closure of Scioto and the PLRA Motion. On November 21, 2013, the State announced its intent to close Scioto on May 3, 2014. Citing the declining population there, the Director of Ohio DYS wrote, “As of [November 20, 2013], there were 38 youth at [Scioto] (20 males and 18 females who reside separately). Male youth will be gradually reassigned to the remaining facilities according to their security, educational and programming needs.” See Letter from Harvey Reed, DYS Director, to Stakeholders (Nov. 21, 2013) (Attach. F) (emphasis added). On December 18, 2013, the State filed a motion under the Prison Litigation Reform Act, 18 U.S.C. § 3626(b) (“PLRA”), to terminate U.S. v. Ohio. The next day, December 19, 2013, the United States filed a preliminary opposition. Also that day, the Court held a joint status conference with counsel in this case and S.H. v. Reed, No. 2:04-cv-01206 (filed Dec. 20, 2004) and set a joint settlement conference for January 29, 2014. The State withdrew its PLRA motion without prejudice to renew its motion should the parties fail to settle, and the United States withdrew its PLRA opposition without prejudice.7
7 The State’s PLRA motion and United States’ response triggered the consent order’s dispute resolution process, which culminated in a court-ordered mediation on January 29, 2014. The dispute resolution period ended on February 27, 2014, meaning the parties are free to submit this dispute to the Court.
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True to its word, the State gradually assigned the Scioto boys to other Facilities. The United States has learned that there are at least six boys who were once at Scioto and are now elsewhere in DYS custody. Discovery has been limited, which prevents the United States from learning the extent to which former Scioto boys are still experiencing high levels of seclusion. The United States expects that updated discovery and records for boys not on the mental health caseload will reveal that boys at the Facilities are still experiencing excessive seclusion.
B. Excessive Seclusion Is Harming Boys with Mental Health Disorders. On January 14, 2014, the State provided data revealing the depth of the seclusion problem. In the second half of 2013, the State imposed almost 60,000 seclusion hours on boys on the mental health caseload at the Facilities:

Prehearing And Intervention Seclusion Hours Cuyahoga
Scioto
Indian River
Circleville
Total

July 2013
434.45 102.05 277.92 336.00 2,025.13 1,657.33 930.38 2,256.17 8,019.43

Aug 2013
624.37 47.88 528.14 984.17 1,938.72 3,072.00 1,319.01 2,448.00 10,962.29

Sept 2013

Oct 2013

1,027.85 16.10 108.75 72.00 2,091.99 2,105.60 1,444.17 1,752.00 8,618.46

1,433.47 143.78 403.52 457.75 1,908.29 997.20 2,775.69 4,919.33 13,039.03

Nov 2013
864.97
232.44 240.00 1,475.24 384.00 3,048.87 6,420.10 12,665.62

Dec 2013

Totals

629.34 5,324.26

286.83 72.00 1,763.57 816.00 850.71 2,141.73 6,560.18

3,999.52 20,235.07 30,306.16 59,865.01

That may be only the tip of the iceberg. The State did not provide records covering the

first six months of 2013, any part of 2014, or any boys who are not on the mental health caseload

– about half of the population at the Facilities. Even this limited data the State provided shows

that seclusion remains unchecked at the Facilities.

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As poor as the State’s track record has been, its overreliance on seclusion is getting worse, not better. In June 2013, Dr. Dedel found that Scioto boys who committed an act of violence received seclusion as a sanction 72 percent of the time. See Fourth Compliance Report at 25, U.S. v. Ohio, ECF No. 114. By September 2013, that number had grown to approximately 90 percent, which is a “significant increase.” See U.S. v. Ohio, ECF No. 127 at 27.
None of this should come as a surprise to the State. Dr. Andrea Weisman, a subject matter expert in the S.H. case, found that the DYS head psychologist, Dr. Hamming, noted that “half of the kids are in seclusion (on Buckeye) a good majority of the time.” See Report by Andrea Weisman, S.H. “Compliance with Consent Order Provisions Regarding Mental Health,” at 6 (Dec. 16, 2013) (“Weisman Report I”) (Attach. G). Dr. Weisman further explained that Dr. Hamming’s note “raises concern that the youth who have transitioned out of the Progress Unit are still being managed with long stays in seclusion, by way of the IRAV and sanction seclusion processes rather than by way of a maximum security unit.” Id. at 6.
Three facts are beyond dispute: The State secludes boys with mental health disorders at the Facilities a tremendous amount, the State knows it, and the State won’t address it. If these boys are to be protected from the irreparable harm of excessive and repeated seclusion, it is up to this Court to protect them.
C. Boys with Mental Health Disorders Suffer Tremendous Harm from Seclusion. The harm from seclusion falls disproportionately on boys with mental illness – the very boys least able to cope with repeated and extended isolation. Dr. Weisman found that the State places mentally ill boys into seclusion more often than general population boys, and “mentally ill youth are disproportionately engaging in behaviors likely to result in their being secluded.” See
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“Compliance with Consent Order Provisions Regarding Mental Health,” S.H. v. Reed, ECF No. 388-2.
The State’s excessive reliance on seclusion is rooted in the deficiencies in its mental health care treatment. Dr. Weisman explained, “It is clear to me that the deficiencies in behavioral health care led to the high rates of seclusion for youth at Scioto, and that the same deficiencies exist at the other three DYS facilities.” See Weisman Report I at 6 (emphasis added). Dr. Dedel also warned that seclusion suppresses a boy’s negative behavior during the time that he is behind a locked door but denies him access to the very treatment programs needed to change his behavior. See U.S. v. Ohio, ECF No. 127 at 29.
Indeed, the State does not modify boys’ treatment plans or adjust their mental health treatment following misconduct, so the cycle of violence leading to seclusion continues. When a boy with a mental health disorder is placed in seclusion, “it is incumbent on the practitioners to modify the [Integrated Treatment Plan] to extinguish the behavior.” See Weisman Report I at 5. If there is no corresponding modification of the treatment plan, Dr. Weisman predicted that the “seclusion will just exacerbate the behavioral problems DYS is seeking to extinguish.” See Weisman Report I at 5 (emphasis added).
D. The State Can Operate the Facilities Safely and Securely Without the Use of Excessive Seclusion or Restraints.
The State can operate a safe, secure facility without resorting to seclusion. Dr. Dedel has conducted reviews of approximately 60 juvenile correctional facilities. She has repeatedly informed the parties that, in her experience, juvenile facilities routinely maintain control over youth while using minimal levels of seclusion, levels significantly below those that the State uses. Separately, Paul DeMuro, the former Pennsylvania Commissioner of Children and Youth
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and a nationally recognized expert on the operations of juvenile justice facilities, opines that it is possible to maintain security and deliver effective programming while using minimal levels of seclusion. In fact, Mr. DeMuro confirms that high rates of seclusion, such as those used by the State, impede the delivery of effective programming and worsen the very behaviors that seclusion targets. See Decl. of Paul DeMuro at ¶¶ 4-6 (Attach. H).
DYS’ disciplinary policies contribute to the seclusion problem at the Facilities. Dr. Dedel noted, “DYS’ continued use of disciplinary seclusion remains outside the norm. The Monitor’s experience in the field suggests that most jurisdictions limit the length of stay in seclusion to 72 hours, compared to the 120 hours permitted by DYS policy.” U.S. v. Ohio, ECF No. 127 at 31. In the most recent monitoring period, 27 percent of instances of intervention seclusion at Scioto were for the maximum 120 hours. Id. at 29. That is five straight days of isolation, depriving the boys of mental health care treatment the entire time.
Seclusion at the Facilities must be addressed for the best possible reason: It is hurting these boys. “Solitary confinement can cause serious psychological, physical, and developmental harm, resulting in persistent mental health problems or, worse, suicide. . . . These risks are magnified for children with disabilities or histories of trauma and abuse.” ACLU, “Alone & Afraid: Children Held in Solitary Confinement and Isolation in Juvenile Detention and Correctional Facilities” (Nov. 2013). “[D]ue to their ‘developmental vulnerability,’ adolescents are particularly at risk of adverse reactions from prolonged isolation and solitary confinement.” American Academy of Child & Adolescent Psychiatry, “Policy Statements: Solitary Confinement of Juvenile Offenders” (April 2012).8
8 See also Lindsay Hayes, Office of Juvenile Justice and Delinquency Prevention, Juvenile 11

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Dr. Dedel agrees that seclusion of youth in correctional facilities should be a thing of the past. She noted, “Recent publications by the ACLU/Human Rights Watch, the United Nations’ General Assembly, and other scholars suggest an evolving standard around the practice. Indeed, the upcoming revision of the Juvenile Detention Alternative Initiatives’ standards will prohibit the practice of disciplinary seclusion.” See U.S. v. Ohio, ECF No. 127 at 31.
ARGUMENT Fed. R. Civ. P. 65 allows issuance of a temporary restraining order if there is notice to the adverse party and an opportunity for a hearing. Certified Restoration Dry Cleaning Network v. Tenke Corp., 511 F.3d 535, 552 (6th Cir. 2007) (reversing denial of preliminary injunction for failure to hold a hearing). Issuance of injunctive relief is a matter for the trial court’s discretion. Galper v. U.S. Shoe Corp., 815 F. Supp. 1037, 1043 (E.D. Mich. 1993) (granting preliminary injunction prohibiting plaintiff’s eviction from her place of business).
A. This Court Should Grant a Temporary Restraining Order to Prevent the Excessive Seclusion of Boys with Mental Health Disorders. Granting a temporary restraining order involves an evaluation of four factors: (1) Whether the movant has a strong likelihood of success on the merits; (2) Whether the movant would suffer irreparable injury without the injunction; (3) Whether the issuance of the injunction would cause substantial harm to others; and (4) Whether the public interest would be served by issuance of the injunction.
Suicide in Confinement: A National Survey at 3 (2009) (“Although little research has been conducted regarding youth suicide in custody, the information that is available suggests a high prevalence of self-injurious behavior in juvenile correctional facilities. . . . The study found that almost 22 percent of confined youth seriously considered suicide, 20 percent made a plan, 16 percent made at least one attempt, and 8 percent were injured in a suicide attempt during the previous 12 months.”).
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Welch v. Brown, No. 13-1476, 2014 WL 25641 (6th Cir. 2014) (granting preliminary injunction preventing city from changing terms of retirees’ benefits package) (citations omitted).
These considerations are “factors to be balanced, not prerequisites that must be met.” Washington v. Reno, 35 F.3d 1093, 1099 (6th Cir.1994) (affirming issuance of injunction prohibiting prison officials from using trust fund proceeds to fund a new phone system). The district court need not make specific findings regarding each of the four factors if fewer factors are dispositive of the issue. See Six Clinics Holding Corp., II v. Cafcomp Sys., Inc., 119 F.3d 393, 400 (6th Cir. 1997) (“A preliminary injunction is customarily granted on the basis of procedures that are less formal and evidence that is less complete than in a trial on the merits.”).
In this case, the balancing of these factors weighs heavily in favor of enjoining the State’s continued use of excessive seclusion at the Facilities on boys with mental health disorders.
1. The United States Has Demonstrated a Likelihood of Success on the Merits. To show a likelihood of success on the merits, it is enough that the movant raises “questions going to the merits so serious, substantial, difficult and doubtful, as to make them a fair ground for litigation and thus for more deliberate investigation.” Brandeis Mach. & Supply Corp. v. Barber-Greene Co., 503 F.2d 503, 505 (6th Cir. 1974) (preliminary injunction granted against illegal tying arrangement) (quotation omitted). The United States can demonstrate likelihood of success on the merits. Excessive seclusion of juveniles is inherently punitive and violates the Fourteenth and Eighth Amendments to the Constitution. Courts have held that the “use of isolation [on children] was not within the range of acceptable professional practices and constitutes punishment in violation of the plaintiffs’ Due Process rights.” R.G. v. Koller, 415 F. Supp. 2d 1129, 1155 (D. Haw. 2006)
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(relying on expert testimony that “[p]rolonged isolation or seclusion . . . can cause serious psychological consequences”). Numerous courts have recognized the harm to juveniles from isolation and have found it violates Due Process. See generally H.C. v. Jarrard, 786 F.2d 1080, 1088 (11th Cir. 1986) (“Juveniles are even more susceptible to mental anguish than adult convicts.”); Santana v. Collazo, 714 F.2d 1172 (1st Cir. 1983) (experts’ testimony on lack of therapeutic and disciplinary benefits from isolation sufficient to warrant remand for further factual findings); Feliciano v. Barcelo, 497 F. Supp. 14, 35 (D.P.R. 1979) (“Solitary confinement of young adults is unconstitutional.”); Lollis v. N.Y. State Dep’t of Soc. Servs., 322 F. Supp. 473, 480 (S.D.N.Y. 1970) (concluding that the extended use of isolation on children is “cruel and inhuman,” and “counterproductive to the development of the child”).
The United States has established that boys with mental health disorders at the Facilities are secluded for weeks at a time, even when they demonstrate suicidal ideation or actions. Despite the concerted efforts of monitoring teams of subject matter experts for many years, the State continues to impose seclusion on boys with mental health disorders as a matter of course. The State does not deny the extent to which it secludes boys at the Facilities; when confronted with over 100 hours of seclusion in a single month, it dismissed that as “not alarming.” Attach. B. Even as evidence mounted that boys with mental health disorders were suffering, the State turned its resources and attention toward terminating this case under the PLRA rather than addressing the problems at the Facilities. There can be no factual dispute that the State is handing out thousands of seclusion hours and that is hurting boys at the Facilities.
Based on the undisputed evidence of the State’s relentless use of seclusion on boys with mental health disorders, the United States has demonstrated a likelihood of success sufficient to justify a temporary restraining order.
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2. The Boys at the Facilities Will Suffer Irreparable Injury Without a Temporary Restraining Order. The United States can demonstrate irreparable harm to boys with mental health disorders at the Facilities. “Irreparable harm” means that the plaintiff is unlikely to be made whole by an award of damages at the end of the trial. Farnam v. Walker, 593 F. Supp. 2d 1000, 1012 (C.D. Ill. 2009) (granting preliminary injunction requiring prison to provide medical care for inmate). Here, a monetary award would be cold comfort for the tremendous mental and physical harm the boys at the Facilities are suffering. They have endured days and even weeks of seclusion at the Facilities, to the point where some boys threaten suicide or are driven to hurt themselves. Their Fourteenth Amendment and Eighth Amendment rights have been impaired, and money damages cannot possibly fix that. These boys should not have to suffer needlessly while the United States, the United States v. Ohio and S.H. monitors, and the monitors’ subject matter experts try to persuade the State to change its ways. See, e.g., Farnam, 593 F. Supp. 2d at 1013 (“[M]oney hardly seems an adequate remedy for . . . significant pain and suffering.”). To substantiate a claim that irreparable injury is likely to occur, a movant “must provide some evidence that the harm has occurred in the past and is likely to occur again.” See Mich. Coal. of Radioactive Material Users, Inc. v. Griepentrog, 945 F.2d 150, 154 (6th Cir. 1991) (finding irreparable harm in state’s refusal to allow access to sites for dumping of radioactive waste). Here, the State’s own records prove excessive seclusion has occurred in the past. Moreover, the State’s own words prove excessive seclusion will occur in the future. When Dr. Dedel discovered that some Scioto boys had been secluded for at least 10 percent of their time in custody, the State dismissed her findings as “not alarming.” Attach. B. When the monitor sought help for one boy who showed extreme distress, visible injuries, and suicidal
15

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behavior during numerous episodes of seclusion, the State sought the resignation of the subject matter expert who investigated. The State’s active resistance to efforts to reduce the suffering of secluded boys with mental health disorders shows irreparable harm will continue unless this Court steps in.
3. A Temporary Restraining Order Would Not Cause Substantial Harm to Others. To determine whether the temporary restraining order would cause harm to others, the Court should balance the hardships by comparing relevant harms to plaintiff and defendant. Hughes Network Sys., Inc. v. InterDigital Commc’ns Corp., 17 F.3d 691, 693 (4th Cir. 1994) (vacating denial of preliminary injunction where district court failed to balance relative harms). Here, the harm to the boys with mental health disorders is significant and immediate. They are isolated for long periods, they are denied exercise outside of their rooms, and they often cannot receive essential programming, education and mental health care. At least one boy (K.R.) has hurt himself, and several more displayed suicidal tendencies. Isolation of juveniles greatly increases the risk of suicide or self-harm. Dr. Dedel warned, “The risk of self-harm increases when youth are isolated. Approximately ½ of the suicides that occur in juvenile correctional facilities occur among youth who are in disciplinary seclusion.” See Seclusion Report at 1. In contrast, the potential harm to the State from the proposed relief is minimal and speculative if there is any harm at all.9 As expert DeMuro explained, it is possible to run a safe
9 Reducing seclusion may actually yield cost savings for the State. A recent study found, “[s]ubstantial savings can result from effectively changing the organizational culture to reduce and prevent the use of restraint and seclusion.” Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, The Business Case for Preventing and Reducing Restraint and Seclusion Use, at 4 (2011).
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and secure facility without the State’s current overreliance on seclusion. DeMuro Decl. at ¶¶ 46, Attach. H. Under the proposed temporary restraining order, the State would retain authority and discretion to run the Facilities consistent with this Court’s order. For instance, the State could use seclusion as a temporary cool-down device or to restore order for a short time after an episode of chaos. What the State could not do is continue to use lengthy and repeated seclusion as its default, one-size-fits-all method for handling disciplinary issues. See Farnam, 593 F. Supp. 2d at 1016 (in Eighth Amendment challenge alleging deliberate indifference to serious medical needs, potential harm from erroneously granting a preliminary injunction was slight compared to the potential harm from erroneously denying it); see also Beerheide v. Zavaras, 997 F. Supp. 1405, 1411 (D. Colo. 1998) (balance of harms favored prisoners requesting kosher diet despite prison’s objection based on cost and security concerns).
When the overwhelming harm to the boys at the Facilities from excessive seclusion is weighed against the possible inconvenience to the State of temporarily changing its seclusion practices pending a final determination of what those practices should be, the balance of hardships weighs heavily in favor of the United States.
4. A Temporary Restraining Order to Prevent the Excessive Seclusion of Boys with Mental Health Disorders Would Serve the Public Interest. The Court should evaluate whether “the public interest that would be served by the granting of a preliminary injunction outweighs any public interest that would be served by denying it.” United Food & Commercial Workers Union v. Sw. Ohio Reg’l Transit Auth., 163 F.3d 341, 363 (6th Cir. 1998) (public had an interest in free expression of ideas in bus ads, and transit authority failed to prove impact on safe and efficient transportation supporting advertising
17

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ban); see Galper, 815 F. Supp. at 1044 (preventing plaintiff’s eviction from her office served the
public interest because eviction “would disrupt the service she provides to [5,000] patients”).
Protecting the constitutional rights of juveniles is in the public interest. The Violent
Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141, explicitly grants the
Attorney General the authority to bring suit against any governmental entity that has engaged in
a pattern or practice of depriving juveniles of their rights secured by the Constitution or federal
statute. In addition, the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997,
authorizes the United States to investigate and remedy unconstitutional conditions in juvenile
facilities. 42 U.S.C. § 1997a(a). The existence and enforcement of these federal statutes
demonstrates a substantial and compelling public interest in protecting the rights of boys with
mental health disorders from the harm of excessive seclusion.
Further, a national enforcement priority of the United States is preventing the use of
unlawful seclusion on persons in custody who have significant mental health needs. In the past
ten months alone, the United States has issued investigative findings and statements of interest in pursuit of this priority.10 The compelling public interest, combined with the United States’
10 For example, on May 31, 2013, and February 24, 2014, the United States issued findings that the manner in which the Pennsylvania Department of Corrections used prolonged isolation on inmates with serious mental illness subjected those inmates to a risk of serious harm and violated the Eighth Amendment of the U.S. Constitution and Title II of the Americans with Disabilities Act (“ADA”), 42 U.S.C. §§ 12131-34. On February 13, 2014, the United States filed a Statement of Interest in G.F. v Contra Costa County, No. 3:13-cv-03667-MEJ (N.D. Cal.), arguing that a juvenile detention facility is obligated under the ADA, 42 U.S.C. § 12101, to provide reasonable programming modifications enabling youth with disabilities to avoid imposition of seclusion due to their disability-related behaviors and to receive education and related programming while in seclusion. On August 9, 2013, the United States filed a Statement of Interest in Coleman v. Brown, No. 2:90-cv-0520 (E.D. Cal.), reaffirming, in a case challenging California’s use of prolonged isolation on prisoners with serious mental illness, the United States’ broad interest in preventing the unlawful use of solitary confinement. See Special
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showing of irreparable harm, likelihood of success on the merits, and balancing of harms, justifies a temporary restraining order.

B. The Temporary Restraining Order Satisfies the PLRA.

The Prison Litigation Reform Act (“PLRA”) bears on the scope of the prospective relief

this Court can order. It states:

Preliminary injunctive relief. . . . Preliminary injunctive relief must be narrowly drawn, extend no further than necessary to correct the harm the court finds requires preliminary relief, and be the least intrusive means necessary to correct that harm. The court shall give substantial weight to any adverse impact on public safety or the operation of a criminal justice system caused by the preliminary relief and shall respect the principles of comity set out in paragraph (1)(B) in tailoring any preliminary relief.
18 U.S.C.A. § 3626(a)(2) (emphasis added).

As described in the Proposed Order, the United States seeks a temporary restraining order

to enjoin the State from imposing excessive amounts of seclusion on boys with mental health

disorders. This targeted relief complies with the PLRA requirements because:

•

It extends no further than necessary to correct the harm because it allows the State

to use seclusion in a controlled fashion where necessary while preserving boys’

access to essential education, exercise, programming and mental health care;

•

It is narrowly tailored because it encompasses only boys at the Facilities with

mental health disorders, as they are the ones who suffer the most from excessive

seclusion; and

•

It is the least restrictive means necessary because it vests in the State discretion to

decide when seclusion is unavoidable and what offenses will result in seclusion.

The United States’ requested relief is an appropriate exercise of the Court’s equitable

powers, so the Court should issue a temporary restraining order and set an expedited hearing on

issuance of a preliminary injunction, followed by expedited discovery and a hearing on the

Litigation Section, Civil Rights Division, United States Department of Justice, cases and statements of interest, at http://www.justice.gov/crt/about/spl/findsettle.php.
19

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 21 of 26 PAGEID #: 2959 United States’ request for a permanent injunction. CONCLUSION The United States has established that the State is excessively secluding boys with mental health disorders, that boys are suffering irreparable harm, and that the State has not changed its practices. This Court should act now and grant an immediate temporary restraining order, a preliminary injunction hearing and, after expedited discovery and briefing, a hearing on the issuance of a permanent injunction to protect the constitutional and federal rights of these boys.
20

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 22 of 26 PAGEID #: 2960

DATE: March 12, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders____________ DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov
STEVEN M. DETTLEBACH United States Attorney Northern District of Ohio
/s/ Michelle L. Heyer___________ MICHELLE L. HEYER, Reg. No. 0065723 Assistant United States Attorney Northern District of Ohio 801 West Superior Avenue, Suite 400 Cleveland, Ohio 44113 (216) 622-3686/(216) 622-3781 (T) (216) 522-2404 (F) michelle.heyer@usdoj.gov

Respectfully submitted,
JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
JONATHAN M. SMITH Chief Special Litigation Section
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section
CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
/s/ Silvia J. Dominguez-Reese ___ SILVIA J. DOMINGUEZ-REESE Trial Attorney Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547(T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorneys for Plaintiff

21

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 23 of 26 PAGEID #: 2961
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that this date, March 12, 2014, I caused the foregoing to be
electronically filed with the Clerk of the Court using the CM/ECF system, which will
simultaneously serve notice of such filing to counsel of record and the Court Monitor to their
registered electronic mail addresses.
/s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547 (T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorney for Plaintiff

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 24 of 26 PAGEID #: 2962

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE STATE OF OHIO, et al.,

)

)

Defendants.

)

____________________________________)

CIVIL ACTION NO: 2:08-cv-475 JUDGE ALGENON L. MARBLEY

[PROPOSED] ORDER GRANTING UNITED STATES’ MOTION FOR TEMPORARY RESTRAINING ORDER, SETTING A PRELIMINARY INJUNCTION HEARING, AND GRANTING
EXPEDITED DISCOVERY FOR A PERMANENT INJUNCTION HEARING

Upon consideration of the parties’ submissions and the applicable law, the Court hereby

grants the United States’ Motion for a Temporary Restraining Order and sets a schedule for the

United States’ request for a Preliminary and Permanent Injunction as follows:

I. This Court, as an interim response to the State’s infliction of unlawful and irreparable harm on boys through its seclusion and mental health practices, hereby issues a temporary restraining order that the State:

A. Stop secluding any boy with an identified mental health disorder for more than 24 hours without providing him, outside of his confinement area and during normal facility programming times, at least four hours of programming, exercise, education, or combinations thereof;

B. Stop imposing more than three consecutive days of seclusion in any form (e.g., prehearing seclusion and intervention seclusion) on any boy with an identified mental health disorder; and

C. Stop imposing more than three days of seclusion in any form within a 30-day period on any boy with an identified mental health disorder without first:

1. Conducting a comprehensive mental health treatment review of the boy that includes the treatment team meeting and reviewing the boy’s mental health treatment plan to consider and address potential problems with the plan and its implementation;

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 25 of 26 PAGEID #: 2963

2. Obtaining the prior written approval of the Deputy Director of DYS responsible for Facility programming; and

3. Providing written notice to the United States and monitor within 24 hours of a youth exceeding three days of seclusion within a single month, describing the amount of seclusion, reason for seclusion, treatment provided in response to seclusion, whether the youth’s behavior intervention plan was modified or created, and alternatives to seclusion that were rejected.

D. Provide monthly to the monitor an AMS printout of monthly seclusion hours for boys at the Facilities; and

E. Refrain from substituting restraints for seclusion.

II. The Court will hold an expedited hearing to determine the United States’ entitlement to a preliminary injunction.

III. The Court hereby sets an expedited schedule for discovery and further briefing in preparation for a hearing on a permanent injunction. At the permanent injunction hearing, the Court will determine the circumstances and limitations governing the use of seclusion (or restraints as a substitute for seclusion) on boys with mental health disorders at the Facilities, particularly given that the proposed temporary restraining order’s terms do not extend far enough to address the extent of the State’s violations.
The Court hereby adopts the following schedule for expedited discovery:

Hearing on TRO Motion Hearing on Motion to Supplement Parties Serve Requests for Production of Documents and Interrogatories Parties Identify Experts Parties File Briefs on Issuance of Preliminary Injunction Hearing on Issuance of Preliminary Injunction Responses to Requests for Production of Documents and Interrogatories Plaintiff’s Experts Tour Facilities Monitor Team Reports Filed by Dedel and Glindmeyer Plaintiff Deposes DYS Staff Parties Serve Requests for Admission Parties Respond to Requests for Admission Parties’ Serve Expert Reports

March 21, 2014 March 21, 2014 March 24, 2014
March 25, 2014 March 28, 2014 April 2, 2014 April 4, 2014
April 6-11, 2014 April 21, 2014 April 28, 2014 April 28, 2014 May 5, 2014 May 5, 2014

2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131 Filed: 03/12/14 Page: 26 of 26 PAGEID #: 2964

Depositions of Experts Pre-Hearing Briefs for Permanent Injunction Hearing to Determine Permanent Injunction

May 12-16, 2014 May 27, 2014 June 7, 2014

It is so ordered.
Signed this ____ day of ____________, 2014
___________________________________ HONORABLE ALGENON MARBLEY UNITED STATES DISTRICT JUDGE

3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 1 of 37 PAGEID #: 2965
Attachment A

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 2 of 37 PAGEID #: 2966

Coe. Cynthia (CRT)

From: Sent: To: Cc:
Subject:

Alphonse Gerhardstein [AGerhardstein@gbfirm.com] Saturday, January 11, 2014 3:25 PM Thomas N. Anger Judith B. Goldstein; Terry Schuster; Kim Tandy; Tayloe, Benjamin (CRT); Cae, Cynthia
DomirlQLlez··R"ese, Silvia (CRT); Will Harrell; Andrea Weismann; daphne glindmeyer FM'""."lrm needed

Tom - Thanks for the cooperation Kim and I got at CJCF yesterday. [write to urge prompt action regarding • • •

_ . I am not a clinician but I have been representing mentally ill inmates for 37 years. Mr.

strikes me as

extremely mentally iii. More importantly, he seems to be experiencing excessive seclusion - particularly in the

Observation Cell on Oak - which appears to make him worse.

I do not have his file. Only my interview. He reports that he is taking significant psych meds. Staff and the client both reported that he bangs his head frequently. He had fresh head injuries as I spoke to him. Something drives him to self destructive behavior and whatever has been tried so far does not seem to be working. I certainly got the impression that he remains at a current risk of seriously harming himself. I ask that DYS, Dr. Weisman and Dr. Glindmeyer take a careful look at this young man and act promptly to ensure his safety and adequate treatment. Thanks very much.

Alphonse A. Gerhardstein Gerhardstein & Branch Co LPA
432 Walnnt Street, Suite 400 Cincinnati, OR 45202 Office 513.621.9100 FAX 513.345.5543
www.gbfirrn.com

From: Judith B. Goldstein [mailto:Judith.Goldstein@ohioattorneygeneral.gov] Sent: Friday, January 10, 2014 1:37 PM To: Terry Schuster; Thomas N. Anger; Calhoun, Dustin; Alphonse Gerhardstein; Kim Tandy; Tayloe, Benjamin (CRT); Cae, Cynthia (CRT); Dominguez-Reese, Silvia (CRT); Will Harrell; Andrea Weismann; daphne glindmeyer Subject: RE: Summary of parties' agreement re: follow-up to Glindmeyer and Weisman reports
I will certainly check into this asap. I do know that for the documents requested by Dr. Weisman (which were listed in 'tour summary as due on Jan. 6th), we were following her mid-January deadline because we were working under the understanding that she needed documents for a report and plaintiff's counsel needed different documents for the Jan.
29th conference. I'll get back to you with a response.
Judith B. Goldstein
Uuit Coordinator - Criminal Justice Section/Corrections Litigation Unit
Office of Ohio Attorney General Mike DeWine 150 East Gay Street, 16th Floor Columbus, Ohio 43215 Office number: 614-644-8685
Judith.Goldstein@OhioAttorneyGeneral.gov

1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 3 of 37 PAGEID #: 2967
Confidentiality Notice: This message is intended for use only by the individual or entity to whom or which it is addressed and may contain information that is privileged, confidential and/or otherwise exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify me immediately by telephone.
From: Terry Schuster [mailto:shmonitor.schuster@qmail.coml Sent: Friday, January 10, 2014 1:33 PM To: Judith B. Goldstein; Thomas N. Anger; Calhoun, Dustin; Alphonse Gerhardstein; Kim Tandy; Tayloe, Benjamin (CRT); Coe, Cynthia (CRT); Dominguez-Reese, Silvia (CRT); Will Harrell; Andrea Weismann; daphne glindmeyer Subject: Fwd: Summary of parties' agreement re: follow-up to Glindmeyer and Weisman reports
Hi Judy,
We need some further explanation from you. You said in your recent email that Defendant has provided all of the documents and met all of the deadlines agreed to in chambers. I am forwarding the email that I sent out to everyone on Dec. 22nd. It includes an attached summary of the parties' agreement in chambers.
As far as we can tell, DYS has not provided any of the documents and information on the second page of the attached summary.
Additionally, DYS has not provided the items listed on the first page under the heading "QAlQI and peer review for mental health" or under the heading "discipline for youth on the mental health caseload". [Note that we agreed with Dustin's alternate definition of "frequent flyers," which he included in an email response to this Dec. 22nd emaiL]
I have also attached a short memo that Dr. Weisman wrote up for Will explaining what she is able to report on (by Monday) based on what she's been provided so far, and what she's not able to report on.
It seems as though DYS has overlooked quite offew of the items that were included in this summary. Can you please explain what happened?
Thanks, Terry and Will
---------- Forwarded message ---------From: Terry Schuster <shmonitor.schuster@gmail.com> Date: Sun, Dec 22, 2013 at 8:28 PM Subject: Summary ofparties' agreement re: follow-up to Glindmeyer and Weisman reports To: "Judith B. Goldstein" <Judith.Goldstein@ohioattorneygeneraLgov>, "Thomas N. Auger" <thomas.anger@ohioattorneygeneraLgov>, "Calhoun, Dustin" <dustin.calhoun@dys.ohio.gov>, "Reed, Harvey" <Harvey.Reed@dys.ohio.gov>, "linda.janes@dvs.ohio.gov" <linda.janes@dys.ohio.gov>, "Trim, Ginine" <ginine.trim@dys.ohio.gov>, Will Harrell <shmonitor.harrell@gmaiLcom>, Alphonse Gerhardstein <AGerhardstein@gbfirm.com>, Kim Tandy <ktandy@childrenslawkv.org>, "Dominguez-Reese, Silvia (CRT)" <Silvia.Dominguez-Reese@usdoj.gov>, "Tayloe, Benjamin (CRT)" <Benjarnin.Tayloe@usdoj.gov>, "Coe, Cynthia (CRT)" <Cvnthia.Coe@usdoj.gov>, daphne glindmeyer <dglindmever@gmaiLcom>, Audrea Weismann <Aweisman@aoLcom>, Kelly Dedel <kelly.dedel@gmaiLcom>
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 4 of 37 PAGEID #: 2968
Dear DYS administrators, DYS counsel, S.H. counsel, and DOJ, On Thursday we discussed various follow-up items from the reports written by Dr. Glindmeyer and Dr. Weisman. I have attached a sunnnary. If anyone needs clarification on any ofthe items in the sunnnary, please let us know by close of business on Monday, The deadline for the documentation itemized in the attached sunnnary is January 6th. If you need a couple of extra days, let us know -- we have some wiggle room on that deadline, but we are aiming to circulate our final mental health and psychiatry reports on Jan. 13th, so we'll need all of the documentation sometime on the week of January 6th. We plan to file the final reports with the Court before January 25th. Thanks, Terry
Terry Schuster, Esq. Special Assistant to the Federal Court Monitor S.H v. Reed Monitoring Team (512) 468-4486 sbmonitor.schuster@grnail.com
Terry Schuster, Esq. Special Assistant to the Federal Court Monitor S.H v. Reed Monitoring Team (512) 468-4486 shmonitor.schuster@gmail.com
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 5 of 37 PAGEID #: 2969
Attachment B

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 6 of 37 PAGEID #: 2970

Coe. Cynthia (CRT)

From: Sent: To: Subject:

Dominguez-Reese, Silvia (CRT) Thursday, March 06, 2014 5:48 PM Cae, Cynthia (CRT) FW: Seclusion concems at SJCF

From: Calhoun, Dustin [mailto:Dustin,Calhoun@dys.ohio.gov] Sent: Wednesday, December 04, 2013 11:59 AM To: Tayloe, Benjamin (CRT); Dominguez-Reese, Silvia (CRT)
Cc: 'Thomas N. Anger'; Judith B. Goldstein
Subject: Seclusion concems at SJCF

Silvia and Bo,

It was a pleasure speaking with the two of you this morning and I believe our conversation was very productive. Before I addressed the potential for contracting with Kelly with Director Reed, I wanted to drill down and see exactly what we are dealing with and looked at the numbers for November.

Out of the 10 young men that were referenced in Kelly's report, the following five are all that remain at Scioto:

• • • • • • • • • • • • • • • • with the caveat that

is scheduled to be released tomorrow.

The following represents the seclusion HOURS for the month of November for the above youth:

4.5 hours 1.45 hours 142.3 hours (Act of Violence) 80.93 hours (Act of Violence) 1.0 hour
As you can see, the seclusion hours are not alarming for these youth. After reviewing this email, please advise if your
has changed.

Thanks,

Dustin J. Calhoun· Chief Legal Counsel Ohio Department of Youth Services 30 West Spring Street, Sth Floor Columbus, Ohio 43215 614.728.7353 (Office) 614.752.9078 (Fax) Dustin.Calhoun@dys.ohio.gov

This message, and any response to it, may constitute a public record and thus may be publicly available to anyone who requests it in accordance with Chapter 149 of the Ohio Revised Code,
1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 7 of 37 PAGEID #: 2971
Attachment C

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 8 of 37 PAGEID #: 2972

Coe, Cynthia (CRT)

From: Sent: To: Subject:

Alphonse Gerhardstein [AGerhardstein@gbfirm.com] Wednesday, January 15, 2014 2:24 PM Tayloe, Benjamin (CRT); Coe, Cynthia (CRT); Dominguez-Reese, Silvia (CRT)
FW: Request that Dr. Weisman resign

fyi

From: Will Harrell [mailto:shmonitor.harrell@gmail,com]
Sent: Wednesday, January 15, 2014 12:02 PM To: Alphonse Gerhardstein
Cc: Judith B. Goldstein; ktandy@childrenslawky,org; Thomas N. Anger; dustin.calhoun@dys.ohio.gov; Terry Schuster; Andi Weisman
Subject: Re: Request that Dr. Weisman resign

Judy:

I've reviewed your letter and the email from AI. I've also discussed the allegations with Dr. Weisman. Here is my opinion.

1. Andi did not step outside of her monitor boundaries in following up on this kid's situation as reported to us by

.AJ. In fact, I explicitly asked her to do so. Al reported his concerns about youth

and requested that DYS

and the monitors look into it. The concerns Al reported relate precisely to

ssue that remains in this

c.ase--seclusion ofyouth with mental health disorders. Al informed us that _mother was actively

involved with him and therefor she would be a good source of information

s. We are authorized to

gather information from any source we deem necessary such as staff, youth, advocates, oversight bodies and

family members. We have done so throughout the span of this case and we will continue to do so.

2. Andi maintains that she didn't release private medical information to anyone without the youth's consent. I have no reason to believe she did. Andi didn't have any private medical information to release.

3. Andi maintains that she didn't render psychological services or a psychological evaluation. I have no reason to believe she did. She never spoke with this youth. And when she spoke with his mother, she was merely gathering information relevant to her review ofthe seclusion of youth on the mental health case load.

5. There is nothing slanderous about Andi's statement in her report. She is reporting what _mother stated

to her. However, we will adjust the tone of that statement before submitting the report to t

for the

record.

There have been many situations in the past where in the course of our monitoring we have uncovered an individual case that required urgent attention or that an urgent case is brought to our attention by plaintiffs council or other individuals. When that happens, we try to get it to the attention ofthe appropriate DYS officials as soon as we can. This was simply another one of those instances and it appears that this youth is now getting the attention he needed. How is that not a good thing? I assure you that is what Judge Marbley expects of us.

I am willing to seek Judge Marbley's opinion on this matter or you can bring it to him directly. But I advise you to drop this distraction and get refocused on resolving the remaining substantive issues in the case. The Attorney General's office has been trying to get Dr. Weisman removed from this case for over a year. Rather than shoot the messenger, I suggest you address the message.

1

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 9 of 37 PAGEID #: 2973
Regards, Will Harrell
On Wed, Jan 15,2014 at 8:30 AM, Alphonse Gerhardstein <AGerhardstein01gbfirm.com> wrote: Dear Judy - Will shared with us your letter requesting Dr. Weisman's resignation. Plaintiffs do not agree to your request. As you may know from previous disputes the agreement of Plaintiffs' counsel is necessary in order to remove a member of the monitoring team. We have not even been advised ofthe facts of the underlying dispute.
Here is what I know. Because of concern for one youth's safety, I requested DYS and the monitor team experts to look into the circumstances of a specific youth I interviewed last Friday. The youth called his mother who in turn called me. She had information on his history. I passed her name and number to Will and the monitor experts and it is my understanding that Will requested that Dr. Weisman talk to the mother. There is absolutely nothing wrong with those actions. It is not unusual. It has always been our practice to permit members of the monitoring team to access information from persons with knowledge. See e.g., Doc. 108 at page 82 where Monitors are allowed "unobstructed access to staff and youth and other persons having information relevant to the implementation ofthis Stipulation." I spoke with the youth's mom this morning and she reports that she speaks with her son by phone frequently and visits at least once a month. She seems genuinely excited that he will get effective treatment as result ofthe current efforts. It seems to me everyone is working to make that happen.
As far as I know the needs ofthe youth are now being evaluated. That was the goal. There is no basis here for DYS to seek anyone's resignation. Please call me to discuss the matter.
Alphonse A. Gerhardstein Gerhardstein & Branch Co LPA 432 Walnut Street, Suite 400 Cincinnati, OH 45202 Office 513.621.9100 FAX 513.345.5543 www.gbfirm.com
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 10 of 37 PAGEID #: 2974
Attachment D

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 11 of 37 PAGEID #: 2975

Office (614) 644"7233

Fax (614) 728-9327

.

150 East Gay Street, 16th Floor

Oolumbus, Ohio 43215

www.OhloAttorneyGeneral.gov

August 22, 20:1.3

Benjamin 0. Tayloe Jr., Esq. U. S. Department of Justice Civil Rights Division
950 Pennsylvania Avenue NW Washington, DO 20530

Alphonse Gerhardst.,in, Esq. Gerha'rdsteln & Bra rich Co., LPA 432 Walnut street, Suite 400 Clnolnnati, OH 45202

Kim Tandy-Brown, ·Esq.
Ohlldren's Law Center 1002 Russell Street
Covington, KY 410:11

RE: Use of Programmatlo Restraints and Restructuring of Progress Unit

Dear Attomeys for S.H. and the Department of Justice:

DYS has decided to make the following ohanges to th_e Progress Unit:

First, the Progress Unit wlll be restructured In such a way that any youth admitted to
Progress will be placed on Transition Phase I. Further, any youtb demoted from Transition Phase II will be demotedonly to Transition Phase I. No youth will be demoted from Transition Phase I.
Second, incidental to this ohange, DYS will no longer be using programmatic restraints:

These ohanges will be formalized and incorporated Into polioy as SOOIl as possible. During

this transition time, DYS will neither admit nor demote youth into Phase I, nor will It use

programmatio restraints.

.

Thank you for your continued input and patlenoe as DYS makes these ohanges.

Very truly yours,

MIKE: DeWINiO Ohio Attomey General
s[fhomas N. Anger THOMAS N_ ANGER Ms1stentAttomey General

TNA:mcc
cc: Jackie Ouncannan Kelly Dedel SIlvia Dominguez Will Harrell Rashida ogletree Terry Schuster

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 12 of 37 PAGEID #: 2976
Attachment E

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 13 of 37 PAGEID #: 2977

MEMORANDUM

TO:
FROM: RE: DATE:

Tom Anger, Linda Janes, Amy Ast-Ohio DYS Bo Tayloe, Silvia Dominguez-U.S. DOJ Kelly Dedel, Ph.D., Lead Monitor U.S. v State of Ohio Results of Seclusion Analysis
November 8, 2013

As you know, while I was on site at Scioto during the week of October 14,2013, I became curious about the accumulation of seclusion hours for certain youth. While on site, I noted that the IH Officer and Superintendent used a tempered approach in the number of seclusion hours ordered as a sanction for individual AOVs (e.g., they did not order the maximum permissible, but more often something less). However, I also noticed that the same youth's names kept coming up in the documentation, over and over again.
I did not have time to further investigate this while I was on site, so upon returning home, I requested additional documents to examine this "accumulation" question. Using the AMS seclusion reports for the entire 6-month monitoring period, I calculated the number of hours/days each youth spent in seclusion. At first, I simply estimated the number of days the youth was in custody during that time, e.g., if he had any seclusion time during the month of June, I assumed he was there for the entire month. Once I obtained the preliminary results, I felt the need to make the analysis more precise and requested the exact admission and release dates for each youth so that I could know the precise number of days in custody, and therefore the proportion of that time that the youth spent in seclusion.
The results of this analysis are summarized in the table below. It includes youth whose total seclusion hours/days was 10% or more of their time in custody during the 6-month period. [Note: the total time in seclusion was not consecutive.] Of course, the AMS records show that there are some youth who spent very little time in seclusion. However, the AMS records also show that there are a number of youth who spent a considerable amount of time (20, 30, 40, nearly 50 days) in seclusion. Depending on how long the youth was in custody, this could amount to significant proportions of his time at Scioto.
As you know, I have serious concerns about the use of seclusion as a sanction:
• The risk of self-harm increases when youth are isolated. Approximately Y, of the suicides that occur in juvenile correctional facilities occur among youth who are in disciplinary seclusion.
• Isolation has the potential to exacerbate mental illnesses.
• Seclusion suppresses violent behavior in the moment, but does nothing to address the underlying causes of it. Instead, youth often emerge from seclusion feeling angry, frustrated and irritable-likely the very emotions that triggered their violent behavior in the first place.

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 14 of 37 PAGEID #: 2978
• Seclusion disengages youth from the people and programs that they need to access in order to develop the awareness, skills and desire to control their violent behavior.
Although I believe it to be ineffective, when youth experience seclusion in very small doses, I don't necessarily believe it is harmful. However, when youth's exposure to seclusion accumulates, as it has forthe youth listed in the table below, I believe the risk of harm is much more significant.
I offer these data as a starting point for a conversation about how to mitigate these risks for the youth who have chronic, aggressive misconduct. Obviously, preventing the misconduct via effective treatment is the best solution. Dr. Glindmeyer is reviewing these youth's mental health records and may be able to make some recommendations toward that end. When treatment is not sufficient, finding ways to address the youth's behavior that are compatible with, rather than counterproductive to, the goal of rehabilitation seems essential.
I plan to summarize these results in the upcoming Monitor's Report, but hope that we can initiate a problem-solving discussion about where to go from here in the meantime.
Respectfully,
Kelly Dedel, Ph.D. Lead Monitor, U.S. v. State af Ohia

[OJ.]

74

[B.D.]

184

[A. F.]

184

[T.R.]

184

[D.H.]

184

[J.A.]

141

[T.H.]

109

[M.G.]

137

[R.B.]

184

[K.A.]

184

[0.5.]

184

28.54 49.56 43.83 35.36 33.59 24.56 16.27 17.55 23.24 20.57 17.62

38.57% 26.93% 23.82% 19.21% 18.25% 17.42% 14.92% 12.81% 12.63% 11.18%
9.6%

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 15 of 37 PAGEID #: 2979
Attachment F

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 16 of 37 PAGEID #: 2980
Ohio I Department of Youth Services
John R. Kasich, Governor Harvey J. Reed, Director

November 21,2013

TO: FROM: RE:

Stakeholders Director Reed Facility Closure

I want to inform you of the Department's decision to close the Scioto Juvenile Correctional Facility (SJCF) on May 3, 2014. Over the course of the past two years, the DYS population has dropped from an average of 685 youth in October 2011 to 525 youth in October 2013. With a 23 percent drop in population, closing the facility improves the efficiency of our operations.
As of yesterday, there were 38 youth at SJCF (20 males and 18 females who reside separately). Male youth will be gradually reassigned to the remaining facilities according to their security, educational and programming needs. I am confident that our staff is well-equipped to handle these youth safely and effectively. We are evaluating the appropriate placement options for our female youth, including placement at private residential facilities and Community Corrections Facilities (CCFs), and will certainly keep you informed as the plan advances.
We are required to follow all layoff procedures according to union contracts and the Ohio Revised Code; however, we will offer a DYS position to all staff impacted by this closure and who are not ready to retire. During the next few weeks, we will work closely with the affected bargaining unit and exempt staff to identifY positions for which they are qualified.
Thank you for your cooperation and support. Please do not hesitate to contact us with any questions or concerns by emailing guestions@dys.ohio.gov.

Cenlra! Office 30 W. Spring Sireet, 51h Floor
Columbus, Ohio 43215-2256

6141466-4314 www.dys.ohio.gov

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Attachment G

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 18 of 37 PAGEID #: 2982
S.H. v. Reed
Re: Compliance with Consent Order Provisions regarding Mental Health Submitted by: Andrea Weisman, PhD. December 16,2013
Sub-topic II.C.1.a. QAjQI and peer review for mental health and psychiatry
Mental Health Compliance Rating - Partial Compliance
Methodology: Peer Review forms were received from each facility: CJCF - N=6, CHJCFN=8, Scioto - N=7, IRJCF - N=6.
Observations: These reviews are titled Clinical File Reviews and reflect provider's assessment of 14 areas of concern including, whether the ITP is strength-based, whether there is evidence that parents/guardians have been communicated with, whether the SOAP format was utilized in the documentation of group and individual sessions, etc. The newly created form provides check boxes (Compliant, Non-Compliant and N/A). Problems noted include: when non-compliant or N/A is checked there frequently is no narrative explaining why the rating was given. In addition, there are numerous examples of unchecked boxes or multiple responses to the same question. This check box approach does not really get at the quality oftreatment provided or the clinical efficacy of their interventions. In order to determine the efficacy of treatment, DYS would, for example, need to look at such issues as whether the Sex Offender program is working, and for which populations of youth is it working? Are there racial, intelligence, psychiatric diagnostic factors that correlate with youth's ability to complete the program in a timely way. DYS would also need to examine such issues as what subgroups of youth are effectively participating in their CBT curriculum or individual therapy, as evidenced by youth engaging in fewer acts of violence or meeting treatment objectives. And DYS would be advised to look at whether group and individual services are being offered at the recommended frequency, also by the demographic variables identified above.
In addition, Behavioral Health Peer Review forms specifically focused on ITPs were received from CJCF (N=16). These forms assess the ITP objectives in terms ofthe acronym SMART: Specific (What do we want them to accomplish?), Measurable (Concrete criteria established to measure progress. How much, how many, how will I know when it is accomplished), Attainable (Plan the steps and associated timeframe wisely), Realistic (Is the youth willing and able to meet the objective?) and Timely (Are
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the time frames associated with objective). This is a form that collects provider's responses on 5 separate Likert scales which range from strongly disagree to strongly agree (with "neutral" in the center of the scale. Most providers rated the ITPs as meeting SMART expectations.
Since ITPs were also presented for review, it was possible to determine the accuracy of ratings on the SMART Peer review forms. For example, one form which rated the ITP positively on all indicators, in fact contained an objective that read "Learn and practice Skill Card #12: Following instructions and Skill Card #1: Listening over the next 30 days." In still another, the objective read "(Youth) and I will continue working together in individual sessions to identify his coping skills, coping strategies, common thinking errors and his goals, dreams and hopes for the future. This social worker plans on continuing to provide regular support, encouragement and advice in order to aid (youth) in balancing his thinking. We will complete the CBT packet entitled "Functional Behaviors - Making Choices that Work." Neither of these objectives identifies the new skill the youth will learn. I have provided consistent feedback over the years: Talking about completion of skill cards or CBT packets is not the same thing as skill acquisition. If the objective is completion of an assignment, the providers aren't measuring whether the problem behavior has decreased when they monitor for progress. And referencing what the social worker will do to provide support and encouragement is also not appropriate for inclusion in the statement of an objective. As a consequence, this peer review process has not meaningfully addressed the integrity of the ITPs.
There are additional problems with the Peer Review process. Many ofthe SMART Review forms are inaccurately filled out. With some providers rating that they "strongly disagree" that an objective meets the SMART indicators while the accompanying narrative would suggest the provider actually found the objectives to be compliant in the context of SMART. Also, where "neutral" is provider's rating, there is frequently no narrative to explain the rating. It is substantially unclear what value is added with this rating, particularly if it has no narrative clarifying what the rating means.
While there are continuing difficulties with the QI processes, there is evidence that . psychology supervisors are focused on improving ITPs. Both Drs. Dunphy and Hamning should receive particular praise for their efforts to improve the quality of ITPs as evidenced by their thoughtful feedback to clinicians in both Behavioral Health Staff Meeting minutes and on their supervision notes. However their efforts are not reflected in the documentation provided for review.
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Required Action: DYS needs to provide additional training on the writing of ITPs and on the forms in used for their peer review process.
Sub-topic II.C.l.e. Case formulation, fidelity to treatment provided to treatment model, treatment planning and treatment teams
Compliance Rating: Partial Compliance - Case formulation, treatment planning and treatment teams
Compliance Rating: Non- Compliant - Fidelity to treatment provided to treatment model
Methodology:Four Individual Treatment Plans (ITP) from each ofthe four facilities were reviewed. CJCF presented an additional 13 ITPs along with their Peer Review documentation. This documentation was sufficient to comment on case formulation, treatment planning and treatment teams. There was no documentation offered for review of fidelity to treatment provided to treatment model.
Observations: Treatment planning and ITPs continue to be a challenge for all facilities. Although we'd previously identified problems with the conceptualization and encoding of ITPs, and asked DYS to produce ITPs that was responsive to this observation, none of the currently reviewed ITPs are strength-based, nor do they present goals or objectives in concrete, measurable terms. Examples across facilities include: Goal: "{Youth will address his pro criminal identify mindset and work towards identifying a non criminal identity." The corresponding objective is "{Youth and 1will complete the packet "Problems with Authority in our individual sessions." Goal: "(Youth) will be able to maintain control over disturbing thoughts and feelings and related impulses that contribute to criminal behavior." The corresponding objective reads: "I will use CBT techniques to develop an understanding of and be able to identify in everyday situations, the ways in which thoughts feelings, behaviors and consequences are connected and related to each other." Goal: "Correct irrational thinking, which leads to anger and interpersonal problems." And again, the corresponding objective reads: "I will use materials from MAV and CBT groups, including thinking reports, to review the last 5 incidents of angry outbursts and all future incidents to identify the specific triggers that were connected with these incidents."
As has been discussed previously, a case formulation is the essential framework for the development of Individual Treatment Plans (ITP). Treatment goals need to reflect real world concerns - issues that must be addressed in order for the youth to return to the community. Objectives should be designed to develop and measure skill acquisition. Plans need to be assessed in terms oftheir efficacy in helping the youth acquire the desired skills, and revised monthly - or more often - if it becomes clear that the ITP is not working. Articulating objectives as the completion of paper and pencil tasks or
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studying Skill Cards does not address the development of new replacement behaviors. These are rather, strategies being employed in the service ofthe development of new skills, they are not in and of themselves, evidence of skill acquisition.
Required Action: UntillTPs are made more meaningful, mental health service delivery is compromised. The ITP is a roadmap, and if it doesn't outline what the staff is trying to achieve with the youth, there's no way for providers to assess whether the youth is improving. If DYS is to receive an improved compliance rating with regard to fidelity monitoring, they will have to produce evidence that they are engaging in such monitoring. This is a recommendation that has been made repeatedly over the years.
Sub-topic II.C.l.f. Behavior contracts
Compliance rating - Partial Compliance Methodology: Five Intensive Behavior Contracts from each facility were reviewed.
Comments: As a general matter, there is noted improvement in the Intensive Behavior Contracts. There is consistency across facilities in their use of a newly revised Intensive Behavior Contract format. The Contracts now evidence only one or two target behaviors, some document the frequency of occurrence of the noxious behavior, and all offer both incentives and consequences. All Contracts are now scheduled for review 7 days from the date of its signing, and, Contracts evidence attempts to articulate goals in incremental steps: "I (youth) agree I will perform the following behavior: maintain a distance of an arm's length when upset, use respectful language when discussing my issue, and maintain a low voice volume lout of 3 times," "I will maintain an arm's length of space between myself and all female staff lout of 2 times."
There are however, some continuing challenges with the Contracts. In particular, the incentives are not sufficiently incentivizing: "I will earn an extra snack provided by the UM or SWat a predetermined time," "I can listen to 15 minutes of music in my SW or psychologist's office," "15 minutes with an MP3 player on her unit," "I will earn 10 minutes in my room." As has been noted previously, incentives should be both proximate to the production ofthe desired behavior and should be sufficiently incentivizing so as to be rewarding to the youth. An extra 10 minutes in one's room at the end of a week of not engaging in target behaviors just not enough of a carrot for an adolescent. Incentives should be meaningful and determined in collaboration with the youth. In order to be maximally rewarding, as previously noted, they should also be more proximate to the production of desired behavior -like daily.
In addition, all Contracts begin with the statement that "I (youth) enter into the following contract in order to create and maintain order and harmony in the facility." In point of fact, Behavior Contracts are entered into in order to enhance the youth's ability to engage in replacement behaviors - that is, new behaviors that replace the target
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behaviors. If and when successful, it is likely that it will facilitate "order and harmony in the facility," however, that is not the purpose of the Contracts.
Contracts reviewed were developed from July through October. None were signed by the youth, clinician, UM, or supervisory behavioral health staff. No evidence was provided that any ofthe Contracts were reviewed. As such, itis impossible to know whether these Contracts were implemented, or if revising these Contracts was just a training exercise for the practitioners. As a consequence, it is impossible to determine if these Contracts are more efficacious than their predecessors. To determine the efficacy of the Contracts, DYS would have to track whether the youth met the goal and got the reward, or didn't meet the goal and got the consequence.
Required Action: DYS needs to provide documentation that reviews ofthe behavior contracts is occurring and that they are reducing the target behaviors.
Sub-topic II.C.l.h. Discipline for youth on the mental health caseload through the intervention hearing process
Compliance Rating - Partial Compliance
Since my preliminary recommendations in November, 2013, no new documentation has been presented for review regarding discipline for youth on the mental health caseload. We were advised that DYS has revised their policy "Intervention Procedures for Youth with Mental Illness, Cognitive or Development'll Disabilities (policy 303.01.04). Policy now requires that clinicians attend intervention hearings if: there are mental health and/or developmental issues that may have impacted the youth's behavior at the time ofthe rule violation, and ifthere are mental health and/or developmental issues that should be considered regarding disposition of the youth iffound proven.
This was recommended in our earlier Mental Health findings report, and it is all to the good that DYS is incorporating this recommendation into their operating procedures.
I have substantial concern however, that DYS is continuing to seclude mentally ill youth who are charged with rule infractions. While some amount of room confinement may be appropriate in some instances, when mentally ill youth are secluded, especially for protracted periods, they suffer harmful consequences. When a mentally ill youth winds up in secluSion, it is incumbent on the practitioners to modify the ITP appropriately to extinguish the behavior. If the youth continues in seclusion without a corresponding modification of his/her ITP,.the seclusion will just exacerbate the behavior problems DYS is seeking to extinguish.
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In a Behavioral Health Staff Meeting note from Dr. Hamning at Scioto (8/21/13)' he documents that "half ofthe kids are in seclusion (on Buckeye) a good majority of time." In particular, I have concern about how youth who were transferred off the Progress Units - all of whom were on the mental health case load - are being managed in their new units. Historically - before DYS undertook drastic reforms to change the PROGRESS Unit program design - the PROGRESS Unit and SMUs before it exacerbated challenging youth behavior by keeping youth locked in their cells for most or all of the day, for weeks or months on end. Dr. Hamning's note raises concerns that the youth who have transitioned out ofthe PROGRESS Unit are still being managed with long stays in seclusion, by way of the IRAV and sanction seclusion processes rather than by way of a maximum security housing unit. If DYS's treatment interventions have not evolved enough to identify why these youth and others with serious mental health issues are behaving in the ways that they are, it is more likely that these youth will spend significant lengths oftime in seclusion, an intervention that actually undermines the effectiveness of treatment.
In order to establish whether or not this is occurring, it will be necessary to review AMS logs, ITPs, Behavior Management Plans and seclusion hours for all the youth who transferred off Progress to other units.
Of course the concern extends to other mentally ill youth in DYS facilities.
Since DYS's announcement regarding the closure of Scioto, plaintiffs have expressed their concern "that youth on the mental health caseload who did not receive adequate treatment in the PROGRESS Unit will now be dispersed to the remaining institutions and continue to have deficient case formulation, treatment planning, behavior contracts, excessive diSCipline and excessive segregation. Similar youth who would have otherwise been transferred to the PROGRESS unit may be facing the same problem." It is clear to me that the deficiencies in behavioral health care led to high rates of seclusion for youth at Scioto, and that the same deficiencies exist at the other three DYS facilities. What I do not know from the documentation I have been provided is whether youth with mental illnesses are experiencing high rates of seclusion at the other three DYS facilities. Given the recent closures of both the PROGRESS Unit and Scioto JCF, plaintiffs' question regarding whether youth with behavioral challenges at other facilities spend a significant portion oftheir DYS stays in seclusion is a valid one. Such a determination, however, could be made only after a more thorough review of the AMS data and treatment files of mental health caseload youth who have experienced multiple Intervention Hearings over the last six months.
Required Action: By mid-January DYS should produce documentation that identifies the seclusion hours for "frequent fliers" and indicate whether they are on the mental health caseload. This, along with their ITPs and Intensive Behavior Management Plans will help to determine if IDTs are addressing the behavior that has led to seclusion, and the harmful effects of seclusion itself.
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Attachment H

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 25 of 37 PAGEID #: 2989

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, Plaintiff,
v.
THE STATE OF OHIO, et al., Defendants.

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)

)

)

)

)

CIVIL ACTION NO:

)

2:08-cv-475

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)

)

)

DECLARATION OF PAUL DEMURO

Paul DeMuro declares as follows under penalty of perjury:

L My name is Paul DeMuro. I submit this declaration in support of the United States' motion for a temporary restraining order. My address is 1201 Futch Creek Rd., Wilmington, N.C. 28411. I have been retained by the United States to, among other things, provide my opinion whether limitations proposed by the United States on the use of seclusion ofjuveniles are reasonable, appropriate, and capable of being implemented rapidly without causing significant disruption to security and operations in a juvenile justice facility.

2. I have over forty-three years of experience in juvenile justice and child welfare services. I have been superintendent of a large urban, secure juvenile detention center, as well as superintendent of a large training school for juvenile delinquents. I have served as Assistant Commissioner of the Massachusetts Department of Youth Services, overseeing all parole supervision for adjudicated juveniles h'1 Massachusetts. In the late 1970's, I was appointed by the Governor of Pennsylvania to serve as the Commissioner of Children and Youth in Pennsylvania. As the Commissioner, I supervised the superintendents of Pennsylvania's juvenile justice institutions, including all of the state's secure institutions for the most violent juvenile offenders. As Commissioner, I developed state regulations that governed the operation of secure county juvenile detention centers. I have developed public and contract residential and nonresidential programs for delinquent youth, including model secure treatment programs for violent offenders.

3. I am knowledgeable about contemporary juvenile justice and child welfare program standards, policies and practices. For over six years I served as the

Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 26 of 37 PAGEID #: 2990
Federal Court monitor in a class action case in Florida, overseeing on a regular basis conditions of confinement in Florida's secure juvenile correctional institutions. I held a similar appointment for the Federal District Court in Oklahoma. As Federal Court monitor, I monitored Florida's and Oklahoma's secure institntional and community programs for youths and reported to the Federal Court. More recently, I have served as a Federal Court monitor in a New Orleans secure juvenile detention case, and I presently serve as a Federal Court Monitor in Mississippi in a case involving a secure commitment program for youth tried and convicted as adults. The use of disciplinary seclusion is severely limited in both the New Orleans and Mississippi secure programs. I have been appointed as a mediator in a number of cases to help resolve class action juvenile justice and child welfare cases. As a consultant, I routinely evaluate juvenile justice and child welfa.'"C programs and services. I have reviewed juvenile justice institntions, including juvenile justice secure institntions and child welfare programs in Alabama, Arizona, California, Florida, Georgia, Kentncky, Illinois, Louisiana, Maryland, Mississippi, New Jersey, New York City, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota and Texas. I have evaluated a variety of state and COllllty run juvenile correctional institntions, including secure juvenile facilities, for the United States Department of Justice (the "DOJ"). My clients have included state juvenile justice agencies, state child welfare agencies, county juvenile justice agencies, the U.S. Department ofJustice, the National Juvenile Detention Association (now part ofthe National Partnership for Juvenile Services), and private Foundations. I have co-edited an anthology regarding violent offenders (Violent Juvenile Offenders, I984) and have co-authored a book regarding the problems of overcrowding in the California Youth Authority's secure institutions (Reforming the CYA, 1988). I have written a number of reports and articles concerning young offenders and secure institntional and alternative programs designed to serve them. Exhibit I contains my cv and my consulting prospectus, which contains a list ofmy publications. Exhibit II identifies court cases in which I have served as an expert witness or court-appointed expert/monitor.
4. The opinions expressed in this declaration are based on my experience in the field and my knowledge ofjuvepile justice standards, policies and practices. I have not reviewed Ohio Department ofJuvenile Corrections' ("DYS") policies or practices, nor have I reviewed DYS data or records or interviewed Ohio staff or juveniles. However, it is clear that the use ofseclusion in juvenile institutions causes more harm than good and, therefore, the use of and the duration of seclusion should be limited to the absolute minimum degree possible.1 Youth in isolation cannot participate in programs designed to address their problems. In
I See, "The Use of Seclusion IS Not Evidence Based Practice", The Journal of Child Abuse and Adolescent Psychiatric Nursing, Oct -Dec. 2001. Linda Finke, the author ofthis article, concludes that "the scientific evidence available illustrates that the use of seclusion with children is not therapeutic and is, in fact, hannfuL .." Also consider what a non-academic expert John Me Cain says about isolation: an awful thing, solitary... .It crushes your spirit and weakens your resistance more than any other form of mistreatment." The New Yorker, March 30, 2009, Atul Gawande, "Annals ofHuman Rights: Hellhole".
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essence youth who are perceived as being most in need of rehabilitative services are, when they are in isolation, denied access to those supportive interventions. In addition, isolation has direct negative consequences. Youth in isolation are more likely to commit suicide and/or to self mutilate than youth in the general population. Youth in isolation often become depressed; many youth in isolation become angry and more agitated and thus even more resentful of staff. The use of isolation is counterproductive. Isolated yonth often feel more depressed and desperate. Locking a youth in a cell does not reduce a youth's acting out. Its use only makes matters worse.
5. I understand that the United States has proposed the following limitations on the use of seclusion at facilities operated by DYS. (My specific observations regarding them are set forth in italics):
A. Refrain from secluding any boy with an identified mental health disorder for more than 24 hours without providing hlln, outside of his confinement area 811d during normal facility prograJUmiug times, at least four hours of programming (e.g., mental health counseling, exercise, education or combinations thereof);
B. Refrain from imposing more than three consecutive days of seclusion in any form (e.g., prehearing seclusion and intervention seclusion) on any boy with an identified mental health disorder. In fact, the pre-hearing time should be limited to the degree possible. Youth should not be placed in
seclusion on a pre-hearing basis ifthey are in control. All youth in
seclusion either on a pre-hearing basis or on a diSCiplinary basis should be out ofthe confinement area/cellfor at leastfour hours in any given twenty-:four hour period during normal programming time. There is no evidence to suggest that longer periods ofseclusion improve a youth's behavior. In fact the available evidence strongly pOints in the exact opposite direction, for all youth, andparticularlyfor youth with mental health problems.
C. Refrain from imposing more than three days of seclusion in any form \vithin a 30-day period on any boy with an identified mental health disorder without first:
1. Conducting a comprehensive mental health treatment review of the boy that includes the treatment team meeting and reviewing the boy's mental health treatment pl8l1 to consider and address potential problems with the plan 8l1d its in1plementation. The treatment review should include the key staffresponsible for the youth (including the security, clinical and educational stafJ). In all possible cases the specific youth shouldparticipate in the treatment review. The purpose ofthe review/meeting would be to develop a specific and detailed behavioral plan that is designed to
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safely supervise the youth in the program - without relying on seclusion/isolation;
2. Obtaining the prior written approval ofthe Deputy Director of DYS responsible for Facility programming; and
3. Providing written notice to the United States and monitor within 24 hours of a yonth exceeding three days of seclusion within a single month, describing the amount of seclusion, reason for seclusion, treatment provided in response to seclusion, whether the youth's behavior intervention plan was modified or created, and alternatives to seclusion that were rejected.
D. Refrain from imposing restraints as an alternative to seclusion.
6. In my opinion, these limitations are reasonable, appropriate, and capable of being implemented in a short period of time without causing significant disruption to security and operations.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on March 7, 2014

C!dtJ eM
Pl(ul DeMuro

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Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 29 of 37 PAGEID #: 2993
Exhibit I, Consulting Prospectus
DeMuro: CONSULTING PROSPECTUS
PROFESSIONAL EXPERIENCE
Forty-three years experience managillg people, programs, budgets and processes for youth serving programs; extensive experience providillg a wide range of consultiilg services to support progressive efforts to improve programs for troubled youth and families. Examples: Functions as a senior consultant to the Annie E. Casey Foundation's child welfare and juvenile justice initiatives; helps plan and evaluate innovative child welfare and juvenile justice projects. Experienced at conductiilg fact-findiilg evaluations of community-based and illstitutional programs; retained by public illterest attorneys in a variety of federal and state court cases. Experienced expert witness.
Developed mediated settlements ill child welfare and juvenile justice class action litigation ill Oklahoma, Tennessee and Hamilton County, Ohio. Appoillted by Federal Courts ill Florida and Oklahoma and New Orleans to monitor consent decrees designed to improve services for children, youth and families. Designed case management systems for Hawaii's and Missouri's state youth services organization; conducts risk assessment studies and other policy studies for a variety of states; designs and conducts training seminars for child welfare and juvenile justice staff. Editor, Violent Juvenile Offenders: An Anthology, 1984; co-author, Reforming the California Youth Authority, 1988; author of Annie E. Casey training monographs and several articles; former Vice-president, National Council on Criine and Delillquency. Held a variety of leadership positions withiil state governments: e.g., Pennsylvania Commissioner of Children and Youth. Curriculum vitae available.
CONSULTING SERVICES
Developing and Monitoring Court Ordered Settlements
Designs, implements and monitors step-by-step plans to comply with court ordered mandates, usually as a result of class action litigation. Examples: Developed settlement agreements/court ordered implementation plans for class action law suits ill Florida, Indiana, New Mexico, New Orleans, Oklahoma, Tennessee and Hamilton County, Ohio. Appoillted by Federal District Courts to serve on Court appointed Panels to develop and negotiate settlement agreements, and ill Oklahoma and Florida to monitor class action settlements. Able to develop agreements among parties regardillg settlillg class action litigation.
Fact Finding, Negotiating and Expert Witness Services
Organizes and implements fact-findillg investigations to help resolve litigation involving
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Exhibit I, Consulting Prospectus
public and private youth serving agencies. Expert in assessing conditions of confinement. Identifies and leads highly qualified teams of professionals to evaluate community based and institutional programs. Able to enter adversarial situations, discover the facts, and assist in either resolving/mediating the case or preparing for trial. Experienced at interviewing children, youth and staff involved in law suits. Has helped develop settlement agreements and has testified at numerous trials in Federal and state courts. Examples: Retained by the Civil Rights Division of U.S. Justice Department and public interest law firms to investigate and document alleged unconstitutional conditions in a number of private and public institutions throughout the country.
Policy Oriented Research
Over forty years experience writing and directing policy studies, articles, reports, evaluations and other materials designed to analyze public policy questions and present alternative courses of action. Examples: Directed risk assessment studies of institutional populations in five states; these studies often help bring about major organizational change. Retained by state legislative committee in Tennessee to conduct studies on juvenile justice issues, child welfare and managed health care issues. Co-authored book analyzing California's juvenile justice system. Co-edited a book on violent juvenile offenders and published a number of reports and articles concerning troubled youth and public policy.
Evaluation and Technical Assistance
Conducts management and program evaluations of public & contracted youth serving programs and agencies. Analyzes problems and develops specific recommendations. Examples: Foundation supported evaluation of Hawaii's juvenile justice system (nopportunity for Refo=n, 1987) and program evaluation of Toledo, Ohio's substance abuse programs; developed mediated settlement in a New Mexico conditions of confinement case (2009). Conducts comprehensive evaluations of detention centers and training schools. Examples: evaluation of Maryland training school (Hickey) which led to the refo= and privatization of that institution; evaluation of Cleveland's detention center and Toledo's detention system. Conducts program and systemic reviews of public youth serving programs for state legislative committees. Example: Review of Iowa's residential programs for delinquent youth. Provides technical assistance/planning to Directors of state agencies. Examples: Senior consultant to the Annie E. Casey's highly successful initiative aimed at reforming juvenile detention (JDAl) in several public jurisdictions. Helped develop case management and day treatment services in Missouri. Assisted public interest law firm in Mississippi to close a refo= school for girls (Columbia).
Plan and Conduct Staff Training
Plans, directs and offers a variety of training workshops, seminars and other training efforts designed to improve the skill level and knowledge of direct service staff.
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Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 31 of 37 PAGEID #: 2995
Exhibit I, Consulting Prospectus
Examples: designed and conducted team-building and case management training for executive staff ofthe Missouri and Alabama Departments of Youth Services. Plans and conducts skill-building workshops for public defenders sponsored by the American Bar Association; plans and conducts training workshops for child welfare staff sponsored by the Anuie E. Casey Foundation: Conducts child welfare training: e. g. ,"Team Decision Making" in a number ofjurisdictions.
Direct Services -- Program Development
Plans, organizes and implements innovative and cost effective, youth services within gove=ent and non-profit organizations at the local, state and national levels. Examples: Developed statewide system ofnon-residential interventions in Massachusetts for adjudicated delinquents. Planned and directed nationally recognized community-based program model for adjudicated delinquents in Cook County. Planned crisis intervention program for Toledo, Ohio. Implemented model correctional program for the U.S. Department of Justice, developing multi-site, state-of-the-art, intensive, secure programs for violent juvenile offenders.
PARTIAL CLIENT LIST Government Agencies:
U. S. Justice Department, Civil Rights Division, Washington, DC.
State Human Service Departments, Child Welfare & Juvenile Justice Agencies: (e.g., Hawaii, Indiana, Missouri, New Jersey, Oklahoma, Pennsylvania, Tennessee & Texas)
State Legislative Committees: Iowa & Tennessee
County Human Service, Child Welfare & Juvenile Justice Agencies: (e.g. Cook, Ill.; Cuyahoga, Hamilton, Lucas Counties, Ohio; Jefferson County, Ala.; Multnomah, Oregon.)
County Juvenile Probation: (e.g.. Lucas Co. Ohio; Tarrant County, Fort Worth, Texas)
Federal Courts:
Federal District Courts: Tallahassee, Fl.; Oklahoma City, OK. & Washington, DC
Private Foundations:
The Anuie E Casey Foundation, Baltimore, Maryland. The MacArthur Foundation, Chicago, Ill.
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Exhibit I, Consulting Prospectns
Public Interest Law:
The American Bar Association's Juvenile Justice Center Juvenile Law Center, Philadelphia, PA National Center for Youth Law, San Francisco Public Defenders Office, Dade Co" Fl Youth Law Center, San Francisco. The Southern Poverty Law Center, AL
Private Attorneys:
Goldstein & McGroder, Phoenix, Arizona Robert Link, Jacksonville, Fla. Covington & Burling, Washington, DC
Research, Policy & Technical Assistance Centers:
The National Juvenile Detention Association The John Howard Association The Urban Institute.
List of Publications and Reports As of 1/31114
Books
Violent Juvenile Offenders: An Anthology, National Council on Crime and Delinquency, 1984. Co-editor.
Reforming The California Youth Authority, Common Knowledge Press, 1988. Co-author.
Articles and Reports [some co-authored]
"Preliminary Plan: Reducing the Population in Florida's Training Schools", March 1986. Report to the Federal District Court, Tallahassee, Fl.
"Report of the Jerry M. Panel", March, 1987. Submitted to Washington, D.C. Superior Court.
"Adjudicated Youth in Delaware Who Need Secure Care", National Council on Crime And Delinquency, 1987.
"Hawaii's Juvenile Justice System: Opportunity for Reform", August 1987. Funded by the Clark Foundation, New York, NY.
"Resisting the Adultification of Juvenile Corrections: Rational Programs for Violent Juvenile
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Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 33 of 37 PAGEID #: 2997
Exhibit I, Consulting Prospectns
Offenders", American Psychological Association Newsletter, Winter, 1988.
"At the Crossroads: A Population Profile of Youth Committed to the Alabama Department of Youth Services", 1989. Funded by the Clark Foundation, New York, NY.
"Population Profile and Risk Assessment Study: Mississippi Department of Youth Services", February 1989, Center for Study of Youth Policy, University of Michigan.
"Risk Assessment of Adjudicated Delinquents, Division for Children and Youth Services, State of New Hampshire," December 1989, Center for Study of Youth Policy, University of Michigan.
"Framework for Dispositional Decisions", Alabama Division of Youth Services, 1990.
"In Search of Excellence: Reflections Regarding the Improvement of the Missouri Division of Youth Services", April 1990.
"Comprehensive Services for Oklahoma's Delinquent, Deprived, lNT & lNS Children: The Terry D. Panel Report", December 1990. Submitted to the Federal District Court, Oklahoma City, Oklo
Final Report of the Alabama Detention Project", July 1991. Prepared for the State of Alabama, Juvenile Detention Advisory Committee.
"Final Report: Iowa's Service Delivery System For China & Delinquent Youth", June 30, 1993. Study conducted for the Iowa State Legislature.
"OverCrowding in Juvenile Detention: Some Concrete Suggestions", June 1996.
"Conditions of Confmement Review: Cuyahoga County Juvenile Detention Center", NJDA, September 1997.
"Developing Partnerships with Neighborhoods and Local Co=unities", the Family to Family Initiative, the Casey Foundation, 1997.
"Team Decision-making: Involving the Family and Co=unity in Child Welfare Decisions", the Family to Family Initiative, the Casey Foundation, 1997.
A Reasonable Alternative to Locking More Kids Up: The Development of Jurisdictional Core Groups, [with Earl Dunlap], Special Edition: Journal for Juvenile Justice Issues. and Detention Services, NJDA, Spring, 1998.
Crowding in Juvenile Detention Centers: A Problem Solving Manual, [with Sue Burrell, Earl Dunlap, Carl Sanniti and Loren Warboys], OJJDP, December 1998.
Consider the Alternatives: Planning & Implementing Non-Secure Detention Alternatives", the Casey Foundation, November, 1999.
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Case: 2:08-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 34 of 37 PAGEID #: 2998
Exhibit I, Consulting Prospectus
"Be All You Can Be - Reflection on Leadership Development & Staff Training", Spring 2003, Journal for Juvenile Justice and Detention Services, Spring 2003. "Good News From Toledo: Real Improvements in Detention", Journal for Juvenile Justice and Detention Services, Fall 2003. "Boot Camps Revisited", Journal of Juvenile Justice Services, National Partnership for Juvenile Services, Vol. 22, # 1,2008. "Why Child Welfare Agencies Should Limit the Role of Residential Care", Journal of Juvenile Justice Services, National Partnership for Juvenile Services, Vol. 22, # 1,2008. "Toward Abolishing the Use ofDisciplinary Isolation in Juvenile Justice Institutions: Some Initial Ideas", January 22,2014. Published on the web.
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CEaxshei:bi2t :I0, c8v-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 35 of 37 PAGEID #: 2999
Paul DeMuro: 1201 Futch Creek Rd., WilnringtonNC2841l. 91O-681-378l. e-mail: PDeMuro@aol.com
Paul DeMuro
PROFESSIONAL STRENGTHS
* Providing a wide variety of consulting services to youth serving agencies
* Planning and conducting fact-finding and dispute resolution efforts
* Planning and directing program and policy oriented research and evaluation efforts * CommUnicating effectively to staff, the public and media
* Planning and implementing successful programs
* Providing imaginative and cost effective leadership for innovative youth policy
initiatives
* Managing complex contract, budget, personnel and program interventions * Planning & providing a variety of stafftraining initiatives * Supervising, developing and motivating staff * Producing successfully under intense financial, political and time pressures
BACKGROUND
Forty three experience managing staff, programs, budgets and processes designed to improve a wide variety of youth serving agencies. Experienced at conducting fact-finding evaluations. of community-based and institutional programs; expert on conditions of confinement. Retained by the US Justice Department and public interest attorneys in a variety of federal and state court cases. Experienced expert witness. Developed mediated settlements in child welfare class action litigation in Oklahoma, Tennessee and Hamilton County, Ohio. Appointed by Federal Courts in Florida and Oklahoma to monitor statewide consent decrees designed to improve services for children, youth and families. Designed case management systems for Hawaii's and Missouri's state youth services organizations; conducted risk assessment and policy studies for state and county agencies; designed and conducted trai..iJ.i.ng seminars for child welfare and juvenile justice staff. Presently serves as a senior consultant for the Annie E. Casey Foundation and the National Juvenile Detention Association. Consulting prospectus, list of publications and references available upon request. Married with four children. Interests include reading, tennis and music.
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CEaxshei:bi2t :I0, 8cv-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 36 of 37 PAGEID #: 3000
Paul DeMuro: 1201 Futch Creek Rd., Wilmington NC 28411. 910-681-3781. e-mail: PDeMuro@aol.com
EDUCATION
BA, Villanova University, 1963.
MA, Villanova, 1965.
EMPLOYMENT HISTORY'
1983 - to present. Founder andprincipal staffof a small, flexible consulting fi= that provides a variety of policy, program, management and conflict resolution services to private and public youth serving agencies. Clients include the US Justice Department, federal Courts, state and county agencies, private foundations, public interest attorneys and the private Bar,
1979 - 1983. Vice-Presidentfor Program Services, National Council on Crime and Delinquency. Responsible for field related activities of nationally prominent criminal justice agency. Managed national projects, maintained liaison with other national and state organizations; conducted policy and evaluation studies; supervised and delivered technical assistance to state and local juvenile justice agencies. Prepared and delivered testimony to US Congress and state legislative bodies. Prepared publications; developed and offered training to professional staff. While with NCCD, directed two national juvenile justice projects: (1) Citizen Advocacy Network project, a $1.5 million dollar, four state effort to involve local citizens in efforts aimed at improving their juvenile justice systems; (2) Violent Juvenile Offender Research and Development Project, a $3.5 million dollar project aimed at testing innovative interventions for violent offenders: developed program models and request for proposals; supervised competitive bidding process; and oversaw all fiscal and program reporting to the US Justice Department.
1978 - 1979. Commissioner ofChildren and Youth, Pennsylvania Department ofPublic Welfare. Responsible for $300 million dollars of state funding to provide management and program supports for services to over 35,000 children and youth. Policy and program responsibilities included the state's day care, child welfare and juvenile justice programs. Prepared budgets, developed regulations, drafted legislation and represented the Governor's office in local, state and national negotiations. Supervised the state training school system.
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CEaxshei:bi2t :I0, 8cv-cv-00475-ALM-MRA Doc #: 131-1 Filed: 03/12/14 Page: 37 of 37 PAGEID #: 3001
Paul DeMuro: 1201 Futch Creek Rd., WihuingtonNC2841I. 910-681-3781. e-mail: PDeMuro@aoI.com
1975 - 1978. Director, Office ofCorrections Education. Created and directed this office which had fiscal, planning and evaluation responsibility for educational programs in the state's run adult and juvenile correctional institutions which held over 9,000 offenders.
1973 - 1975. Director, Unified Delinquency Intervention Services, Illinois Department ofChildren and Family Services. Planned and implemented this nationally recognized model that serves adjudicated youth. UDIS diverts youth from institutional placement by using a network of community-based placements and strong case management.
1970 - 1973. Massachusetts Department ofYouth Services (DYS). With DYS held three positions of increasing responsibilities: Assistant Commissioner for Aftercare (1972 - 73), supervised all non-institutional programs for adjudicated youth (e.g., parole, group homes, non-residential interventions, etc.). Supervised seven regional offices with 220 staff and a purchase of service budget of $5 million; Director ofNon-Residential Programs ( 1971 - 72), developed and administered a statewide network of non-residential interventions providing educational, vocational, counseling and mentoring supports to more than 1000 youth living at home or in foster care. Sponsors of programs included churches, community groups and traditional youth serving agencies. Superintendent, Shirley Industrial School (1970- 71), responsible for 125 bed refonn school for "hard core" delinquents aged 14 - 18.
1963 - 1970. University English Instructor, Ohio State University (1965 - 70); Villanova (1963 -1965).
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 Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 1 of 32 PAGEID #: 3239
Monitors’ Review of DYS’ Contracted Programs for Girls
S.H. v Reed (Civil Action No. 2:04-cv-1206) U.S. v State of Ohio (Civil Action No. 2:08-cv-475)
Submitted by: Kelly Dedel, Ph.D., Lead Monitor, U.S. v State of Ohio Will Harrell, J.D., Lead Monitor, S.H. v Reed Daphne Glindmeyer, M.D., Subject Matter Expert Andrea Weisman, Ph.D., Subject Matter Expert Submitted November 30, 2015

Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 2 of 32 PAGEID #: 3240
Table of Contents
Introduction .................................................................................................................... 3
 Column A: MH Assessment, Treatment Planning and the Provision of Services .. 8
 Column B: Use of Seclusion in Response to Aggressive Behavior ......................... 15
 Column C: MH Response to Youth who Engage in Aggressive Behavior ............. 20
 Summary and Conclusions ........................................................................................... 32

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Introduction
On May 20, 2014, the Parties to S.H. v Reed (Civil Action No. 2:04-cv-1206) and U.S. v State of Ohio (Civil Action No. 2:08-cv-475) filed a joint motion for entry of an agreed order to resolve the issues remaining in both Settlement Agreements. The resulting Court Order required DYS to undertake specific actions, outlined in “The Grid” (Exhibit A to the Order), to improve mental health services and reduce the seclusion of male youth on the mental health caseload at three DYS facilities. Compliance with the Grid at Circleville, Cuyahoga Hills and Indian River is discussed in a separate report.
The Court Order clearly indicates that the Grid applies only to “youth at facilities directly managed by DYS,” but goes on to specify that “youth at other facilities shall receive mental health services consistent with those described [in the Grid] but appropriately tailored for such non-DYS managed facilities.” In other words, DYS needs to ensure that comparable services are delivered to girls who are served at facilities contracted by DYS.
The parameters for monitoring the provision of services at non-DYS facilities are also clearly articulated in the Court Order. Rather than monitoring that includes the extensive activities discussed in Doc 359 in S.H. v Reed or in Doc 85 in United States v Ohio, monitoring for the girls facilities was limited to “a review of youth files or other materials requested by the monitor or subject matter experts” (i.e., a paper review). If the Monitor or subject matter experts identified a troubling practice among the documents they reviewed, the Parties would then meet and confer to negotiate additional access. Fortunately, this did not occur during the review of documents or the various explanatory discussions held among the Monitors, subject matter experts and DYS staff.
Our findings should be viewed within the context of the limited access granted by the Court Order. Although the review of documents was ultimately reassuring (i.e., the documents did not reveal troubling practices that warranted more in-depth access to the facilities), the methodology specified in the Court Order limited what the Monitor and subject matter experts could know about the facilities and thus what the Team is able to say about the delivery of services. On one hand, the documentation and data surrounding seclusion practices (Column B of the Grid) were sufficient for the Monitor to conclude that the girls’ facilities have comparable (in some cases, better) practices to what the Team has seen in the DYS facilities for boys. Conclusions about mental health treatment were slightly more difficult given that the subject matter experts were not able to interview youth or staff or observe group treatment, which would normally be a central part of their program assessments. Fortunately, given their greater access to the facilities, DYS provided the Monitoring Team with extensive documentation flowing from a variety of quality assurance and technical assistance activities. These documents were very helpful in assessing the quality of care and also cause the Monitoring Team to feel confident in DYS’ capacity to conduct robust quality assurance activities designed to continue to improve the quality of services to girls.
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Ultimately, the Monitoring Team found sufficient evidence to state that quality mental health treatment was occurring at all three facilities.
Originally, the Team reviewed records, data and other documentation for girls housed in the facilities between September 2014 and February 2015 (i.e., the same review period used for our most recent assessment of DYS’ facilities for boys). In June 2015, one of the three facilities (CAS) was placed on a Corrective Action Plan by DYS to remedy problems associated with the use of seclusion and the quality of mental health treatment. In order to assess the magnitude of improvements, the Team reviewed a second set of records, data and other documentation for girls housed in the facilities during July, August and September 2015. Our opinions about the extent to which services for girls are comparable to those available to DYS boys are based on data from both time periods.
DYS’ Contracted Facilities for Girls
In mid-2014, DYS closed its Girls’ Unit at the Scioto Juvenile Correctional Facility. The girls housed at Scioto were either released to the community on an aftercare plan or were transferred to one of three facilities that DYS contracted to provide services for girls committed to DYS custody. The facilities include:
• Center for Adolescent Services (CAS) operates a 15-bed unit exclusively for girls committed to DYS. Upon completion of a 3-day clinical intake, the Clinical Intake Assessment is sent to the DYS Administrator for Female Placements and Programs. When a girl is identified with a mental health diagnosis, referrals are sent to one of the two residential mental health facilities (below). Girls who do not transfer to the mental health facilities remain at CAS.
• Applewood is licensed by the Ohio Department of Mental Health and Addiction Services (ODMHAS) as a Type I facility, providing room and board, personal care and certified mental health services to adolescent girls, age 12 to 18. DYS contracts for six beds at Applewood. Applewood’s ODMHAS license is current until 8/23/17.
• Pomegranate is also licensed by the Ohio Department of Mental Health and Addiction Services (ODMHAS) as a Type I facility and provides the same type of care as Applewood to adolescent girls, age 12 to 20. DYS contracts for 10 beds at Pomegranate. Pomegranate’s ODMHAS license is current until 1/26/2016.
Combined, these three facilities served a total of 53 DYS girls between September 1, 2014 and September 30, 2015. Six girls had more than one admission during that period of time. On September 1, 2014, there were 14 girls at CAS, 6 girls at Pomegranate and 4 girls at Applewood (total, 24 girls). On October 15, 2015, there were 6 girls at CAS, 9 girls at Pomegranate and 6 girls at Applewood (total, 21 girls).
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DYS Oversight of Contract Facilities for Girls
DYS fortified its regular contract monitoring (predominantly a financial audit) to include a monitoring process to oversee the quality of services delivered (“DYS monitoring”). DYS staff make frequent (i.e. 2-3 times per month) visits to the facilities and a formal monitoring report is also produced every 6 months. The first DYS monitoring reports were issued in April/May 2015 and the second round was issued in October 2015. Components include:
• Youth involvement in programming • Grievance, legal assistance, and PREA protections • Physical plant assessment • Licensure and certifications • Treatment services, including whether interventions are evidence-based and whether
families are engaged, as well as the frequency of individual and group sessions • Youth File Reviews to assess intake assessment and treatment planning, case notes,
and discharge planning • Education and Medical services • Incident reporting, crisis management and disciplinary practices, including the use of
seclusion and the use of physical restraints • Youth and staff interviews
CAS: DYS staff visited the facility at least 3 times per month during both review periods, and met monthly with Court Administrators and CAS administrators. The May 2015 DYS monitoring report did not identify any deficiencies related to services required by the Court Order. However, in the Monitor’s opinion, the report could have benefitted from a more quantitative, detailed focus with regard to the extent to which treatment plans and case notes were judged to be adequate and the extent to which the seclusion policy was being followed. The first DYS monitoring report described what should happen, but did not delve into whether practices are conforming to policy. Seclusion data are now available to DYS through the AMS system, which should facilitate this type of analysis.
Shortly after the first DYS monitoring report was issued, data regarding the implementation of CAS’ revised seclusion policy became available. While DYS noticed a significant decrease in the duration of seclusion episodes, an increase in the frequency with which seclusion was also evident. As a result, DYS placed CAS on a Corrective Action Plan to ensure that seclusion was used only as a last resort and only in response to an imminent threat to safety of youth or staff. As required by the Plan, as of July 31st, the policy was revised slightly and all CAS staff were retrained to limit the situations in which seclusion is used. DYS conducts on-going targeted reviews to ensure that seclusion is used appropriately. In addition, in June 2015, DYS became concerned about a lack of documentation that reflected the delivery of individual and group treatment that DYS knew to be occurring. A Corrective Action Plan was implemented to ensure existing databases were utilized to capture progress notes from all providers, with the results to be reviewed with DYS on August 31, 2015. Subsequent
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information provided by DYS showed that the seclusion policy has now been implemented as designed and that the quality of mental health services has improved considerably.
The October 2015 DYS monitoring report indicated that the new Director appears to have energized the facility. New activities have been implemented (e.g., field day, contests, recreation activities) and the physical environment had been upgraded with new furniture and room decorations. The University of Cincinnati has been providing technical assistance to improve the quality of treatment planning. While the DYS monitoring report indicates that seclusion practices “closely mirror DYS practices,” summary data on the use of room restriction would be useful in future reports to provide a baseline against which subsequent review periods can be measured.
Pomegranate: DYS staff visited the facility at least 3 times per month during both review periods (occasionally as often as 7 times per month) and met with both the CEO and Clinical Director of the program. The May 2015 DYS monitoring report describes a program that is safe and treatment-focused and did not identify any deficiencies related to the services required by the Court Order. During the review period for this report, the facility hired a Compliance Manager to ensure that policies were properly implemented, to handle grievances and to manage licensure. Just before the first review period for this report began, concerns about the Alternative Program (discussed in more detail, below) were identified by one of the Plaintiff’s counsel. While the problems were resolved during the review period, it would have been helpful for the DYS monitoring report to include both the history and the current practices for the Alternative Program as a response to violent behavior in order to illustrate that, in its current form, it is not a seclusion-based intervention. [As a result, the Alternative Program was not monitored during the July/August/September 2015 period.]
The October 2015 DYS monitoring report indicated that DYS girls had all been moved to one unit, which made managing the schedule easier and prevented many of the treatment disruptions that were caused by multiple clinicians serving this population (i.e., individual treatment and group treatment appointments sometimes overlapped). The physical environment of the facility had improved and furnishings had been upgraded. The substance use treatment curriculum was upgraded, and work continued on improving the specificity of substance use related treatment goals. The facility, at DYS’ suggestion, is working to establish a treatment team process.
Applewood: DYS staff visited the facility once per month during the first review period, and the frequency increased to two or three times per month during the second review period. The April 2015 DYS monitoring report describes a program that is focused on safety and treatment and did not identify any deficiencies related to the services required by the Court Order. The October 2015 DYS monitoring report noted an expansion of the substance use treatment options, now provided by a full-time AOD counselor. Services were previously contracted. DYS monitors also noted that treatment files are extensive due to the high volume of treatment youth receive (e.g., 3 to 4 hours of group treatment per day, plus
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individual sessions). The DYS monitoring report also applauded Applewood staff’s interactions with the Release Authority on behalf of DYS girls.
In addition to overall program monitoring, DYS also deploys behavioral health resources to monitor the quality of treatment being provided by each of the three girls’ programs (“QA process/reports”). Using the same quality assurance tools used to review treatment at DYS’ boys’ facilities, DYS behavioral health staff review treatment plans and case notes for two girls on each clinician’s caseload. A QA summary of the September-October 2015 reviews was provided to the Monitoring Team, along with the score sheets for each file that was reviewed. The recommendations resulting from these QA reviews focused mostly on improving the individualization of goals and objectives and ensuring the correspondence between goals and objectives and the content of treatment sessions. When deficiencies were noted (and not many were), DYS provided targeted technical assistance and observed rather immediate improvements among some of the clinicians.
In summary, DYS has developed a solid protocol for overseeing the girls’ programs and has implemented a robust quality assurance process that goes well beyond traditional “contract monitoring.” Not only did the Monitoring Team conclude that treatment services and seclusion practices are, for the most part, comparable to the boys’ programs, but also that DYS’ process for assessing quality and improving program performance is as robust as what is implemented in DYS’ boys’ facilities.
In the next sections of this report, the Monitor and subject matter experts briefly describe what the Grid requires of the DYS facilities and then discuss the services that are provided to the girls in the contracted facilities and whether they are comparable to what the Grid requires. The discussion is organized around the Columns that were the defining feature of the Grid: Column A refers to the quality of mental health assessments, treatment planning and the provision of mental health services (reviewed by Dr. Glindmeyer); Column B refers to the use of seclusion as a response to youth’s aggressive behavior (reviewed by Dr. Dedel); and Column C refers to the mental health response to youth who engage in violent behavior (reviewed by Dr. Weisman).
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Column A. (Reviewed by Dr. Glindmeyer)
Mental Health Assessments, Treatment Planning and the Provision of Mental Health Services
What the Grid requires of DYS facilities.
 Column A of the Grid was developed to ensure that youth receive adequate mental health
 assessments, appropriate treatment planning with goals derived from the assessments, and
 mental health treatment that is consistent with stated treatment goals.

This portion of the Grid has two parts. The first is to verify treatment integrity. The Grid requires that quality assurance tools are developed and that audits are conducted to ensure that individual treatment is aligned with treatment goals, and that group therapy treatments display fidelity to design. As such, it would be necessary for case review or record review to reveal correlation between the content of individual sessions and treatment goals. It would also be necessary for group therapy interactions to be reviewed to ensure treatment fidelity.
The second potion of Column A focuses on mental health assessments. The Grid requires that quality assurance tools are developed and audits are conducted to ensure that an initial BioPsychoSocial assessment, inclusive of a broad range of information from a variety of sources that is summarized in a clinical diagnostic formulation, is developed. Then the clinical issues identified via the assessment must be reflected in the youth’s treatment plan. As such, it would be necessary for case review or record review to assess the quality of the diagnostic formulation and the treatment plan developed as a result.
The following review assesses the extent to which the contracted girls’ facilities: 1) exhibit treatment integrity with regard to correlation between the content of individual sessions and treatment goals; 2) have group therapy interactions that reveal treatment fidelity; 3) develop appropriate BioPsychoSocial assessments that are appropriately summarized in a clinical diagnostic formulation; and 4) develop treatment plans that are based on the issues identified via the clinical diagnostic formulation.
Methodology In order to determine the level of compliance with Column A for facilities housing female youth, multiple documents were reviewed. As the subject matter expert for Column A was not able to make site visits per the Court Order, DYS provided extensive information obtained via their own on-site monitoring. This included the following:
• DYS provided descriptive information regarding the units at CAS, Applewood, and Pomegranate. This included the process by which each youth is assessed and transferred from CAS to a mental health destination facility (i.e. Applewood or Pomegranate) if mental health treatment is determined to be necessary.
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• As Applewood and Pomegranate would not provide copies of policies to the Monitoring Team, DYS conducted an in-depth review of policy and procedure from each program and responded to specific questions from the Monitoring Team. With regard to Column A, this included: o The structure of mental health services at both Applewood and Pomegranate. o Individual treatment planning process at both Applewood and Pomegranate. o Provision of mental health treatment at both Applewood and Pomegranate. o Documentation of mental health services at both Applewood and Pomegranate.
• DYS provided detailed information regarding mental health treatment services at each of the facilities. This included the names and the schedules of each of the mental health providers at the facility, the mental health treatment schedule (i.e. number of groups each youth received weekly, and the amount of individual therapy each youth received weekly). Information also included the types of groups that were provided to the girls (i.e. DBT, stress reduction, emotional regulation).
• A list of all girls who were housed in any of the three facilities between September 2014 and February 2015. This included information regarding which facilities each girl was housed in.
• Results of surveys for residential services performed by their state licensing agency, the Ohio Department of Mental Health and Addiction Services. o The Applewood survey was performed September 4, 2013. This survey was essentially a quality assurance review that included a review of the youth’s personal care plan and progress notes. It was noted that the license renewal for Applewood was approved August 24, 2014 with an expiration date of August 23, 2015, and then extended to August 23, 2017. o Pomegranate was reviewed October 28, 2014. While the review of Applewood noted above included a review of mental health documentation, this documentation was not included for Pomegranate. Regardless, the Pomegranate survey was performed October 28, 2013 and the current license expires January 26, 2016.
• While the programs declined to release information regarding facility-generated quality assurance, DYS performed multiple monitoring site visits to the programs and provided reports of their ongoing contract monitoring, which included a review of mental health treatment services. As such, although the subject matter expert was not able to independently visit and observe treatment, ODYS provided reports of their observations of the services rendered.
These summaries were based on multiple site visits as described below:
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o Pomegranate was visited by DYS reviewer, Nan Hoff, on eighteen occasions between January 12,2015 and April 27, 2015. An additional twenty visits occurred between May 15, 2015 and September 30, 2015.
o CAS was visited by DYS reviewer, Nan Hoff, on twenty occasions between October 2, 2014 and April 29, 2015. An additional seventeen visits occurred between May 7, 2015 and September 17, 2015.
o Applewood was visited by DYS reviewer, Nan Hoff, on eight occasions between October 15, 2014 and March 24, 2015. An additional twelve visits occurred between April 9, 2015 and October 5, 2015.
• Medical records for specific youth were provided: o At CAS, many of the girls only remained there a short time pending referral and transfer to either Applewood or Pomegranate. As such, a summary of assessments, orientation, group attendance, and progress was provided for a total of seven youth (TL, AL, DT, JM, AW, AY and CS). For the second review period, documentation was provided for youth LB, JW, and KR. In addition, two conference calls regarding the treatment/treatment planning of youth LB were held. o Three youth records from Applewood were provided for review (AL, CS, and TL). For the second review period, documentation was provided for youth VW and AS. o Six youth records from Pomegranate were provided for review (AW, AY, BE, DT, JM, and RLB).
• Given reviews at CAS where DYS determined inadequacies existed, action plans were authored. The action plan pertinent to Column A was regarding documentation of treatment services. In the initial document request, information from CAS, specifically treatment documentation was missing. While there was notation that treatment occurred, it was included in the daily log. As such, DYS made the decision to draft an action plan which has reportedly been both well received and implemented by CAS. Conversations with DYS behavioral health staff indicated that interim reviews of treatment documentation indicated improvement. Ultimately, DYS determined that ongoing quality assurance monitoring would occur at all three facilities.
• On July 29, 2015 an interim review of the progress toward compliance with the CAS action plan for documentation of mental health treatment was conducted by DYS. Per this review, treatment specialists had been entering progress notes effective June 12, 2015. Furthermore, DYS, via the Chief of Behavioral Health Services, provided a detailed review of CAS documentation dated July 31, 2015. Per this review: o Group notes regarding nine different youth were reviewed, individual progress notes from South Community Behavioral Health Care regarding four different youth were reviewed, and individual progress notes regarding two different youth from Wright State University School of Professional Psychology were
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reviewed. This review included a qualitative analysis of the CAS documentation inclusive of documents provided via contracted providers (South Community Mental Health Center and Wright State University School of Professional Psychology). This document included areas in need of improvement and indicated plans to address areas in need of improvement via staff training. There was also documentation of plans for ongoing quality assurance reviews to determine ongoing improvement and compliance with the corrective action plan.
• Subsequent QA reviews were performed at all three facilities. The review for the month of August (completed October 5, 2015) and for September (completed November 2, 2015) revealed in-depth quality assurance monitoring of the integrated treatment plan and case notes at all three facilities. Group therapy was observed at both Pomegranate and CAS. Applewood group therapy could not be observed due to confidentiality issues. Youth who were not assigned to DYS also participate in these groups. In addition, treatment team meetings were observed at all three facilities. o Quality assurance monitoring indicated that DYS is identifying issues at all facilities; specifically, areas where cross-training and technical assistance are necessary. This is the goal of quality assurance. What is most important is that DYS is able to identify areas where improvement is necessary and develop technical assistance to address weaknesses.
What the documents revealed is provided to girls at the facilities contracted by DYS.
CAS With the initiation of this monitoring review, DYS developed program monitoring and quality assurance reviews for CAS. In doing so, weaknesses were identified at CAS and corrective action plans were developed. Action Plan 4 specifically addresses the documentation of treatment services provided at CAS.
While it is noted that CAS is not technically a mental health facility, diagnostic assessments, treatment plans, individual therapy, and group therapy are provided. Action Plan 4 requires that the youth’s treatment and progress in treatment is recorded in the JCS (Juvenile Court System) database. In addition, progress notes from outside providers must be included in the youth’s record. This Action Plan requires a joint review by CAS and DYS by August 31, 2015. In the interim, the Chief of Behavioral Health Services of DYS conducted a review of CAS documentation dated 6.1.15 through 7.15.15. This review revealed areas of improvement in that CAS is now documenting group therapy via case notes, and documenting the specific CBT skill taught in the group. The review also identified additional areas in need of improvement. For example, the review noted the need for individualization of progress notes, better descriptions of the methods utilized to teach CBT skills, documentation of the youth’s understanding of a specific skill, documentation of the youth’s progress in treatment
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(or the lack thereof), and better correlation with the individualized service plan (treatment plan).
In an effort to ensure ongoing progress, CAS and DYS have developed a QA plan, and DYS plans to implement a QA process at CAS similar to that present in the facilities that house boys. This would reportedly include a review of group therapy interaction, file review using QA tools, with onsite training and coaching as necessary. In conversation with DYS staff, it was noted that CAS administration is willing and open to improvement efforts.
Documents inclusive of seven youth records were provided for review. These records predated the improvements noted in the DYS review documented above. The strength of the CAS program is the initial youth assessments. These were individualized, generally detailed, and provided information to allow for the development of an individualized service plan, or as titled at CAS, the personal program plan.
However, the personal program plan was essentially a checklist and not individualized. Goals were not measurable, nor were specific interventions identified outside of a checklist of available group interactions. Progress notes regarding group and individual therapeutic interactions were included in shift notes and did not describe the group therapy or individual therapy adequately. As noted above, these documentation issues were being addressed via ongoing QA review by DYS with corrective action plans developed as needed to include staff training and mentorship.
For the second review period, additional youth records and quality assurance monitoring results were reviewed. This revealed marked improvements in the documentation of treatment including individual and group therapies. Quality assurance monitoring is ongoing. While there remain issues in documentation, (e.g. the need for consistent treatment goals, consistent use of SOAP note format for documentation of group therapy), what is important is that improvements are apparent and DYS is able to identify the weaknesses and has plans for ongoing technical assistance to address these.
Applewood DYS performs contract monitoring site visits at this facility. Between 10.1.14 and 4.1.15, eight visits were conducted. Documentation received from this facility included three youth records containing mental health assessments, individualized service plan, group counseling notes, and individual counseling notes. While checklists were utilized to populate some sections of the mental health assessments, a case formulation was included. These were individualized and provided information to allow for the development of the treatment plan (service plan).
Service plan goals did not appear to be individualized, with similar goals noted in different records. There was a need for improvement in documentation in both group and individual therapy progress notes. For example, improvements in goal development would allow for these goals to be addressed in individual therapy with progress toward specific goals
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outlined in the progress notes. However, even with the documentation issues, it was apparent that treatment was occurring at this facility.
QA is also performed by the facility, although these data were not available for review. DYS reported plans to obtain the records of girls receiving treatment at this facility and to perform their own record reviews for QA purposes on a regular basis.
For the second monitoring period, an additional twelve DYS contract monitoring visits occurred between April 9, 2015 and October 5, 2015. In addition, DYS has implemented in depth quality assurance of treatment team meetings, individualized treatment plans, and case notes. As group therapy at this facility includes youth not assigned to DYS, group therapy encounters were not observed. Quality assurance monitoring for this facility revealed that goals and objectives for treatment planning were written in template format; however, other information, specifically the specific needs of the individual youth with regard to mental health treatment was individualized.
Pomegranate DYS performs contract monitoring site visits at this facility. Between 1.12.15 and 5.12.15, 18 visits were conducted. Documentation received from this facility included six youth records containing the diagnostic assessment, individualized service plan, group therapy progress notes, and individual therapy progress notes. While the group and individual counseling notes were descriptive of the treatment provided, there was a need for improvement in the case formulation development. However, even with the documentation issues, it was apparent that treatment was occurring at this facility.
QA is also performed at this facility, although these data were not available for review. DYS reported plans to obtain the records of girls receiving treatment at this facility and to perform their own record review for QA purposes on a regular basis.
For the second monitoring period, an additional twenty DYS contract monitoring visits occurred between May 15, 2015 and September 30, 2015. In addition, DYS has implemented in-depth quality assurance of the individualized treatment plan, case notes, group therapy observations, and treatment team meetings. Quality assurance monitoring for this facility revealed that goals and objectives were similar for all girls and that some therapy notes were superficial. There were also therapists who demonstrated therapy notes that were well written.
Whether the services received by the girls at facilities contracted by DYS are comparable to those delivered to the boys at DYS facilities, and therefore, whether DYS is in substantial compliance with the Court Order.
Please note that this review has limitations, as the monitors and subject matter experts were not able to visit the facilities, meet with clinicians, interview youth, observe group therapies,
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or conduct other activities typical of a facility review. As such, it was necessary to rely on a review of youth records and other reviews conducted by DYS behavioral health staff. In the DYS facilities housing boys, DYS has done a good job of developing quality assurance (QA) tools, using these tools to identify weaknesses in the system, and developing corrective action plans to address these weaknesses. This has resulted in an adequate quality assurance program. Admittedly, the early QA activities conducted via DYS have been staff dependent; however, over time, it is hoped that these activities will become routine, and utilized at both the central office and facility level to effect change in the system.
Per the DYS quality assurance review of CAS, it was reported that mental health services were occurring commensurate with what is occurring at the boy’s facilities. While in the initial review, this was not directly seen in the documents reviewed by the subject matter expert, DYS has reviewed the documentation and expressed confidence in the treatment being provided. DYS also has pledged to continue QA monitoring of this facility. For the second review period, treatment documents revealed improvements. In addition, DYS quality assurance monitoring has continued on a monthly basis. Again, while this has revealed improvements, there remain issues that have been identified and are being addressed via technical assistance. As such, to the extent possible given the limits of the methodology for this review, services appear to be commensurate to those provided to the boys.
At Applewood and Pomegranate, it was apparent that treatment was occurring. Both of these facilities have their own QA process, although the results were not available for review by the Monitoring Team. In addition to the current site visit monitoring that DYS is conducting, DYS Behavioral Health staff review the treatment records for youth receiving treatment in these facilities for QA purposes. Although the need for improvements in documentation was noted, there was no question that treatment was occurring. As a result, to the extent possible given the limits of the methodology for this review, services appear to be commensurate to those provided to the boys. For the second review period, ongoing quality assurance monitoring revealed results consistent with the first review for both of these facilities.
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Column B. (Monitored by Dr. Dedel)
Use of Seclusion in Response to Youth’s Aggressive Behavior
What the Grid requires of DYS facilities.
Column B of the Grid was designed to reduce the reliance on seclusion as a response to youth’s aggressive behavior. Ultimately, DYS was required to prohibit the use of disciplinary seclusion (which it did as of January 1, 2015) and to significantly reduce the length of time that youth remained in pre-hearing seclusion immediately following a violent incident. The length of stay could no longer be pre-determined and was to be based on the youth’s readiness to safely return to regular programming. A regular schedule of opportunities for youth to process their behavior with staff is required, starting at the 4-hour mark, and then repeating every 3 hours if the youth initially refuses. Pre-release interviews (i.e., Safe to Release interviews) are designed to inquire about the underlying causes of the youth’s behavior and how the youth might respond differently in the future.
The following review assesses the extent to which the contracted girls’ facilities: 1) impose seclusion as a disciplinary sanction for violent misconduct; and 2) utilize seclusion as an immediate response to a youth’s violent behavior and how long that seclusion lasts.
What the documents revealed is provided to girls at the facilities contracted by DYS.
Applewood and Pomegranate Per ODMHAS licensing requirements, seclusion is not permitted at either facility. Nothing in the documents received indicated that the practice is ever used at Applewood. DYS staff reported that the doors to the youth’s rooms do not lock and the facility does not have “seclusion rooms.” Furthermore, the Quality Assurance review indicated that youth who are agitated may be placed on 1x1 status, where a staff person remains with the youth at all times, including sitting outside the open doorway if the youth is in her room.
While seclusion is also not permitted at Pomegranate, just before the first review period began (August 2014), one of the Plaintiff’s attorneys received reports from girls that they were being placed in “Alternative Program” (AP) for several days at a time and that AP consisted of serving time in a hallway where the doors at both ends and rooms on the sides were locked. Girls had little interaction with staff and program services were not continued during this time. While it was not imposed in the traditional way (i.e., hallway versus resident’s room), Plaintiffs counsel and the Monitoring Team felt that AP had the essential features of “seclusion.”
Subsequent discussions with DYS led to shared concern and DYS administrators took immediate steps to change the practice. In early September 2014, DYS administrators visited the program and communicated their concerns to the program’s CEO, who also took
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immediate action. Following staff meetings on all three shifts, the Alternative Program policy was immediately revised (effective 9/9/14), staff were re-trained and youth were informed about what they should expect. AP was immediately adjusted to remove the features that created the greatest concern and now does not include any type of seclusion in a locked room or area.
Currently, youth may be placed on AP immediately following an aggressive incident in order to separate them from potential victims. They are in a hallway, but are permitted free access to their rooms and have a place to sit, eat, and do treatment and school work. Staff are present at all times and are constantly interacting with the youth. DYS staff have been invited back multiple times to observe the program and to talk to girls who’ve spent time in it and have found that it is being implemented as designed.
Although it is troubling that these problems were not discovered by the program itself, or by DYS during the course of its program monitoring, both the facility and DYS enacted procedures to ensure that disciplinary practices continued to be aligned with DYS policies and program licensing requirements. The facility hired a Compliance Manager and one of her tasks is to monitor the AP. DYS is also informed every time a youth is placed in AP, for what reason and for how long. These incidents are compiled in a running log, which was provided to the Monitor. During the 1st 6-month review period for this report, AP was used 7 times, with an average length of stay of 25 hours (range 11-39 hours).
As noted above, youth are no longer secluded while on AP, so the various provisions required by the Grid for DYS facilities do not apply. As a result, AP was not monitored during the 2nd review period.
CAS CAS is part of a community corrections facility, not a mental health facility, so it is not subjected to the same licensing requirements regarding seclusion as Applewood and Pomegranate. During an August 2014 site visit, one of the Plaintiff’s attorneys indicated that several girls indicated that they’d been placed in seclusion for either 24- or 48-hour periods. While these lengths of stay were commensurate with what DYS permitted in its facilities at the time, in a conversation with the Monitoring Team in September 2014, DYS noted that it intended to ensure that CAS’ policies and practices regarding seclusion evolved alongside DYS’.
CAS drafted a new policy (3C-11) in mid-September 2014 that included all of the major components required by the Grid. The policy:
• Prohibits the use of room confinement as a punishment and permits its use only for the purpose of de-escalation/imminent threat;
• Requires 30-minute assessments/justifications if the restriction is going to be
 continued;

• Gives the line staff authority to release the youth once calm;
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• Requires the Program Director to become involved if the youth has not been released at the 8-hour mark;
• Includes an insight-oriented component (requires a Thinking Error Report); and • Is fortified by the “Rules of Conduct” policy, which does not list room confinement as a
permissible sanction for any of the rule violations.
Since then, DYS has pushed further to ensure that CAS’ policy reflects the best practices identified in the DYS-managed facilities. Currently, DYS and CAS are working to implement a Corrective Action Plan that includes: 1) ensuring that room confinement is used only as a last resort; 2) better structuring the assessment of the youth’s readiness for release; 3) referring all youth placed on room confinement to the clinical team; 4) reviewing room restriction data on a weekly basis to ensure compliance with policy; and 5) reviewing all AMS reports on a daily basis at DYS Central Office.
While the policy was drafted in September 2014, it was not implemented until March 1, 2015 due to distractions caused by County and Court Administrator program audits. That said, the table below show a declining average length of stay and increasingly larger proportions of youth who were released within 4 hours (the threshold set by DYS’ new policy and the Grid).
Of the 45 seclusion episodes during the 1st review period (October 2014-April 2015), 56% (n=25) were completed in 4 hours or less, 13% (n=13) were completed in 4-8 hours, 11% (n=5) were completed in 8-12 hours, and 20% (n=9) lasted longer than 12 hours (all of which included an overnight stay). The average length of stay during the 1st review period was 6.06 hours and the longest length of stay was 26.1 hours. These data are comparable to the durations observed at the DYS-managed facilities during the review period.
Of the 49 seclusion episodes during the 2nd review period (May 2015 through September 2015), 92% (n=45) were completed in 4 hours or less. Only 3 episodes (6%) were between 4 and 8 hours, and only 1 episode (2%) was between 8 and 12 hours. The average length of stay during the 2nd review period was 1.84 hours and the longest length of stay was 8.80 hours. These lengths of stay are significantly shorter than those witnessed in the DYS boys’ facilities at the conclusion of the monitoring period for boys (August 2015).
As noted in the introduction to this report, DYS closely oversees the use of seclusion at CAS by reviewing AMS reports on a daily basis and providing feedback to the site about whether the use of seclusion appeared to be justified or whether alternative strategies could have been effective. This oversight, coupled with a additional policy revisions completed in July 2015 have decreased the frequency of seclusion to levels that approximate what occurs in DYS’ boys facilities.
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CAS: Use of Seclusion, October 2014 through September 2015

Oct Nov Dec Jan Feb Mar Apr May June July

ADP

6.7

8.9 11.5 10.3 10.1 10.0 9.2 6.8

9.3 9.9

# episodes

~

5

10

5

1

11 13

5

12

16

% less than 4 hrs.

~

20% 30% 20%

~ 91% 77% 100% 100% 88%

% 4 to 8 hrs.

~

60%

~

40% 100% ~

~

~

~ 13%

% 8-12 hrs.

~

~

20%

~

~

~ 23% ~

~

~

% 12+ hrs.**

20% 50% 40%

~

9% ~

~

~

~

ALOS

0.0

7.3 12.29 12.2 6.0 3.07 1.6

1.3 1.24 1.89

LOS range

~

2.017.5

1.221.5

1.526.1

~

0.5- 0.5- 0.519.2 11.9 1.5

0.5- 0.53.0 5.37

*Most of the seclusion episodes lasting more than 8 hours included an overnight stay (8.75 hours of total time were sleeping hours).

Aug 9.2 9 89% 11% ~ ~ 1.9 0.55.75

Sept 8.7 7 71% 14% 14% ~ 2.88 0.428.80

One of the concerns that led to the Grid’s development was the accumulation of seclusion hours on certain youth with high-frequency aggressive behaviors. During the 1st review period, two girls had a significantly higher number of seclusion episodes than the others. One (S.S.) had 8 total episodes with a total seclusion time of 120.5 hours over a 5-month period. This translates to her spending approximately 3.3% of her time in custody in seclusion. The other (S.J.) had 7 total episodes with a total seclusion time of 42.50 hours over a 2-month period. This translates to her spending approximately 3.0% of her time in custody in seclusion. During the 2nd review period, one girl (L.B.) accounted for 23 of the 32 seclusion episodes (72%) in July, August and September. Her total time in seclusion (53.3 hours) translated to only 2.5% of her time in custody. These rates of accumulation are significantly below the levels that originally generated concerns about the use of seclusion at the DYS boys’ facilities.
The key mechanism for shortening the length of stay in seclusion is the use of a robust process for assessing the youth’s readiness for return to the regularly scheduled activities of the unit. CAS has implemented a process that is as strong as any reviewed by the Monitor across the country. CAS’ Room Restriction Form requires a detailed description of the youth’s behavior that qualifies as a threat to self or others and supervisory approval of the initial placement in seclusion. Every 30 minutes thereafter, staff members must provide a narrative description of the youth’s mood, attitude, behavior, statements, non-verbal cues, etc. that justify either the continued use of room restriction or the youth’s removal. After one hour, the On-Duty Administrator interviews the youth and determines whether she can safely return to scheduled programming or whether she remains a threat to self or others and must remain in room restriction.

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The Monitor reviewed the Room Restriction forms for all 32 youth who were placed in Room Restriction during July, August and September 2015. Only very small and very infrequent errors were noted among them (e.g., a single missing or late 30-minute check; justifications for continuing room confinement that could have used some additional information). It’s worth highlighting that it is not CAS’ protocol or format for review that makes its process so outstanding, but rather the level of detail and richness of descriptions that are provided by CAS’ staff about the girls’ situations at any given time.
Whether the services received by the girls at facilities contracted by DYS are comparable to those delivered to the boys at DYS facilities and therefore, whether DYS is in substantial compliance with the Court Order.
Currently, neither of the two facilities licensed by ODMHAS utilizes any behavior management practice that includes secluding a girl alone in a locked room. While prior to the beginning of the review period, implementation problems with the Alternative Program at Pomegranate did result in girls being secluded in a locked hallway, once the problem was brought to the program administrator’s attention, the practice ceased. This has been verified by DYS staff who make frequent on-site visits to the facility. The Alternative Program remains an option, but the girls are not secluded and continue to be engaged in programming throughout their time in AP. In summary, the document review completed by the Monitor indicated that current behavior management practices at Applewood/Pomegranate are aligned with what was required by the Grid at the DYS-managed boys’ facilities.
CAS uses seclusion to de-escalate a youth who is out of control, but the new policy drastically shortened the length of stay. Data from the past 12 months reveal that the frequency and duration of the seclusion episodes (even before the new policy was put into effect) are very short, compatible with what is commonly necessary to de-escalate a youth who is a threat to self or others, and are similar to what has been witnessed at the DYS boys’ facilities. Furthermore, the process for assessing youth’s readiness to return to regular programming is outstanding. Youth are assessed very frequently (i.e., every 30 minutes) and staff provide rich, detailed narratives about the youth’s current state of mind at each interval. Taken together, CAS’ use of seclusion easily satisfies the requirements of Column B of the Grid.
In all three facilities, a structured quality assurance process has been implemented to ensure that services meet the needs of the girls housed at the facilities. DYS is encouraged to include quantitative seclusion data in its QA reports for CAS. DYS’ close oversight of the use of seclusion at CAS, coupled with its demonstrated willingness to use the Corrective Action tool to ensure that practices are aligned with DYS managed facilities, create considerable confidence that continued external oversight around the use of seclusion from the Monitoring Team is not necessary.
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Column C. (Monitored by Dr. Weisman)
Mental Health Response to Youth’s Aggressive Behavior
This report provides observations of each of the girls’ facilities during two distinct monitoring periods. The first monitoring period covered the six months between January and June 2015. The second monitoring period covered the three months between July and September 2015. Findings for each facility for these distinct time frames will be noted in the text as Review One (January – June, 2015) and Review Two (July – September, 2015).
What the Grid requires of DYS facilities.
There are two essential requirements of Column C, and while the girls’ facilities do not have to provide identical services, they must provide comparable services. The first requirement is a review and potential revision of the individual treatment plan following each AOV. In reviewing this documentation it was clear that each of the facilities provided both individual and group interventions in a timely manner following each girl’s involvement in a single AOV. Documentation does not specifically identify the AOV in the intervention notes, however the focus of these sessions is on emotional regulation which is clearly a clinical issue informing the girls’ behavioral dyscontrol.
This report will not dissect these interventions. It must be assumed that the facilities are providing appropriate care given their licensing requirements by the Department of Mental Health and the fact that the girls only engaged in one AOV. This speaks to the effectiveness of their interventions.
The second requirement of Column C is a formalized process in place to address the mental health needs of youth who engage in repeated acts of violence (AOV). Within DYS secure facilities for boys, youth who engage in repeated AOVs are managed by Special Review Teams (SRT) consisting of the youth, the youth’s primary clinician, Unit Manager and social worker. The purpose of the SRT is to identify the causes and functions of the AOVs, to prescribe more intensive interventions aimed at addressing the root causes of the behavior, and to recommend updates to the Individual Service Plan (ISP).
The focus of this report will be on the facilities’ clinical management of girls’ who engage in repeated AOVs.
Methodological Note.
The facilities did not provide their policies for the auditors to review. We were also unable to make site visits to the facilities, observe programming or speak with the girls. As a result, this report relies heavily on the extensive analysis and on-going QA activities by ODYS and the subject matter expert’s thorough review of the following documents:
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v For Round Two, the Monitoring Team received DYS Behavioral Health Quality Assurance summary (dated 11/2/15) and the underlying score sheets for each record reviewed. This QA protocol mirrors that implemented in the DYS boys’ facilities. This Behavioral Health QA review was summarized in the introduction to this report.
v For each monitoring period, the Monitoring Team received Nan Hoff’s monitoring reports as follows:
• Review One – CAS (5/15/15); Pomegranate (5/12/15); Applewood (4/1/15) • Review Two – CAS, Pomegranate and Applewood (10/13/15)
Information contained in these documents is summarized in the introduction to this report.
v For each monitoring period, the Monitoring Team received facility-specific Incident Tracking forms detailing the dates, incident descriptions and consequences of AOVs for individual youth:
• Review One – Pomegranate (2– 7/15); Applewood (1/15 – 6/15)1 • Review Two - CAS, Pomegranate and Applewood (7/15 – 9/15)
This information was used to identify the number of girls who met the AOV threshold so that the subject matter expert could ascertain whether they received services comparable to what is required by the Grid. It should be noted at the outset that there were a total of 28 youth in residence at the three facilities during the first review period. During this period, seven youth met the SRT threshold, or 25%. During the second review period there were 21 youth in residence. Of these, only three met the SRT threshold, or 14%. This speaks to the relative infrequency of a youth engaging in multiple AOVs, and to the overall improvement in the facilities’ management of some of the most challenging behavior.
v For each monitoring period the Monitoring Team received youth-specific treatment plans and progress notes.
v Since the Monitoring Team did not have access to the facilities’ policies, on August 14, 2015, the Chief of Behavioral Health Services provided the Monitoring Team with a detailed memo describing the processes in place at each of the facilities for their management of youth who engaged in AOVs.
1 The Monitoring Team did not request a specific listing of AOVs for Round 1, relying instead on DYS’ identification of girls who engaged in AOVs. In Round 2, the Team requested and received this list so that the identification of girls who engaged in AOVs was made independently.
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Given the small number of youth involved in the review from each of the three facilities, calculation of compliance ratings in terms of percentages makes little sense. Instead, evidence of compliance, when it occurs, is noted for each youth.
Pomegranate
Review One (1/15 – 6/15): DYS provided the following background on Pomegranate policies based on their site visits, document reviews and interviews with staff and youth. The following processes are in place to respond to and address AOVs:
• In-the-moment processing of AOVs; • CBT Packets as part of the Alternative Placement intervention2; • Critical Incident Reviews following incidents in which a youth causes or sustains a
serious injury (though none of the DYS girls have been involved in an incident which would trigger such a review); • Monthly SAVE Committee (i.e., Staff Against Violent Environments) in which the underlying causes of restraints are examined and specific interventions are prescribed.
The subject matter expert reviewed the mental health records for six girls. Of these, five had had altercations that met the SRT threshold. In each instance, the therapist met with the youth immediately following the incident to process the event, and the youth was subsequently returned to programming. In one instance, a youth (JM) received an extra 90 days due to her altercation. Pomegranate has no requirement that the ISP be reviewed and revised or modified following AOVs.
DYS provided substantial information to help us better understand how the other interventions, listed above, provide services that are functionally equivalent to the SRT process that is available to DYS boys. To summarize the information the Monitoring Team received from DYS:
According to policy, after each act of violence, there is a Critical Incident Review (CIR), that includes staff, a shift supervisor and administrative staff. Monthly there is a Staff Against Violent Environments (SAVE) committee meeting which reviews all AOVs. It is within this forum that Root Causes of the AOVs are addressed. While there is no formal written policy to govern this, programming operates from a CBT/DBT model, which dictates that any behavioral concerns are reviewed, discussed and worked into the client’s individual case
2 As noted previously in this report, Pomegranate uses what they refer to as Alternative Programming for some youth who engage in AOVs. AP does not have a pre-determined duration. Programming is taken to youth who are on AP and staff is always present. With regard to Column C requirements, one of the requirements while on AP is to complete a CBT packet related to the event leading to AP and to process the information in the packets with staff. The youth’s primary clinician is required to meet with the youth while on AP.
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conceptualization. That conceptualization of the case translates into interventions within the client’s program and related to the client’s ISP goals. Safety plans are used as needed. By policy, treatment team meetings are to be held “no less than once a month and at clinical junctions,” though the current practice is to have weekly team meetings and clinical staffings are scheduled more frequently if needed.
DYS conducted in-depth reviews of CIR and SAVE meeting minutes and talked about the process with program staff. In their summary report provided to the monitors, DYS stated, “CIRs are triggered by a youth causing or sustaining serious injuries, etc., and are targeted to ascertain the cause of the incident / outcome and to learn from the incidents to avoid critical incidents in the future. No DYS girls have needed a CIR in the recent past.” DYS reported that the SAVE committee minutes focuses on institutional reforms that responded to trends noted in AOVs and other undesirable occurrences. For example, DYS noted that ”The July 2015 SAVE minutes included the following: revamp the coping skills, addressing what the youth need to be successful, providing tangible items for the youth to use, implementing a pilot program, and creation of behavior management plans.”
In addition, DYS reported that, “The SAVE Committee did a day-by-day break down of restraints in June. They discovered some trends as it related to days of the week and addressed staffing levels on those days. The Committee also reviewed a list of kids who had the highest number of restraints and the Restraint Reduction Group was assigned to meet and further discuss those youth.”
Although DYS’ information suggested that the CIR and SAVE Committee meetings had been implemented as prescribed in policy, the Monitoring Team was also interested in whether these interventions were effective in reducing violence among girls with mental health issues. On 8/13/15, DYS provided the following outcome data:
• Five girls would have met the criteria for SRT at some point over the past 16 months; • The range of days the SRT would’ve been active ranged from 14 to 73 days. [Note that
by policy, the minimum active time is 14 days.] The median was 25 days. • No girl would have met the SRT criteria in the month immediately following her initial
SRT, though one girl would have again met criteria 4 months later.
Subject Matter Expert’s Assessment: Review One.
Although the subject matter expert was not personally able to review some of the documentation related to Column C, DYS made every effort to fill in the blanks by going on site and reviewing the substance of the relevant documentation. The Monitoring Team was provided with detailed findings from the DYS staff conducting these reviews. The documents the subject matter expert personally reviewed, along with the summaries received from DYS, suggest that although Pomegranate does not have an SRT per se, the immediate intervention following the AOV, ongoing clinical interactions and the CIR and SAVE meetings combine to form a comparable process to what is in place for boys at DYS. Outcome data suggest that
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these have been effective in limiting the girls’ involvement in AOVs.
Review Two (7/15 – 9/15): Pomegranate had no youth who engaged in repeated AOVs during this monitoring period. To be clear, none of the girls met the threshold for an SRT. There was one AOV in July, two in August and two in September. Only one girl had two AOVs within this time frame, but those were spaced so as to not meet the requirements.
This is remarkable progress. As DYS noted in their report (8/13/15), five girls had met the SRT threshold in the prior 6 months. In the subsequent three months reviewed, no girls met the threshold. This certainly suggests improvement in Pomegranate’s management of these events.
In her Monitoring report of 10/13/15, Nan Hoff notes the many changes that have been implemented at Pomegranate. According to her report:
• DYS girls are now housed on one unit making it easier to provide programming. • The unit the girls are housed on has been softened. All girls painted murals on the
walls of their rooms, and a mural for the common area is underway. • Girls are able to attend community activities such as weekend home passes, shopping
with staff, going to museums, walking in the neighborhood and going out for dinner. • Educational achievement of the girls is going well with two girls having graduated
high school and one attending college. • A Treatment Team model that meets monthly with each youth is being implemented. • The Director of Pomegranate has scheduled refresher training for all staff on trauma
informed care.
These changes are huge and no doubt account for the calming of the youth on the unit. The collaboration between DYS and Pomegranate resulting in Pomegranate’s use of strategies now commonly in use in DYS facilities is to be commended. Issues such as the softening of the environment, implementing treatment teams, community-outings and a greater focus on trauma-informed care are clearly having a positive impact on the behavior of the girls.
Subject Matter Expert’s Assessment: Review Two.
Pomegranate has made significant progress in their ability to provide meaningful services to the DYS youth in their care. Evidence of this is the reduction of youth with repeated AOVs from the first to the second review. At the time of Nan Hoff’s review, there were 9 girls in residence at Pomegranate. None of the girls at Pomegranate met the threshold for an SRT. The benefits of the collaborative relationship between DYS and Pomegranate are clearly in evidence.
However, a concern remains about the lack of individualization of treatment plans for girls at Pomegranate. The plans reviewed by the subject matter expert were nearly identical. It is
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recommended that going forward DYS and Pomegranate work on improving the girls’ treatment plans. DYS has noted the similarity in goals and objectives (as stated in their 11/2/15 Quality Assurance Summary) and plans to continue to work with the clinicians on this issue.
Applewood
Review One (1/15 – 6/15): DYS provided the following background on Applewood’s policies based on their site visits, document reviews and interviews with staff and youth, the following process are in place to respond to and address AOVs:
• In-the-moment processing of AOVs; • Addressing AOVs during regularly scheduled treatment interventions; • Reviewing AOVs during weekly clinical rounds and prescribing necessary

interventions;
 • Monthly team meetings that include summaries of issues that can be then integrated
into youth’s treatment, reflected in progress notes; and • 90-Day Review Meetings.
These interventions are all prescribed by policy, and DYS’ oversight verified their implementation. Although the program did not provide policies to the Monitoring Team, DYS responded to a series of structured questions from us about the substance of policies. DYS reported that according to policy, acts of violence should be processed with staff in the moment, if feasible. Client cases should be reviewed weekly in clinical rounds. Participants in clinical rounds should consist of the entire treatment team. At this time any/all incidents should be reviewed, as well as the youth’s response to interventions and progress in treatment. Additionally, clients should be individually reviewed monthly with the treatment team and community stakeholders (i.e., probation officers, legal guardians, custodians, etc.).
The subject matter expert personally reviewed mental health records for three girls. Of these, two had engaged in AOVs that met the SRT threshold. The mental health records consisted of Group Therapy Notes, Individual Therapy Notes, Partial Hospitalization notes and an Intake Mental Health Assessment.
For the period 1/31 – 3/2, Applewood reported five serious incidents. Youth AL was responsible for four of these incidents. ISP goals and interventions, developed upon intake, were focused on “emotional regulation” and substance abuse. There was evidence that AL’s AOV were addressed in the context of a group on two separate occasions (3/5 and 3/6/15).
Applewood may use a “shut down” intervention and/or a “cottage restriction.” In policy, these practices are defined as follows: “Shut Down: Failure to follow transition rules i.e., remaining in assigned hallway during hygiene routine or causing a significant bedtime disruption,
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continually out of area, or using doorway that sounds an alarm. Client will be restricted to sitting in their room during all transition periods. (2) Cottage Restriction: Attempted or successful AWOL as defined as leaving campus without permission will result in 72-hour cottage restriction.” It is said that these are used in rare circumstances. However, all three of the girls had experienced these or other consequences following their AOV: Youth AL – Separation Plan, Youth CS – Shut Down, Youth TL – Unit Restriction.
Youth TL was placed on Unit Restriction for a lengthy period due to her unrelenting selfinjurious behavior. During this time she was not able to attend groups in an abundance of caution for her safety. She did however, receive focused individual therapy during this period. She was also placed on a Safety Plan that was reviewed weekly. It is clear from reviewing the Safety Plans developed between 4/16/15 and 6/8/15 that the strategies Applewood was implementing had the desired effect because over this period TL was able to earn back restricted items and begin attending groups.
Although DYS’ information suggested that the various interventions had been implemented as prescribed in policy, the Monitoring Team was also interested in whether these interventions were effective in reducing violence among girls with mental health issues. On 8/13/15, DYS provided the following outcome data:
o Five girls met criteria for an SRT at some point in time over the last 16 months. o The range of days the girls would have been on an SRT ranged from 14 to 29 days
(Note: the minimum is 14 days since a person is kept on the SRT for a minimum of 14 days following the date they meet the threshold). The median was 19 days. o Only one girl would have gone back on an SRT after coming off her first SRT. o No girls would have met the criteria for an SRT in the month following the month she came off an SRT (i.e., in consecutive months).
Subject Matter Expert’s Assessment: Review One.
There is sufficient evidence to assert that Applewood addresses AOVs in a manner consistent with Column C requirements. Some of the supporting documentation that would have provided additional evidence that their formalized processes are in place seems to be attributable to their manner of documentation. Meetings in which more than one youth is discussed do not appear in the individual notes of the youths’ in question, and thus were not provided to the Monitoring Team in response for our request for individual treatment records.
Applewood’s treatment plans are not individualized. The treatment plans for the three girls reviewed were nearly identical – this despite the fact that the girls presented with some of the same, but some distinct issues. It is recommended that DYS monitor the adequacy of Applewood’s case formulations and their relationship to service provision. As with Pomegranate, it is recommended that DYS work with Applewood to improve the girls’
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treatment plans.
Review Two (7/15 – 9/15): Applewood had two youth who met the SRT threshold during this review period:
• TL - AOVs: 7/24 (H), 7/27 (S) and 8/3 (S) • TW - AOVs: 9/19 (S) and 9/28 (S)
TL is the same youth reviewed in Round One, and she remained unsafe during the second review period. Following TL’s AOV on 8/3/15, she received individual or group counseling everyday from 8/6/15 through 8/15/15.
There are two notes indicating that TW directly addressed the restraint episode related to her AOV during an individual therapy session on 9/23; the second note states that TW brought up her AOV during group on 9/24. Thereafter, TW received a daily combination of individual and group therapies from 10/1 -10/15/15.
Subject Matter Expert’s Assessment: Review Two.
Applewood’s policies and practices conform to the requirements of Column C. While Applewood’s documentation does not exactly mirror what is required of clinicians at the boys’ facilities, there is ample evidence that the girls are receiving services which are at least as intensive as those the boys’ receive.
The subject matter expert again notes the lack of individualization of treatment plans. The treatment plans for both girls are nearly identical and do not seem to be reviewed or revised following an AOV.
CAS
Review One (1/15 – 6/15): The subject matter expert personally reviewed the mental health records for six youth. There was considerable overlap of youth who were presented at Pomegranate and Applewood. The following youth appeared in multiple settings:
• AL (CAS and Pomegranate) • AW (CAS and Applewood) • AY (CAS then Pomegranate then CAS) • TL (CAS and Applewood)
This is because, as noted previously, CAS serves as both the receiving facility for girls to be served in any of the three facilities and as a provider of services for those youth determined not to be in need of more specialized mental health services. If the youth evidences mental health concerns, she is referred to either Applewood or Pomegranate. On occasion, girls who do not do well in these more therapeutic programs, or who are determined not to have
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mental health concerns of sufficient severity to require their maintenance in these programs, are returned to CAS.
Of the six girls reviewed by the subject matter expert, three had engaged in AOVs. None of these met the threshold for an SRT. The only information provided regarding CAS’ response to these events indicated that:
• Youth AW: placed in her room on 15 minute checks • Youth DT: physically restrained, placed in room and on Unit Restriction • Youth AY: placed on a behavior contract
In addition to the types of interventions that were provided and whether they were functionally equivalent to what is provided to the DYS boys, the Monitoring Team was also interested in whether CAS’ services were effective in reducing violence among the girls. According to data reviewed by ODYS (8/21/15): “CAS went 11 consecutive months with no girl meeting the criteria for an SRT. One girl met the criteria in July (that was the first one to meet the criteria in 11 months). Since then, a medication consultation has occurred for her. Medication adjustments have been made. SOPP is providing individual therapy. Family members have been brought in and family sessions are starting. (In addition), a case conference with Pomegranate was held to see about the possibility of them getting involved.”
This youth will be discussed in greater detail in the second review.
Subject Matter Expert’s Assessment: Review One.
Documentation provided from CAS was insufficient to comment on their processes in addressing youth who engage in repeated AOVs and the extent to which they may be comparable to what occurs in the ODYS facilities for boys.
CAS has entered into a Corrective Action Plan with DYS to ensure that their documentation is more robust:
• The Treatment Specialists have been entering JCS notes effective June 12, 2015. These notes reflect the resident’s progress in CBT groups. These notes are continuously being reviewed to ensure they are clear and individualized to the resident
• CAS has begun providing copies of Individualized Service Plans, Diagnostic Assessments and therapeutic goals for all residents on their caseload. As of August 1, 2015 they will be providing notes regarding each therapy session.
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• The psychiatrist will provide weekly updates on youth seen and monthly psychiatric notes.
Review Two (7/15 – 9/15): One youth (LB) accounted for nine of the 14 AOVs that occurred during this time frame (63%). LB engaged in three Severe AOVs in July, four Severe AOVs in August and two Severe AOVs in September. She is the only youth to have met the SRT threshold. It should be noted that she is the first youth to have met this threshold in 11 months.
LB is a very complicated case and managing her assaultive, oppositional behavior has been a huge challenge for all concerned. DYS Central Office’s involvement in this case and general oversight of CAS’ clinical management of DYS youth in their care has been extensive and impressive. There have been multiple case conferences and visits between DYS and CAS to jointly development a clinical strategy to address her needs. On 9/23, Dr. Dachowski (who participated in all case conferences) spoke directly with Dr. Hart about LB’s diagnoses and medications. There have been two case conferences that involved staff from CAS, DYS Central Office, and the mental health subject matter experts. All this clinical dialogue resulted in articulation of a set of strategies to address her behavior and underlying issues, among which was a decision to place LB on a behavior management plan. On 10/6, Dr. Stinson shared a draft behavior management plan with CAS for their input and on 10/7 he went to CAS to present the plan to LB.
The level of clinical attention devoted to LB meets or exceeds the requirements of Column C.
There have been remarkable improvements in the quality of clinical service provision at CAS. Perhaps most importantly, in the time since the first review, CAS has a new director with a treatment focus. According to Nan Hoff’s monitoring report (10/13/15), the following improvements have been implemented at CAS:
• Monthly clinical meetings which the youth attends (analogous to a treatment team); • University of Cincinnati Is working with the CAS clinical staff In the development
individualized goals and objectives for the girl; • Inclusion of girls in all levels of decision-making regarding the changes that are
occurring.
• Colorful, softer furniture has replaced the harder institutional furniture; • Colorful artwork and posters are now displayed in the main hallway greeting all who
enter; • Girls are now able to hang pictures and quotes on the walls of their rooms;
Nan Hoff notes in her monitoring report that, “with the arrival of a treatment focused director and changes, there’s a major culture change going on.”
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Subject Matter Expert’s Assessment: Review Two.
CAS has demonstrated remarkable improvement in their delivery of treatment services for DYS girls. This is undoubtedly a result of the hugely successful collaboration between CAS and DYS Central Office, and the newly appointed treatment oriented director. The hoped for outcome of the CAP, and oversight by DYS has occurred. CAS is now functionally equivalent to the DYS boys’ with regard to Column C requirements.
Other Services Provided to DYS Girls at Contracted Facilities.
Pomegranate While not directly related to Column C indicators, surely it can be said that the groups, programs and activities offered at a facility play a role in engaging youth and reducing the likelihood of AOVs. Pomegranate offers a rich array of groups and activities, including:
• Values in Ourselves • Art Making Studio • Breaking the Ice • Decision Making • Team Building • Life Skills • Self-Esteem • Positive Skills • Life Skills • Understanding Symptoms • Behavior • Team Building • Decision Making While the groups have different foci, in all, basic Dialectical Behavioral Therapy (DBT) skills are emphasized. In reading through group notes, the array of strategies used to engage youth appears thoughtful and accessible.
Applewood Among the groups offered at Applewood are:
• CBT • Social Awareness • Emotional Healing through Art • Stress Reduction • Emotional Regulation • Nurture and Grow • Creative Cultural Art • Bibliotherapy • Resiliency
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Case: 2:08-cv-00475-ALM-MRA Doc #: 160 Filed: 12/08/15 Page: 31 of 32 PAGEID #: 3269
• Self-Care/Hygiene • Anger Management • Relational Aggression • Boundaries • Needs, Wants and Expectations • Communication • Beyond the Violence • Empathy and Compassion • Conflict Resolution • Me, Myself and I • How to Train Your Dragon • Healthy Habits • Independent Living Once again, this is a rich array of groups and activities that engage youth in a variety of modalities focused essentially on emotional regulation.
CAS The groups offered at CAS are:
• Motivation to Change • DBT Emotional Regulation • EQUIP • Girls Moving On • Strengthening Families
Girls may be enrolled in two different groups at any given time.
Whether the services received by the girls at facilities contracted by DYS are comparable to those delivered to the boys at DYS facilities, and therefore, whether DYS is in substantial compliance with the Court Order.
Both Applewood and Pomegranate are licensed mental health facilities that provide a rich array of programming to DYS girls. Information obtained directly from the providers and summaries from DYS about information they collected while on site suggest that the programming received by girls in these facilities following an AOV is comparable to what boys in ODYS facilities receive. DYS oversight and technical assistance to these facilities is excellent.
CAS is not a mental health facility and so the level of therapeutic programming is contemplated to be somewhat reduced. While programming at CAS is not comparable to what is offered at Pomegranate and Applewood, overall CAS has made enormous gains in their clinical service provision and documentation. The corrective action plan that DYS placed CAS on is having its intended effect.
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Summary & Conclusion
The following chart illustrates that practices at the contracted girls facilities were assessed as being functionally equivalent to services prescribed by the Grid for boys at DYS facilities. Our second review revealed significant progress at CAS with the quality of treatment, documentation in clinical progress notes, and further restrictions on the use of seclusion—all of which were products of a very effective Corrective Action Plan.

Are Services Functionally Equivalent to Services for Boys at DYS Facilities?

Facility

Column A: quality of MH assessments,
treatment planning and provision of MH services

Column B: use of seclusion as a response
to youth’s aggressive behavior

Applewood

✓

✓

Pomegranate

✓

✓

CAS

✓

✓

Column C: MH response to youth who engage in aggressive
behavior
✓
✓
✓

32.

 IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA, Plaintiff,
v. THE STATE OF OHIO, et al.,
Defendants.

:

:

Case No. 2:08-CV-00475

:

:

JUDGE ALGENON L. MARBLEY

:

:

Magistrate Judge Abel

:

:

:

OPINION & ORDER This matter is before the Court on Plaintiff United States of America’s Motion for Leave

to File Supplemental Complaint (Doc. 130). The United States seeks leave to supplement its

Complaint in order to reassert its claims with regard to various Department of Youth Services

Detention Facilities, based on newly-discovered evidence of wide-spread overuse of seclusion of

youths with mental health needs. Defendants oppose (Doc. 134), on the grounds that the United

States improperly seeks, effectively, to change the terms of the Consent Decree in this case, that

the dismissal of the United States’ previous claims was an adjudication on the merits, and that

Defendants would be prejudiced by supplementation.

For the reasons set forth herein, the United States’ Motion is hereby GRANTED.

I. BACKGROUND The United States commenced this action against the State of Ohio, its Governor, its

Department of Youth Services (“DYS”), and various DYS officials on May 16, 2008, alleging

constitutional violations at eight juvenile correctional facilities in Ohio: Circleville, Cuyahoga

Hills, Indian River, Marion, Mohican, Ohio River, Scioto, and the Freedom Center. (Complaint,

Doc. 2, ¶ 1). In particular, the United States alleged a pattern or practice of failing to protect

youths from harm and undue risk of harm, meet youth medical needs, provide adequate mental

health care, and offer adequate special education services, in violation of federal constitutional and statutory rights. (Id., ¶¶ 22-32). Among the allegations in the original Complaint was the charge that Defendants failed adequately to protect youths at the Facilities from harm or risk of harm due to “unwarranted use of seclusion.” (Id., ¶ 22(b)).
On June 5, 2008, the Parties filed a Joint Motion for Entry of Stipulation and Conditional Dismissal of the Complaint, resolving the United States’ claims as to the Scioto and Marion Facilities, and asking the Court conditionally to dismiss its claims as to the remaining six stateoperated Facilities. (Joint Motion for Stipulation, Doc. 6). The Court entered the agreed Stipulation for Injunction Relief on June 24, 2008. As an integral part of the Stipulation was a provision that the State would development and implement policies, procedures, and practices to guide the use of seclusion (as defined in the Stipulation), including documentation and review of its use. (Stipulation, Doc. 8 at 5, 7). On December 15, 2009, in response to the closing of the Marion Facility, the Stipulation was amended to address only the Scioto Facility. (Doc. 27 at 1).
On May 20, 2011, the Parties again moved to amend the Stipulation (Doc. 80), which the Court granted on June 6, 2011 (Doc. 81), and which ultimately resulted in the Amended Stipulation for Injunctive Relief, entered June 28, 2011 (Doc. 85). This Amended Stipulation terminated 20 provisions under the Stipulation’s “Substantive Remedial Provisions”; the provision regarding “seclusion” was not removed. (See Doc. 85 at 3-4, 7). The Stipulation also appointed a new Monitor, Dr. Kelly Dedel, and modified the monitoring process. (Id. at 18-22).
In December 2012, the United States initiated a dispute-resolution procedure, pursuant to the terms of the Amended Stipulation, with regard to the use of seclusion for youth on the “PROGRESS Unit” at the Scioto Facility. On December 19, 2012, it sought a Consent Order resolving this issue (Doc. 107), which the Court entered on January 18, 2013 (Doc. 109).
2

On November 21, 2013, in a letter from DYS Director Harvey Reed, DYS announced that it would close the Scioto Facility, and move any boys remaining at Scioto to other Facilities by May 2014. (Doc. 130-1 at 14).
On December 18, 2013, Defendants moved to terminate this case under Paragraph VII(E) of the Amended Stipulation, and pursuant to the Prison Litigation Reform Act of 1995, 18 U.S.C. § 3626 et seq. (“PLRA”) (Doc. 121). As a result of negotiations with all stakeholders held in the Court’s chambers, however, Defendants withdrew their Motion on December 24, 2013 (Doc. 125). Further negotiations were held on January 29, 2014. (See Doc. 128).
According to the United States, “recent developments” since the events of late 2013 have revealed further allegedly unconstitutional conditions at the Scioto Facility, as well as other DYS Facilities. (Doc. 130 at 3). In particular, the United States alleges that it was discovered in November 2013 that Defendants were “excessively secluding youth at Scioto who have significant mental health needs.” (Id. at 5). The United States also cites the planned closure of the Scioto Facility, and the aborted December PLRA Motion as other troubling recent developments. (Id. at 6-7). Furthermore, the United States alleges that records produced by Defendants on January 17, 2014, demonstrate that Ohio “is also excessively secluding youth with mental health needs at its other DYS facilities.” (Id. at 3, 6).
The United States thus insists that, after the breakdown of negotiations in January 2014, and the failure of the Parties to reach any further agreement, it was compelled to file the Motion sub judice, as well as the companion motion seeking a temporary restraining order regarding the use of seclusion on youths with mental health needs at DYS facilities (Doc. 131).
II. STANDARD OF REVIEW Under Fed. R. Civ. P. 15(d), upon motion and “reasonable notice,” the Court may permit a party to serve a supplemental pleading setting out “any transaction, occurrence, or event that
3

happened after the date of the pleading to be supplemented.” When a party “assert[s] additional claims for relief,” however, “[a] Rule 15(a) motion for leave to amend the complaint, not a Rule 15(d) motion to supplement the pleading, is the appropriate mechanism.” Michael v. Ghee, 498 F.3d 372, 386 (6th Cir. 2007). Rule 15(a) permits a party to amend a pleading with the Court’s leave, which should be “freely given[] . . . when justice so requires.” Fed. R. Civ. P. 15(a)(2). The purpose of Rule 15 for amended and supplemental pleadings is “to provide maximum opportunity for each claim to be decided on its merits rather than on procedural technicalities.” Roger v. Lehman Bros. Kuhn Loeb, Inc., 621 F. Supp. 114, 119 (S.D. Ohio 1985) (citing McHenry v. Ford Motor Co., 269 F.2d 18 (6th Cir. 1959)).
The same standard of review and rationale apply under both Rules 15(a) and 15(d). Spies v. Voinovich, 48 F. App’x. 520, 527 (6th Cir. 2002) (citing Glatt v. Chicago Park Dist., 87 F.3d 190, 194 (7th Cir. 1996)); Maclin v. Holden, No. 12-CV-12480, 2013 WL 4521124, at *2 (E.D. Mich. Aug. 27, 2013). The grant or denial of a motion to supplement a pleading is left “to the discretion of the trial court.” Allen v. Reynolds, 895 F.2d 1412, at *2 (6th Cir. Feb. 13, 1990). In exercising its discretion, the Court may consider such factors as “undue delay, bad faith or dilatory motive on the part of the movant, repeated failure to cure deficiencies by amendments previously allowed, undue prejudice to the opposing party by virtue of allowance of the amendment, [and] futility of the amendment.” Foman v. Davis, 371 U.S. 178, 182 (1962). In the absence of any such “apparent or declared reason,” however, leave sought should be “freely given.” Id. In determining prejudice to a party, the Court should take into account whether the assertion of the new claim or defense would “require the opponent to expend significant additional resources to conduct discovery and prepare for trial[,] significantly delay the resolution of the dispute[,] or prevent the plaintiff from bringing a timely action in another
4

jurisdiction.” Phelps v. McClellan, 30 F.3d 658, 662-63 (6th Cir. 1994). In general, “[a] trial court does not abuse its discretion in refusing to allow supplementation of a complaint which would add extraneous matter late in the case.” Tesfa v. Am. Red Cross, No. 2:12-CV-0397, 2013 WL 5722808, at *2 (S.D. Ohio Oct. 21, 2013); see also McCormack v. Frank, 34 F.3d 1068, at *5 (6th Cir. Aug. 10, 1994) (court did not abuse its discretion when it denied a motion to supplement, where granting would require re-opening discovery and further delay trial). Nor does a Court abuse its discretion by “deny[ing] a motion for leave to amend a complaint if such complaint, as amended, could not withstand a motion to dismiss.” Neighborhood Dev. Corp. v. Advisory Council on Historic Preservation, 632 F.2d 21, 23 (6th Cir.1980) (citation omitted).
III. ANALYSIS The United States seeks leave to file its Proposed Supplemental Complaint, which, it argues, “including allegations concerning newly discovered events involving Defendants’ pattern or practice of harming youth through unnecessary seclusion and denial of adequate mental health care and rehabilitative treatment.” (Doc. 130 at 7). The United States asserts that its Proposed Supplemental Complaint details allegations of Ohio’s closure of the Scioto Facility, its transfer of boys to other DYS Facilities where the same conditions exist, and its pattern or practice of harming youths through excessive seclusion and inadequate treatment at those other Facilities. (Id.). These new allegations, it explains, are based upon information revealed by the Monitor in this case, as well as the associated S.H. case.1 (Id.). In support of its Motion, the United States argues, first, that its conditional dismissal with regard to the DYS Facilities other than Scioto and Marion (see Doc. 6; Doc. 7) was without prejudice, and therefore does not bar its Proposed Supplemental Complaint. (Doc. 130 at 8). It further argues that leave to supplement should be freely granted, since its Supplemental
1 S.H. v. Reed, No. 2:04-CV-1206 (S.D. Ohio).
5

Complaint properly concerns events that took place after the filing of the original Complaint, and moreover that supplementing the Complaint would avoid piecemeal litigation and allow for the complete and efficient adjudication of the entire controversy between the Parties. (Id. at 9-11).
The United States emphasizes its fear that Ohio could seek to “avoid its obligations in this suit to the Scioto youth simply by transferring them to other DYS facilities,” and it should therefore be granted leave to prevent this end-run by the State. (Id. at 11). The United States additionally argues that Ohio would not be prejudiced by the new Complaint, since it has “received ample notice,” because these claims were part of the original Complaint, and because the United States acted as soon as it was aware of the present conditions. (Id. at 11-12). The United States adds that supplementation will not cause delay, since there is presently no discovery schedule or trial date set. (Id. at 14-15). Finally, the United States insists that its new allegations are “related and substantially similar” to the original Complaint, since they “share core questions of law and fact,” and are thus “not so different as to cause prejudice to the defendant.” (Id. at 13-14) (quotation omitted).
Defendants oppose the United States’ request on several grounds. First, Defendants argue that the January 18, 2013 Consent Order governs this case. (Doc. 134 at 2). Defendants maintain that the United States cannot unilaterally alter the Consent Order, absent an unanticipated change in fact or law, which, Defendants argue, has not occurred here, given that the closure of Scioto was anticipated well in advance, and follows in the wake of the closure of other DYS Facilities, such as Marion and Mohican. (Doc. 134 at 2). Defendants also argue that the current increase in seclusion hours is also not unanticipated, since “[s]eclusion hours go up and down,” and Ohio has been in at least Partial Compliance in this regard. (Id. at 3).
6

Defendants further assert that because the United States’ Complaint has been dismissed twice—first, by stipulation, on June 12, 2008 (Doc. 7), and again, by the Amended Stipulation, on June 28, 2011 (Doc. 85)—the second dismissal “operates as an adjudication on the merits.” (Doc. 134 at 3) (citing Fed. R. Civ. P. 41(a)(1)(B)). Defendants add that the claims asserted by the United States are time-barred, since under any theory, the statute of limitations relevant to the claims is not more than two years, which elapsed at least by 2012. (Doc. 134 at 4-5).
Defendants also argue that they would be prejudiced by the United States’ supplementation. Because the United States knew about the use of seclusion since at least 2008, Defendants insist, but has waited nearly six years and twice dismissed most of the DYS Facilities from the case, the delay should not be excused by granting leave to supplement. (Id. at 5-6). Defendants also point to the prejudice that would result if the United States were allowed to alter the burden of proof: Defendants oppose supplementation that would “hold all DYS facilities to the standard set out in the Consent Decree,” which is limited by its terms to Scioto and which exceeds minimum constitutional guarantees. (Id. at 6). Thus, Defendants argue that the United States should instead file a new Complaint, as the original Complaint already address seclusion, and accordingly the Supplemental Complaint cannot meet Rule 15(d)’s standard of transactions or occurrences “that happened after the date” of the original Complaint. (Id. at 6-7).
A. Procedural Bars to Supplementation or Amendment Defendants raise three procedural bars to the United States’ Motion: (1) the January 18, 2013 Consent Order; (2) the “two dismissal rule” of Fed. R. Civ. P. 41(a)(1)(B); and (3) the statute of limitations. The Court considers each in turn.
1. The Consent Order First, the January 18, 2013 Consent Order (Doc. 109) is inapplicable here. Indeed, neither the Consent Order, nor the Amended Stipulation (Doc. 85), address the allegations raised
7

by the United States in its Proposed Supplemental Complaint, both because those earlier Orders address different facilities, and because they address different substantive conduct. The Stipulation (Doc. 7) and Amended Stipulation concern the United States’ original claims, with regard to the Scioto and Marion Facilities, not the Circleville, Cuyahoga Hills, and Indian River Facilities targeted here. Moreover, while the Proposed Supplemental Complaint undoubtedly contains some allegations touching on the Scioto Facility (see Doc. 1301-1, ¶¶ 19-21, 23), these new allegations specifically concern conduct occurring in 2013 and 2014.
The State’s suggestion that the United States “now seeks to hold all DYS facilities to the standard set out in the Consent Decree” (Doc. 134 at 6) is difficult to reconcile with the actual language of the United States’ Proposed Supplemental Complaint and Motion to Supplement. Nowhere does the Proposed Supplemental Complaint reference the Consent Order. Moreover, as it acknowledges, the United States retains the burden of “prov[ing] the allegations in the supplemental complaint.” (Doc. 136 at 2).
2. Rule 41(a) Defendants also mistakenly rely on Fed. R. Civ. P. 41(a). Rule 41(a)(1)(B) mandates that voluntary dismissal, by notice filed by a plaintiff before service of an answer or motion for summary judgment, or by a joint stipulation of dismissal, is generally without prejudice; except that a dismissal of a “previously dismissed . . . federal- or state-court action based on or including the same claim” has the effect of an adjudication on the merits. Fed. R. Civ. P. 41(a)(1)(A), (B). In this case, however, dismissal of the United States’ claims relating to the other DYS Facilities was accomplished by Court Order. The Parties jointly moved the Court “to enter as its Order” the Stipulation resolving the United States’ claims as to Scioto and Marion, “and, separately, to conditionally dismiss the United States’ complaint” as to the other Facilities. (Doc. 6 at 1). On June 12, 2008, the Court so ordered. (Doc. 7 at 1). Thus, the relevant
8

provision of the Federal Rules is Rule 41(a)(2). Under this Rule, unless the Court’s Order states otherwise, dismissal is without prejudice. The Court’s Order here did not state otherwise.
Moreover, it is difficult to discern the “second” dismissal referenced by Defendants. Defendants suggest that the United States “again dismissed” its Complaint on June 28, 2011. (See Doc. 134 at 3). In fact, this Amended Stipulation had the effect of “terminat[ing] 20 provisions under section III [of the Stipulation],” appointing a new monitor, and modifying the monitoring process. (Doc. 85 at 4). As the original Stipulation that was modified by this amendment concerned only the Scioto Facility, no claims were “again dismissed” at this time with regard to the other facilities, and, even with regard to Scioto, the Amended Stipulation could not dismiss claims based on events which did not occur until 2013.
3. Statute of Limitations Lastly, Defendants’ reliance on the applicable statute of limitations for the claims referenced in the Proposed Supplemental Complaint is unavailing. The Court need not decide whether O.R.C. § 2305.19’s limitations period governs, since the Proposed Supplemental Complaint alleges conduct which occurred since 2013, and is alleged to be ongoing. Moreover, it is axiomatic that when the United States sues in its own right on behalf of the public interest, it is not subject to state statutes of limitations. Occidental Life Ins. Co. of California v. E.E.O.C., 432 U.S. 355, 382 (1977); E.I. DuPont De Nemours & Co. v. Davis, 264 U.S. 456, 462 (1924) (“An action by the United States in its governmental capacity . . . is subject to no time limitation, in the absence of congressional enactment clearly imposing it.”); United States v. City of Columbus, No. 2:99-CV-1097, 2000 WL 1133166, at *10 (S.D. Ohio Aug. 3, 2000).
B. Prejudice to Defendants In assessing prejudice from a motion to supplement or to amend, the Court must assess whether granting the motion would cause undue delay, require the opponent to expend
9

significant additional resources to conduct discovery or prepare for trial, significantly delay final resolution, or prevent the plaintiff from bringing an action in another jurisdiction. Phelps, 30 F.3d at 662-63. Delay alone is not a ground for denying leave. Dana Corp. v. Blue Cross & Blue Shield Mutual, 900 F.2d 882, 883 (6th Cir. 1990). Rather, the opposing party “must demonstrate significant prejudice.” Brown v. Worthington Steel, Inc., 211 F.R.D. 320, 323 (S.D. Ohio 2002) (citing Duggins v. Steak ‘N Shake, Inc., 195 F.3d 828, 834 (6th Cir. 1999); Moore v. City of Paducah, 790 F.2d 557, 562 (6th Cir. 1986)).
In general, the longer the period of unexplained delay, the lesser the burden of demonstrating prejudice. Phelps, 30 F.3d at 662-63. Courts have focused particularly, however, on the phase of litigation during which the motion was filed. Thus, courts have frequently found prejudice where the motion is filed after the discovery deadline has passed, Duggins, 195 F.3d at 843, or where only a month remained before trial, United States v. Midwest Suspension and Brake, 49 F.3d 1197, 1202 (6th Cir. 1995). Nevertheless, “even amendments made on the eve of trial are permissible when there is no demonstrable prejudice.” Brown, 211 F.R.D. at 323 (citing United States v. Wood, 877 F.2d 453, 456–57 (6th Cir.1989)).
Defendants here have failed to demonstrate that they will be prejudiced if the United States is permitted to supplement its Complaint. Although Defendants argue, correctly, that the United States was aware of the use of seclusion at DYS Facilities since the start of this litigation, the Proposed Supplemental Complaint clearly alleges new and more serious violations of the constitutional rights of youth via the excessive use of seclusion and denial of adequate mental health treatment at DYS Facilities. (Doc. 130-1, at 5-7, ¶¶ 18-29).
Defendants also misconstrue the burden that the Supplemental Complaint will place upon the Parties. As explained above, the United States does not argue that the other DYS Facilities,
10

beyond only Scioto, should be governed by the Amended Stipulation or the Consent Decree.

Indeed, the United States concedes that it will bear the burden of proof as all plaintiffs do, and it

“intends to litigate its claims regarding the other Facilities to a final judgment.” (Doc. 136 at 7).

Beyond this burden-shifting argument, Defendants do not explain how they would be

prejudiced by the United States’ Proposed Supplemental Complaint: they cannot point to any

discovery deadlines that have lapsed, or any trial schedule that would be delayed; nor can they

direct the Court to any additional, burdensome discovery they will be compelled to undertake

that is not already a part of the ongoing monitoring process in this case. Instead, Defendants

suggest that the United States ought to file a separate lawsuit to address the alleged ongoing

violations. (Doc. 134 at 6). This is precisely the sort of piecemeal litigation and needless waste

of judicial resources that Rule 15 was designed to avoid. In short, the Court cannot conclude that

granting leave here, well before trial or close of discovery, would be the sort of supplementation

that “would profoundly alter and expand the scope and nature of plaintiffs’ claims” or “result in

significant delay of th[e] litigation.” Marshall v. City of Columbus, No. 2:05-CV-484, 2008 WL

4334616, at *2 (S.D. Ohio Sept. 17, 2008).

IV. CONCLUSION The United States has succeeded in pleading further transactions, occurrences, and events

taking place after the date of the original Complaint, and demonstrating good cause for leave to

supplement under Fed. R. Civ. P. 15(d). Defendants have established no procedural bar,

prejudice, or other reason to show why leave should not be freely given in accordance with the

Rule. Accordingly, the United States’ Motion (Doc. 130) is hereby GRANTED.

IT IS SO ORDERED. DATED: March 28, 2014

/s/ Algenon L. Marbley ALGENON L. MARBLEY UNITED STATES DISTRICT JUDGE

11

 Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 1 of 9 PAGEID #: 3050

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

UNITED STATES OF AMERICA,
Plaintiff,
v.
THE STATE OF OHIO; The Honorable John Kasich The Ohio Department of Youth Services Harvey Reed, Director of Ohio Youth Services Indian River Juvenile Correctional Facility Cuyahoga Hills Juvenile Correctional Facility Circleville Juvenile Correctional Facility Scioto Juvenile Correctional Facility,
Defendants.

)

)

)

)

)

CIVIL ACTION NO:

)

2:08-cv-475

)

)

)

)

)

)

)

)

)

)

)

SUPPLEMENTAL COMPLAINT

THE UNITED STATES OF AMERICA (“Plaintiff”), by its undersigned attorneys,

hereby files this Supplemental Complaint and alleges upon information and belief:

1. The United States files this Supplemental Complaint in the above captioned

matter pursuant to the pattern or practice provision of the Violent Crime Control and Law

Enforcement Act of 1994, 42 U.S.C. § 14141, to enjoin the named Defendants from depriving

youth confined in the Circleville Juvenile Correctional Facility, Cuyahoga Hills Juvenile

Correctional Facility, Indian River Juvenile Correctional Facility, and Scioto Juvenile

Correctional Facility (collectively, the “DYS facilities”) of rights, privileges, or immunities

secured or protected by the Constitution and laws of the United States.

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 2 of 9 PAGEID #: 3051
Jurisdiction, Standing and Venue 2. This Court has jurisdiction over this action pursuant to 28 U.S.C. §§ 1331 and 1345. 3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 14141. 4. Venue in the United States District Court for the Southern District of Ohio is proper pursuant to 28 U.S.C. § 1391.
Defendants 5. Defendant State of Ohio (“State”) is responsible for the administration of juvenile justice in the State and operates, or contracts for the operation of, all juvenile justice facilities in the State. This action concerns the administration of the DYS facilities, which house youth in State custody who are confined for periods of time established by juvenile county courts. 6. Defendant John R. Kasich is the Governor of Ohio and, in this capacity, heads the executive branch of Ohio’s government. The Governor of Ohio, as chief of the executive branch, has the duty to ensure that the departments that compose the executive branch of Ohio government guarantee the federal constitutional and statutory rights of all of the citizens of Ohio, including the youth confined in the DYS facilities. 7. Defendant Ohio Department of Youth Services (“DYS”) establishes the general policy to be followed by its juvenile institutions and contractors; provides leadership in developing programs to rehabilitate youth committed to State custody; and is responsible for the promulgation of all rules and regulations necessary and appropriate to the administration and operation of the DYS facilities.
2

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 3 of 9 PAGEID #: 3052
8. Defendant Harvey J. Reed is Director of the DYS and, in this capacity, exercises administrative control of, and responsibility for, the DYS Facilities.
9. Circleville Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
10. Cuyahoga Hills Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
11. Indian River Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
12. Scioto Juvenile Correctional Facility is a juvenile correctional facility within the State of Ohio, a part of DYS, and under the administrative control of and responsibility of Director Harvey J. Reed.
13. The individual Defendants named in Paragraphs 6 and 8 above are officers or agents of the State of Ohio and are sued in their official capacity only.
Factual Allegations 14. Defendants are legally responsible, in whole or in part, for the operation of the DYS facilities and for the health and safety of the youth confined at the DYS facilities. 15. Defendants are governmental authorities with responsibility for the administration of juvenile justice or the incarceration of juveniles within the meaning of 42 U.S.C. § 14141. 16. Defendants are obligated to operate the DYS facilities in a manner that does not infringe upon the federal rights, as protected by the Fourteenth and Eighth Amendments to the
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 4 of 9 PAGEID #: 3053
Constitution of the United States and by other federal law, of individuals confined at the DYS facilities.
17. At all relevant times, Defendants have acted or failed to act, as alleged herein, under color of state law.
18. On or about November 8, 2013, the lead monitor in United States v. Ohio, 2:08-cv-475, investigated the accumulation of seclusion hours among some youth at the Scioto Juvenile Correctional Facility. She wrote that she found the State had secluded ten youths for over 10 percent of their time in custody during a six-month period in 2013.
19. On or about January 17, 2014, DYS released information showing that youths on the mental health caseload at Cuyahoga Hills Juvenile Correctional Facility, Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility and Scioto Juvenile Correctional Facility had spent approximately 59,865 hours in seclusion from approximately July 2013 through December 2013.
20. On November 21, 2013, DYS announced it would close Scioto Juvenile Correctional Facility and the youths would be gradually reassigned to the remaining facilities. Plaintiff believes that some Scioto youth were transferred to Cuyahoga Hills Juvenile Correctional Facility, Indian River Juvenile Correctional Facility and/or Circleville Juvenile Correctional Facility.
21. On or about January 17, 2014, DYS released information showing that some youth on the mental health caseload at Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility and Scioto Juvenile Correctional Facility had been placed in seclusion for long periods of time, including seclusion of 19 days for one youth and 21 days for another youth.
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 5 of 9 PAGEID #: 3054
22. On or about January 17, 2014, DYS released information showing that one youth on the mental health caseload at Cuyahoga Hills Juvenile Correctional Facility had been placed in pre-hearing seclusion for 4.88 days, in contravention of DYS policy concerning the maximum length of pre-hearing seclusion.
23. On or about January 17, 2014, DYS released information showing that some youth on the mental health caseload at Cuyahoga Hills Juvenile Correctional Facility, Indian River Juvenile Correctional Facility, Circleville Juvenile Correctional Facility and Scioto Juvenile Correctional Facility had been placed in seclusion despite DYS’ observation that the youths had displayed suicidal ideation, self-injurious behavior or were on suicide watch.
24. Numerous national studies have established that seclusion of youth with mental health disorders even for short periods of time can severely harm youth. ACLU, “Alone & Afraid: Children Held in Solitary Confinement and Isolation in Juvenile Detention and Correctional Facilities” (Nov. 2013); American Academy of Child & Adolescent Psychiatry, Policy Statements: Solitary Confinement of Juvenile Offenders” (April 2012); Lindsay Hayes, Office of Juvenile Justice and Delinquency Prevention, Juvenile Suicide in Confinement: A National Survey (2009).
25. On or about January 10, 2014, the lead monitor in United States v. Ohio, 2:08-cv-475, found that Scioto youths who spent long periods of time in seclusion often were not receiving mental health treatment via group during their seclusion time. She found instead that these youths were receiving daily visits by mental health staff during the seclusion period, but these visits were documented as brief checks per protocol, and were not treatment oriented.
26. On or about December 16, 2013, a subject matter expert in S.H. v. Reed, No. 2:04-cv-1206, stated that if a youth with a mental health disorder is placed in seclusion, it is
5

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 6 of 9 PAGEID #: 3055
incumbent on DYS to modify the youth’s integrated treatment plan. If a youth with a mental health disorder is placed in seclusion and DYS does not modify the youth’s integrated treatment plan, seclusion may exacerbate the youth’s behavioral problems. On information and belief, DYS has not so modified youths’ treatment plans.
27. Defendants have engaged, and continue to engage, in a pattern or practice of failing to provide adequate mental health care and rehabilitative treatment to youth at the DYS facilities in the following specific respects, among others:
a. the provision of adequate screening and assessments; b. the provision of adequate treatment planning; and c. the provision of adequate psychological services. 28. Defendants have engaged, and continue to engage, in a pattern or practice of failing to ensure that youth with mental health disorders at the DYS facilities are adequately protected from harm and from undue risk of harm in the following specific respects, among others: a. protection from the unnecessary use of seclusion; and b. protection from the use of seclusion as a barrier or obstacle to receiving adequate mental health care and rehabilitative treatment at the DYS facilities. 29. Defendants have engaged, and continue to engage, in a pattern or practice of subjecting youth with mental health disorders at the DYS facilities to unnecessary periods of seclusion with: a. the specific intent to punish; or b. no reasonable relation to a legitimate governmental objective and instead as a form of punishment.
6

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 7 of 9 PAGEID #: 3056
Violations Alleged 30. The United States incorporates by reference the allegations set forth in Paragraphs 14 through 29 as if fully set forth herein. 31. The acts and omissions alleged in Paragraphs 18 through 29 constitute a pattern or practice of conduct that violates the federal rights, as protected by the Eighth and Fourteenth Amendments to the Constitution of the United States, of youth confined at the DYS Facilities. 32. Unless restrained by this Court, Defendants will continue to engage in the acts and omissions set forth in Paragraphs 18 and 29 that deprive youth confined at the DYS facilities of rights, privileges, or immunities secured or protected by the Constitution of the United States and federal law, and will cause irreparable harm to these youth.
PRAYER FOR RELIEF 33. The Attorney General is authorized, pursuant to 42 U.S.C. § 14141, to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Court enter an order: a. Declaring that the acts, omissions, and practices of Defendants set forth in Paragraphs 18 through 29 above constitute a pattern or practice of conduct that deprives the DYS facilities’ youth of rights, privileges, or immunities secured or protected by the Constitution or laws of the United States, and that those acts, omissions, and practices violate the Constitution and laws of the United States; b. Permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practices set forth in Paragraphs 18 through 29 above, and
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 8 of 9 PAGEID #: 3057

requiring Defendants to take such actions as will ensure that lawful conditions of confinement are afforded to youth at the DYS Facilities; and
c. Granting such other and further equitable relief as the Court may deem just and proper.

DATE: March 31, 2014
CARTER STEWART United States Attorney Southern District of Ohio
/s/ Deborah F. Sanders____________ DEBORAH F. SANDERS (0043575) Assistant United States Attorney Southern District of Ohio 303 Marconi Boulevard, Suite 200 Columbus, Ohio 43215 (614) 469-5715 (T) (614) 469-5653 (F) Deborah.Sanders@usdoj.gov

Respectfully submitted,
JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division United States Department of Justice
JONATHAN M. SMITH Chief Special Litigation Section
BENJAMIN O. TAYLOE, JR. Deputy Chief Special Litigation Section
CYNTHIA COE ALEXANDRA L. SHANDELL Trial Attorneys Special Litigation Section
/s/ Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 616-8547 (T) (202) 514-4883 (F) Silvia.Dominguez-Reese@usdoj.gov
Attorneys for Plaintiff

8

Case: 2:08-cv-00475-ALM-MRA Doc #: 140 Filed: 03/31/14 Page: 9 of 9 PAGEID #: 3058
CERTIFICATE OF SERVICE I HEREBY CERTIFY that this date, March 31, 2014, I caused the foregoing to be electronically filed with the Clerk of the Court using the CM/ECF system, which will simultaneously serve notice of such filing to counsel of record and the Court Monitor to their registered electronic mail addresses.
s/Silvia J. Dominguez-Reese SILVIA J. DOMINGUEZ-REESE Trial Attorney Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW Washington, DC 20530 Telephone: (202) 616-8547 Facsimile: (202) 514-4883 Email: Silvia.Dominguez-Reese@usdoj.gov Attorney for Plaintiff
9

 Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 1 of 34 PAGEID #: 3159
	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

	
  

Monitors’	
  6-­‐Month	
  Report	
  on	
  Compliance	
  with	
  The	
  Grid	
  

	
  

S.H.	
  v	
  Reed	
  	
  (Civil	
  Action	
  No.	
  2:04-­‐cv-­‐1206)	
  

U.S.	
  v	
  State	
  of	
  Ohio	
  (Civil	
  Action	
  No.	
  2:08-­‐cv-­‐475)	
  	
  

	
   	
   	
   	
   Submitted	
  by:	
   	
   Kelly	
  Dedel,	
  Ph.D.,	
  Lead	
  Monitor,	
  U.S.	
  v	
  State	
  of	
  Ohio	
   Will	
  Harrell,	
  J.D.,	
  Lead	
  Monitor,	
  S.H.	
  v	
  Reed	
   Daphne	
  Glindmeyer,	
  M.D.,	
  Subject	
  Matter	
  Expert	
   Andrea	
  Weisman,	
  Ph.D.,	
  Subject	
  Matter	
  Expert	
   	
  

	
  

	
  

Submitted	
  June	
  10,	
  2015	
  

	
  

	
  

1.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 2 of 34 PAGEID #: 3160
	
  
Table	
  of	
  Contents	
   	
  
Introduction	
  and	
  Executive	
  Summary	
.   .........................................................................................................	
 3  	
   Column	
  A:	
  Prevention	
  Strategies	
  .................................................................................................................	
 6  	
  
Overall	
  Performance	
  Measures	
  (A)	
.   ................................................................................................	
 6  	
   Verifying	
  Treatment	
  Integrity	
  (A.1)	
 .  ................................................................................................	
 8  	
   Developing	
  BioPsychoSocial	
  Assessments	
  (A.2)	.
  ...........................................................................	
 1  3	
   Other	
  Information	
.   ........................................................................................................................	
 1  5	
   Compliance	
  Assessment	.
  ...............................................................................................................	
 1  6	
   Column	
  B:	
  Immediate	
  Intervention	
  Strategies	.
  ..........................................................................................	
 1  7	
   Reduce	
  Reliance	
  on	
  Seclusion	
  (B.1)	.
  ..............................................................................................	
 1  7	
   Reduce	
  Duration	
  of	
  Seclusion	
  (B.2)	
.  ..............................................................................................	
 1  7	
   Reduce	
  Harm	
  Associated	
  with	
  Seclusion	
  (B.3)	
 .  .............................................................................	
 1  9	
   Reduce	
  Accumulation	
  of	
  Seclusion	
  (B.4)	
.  ......................................................................................	
 2  0	
   Provide	
  Crisis	
  Intervention	
  while	
  In	
  PHS	
  (B.5)	.
  ..............................................................................	
 2  1	
   Eventually	
  Eliminate	
  the	
  Use	
  of	
  Disciplinary	
  Seclusion	
.   ................................................................	
 2  5	
   Other	
  Information	
.   ........................................................................................................................	
 2  5	
   Compliance	
  Assessment	.
  ...............................................................................................................	
 2  8	
   Column	
  C:	
  Strategies	
  for	
  the	
  Aftermath	.
  ....................................................................................................	
 3  0	
   Treatment	
  Plan	
  Review	
  (C.1)	.
  ........................................................................................................	
 3  0	
   Special	
  Review	
  Team	
  (C.2)	
  ............................................................................................................	
 3  1	
   Other	
  Information	
.   ........................................................................................................................	
 3  3	
  
Compliance	
  Assessment	.
  ...............................................................................................................	
 3  4	
  

	
  

2.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 3 of 34 PAGEID #: 3161
	
  
Introduction	
  and	
  Executive	
  Summary	
  
	
   On	
  May	
  20,	
  2014,	
  the	
  Parties	
  to	
  S.H.	
  v	
  Reed	
  	
  (Civil	
  Action	
  No.	
  2:04-­‐cv-­‐1206)	
  and	
  U.S.	
  v	
  State	
  of	
   Ohio	
  (Civil	
  Action	
  No.	
  2:08-­‐cv-­‐475)	
  filed	
  a	
  joint	
  motion	
  for	
  entry	
  of	
  an	
  agreed	
  order	
  to	
  resolve	
   the	
  issues	
  remaining	
  in	
  both	
  Settlement	
  Agreements.	
  The	
  resulting	
  Court	
  Order	
  required	
  DYS	
  to	
   undertake	
  specific	
  actions,	
  outlined	
  in	
  “The	
  Grid”	
  (Exhibit	
  A	
  to	
  the	
  Order),	
  to	
  improve	
  mental	
   health	
  services	
  and	
  reduce	
  the	
  seclusion	
  of	
  youth	
  who	
  are	
  on	
  the	
  mental	
  health	
  caseload.	
  The	
   Court	
  also	
  consolidated	
  the	
  civil	
  actions	
  for	
  the	
  purpose	
  of	
  case	
  monitoring,	
  though	
  the	
  actions	
   retained	
  their	
  separate	
  status.	
  This	
  report	
  discusses	
  DYS’	
  application	
  of	
  the	
  Grid	
  to	
  its	
  three	
   male	
  facilities:	
  Circleville,	
  Cuyahoga	
  Hills	
  and	
  Indian	
  River.	
  DYS	
  does	
  not	
  operate	
  any	
  facilities	
  for	
   girls—these	
  services	
  are	
  contracted	
  out	
  to	
  private	
  providers.	
  The	
  extent	
  to	
  which	
  DYS	
  girls	
  in	
   these	
  facilities	
  have	
  access	
  to	
  comparable	
  mental	
  health	
  treatment	
  and	
  protection	
  from	
  harmful	
   seclusion	
  practices	
  will	
  be	
  discussed	
  in	
  a	
  separate	
  report.	
  	
   	
   The	
  Grid	
  is	
  the	
  product	
  of	
  a	
  collaborative	
  effort	
  between	
  DYS	
  and	
  the	
  Monitoring	
  Team.	
  It	
   prescribes	
  specific	
  practices	
  designed	
  to	
  improve	
  the	
  quality	
  of	
  mental	
  health	
  services,	
  to	
   reduce	
  the	
  potential	
  for	
  youth	
  violence	
  and	
  to	
  reduce/eliminate	
  the	
  system’s	
  use	
  of	
  seclusion	
  as	
   a	
  response	
  to	
  youth	
  violence.	
  Monitoring	
  responsibilities	
  were	
  divided	
  up	
  according	
  to	
  the	
  Grid,	
   with	
  each	
  column	
  assigned	
  to	
  a	
  member	
  of	
  the	
  Monitoring	
  Team.	
  “Column	
  A,”	
  monitored	
  by	
  Dr.	
   Daphne	
  Glindmeyer,	
  prescribes	
  strategies	
  for	
  improving	
  the	
  quality	
  of	
  mental	
  health	
   assessments,	
  treatment	
  plan	
  formulations	
  and	
  therapeutic	
  interventions.	
  “Column	
  B,”	
   monitored	
  by	
  Dr.	
  Kelly	
  Dedel,	
  prescribes	
  strategies	
  for	
  reducing	
  the	
  use	
  and	
  duration	
  of	
   seclusion	
  as	
  a	
  de-­‐escalation	
  tool	
  and	
  also	
  prescribes	
  strategies	
  for	
  limiting/eliminating	
  the	
   practice	
  of	
  disciplinary	
  confinement.	
  “Column	
  C,”	
  monitored	
  by	
  Dr.	
  Andrea	
  Weisman,	
  prescribes	
   strategies	
  to	
  fortify	
  the	
  therapeutic	
  response	
  to	
  youth	
  who	
  engage	
  in	
  frequent	
  acts	
  of	
  violence.	
  	
   	
   The	
  Grid	
  identifies	
  key	
  performance	
  measures	
  for	
  each	
  column	
  and	
  prescribes	
  an	
  expected	
   performance	
  level	
  for	
  each	
  one.	
  For	
  example,	
  measure	
  A.1	
  requires	
  90%	
  of	
  all	
  cases	
  reviewed	
  to	
   show	
  correspondence	
  between	
  the	
  content	
  of	
  individual	
  treatment	
  sessions	
  and	
  treatment	
   goals.	
  Each	
  month,	
  DYS	
  submits	
  data	
  to	
  assess	
  the	
  level	
  of	
  performance	
  on	
  each	
  measure	
  to	
  the	
   Monitoring	
  Team.	
  Once	
  analyzed,	
  the	
  responsible	
  Team	
  member	
  provided	
  oral	
  or	
  written	
   feedback	
  to	
  DYS,	
  designed	
  to	
  recognize	
  program	
  components	
  that	
  were	
  performing	
  at	
  the	
   expected	
  level	
  and	
  to	
  solve	
  problems	
  related	
  to	
  underperformance	
  when	
  it	
  occurred.	
  	
   	
   Frequent	
  conference	
  calls,	
  email	
  exchanges	
  and	
  two	
  on-­‐site	
  visits,	
  one	
  in	
  October	
  2014	
  and	
   another	
  in	
  March	
  2015,	
  supplemented	
  the	
  information	
  gleaned	
  from	
  these	
  data.	
  This	
  report	
   compiles	
  this	
  information	
  and	
  details	
  DYS’	
  progress	
  on	
  all	
  components	
  of	
  the	
  Grid	
  during	
  the	
   first	
  6-­‐months	
  of	
  the	
  implementation	
  of	
  the	
  new	
  Seclusion	
  Policy,	
  which	
  went	
  into	
  effect	
  on	
  July	
   1,	
  2014.	
  Several	
  of	
  the	
  new	
  mental	
  health	
  procedures	
  were	
  in	
  place	
  before	
  that	
  date,	
  though	
   data	
  were	
  not	
  collected	
  during	
  the	
  early	
  implementation	
  phase.	
  	
   	
   On	
  a	
  monthly	
  basis,	
  the	
  Monitors	
  identified	
  whether	
  the	
  performance	
  measures	
  were	
  met	
  at	
   the	
  level	
  required	
  by	
  the	
  grid	
  (i.e.,	
  in	
  most	
  cases,	
  90%).	
  To	
  date,	
  overall	
  compliance	
  has	
  not	
  been	
   assessed	
  as	
  the	
  Court	
  Order	
  requires	
  “monitoring	
  [to]	
  continue	
  until	
  Defendants	
  have	
   maintained	
  substantial	
  compliance	
  with	
  all	
  provisions	
  and	
  performance	
  measures	
  for	
  six	
   months.”	
  This	
  report	
  compiles	
  performance	
  data	
  for	
  the	
  first	
  six-­‐month	
  period	
  so	
  that	
  overall	
   compliance	
  can	
  be	
  assessed.	
  	
  

	
  

3.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 4 of 34 PAGEID #: 3162
	
  
	
   	
   	
  
Column	
  A	
  Summary:	
  Prevention	
  Strategies	
  
• During	
  the	
  6-­‐month	
  monitoring	
  period,	
  each	
  facility	
  increased	
  the	
  proportion	
  of	
  youth	
   on	
  the	
  mental	
  health	
  caseload	
  (MHCL)	
  who	
  were	
  not	
  involved	
  in	
  acts	
  of	
  violence	
  (AOV)	
   from	
  a	
  baseline	
  (55%	
  to	
  64%).	
  	
  
• During	
  the	
  6-­‐month	
  monitoring	
  period,	
  small	
  proportions	
  of	
  youth	
  on	
  the	
  MHCL	
  (6%)	
   were	
  involved	
  in	
  frequent	
  AOVs.	
  The	
  majority	
  of	
  youth	
  who	
  initially	
  met	
  the	
  3+	
  AOV	
   threshold	
  went	
  on	
  to	
  curb	
  their	
  aggressive	
  behavior	
  in	
  the	
  subsequent	
  months.	
  This	
   indicates	
  that	
  the	
  mental	
  health	
  interventions—and	
  other	
  enhancements	
  to	
  the	
  facility	
   programs—had	
  a	
  positive	
  effect	
  on	
  DYS	
  youth.	
  	
  
• Quality	
  assurance	
  tools	
  have	
  been	
  developed	
  and	
  implemented	
  to	
  monitor	
  the	
  quality	
   of	
  DYS	
  mental	
  health	
  services.	
  	
  
• System	
  wide,	
  DYS	
  achieved	
  the	
  90%	
  benchmark	
  related	
  to	
  the	
  correspondence	
  between	
   individual	
  treatment	
  goals	
  and	
  the	
  content	
  of	
  individual	
  therapy	
  sessions.	
  
• System	
  wide,	
  DYS	
  easily	
  exceeded	
  the	
  required	
  performance	
  level	
  related	
  to	
  the	
   integrity	
  of	
  group	
  treatment.	
  Of	
  the	
  group	
  sessions	
  audited,	
  98%	
  scored	
  80%	
  or	
  better	
   on	
  the	
  quality	
  assurance	
  tool.	
  	
  
• System	
  wide,	
  DYS	
  achieved	
  the	
  90%	
  benchmark	
  related	
  to	
  ensuring	
  that	
  initial	
   assessments	
  contained	
  a	
  high-­‐quality	
  clinical/diagnostic	
  formulation.	
  
• System	
  wide,	
  DYS	
  exceeded	
  the	
  required	
  performance	
  level	
  regarding	
  treatment	
  plans	
   reflecting	
  the	
  clinical/diagnostic	
  formulation.	
  Of	
  the	
  cases	
  audited,	
  94%	
  met	
  the	
   requirements	
  of	
  the	
  quality	
  assurance	
  tool.	
  	
  
• In	
  Dr.	
  Glindmeyer’s	
  opinion,	
  DYS	
  is	
  in	
  substantial	
  compliance	
  with	
  the	
  requirements	
  of	
   Column	
  A	
  of	
  the	
  Grid.	
  	
  
	
  
	
  
Column	
  B	
  Summary:	
  Immediate	
  Intervention	
  Strategies	
  
• DYS	
  policy	
  prohibited	
  the	
  use	
  of	
  disciplinary	
  seclusion	
  as	
  a	
  response	
  to	
  youth	
   misconduct	
  on	
  January	
  1,	
  2015,	
  although	
  two	
  of	
  the	
  three	
  facilities	
  ceased	
  the	
  practice	
   several	
  months	
  before	
  the	
  official	
  policy	
  change.	
  As	
  a	
  result,	
  some	
  of	
  the	
  requirements	
   of	
  the	
  Grid	
  no	
  longer	
  applied	
  and	
  were	
  not	
  monitored	
  throughout	
  the	
  six-­‐month	
  period.	
  
• DYS	
  drastically	
  reformed	
  its	
  use	
  of	
  prehearing	
  seclusion	
  (PHS),	
  removing	
  predetermined	
   lengths	
  of	
  stay	
  ranging	
  between	
  24	
  and	
  72	
  hours	
  and	
  replacing	
  them	
  with	
  assessments	
   related	
  to	
  the	
  youth’s	
  current	
  behavior	
  and	
  his	
  willingness	
  to	
  process	
  the	
  events	
  with	
   staff.	
  As	
  a	
  result,	
  the	
  large	
  majority	
  (80%)	
  of	
  PHS	
  episodes	
  concluded	
  within	
  4	
  hours,	
   with	
  the	
  remaining	
  concluding	
  within	
  8-­‐12	
  hours.	
  Longer	
  lengths	
  of	
  stay	
  were	
  typically	
   the	
  result	
  of	
  the	
  timing	
  of	
  the	
  incident—those	
  occurring	
  in	
  the	
  late	
  evening	
  generally	
   result	
  in	
  an	
  overnight	
  stay	
  on	
  PHS.	
  Occasionally,	
  youth	
  refused	
  to	
  process	
  the	
  event,	
  but	
   were	
  revisited	
  by	
  staff	
  within	
  2-­‐3	
  hours.	
  Over	
  the	
  past	
  six	
  months,	
  of	
  the	
  over	
  700	
   episodes	
  of	
  PHS,	
  none	
  lasted	
  beyond	
  24	
  hours.	
  	
  
• While	
  the	
  quality	
  of	
  the	
  processing	
  of	
  events	
  between	
  youth	
  and	
  staff	
  was	
  slower	
  to	
   develop	
  into	
  a	
  substantive	
  conversation,	
  by	
  the	
  end	
  of	
  the	
  monitoring	
  period,	
   approximately	
  80%	
  of	
  the	
  Safe	
  to	
  Release	
  interviews	
  were	
  sufficient	
  to	
  inform	
  the	
   therapeutic	
  conversation	
  between	
  youth	
  and	
  behavioral	
  health	
  staff	
  that	
  occurred	
  

	
  

4.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 5 of 34 PAGEID #: 3163
	
  

within	
  a	
  few	
  days	
  of	
  the	
  incident.	
  Data	
  from	
  March	
  (not	
  presented	
  in	
  this	
  report)	
   revealed	
  that	
  all	
  three	
  facilities	
  exceeded	
  the	
  required	
  90%	
  performance	
  level.	
  	
   • As	
  a	
  result	
  of	
  these	
  changes,	
  the	
  accumulation	
  of	
  seclusion	
  hours	
  by	
  individual	
  youth	
   who	
  engage	
  in	
  high-­‐frequency	
  AOVs	
  is	
  nowhere	
  near	
  the	
  levels	
  that	
  originally	
  created	
   concern	
  (for	
  background,	
  see	
  Dr.	
  Dedel’s	
  report	
  on	
  seclusion	
  practices	
  at	
  Scioto	
  JCF,	
   November	
  2013).	
  Rather	
  than	
  the	
  hundreds	
  of	
  hours	
  of	
  seclusion	
  that	
  some	
  youth	
   accumulated	
  before	
  the	
  Grid	
  went	
  into	
  effect,	
  since	
  the	
  Grid’s	
  implementation,	
  even	
   youth	
  with	
  high-­‐frequency	
  AOVs	
  accumulated	
  only	
  20-­‐30	
  hours	
  of	
  seclusion	
  each	
   month.	
   • DYS	
  has	
  developed	
  and	
  implemented	
  a	
  comprehensive	
  Quality	
  Assurance	
  process	
  that	
   attends	
  to	
  the	
  duration	
  of	
  seclusion,	
  its	
  accumulation,	
  and	
  the	
  integrity	
  and	
  timeliness	
   of	
  the	
  Safe-­‐to-­‐Release	
  process.	
  This	
  process	
  is	
  a	
  suitable	
  replacement	
  for	
  external	
   oversight	
  from	
  the	
  Monitor.	
  	
  	
   • In	
  Dr.	
  Dedel’s	
  opinion,	
  DYS	
  is	
  in	
  substantial	
  compliance	
  with	
  the	
  requirements	
  of	
  Column	
   B	
  of	
  the	
  Grid.	
   	
   	
  
Column	
  C	
  Summary:	
  Strategies	
  for	
  the	
  Aftermath	
  
• System	
  wide,	
  treatment	
  plans	
  were	
  reviewed	
  within	
  2	
  days	
  of	
  the	
  AOV	
  in	
  77%	
  of	
  the	
   cases	
  reviewed.	
  Delays	
  occurred	
  because	
  of	
  weekend	
  coverage	
  and	
  the	
  availability	
  of	
   clinicians	
  involved	
  with	
  the	
  youth.	
  The	
  small	
  number	
  of	
  cases	
  reviewed	
  skews	
  the	
   understanding	
  of	
  what	
  is	
  truly	
  occurring	
  at	
  the	
  facilities.	
  Furthermore,	
  compliance	
  rates	
   improved	
  significantly	
  in	
  recent	
  months.	
  
• System	
  wide,	
  the	
  treatment	
  plans	
  were	
  fortified	
  or	
  revised	
  in	
  84%	
  of	
  the	
  cases	
   reviewed.	
  Six-­‐month	
  averages	
  at	
  the	
  individual	
  facilities	
  were	
  93%	
  at	
  Circleville,	
  84%	
  at	
   Cuyahoga	
  Hills	
  and	
  76%	
  at	
  Indian	
  River.	
  Small	
  sample	
  sizes	
  and	
  database	
  issues	
   obscured	
  the	
  significant	
  gains	
  DYS	
  has	
  made.	
  	
  
• System	
  wide,	
  a	
  Special	
  Review	
  Team	
  (SRT)	
  was	
  convened	
  within	
  2	
  days	
  of	
  a	
  youth’s	
   meeting	
  the	
  AOV	
  threshold	
  (3+	
  high	
  severity	
  or	
  2+	
  severe	
  offenses)	
  in	
  87%	
  of	
  the	
  cases	
   reviewed.	
  Six-­‐month	
  averages	
  at	
  the	
  individual	
  facilities	
  were	
  95%	
  at	
  Cuyahoga	
  Hills,	
   84%	
  at	
  Circleville,	
  and	
  83%	
  at	
  Indian	
  River.	
  In	
  all	
  instances,	
  the	
  SRT	
  was	
  held	
  within	
  4	
   days.	
  Delays	
  occurred	
  in	
  order	
  to	
  permit	
  the	
  youth’s	
  treating	
  clinician	
  to	
  participate	
  in	
   the	
  meeting.	
  	
  
• System	
  wide,	
  the	
  SRT	
  explored	
  and	
  provided	
  interventions	
  relevant	
  to	
  the	
  causes	
  and	
   functions	
  of	
  the	
  youth’s	
  behavior	
  in	
  only	
  72%	
  of	
  the	
  cases	
  reviewed.	
  Six-­‐month	
  averages	
   for	
  the	
  individual	
  facilities	
  are	
  93%	
  at	
  Indian	
  River,	
  82%	
  at	
  Cuyahoga	
  Hills	
  and	
  41%	
  at	
   Circleville.	
  However,	
  there	
  is	
  ample	
  evidence	
  that	
  the	
  interventions	
  provided	
  did	
  curb	
   instances	
  of	
  youth	
  aggression.	
  	
  
• In	
  Dr.	
  Weisman’s	
  opinion,	
  DYS	
  is	
  in	
  substantial	
  compliance	
  with	
  the	
  requirements	
  of	
   Column	
  C	
  of	
  the	
  Grid.	
  	
  
	
   	
  

	
  

	
  

	
  

	
  

5.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 6 of 34 PAGEID #: 3164
	
  

	
   Column	
  A.	
  Prevention	
  Strategies	
  (Assigned	
  Monitor:	
  Dr.	
  Daphne	
  Glindmeyer)	
  

What	
  the	
   Grid	
   Requires	
  

(A)	
  Overall	
  Performance	
  Measure	
  	
   • Increase	
  proportion	
  of	
  youth	
  who	
  do	
  not	
  engage	
  in	
  AOV	
   • Decrease	
  number	
  and	
  proportion	
  of	
  MHCL	
  youth	
  who	
  engage	
  in	
  3+	
  AOVs	
   each	
  month	
  by	
  10%	
  each	
  month.	
  	
  

Monitor’s	
   Assessment	
  

While	
  originally	
  attached	
  to	
  “Column	
  A,”	
  it	
  turned	
  out	
  that	
  the	
  data	
  required	
  to	
   assess	
  these	
  outcomes	
  were	
  submitted	
  to	
  the	
  Monitor	
  for	
  “Column	
  B,”	
  so	
   responsibility	
  for	
  monitoring	
  them	
  was	
  shifted	
  to	
  Dr.	
  Dedel,	
  who	
  authored	
  this	
   section,	
  “Overall	
  Performance	
  Measures.”	
  	
   	
   The	
  table	
  below	
  shows	
  the	
  proportion	
  of	
  youth	
  on	
  the	
  MHCL	
  who	
  did	
  not	
   engaged	
  in	
  acts	
  of	
  violence	
  (AOV)	
  each	
  month,	
  by	
  facility	
  and	
  system-­‐wide.	
  The	
   Grid	
  requires	
  an	
  increase	
  from	
  a	
  baseline	
  (i.e.,	
  average	
  Jan-­‐June,	
  2014).	
  As	
  shown,	
   while	
  the	
  month-­‐to-­‐month	
  increases	
  were	
  not	
  always	
  steady,	
  each	
  facility’s	
  6-­‐ month	
  average	
  reveals	
  an	
  increase	
  over	
  the	
  baseline.	
  Circleville	
  and	
  Cuyahoga	
   Hills	
  both	
  increased	
  the	
  proportion	
  of	
  youth	
  on	
  the	
  MHCL	
  without	
  an	
  AOV	
  by	
  5%,	
   while	
  Indian	
  River’s	
  proportion	
  increased	
  18%.	
  Overall,	
  roughly	
  two-­‐thirds	
  of	
  DYS	
   youth	
  on	
  the	
  MHCL	
  did	
  not	
  engage	
  in	
  acts	
  of	
  violence	
  each	
  month.	
  Prior	
  to	
  the	
   Grid’s	
  implementation,	
  only	
  about	
  half	
  remained	
  AOV-­‐free	
  each	
  month.	
  	
   	
  

Proportion	
  of	
  youth	
  on	
  the	
  MHCL	
  with	
  no	
  AOV	
  

	
  

Baseline	
   Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

54%	
   69%	
   58%	
   45%	
   67%	
   59%	
   58%	
   59%	
  

Cuyahoga	
  Hills	
  

61%	
   71%	
   75%	
   63%	
   64%	
   59%	
   62%	
   66%	
  

Indian	
  River	
  

50%	
   59%	
   72%	
   61%	
   80%	
   68%	
   68%	
   68%	
  

DYS	
  AVERAGE	
  

55%	
   66%	
   68%	
   56%	
   70%	
   62%	
   63%	
   64%	
  

	
  	
   The	
  Grid	
  also	
  required	
  decreases	
  in	
  the	
  proportion	
  of	
  youth	
  on	
  the	
  MHCL	
  who	
   engaged	
  in	
  frequent	
  acts	
  of	
  violence	
  each	
  month	
  (i.e.,	
  3+	
  AOVs).	
  A	
  baseline	
  was	
   not	
  calculated	
  due	
  to	
  the	
  significant	
  workload	
  involved	
  in	
  compiling	
  historical	
   data.	
  The	
  table	
  below	
  shows	
  each	
  facility’s	
  performance	
  level	
  over	
  the	
  6-­‐month	
   period.	
  Once	
  again,	
  the	
  decreases	
  were	
  not	
  always	
  steady,	
  but	
  overall,	
  the	
   proportion	
  of	
  youth	
  with	
  high-­‐frequency	
  AOVs	
  was	
  smaller	
  toward	
  the	
  end	
  of	
  the	
   monitoring	
  period	
  as	
  compared	
  to	
  the	
  beginning	
  (Sept-­‐Nov	
  average	
  =	
  7.0%;	
  Dec-­‐ Feb	
  average	
  =	
  5.3%).	
  This	
  pattern	
  holds	
  for	
  both	
  Circleville	
  (Sept-­‐Nov	
  average	
   11.6%	
  versus	
  Dec-­‐Feb	
  average	
  6.6%)	
  and	
  Cuyahoga	
  Hills	
  (Sept-­‐Nov	
  average	
  6.0%	
   versus	
  Dec-­‐Feb	
  average	
  4.6%),	
  though	
  not	
  for	
  Indian	
  River	
  (average	
  3.3%	
  versus	
   4.0%)	
  due	
  to	
  the	
  low	
  number	
  of	
  youth	
  with	
  frequent	
  AOVs	
  throughout	
  the	
   monitoring	
  period.	
  	
   	
   	
   	
   	
   	
  

	
  

6.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 7 of 34 PAGEID #: 3165
	
  

Proportion	
  of	
  youth	
  on	
  the	
  MHCL	
  with	
  3+	
  AOV	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

10%	
   10%	
   15%	
   3%	
   9%	
   8%	
   9%	
  

Cuyahoga	
  Hills	
  

3%	
   5%	
   10%	
   3%	
   6%	
   5%	
   5%	
  

Indian	
  River	
  

8%	
   0%	
   2%	
   2%	
   5%	
   5%	
   4%	
  

DYS	
  AVERAGE	
  

7%	
   5%	
   9%	
   3%	
   7%	
   6%	
   6%	
  

	
   While	
  the	
  changes	
  did	
  not	
  conform	
  to	
  the	
  rigid	
  mathematical	
  formula	
  originally	
   proposed,	
  in	
  both	
  cases,	
  the	
  data	
  suggest	
  that	
  fewer	
  MHCL	
  youth	
  engaged	
  in	
   AOVs	
  and	
  fewer	
  engaged	
  in	
  high-­‐frequency	
  AOVs	
  than	
  before	
  the	
  Grid	
  was	
   implemented.	
  By	
  way	
  of	
  context,	
  note	
  that	
  the	
  MHCLs	
  were	
  generally	
  between	
   60-­‐70	
  youth	
  in	
  each	
  facility	
  each	
  month,	
  so	
  in	
  most	
  months,	
  fewer	
  than	
  5	
  youth	
  at	
   each	
  facility	
  were	
  engaging	
  in	
  high-­‐frequency	
  AOVs.	
  	
   	
   As	
  the	
  monitoring	
  period	
  progressed,	
  the	
  Monitor	
  became	
  aware	
  that	
  the	
  rigid	
   mathematical	
  formula	
  prescribed	
  by	
  the	
  grid	
  may	
  not	
  be	
  as	
  useful	
  as	
  we	
  originally	
   hoped,	
  due	
  mostly	
  to	
  the	
  small	
  numbers	
  of	
  youth	
  with	
  high-­‐frequency	
  AOVs.	
  The	
   low	
  base	
  rate	
  makes	
  continual	
  reductions	
  very	
  difficult	
  to	
  achieve.	
  The	
  Monitor,	
   DYS	
  and	
  Plaintiffs	
  agreed	
  that	
  a	
  more	
  useful	
  metric	
  would	
  be	
  the	
  extent	
  to	
  which	
   the	
  same	
  youth	
  were	
  involved	
  in	
  high-­‐frequency	
  AOVs	
  over	
  and	
  over	
  again,	
  as	
   this	
  would	
  be	
  a	
  better	
  indicator	
  of	
  the	
  effectiveness	
  of	
  mental	
  health	
   interventions	
  (see	
  “Column	
  C”).	
  	
   	
   An	
  analysis	
  of	
  all	
  the	
  youth	
  who	
  met	
  the	
  3+	
  AOV	
  threshold	
  across	
  the	
  6-­‐month	
   period	
  revealed	
  that	
  the	
  large	
  majority	
  of	
  DYS	
  youth	
  who	
  initially	
  met	
  the	
   threshold	
  went	
  on	
  to	
  curb	
  their	
  aggressive	
  behavior	
  in	
  short	
  order.	
  Collectively,	
   49	
  youth	
  met	
  the	
  3+	
  AOV	
  threshold	
  at	
  least	
  once	
  during	
  the	
  monitoring	
  period,	
   and	
  only	
  12	
  youth	
  (24%)	
  met	
  the	
  threshold	
  multiple	
  times.	
  This	
  suggests	
  that	
  the	
   Special	
  Review	
  Team	
  (SRT;	
  see	
  “Column	
  C”)	
  and	
  the	
  many	
  other	
  program	
   improvements	
  that	
  are	
  part	
  of	
  DYS’	
  Path	
  to	
  Safer	
  Facilities	
  have	
  been	
  effective	
  in	
   reducing	
  youth	
  violence.	
  Some	
  of	
  the	
  youth	
  continued	
  to	
  engage	
  in	
  aggressive	
   behavior,	
  but	
  at	
  a	
  reduced	
  frequency.	
  Individual	
  facility	
  data	
  is	
  presented	
  below:	
  
• At	
  Circleville,	
  a	
  total	
  of	
  20	
  youth	
  met	
  the	
  3+	
  AOV	
  threshold	
  during	
  the	
  6-­‐ month	
  period.	
  Of	
  these,	
  only	
  7	
  youth	
  (35%)	
  met	
  the	
  threshold	
  in	
  multiple	
   months.	
  Among	
  the	
  7	
  youth,	
  three	
  met	
  the	
  threshold	
  3	
  or	
  more	
  times,	
   while	
  the	
  other	
  4	
  met	
  the	
  threshold	
  only	
  2	
  times.	
  	
  
• At	
  Cuyahoga	
  Hills,	
  a	
  total	
  of	
  18	
  youth	
  met	
  the	
  3+	
  AOV	
  threshold	
  during	
   the	
  6-­‐month	
  period.	
  Of	
  these,	
  only	
  4	
  youth	
  (22%)	
  met	
  the	
  threshold	
  in	
   multiple	
  months.	
  All	
  of	
  these	
  youth	
  met	
  the	
  threshold	
  only	
  2	
  times.	
  	
  
• At	
  Indian	
  River,	
  a	
  total	
  of	
  11	
  youth	
  met	
  the	
  3+	
  AOV	
  threshold	
  during	
  the	
   6-­‐month.	
  Of	
  these,	
  only	
  1	
  youth	
  (10%)	
  met	
  the	
  threshold	
  in	
  multiple	
   months	
  (3	
  months).	
  	
  
	
   In	
  summary,	
  aggregate	
  data	
  and	
  individual	
  analyses	
  suggest	
  that	
  the	
  proportion	
   of	
  MHCL	
  youth	
  who	
  engage	
  in	
  any	
  aggressive	
  behavior	
  has	
  decreased	
  throughout	
   the	
  monitoring	
  period,	
  as	
  has	
  the	
  proportion	
  of	
  youth	
  who	
  engage	
  in	
  high	
  

	
  

7.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 8 of 34 PAGEID #: 3166
	
  

	
  
What	
  the	
   Grid	
   Requires	
  

frequency	
  aggressive	
  behavior.	
  The	
  interventions	
  applied	
  to	
  those	
  with	
  high-­‐ frequency	
  AOVs	
  appear	
  to	
  be	
  effective,	
  given	
  that	
  very	
  only	
  about	
  one-­‐quarter	
  of	
   these	
  youth	
  continue	
  their	
  high-­‐frequency	
  AOVs	
  in	
  subsequent	
  months.	
  	
  
(A.1)	
  Verify	
  Treatment	
  Integrity	
   • Quality	
  Assurance	
  tools	
  and	
  audits	
  that	
  ensure	
  individual	
  treatment	
  is	
   aligned	
  with	
  treatment	
  goals.	
   • Quality	
  Assurance	
  tools	
  and	
  audits	
  that	
  ensure	
  group	
  treatment	
  displays	
   fidelity	
  to	
  design.	
  	
  
(A.1)	
  Performance	
  Measures	
   • 90%	
  of	
  all	
  cases	
  reviewed	
  showed	
  correspondence	
  between	
  content	
  of	
   individual	
  sessions	
  and	
  treatment	
  goals.	
   • 90%	
  of	
  all	
  groups	
  included	
  in	
  the	
  sample	
  scored	
  80%	
  or	
  better	
  on	
  a	
   measure	
  of	
  treatment	
  fidelity.	
  	
  

Monitor’s	
   Assessment	
  

Quality	
  assurance	
  tools	
  have	
  been	
  developed	
  and	
  monthly	
  audits	
  of	
  both	
  group	
   therapy	
  treatment	
  and	
  documentation	
  indicating	
  treatment	
  is	
  aligned	
  with	
   treatment	
  goals	
  have	
  occurred	
  as	
  required	
  by	
  the	
  Grid.	
  DYS	
  provided	
  copies	
  of	
  all	
   documents	
  used	
  to	
  conduct	
  the	
  QA	
  reviews	
  each	
  month.	
  Dr.	
  Glindmeyer	
   reviewed	
  approximately	
  10-­‐15%	
  of	
  these	
  documents	
  in	
  order	
  to	
  validate	
  the	
   conclusions	
  of	
  the	
  QA	
  reviewers.	
  In	
  general,	
  Dr.	
  Glindmeyer’s	
  assessment	
  of	
   adequacy	
  matched	
  the	
  QA	
  reviewer’s	
  assessment.	
  	
   	
   A.1(a)	
   	
   In	
  order	
  to	
  determine	
  the	
  integration,	
  a	
  Behavioral	
  Health	
  Supervisor	
  must	
  review	
   an	
  integrated	
  treatment	
  plan	
  (ITP)	
  and	
  corresponding	
  case	
  notes	
  for	
  two	
  youth	
   on	
  each	
  clinician’s	
  caseload	
  every	
  month.	
  	
  The	
  following	
  information	
  is	
  reviewed:	
  
• General	
  Elements	
   o Did	
  the	
  clinician	
  meet	
  with	
  the	
  youth	
  face	
  to	
  face	
  within	
  7	
  days	
  of	
   arrival	
   o The	
  ITP	
  identifies	
  the	
  youth’s	
  presenting	
  issues	
   o The	
  ITP	
  is	
  approved	
  within	
  30	
  days	
  of	
  the	
  youth’s	
  arrival	
  to	
  the	
   facility	
  
• ITP	
  Goal	
  Key	
  Elements	
   o Are	
  all	
  goals	
  individualized	
   o Are	
  all	
  goals	
  written	
  in	
  strength	
  based	
  language	
   o Are	
  all	
  goals	
  related	
  to	
  documented	
  presenting	
  issues	
   o Are	
  the	
  youth’s	
  criminogenic	
  needs	
  addressed	
  
• ITP	
  Objective	
  Key	
  Elements	
   o Is	
  there	
  at	
  least	
  one	
  objective	
  for	
  each	
  goal	
   o All	
  objectives	
  include	
  duration	
   o All	
  objectives	
  include	
  frequency	
   o All	
  objectives	
  are	
  written	
  in	
  concrete,	
  specific	
  behavioral	
  terms	
   o The	
  objectives	
  are	
  written	
  in	
  a	
  language	
  that	
  the	
  youth	
   understands	
   o Each	
  objective	
  identifies	
  the	
  IDT	
  member	
  responsible	
  for	
  the	
  

	
  

8.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 9 of 34 PAGEID #: 3167
	
  
service	
  delivery	
   o If	
  the	
  youth	
  has	
  been	
  active	
  in	
  Security	
  Threat	
  Group	
  (STG)	
  
activity,	
  an	
  objective	
  has	
  been	
  developed	
  to	
  address	
  this	
  behavior	
   • Individual	
  Session	
  Key	
  Elements	
  
o Do	
  the	
  notes	
  reflect	
  that	
  the	
  clinician	
  addressed	
  the	
  youth’s	
  ITP	
   goals	
  and	
  or	
  objectives	
  during	
  90%	
  of	
  the	
  individual	
  sessions	
  
o Are	
  individual	
  session	
  notes	
  in	
  a	
  Subjective,	
  Objective,	
   Assessment,	
  Plan	
  (SOAP)	
  format	
  
o Does	
  each	
  section	
  of	
  the	
  SOAP	
  note	
  contain	
  appropriate	
  content	
   • Group	
  Key	
  Elements	
  
o Are	
  group	
  notes	
  in	
  SOAP	
  format	
   o Does	
  each	
  section	
  of	
  the	
  SOAP	
  note	
  contain	
  appropriate	
  content	
   o Are	
  groups	
  attended	
  by	
  the	
  youth	
  specific	
  to	
  the	
  youth’s	
  needs	
  as	
  
outlined	
  in	
  the	
  ITP	
   • Case	
  notes	
  Key	
  Elements	
  
o Do	
  all	
  individual	
  session	
  notes	
  contain	
  the	
  clinician’s	
  name	
  and	
   credentials	
  
o Do	
  all	
  group	
  notes	
  contain	
  the	
  clinician’s	
  name	
  and	
  credentials	
   o Was	
  session	
  length	
  documented	
  in	
  90%	
  of	
  the	
  case	
  notes	
   o Was	
  the	
  treatment	
  dosage	
  documented	
  in	
  90%	
  of	
  the	
  case	
  notes	
   o Were	
  90%	
  of	
  the	
  notes	
  entered	
  the	
  same	
  day	
   • Sex	
  Offender	
  Programming	
   o Was	
  a	
  JSOAP	
  completed	
  within	
  30	
  calendar	
  days	
  of	
  arrival	
  to	
  the	
  
parent	
  facility	
   o If	
  the	
  youth	
  was	
  adjudicated	
  on	
  a	
  sex	
  offense,	
  is	
  it	
  documented	
  in	
  
the	
  Court	
  Request	
  section	
  of	
  the	
  ITP	
   o If	
  the	
  youth	
  was	
  adjudicated	
  on	
  a	
  sex	
  offense,	
  is	
  there	
  a	
  goal	
  and	
  
objectives	
  that	
  address	
  Sex	
  Offender	
  Programming	
   o Within	
  45	
  calendar	
  days	
  of	
  arrival	
  to	
  the	
  parent	
  facility,	
  the	
  youth	
  
started	
  sex	
  offender	
  programming	
   o Was	
  a	
  6	
  month	
  sex	
  offender	
  reassessment	
  completed	
   o Was	
  a	
  comparison	
  of	
  the	
  Scale	
  3	
  outcomes	
  documented	
  in	
  the	
  
narrative	
   • Monthly	
  Interdisciplinary	
  Treatment	
  Team	
  (IDT)	
  Summary	
  Process	
  
o A	
  current	
  IDT	
  summary	
  is	
  present	
   o Does	
  the	
  current	
  IDT	
  summary	
  include:	
  
§ The	
  current	
  group	
  enrollment	
   § The	
  number	
  of	
  individual	
  sessions	
  attended	
  and	
  not	
  
attended	
   § An	
  explanation	
  for	
  unattended	
  individual	
  sessions	
   § Therapeutic	
  work	
  being	
  processed	
  in	
  individual	
  sessions	
   § The	
  number	
  of	
  groups	
  attended	
  and	
  not	
  attended	
   § An	
  explanation	
  for	
  unattended	
  groups	
   § The	
  level	
  of	
  youth’s	
  participation	
  in	
  group	
   § The	
  youth’s	
  integration	
  of	
  skills	
  acquired	
   § Progress	
  or	
  lack	
  thereof	
  toward	
  ITP	
  goals	
  and	
  objectives	
   § Stages	
  of	
  Change	
  as	
  it	
  relates	
  to	
  ITP	
  goals	
  and	
  objectives	
  

	
  

9.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 10 of 34 PAGEID #: 3168
	
  

§ New	
  programming	
  recommendations	
   § Family	
  engagement/contact	
   § Medication	
  changes	
   § Changes	
  to	
  mental	
  health	
  status/updates	
   § Education	
  progress	
   § Employment	
  progress	
   § Based	
  on	
  the	
  Planned	
  Expiration	
  Date	
  (PED),	
  is	
  the	
  youth	
  
on	
  track	
  to	
  complete	
  dosage	
  hours	
  
	
  
The	
  following	
  is	
  a	
  summary	
  of	
  quality	
  assurance	
  audit	
  data	
  from	
  the	
  six-­‐month	
  
monitoring	
  period.	
  The	
  Grid	
  required	
  90%	
  of	
  all	
  cases	
  reviewed	
  to	
  show	
  
correspondence	
  between	
  the	
  content	
  of	
  individual	
  therapy	
  and	
  treatment	
  goals.	
  
	
  

Correspondence	
  between	
  Content	
  of	
  Therapy	
  and	
  Individual	
  Treatment	
  Goals	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

90%	
   69%	
   81%	
   94%	
   85%	
   68%	
   81%	
  

Cuyahoga	
  Hills	
  

84%	
   91%	
   89%	
   88%	
   100%	
   100%	
   92%	
  

Indian	
  River	
  

96%	
   100%	
   100%	
   100%	
   93%	
   100%	
   98%	
  

DYS	
  AVERAGE	
  

90%	
   87%	
   90%	
   94%	
   93%	
   89%	
   90%	
  

Sample	
  Size:	
  Circleville	
  n=112;	
  Cuyahoga	
  Hills	
  n=113;	
  Indian	
  River	
  n=168	
  

	
   While	
  individual	
  facilities	
  occasionally	
  fell	
  below	
  the	
  required	
  performance	
  level,	
   overall	
  DYS	
  achieved	
  the	
  90%	
  benchmark.	
  When	
  the	
  QA	
  review	
  indicated	
  that	
  the	
   facility	
  did	
  not	
  meet	
  expectations,	
  DYS	
  took	
  appropriate	
  action,	
  as	
  described	
   below.	
  	
   	
   Following	
  each	
  of	
  the	
  QA	
  sections	
  outlined	
  above,	
  the	
  Behavioral	
  Health	
   Supervisor	
  is	
  given	
  the	
  option	
  to	
  recommend	
  a	
  Performance	
  Improvement	
  Plan	
   (PIP)	
  for	
  the	
  clinician	
  under	
  review.	
  	
  As	
  noted	
  in	
  the	
  outline	
  above,	
  the	
  quality	
   assurance	
  measures	
  for	
  this	
  performance	
  measure	
  are	
  detailed.	
  	
  A	
  review	
  of	
  the	
   quality	
  assurance	
  results	
  for	
  each	
  of	
  the	
  three	
  facilities	
  revealed	
  that	
  two	
   facilities,	
  CHJCF	
  and	
  IRJCF	
  have	
  had	
  a	
  general	
  increase	
  in	
  compliance	
  percentages,	
   with	
  each	
  scoring	
  100%	
  in	
  the	
  February	
  review.	
  	
  CJCF	
  has	
  experienced	
  some	
   challenges,	
  with	
  a	
  drop	
  in	
  scores	
  from	
  85%	
  in	
  January	
  to	
  68%	
  in	
  February.	
  	
  It	
   should	
  be	
  noted	
  that	
  the	
  decrease	
  in	
  scores	
  at	
  CJCF	
  in	
  the	
  month	
  of	
  February	
  was	
   due	
  to	
  some	
  clinicians	
  experiencing	
  difficulties.	
  	
  	
  	
   	
   There	
  were	
  a	
  total	
  of	
  three	
  staff	
  on	
  performance	
  improvement	
  plans	
  (PIP)	
  at	
  CJCF	
   in	
  the	
  month	
  of	
  February.	
  	
  One	
  of	
  these	
  staff	
  had	
  been	
  placed	
  on	
  a	
  PIP	
  in	
   November	
  2014.	
  	
  As	
  of	
  February,	
  this	
  staff	
  was	
  continuing	
  to	
  experience	
  difficulty,	
   as	
  it	
  was	
  noted	
  that	
  only	
  half	
  of	
  the	
  youth	
  assigned	
  to	
  this	
  staff’s	
  caseload	
  had	
   been	
  seen	
  for	
  individual	
  sessions	
  during	
  the	
  month.	
  	
  Two	
  additional	
  staff	
  were	
   placed	
  on	
  PIP	
  in	
  the	
  month	
  of	
  February	
  2015.	
  	
  Both	
  of	
  these	
  staff	
  were	
  noted	
  to	
   have	
  deficiencies	
  with	
  regard	
  to	
  meeting	
  with	
  youth	
  for	
  individual	
  sessions	
  on	
  a	
   regularly	
  scheduled	
  basis.	
  	
  The	
  PIP	
  noted	
  that	
  these	
  individual’s	
  would	
  be	
   reviewed	
  on	
  a	
  monthly	
  basis.	
  	
  Given	
  the	
  deficiencies	
  and	
  how	
  this	
  has	
  negatively	
  

	
  

10.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 11 of 34 PAGEID #: 3169
	
  
affected	
  the	
  outcome	
  of	
  the	
  data,	
  and	
  more	
  importantly,	
  the	
  potential	
  for	
   negative	
  outcomes	
  for	
  the	
  youth	
  in	
  their	
  care,	
  more	
  frequent	
  (i.e.	
  weekly)	
   reviews	
  are	
  recommended	
  during	
  the	
  period	
  of	
  time	
  these	
  treatment	
  providers	
   are	
  on	
  PIP.	
   	
   Overall	
  marked	
  improvement	
  in	
  both	
  treatment	
  planning	
  and	
  documentation	
  of	
   treatment	
  provided	
  were	
  noted.	
  	
  In	
  general,	
  goals	
  were	
  individualized,	
  were	
   related	
  to	
  presenting	
  issues,	
  and	
  included	
  objectives	
  that	
  were	
  measurable	
  and	
   time	
  limited.	
  	
  When	
  reviewing	
  associated	
  individual	
  treatment	
  progress	
  notes,	
   there	
  was	
  greater	
  attention	
  to	
  documenting	
  the	
  youth’s	
  progress	
  toward	
   treatment	
  goals.	
  	
  There	
  was	
  an	
  overall	
  need	
  for	
  improvement	
  with	
  regard	
  to	
   documentation	
  of	
  reviewing	
  skills	
  that	
  either	
  the	
  youth	
  had	
  learned	
  and	
  was	
   implementing	
  or	
  that	
  the	
  youth	
  needed	
  to	
  improve.	
  	
  It	
  should	
  be	
  noted	
  that	
  this	
   is	
  a	
  very	
  difficult	
  concept	
  for	
  clinicians	
  to	
  integrate	
  into	
  their	
  documentation.	
  	
  	
   	
   Although	
  it	
  was	
  not	
  always	
  found	
  in	
  the	
  record,	
  site	
  visits	
  and	
  interviews	
  with	
  the	
   youth	
  indicated	
  that	
  clearly,	
  youth	
  were	
  learning	
  skills.	
  	
  Youth	
  were	
  noted	
  to	
  be	
   able	
  to	
  state	
  their	
  treatment	
  goals	
  and	
  to	
  verbalize	
  skills	
  that	
  they	
  had	
  learned	
   and	
  how	
  they	
  were	
  using	
  these	
  skills.	
  	
   	
   Given	
  the	
  overall	
  improvement	
  with	
  regard	
  to	
  the	
  correlation	
  between	
  ITP	
  goals	
   and	
  treatment	
  provided,	
  this	
  portion	
  of	
  provision	
  A.1.	
  is	
  in	
  substantial	
   compliance.	
  	
  It	
  is	
  understood	
  that	
  some	
  quality	
  assurance	
  scores	
  were	
  below	
  the	
   level	
  needed	
  for	
  compliance;	
  however,	
  what	
  is	
  most	
  important	
  is	
  that	
  the	
  quality	
   assurance	
  process	
  is	
  in	
  place	
  at	
  the	
  facility,	
  that	
  ODYS	
  was	
  able	
  to	
  identify	
  these	
   deficiencies,	
  and	
  that	
  staff	
  were	
  working	
  to	
  improve	
  the	
  overall	
  provision	
  of	
   mental	
  health	
  care.	
   	
   A.1(b)	
   	
   Quality	
  assurance	
  monitoring	
  for	
  group	
  therapy	
  includes	
  a	
  review	
  of	
  elements	
  of	
   group	
  structure,	
  content,	
  and	
  fidelity	
  to	
  a	
  treatment	
  manual	
  (if	
  applicable).	
  	
  This	
   is	
  accomplished	
  by	
  having	
  the	
  quality	
  assurance	
  reviewer	
  attend	
  group	
  and	
  score	
   the	
  following	
  items:	
   	
  
• Did	
  the	
  group	
  begin	
  on	
  time	
   • Did	
  the	
  group	
  last	
  an	
  appropriate	
  length	
  of	
  time	
   • Were	
  the	
  facilitators	
  prepared	
  for	
  group	
   • Was	
  the	
  group	
  set	
  up	
  in	
  a	
  circle	
  or	
  a	
  U	
   • Did	
  the	
  facilitators	
  review	
  the	
  group	
  rules	
  at	
  the	
  beginning	
  of	
  group	
   • Did	
  the	
  facilitators	
  review	
  the	
  objectives	
  at	
  the	
  beginning	
  of	
  group	
   • Did	
  the	
  facilitators	
  collect	
  homework	
   • Did	
  all	
  youth	
  role	
  play	
  or	
  practice	
  the	
  skill	
  being	
  taught	
   • Did	
  the	
  facilitators	
  use	
  reflective	
  listening	
   • Did	
  the	
  facilitators	
  use	
  open	
  ended	
  questions	
   • Did	
  the	
  facilitators	
  make	
  the	
  material	
  relevant	
  and	
  interesting	
  to	
  the	
  
youth	
  

	
  

11.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 12 of 34 PAGEID #: 3170
	
  

• Did	
  the	
  facilitators	
  connect	
  the	
  group	
  discussion	
  to	
  the	
  objectives	
  at	
  the	
   end	
  of	
  group	
  
• Did	
  the	
  facilitators	
  encourage	
  all	
  youth	
  to	
  participate	
   • Did	
  the	
  facilitators	
  hold	
  all	
  youth	
  accountable	
  for	
  group	
  expectations	
  
throughout	
  the	
  meeting	
   • Did	
  the	
  facilitators	
  manage	
  the	
  group	
  effectively	
   • Did	
  the	
  facilitators	
  manage	
  inappropriate	
  youth	
  so	
  that	
  they	
  did	
  not	
  
disrupt	
  the	
  group	
  process	
   	
   The	
  following	
  is	
  a	
  summary	
  of	
  quality	
  assurance	
  audit	
  data	
  from	
  the	
  six-­‐month	
   monitoring	
  period.	
  The	
  Grid	
  requires	
  90%	
  of	
  all	
  groups	
  included	
  in	
  the	
  sample	
  to	
   score	
  80%	
  or	
  better	
  on	
  a	
  measure	
  of	
  treatment	
  fidelity	
  (i.e.,	
  the	
  QA	
  tool).	
  	
   	
  

Treatment	
  Fidelity	
  for	
  Groups	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

100%	
   89%	
   100%	
   100%	
   100%	
   100%	
   98%	
  

Cuyahoga	
  Hills	
  

100%	
   100%	
   100%	
   100%	
   100%	
   100%	
   100%	
  

Indian	
  River	
  

91%	
   100%	
   88%	
   100%	
   100%	
   100%	
   97%	
  

DYS	
  AVERAGE	
  

97%	
   96%	
   96%	
   100%	
   100%	
   100%	
   98%	
  

Sample	
  Size:	
  Circleville	
  n=43;	
  Cuyahoga	
  Hills	
  n=33;	
  Indian	
  River	
  n=48	
  

	
   	
   When	
  reviewing	
  the	
  tabulated	
  results	
  from	
  group	
  therapy	
  quality	
  assurance,	
  it	
  is	
   notable	
  that	
  for	
  the	
  last	
  three	
  months,	
  all	
  facilities	
  scored	
  100%	
  on	
  quality	
   assurance	
  measures.	
  	
  	
   	
   Over	
  this	
  monitoring	
  period,	
  two	
  onsite	
  visits	
  were	
  performed	
  at	
  each	
  of	
  the	
   three	
  facilities.	
  Group	
  therapy	
  interactions	
  were	
  observed	
  during	
  the	
  visits.	
  	
   Overall,	
  marked	
  improvements	
  in	
  group	
  therapy	
  were	
  noted.	
  For	
  example,	
  in	
   previous	
  monitoring	
  visits	
  there	
  were	
  occasions	
  where	
  groups	
  were	
  disorganized,	
   had	
  no	
  clear	
  goals/objectives,	
  and	
  disruptive	
  youth	
  were	
  allowed	
  to	
  interrupt	
  the	
   group	
  process.	
  	
  	
   	
   In	
  the	
  last	
  two	
  visits	
  (September	
  2014	
  and	
  March	
  2015),	
  youth	
  were	
  observed	
  to	
   be	
  engaged	
  in	
  the	
  group	
  therapy	
  process	
  and	
  were	
  able	
  to	
  discuss	
  cognitive	
   behavioral	
  therapy	
  techniques	
  they	
  had	
  learned	
  as	
  well	
  as	
  how	
  to	
  implement	
   these	
  techniques.	
  It	
  was	
  noted	
  that	
  groups	
  were	
  more	
  interesting	
  for	
  the	
  youth	
   and	
  held	
  their	
  attention	
  given	
  the	
  use	
  of	
  “real	
  world”	
  examples	
  that	
  the	
  youth	
   could	
  relate	
  to.	
  In	
  particular,	
  “Men’s	
  Group”	
  observed	
  at	
  CHJCF	
  during	
  the	
  March	
   2015	
  monitoring	
  visit,	
  was	
  an	
  example	
  of	
  marked	
  improvement	
  in	
  group	
  therapy	
   programming.	
  Youth	
  were	
  engaged	
  in	
  the	
  process,	
  discussing	
  role-­‐plays,	
  and	
   facilitators	
  used	
  the	
  youth’s	
  discussions	
  as	
  examples	
  of	
  cognitive	
  behavioral	
  skills.	
   	
   Given	
  the	
  results	
  of	
  quality	
  assurance	
  monitoring	
  coupled	
  with	
  group	
  therapy	
   observations	
  performed	
  during	
  the	
  last	
  two	
  monitoring	
  visits,	
  this	
  portion	
  of	
  A.1.	
   of	
  the	
  Grid	
  is	
  in	
  substantial	
  compliance.	
  

	
  

12.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 13 of 34 PAGEID #: 3171
	
  

What	
  the	
   Grid	
   Requires	
  

(A.2)	
  Develop	
  BioPsychoSocial	
  Assessment	
  that	
  includes	
  Clinical	
  and	
  Diagnostic	
   Formulation	
  
• Initial	
  BioPsychoSocial	
  Assessment	
  includes	
  a	
  broad	
  range	
  of	
   informational	
  sources	
  and	
  culminates	
  in	
  a	
  clinical	
  formulation	
  and	
   diagnostic	
  formulation,	
  which	
  is	
  reflected	
  in	
  the	
  youth’s	
  treatment	
  plan.	
  	
  
• Quality	
  Assurance	
  Tools	
  will	
  be	
  developed.	
  	
   (A.2)	
  Performance	
  Measures	
  
• 90%	
  of	
  initial	
  assessments	
  include	
  a	
  solid	
  clinical/diagnostic	
  formulation.	
   • 90%	
  of	
  treatment	
  plans	
  reflect	
  information	
  from	
  the	
  formulation.	
  	
  

Monitor’s	
   Assessment	
  

Quality	
  assurance	
  tools	
  have	
  been	
  developed	
  and	
  monthly	
  audits	
  of	
  both	
  the	
   BioPsychoSocial	
  assessment	
  and	
  the	
  resultant	
  treatment	
  plan	
  are	
  occurring,	
  as	
   required	
  by	
  the	
  Grid.	
  DYS	
  provided	
  copies	
  of	
  all	
  documents	
  used	
  to	
  conduct	
  the	
   QA	
  reviews	
  each	
  month.	
  Dr.	
  Glindmeyer	
  reviewed	
  approximately	
  10-­‐15%	
  of	
  these	
   documents	
  in	
  order	
  to	
  validate	
  the	
  conclusions	
  of	
  the	
  QA	
  reviewers.	
  In	
  general,	
   Dr.	
  Glindmeyer’s	
  assessment	
  of	
  adequacy	
  matched	
  the	
  QA	
  reviewer’s	
   assessment.	
  	
   	
   A.2(a)	
   	
   In	
  order	
  to	
  determine	
  compliance	
  with	
  standards	
  for	
  the	
  BioPsychoSocial	
   assessment,	
  the	
  QA	
  auditor	
  reviews	
  charts	
  to	
  score	
  the	
  following	
  metrics:	
   	
  
• Did	
  the	
  clinician	
  complete	
  the	
  Mental	
  Status	
  Examination	
  Sections	
   o Each	
  area	
  of	
  the	
  mental	
  status	
  examination	
  is	
  then	
  separately	
   scored	
  
• Summary	
  and	
  Recommendations	
   o Did	
  the	
  clinician	
  describe	
  how	
  the	
  person	
  came	
  to	
  the	
  particular	
   problems	
   o Did	
  the	
  clinician	
  identify	
  influences	
  involved	
   o Did	
  the	
  clinician	
  identify	
  the	
  youth’s	
  strengths	
   o Did	
  the	
  clinician	
  identify	
  how	
  the	
  youth	
  has	
  coped	
  thus	
  far	
   o Did	
  the	
  case	
  formulation	
  describe	
  the	
  relationship	
  between	
  the	
   various	
  factors	
  and	
  the	
  problems	
  that	
  are	
  present	
   o Did	
  the	
  clinician	
  recommend	
  interventions	
  and	
  behavior	
   management	
  techniques	
  that	
  will	
  address	
  the	
  youth’s	
  needs	
   o Did	
  the	
  clinician	
  identify	
  PREA	
  needs	
   o Did	
  the	
  clinician	
  recommend	
  treatment	
  and	
  programming	
   recommendations	
  that	
  address	
  the	
  youth’s	
  needs	
  
	
   The	
  following	
  chart	
  summarizes	
  the	
  quality	
  assurance	
  data	
  from	
  the	
  six-­‐month	
   monitoring	
  period.	
  The	
  Grid	
  requires	
  90%	
  of	
  initial	
  assessments	
  to	
  include	
  a	
  solid	
   clinical/	
  diagnostic	
  formulation.	
   	
   	
   	
   	
   	
  

	
  

13.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 14 of 34 PAGEID #: 3172
	
  

	
  

Initial	
  Assessment	
  includes	
  a	
  Quality	
  Clinical/Diagnostic	
  Formulation	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

100%	
   100%	
   88%	
   100%	
   100%	
   100%	
   98%	
  

Cuyahoga	
  Hills	
  

33%	
   67%	
   100%	
   67%	
   100%	
   100%	
   78%	
  

Indian	
  River	
  

80%	
   100%	
   80%	
   100%	
   100%	
   100%	
   93%	
  

DYS	
  AVERAGE	
  

71%	
   89%	
   89%	
   89%	
   100%	
   100%	
   90%	
  

Sample	
  Size:	
  Circleville	
  n=26;	
  Cuyahoga	
  Hills	
  n=47;	
  Indian	
  River	
  n=23	
  

	
   	
   As	
  noted	
  in	
  the	
  table	
  above,	
  there	
  have	
  been	
  improvements	
  in	
  the	
  mental	
  health	
   assessments	
  performed	
  at	
  all	
  facilities.	
  	
  For	
  the	
  last	
  two	
  months,	
  all	
  initial	
   assessments	
  reviewed	
  via	
  quality	
  assurance	
  at	
  all	
  three	
  facilities	
  have	
  scored	
   100%.	
  	
  	
   	
   In	
  an	
  effort	
  to	
  achieve	
  compliance	
  with	
  this	
  provision,	
  and	
  to	
  improve	
  behavioral	
   health	
  services	
  overall,	
  ODYS	
  changed	
  the	
  format	
  of	
  the	
  initial	
  mental	
  health	
   appraisal,	
  putting	
  focus	
  on	
  the	
  review	
  of	
  symptoms	
  indicating	
  a	
  mental	
  health	
   disorder	
  and	
  on	
  the	
  development	
  of	
  the	
  case	
  formulation.	
  These	
  changes	
  were	
   evident	
  in	
  the	
  most	
  recent	
  monitoring	
  visit	
  in	
  March	
  2015.	
  Assessments	
  were	
   noted	
  to	
  be	
  thorough,	
  with	
  cogent	
  case	
  formulations	
  that	
  could	
  be	
  used	
  in	
  order	
   to	
  author	
  a	
  relevant	
  ITP.	
   	
   Currently,	
  the	
  mental	
  health	
  appraisal	
  includes	
  information	
  regarding	
  the	
  youth’s	
   developmental	
  history,	
  family	
  history,	
  trauma	
  history,	
  childhood	
  conduct,	
   educational	
  history,	
  work	
  history,	
  relationship	
  history,	
  legal	
  history,	
  medical	
   history,	
  alcohol	
  and	
  substance	
  use	
  history,	
  mental	
  health	
  treatment	
  history,	
   suicidal/self-­‐injurious	
  behavior	
  history,	
  current	
  offense,	
  mental	
  status	
   examination,	
  a	
  review	
  of	
  symptoms	
  for	
  various	
  mental	
  health	
  disorders	
   (depression,	
  mania,	
  anxiety,	
  panic,	
  post-­‐traumatic	
  stress,	
  risk	
  to	
  self	
  or	
  others),	
   psychological	
  assessment/screening	
  results,	
  diagnoses,	
  case	
  conceptualization,	
   and	
  recommendations.	
  	
  	
   	
   Given	
  the	
  comprehensive	
  nature	
  of	
  these	
  assessments,	
  a	
  much	
  better	
  “picture”	
   of	
  the	
  youth’s	
  mental	
  health	
  functioning	
  is	
  elucidated.	
  	
  Review	
  of	
  completed	
   mental	
  health	
  appraisals	
  revealed	
  vast	
  improvements	
  over	
  the	
  course	
  of	
  the	
   monitoring	
  period.	
  	
  As	
  such,	
  this	
  portion	
  of	
  A.2.	
  is	
  in	
  substantial	
  compliance.	
   	
   A.2(b)	
   Review	
  of	
  the	
  Individualized	
  Treatment	
  Plan	
  (ITP)	
  is	
  completed	
  via	
  the	
  quality	
   assurance	
  monitoring	
  outlined	
  in	
  provision	
  A.1.	
  	
  That	
  data	
  is	
  then	
  utilized	
  in	
   determining	
  compliance	
  for	
  this	
  provision.	
  	
  Given	
  the	
  improvement	
  in	
  the	
  quality	
   of	
  the	
  mental	
  health	
  appraisal,	
  behavioral	
  health	
  staff	
  have	
  the	
  opportunity	
  to	
   author	
  goals	
  and	
  objectives	
  that	
  are	
  meaningful	
  and	
  address	
  the	
  specific	
  skills	
   that	
  youth	
  need	
  to	
  acquire.	
  	
  	
   	
  

	
  

14.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 15 of 34 PAGEID #: 3173
	
  

The	
  Grid	
  requires	
  90%	
  of	
  ITPs	
  to	
  reflect	
  information	
  from	
  the	
  clinical/diagnostic	
   formulation.	
  Quality	
  assurance	
  data	
  for	
  the	
  six-­‐month	
  monitoring	
  period	
  is	
   presented	
  below.	
  	
   	
  

Treatment	
  Plans	
  Reflect	
  Information	
  from	
  Diagnostic	
  Formulation	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

80%	
   100%	
   88%	
   78%	
   100%	
   82%	
   88%	
  

Cuyahoga	
  Hills	
  

100%	
   82%	
   100%	
   100%	
   100%	
   100%	
   97%	
  

Indian	
  River	
  

100%	
   100%	
   100%	
   97%	
   94%	
   94%	
   98%	
  

DYS	
  AVERAGE	
  

93%	
   94%	
   96%	
   92%	
   98%	
   92%	
   94%	
  

Sample	
  Size:	
  Circleville	
  n=213;	
  Cuyahoga	
  Hills	
  n=117;	
  Indian	
  River	
  n=163	
  

	
   	
   Review	
  of	
  ITP	
  documents	
  revealed	
  marked	
  improvements	
  with	
  regard	
  to	
  specific	
   goals	
  and	
  objectives	
  developed	
  for	
  individual	
  youth.	
  	
  Overall,	
  DYS	
  met	
  this	
   performance	
  measure	
  in	
  94%	
  of	
  the	
  cases	
  reviewed.	
  Although	
  there	
  are	
  some	
   specific	
  staff	
  that	
  need	
  to	
  improve	
  in	
  this	
  area,	
  what	
  is	
  important	
  is	
  that	
  ODYS	
  has	
   developed	
  a	
  quality	
  assurance	
  process,	
  that	
  they	
  are	
  able	
  to	
  identify	
  issues	
  with	
   regard	
  to	
  mental	
  health	
  services,	
  and	
  address	
  those	
  issues	
  via	
  supervision	
  and	
   training	
  of	
  staff.	
  	
  As	
  such,	
  this	
  portion	
  of	
  A.2.	
  is	
  in	
  substantial	
  compliance.	
  

Other	
  

The	
  Monitors	
  regularly	
  interacted	
  with	
  DYS	
  administrators	
  and	
  facility	
  staff	
  via	
  bi-­‐

Information	
   weekly	
  conference	
  calls	
  and	
  frequent	
  email	
  exchanges.	
  The	
  Monitoring	
  Team	
  also	
  

participated	
  in	
  two	
  one-­‐day	
  site	
  visits	
  to	
  each	
  facility,	
  one	
  in	
  October	
  2014	
  and	
  

one	
  in	
  March	
  2015.	
  Contextual	
  information	
  and	
  findings	
  from	
  site	
  visits	
  are	
  

discussed	
  here.	
  	
  

Monitor’s	
   Assessment	
  

Following	
  the	
  initial	
  monitoring	
  visit	
  in	
  October	
  2014,	
  recommendations	
  included	
   the	
  need	
  for	
  improved	
  justification	
  of	
  diagnoses	
  via	
  the	
  case	
  formulation,	
   improvements	
  in	
  ITP	
  goals	
  and	
  objectives,	
  and	
  improvements	
  in	
  group	
  therapies.	
  	
   At	
  that	
  time,	
  it	
  was	
  noted	
  that	
  two	
  of	
  the	
  three	
  facilities	
  were	
  on	
  track	
  and	
   improving	
  as	
  expected.	
  	
  There	
  was	
  a	
  need	
  for	
  behavioral	
  health	
  leadership	
  at	
   CJCF,	
  which	
  impeded	
  this	
  facility’s	
  progress.	
   	
   Following	
  the	
  first	
  monitoring	
  visit	
  of	
  this	
  reporting	
  period,	
  ODYS	
  and	
  the	
   monitors	
  agreed	
  to	
  participate	
  in	
  conference	
  calls	
  to	
  include	
  behavioral	
  health	
   staff.	
  	
  The	
  purpose	
  of	
  the	
  calls	
  was	
  to	
  review	
  challenging	
  cases	
  and	
  to	
  discuss	
   both	
  mental	
  health	
  appraisals	
  and	
  ITP	
  goals/objectives.	
  	
  These	
  conference	
  calls	
   have	
  been	
  helpful	
  both	
  to	
  the	
  monitors	
  and	
  to	
  the	
  behavioral	
  health	
  staff.	
   	
   In	
  the	
  intervening	
  period	
  between	
  the	
  two	
  monitoring	
  visits,	
  ODYS	
  behavioral	
   health	
  administration	
  focused	
  on	
  both	
  the	
  quality	
  of	
  behavioral	
  health	
  treatment	
   and	
  documentation.	
  	
  This	
  focus	
  was	
  evident	
  given	
  the	
  overall	
  improvements	
   noted	
  during	
  the	
  second	
  monitoring	
  visit	
  in	
  March	
  2015.	
  	
  At	
  that	
  time,	
  groups	
   were	
  improved	
  and	
  were	
  noted	
  to	
  reinforce	
  CBT	
  skills	
  that	
  youth	
  had	
  learned	
  via	
   other	
  group	
  interactions	
  or	
  via	
  individual	
  therapies.	
  	
  The	
  mental	
  health	
  appraisal	
   format	
  change	
  had	
  been	
  implemented,	
  resulting	
  in	
  higher	
  quality	
  assessments	
  

	
  

15.	
  

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with	
  case	
  formulations	
  that	
  aided	
  in	
  the	
  development	
  of	
  ITP	
  goals	
  and	
  objectives.	
  	
   Although	
  there	
  were	
  areas	
  that	
  remained	
  in	
  need	
  of	
  improvement,	
  for	
  example,	
   the	
  documentation	
  of	
  skill	
  acquisition	
  and	
  implementation,	
  it	
  was	
  apparent	
  that	
   ODYS	
  was	
  committed	
  to	
  ongoing	
  quality	
  assurance	
  monitoring	
  and	
  staff	
   development	
  in	
  the	
  pursuit	
  of	
  improved	
  behavioral	
  health	
  services.	
  

Compliance	
   The	
  Court	
  Order	
  requires	
  DYS	
  to	
  meet	
  the	
  each	
  of	
  the	
  performance	
  measures	
  at	
   Assessment	
   the	
  required	
  level	
  each	
  month	
  for	
  six	
  months.	
  	
  

Monitor’s	
   Assessment	
  

As	
  discussed	
  in	
  the	
  individual	
  paragraph	
  subparts	
  above,	
  DYS	
  has	
  demonstrated	
   overall	
  improvements	
  in	
  behavioral	
  health	
  services.	
  	
  While	
  there	
  are	
  some	
  areas	
   that	
  have	
  not	
  met	
  the	
  cut	
  off	
  for	
  quality	
  assurance	
  monitoring,	
  this	
  does	
  not	
   mean	
  that	
  DYS	
  is	
  in	
  noncompliance.	
  	
  	
   	
   It	
  is	
  notable	
  that	
  DYS	
  has	
  developed	
  a	
  quality	
  assurance	
  monitoring	
  program,	
  has	
   the	
  ability	
  to	
  identify	
  weaknesses	
  and	
  deficiencies,	
  and	
  has	
  taken	
  steps	
  to	
  address	
   these	
  issues	
  through	
  staff	
  development	
  or	
  alterations	
  in	
  documentation	
   requirements	
  or	
  mental	
  health	
  programming.	
  	
  In	
  the	
  presence	
  of	
  these	
  system	
   changes,	
  it	
  is	
  apparent	
  that	
  current	
  administrative	
  behavioral	
  health	
  staff	
  have	
   both	
  the	
  desire	
  and	
  ability	
  to	
  continue	
  to	
  self	
  monitor	
  and	
  ensure	
  services	
   consistent	
  with	
  this	
  Court	
  Order.	
  

	
  

	
  

	
  

	
  

	
  

16.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 17 of 34 PAGEID #: 3175
	
  

	
   Column	
  B.	
  Immediate	
  Intervention	
  Strategies	
  (Assigned	
  Monitor:	
  Dr.	
  Kelly	
  Dedel)	
  

What	
  the	
   Grid	
   Requires	
  

(B.1)	
  Reduce	
  Reliance	
  on	
  Seclusion	
   • No	
  Intervention	
  Seclusion	
  (IS)	
  for	
  high	
  severity	
  offenses	
  (e.g.,	
  fight,	
   consensual	
  sexual	
  activity),	
  unless	
  the	
  victim	
  requires	
  off-­‐grounds	
   emergency	
  medical	
  treatment,	
  and	
  then	
  up	
  to	
  24	
  hours	
  can	
  be	
  imposed.	
  	
   • Interdisciplinary	
  Team	
  (IDT)	
  determines	
  sanction.	
  	
   • Policy	
  to	
  be	
  implemented	
  by	
  September	
  1,	
  2015.	
  
(B.1)	
  Performance	
  Measures	
   • Proportion	
  of	
  youth	
  who	
  commit	
  High	
  Severity	
  infractions	
  who	
  were	
   given	
  IS	
  (should	
  be	
  0%,	
  unless	
  victim	
  required	
  off	
  grounds	
  medical	
   treatment).	
  	
  	
  

Monitor’s	
   Assessment	
  

The	
  first	
  section	
  of	
  “Column	
  B”	
  seeks	
  to	
  reduce	
  the	
  use	
  of	
  seclusion,	
  limiting	
  its	
   use	
  to	
  “severe”	
  rule	
  violations.	
  DYS	
  SOP	
  301.01.02,	
  “Youth	
  Intervention	
   Sanctions,”	
  signed	
  into	
  effect	
  September	
  1,	
  2014,	
  eliminated	
  the	
  use	
  of	
   Intervention	
  Seclusion	
  (IS)	
  for	
  high	
  severity	
  violations,	
  unless	
  one	
  of	
  the	
   participants	
  required	
  emergency	
  medical	
  treatment	
  (in	
  which	
  case	
  24	
  hours	
  could	
   be	
  imposed).	
  High-­‐severity	
  violations	
  includes	
  fights	
  and	
  consensual	
  sexual	
   activity,	
  which	
  are	
  violations	
  that	
  used	
  to	
  carry	
  IS	
  time,	
  depending	
  on	
  the	
   previous	
  number	
  of	
  infractions.	
  	
   	
   The	
  new	
  policy	
  required	
  the	
  Interdisciplinary	
  Team	
  (IDT)	
  to	
  determine	
  the	
  youth’s	
   sanction,	
  which	
  could	
  include	
  privilege,	
  commissary	
  or	
  activity	
  restrictions	
  or	
   restorative	
  and	
  learning	
  activities.	
  Between	
  September	
  and	
  December	
  2014,	
  none	
   of	
  the	
  facilities	
  imposed	
  IS	
  for	
  any	
  high-­‐severity	
  rule	
  violation.	
  Starting	
  January	
  1,	
   2015,	
  DYS	
  prohibited	
  the	
  use	
  of	
  Intervention	
  Seclusion	
  for	
  a	
  rule	
  violation	
  of	
  any	
   severity.	
  SOP	
  301.01.02	
  was	
  revised	
  again	
  on	
  January	
  1,	
  2015	
  and	
  all	
  references	
   to	
  Intervention	
  Seclusion	
  were	
  removed.	
  In	
  summary,	
  DYS	
  met	
  the	
  performance	
   measure	
  at	
  the	
  required	
  level	
  for	
  the	
  entire	
  6-­‐month	
  monitoring	
  period.	
  	
  

What	
  the	
   Grid	
   Requires	
  

(B.2)	
  Reduce	
  Duration	
  of	
  Seclusion	
  	
  
• Safe	
  to	
  Release:	
  DYS	
  will	
  decrease	
  the	
  minimum	
  length	
  of	
  stay	
  (LOS)	
  for	
   youth	
  engaged	
  in	
  AOVs	
  to	
  two	
  to	
  four	
  hours,	
  not	
  to	
  exceed	
  24	
  hours.	
  	
   o The	
  Safe	
  to	
  Release	
  (STR)	
  process	
  will	
  be	
  initiated	
  within	
  2	
  and	
  4	
   hours	
  and	
  if	
  the	
  youth	
  refuses	
  to	
  engage	
  or	
  the	
  suitability	
  of	
  the	
   climate	
  indicates	
  safety	
  concerns,	
  staff	
  will	
  attempt	
  to	
  engage	
  the	
   youth	
  every	
  2	
  to	
  3	
  hours	
  thereafter,	
  up	
  to	
  the	
  24	
  hour	
  period.	
  	
   o If	
  the	
  24-­‐hour	
  period	
  is	
  reached	
  and	
  the	
  youth	
  continues	
  to	
   refuse	
  or	
  the	
  suitability	
  of	
  the	
  climate	
  indicates	
  safety	
  concerns,	
   the	
  Superintendent	
  must	
  approve	
  any	
  further	
  seclusion.	
  	
  
• Intervention	
  Time	
  for	
  Severe	
  AOV:	
  decrease	
  IS	
  imposed	
  for	
  Severe	
  AOVs	
   (e.g.,	
  assault,	
  sexual	
  exposure/assault);	
  imposed	
  by	
  hearing	
  officer;	
  not	
   consecutive	
  to	
  PHS.	
   o 1st	
  gets	
  credit	
  for	
  time	
  served;	
  2nd	
  gets	
  up	
  to	
  4	
  hours;	
  3rd	
  gets	
  up	
   to	
  8	
  hours;	
  4th	
  gets	
  up	
  to	
  12	
  hours;	
  5th	
  +	
  gets	
  up	
  to	
  24	
  hours.	
  	
   o The	
  number	
  of	
  previous	
  severe	
  rule	
  violations	
  is	
  considered	
  zero	
   if	
  a	
  youth	
  goes	
  30	
  days	
  without	
  a	
  severe	
  rule	
  violation,	
  unless	
  the	
  

	
  

17.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 18 of 34 PAGEID #: 3176
	
  

Superintendent	
  decides	
  otherwise.	
  	
   o IS	
  is	
  served	
  on	
  Saturday	
  and	
  Sunday.	
  DYS	
  shall	
  not	
  substitute	
  
physical	
  restraints	
  for	
  seclusion	
  time.	
  	
   (B.2)	
  Performance	
  Measures	
  
• Proportion	
  of	
  youth	
  released	
  at	
  4	
  hours	
  or	
  less	
   • 100%	
  of	
  youth	
  were	
  sanctioned	
  according	
  to	
  the	
  IS	
  graduated	
  scheme	
   • 0%	
  of	
  youth	
  spent	
  more	
  than	
  72	
  hours	
  in	
  seclusion	
  in	
  a	
  rolling	
  30-­‐day	
  
period	
  (except	
  in	
  rare	
  circumstances	
  with	
  approval)	
  

Monitor’s	
   Assessment	
  

The	
  next	
  section	
  of	
  the	
  Grid	
  focuses	
  on	
  reducing	
  the	
  duration	
  of	
  seclusion—both	
   Pre-­‐Hearing	
  Seclusion	
  (PHS)	
  and	
  Intervention	
  Seclusion	
  (IS).	
  	
   	
   Pre-­‐Hearing	
  Seclusion	
  (PHS)/Safe	
  to	
  Release	
  (STR)	
   Prior	
  to	
  the	
  implementation	
  of	
  the	
  new	
  Seclusion	
  Policy	
  (SOP	
  301.05.04,	
  effective	
   September	
  1,	
  2014),	
  DYS	
  utilized	
  a	
  structured	
  decision	
  making	
  tool,	
  Individualized	
   Response	
  to	
  Acts	
  of	
  Violence	
  (IRAV).	
  Scores	
  on	
  this	
  instrument	
  were	
  associated	
   with	
  minimum	
  lengths	
  of	
  stay	
  in	
  PHS	
  that	
  ranged	
  between	
  24	
  and	
  72	
  hours.	
  Most	
   youth	
  who	
  engaged	
  in	
  violent	
  behavior	
  spent	
  72	
  hours	
  in	
  isolation	
  immediately	
   following	
  the	
  event.	
  The	
  new	
  policy,	
  implemented	
  September	
  1,	
  2014,	
  changed	
   the	
  metric	
  by	
  which	
  the	
  duration	
  of	
  PHS	
  was	
  determined.	
  Rather	
  than	
  being	
   based	
  on	
  the	
  IRAV	
  score,	
  the	
  length	
  of	
  time	
  in	
  PHS	
  became	
  based	
  on	
  the	
  youth’s	
   current	
  behavior	
  and	
  his	
  willingness	
  to	
  process	
  the	
  event	
  that	
  escalated	
  to	
   violence.	
   	
   The	
  Grid	
  requires	
  facilities	
  to	
  provide	
  an	
  opportunity	
  for	
  release	
  within	
  4	
  hours	
  of	
   being	
  placed	
  in	
  PHS.	
  [The	
  process	
  for	
  release	
  is	
  discussed	
  in	
  more	
  depth	
  in	
  B.5,	
   below.]	
  If	
  the	
  youth	
  is	
  not	
  ready	
  for	
  release	
  by	
  the	
  4-­‐hour	
  mark,	
  subsequent	
   opportunities	
  for	
  release	
  must	
  be	
  provided	
  every	
  2-­‐3	
  hours	
  thereafter,	
  up	
  to	
  a	
   maximum	
  of	
  24	
  hours.	
  	
   	
   Each	
  month,	
  DYS	
  submitted	
  data	
  on	
  the	
  duration	
  of	
  every	
  episode	
  of	
  PHS	
  from	
  all	
   three	
  facilities	
  to	
  the	
  Monitor.	
  While	
  no	
  specific	
  performance	
  requirements	
  were	
   imposed	
  as	
  to	
  the	
  proportion	
  of	
  youth	
  who	
  must	
  be	
  released	
  at	
  the	
  4-­‐hour	
  mark	
   (because	
  release	
  is	
  meant	
  to	
  be	
  dependent	
  on	
  the	
  youth’s	
  behavior,	
  not	
   artificially	
  determined),	
  the	
  Grid	
  requires	
  these	
  data	
  to	
  be	
  tracked.	
  The	
  table	
   below	
  shows	
  the	
  proportion	
  of	
  youth	
  in	
  PHS	
  who	
  were	
  released	
  in	
  4	
  hours	
  or	
  less:	
   	
  

Proportion	
  of	
  Youth	
  in	
  PHS	
  Released	
  in	
  4-­‐hours	
  or	
  Less	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

88%	
   74%	
   48%	
   77%	
   88%	
   88%	
   77%	
  

Cuyahoga	
  Hills	
  

86%	
   94%	
   98%	
   98%	
   98%	
   98%	
   95%	
  

Indian	
  River	
  

73%	
   66%	
   55%	
   83%	
   61%	
   67%	
   68%	
  

DYS	
  AVERAGE	
  

82%	
   78%	
   67%	
   86%	
   83%	
   84%	
   80%	
  

	
   In	
  contrast	
  to	
  the	
  period	
  preceding	
  the	
  implementation	
  of	
  the	
  new	
  seclusion	
   policy	
  where	
  youth	
  routinely	
  spent	
  24-­‐72	
  hours	
  in	
  PHS,	
  80%	
  of	
  the	
  youth	
  in	
  PHS	
   during	
  the	
  6-­‐month	
  monitoring	
  period	
  were	
  released	
  within	
  4	
  hours.	
  Deeper	
  

	
  

18.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 19 of 34 PAGEID #: 3177
	
  

What	
  the	
   Grid	
   Requires	
  

analysis	
  of	
  the	
  data	
  revealed	
  that	
  longer	
  periods	
  of	
  PHS	
  were	
  associated	
  with	
   youth’s	
  refusal	
  to	
  engage	
  in	
  the	
  release	
  process	
  and	
  the	
  time	
  of	
  day	
  in	
  which	
  the	
   incident	
  occurred.	
  Incidents	
  occurring	
  later	
  in	
  the	
  evening	
  generally	
  required	
  an	
   overnight	
  stay	
  in	
  PHS,	
  though	
  youth	
  were	
  generally	
  released	
  by	
  9am	
  the	
  following	
   morning.	
  Across	
  the	
  6-­‐month	
  period,	
  which	
  included	
  706	
  episodes	
  of	
  PHS,	
  none	
   of	
  the	
  episodes	
  extended	
  beyond	
  24	
  hours.	
  	
   	
   Intervention	
  Seclusion	
   From	
  September	
  to	
  December	
  2014,	
  facilities	
  were	
  permitted	
  to	
  impose	
   Intervention	
  Seclusion	
  as	
  a	
  sanction	
  for	
  “severe”	
  rule	
  violations	
  (e.g.,	
  assaults	
  on	
   youth,	
  assaults	
  on	
  staff,	
  sexual	
  misconduct).	
  The	
  new	
  seclusion	
  policy,	
  effective	
   September	
  1,	
  2014,	
  drastically	
  reduced	
  the	
  amount	
  of	
  IS	
  time	
  that	
  could	
  be	
   imposed.	
  Prior	
  to	
  the	
  new	
  policy,	
  youth	
  routinely	
  spent	
  3	
  to	
  5	
  days	
  (72	
  to	
  120	
   hours)	
  in	
  IS.	
  The	
  new	
  policy	
  limited	
  IS	
  time	
  to	
  up	
  to	
  time	
  served	
  in	
  PHS	
  for	
  the	
  1st	
   offense	
  within	
  a	
  30	
  day	
  period,	
  up	
  to	
  4	
  hours	
  for	
  the	
  2nd	
  offense,	
  up	
  to	
  8	
  hours	
  for	
   the	
  3rd	
  offense,	
  etc.	
  	
   	
   Even	
  when	
  it	
  was	
  permitted,	
  IS	
  was	
  not	
  used	
  very	
  often	
  during	
  the	
  monitoring	
   period.	
  Of	
  the	
  over	
  700	
  AOVs	
  recorded	
  during	
  the	
  monitoring	
  period,	
  IS	
  was	
   imposed	
  in	
  only	
  28	
  cases	
  (less	
  than	
  4%	
  of	
  the	
  AOV	
  incidents).	
  Circleville	
  was	
  the	
   only	
  facility	
  that	
  imposed	
  IS	
  during	
  the	
  monitoring	
  period.	
  Indian	
  River	
  and	
   Cuyahoga	
  Hills	
  did	
  not	
  use	
  it	
  at	
  all.	
  Although	
  used	
  infrequently	
  and	
  restricted	
  in	
   duration	
  by	
  the	
  Grid/policy,	
  Circleville	
  made	
  frequent	
  errors	
  in	
  the	
  amount	
  of	
   time	
  imposed.	
  Of	
  the	
  28	
  total	
  cases	
  of	
  IS,	
  13	
  youth	
  (46%)	
  were	
  sanctioned	
  outside	
   of	
  the	
  permissible	
  ranges.	
  Most	
  often,	
  youth	
  with	
  a	
  1st	
  severe	
  offense	
  were	
  not	
   sentenced	
  to	
  time	
  served	
  in	
  PHS,	
  as	
  required	
  by	
  policy.	
  All	
  of	
  the	
  28	
  youth	
   received	
  either	
  4	
  or	
  8	
  hours	
  of	
  IS	
  time.	
  [Note	
  the	
  contrast	
  to	
  pre-­‐Grid,	
  where	
   youth	
  routinely	
  served	
  72-­‐120	
  hours.]	
  Rather	
  than	
  belabor	
  the	
  underlying	
  causes	
   of	
  the	
  problems	
  with	
  using	
  the	
  grid,	
  DYS	
  and	
  the	
  Monitors	
  simply	
  pushed	
  forward	
   to	
  the	
  eventual	
  elimination	
  of	
  the	
  practice.	
  DYS	
  policy	
  prohibited	
  the	
  use	
  of	
   Intervention	
  Seclusion	
  on	
  January	
  1,	
  2015.	
  Data,	
  youth	
  and	
  staff	
  interviews	
  all	
   confirm	
  that	
  Intervention	
  Seclusion	
  is	
  no	
  longer	
  used	
  in	
  response	
  to	
  youth	
   violence.	
  	
   	
   So,	
  in	
  summary,	
  most	
  of	
  the	
  instances	
  of	
  PHS	
  are	
  now	
  very	
  short	
  in	
  comparison	
  to	
   the	
  past—80%	
  conclude	
  in	
  4	
  hours	
  or	
  less.	
  While	
  there	
  were	
  problems	
  with	
  the	
   imposition	
  of	
  IS	
  for	
  the	
  small	
  number	
  of	
  cases	
  in	
  which	
  it	
  was	
  used	
  at	
  one	
  facility,	
   the	
  practice	
  was	
  abolished	
  entirely	
  on	
  January	
  1,	
  2015	
  and	
  thus	
  further	
  remedy	
  is	
   not	
  needed.	
  	
  
(B.3)	
  Reduce	
  Harm	
  Associated	
  with	
  Seclusion	
  	
   • Intervention	
  Seclusion	
  is	
  imposed	
  only	
  on	
  Saturday	
  &	
  Sunday,	
  to	
  reduce	
   interference	
  with	
  core	
  programming	
   • For	
  IS,	
  provide	
  1	
  hour	
  out	
  for	
  every	
  4	
  hours	
  in	
  seclusion,	
  during	
  waking	
   hours	
   • Youth	
  in	
  IS	
  participate	
  in	
  treatment	
  activities,	
  school	
  and	
  recreation	
  out	
   of	
  their	
  rooms	
  and	
  time	
  counts	
  toward	
  seclusion	
  hours	
  if	
  behavior	
  is	
   appropriate	
  

	
  

19.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 20 of 34 PAGEID #: 3178
	
  

(B.3)	
  Performance	
  Measures	
   • 90%	
  of	
  youth	
  in	
  Intervention	
  Seclusion	
  spent	
  4	
  in/1	
  out	
  during	
  waking	
   hours	
   • 90%	
  of	
  youth	
  in	
  Intervention	
  Seclusion	
  participated	
  in	
  all	
  programming	
   (e.g.,	
  recreation,	
  treatment)	
  that	
  was	
  scheduled	
  during	
  seclusion	
  time	
  

Monitor’s	
   Assessment	
  

As	
  noted	
  above,	
  Intervention	
  Seclusion	
  was	
  used	
  only	
  28	
  times	
  during	
  the	
   monitoring	
  period,	
  at	
  Circleville	
  during	
  September-­‐November	
  2014.	
  Of	
  these	
   instances,	
  only	
  8	
  of	
  the	
  28	
  (29%)	
  imposed	
  IS	
  for	
  longer	
  than	
  4	
  hours.	
  For	
  these	
  8	
   cases:	
  
• All	
  8	
  instances	
  were	
  served	
  on	
  Saturday	
  or	
  Sunday;	
   • 4	
  of	
  the	
  8	
  (50%)	
  received	
  one-­‐hour	
  out	
  for	
  every	
  4	
  hours	
  in;	
  and	
   • 4	
  of	
  the	
  8	
  (50%)	
  participated	
  in	
  the	
  regularly	
  scheduled	
  programming	
  
during	
  that	
  time	
  (most	
  often,	
  recreation	
  or	
  leisure	
  time).	
  	
   In	
  two	
  of	
  the	
  4	
  non-­‐compliant	
  cases,	
  documentation	
  to	
  establish	
  compliance	
  with	
   the	
  policy	
  could	
  not	
  be	
  located.	
  In	
  the	
  other	
  two	
  cases,	
  the	
  proper	
  procedures	
   were	
  not	
  followed.	
  Although	
  the	
  performance	
  levels	
  do	
  not	
  meet	
  the	
  thresholds	
   established	
  by	
  the	
  Grid,	
  DYS	
  and	
  the	
  Monitor	
  chose	
  not	
  to	
  belabor	
  corrective	
   action	
  given	
  that	
  the	
  practice	
  of	
  Intervention	
  Seclusion	
  was	
  abolished	
  altogether	
   on	
  January	
  1,	
  2015.	
  	
  

What	
  the	
   Grid	
   Requires	
  

(B.4)	
  Reduce	
  Accumulation	
  of	
  Seclusion	
  	
   • To	
  apply	
  more	
  than	
  72	
  hours	
  of	
  seclusion	
  in	
  a	
  30-­‐day	
  period,	
  must	
   conduct	
  Treatment	
  Plan	
  Review	
  (see	
  C.1),	
  obtain	
  approval	
  from	
  Bureau	
   Chief/Deputy	
  Director,	
  provide	
  information	
  to	
  Monitors.	
  
	
  (B.4)	
  Performance	
  Measures	
   • Number	
  of	
  youth	
  secluded	
  each	
  month	
  and	
  the	
  number	
  of	
  hours	
  in	
   seclusion	
   • Number	
  of	
  youth	
  who	
  spent	
  more	
  than	
  72-­‐hours	
  in	
  a	
  30-­‐day	
  period	
   o 90%	
  received	
  treatment	
  plan	
  review	
   o 990%	
  received	
  approval	
  for	
  exception	
  to	
  the	
  72	
  hour	
  rule	
  

Monitor’s	
   Assessment	
  

In	
  November	
  2013,	
  Dr.	
  Dedel	
  (the	
  Lead	
  Monitor	
  on	
  the	
  DOJ	
  case)	
  drafted	
  a	
  memo	
   to	
  the	
  Parties	
  that	
  examined	
  the	
  way	
  in	
  which	
  seclusion	
  hours	
  accumulated	
  for	
   individual	
  youth	
  who	
  engaged	
  in	
  high-­‐frequency	
  AOVs	
  at	
  Scioto	
  JCF.	
  Some	
  of	
  the	
   youth	
  included	
  in	
  the	
  analysis	
  spent	
  well	
  over	
  200	
  hours	
  in	
  seclusion	
  each	
  month.	
   The	
  Grid	
  sought	
  to	
  remedy	
  that	
  problem	
  by	
  placing	
  limits	
  on	
  the	
  amount	
  of	
  time	
   that	
  could	
  be	
  imposed	
  and	
  by	
  creating	
  additional	
  protections	
  for	
  youth	
  who	
   accumulated	
  significant	
  seclusion	
  time.	
  The	
  threshold	
  for	
  additional	
  protections	
   was	
  established	
  in	
  the	
  Court	
  Order	
  at	
  72	
  hours	
  of	
  accumulated	
  seclusion	
  in	
  a	
   rolling	
  30-­‐day	
  period.	
  	
   	
   With	
  the	
  implementation	
  of	
  the	
  new	
  seclusion	
  policy	
  that	
  changed	
  the	
  maximum	
   limits	
  for	
  PHS	
  and	
  severely	
  restricted	
  the	
  use	
  of	
  IS	
  came	
  significant	
  reductions	
  in	
   the	
  accumulation	
  of	
  seclusion,	
  even	
  among	
  youth	
  with	
  high-­‐frequency	
  AOVs.	
  As	
   discussed	
  in	
  “Column	
  A	
  Overall	
  Measures,”	
  a	
  handful	
  of	
  youth	
  at	
  each	
  facility	
   engaged	
  in	
  3	
  to	
  6	
  AOVs	
  per	
  month.	
  Prior	
  to	
  the	
  new	
  policy,	
  it	
  would	
  not	
  have	
   been	
  uncommon	
  for	
  youth	
  to	
  spend	
  3	
  days	
  in	
  PHS	
  and	
  3	
  to	
  5	
  days	
  in	
  IS	
  for	
  each	
  of	
  

	
  

20.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 21 of 34 PAGEID #: 3179
	
  

these	
  offenses.	
  In	
  other	
  words,	
  he	
  could	
  have	
  easily	
  spent	
  the	
  majority	
  of	
  his	
  time	
   in	
  custody	
  that	
  month	
  in	
  seclusion,	
  separated	
  from	
  the	
  people,	
  programs	
  and	
   relationships	
  that	
  were	
  tasked	
  with	
  providing	
  rehabilitative	
  services.	
   	
   As	
  shown	
  in	
  the	
  table	
  below,	
  during	
  the	
  monitoring	
  period,	
  seclusion	
  hours	
   simply	
  did	
  not	
  accumulate	
  with	
  the	
  same	
  magnitude	
  that	
  created	
  concern	
  in	
  Dr.	
   Dedel’s	
  November	
  2013	
  memo.	
  The	
  table	
  below	
  shows	
  the	
  seclusion	
  hours	
  for	
   the	
  single	
  youth	
  in	
  each	
  facility	
  with	
  the	
  highest	
  total	
  number	
  of	
  hours	
  each	
   month.	
  Most	
  of	
  the	
  time,	
  the	
  youth	
  with	
  the	
  highest	
  total	
  seclusion	
  hours	
  spent	
   less	
  than	
  20	
  hours	
  in	
  seclusion	
  each	
  month.	
   	
  

Total	
  Seclusion	
  Hours	
  for	
  the	
  Single	
  Youth	
  with	
  the	
  Highest	
  Accumulation	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

25.8	
   30.8	
   32.4	
   12.5	
   19.2	
   19.3	
   23.3	
  

Cuyahoga	
  Hills	
  

11.3	
   8.0	
   15.3	
   10.2	
   11.2	
   13.5	
   11.6	
  

Indian	
  River	
  

29.5	
   20.4	
   22.8	
   17.4	
   28.6	
   13.4	
   22.0	
  

	
   Because	
  DYS	
  successfully	
  limited	
  the	
  total	
  number	
  of	
  hours	
  that	
  youth	
  spent	
  in	
   seclusion,	
  the	
  protective	
  measures	
  built	
  into	
  the	
  Grid	
  for	
  youth	
  who	
  accumulated	
   72+	
  hours	
  of	
  seclusion	
  in	
  a	
  rolling	
  30-­‐day	
  period	
  (e.g.,	
  treatment	
  plan	
  reviews;	
   approval	
  by	
  DYS	
  Administrators)	
  were	
  never	
  utilized.	
  	
   	
   In	
  summary,	
  DYS	
  successfully	
  limited	
  the	
  accumulation	
  of	
  seclusion	
  hours,	
  even	
   for	
  youth	
  with	
  high-­‐frequency	
  AOVs.	
  Across	
  the	
  6-­‐month	
  period,	
  of	
  the	
  hundreds	
   of	
  youth	
  who	
  committed	
  AOVs,	
  the	
  highest	
  accumulation	
  was	
  32.4	
  hours	
  in	
  a	
   single	
  month,	
  compared	
  to	
  the	
  period	
  before	
  the	
  policy	
  was	
  changed	
  when	
  youth	
   with	
  high-­‐frequency	
  AOVs	
  could	
  easily	
  accumulate	
  200-­‐500	
  hours	
  in	
  seclusion	
  in	
  a	
   single	
  month.	
  	
  

What	
  the	
   Grid	
   Requires	
  

(B.5)	
  Provide	
  Crisis	
  Intervention	
  while	
  in	
  PHS	
  	
   • STR	
  process	
  will	
  be	
  initiated	
  with	
  every	
  youth	
  engaged	
  in	
  AOV	
  between	
   two	
  and	
  four	
  hours;	
  subsequent	
  checks	
  every	
  2-­‐3	
  hours	
   • STR	
  process	
  will	
  include	
  a	
  structured	
  interview	
  by	
  SW/UM/OM	
  that	
   discusses	
  triggers,	
  decision-­‐making,	
  external	
  influences	
  on	
  behavior.	
  
(B.5)	
  Performance	
  Measures	
   • STR	
  process	
  was	
  initiated	
  with	
  90%	
  of	
  youth	
  within	
  4	
  hours	
  of	
  AOV	
   • 90%	
  of	
  STR	
  checks	
  examine	
  the	
  underlying	
  causes	
  of	
  the	
  youth’s	
   behavior,	
  both	
  internal	
  and	
  external	
  

Monitor’s	
   Assessment	
  

In	
  order	
  to	
  better	
  calibrate	
  the	
  youth’s	
  length	
  of	
  stay	
  in	
  pre-­‐hearing	
  seclusion	
  to	
   when	
  he	
  could	
  safely	
  return	
  to	
  the	
  general	
  population,	
  DYS	
  created	
  the	
  “Safe	
  to	
   Release”	
  process.	
  This	
  process	
  uses	
  a	
  structured	
  interview	
  guide	
  that	
  helps	
  youth	
   to	
  process	
  the	
  antecedents	
  and	
  consequences	
  of	
  his	
  aggressive	
  behavior.	
  The	
   interview	
  must	
  be	
  first	
  attempted	
  within	
  4	
  hours	
  of	
  the	
  youth’s	
  placement	
  in	
  PHS.	
   If	
  the	
  youth	
  engages	
  in	
  the	
  process,	
  he	
  is	
  released.	
  If	
  the	
  youth	
  refuses	
  the	
   process	
  or	
  provides	
  evidence	
  that	
  he	
  continues	
  to	
  present	
  a	
  risk	
  to	
  facility	
  safety,	
   his	
  stay	
  in	
  PHS	
  is	
  extended.	
  An	
  attempt	
  to	
  engage	
  the	
  youth	
  in	
  the	
  process	
  must	
  

	
  

21.	
  

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be	
  made	
  at	
  least	
  every	
  2-­‐3	
  hours	
  thereafter,	
  until	
  he	
  is	
  released.	
  In	
  practice,	
  the	
   STR	
  interviews	
  generally	
  occur	
  well	
  within	
  the	
  required	
  timelines.	
  Most	
  recently,	
   facilities	
  are	
  striving	
  to	
  engage	
  the	
  youth	
  at	
  the	
  initial	
  2-­‐hour	
  mark,	
  instead	
  of	
  the	
   4-­‐hour	
  mark.	
  	
   	
   STR	
  Timeliness	
   The	
  table	
  below	
  shows	
  the	
  extent	
  to	
  which	
  the	
  required	
  timelines	
  were	
  met	
  each	
   month.	
  The	
  proportion	
  of	
  cases	
  that	
  met	
  the	
  required	
  timelines	
  includes	
  both	
   youth	
  who	
  were	
  released	
  within	
  4	
  hours	
  (approximately	
  80%	
  of	
  all	
  cases,	
  as	
   discussed	
  in	
  B.2	
  above)	
  and	
  those	
  who	
  remained	
  in	
  PHS	
  after	
  an	
  initially	
  refusing	
   to	
  participate	
  in	
  the	
  process,	
  but	
  were	
  subsequently	
  engaged	
  in	
  an	
  STR	
  interview	
   within	
  the	
  required	
  timelines.	
   	
  

Proportion	
  of	
  STR	
  Interviews	
  Conducted	
  within	
  Required	
  Timelines	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

94%	
   88%	
   66%	
   86%	
   98%	
   94%	
   88%	
  

Cuyahoga	
  Hills	
  

93%	
   97%	
   100%	
   100%	
   100%	
   100%	
   98%	
  

Indian	
  River	
  

87%	
   91%	
   100%	
   100%	
   97%	
   93%	
   95%	
  

DYS	
  TOTAL	
  

91%	
   92%	
   89%	
   95%	
   98%	
   96%	
   94%	
  

	
   As	
  shown	
  in	
  the	
  table	
  above,	
  Cuyahoga	
  Hills	
  and	
  Indian	
  River	
  exceeded	
  the	
   required	
  90%	
  performance	
  level	
  each	
  month	
  while	
  Circleville	
  sometimes	
   struggled	
  to	
  meet	
  the	
  required	
  performance	
  level.	
  Even	
  so,	
  Circleville	
  exceeded	
   the	
  required	
  level	
  during	
  the	
  last	
  part	
  of	
  the	
  monitoring	
  period,	
  with	
  a	
  6-­‐month	
   average	
  nearly	
  at	
  the	
  90%	
  level.	
  	
   	
   Originally,	
  responsibility	
  for	
  the	
  STR	
  interviews	
  was	
  delegated	
  entirely	
  to	
  the	
   Operations	
  Manager.	
  The	
  OMs	
  at	
  each	
  facility	
  had	
  to	
  track	
  the	
  timelines	
  for	
   multiple	
  youth	
  on	
  PHS,	
  while	
  at	
  the	
  same	
  time	
  ensure	
  that	
  count,	
  movement,	
   incident	
  report	
  recording	
  and	
  entry,	
  and	
  other	
  facility	
  operational	
  functions	
   occurred	
  timely	
  and	
  on	
  schedule.	
  This	
  turned	
  out	
  to	
  be	
  very	
  difficult.	
  A	
  quality	
   STR	
  requires	
  about	
  20	
  minutes	
  to	
  conduct.	
  If	
  the	
  STR	
  was	
  due	
  just	
  before	
  count	
  or	
   movement,	
  the	
  OM	
  was	
  left	
  with	
  several	
  unappealing	
  choices.	
  The	
  OM	
  could	
   choose	
  to	
  rush	
  the	
  interview	
  to	
  complete	
  it	
  before	
  count	
  started,	
  or	
  could	
  start	
   the	
  STR	
  interview,	
  interrupt	
  it	
  for	
  count,	
  and	
  then	
  complete	
  it	
  after	
  count	
  cleared,	
   or	
  could	
  begin	
  the	
  STR	
  process	
  after	
  count	
  cleared—which	
  meant	
  missing	
  the	
  STR	
   timeline.	
  For	
  this	
  and	
  other	
  reasons	
  related	
  to	
  the	
  quality	
  of	
  the	
  interviews	
   (discussed	
  below),	
  responsibility	
  for	
  the	
  STR	
  interviews	
  was	
  eventually	
  dispersed	
   among	
  the	
  OMs,	
  social	
  workers,	
  behavioral	
  health	
  clinicians	
  and	
  Unit	
  Managers.	
   This	
  adjustment	
  led	
  to	
  the	
  higher	
  rates	
  of	
  performance	
  at	
  required	
  levels	
   witnessed	
  at	
  the	
  end	
  of	
  the	
  monitoring	
  period.	
  	
   	
   Although	
  one	
  of	
  the	
  three	
  facilities	
  did	
  not	
  quite	
  meet	
  the	
  required	
  performance	
   level	
  of	
  90%,	
  system-­‐wide,	
  the	
  STR	
  interviews	
  proceeded	
  according	
  to	
  the	
   required	
  timelines	
  in	
  94%	
  of	
  the	
  706	
  PHS	
  episodes	
  occurring	
  during	
  the	
  6-­‐month	
   period.	
  	
  

	
  

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   STR	
  Quality	
   The	
  Parties	
  and	
  the	
  Monitoring	
  Team	
  shared	
  the	
  same	
  intention	
  about	
  engaging	
   youth	
  in	
  PHS	
  in	
  an	
  interactive	
  process	
  to	
  identify	
  the	
  underlying	
  causes	
  of	
  his	
   behavior	
  so	
  that	
  he	
  could	
  be	
  quickly	
  returned	
  to	
  the	
  general	
  population	
  and	
   appropriate	
  safety	
  or	
  therapeutic	
  responses	
  could	
  be	
  put	
  into	
  place.	
  Although	
  the	
   vision	
  was	
  clear,	
  the	
  pathway	
  for	
  getting	
  there	
  was	
  not.	
  First,	
  as	
  noted	
  above,	
  the	
   original	
  plan	
  to	
  make	
  the	
  OMs	
  solely	
  responsible	
  for	
  carrying	
  out	
  the	
  STR	
  process	
   proved	
  to	
  be	
  impractical.	
  Diffusing	
  this	
  responsibility	
  seems	
  to	
  provide	
  the	
   flexibility	
  needed	
  to	
  ensure	
  that	
  timelines	
  are	
  met,	
  and	
  also	
  provides	
  choices	
   among	
  staff	
  doing	
  the	
  interview,	
  some	
  of	
  whom	
  may	
  have	
  a	
  stronger	
  rapport	
   with	
  the	
  youth.	
  	
   	
   Second,	
  the	
  content	
  of	
  the	
  interview	
  guide	
  needed	
  adjustment	
  to	
  ensure	
  that	
  it	
   cued	
  staff	
  to	
  ask	
  specific	
  questions	
  that	
  elicited	
  detailed	
  answers.	
  These	
  changes	
   were	
  articulated	
  during	
  a	
  meeting	
  in	
  early	
  December	
  2014	
  among	
  Central	
  Office	
   staff,	
  OMs,	
  and	
  UMs	
  who	
  shared	
  their	
  experiences	
  of	
  using	
  the	
  form	
  and	
  made	
   suggestions	
  for	
  how	
  to	
  improve	
  the	
  quality	
  of	
  the	
  information	
  obtained.	
  The	
  new	
   form	
  was	
  put	
  into	
  use	
  in	
  mid-­‐December	
  2014.	
   	
   Third,	
  the	
  process	
  for	
  monitoring	
  the	
  quality	
  of	
  the	
  STR	
  interviews	
  to	
  determine	
   whether	
  it	
  met	
  the	
  requirements	
  of	
  the	
  Grid	
  was	
  also	
  a	
  challenge.	
  For	
  the	
  first	
   few	
  months,	
  each	
  STR	
  sampled	
  was	
  rated	
  as	
  to	
  whether	
  it	
  provided	
  sufficient	
   answers	
  to	
  each	
  of	
  the	
  11	
  questions	
  on	
  the	
  STR	
  form.	
  However,	
  very	
  few	
  STR	
   forms	
  scored	
  well	
  using	
  this	
  method,	
  and	
  at	
  times,	
  the	
  score	
  seemed	
  at	
  odds	
  with	
   the	
  overall	
  sufficiency	
  of	
  the	
  STR	
  interview.	
  Furthermore,	
  given	
  that	
  1)	
  the	
  vast	
   majority	
  of	
  youth	
  were	
  being	
  released	
  at	
  the	
  4	
  hour	
  mark	
  based	
  on	
  the	
  STR	
   interviews	
  and	
  2)	
  very	
  few	
  youth	
  were	
  engaging	
  in	
  AOVs	
  proximal	
  to	
  their	
  release	
   from	
  PHS,	
  we	
  felt	
  that	
  the	
  OMs	
  were	
  making	
  release	
  decisions	
  that	
  protected	
   facility	
  safety	
  and	
  did	
  not	
  hold	
  youth	
  in	
  PHS	
  for	
  undue	
  periods	
  of	
  time.	
  These	
   were	
  the	
  most	
  important	
  outcomes	
  relevant	
  to	
  Column	
  B,	
  but	
  somehow	
  the	
   method	
  to	
  assess	
  the	
  quality	
  of	
  the	
  STR	
  forms	
  was	
  missing	
  the	
  point	
  (i.e.,	
  so	
  many	
   were	
  scoring	
  poorly).	
  	
   	
   In	
  an	
  effort	
  to	
  identify	
  a	
  scoring	
  method	
  with	
  better	
  face	
  validity,	
  the	
  Monitor	
  and	
   DYS	
  revised	
  the	
  monitoring	
  strategy.	
  Given	
  some	
  of	
  the	
  other	
  protections	
  in	
   place—namely,	
  that	
  Behavior	
  Health	
  staff	
  conducted	
  a	
  treatment	
  plan	
  review	
   within	
  48	
  hours	
  of	
  each	
  AOV—there	
  was	
  less	
  pressure	
  for	
  the	
  OM	
  to	
  obtain	
  all	
  of	
   the	
  details	
  during	
  the	
  STR	
  interviews.	
  Instead,	
  we	
  wanted	
  to	
  ensure	
  that	
  the	
  STR	
   form	
  gave	
  the	
  BH	
  clinician	
  sufficient	
  information	
  to	
  start	
  the	
  conversation	
  about	
   what	
  happened	
  and	
  why	
  in	
  their	
  meetings	
  with	
  the	
  youth.	
  Thus,	
  beginning	
  in	
   November	
  2014,	
  a	
  more	
  holistic	
  monitoring	
  strategy	
  was	
  utilized—a	
  single	
  yes/no	
   question:	
  did	
  the	
  STR	
  provide	
  sufficient	
  information	
  for	
  BH	
  staff	
  to	
  start	
  a	
   discussion	
  about	
  what	
  happened,	
  how	
  the	
  youth	
  felt	
  about	
  it	
  at	
  the	
  time	
  of	
  the	
   incident	
  and	
  then	
  later	
  during	
  the	
  interview,	
  and	
  what	
  the	
  youth	
  said	
  about	
  what	
   could	
  be	
  different	
  the	
  next	
  time?	
  In	
  addition,	
  the	
  monthly	
  reports	
  provided	
  to	
  the	
   Monitor	
  began	
  to	
  include	
  data	
  on	
  whether	
  the	
  treatment	
  plan	
  reviews	
  were	
  

	
  

23.	
  

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occurring	
  within	
  48	
  hours	
  as	
  required.	
  	
   	
   The	
  table	
  below	
  summarizes	
  progress	
  in	
  this	
  area.	
  Specific	
  percentages	
  are	
  not	
   included	
  for	
  September	
  and	
  October	
  because	
  at	
  the	
  time,	
  the	
  Monitor	
  was	
   scoring	
  each	
  of	
  the	
  interview	
  questions	
  separately,	
  and	
  had	
  yet	
  to	
  land	
  upon	
  a	
   meaningful	
  way	
  to	
  synthesize	
  the	
  data.	
  However,	
  both	
  the	
  Monitor	
  and	
  DYS	
   agreed	
  that	
  of	
  the	
  70	
  STR	
  forms	
  reviewed	
  during	
  that	
  period,	
  only	
  a	
  few	
  were	
  of	
   good	
  quality	
  and	
  the	
  vast	
  majority	
  did	
  not	
  reach	
  the	
  standards	
  required	
  by	
  the	
   Grid.	
  	
   	
  

Proportion	
  of	
  STR	
  Interviews	
  of	
  Sufficient	
  Quality	
  to	
  Initiate	
  BH	
  Treatment	
  	
  

	
  

Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   AVG	
  

Circleville	
  

~	
  

~	
   50%	
   73%	
   93%	
   80%	
   74%	
  

Cuyahoga	
  Hills	
  

~	
  

~	
   50%	
   45%	
   47%	
   75%	
   54%	
  

Indian	
  River	
  

~	
  

~	
   60%	
   69%	
   80%	
   93%	
   76%	
  

DYS	
  TOTAL	
  

~	
  

~	
   53%	
   62%	
   73%	
   83%	
   68%	
  

	
   Throughout	
  the	
  rest	
  of	
  the	
  monitoring	
  period,	
  overall	
  progress	
  has	
  been	
  steady.	
   Using	
  a	
  single	
  holistic	
  measure	
  of	
  sufficiency,	
  the	
  Monitor	
  assessed	
  180	
  additional	
   STR	
  forms	
  and	
  reviewed	
  the	
  assessments	
  with	
  DYS	
  staff	
  to	
  ensure	
  general	
   agreement.	
  As	
  shown	
  in	
  the	
  table	
  above,	
  progress	
  has	
  been	
  steady.	
  Each	
  month,	
   an	
  additional	
  10%	
  of	
  the	
  STR	
  interviews	
  were	
  assessed	
  as	
  being	
  of	
  sufficient	
   quality.	
  In	
  the	
  final	
  month	
  of	
  this	
  6-­‐month	
  monitoring	
  period,	
  83%	
  of	
  the	
  STR	
   forms	
  provided	
  sufficient	
  detail	
  for	
  the	
  OMs	
  to	
  make	
  a	
  safe	
  release	
  decision	
  and	
   for	
  BH	
  staff	
  to	
  initiate	
  a	
  treatment	
  plan	
  review	
  with	
  the	
  youth	
  a	
  couple	
  days	
  later.	
   March	
  data	
  (not	
  included	
  in	
  this	
  report)	
  revealed	
  that	
  all	
  three	
  facilities	
   performed	
  above	
  the	
  required	
  90%	
  level.	
  	
  	
   	
   One	
  of	
  the	
  things	
  that	
  became	
  particularly	
  visible	
  toward	
  the	
  end	
  of	
  the	
   monitoring	
  period	
  was	
  the	
  synergy	
  created	
  among	
  disciplines	
  as	
  they	
  tackled	
  the	
   problem	
  of	
  youth	
  violence.	
  Several	
  times	
  during	
  monthly	
  conference	
  calls	
  and	
   while	
  the	
  Monitoring	
  team	
  was	
  on	
  site,	
  BH	
  staff	
  noted	
  how	
  helpful	
  they	
  found	
  the	
   information	
  in	
  the	
  STR	
  interviews	
  to	
  be.	
  Similarly,	
  the	
  increasing	
  success	
  with	
   which	
  BH	
  staff	
  were	
  conducting	
  the	
  treatment	
  plan	
  reviews	
  in	
  a	
  timely	
  manner	
   helped	
  the	
  direct	
  care	
  staff	
  to	
  feel	
  confident	
  that	
  the	
  STR	
  process	
  had	
  come	
  full	
   circle	
  (these	
  data	
  are	
  presented/discussed	
  in	
  “Column	
  C,”	
  but	
  were	
  also	
  reviewed	
   each	
  month	
  by	
  the	
  Monitor	
  and	
  DYS	
  staff	
  charged	
  with	
  implementing	
  the	
  STR	
   process).	
  	
   	
   In	
  summary,	
  although	
  Circleville	
  initially	
  experienced	
  difficulty	
  with	
  timeliness,	
  by	
   the	
  end	
  of	
  the	
  monitoring	
  period,	
  all	
  three	
  facilities	
  had	
  a	
  solid	
  track	
  record	
  of	
   initiating	
  the	
  STR	
  process	
  within	
  required	
  timelines.	
  Overall,	
  94%	
  the	
  706	
   episodes	
  of	
  PHS	
  included	
  STR	
  interviews	
  that	
  were	
  completed	
  within	
  required	
   timelines.	
  	
  The	
  STR	
  administration	
  and	
  monitoring	
  process	
  required	
  several	
   iterations	
  to	
  land	
  on	
  a	
  structure	
  that	
  retained	
  the	
  proper	
  focus	
  on	
  safety	
  and	
   length	
  of	
  stay.	
  In	
  the	
  end,	
  the	
  STR	
  interviews	
  have	
  proved	
  to	
  be	
  a	
  valuable	
  

	
  

24.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 25 of 34 PAGEID #: 3183
	
  

contribution	
  to	
  the	
  system’s	
  response	
  to	
  violence.	
  While	
  the	
  facilities	
  have	
  not	
   yet	
  consistently	
  reached	
  the	
  90%	
  performance	
  level	
  required	
  by	
  the	
  Grid,	
  the	
   Monitor	
  believes	
  that	
  the	
  process,	
  as	
  it	
  exists	
  at	
  the	
  time	
  this	
  report	
  was	
  written,	
   is	
  sufficient	
  to	
  satisfy	
  the	
  objectives	
  of	
  the	
  Grid	
  and	
  Court	
  Order.	
  	
  	
  

What	
  the	
   Grid	
   Requires	
  

(B.6)	
  Eventually	
  Eliminate	
  the	
  Use	
  of	
  Disciplinary	
  Seclusion	
   • DYS	
  is	
  committed	
  to	
  the	
  eventual	
  elimination	
  of	
  disciplinary	
  seclusion	
  for	
   all	
  youth	
  housed	
  in	
  a	
  DYS	
  facility.	
  Thus,	
  six	
  months	
  from	
  the	
  acceptance	
  of	
   this	
  settlement,	
  DYS	
  will	
  engage	
  the	
  Monitors	
  and	
  subject	
  matter	
  experts	
   in	
  formulating	
  the	
  steps	
  to	
  take,	
  and	
  the	
  timeline	
  for	
  completing	
  those	
   steps,	
  to	
  eliminate	
  disciplinary	
  seclusion.	
  	
  	
  
(B.6)	
  Overall	
  Performance	
  Measure	
   • Reduce	
  the	
  number	
  of	
  youth	
  who	
  serve	
  72+	
  hours	
  in	
  seclusion	
  per	
  month	
   by	
  10%	
  each	
  month,	
  compared	
  to	
  the	
  previous	
  month.	
  	
  

Monitor’s	
   Assessment	
  

DYS	
  abolished	
  the	
  practice	
  of	
  Intervention	
  Seclusion	
  on	
  January	
  1,	
  2015,	
  though	
   two	
  of	
  the	
  three	
  facilities	
  abandoned	
  the	
  practice	
  many	
  months	
  before	
  then.	
  	
   	
   As	
  noted	
  in	
  B.4,	
  above,	
  none	
  of	
  the	
  youth	
  housed	
  in	
  DYS	
  during	
  the	
  monitoring	
   period	
  even	
  approached	
  the	
  72-­‐hour	
  limit	
  imposed	
  by	
  the	
  Grid.	
  Throughout	
  that	
   time,	
  the	
  youth	
  with	
  the	
  highest	
  accumulation	
  totaled	
  32.4	
  hours	
  in	
  a	
  single	
   month,	
  which	
  is	
  well	
  below	
  the	
  threshold	
  established	
  by	
  the	
  Grid.	
  	
  

Other	
  

The	
  Monitors	
  regularly	
  interacted	
  with	
  DYS	
  administrators	
  and	
  facility	
  staff	
  via	
  bi-­‐

Information	
   weekly	
  conference	
  calls	
  and	
  frequent	
  email	
  exchanges.	
  The	
  Monitoring	
  Team	
  also	
  

participated	
  in	
  two	
  one-­‐day	
  site	
  visits	
  to	
  each	
  facility,	
  one	
  in	
  October	
  2014	
  and	
  

one	
  in	
  March	
  2015.	
  Contextual	
  information	
  and	
  findings	
  from	
  site	
  visits	
  are	
  

discussed	
  here.	
  	
  

Monitor’s	
   Assessment	
  

Rather	
  than	
  implementing	
  the	
  requirements	
  of	
  the	
  Grid	
  in	
  a	
  stand-­‐alone	
  fashion,	
   DYS	
  engaged	
  in	
  a	
  process	
  to	
  examine	
  the	
  larger	
  environment	
  in	
  which	
  the	
   reforms	
  would	
  be	
  made.	
  This	
  examination	
  led	
  to	
  a	
  series	
  of	
  reforms,	
  going	
  far	
   beyond	
  the	
  requirements	
  of	
  the	
  Grid,	
  articulated	
  in	
  DYS’	
  Path	
  to	
  Safer	
  Facilities.	
   The	
  model	
  includes	
  enhancements	
  to	
  mental	
  health	
  treatment	
  and	
  changes	
  to	
   the	
  use	
  of	
  pre-­‐hearing	
  and	
  disciplinary	
  seclusion	
  required	
  by	
  the	
  Grid,	
  but	
  also	
   requires	
  changes	
  in	
  the	
  facility	
  environment	
  and	
  programming	
  needed	
  to	
  ensure	
   successful	
  implementation	
  of	
  the	
  reforms	
  flowing	
  from	
  the	
  Court	
  Order.	
  Some	
  of	
   these	
  innovations	
  are	
  discussed	
  below,	
  because	
  they	
  are	
  directly	
  related	
  to	
  the	
   problem	
  of	
  youth	
  violence	
  that	
  is	
  at	
  the	
  core	
  of	
  the	
  reforms	
  required	
  by	
  the	
  Grid.	
  	
   	
   All	
  DYS	
  facilities	
  utilize	
  the	
  Strength	
  Based	
  Behavior	
  Management	
  System	
   (SBBMS)	
  to	
  ensure	
  that	
  behavioral	
  expectations	
  are	
  clear	
  and	
  that	
  youth	
  are	
   appropriately	
  incentivized	
  to	
  meet	
  them.	
  Youth	
  who	
  meet	
  expectations	
  for	
   sustained	
  periods	
  of	
  time	
  are	
  provided	
  access	
  to	
  increasingly	
  attractive	
  rewards	
   and	
  incentives	
  on	
  a	
  daily,	
  weekly	
  and	
  long-­‐term	
  basis	
  by	
  being	
  promoted	
  to	
   higher	
  phases.	
  As	
  part	
  of	
  the	
  Path	
  to	
  Safer	
  Facilities	
  plan,	
  the	
  SBBMS	
  programs	
   were	
  enhanced	
  with	
  more	
  robust	
  rewards	
  to	
  ensure	
  they	
  were	
  meaningful	
  to	
   youth.	
  	
   	
  

	
  

25.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 26 of 34 PAGEID #: 3184
	
  
In	
  addition,	
  some	
  of	
  the	
  facilities	
  changed	
  the	
  way	
  in	
  which	
  youth	
  are	
  housed—by	
   need	
  rather	
  than	
  risk,	
  as	
  determined	
  by	
  the	
  Ohio	
  Youth	
  Assessment	
  System	
   (OYAS).	
  Housing	
  youth	
  by	
  needs	
  means	
  that	
  youth	
  of	
  all	
  security	
  levels	
  (Close,	
   Medium,	
  Low)	
  can	
  now	
  be	
  housed	
  together.	
  SBBMS	
  provides	
  for	
  three	
  phases	
   within	
  each	
  security	
  level,	
  which	
  means	
  that	
  now	
  that	
  the	
  levels	
  are	
  integrated,	
   staff	
  are	
  tasked	
  with	
  implementing	
  9	
  different	
  bedtimes	
  (one	
  for	
  each	
  of	
  the	
  3	
   phases	
  within	
  each	
  of	
  the	
  3	
  security	
  levels).	
  This	
  is	
  just	
  one	
  example	
  of	
  how	
   SBBMS	
  needed	
  to	
  be	
  restructured	
  so	
  that	
  it	
  better	
  supported	
  all	
  of	
  these	
   innovations,	
  so	
  that	
  it	
  was	
  easier	
  for	
  staff	
  to	
  implement	
  consistently	
  and	
  to	
   improve	
  youth	
  and	
  staff	
  buy-­‐in.	
  	
   	
   Furthermore,	
  now	
  that	
  disciplinary	
  seclusion	
  is	
  no	
  longer	
  imposed	
  in	
  response	
  to	
   youth	
  violence,	
  consequences	
  for	
  misconduct	
  needed	
  to	
  be	
  found	
  among	
  the	
   options	
  available	
  via	
  SBBMS.	
  These	
  consequences	
  now	
  rely	
  on	
  activity	
  restrictions	
   and	
  time-­‐limited	
  suspensions	
  of	
  various	
  incentives	
  earned	
  under	
  the	
  program.	
   Shifting	
  responsibility	
  for	
  sanctioning	
  misconduct	
  to	
  SBBMS,	
  via	
  the	
  IDTs,	
  meant	
   that	
  the	
  facilities	
  needed	
  new	
  procedures	
  for	
  imposing	
  and	
  monitoring	
  the	
   completion	
  of	
  sanctions.	
  The	
  Monitor	
  recommended	
  that	
  the	
  facility	
  identify	
   ways	
  to	
  ensure	
  that	
  consequences	
  for	
  misconduct—once	
  very	
  visible	
  because	
   youth	
  were	
  on	
  seclusion,	
  but	
  now	
  somewhat	
  hidden	
  because	
  youth	
  continued	
  to	
   be	
  engaged	
  in	
  normal	
  programming—were	
  evident	
  to	
  staff	
  to	
  combat	
  the	
   sentiment	
  that	
  youth	
  were	
  not	
  being	
  held	
  accountable	
  because	
  they	
  were	
  no	
   longer	
  placed	
  in	
  disciplinary	
  seclusion.	
  At	
  Cuyahoga	
  Hills,	
  this	
  was	
  accomplished	
   by	
  posting	
  a	
  list	
  of	
  incidents,	
  along	
  with	
  the	
  sanctions	
  imposed,	
  in	
  the	
  staff	
   briefing	
  room	
  each	
  week.	
  This	
  strategy	
  helped	
  staff	
  to	
  buy-­‐in	
  to	
  the	
  sanctioning	
   process	
  envisioned	
  by	
  the	
  Grid	
  and	
  the	
  Path	
  to	
  Safer	
  Facilities	
  initiative.	
  	
   	
   At	
  Indian	
  River,	
  the	
  SBBMS	
  Coordinator	
  has	
  done	
  a	
  spectacular	
  job	
  helping	
  IDTs	
  to	
   identify	
  sanctions	
  that	
  involve	
  learning	
  activities.	
  This	
  follows	
  best-­‐practice	
   research	
  that	
  shows	
  that	
  deterring	
  misconduct	
  is	
  only	
  part	
  of	
  the	
  equation	
  and	
  is	
   unlikely	
  to	
  create	
  lasting	
  behavior	
  change	
  without	
  an	
  equal	
  focus	
  on	
  teaching	
  the	
   youth	
  “replacement	
  behaviors.”	
  Stated	
  simply,	
  the	
  Coordinator	
  asks	
  the	
  IDT	
  to	
   identify	
  the	
  opposite	
  behavior	
  and	
  to	
  require	
  the	
  youth	
  to	
  learn	
  and	
  demonstrate	
   it	
  over	
  a	
  period	
  of	
  time.	
  For	
  example,	
  if	
  a	
  youth	
  threatens	
  and	
  curses	
  a	
  staff,	
  he	
   must	
  discuss	
  three	
  of	
  that	
  staff’s	
  positive	
  attributes	
  in	
  front	
  of	
  the	
  unit	
  group	
   meeting	
  each	
  day	
  for	
  a	
  week.	
  A	
  thorough	
  accounting	
  of	
  SBBMS	
  changes	
  is	
  beyond	
   the	
  scope	
  of	
  this	
  report,	
  but	
  the	
  process	
  of	
  its	
  reformulation	
  is	
  mentioned	
  to	
   highlight	
  DYS’	
  holistic	
  approach	
  to	
  implementing	
  the	
  reforms	
  required	
  by	
  the	
   Grid.	
  	
   	
   One	
  of	
  the	
  concerns	
  that	
  came	
  with	
  abolishing	
  the	
  practice	
  of	
  disciplinary	
   seclusion	
  was	
  that	
  disciplinary	
  hearing	
  officers	
  might	
  begin	
  to	
  rely	
  on	
  even	
  more	
   punitive	
  sanctions	
  in	
  response	
  to	
  youth	
  violence.	
  Among	
  the	
  options	
  available	
  to	
   hearing	
  officers	
  is	
  to	
  recommend	
  Intervention	
  Time	
  (IT),	
  which	
  extends	
  the	
   youth’s	
  length	
  of	
  stay	
  at	
  the	
  facility	
  once	
  imposed	
  by	
  the	
  Release	
  Authority.	
  When	
   revising	
  the	
  Disciplinary	
  Policy,	
  DYS	
  had	
  the	
  foresight	
  to	
  place	
  limits	
  on	
  the	
  use	
  of	
   IT	
  to	
  ensure	
  that	
  the	
  pendulum	
  did	
  not	
  swing	
  further	
  into	
  the	
  punitive	
  realm.	
  

	
  

26.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 27 of 34 PAGEID #: 3185
	
  

These	
  limits	
  were	
  effective	
  in	
  combating	
  the	
  application	
  of	
  greater	
  amounts	
  of	
  IT	
   in	
  the	
  absence	
  of	
  disciplinary	
  seclusion.	
  DYS	
  collected	
  data	
  on	
  the	
  use	
  of	
  IT	
  six	
   months	
  before	
  and	
  after	
  the	
  Grid	
  was	
  implemented.	
  The	
  results	
  are	
  presented	
   below:	
   	
  

IT	
  Recommended	
  Before	
  and	
  After	
  Disciplinary	
  Policy	
  was	
  Implemented	
  

Facility	
  

Before	
  (#	
  Days)	
  

After	
  (#	
  Days)	
  

%	
  decrease	
  

Circleville	
  

10,075	
  

927	
  

-­‐91%	
  

Cuyahoga	
  Hills	
  

5,978	
  

1,753	
  

-­‐71%	
  

Indian	
  River	
  

22,150	
  

1,420	
  

-­‐94%	
  

DYS	
  TOTAL	
  

38,203	
  

4,100	
  

-­‐89%	
  

*Before	
  spans	
  March	
  1,	
  2014	
  to	
  August	
  31,	
  2014.	
  After	
  spans	
  September	
  1,	
  2014	
  to	
  March	
  1,	
  2015	
  
	
   As	
  shown,	
  the	
  number	
  of	
  days	
  of	
  IT	
  recommended	
  by	
  facility	
  hearing	
  officers	
   decreased	
  drastically—89%—in	
  the	
  six-­‐month	
  period	
  following	
  the	
   implementation	
  of	
  the	
  new	
  Disciplinary	
  Policy.	
  These	
  data	
  are	
  offered	
  in	
  further	
   support	
  of	
  the	
  drastic	
  changes	
  implemented	
  in	
  DYS’	
  approach	
  to	
  managing	
  youth	
   behavior	
  since	
  the	
  Court	
  Order	
  was	
  imposed.	
  	
   	
   Finally,	
  DYS	
  recognized	
  that	
  while	
  Column	
  B	
  created	
  changes	
  in	
  the	
  system’s	
   response	
  to	
  youth	
  violence,	
  and	
  while	
  Columns	
  A	
  &	
  C	
  addressed	
  the	
  mental	
   health	
  issues	
  that	
  underlie	
  some	
  youth’s	
  involvement	
  in	
  aggressive	
  behavior,	
  a	
   significant	
  proportion	
  of	
  youth	
  violence	
  in	
  DYS	
  facilities	
  is	
  driven	
  by	
  youth’s	
  gang	
   involvement,	
  their	
  attempts	
  to	
  recruit	
  other	
  youth,	
  and	
  youth’s	
  attempts	
  to	
  resist	
   the	
  pressure	
  imposed	
  by	
  their	
  gang-­‐involved	
  peers.	
  For	
  this	
  reason,	
  DYS	
  beefed	
   up	
  its	
  gang	
  intelligence	
  and	
  intervention	
  resources.	
  	
   	
   Every	
  facility	
  has	
  a	
  Gang	
  Coordinator.	
  Because	
  the	
  individuals	
  who	
  serve	
  this	
  role	
   at	
  each	
  facility	
  have	
  different	
  strengths	
  and	
  challenges,	
  they	
  were	
  asked	
  to	
   articulate	
  goals	
  and	
  create	
  a	
  work	
  plan	
  that	
  highlighted	
  the	
  approach	
  to	
  be	
  taken	
   to	
  combat	
  gangs’	
  influence	
  in	
  own	
  facility.	
  Circleville’s	
  approach	
  has	
  centered	
  on	
   ways	
  to	
  help	
  gang-­‐involved	
  youth	
  identify	
  the	
  ways	
  in	
  which	
  gang-­‐related	
   violence	
  stands	
  in	
  the	
  way	
  of	
  reaching	
  their	
  goals.	
  The	
  first	
  class	
  of	
  The	
  Power	
  of	
   Peace	
  (POP)	
  included	
  58	
  youth	
  who	
  had	
  influence	
  over	
  other	
  youth	
  (e.g.,	
  STG	
   leaders,	
  physical	
  dominance,	
  cognitive	
  edge).	
  Throughout	
  the	
  program’s	
  40-­‐days,	
   only	
  20	
  of	
  these	
  youth	
  engaged	
  in	
  a	
  subsequent	
  AOV;	
  in	
  other	
  words,	
  two-­‐thirds	
   abstained	
  from	
  aggressive	
  behavior.	
  Interviews	
  with	
  participating	
  youth	
  indicated	
   their	
  incentive	
  to	
  do	
  so,	
  in	
  large	
  part,	
  was	
  to	
  protect	
  their	
  ability	
  to	
  participate	
  in	
   the	
  POP	
  program.	
  A	
  lunchtime	
  program	
  for	
  STG	
  shot-­‐callers	
  was	
  also	
  created	
  to	
   interfere	
  in	
  their	
  ability	
  to	
  communicate	
  and	
  issue	
  orders	
  during	
  the	
  mid-­‐day	
   break	
  in	
  the	
  dormitory.	
  Finally,	
  the	
  facility	
  plans	
  to	
  implement	
  a	
  group	
  to	
  help	
   unaffiliated	
  youth	
  build	
  resistance	
  skills	
  and	
  strategies.	
  The	
  charisma	
  and	
  youth-­‐ focused	
  approach	
  of	
  Circleville’s	
  Gang	
  Coordinator	
  is	
  an	
  enormous	
  asset.	
  	
   	
   Indian	
  River	
  and	
  Cuyahoga	
  Hills	
  were	
  similar	
  to	
  each	
  other	
  in	
  their	
  focus	
  on	
   identifying	
  youth	
  who	
  have	
  not	
  yet	
  affiliated	
  and	
  who	
  are	
  targeted	
  by	
  gang-­‐

	
  

27.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 28 of 34 PAGEID #: 3186
	
  

involved	
  youth’s	
  efforts	
  to	
  recruit.	
  Indian	
  River	
  assigns	
  mentors	
  to	
  these	
  youth	
  to	
   provide	
  additional	
  support	
  for	
  their	
  resistance	
  efforts.	
  The	
  Gang	
  Coordinators	
  at	
   both	
  facilities	
  also	
  participated	
  in	
  IDT	
  meetings	
  in	
  order	
  to	
  ensure	
  that	
  heavily	
   gang-­‐involved	
  youth’s	
  behavior	
  gets	
  brought	
  into	
  the	
  treatment	
  planning.	
  These	
   two	
  Gang	
  Coordinators	
  are	
  very	
  focused	
  on	
  gathering	
  and	
  sharing	
  information	
   about	
  gang	
  involvement	
  so	
  that	
  IDTs	
  and	
  individual	
  staff	
  can	
  begin	
  to	
  handle	
  the	
   issues	
  directly	
  in	
  their	
  interactions	
  with	
  the	
  youth.	
  	
   	
   DYS	
  went	
  far	
  beyond	
  the	
  parameters	
  of	
  the	
  Grid	
  to	
  address	
  youth	
  violence	
  and	
   the	
  system’s	
  response	
  to	
  it.	
  In	
  so	
  doing,	
  they	
  no	
  doubt	
  strengthened	
  the	
   implementation	
  of	
  the	
  new	
  policies	
  because	
  the	
  changes	
  were	
  seen	
  as	
  part	
  of	
  a	
   much	
  larger	
  process	
  designed	
  to	
  improve	
  staff	
  and	
  youth	
  safety	
  and	
  to	
  improve	
   positive	
  youth	
  outcomes.	
  	
  

Compliance	
   The	
  Court	
  Order	
  requires	
  DYS	
  to	
  meet	
  the	
  each	
  of	
  the	
  performance	
  measures	
  at	
   Assessment	
   the	
  required	
  level	
  each	
  month	
  for	
  six	
  months.	
  	
  

Monitor’s	
   Assessment	
  

Although	
  DYS	
  did	
  not	
  meet	
  some	
  of	
  the	
  performance	
  measures	
  at	
  the	
  required	
   level	
  throughout	
  the	
  entire	
  six-­‐month	
  period,	
  the	
  Monitor	
  believes	
  DYS	
  has	
   substantially	
  complied	
  with	
  the	
  requirements	
  of	
  Column	
  B	
  of	
  the	
  grid.	
  	
   	
   The	
  main	
  area	
  in	
  which	
  performance	
  levels	
  were	
  not	
  as	
  high	
  as	
  expected	
  was	
  in	
   the	
  quality	
  of	
  the	
  Safe	
  to	
  Release	
  interviews.	
  As	
  noted	
  in	
  section	
  B.5,	
  above,	
  the	
   STR	
  intervention	
  underwent	
  several	
  changes	
  in	
  process,	
  content	
  and	
  monitoring	
   strategy	
  throughout	
  the	
  six-­‐month	
  period.	
  The	
  final	
  product	
  appears	
  to	
  allow	
   sufficient	
  time	
  for	
  the	
  interviews	
  to	
  be	
  conducted	
  by	
  staff	
  who	
  are	
  trained	
  to	
   engage	
  youth	
  in	
  substantive	
  discussions.	
  The	
  interview	
  form	
  itself	
  asks	
  pointed	
   questions	
  designed	
  to	
  help	
  the	
  youth	
  gain	
  insight	
  into	
  his	
  behavior	
  and	
  how	
   future	
  aggressive	
  behavior	
  could	
  be	
  avoided.	
  Those	
  overseeing	
  the	
  process	
  at	
   both	
  the	
  Central	
  Office	
  and	
  facility	
  level	
  clearly	
  understand	
  the	
  overall	
  purpose	
   and	
  goals	
  of	
  the	
  STR	
  process	
  and	
  are	
  well	
  suited	
  to	
  continue	
  to	
  push	
  for	
  higher	
   quality.	
  STR	
  interviews	
  completed	
  in	
  March	
  and	
  April	
  2015	
  met	
  the	
  90%	
   performance	
  objective	
  at	
  all	
  three	
  facilities.	
  For	
  these	
  reasons,	
  the	
  Monitor	
  does	
   not	
  feel	
  that	
  her	
  continued	
  oversight	
  is	
  necessary	
  to	
  ensure	
  that	
  DYS	
  continues	
  to	
   faithfully	
  implement	
  the	
  reforms	
  required	
  by	
  Column	
  B	
  of	
  the	
  grid.	
  	
   	
   Finally,	
  DYS	
  has	
  developed	
  and	
  implemented	
  an	
  internal	
  Quality	
  Assurance	
   process	
  that	
  examines	
  the	
  duration	
  of	
  seclusion	
  episodes,	
  the	
  accumulation	
  of	
   seclusion	
  on	
  individual	
  youth,	
  and	
  the	
  quality	
  and	
  timeliness	
  of	
  the	
  STR	
  process.	
   From	
  Central	
  Office,	
  monthly	
  data	
  are	
  reviewed,	
  outcomes	
  are	
  summarized,	
  and	
   results	
  are	
  presented	
  to	
  the	
  facility	
  Superintendents	
  each	
  month.	
  These	
   summaries	
  were	
  also	
  shared	
  with	
  the	
  Monitor.	
  All	
  three	
  facilities	
  also	
  conduct	
  on-­‐ site	
  QA	
  of	
  the	
  STR	
  forms,	
  either	
  via	
  a	
  multi-­‐disciplinary	
  team	
  during	
  morning	
   incident	
  reviews	
  or	
  by	
  the	
  Operations	
  Administrator	
  in	
  the	
  daily	
  review	
  of	
  AOVs.	
  If	
   problems	
  are	
  identified,	
  the	
  facility	
  Superintendents	
  are	
  responsible	
  for	
   constructing	
  a	
  Corrective	
  Action	
  Plan.	
  Moving	
  forward,	
  the	
  facilities	
  will	
  utilize	
   Performance	
  Based	
  Standards’	
  (PbS)	
  Facility	
  Improvement	
  Plan	
  (FIP)	
  structure	
  to	
   make	
  improvements.	
  	
  

	
  

28.	
  

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   As	
  noted	
  above,	
  the	
  Monitoring	
  Team	
  participated	
  in	
  bi-­‐weekly	
  calls	
  held	
  among	
   the	
  Superintendents	
  and	
  Central	
  Office	
  staff	
  during	
  which	
  a	
  healthy	
  competition	
   became	
  apparent.	
  Bragging	
  rights	
  are	
  given	
  when	
  large	
  proportions	
  of	
  the	
   seclusion	
  episodes	
  are	
  terminated	
  within	
  4-­‐hours,	
  though	
  the	
  Superintendents	
   are	
  quick	
  to	
  up	
  the	
  ante	
  with	
  “Well,	
  most	
  of	
  ours	
  are	
  going	
  to	
  be	
  within	
  2	
  hours	
   next	
  month.”	
  Furthermore,	
  they	
  often	
  comment	
  that	
  a	
  passing	
  grade	
  on	
  the	
   quality	
  of	
  the	
  STR	
  interviews	
  is	
  no	
  longer	
  sufficient,	
  as	
  they	
  are	
  striving	
  for	
  100%	
   perfection,	
  “no	
  matter	
  what	
  Shari	
  [the	
  QA	
  auditor]	
  says.”	
  Thus,	
  the	
  structured	
  QA	
   process	
  and	
  the	
  culture	
  change	
  among	
  the	
  facility	
  staff	
  in	
  recognizing	
  that	
  their	
   facilities	
  are	
  safer	
  without	
  seclusion	
  will	
  allow	
  DYS	
  to	
  continue	
  their	
  progress	
   without	
  external	
  oversight	
  from	
  the	
  Monitor.	
  	
  

	
  

	
  

	
  

	
  

	
  

	
  

29.	
  

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Column	
  C.	
  Strategies	
  for	
  the	
  Aftermath	
  (Assigned	
  Monitor:	
  Dr.	
  Andrea	
  Weismann)	
  

What	
  the	
   Grid	
   Requires	
  

(C.1)	
  Treatment	
  Plan	
  Review	
   • Within	
  2	
  days	
  of	
  every	
  AOV,	
  the	
  treating	
  clinician/IDT	
  will	
  review	
  the	
   treatment	
  plan	
  to	
  identify	
  antecedents	
  and	
  function	
  of	
  the	
  behavior	
  and	
   to	
  review	
  treatment	
  goals	
  and	
  interventions.	
  If	
  implementation	
  of	
  the	
   existing	
  plan	
  has	
  not	
  been	
  sufficient,	
  it	
  will	
  be	
  fortified.	
  If	
  the	
  existing	
  plan	
   was	
  properly	
  implemented	
  yet	
  ineffective,	
  it	
  will	
  be	
  revised	
  to	
  include	
   additional	
  skill-­‐development	
  or	
  environmental	
  changes.	
  May	
  use	
   Behavior	
  Contract	
  if	
  appropriate.	
  	
   • Intensity	
  of	
  treatment	
  will	
  be	
  increased	
  to	
  3x/week	
  individual	
  sessions	
  for	
   two	
  weeks;	
  daily	
  homework	
  will	
  be	
  assigned.	
  	
  
(C.1)	
  Performance	
  Measures	
   • 90%	
  of	
  youth	
  involved	
  in	
  AOV	
  have	
  a	
  Treatment	
  Plan	
  Review	
  within	
  2	
   days	
  of	
  the	
  incident.	
  	
   • %	
  of	
  cases	
  in	
  which	
  implementation	
  was	
  fortified	
   • %	
  of	
  cases	
  in	
  which	
  interventions	
  were	
  revised	
   o 	
  Above	
  should	
  total	
  100%.	
  Not	
  an	
  option	
  to	
  do	
  nothing.	
  	
  

Monitor’s	
   Assessment	
  

A	
  set	
  of	
  requirements	
  were	
  established	
  to	
  address	
  the	
  mental	
  health	
  needs	
  of	
   youth	
  involved	
  in	
  Acts	
  of	
  Violence	
  (AOV):	
  1)	
  that	
  the	
  Individual	
  Treatment	
  Plan	
   (ITP)	
  would	
  be	
  reviewed	
  within	
  2	
  days	
  to	
  determine	
  if	
  it	
  established	
  goals	
  and	
   objectives	
  that	
  addressed	
  the	
  root	
  causes	
  of	
  the	
  AOVs;	
  and	
  2)	
  that	
  the	
  youth	
  be	
   provided	
  intensified	
  interventions	
  that	
  addressed	
  the	
  root	
  causes	
  of	
  the	
  AOVs.	
   The	
  following	
  tables	
  represent	
  the	
  facilities’	
  compliance	
  with	
  these	
  requirements.	
  	
   	
  

Treatment	
  Plan	
  Review	
  within	
  2	
  Days	
  of	
  Incident	
  

	
  

Aug	
   Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   Mar	
   AVG	
  

Circleville	
  

66%	
   86%	
   100%	
   75%	
   100%	
   ~	
   0%	
   25%	
   65%	
  

Cuyahoga	
  Hills	
  

~	
   100%	
   66%	
   100%	
   66%	
   100%	
   75%	
   100%	
   87%	
  

Indian	
  River	
  

50%	
   60%	
   100%	
   100%	
   ~	
  

~	
   66%	
   100%	
   79%	
  

DYS	
  AVERAGE	
  

58%	
   82%	
   89%	
   92%	
   83%	
   100%	
   71%	
   75%	
   77%	
  

Sample	
  Size:	
  Circleville	
  (n=27),	
  Cuyahoga	
  Hills	
  (n=21),	
  Indian	
  River	
  (n=28);	
  TOTAL	
  DYS	
  n=76	
  

	
   While	
  documentation	
  supports	
  that	
  ITPs	
  were	
  being	
  reviewed,	
  this	
  did	
  not	
  always	
   occur	
  within	
  two	
  days.	
  This	
  was	
  due	
  to	
  weekend	
  coverage	
  and	
  the	
  availability	
  of	
   clinicians	
  involved	
  with	
  the	
  youth.	
  When	
  one	
  looks	
  at	
  the	
  March	
  figures	
  for	
  CHJCF	
   and	
  IRJCF,	
  there	
  is	
  no	
  question	
  that,	
  overall,	
  there	
  has	
  been	
  improvement.	
  	
  As	
  will	
   be	
  noted	
  elsewhere,	
  the	
  small	
  number	
  of	
  youth	
  the	
  grid	
  metrics	
  apply	
  to	
  in	
  any	
   given	
  month	
  skews	
  an	
  understanding	
  of	
  what	
  is	
  really	
  going	
  on	
  on	
  the	
  ground.	
  	
   	
   Subject	
  Matter	
  Expert’s	
  assessment:	
  This	
  Grid	
  requirement	
  is	
  in	
  Substantial	
   Compliance. 	
   	
   	
   	
  

	
  

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What	
  the	
   Grid	
   Requires	
  

	
  

Treatment	
  Plan	
  Intervention	
  Fortified	
  or	
  Revised	
  

	
  

Aug	
   Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   Mar	
   AVG	
  

Circleville	
  

100%	
   57%	
   100%	
   ~	
   100%	
   ~	
   100%	
   100%	
   93%	
  

Cuyahoga	
  Hills	
  

~	
   100%	
   100%	
   50%	
   100%	
   100%	
   100%	
   33%	
   84%	
  

Indian	
  River	
  

66%	
   50%	
   100%	
   ~	
  

~	
  

~	
   66%	
   100%	
   76%	
  

DYS	
  AVERAGE	
  

83%	
   69%	
   100%	
   50%	
   100%	
   100%	
   89%	
   78%	
   84%	
  

Sample	
  Size:	
  Circleville	
  (n=23),	
  Cuyahoga	
  Hills	
  (n=22),	
  Indian	
  River	
  (n=24);	
  TOTAL	
  DYS	
  n=69	
  

	
   Both	
  CJCF	
  and	
  IRJCF	
  achieved	
  100%	
  compliance	
  in	
  March.	
  Both	
  CJCF	
  and	
  CHJF	
   achieved	
  100%	
  compliance	
  in	
  February.	
  CHJCF	
  also	
  achieved	
  100%	
  compliance	
  in	
   December	
  and	
  January.	
  Once	
  again,	
  the	
  resulting	
  percentages	
  required	
  by	
  the	
   metrics	
  of	
  the	
  grid	
  minimize	
  the	
  significant	
  gains	
  DYS	
  has	
  made,	
  which	
  have	
  been	
   substantial.	
  

Central	
  Office	
  has	
  acknowledged	
  that	
  database	
  issues	
  kept	
  them	
  from	
  accurately	
   assessing	
  whether	
  this	
  component	
  of	
  the	
  grid	
  was	
  being	
  complied	
  with.	
  DYS	
   reports	
  that:	
  	
  

“The	
  reports	
  we	
  (now)	
  run	
  show	
  whether	
  the	
  plan	
  was	
  fortified	
  or	
  revised	
  AND	
   that	
  the	
  fortification	
  /	
  revision	
  was	
  properly	
  documented	
  in	
  our	
  database.	
  The	
   documentation	
  of	
  that	
  in	
  the	
  database	
  was	
  not	
  entirely	
  intuitive.	
  As	
  such,	
  many	
   fortifications	
  and	
  revisions,	
  while	
  occurring	
  upon	
  inspection,	
  were	
  not	
  reflected	
  in	
   the	
  database.	
  We	
  recently	
  made	
  a	
  change	
  in	
  how	
  that	
  is	
  recorded	
  in	
  the	
   database—changing	
  where	
  it	
  is	
  recorded	
  so	
  the	
  user	
  does	
  not	
  have	
  to	
  leave	
  one	
   area	
  of	
  the	
  database	
  and	
  open	
  another	
  just	
  to	
  record	
  what	
  they	
  did	
  in	
  the	
  original	
   location,	
  and	
  inserting	
  a	
  forced	
  response	
  so	
  the	
  user	
  will	
  have	
  to	
  tell	
  us	
  what	
  they	
   did	
  or	
  that	
  they	
  did	
  nothing	
  in	
  order	
  to	
  close	
  out.”	
  	
  

It	
  would	
  seem	
  that	
  DYS	
  is	
  poised	
  to	
  report	
  consistent	
  compliance	
  going	
  forward.	
  

Subject	
  Matter	
  Expert’s	
  Assessment:	
  This	
  Grid	
  requirement	
  is	
  in	
  Substantial	
   Compliance	
  
(C.2)	
  Special	
  Review	
  Team	
  (SRT)	
   • Within	
  2	
  days	
  of	
  a	
  youth’s	
  2nd	
  Severe	
  or	
  3rd	
  High	
  severity	
  AOV,	
  he	
  will	
  be	
   referred	
  to	
  the	
  SRT	
  for	
  a	
  clinical	
  staffing,	
  led	
  by	
  the	
  psychologist	
  and	
   specifically	
  focused	
  on	
  understanding	
  and	
  addressing	
  the	
  AOV	
  behavior.	
  	
   • The	
  SRT	
  will	
  function	
  as	
  the	
  IDT	
  until	
  the	
  youth’s	
  behavior	
  improves.	
   • The	
  SRT	
  will	
  explore	
  the	
  causes	
  and	
  functions	
  of	
  the	
  behavior	
  and	
  will	
   prescribe	
  interventions	
  designed	
  to	
  address	
  those	
  causes	
  and	
  functions	
   (e.g.,	
  Intensive	
  Behavior	
  Contract,	
  staff	
  mentor,	
  change	
  unit,	
  skill	
  building	
   work,	
  referral	
  to	
  MH	
  facility,	
  etc.)	
  
(A.2)	
  Performance	
  Measures	
   • Number	
  of	
  youth	
  involved	
  in	
  2	
  Severe	
  or	
  3	
  High	
  AOVs	
  (descriptive	
  data	
   only)	
   • SRT	
  was	
  convened	
  within	
  2	
  days	
  for	
  100%	
  

	
  

31.	
  

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• 90%	
  of	
  the	
  SRTs	
  explored	
  the	
  causes	
  and	
  functions	
  of	
  the	
  behavior	
   • 90%	
  of	
  the	
  SRTs	
  prescribed	
  interventions	
  that	
  addressed	
  those	
  causes	
  
and	
  functions	
  	
  

Monitor’s	
   Assessment	
  

The	
  Special	
  Review	
  Teams	
  (SRTs)	
  were	
  implemented	
  as	
  the	
  strategic	
  clinical	
   intervention	
  for	
  youth	
  who	
  engaged	
  in	
  multiple	
  AOVs	
  within	
  a	
  prescribed	
  period	
   of	
  time.	
  The	
  purpose	
  of	
  the	
  SRT	
  was	
  to	
  delve	
  into	
  the	
  causes	
  and	
  functions	
  of	
  the	
   AOVs	
  and	
  prescribe	
  interventions	
  that	
  would	
  address	
  the	
  root	
  causes.	
  The	
   following	
  tables	
  represent	
  the	
  facilities	
  compliance	
  in	
  holding	
  SRTs	
  within	
  2	
  days	
   of	
  the	
  incident	
  and	
  whether	
  they	
  considered	
  the	
  causes	
  and	
  functions	
  of	
  the	
   behaviors	
  that	
  led	
  to	
  the	
  AOVs.	
  	
   	
  
SRT	
  Convened	
  within	
  2	
  Days	
  of	
  2nd	
  Severe	
  or	
  3rd	
  High	
  Severity	
  AOV	
  

	
  

Aug	
   Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   Mar	
   AVG	
  

Circleville	
  

66%	
   71%	
   100%	
   100%	
   75%	
   ~	
   75%	
   100%	
   84%	
  

Cuyahoga	
  Hills	
  

~	
   100%	
   100%	
   100%	
   66%	
   100%	
   100%	
   100%	
   95%	
  

Indian	
  River	
  

50%	
   70%	
   100%	
   100%	
   ~	
  

~	
   100%	
   75%	
   83%	
  

DYS	
  AVERAGE	
  

58%	
   80%	
   100%	
   100%	
   71%	
   100%	
   92%	
   92%	
   87%	
  

Sample	
  Size:	
  Circleville	
  (n=27),	
  Cuyahoga	
  Hills	
  (n=21),	
  Indian	
  River	
  (n=28);	
  TOTAL	
  DYS	
  n=76	
  

	
   In	
  all	
  instances,	
  the	
  SRT	
  was	
  held	
  within	
  3	
  –	
  4	
  days.	
  The	
  disparity	
  in	
  the	
  timing	
  of	
   what	
  was	
  required	
  and	
  when	
  these	
  outlying	
  instances	
  occurred	
  is	
  explained	
  by	
   the	
  DYS’	
  decision	
  to	
  hold	
  SRT	
  when	
  the	
  involved	
  clinicians	
  were	
  on-­‐site	
  to	
  make	
   the	
  proposed	
  interventions	
  more	
  meaningful.	
  All	
  outlying	
  instances	
  were	
  because	
   of	
  a	
  weekend	
  (or	
  long	
  weekend)	
  intervening.	
  	
  Currently,	
  DYS	
  has	
  amended	
  their	
   process	
  so	
  that	
  SRTs	
  are	
  being	
  held	
  6	
  days	
  a	
  week	
  at	
  each	
  facility.	
  DYS	
  also	
  has	
  an	
  
improved	
  system	
  for	
  identifying	
  youth	
  who	
  have	
  met	
  the	
  SRT	
  threshold	
  

Given	
  the	
  small	
  number	
  of	
  youth	
  (i.e.,	
  4	
  –	
  5)	
  who	
  met	
  the	
  SRT	
  threshold	
  each	
   month,	
  the	
  metrics	
  of	
  the	
  grid	
  seem	
  skewed	
  when	
  applied.	
  Even	
  one	
  “miss”	
   brings	
  the	
  monthly	
  percentage	
  down	
  to	
  75%	
  -­‐	
  80%.	
  	
   	
   Subject	
  Matter	
  Expert’s	
  Assessment:	
  This	
  Grid	
  requirement	
  is	
  in	
  Substantial	
   Compliance	
   	
  

SRT	
  Explored/Prescribed	
  Interventions	
  that	
  Addressed	
  Causes	
  and	
  Functions	
  of	
  Behavior	
  

	
  

Aug	
   Sept	
   Oct	
   Nov	
   Dec	
   Jan	
   Feb	
   Mar	
   AVG	
  

Circleville	
  

33%	
   29%	
   0%	
   50%	
   0%	
   ~	
   75%	
   100%	
   41%	
  

Cuyahoga	
  Hills	
  

~	
   100%	
   100%	
   100%	
   0%	
   100%	
   75%	
   100%	
   82%	
  

Indian	
  River	
  

67%	
   90%	
   100%	
   100%	
   ~	
  

~	
   100%	
   100%	
   93%	
  

DYS	
  AVERAGE	
  

50%	
   73%	
   67%	
   83%	
   0%	
   100%	
   83%	
   100%	
   72%	
  

Sample	
  Size:	
  Circleville	
  (n=27),	
  Cuyahoga	
  Hills	
  (n=21),	
  Indian	
  River	
  (n=28);	
  TOTAL	
  DYS	
  n=76	
  

	
   While	
  interpretation	
  of	
  some	
  documentation	
  was	
  an	
  issue	
  regarding	
  the	
  data	
   reviewed,	
  there	
  is	
  ample	
  evidence	
  that	
  interventions	
  provided	
  did	
  curb	
  instances	
  

	
  

32.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 33 of 34 PAGEID #: 3191
	
  

of	
  youth	
  aggression.	
  	
   	
  
• At	
  CJCF,	
  with	
  a	
  total	
  of	
  27	
  youth	
  meeting	
  the	
  SRT	
  threshold	
  over	
  the	
  six-­‐ month	
  period,	
  there	
  were	
  only	
  7	
  repeaters,	
  with	
  4	
  of	
  these	
  meeting	
  the	
   threshold	
  for	
  two	
  months.	
  	
  That	
  means	
  that	
  of	
  the	
  27	
  youth	
  who	
  met	
  the	
   threshold	
  for	
  one	
  month,	
  74%	
  did	
  not	
  engage	
  in	
  AOVs	
  subsequent	
  to	
  	
  	
  	
   receiving	
  the	
  more	
  intensive	
  treatment.	
  	
   	
  
• At	
  CHJCF,	
  a	
  total	
  of	
  20	
  youth	
  met	
  the	
  SRT	
  threshold	
  during	
  the	
  6-­‐month	
   review.	
  Of	
  these,	
  only	
  4	
  youth	
  met	
  the	
  threshold	
  for	
  two	
  months.	
  That	
   means	
  that	
  80%	
  of	
  the	
  youth	
  did	
  not	
  engage	
  in	
  repeated	
  AOVs	
  following	
   the	
  intensive	
  interventions.	
  	
  	
  
	
   • At	
  IRJCF,	
  a	
  total	
  of	
  14	
  youth	
  met	
  the	
  SRT	
  threshold	
  over	
  the	
  6-­‐month	
   period.	
  Of	
  these,	
  only	
  one	
  repeated	
  for	
  a	
  second	
  month.	
  This	
  means	
  that	
   the	
  intensive	
  interventions	
  were	
  successful	
  in	
  curbing	
  youth	
  aggression	
   93%	
  of	
  the	
  time.	
  
	
   Although	
  it	
  is	
  impossible	
  to	
  say	
  for	
  certain	
  how	
  many	
  AOVs	
  are	
  attributable	
  to	
   STG	
  activity	
  among	
  youth	
  on	
  the	
  MHCL,	
  it	
  is	
  fair	
  to	
  say	
  that	
  this	
  figure	
  is	
   substantial.	
  From	
  information	
  available	
  in	
  the	
  database,	
  it	
  would	
  appear	
  that	
  at	
   least	
  25%	
  of	
  AOVs	
  committed	
  at	
  CHJCF	
  are	
  due	
  to	
  gang	
  involvement.	
  At	
  IRJCF,	
  this	
   figure	
  rises	
  to	
  86%.	
  CJCF	
  had	
  the	
  lowest	
  rate	
  of	
  STG	
  activity	
  with	
  only	
  about	
  15%	
   of	
  youth	
  involved.	
  	
  AOV	
  figures	
  from	
  January	
  to	
  February	
  show	
  more	
  than	
  a	
  50%	
   decrease	
  in	
  activity	
  (from	
  56	
  in	
  January	
  to	
  25	
  in	
  February).	
  The	
  new	
  program	
   implemented	
  at	
  CJCF,	
  The	
  Power	
  of	
  Peace,	
  seems	
  to	
  have	
  made	
  a	
  critical	
   difference	
  in	
  the	
  reduction	
  of	
  gang	
  activity	
  and	
  endorsement.	
  We	
  look	
  forward	
  to	
   its	
  implementation	
  at	
  the	
  other	
  facilities.	
  	
  
	
   	
   Subject	
  Matter	
  Expert’s	
  Assessment:	
  This	
  Grid	
  requirement	
  is	
  in	
  Substantial	
   Compliance	
  

Other	
  

The	
  Monitors	
  regularly	
  interacted	
  with	
  DYS	
  administrators	
  and	
  facility	
  staff	
  via	
  bi-­‐

Information	
   weekly	
  conference	
  calls	
  and	
  frequent	
  email	
  exchanges.	
  The	
  Monitoring	
  Team	
  also	
  

participated	
  in	
  two	
  one-­‐day	
  site	
  visits	
  to	
  each	
  facility,	
  one	
  in	
  October	
  2014	
  and	
  

one	
  in	
  March	
  2015.	
  Contextual	
  information	
  and	
  findings	
  from	
  site	
  visits	
  are	
  

discussed	
  here.	
  	
  

Monitor’s	
   Assessment	
  

The	
  improved	
  quality	
  of	
  mental	
  health	
  care	
  at	
  the	
  facilities	
  is	
  supported	
  by	
  the	
   fact	
  that	
  very	
  few	
  youth	
  on	
  the	
  MHCL	
  engage	
  in	
  AOVs	
  at	
  a	
  frequency	
  that	
  meets	
   the	
  threshold	
  for	
  an	
  SRT.	
  We	
  can	
  assume,	
  as	
  noted	
  in	
  Column	
  A,	
  that	
  between	
  60	
   and	
  70	
  youth	
  at	
  each	
  facility	
  are	
  on	
  the	
  MHCL.	
  With	
  only	
  approximately	
  5	
  youth	
   per	
  month	
  engaging	
  in	
  AOVs	
  sufficient	
  to	
  meet	
  the	
  SRT	
  threshold,	
  which	
  means	
   that	
  93%	
  of	
  youth	
  on	
  the	
  MHCL	
  are	
  doing	
  well	
  with	
  the	
  programs	
  and	
  activities	
   aimed	
  at	
  addressing	
  their	
  needs.	
  Relatively	
  few	
  of	
  the	
  remaining	
  7%	
  went	
  on	
  to	
   commit	
  frequent	
  AOVs	
  in	
  multiple	
  months.	
  	
  	
   	
  

	
  

33.	
  

Case: 2:08-cv-00475-ALM-MRA Doc #: 155 Filed: 06/16/15 Page: 34 of 34 PAGEID #: 3192
	
  
Further,	
  opportunities	
  to	
  sit	
  in	
  on	
  both	
  Inter-­‐Disciplinary	
  Teams	
  (IDTs)	
  and	
  SRTs	
  at	
   all	
  facilities	
  gives	
  rise	
  to	
  the	
  observation	
  that	
  the	
  quality	
  of	
  clinical	
  discourse	
  has	
   been	
  enhanced	
  significantly	
  over	
  the	
  last	
  6	
  months.	
   	
   The	
  case	
  conference	
  process	
  that	
  was	
  implemented	
  by	
  DYS	
  to	
  bring	
  together	
  the	
   mental	
  health	
  subject	
  matter	
  experts	
  from	
  the	
  Monitoring	
  Team	
  and	
  DYS	
   behavioral	
  staff	
  to	
  review	
  the	
  most	
  difficult	
  cases	
  (i.e.,	
  cases	
  that	
  achieved	
  the	
   SRT	
  threshold	
  multiple	
  times	
  a	
  month	
  in	
  multiple	
  months)	
  has	
  proven	
  most	
   productive.	
  	
   	
   To	
  be	
  sure,	
  the	
  constellation	
  of	
  strategies	
  implemented	
  as	
  part	
  of	
  the	
  Path	
  to	
   Safer	
  Facilities,	
  contributes	
  to	
  the	
  huge	
  successes	
  now	
  being	
  experienced	
  by	
  DYS.	
  
Compliance	
   The	
  Court	
  Order	
  requires	
  DYS	
  to	
  meet	
  the	
  each	
  of	
  the	
  performance	
  measures	
  at	
   Assessment	
   the	
  required	
  level	
  each	
  month	
  for	
  six	
  months.	
  	
  
Monitor’s	
   Individual	
  institutions	
  have	
  come	
  into	
  substantial	
  compliance	
  with	
  regard	
  to	
  all	
   Assessment	
   performance	
  measures	
  in	
  Column	
  C	
  of	
  the	
  Grid.	
  	
   	
  

	
  

34.	
  

 Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 1 of 44 PAGEID #: 2661
Second Progress Unit Status Report
Contributors: Amy Ast, Bureau Chief of Facility Operations Laura Dolan, Bureau Chief of Facility Programs Dr. Dachowski, Administrative Psychiatry Dr. Gregory, Behavioral Health Services Administrator Vanessa Tower, Behavioral Health Services Administrator Alexis Witte, Behavioral Health Services Administrator Andrea Jones, Superintendent of SJCF Shannon Komisarek, Direct Deputy of SJCF Jack Vicencio, Program Deputy of SJCF Dr. Hamning, Psychology Supervisor of SJCF
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Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 2 of 44 PAGEID #: 2662
INTRODUCTION The Ohio Department of Youth Services (DYS) and the U.S. Department of Justice (DOJ) negotiated and agreed upon a proposed Consent Order to mediate a process for dispute resolution regarding the PROGRESS Unit at the Scioto Juvenile Correctional Facility, as related to the United Sates v. Ohio and S.H. v. Reed Stipulations. The Consent Order, which was signed by the Court on January 18, 2013 (at which time it was also incorporated into a broader settlement between DYS and the S.H. plaintiff class), sets standards related to PU policies, admissions screening, programming, out‐of‐room time, staffing, treatment planning, length of stay, and promotion and demotion between phases. The first PU Status Report was authored by Drs. Kelly Dedel and Daphne Glindmeyer and was submitted to the court on March 27, 3013.
PURPOSE AND STRUCTURE OF THE REPORT This is the 2nd Status Report and it covers the time period from March 1, 2013 to May 31, 2013. The Parties and Monitors agreed that DYS would be responsible for the data collection, analysis, and completion of this 2nd report. The goal of this report is to act as follow‐up to the first report and to provide documentation and assessment for each of the PU standards, as well as an explanation for standards that are not in compliance. DYS has created action plans for how we will continue to address those areas that are not in Substantial Compliance. DYS was very careful to replicate the Quality Assurance (QA) format of the first report. Our hope with this format is that the State will be able to showcase competency with internal quality assurance through the use of concrete, real time examples. For each of the seven substantive areas in the Order, the report includes the following:
 Status: ODYS used a three‐level system for each substantive area: either substantial compliance, partial compliance or not in substantial compliance. This three‐tiered compliance scheme was agreed to by all Parties, with the recognition that DYS cannot come into compliance with the Consent Order until it has reached substantial compliance with all of the PU standards.
 Standard: A statement of what the State attempted to achieve in the particular area based on the requirements of the Court Order. Each substantive area has multiple standards under it. They are “should be” statements, rather than a current reflection of the PROGRESS Unit.
 Methodology: The source of the data that was used to assess performance toward the standard.
 Analysis and Interpretation: A thorough presentation of the data collected for the timeframe (with the option of providing June data as well) with an interpretation (including trends and red flags) of what the data implies regarding the extent to which the standard is being achieved. Additionally, this section offers an explanation for inconsistencies in the data and reasons behind an apparent lack of compliance in regards to extenuating circumstances.
 Conclusions and Recommendations: Indicates the status of compliance for the standard, by briefly summarizing the findings from the analysis and interpretation. Statements regarding what
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Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 3 of 44 PAGEID #: 2663
shall occur in order for the standard to be achieved in areas that are not yet compliant are listed as recommendations. An accurate description of DYS’s response to the suggested Quality Improvement Plan (QIP) suggested by the Monitors in the 1st Report is addressed in the discussion for each standard. For areas where the State finds itself still not in compliance with a certain standard, the State’s next steps of action will be apparent. It is DYS’s hope that in doing so, we are demonstrating our ability and acceptance of the responsibility for ongoing internal monitoring of the PU. DYS provided a draft of this report to the Monitors and to the plaintiffs in the S.H. and DOJ cases. The Monitors also had access to the underlying source data DYS used to draft the report. Each party provided comments to DYS, which were then used to revise the draft into this final report. Under separate cover, the Monitors will submit a Compliance Report to the Court that assigns compliance ratings, summarizes feedback and impressions and discusses any ongoing concerns. The State believes that this 2nd report shows significant progress in all standards. Although we were not able to grade ourselves as “substantially compliant” in all areas, we have pinpointed the areas in need of improvement and created a realistic plan to ameliorate those issues. As stated in the 1st report, “the PU is a radically different program than it was a year ago” and with this 2nd report, DYS demonstrates that it has tied up some procedural loose ends and improved the substance and quality of the treatment. Furthermore, this 2nd report provides insight into the future actions that will continue to improve the quality and purpose of this unit. Although this report shows many improvements in the PU from the 1st report, DYS is aware that much work remains. For example, we are still struggling with prolonged length of stay on the PU as well as quality Integrated Treatment Plans and Interdisciplinary Team meeting minutes. Having fixed many of the procedural loose ends, the State has been able to and will continue to focus on the quality of services provided to the youth on the PU. Certain themes, such as ITP goals and objectives and IDT minutes lacking the essential information continued to emerge. Again, although a work in progress, the State believes that this report demonstrates a continuing commitment to and improvement in the quality of provided services. The State sincerely hopes that this report will reveal the seriousness with which we approached this task, incorporated the recommendations of the Monitors, and are committed to continued improvement.
X[II.9] Admissions Screening Status: Substantial Compliance
(1) Standard: Admissions Screening. The PU accepts only those youth who can be reasonably expected to respond positively to the type of program and treatment services on the Unit. As such, their behavior and mental health history is reviewed to ensure that the behaviors are not the symptoms of mental illness (including undiagnosed or untreated mental illness). Youth with the following DSM‐IV diagnoses or conditions are excluded from placement on the PU:
 Thought Disorders  Mood Disorders
3

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 4 of 44 PAGEID #: 2664
 Developmental Disorders  Recurring self‐injurious behavior or suicidal ideation
Methodology: The following information was used to determine compliance with the standard:  PROGRESS Placement Table  Mental Health / Cognitive Skills Screen for Placement on Progress Unit
Analysis and Interpretation. The PROGRESS Placement table included the following information: youth’s name; identification number; facility; date the PU packet was received; adjudicated offense; mental health caseload status; educational program (e.g. regular or special education); DSM‐IV diagnoses; reason for request for PU placement; outcome of request (e.g. either approved or denied); the rationale for the approval/denial of placement; and the date of transfer to the unit.
The Mental Health / Cognitive Skills Screen for Placement on the Progress Unit included the following information: youth’s name; DYS number; referring facility; date of birth; mental health caseload status; primary clinician’s name; DSM‐IV diagnoses; 90 day review of psychotropic medication; synopsis of mental health condition; review of cognitive skills; appraisal of adaptive skills; and recommendations.
Five juveniles were referred to the Administrative Psychiatrist for placement onto the Progress Unit from March to May 2013. Two juveniles (40%) were denied by the Facility Resource Administrator prior to their referral packets reaching the Administrative Psychiatrist (OJ and DH). These 2 youth had diagnoses contained in the exclusionary criteria, and thus were not appropriate for the unit. One of the 2 youth denied for placement was also on an IEP for Emotional Disturbance (ED). Consequently, their information was excluded from this analysis. The remaining 3 youth (60%) were accepted onto the Unit.
The number of referrals remained the same from the previous quarter (there were 5 referrals made during the 1st and 2nd quarters). In addition, the number of juveniles accepted onto the unit remained the same from the previous quarter (there were 3 youth admitted to the unit during 1st and 2nd quarters).
None of the juveniles admitted during the 2nd quarter had the diagnoses contained in the exclusionary criteria and were not on the mental health caseload. None of the youth were prescribed psychotropic medication at the time of admission to the unit. Additionally, none of them had documented cognitive limitations or adaptive functioning impairments that would have contraindicated their placement onto the unit. Two of the youth admitted (66%) did have an IEP for Emotional Disturbance (ED).
Individual profiles of the youth admitted are as follows:
JA was not on the mental health caseload and was not prescribed psychotropic medication at the time of the referral. His diagnoses included; Conduct Disorder, Sexual Abuse of a Child, Cannabis Abuse, and Alcohol Abuse. None of these diagnoses are contained in the exclusion list. In addition, JA does not
4

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 5 of 44 PAGEID #: 2665
have an IEP or difficulties with adaptive skills. Furthermore, there were no contraindications to his placement onto the progress unit.
TH was the 2nd youth admitted to the Progress Unit during 2nd quarter. TH was not on the mental health caseload at the time of the referral and was not prescribed psychotropic medication. His diagnoses were Conduct Disorder and Cannabis Abuse. None of these diagnoses are contained in the exclusionary criteria for placement onto the Progress Unit. In addition, he did not exhibit difficulties with adaptive functioning (with the exception of continued aggressive behaviors towards staff and peers). This youth did have an IEP for Emotional Disturbance (ED). His intellectual functioning was estimated as normative at the time of his admission to the Progress Unit. It was noted that cognitive testing was incomplete due to the youth’s lack of compliance with the assessment process. Additionally, there were no apparent contraindications to TH’s placement on the Progress Unit.
AF was the 3rd youth admitted to the Progress Unit during the 2nd quarter. AF was not on the mental health caseload at the time of the referral. His diagnoses included; Conduct Disorder, Reactive Attachment Disorder, and Antisocial Personality Disorder. None of these diagnoses are contained in the exclusion list for the Progress Unit. AF was on an IEP with the classification of Emotional Disturbance (ED). Results of IQ testing placed AF in the Average Range of intellectual functioning with no significant limitations in adaptive functioning. AF’s weakest area was his aggressive behavior against staff and peers. There were no apparent contraindications for his placement on the Progress Unit at time of admission.
*Please see the chart on the subsequent page.

Youth Diagnoses

Phase One

Phase Two

Transition

5

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 6 of 44 PAGEID #: 2666

JA

Conduct Disorder, Sexual He was placed

Abuse of a Child, Cannabis on P1 5/31/13

Abuse, and Alcohol Abuse.

TH

Conduct Disorder and

Cannabis Abuse.

He was on P1 from 3/14/13 to 3/28/13
14 days

He was on P2 from 3/28/13 to 4/24/13 27 days

He was on T1 from 4/24/13 to 5/25/13 31 days

He returned to P1 on 5/25/13 for an AOV

AF

Conduct Disorder, Reactive He was on P1

He was on P2

Attachment Disorder, and from 3/18/13 to from 4/17/13 to

Antisocial Personality

4/17/13

5/31/13

Disorder.

30 days

44 days

He returned to P1 on 5/31/13 for an AOV
Table: The dates of service are current as of 5/31/13.

JH was one of the 2 youth who were denied placement onto the unit. JH was on the mental health caseload and was prescribed psychotropic medication. His mental health diagnoses included the following: Depressive Disorder Not Otherwise Specified; Post Traumatic Stress Disorder; Conduct Disorder; and Cannabis Abuse. The recommendation was for the treatment providers to continue to work with him around trauma issues and to continue to reinforce his behavior contract.
RB was the 2nd youth who was denied placement onto the Progress Unit. RB was on the mental health caseload and prescribed psychotropic medication. His mental health diagnoses included; Mood Disorder, Not Otherwise Specified; Conduct Disorder; and Attention Deficit Hyperactivity Disorder. RB’s intellectual functioning fell within the Average Range and he did not have adaptive functioning impairments. However, he had an IEP for Emotional Disturbance (ED). RB was not on an intensive behavior contract at the time of the referral. The recommendation was for the treatment providers to develop and implement an intensive behavior contract for him.

Conclusions and Recommendations. The rate of referrals to the Unit has remained stable for the past 6 months (5 youth per quarter). During the current quarter, no youth with exclusionary diagnoses was admitted to the unit. In fact, two youth were denied admission to the unit due to the presence of exclusionary diagnoses. In addition, it was

6

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 7 of 44 PAGEID #: 2667
recommended that the youth’s home facilities exhaust treatment options prior to utilizing a more restrictive placement. The facility is in substantial compliance with this standard.
ODYS shall continue the process of having the Administrative Psychiatrist conduct The Mental Health and Cognitive Screen for Placement onto the Progress Unit. The screening process continues to limit the number of referrals and consequently the number of youth placed onto the Progress Unit. In addition, the Facility Resource Administrator shall continue to deny requests that contain insufficient documentation prior to forwarding them to the Administrative Psychiatrist for review. This process also limits the number of inappropriate referrals to the Progress Unit. Additionally, ODYS shall continue to track and cross‐reference Progress Unit referrals via the Requests for Progress Placement Table maintained by the Facility Resource Administrator.
[II.10] Daily Schedule [reviewed by Shannon Komisarek] Status: Partial Compliance
(1) Standard: Out‐of‐Room Time. Youth on the PROGRESS unit have as much out‐of‐room time as youth in the general population. The ability to be out of their room from 7am to 7pm enables the youth to access to the intensive programming to address the behaviors and skill deficits that resulted in their placement on PROGRESS. The designated times when youth are in their rooms are the following: during shift change (40 minutes daily), medication pass (30 minutes daily), Treatment Team (3 to 4 hours per week), and seclusion time that is ordered as a sanction for major rule violations. The access to rehabilitative services fosters an environment where PROGRESS youth have the opportunity to practice the skills acquired through each Phase and are not in a lock down unit that uses isolation as a means to address youth behaviors.
Methodology. The following information is used to determine compliance with the standard:
 PROGRESS Unit Youth Activity History Report sheets that indicate the youth’s activities throughout each day, separated according to whether the youth is in his room or out of his room.
 The review period was March 1‐ May 31. Data was reviewed only for the month of May and not March or April due to improvements being made in the schedule itself and wanting to provide the most current picture of the Unit’s operation.
Analysis and Interpretation. The PROGRESS Unit Youth Activity History Report for the 4‐week period from May 5‐ May 28, 2013 was reviewed.
Each week, a random sample of 2 youth was selected for a total of 8 youth and 48 days. Of the 48 days reviewed, 1 youth was in seclusion for 1 full day and 6 hours the following day, a total of 30 hours during
7

Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 8 of 44 PAGEID #: 2668
the sample time. In other words, on 97% of the days reviewed, the youth were out of their rooms and engaged in the program.
The Order requires youth to be out of their rooms on non‐IDT days for at least 10 hours and 50 minutes (allowing 70 minutes for shift change and med passes during the 12 waking hours). This minimum was exceeded for approximately 89% of the non‐IDT days in the sample. During the 24 day time period review, on 6 of the 56 days (11%), youth were noted to be in their rooms longer than the allotted 70 minutes for shift change/med pass. The in‐ room time exceptions were minimal with time in‐room ranging from 15 to 30 minutes longer than the 70 total minutes permitted by policy. The reasons for the exceptions ranged from a long restroom call to when youth had to go into their rooms because a peer was noncompliant (which averaged 15 minutes). This is a reasonable rate of exception.
The prior Status Report noted concern in the “Technical Assistance Note: Activity Tracking” that the data reflected that youth wee out their rooms during times when they were not, particularly during the IDT meeting times. In reviewing the Youth Activity History reports, the youth were in school approximately for approximately one hour during the IDT meetings. In addition, some youth were in one of the designated recreation rooms on the unit during IDT, which would give them more out of room time than if they were in their rooms during the entire IDT meeting. The discrepancies in the data occurred when the YS’s did document the transfer of youth from school or the recreation room in the unit log once the youth had physically moved locations.
There have been instances where a time period ranging from .3 to 1.5 hours is docuemted as in‐room time without the explanation. The PROGRESS Administrator needs to ensure the staff are including in the narrative if this is due to restroom calls, shift change, med pass, self‐seclusion or any other reason. During these months, the Administrator position was vacant and the clerical staff completing the input did not read the narrative to give the appropriate explanation.
Recommendations. The facility is in compliance with the standard related to out‐of‐room time. The Order’s minimum requirement (10 hours, 50 minutes) was exceeded on 89% of the days reviewed. Although problems with data‐entry and the data collection tool itself make data related to in‐room time difficult to interpret cleanly, the issue is best addressed under the standard related to Quality Assurance. Thus, a Quality Improvement Plan is not necessary to meet the standard regarding out‐of‐room time on the Daily Schedule a Quality Improvement Plan is not necessary to meet the standard regarding out‐of‐room time on the Daily Schedule.
(2) Standard: Daily Activities. Each day, youth on the PU participate in the following activities, out of their rooms:
 Meals;  330 minutes of education, except during intersession;  One hour of large muscle activity (without restraints);  Individual and group treatment conducted by Behavioral Health Staff;
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Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 9 of 44 PAGEID #: 2669
 Structured activities led by Youth Specialists or Volunteers;  Leisure time (one hour on school days, two hours on non‐school days).
Methodology. The following information is used to determine compliance with the standard:
 Youth Activity History that indicates the youth’s activities throughout each day, separated according to whether the youth is in his room or out of his room.
 Review of the Unit Log narrative that details the specific structured program/ activity the youth is involved in.
 Observations of PU activities
Analysis and Interpretation. The Youth Activity History logs for the 4‐week period from May 1‐29, 2013. Each week, a random sample of 2 youth was selected for a total of 8 youth and 58 days. Across the days:
 Three meals were provided to each youth, each day (100%). Youth who were not in seclusion ate outside of their rooms.
 A full day of education was provided to youth who were not in seclusion (100%) [Chancery attendance records were used to verify these data.].
 Recreation was provided on all but 3 days (95%; 3 seclusion days). During March and April Phase 1 youth participated in recreation in gator restraints that had more mobility than the gator restraints used all other instances a Phase 1 youth is out of his room. Starting May 1, Phase 1 youth participated in large muscle recreation in the outside recreation area designated for only Phase 1 youth or in the recreation rooms provided on the unit. The use of the gymnasium for Phase 1 youth is to engage in leisure activities. Youth who are serving Intervention Hearing (IH) seclusion are offered 1 hour large muscle by the GAT leading calisthenics to the youth while they remain in their room. The youth will refuse this recreation time because it is not in the gym or in the recreation room on the unit. Youth are serving other forms of seclusion are not offered large muscle recreation.
 Group and individual treatment was recorded for all but 1 of the 54 non‐seclusion days (98%). The youth was designated to have been in IDT this specific day.
 Structured activities were recorded on all of the non‐seclusion days (100%). One youth was selected each week each week where the schedule, unit log, and documentation were reviewed. The first set of 4 youth who were reviewed had 46% of their activities documented with the staff member leading the activity, but 43% of their activities were not described as being staff led. The second set of 4 youth had 57% of their activities documented with the staff member who led the activity. One youth was selected each week where the schedule, unit log and documentation were reviewed.
 Leisure time was recorded for 19 of the 56 days (66%). Outside leisure recreation was documented 13 times and inside leisure was documented 6 times. The unit schedules are to allow for 1 hour leisure Monday‐Friday and 2 hours Saturday‐Sunday. The Unit Managers have not allotted the 1 hour leisure on the weekdays, but have structured activities as directed by the
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prior Superintendent. Within the last few weeks, the Unit Managers have been instructed to allow the youth to have the one hour leisure time that is permitted by policy.
Technical Assistance Note: Activity Tracking “Structured Activity” is captured in the Youth Activity History logs for each youth. This document, however, does not indicate what the structured activity was or who the staff, i.e., Youth Specialist or Unit Manager, was that lead the activity. The Unit Log was cross reference with the Unit Schedule to determine if the youth are engaging in the activities as prescribed by the UM. What was discovered was that the Youth Specialist is logging the activity that is scheduled; however, not detailing who the staff member is leading the activity. Two youth were reviewed each week. The amount of time that it takes the YS’s and clerical to document the out of room time for each youth has decreased due to the staff becoming comfortable and accustomed to documenting in the unit log.
Conclusions and Recommendations. The lack of recreation opportunities for students in seclusion, the lack of leisure time on weekdays, and the fact that what is recorded as “structured activity” is often not led by an adult indicate that the facility remains in partial compliance with this standard. In order for DYS to meet the standard associated with the activity component of the Daily Schedule; a Quality Improvement Plan should be constructed to assist in the following area:
1. The Youth Specialists (YS’s) need to document in the Unit Log the specific Structured Activity the youth is engaged in and who is delivering this service to the youth. The Youth Activity History Log can then provide the daily and overall information to those who need to review and ensure the Unit Schedule is being followed. It is likely that errors in recording “structured activities” may have obscured the fact that leisure time is being provided on the weekdays.
2. At the writing of this report, there are no Phase 1 PROGRESS youth. When there are Phase 1 youth, the PROGRESS Program Administrator will need to ensure that the YS’s and Unit Managers do not become complacent with documenting exactly where the youth are. As the facility staff have become accustomed to the youth being out of their rooms from 7am‐7pm (minus the allotted 70 minutes to be in their rooms) , the staff make the erroneous assumption that the youth simply being out of their rooms is sufficient.
(3) Standard: Graduate Programming. Youth on the PU who have graduated from high school participate in out‐of‐room structured activities throughout the time that non‐graduates are in school.
Methodology. The following information is used to determine compliance with the standard:
 List of youth who have graduated from high school  Youth Activity Tracking sheets that indicate the youth’s activities throughout each day,
separated according to whether the youth is in his room or out of his room.
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Analysis and Interpretation. The Youth Activity Tracking logs were reviewed to determine how the graduate youth have their school time hours structured for them. During this time period, one youth was identified as the only graduate in the PROGRESS Units.
The PROGRESS Unit Managers meet with the youth as he progresses through the Phases to produce an updated schedule. As he has progressed, his access to opportunities increases. An 8 day time period was reviewed when the youth was a Phase 2. Of the 8 days reviewed, the schedule was documented to be followed 65% of the time. The circumstances that contributed to the schedule not being followed were: the youth refusing to participate in the activity; a volunteer (community or SJCF) not present; the documentation the Youth Specialists documented in the unit log was not specific and accurately reflect what the youth was engaged in. On one day (day 8) the specific activities the youth was engaged in was not accurately documented in the narrative of the Unit Log. The unit staff, inclusive of the Youth Specialists, Unit Manager, and Behavioral health staff report that they follow the schedule, although the youth’s activities are not always documented properly.
Recommendations. While only one youth who had graduated from high school was housed on the PROGRESS Unit during the period of review, data indicate that his schedule was followed only 65% of the time. A Quality Improvement Plan is necessary to meet the standard associated with graduate programming on the Daily Schedule. This plan should include:
1. Ensuring that all youth activities are carefully tracked by the YS who is supervising the youth at any given time. Furthermore, ensure that all staff who have made a commitment to serving graduate youth are responsible for delivering those services. Finally, a youth’s refusals to participate in programming will be discussed during the subsequent IDT meeting.
[II.11] Staffing Status: Substantial Compliance
(1) Standard: Staff Numbers and Training. A sufficient number of adequately trained supervisory and line staff are available to implement the PU program as designed.
 A Unit Manager (UM) works during all waking hours, seven days per week.  All assigned PU Youth Specialists have completed required training within three months of their
assignment.  All Youth Specialists (whether assigned or relief) read and sign the relevant Post Orders.
Methodology. The following information should be used to determine compliance with the standard:
 Average daily populations for Sycamore, Cedar and Buckeye
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 UM schedule  Youth Specialist staffing reports  Staff training records  PU Post Orders and signature pages
Analysis and Interpretation. The Unit Managers The Unit Manager Schedules were reviewed for the time period of March 2013 – June 2013. Unit Manager Coverage was as follows:
 Of the 31 days in March, 25 days met the court requirement, for an average of 81%  Of the 30 days in April, 28 days met the court requirement, for an average of 93%  Although there were 31 days in May, one day was a state holiday so only 30 days were
reviewed. Of the 30 days in May, 23 days met the court requirement, for an average of 77%  Of the 30 days in June, 27 days met the court requirement, for an average of 90%.
Throughout the four month period, time that staff were noted as in “Training”, were counted as coverage because training took place in the facility and the Unit Managers were available if needed. The court order states, “absent minor incidental deviations, the Unit Manager shall work on the PROGRESS Unit during all waking hours (7a‐7p) seven days per week.” The Unit Manager schedule has required that a Unit Manager be available during waking hours, but has not required a Unit Manager on each Progress Unit during waking hours. Training that has occurred within the facility that Unit Managers were required to attend, still allowed for them to be available and to visit the unit throughout the day.
During the month of May, a PROGRESS Unit Manager was placed on Administrative Leave which impacted coverage resulting in seven of the 30 days not covered, therefore not meeting the standard that month. For the month of June, two additional Unit Managers received PROGERESS training and were included in the coverage, resulting in 90% of the days covered. For the four month period, DYS was overall in compliance with the standard.
The Youth Specialists’ The YS shift assignments are as follows: 6 staff on 1st shift, 6 staff on 2nd shift, and 4 staff on 3rd shift for Cedar and Sycamore Units, for a total of 32 positions. The YS shift assignments are as follows for Buckeye Transition Unit: 4 staff on 1st shift, 6 staff on 2nd shift, and 2 staff on 3rd shift for a total of 12 positions. Each of the 44 staff is assigned to 1st, 2nd, or 3rd shift and has two days off per week. In all cases, the staff have two days off in a row. Relief assist in providing coverage for call offs and vacations. In addition, relief staff are often from another shift, or another Progress Unit, and thus are familiar with the policies and procedures of the Progress Unit. Furthermore, all “relief staff” were trained on the Progress Unit Policy.
Youth Specialists Staffing reports for March, April, and May 2013 show the number of staff who actually reported to work each day.
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 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Sycamore Unit during the months of March, there was one shift (March 10th, Sycamore Unit on 1st shift) that did not meet the staffing pattern, therefore 99% of the time, Youth Specialist staffing levels were appropriate.
 Of a total of 90 shifts (including 1st, 2nd, & 3rd) on Sycamore Unit during the month of April, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Sycamore Unit during the month of May, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Cedar Unit during the months of March, there all shifts met the required staffing patter 100% of the time.
 Of a total of 90 shifts (including 1st, 2nd, & 3rd) on Cedar Unit during the month of April, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Cedar Unit during the month of May, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Buckeye Unit during the months of March, there all shifts met the required staffing patter 100% of the time.
 Of a total of 90 shifts (including 1st, 2nd, & 3rd) on Buckeye Unit during the month of April, all shifts met the required staffing pattern 100% of the time.
 Of a total of 93 shifts (including 1st, 2nd, & 3rd) on Buckeye Unit during the month of May, all shifts met the required staffing pattern 100% of the time.
Staffing Levels Determining whether staffing levels are “adequate” requires knowledge of the size of the population the staff are supervising on any given day. Average daily populations (ADP) are normally calculated by adding the number of youth on a unit each day, and dividing the sum by the number of days in the month.

Population Averages, per unit

Unit

March

Sycamore (P1)

6

Cedar (P2)

8

Buckeye (Transition)

6

Total PU

20

April 6 8 6 20

May

Average

6

6

8

8

5

5.7

19

19.7

The first Progress Status report showed a decrease in PU population of 14% over the 4 months reviewed (December 2012, Jan.‐Feb., 2013) Review of population averages per unit for March, April, May 2013, shows that the population averages have basically remained the same. First Progress report shows an overall average of 19.95 for all units over a 4 month period. This reporting period the overall average for the 3 month period is 19.7. This is 1% decrease which is not statistically relevant.
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The weekly staffing reports, coupled with the estimated ADP permit an assessment of the typical staff— youth ratio on Sycamore and Cedar. 1st and 2nd shifts normally had 3 staff on each unit, while 3rd shift normally had 2 staff. About 10% of the time, 1st and 2nd shifts had 4 or 5 staff and 3rd shift had 3 staff. PROGRESS Training The Order requires staff assigned to PROGRESS Unit complete training “specifically relating to working with youth on the PROGRESS Unit and implementing the PROGRESS Unit as designed” within 3‐months of their assignment. The PROGRESS Unit Policy and Handbook was approved by the DOJ Monitor on April 10, 2013. ODYS officials signed off on them, with an effective date of May 31st. ODYS developed an 8hr training based on the policy and handbook for all PROGRESS Unit staff. There were a total of six training sessions held and 100% of the Youth Specialists that are assigned to the PROGRESS Unit and staff that work as PROGRESS relief staff attended the training. Additionally, 100% of the Unit Managers, Behavioral Health Staff, and Administrative Staff attended the training. Assigned staff who were off on Administrative Leave, Disability, or Military were not considered in these results.
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Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 15 of 44 PAGEID #: 2675

POSITION
William Stump (P) Thomas Polk (P) William Samuels (P)
Kim Williams Dion Baines (P)
David James Jim McWatters (P) Bryant Brown (P)
Nicole Curry Mandy Rafter Deb Powell Glenn Comb Anthony Bordeaux Diane Merritt (P) Jesse Pfalzgraf (P) Katherine Mitchem (P) Justin McGrath (P) Joshua Moss (P) Mathew Sanders
Jessica Jefferson (SW) Keeli Cook (SW)
Gertrude Love (MH Nurse) Marius Igwe (SW)
Alvin Braddy (MH Nurse)

DATE TRAINED
5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013 5/21/2013 5/21/2013 5/21/2013 5/21/2013
5/8/2013 5/17/2013 5/17/2013 5/17/2013 5/17/2013

PROGRESS Training May/June 2013

POSITION

DATE TRAINED

YOUTH SPECIALISTS

Tanya Butler (P)

5/21/2013

Marketta Reedus

5/21/2013

Isaiah T. Coleman (P)

5/21/2013

Karl Wilkins Jr

5/24/2013

Fred King

5/24/2013

Malinda Lawrence (P)

5/24/2013

Andrew Bryson

5/24/2013

Tanya Serrell

5/24/2013

Josh Miller

5/24/2013

Melissa Allen

5/24/2013

Victoria A. Tyler

5/24/2013

Dominguez Andres

5/24/2013

Marquetta Dudley

5/24/2013

Adrian Hill (P)

6/14/2013

Saroya Seay (P)

6/14/2013

Jamar A. Hill (P)

6/14/2013

Herman Walker (P)

6/14/2013

Angela King

6/14/2013

Lisa Wynn

6/14/2013

SOCIAL WORKERS / NURSES/PSYCHOLOGY

Princess Cripe (Psychology)

5/17/2013

Irv Jones (Psychology)

5/24/2013

Dr. M.S. Black (Psychology)

6/14/2013

Regina M. Grywalski (OT)

6/14/2013

POSITION
Atha Sanders (P) Yvonne Butler James Littleton (P) Tiffany Logan (P)
Andy Baker Robert Reynolds Chad Boone (P) Grant Zimmerman (P) Stanley Ball (P) Nate Strong (P) Shawn Overstreet Gilbert Cueva (P) Veronica Sellers (P)
Curtis Karn Kehinde Adeyinka (P)
Kevin Judge (P) Velvet Hutchinson (P)
Dedra Johnson (P) Teri Campbell

DATE TRAINED
6/14/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013 6/18/2013

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POSITION

DATE TRAINED

Becki Williams (SWS)
Ven Evans (OM)
Alfred Brown (OM) Yolanda Frierson (UM) Turon Hairston (OM‐TWL) Laurel E. Jeffreys (UM) Shannon Komisarek (Deputy) Vickie Donahue (HSA)

5/8/2013
5/8/2013
5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/17/2013 5/17/2013

Matt Russell (GAT) Jeffrey Adkins (Asst. Principal)
Melissa Lopes (GAT)

5/8/2013 5/21/2013 5/21/2013

Mindy Worly (AG) Ashleigh Hodge (Intern)
Alexis Witte (Intern) Jim Ferrell (CO) Aaron Bauer (CO)

5/8/2013 5/8/2013 5/8/2013 5/8/2013 5/8/2013

POSITION
MANAGEMENT Michael Waryck (UM)
Lataucia Sweeney (OM)
Keith Williams (OA) Jack Vicencio (Deputy) Joel Nussbaum (OM) Trecia Holdren (SWS)
Carlos Davis (UM) Ian McNamara (Rec. Admin)
RECREATION/EDUCATION Richard B. Sommers (Teacher)
Greyland Williams (GAT) Kelly Wright (OA)
CENTRAL OFFICE/NON‐DYS Dave Pigman (CO) Pat Hurley (CO) Ed Dachowski (CO) Vanessa Tower (CO) Chris Freeman (CO)

DATE TRAINED
5/21/2013
5/21/2013
5/21/2013 5/21/2013 6/14/2013 6/14/2013 6/14/2013 6/18/2013
5/24/2013 6/18/2013 6/18/2013
5/8/2013 5/8/2013 5/17/2013 5/17/2013 5/21/2013

POSITION

DATE TRAINED

Nicole Pace (UMA)
Larry Mallory‐Gang Specialist
Curtis Simms (UM)

6/18/2013 6/18/2013 6/18/2013

The previous PROGRESS Status Report identified that Post Orders were “severely outdated”. In reviewing the current Post Orders, they were updated March 6th, 2013 and accurately reflect current
expectations of the PROGRESS Unit.

Conclusion and Recommendations. In the 1st Progress Status Report the monitor recommended the ODYS develop a QA process to appropriately monitor this standard. ODYS is utilizing the 2nd Progress Status report as a QA tool. The
findings demonstrate that ODYS is in substantial compliance.

In only one area (UM coverage in May 2013) did the staffing levels fall below the requirements of the Court Order. This shortage was due to an unexpected staff departure and did not lead to a chronic shortage in UM coverage. Indeed, in the following month, UM coverage exceeded the threshold of 80%. This, along with the other findings discussed here, demonstrate that ODYS is in substantial compliance.
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(2) Standard: Impact on Safety. Recognizing there are many contributing factors to youth violence, staffing levels on the PU are sufficient to ensure that a lack of supervision does not contribute to the opportunity for youth to commit violence against other youth or staff.
Methodology. The following information should be used to determine compliance with the standard:
 Rate of youth‐on‐youth violence for this reporting period  Rate of youth‐on‐staff violence for this reporting period  Disaggregated list of AOVs committed by youth that includes the youth’s name, date and type of
violence.

Analysis and Interpretation The 1st Progress status report showed rates of youth on staff and youth on youth violence for a 3 month
period, November, December and January:

Rates of Violence on the PU

Month

Youth—Staff Number ADP Rate

Nov 12

8

21

.381

Dec 12

6

20

.285

Jan 13

5

19

.263

Youth—Youth

Number ADP Rate

5

21 .238

1

21 .048

1

19 .053

The 2nd Progress Status report reviewed youth on staff and youth on youth violence for a 3 month period, March, April and May 2013:

Rates of Violence on the PU

Month

Youth—Staff Number ADP Rate

Mar 13

3

20

.150

Apr 13

5

20

.250

May 13

2

19

.105

Youth—Youth

Number ADP Rate

0

20 .000

0

20 .000

0

19 .000

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Comparisons:  The average rate of youth on staff assaults for the First Status Report was .310; The average rate of youth on staff assaults for the Second Status Report was .168, for an overall decrease of 46%  The average rate of youth on youth assaults for the First Status Report was .113; The average rate of youth on youth assaults for the Second Status Report was 0, for an overall decrease of 100%
Conclusion and Recommendations. The reduction in youth‐on‐youth violence has contributed to an overall safer environment. Although it’s not clear that there is one contributing factor, what is clear is that the reduction of “in room” time, the emphasis on programming, recreation, and structured activities has had a positive impact. ODYS will continue work towards sustaining the progress made thus far and identify areas for continued improvement.
The rate of youth‐on‐staff violence, while significantly reduced from the previous period, still remains higher than desired. As with youth on youth violence, the overall environment has become safer with an emphasis on programming and structured activities. ODYS will continue to sustain the progress made thus far and identify areas for continued improvement.
With a reduction in overall violence, and evidence that sufficient numbers of staff supervise these youth, ODYS is in substantial compliance with this standard.
In order to maintain substantial compliance, ODYS will continue to: 1. Track rates of violence by collecting the number of AOVs and the ADP each month for the PU, specifically. 2. Analyze incidents involving violence against youth to identify any patterns in unit, location, youth involved, etc. 3. Analyze types of violence perpetrated against staff, their underlying causes and any environmental conditions that create the opportunity for violence to occur (e.g., sufficient staff support during restraints? Ability to collect liquids and throw them? Tensions between individuals that should be mitigated?).
[II.12] Treatment Planning Status: Partial Compliance
(1) Standard: Clinical Staffing [this standard is derived from paragraph II.C.3 of the SH Order] Clinical staffing is sufficient to implement youth’s treatment plans and to conduct Inter‐Disciplinary Team (IDT) meetings. The staffing levels are adjusted when the population fluctuates or upon reasonable professional judgment.
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Methodology. The following information was used to determine compliance with the standard:
 PROGRESS Unit (PU) policy  Standard Operating Procedures  Case notes from the OK database broken down by treatment type  Integrated Treatment Plans (ITPs) approved between 3/1/13‐5/31/13  A tally of the front line staff and their clinical hours provided  Interdisciplinary Team (IDT) minutes
Analysis and Interpretation.
Ratio of clinical staffing During the March 2013‐May 2013 three month time period, the number of youth on the PROGRESS Unit (PU) varied from as low as 11 youth to as high as 17 youth. During this time, there were 8 full time clinicians and treatment providers, 1 full time mental health nurse, and 1 contracted psychiatrist (.5 FTE) who worked primarily on the PU. This creates a ratio that ranged from a low of staff to youth of 1:1.3 to a high of 1:2.1. The clinicians and treatment providers consisted of three psychology staff, four social workers and one Occupational Therapist (OT) (.5FTE). Collectively, these primary staff (along with treatment provided by three Unit Managers, one Unit Administrator, and 1 youth specialist all assigned to the PU provided treatment to these youth during their time on the PU.
Although more than one Youth Specialist provides treatment, the Case Notes Database is limited in some aspects and therefore does not reflect the name of the Youth Specialist providing such treatment. Detailed limitations are noted below:
 The Case Notes database is not designed to incorporate case notes completed by Youth Specialists who conduct group sessions unless the Youth Specialist’s name is documented as part of the case note.
 The drop box identifying the staff completing the session only lists the clinicians or the Unit Manager. Office assistants completing data entry to document the Youth Specialist’s group session did not identify the group facilitator in the body of the case note. Therefore, the case note would need to be compared with the sign in sheet.
Based upon the data reviewed, psychology staff delivered 39% of the received treatment, social work staff delivered 53% of the treatment and the OT delivered 8% of the treatment. There was also evidence that Scioto JCF ensured necessary treatment was occurring, even when assigned staff were absent. For example, case notes revealed that on occasion, staff who were not normally assigned to the PU conducted and documented treatment provided on this Unit.
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Month Lowest Ratio (staff to Highest Ratio (staff to

youth)

youth)

March

1:1.8

1:2.1

April

1:1.4

1:2

May

1:1.3

1:1.6

Research supports the sufficiency of one staff person for every 8 to 10 youth (Deitch, Madore, Vickery and Welch, 2013). Based upon this research, even the highest ratio of 1:2.1 staff:youth ratio identified above is more than sufficient for the provision of behavioral health services.

Another way to demonstrate the effectiveness of the PU staff is to analyze the number of treatments hours they provided. During the 3 month period, the clinicians and treatment providers mentioned above provided 1,432.22 hours of treatment to these youth during the youths’ time on the PU. Of the 8 PROGRESS clinicians and treatment providers, there were 3 psych staff, 4 SW staff, and 1 OT (.5 FTE) staff. Percentage wise, the psych staff contributed to 39% of the received treatment, the SW staff contributed to 53% of the treatment and the OT staff contributed to 8% of the treatment.

According to the data reviewed, the youth received an average of 1.2 hours of treatment a day. The staff provided an average of 15.9 hours of treatment per day, which creates a staff to youth ratio (in treatment hours) of 15.9:1.2. Considering the number of youth on the Unit during this time period (11‐ 17 youth) as well as the expectation that clinicians perform individual and group therapy, this ratio seems to be an accurate reflection of what is occurring. Furthermore, taking into consideration that “treatment” does not include additional programming, such as school, volunteer services, recreation services, or meals, this ratio of treatment is a reasonable expectation.

IDT meetings Of the thirty‐nine IDT meetings that should have been held during the three month period, all 39 meetings occurred. This is a compliance rating of 100%. Furthermore, the IDT was 100% compliant in conducting the weekly meetings as required in the ODYS SOP 404.02.01 “Interdisciplinary Team. “ Please see the discussion below for a more comprehensive outline of staff attendance.

Fluctuations of Rotating Staff During the three‐month period, there were not a high number of fluctuations. Therefore, the number of staff and the amount of treatment provided was adequate to ensure all youth received a consistent level of treatment. Additionally, as there were entries provided by staff members who were not one of the 8 consistent clinicians and treatment providers, it can be interpreted that Scioto JCF has the means and the foresight to ensure that treatment continues, even if there are moments of short staffing. These moments of short staffing include trainings, unexpected call offs, and other unique situations that may occur on any given day.

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Conclusions and Recommendations The facility is in substantial compliance with this standard.
Current staffing levels are more than sufficient to meet the requirements of the Court Order and to ensure youth’s consistent access to treatment that is responsive to individual needs. In order to maintain substantial compliance, recommendations include the following:
1. DYS should continue creating data sets in an effort to easily extract data from the Management by Measurement (MbM) database system. The MbM database extracts data from the OK database.
2. DYS should continue evaluating clinical staff:youth to ensure ratios do not exceed 1 clinical staff to 8‐10 youth and to ensure that youth are receiving an adequate average number of treatment hours per day.
(2) Standard: Treatment Planning. Treatment plans are individualized and include concrete, realistic, measurable goals and objectives that are designed to address the specific behaviors that led to the youth’s placement on the PU. Specific interventions are prescribed in order to assist youth in accomplishing treatment goals. Progress toward treatment goals results in promotion through the PU’s phases and, ultimately, back to the general population.
 Phase 1 (P1) goals focus on acquiring skills to move safely about the unit without the use of restraints once promoted. Skill acquisition is demonstrated by meeting behavioral expectations.
 Phase 2 (P2) goals focus on acquiring skills needed to refrain from aggressive behavior once returned to the general population.
Methodology. The following information was used to determine compliance with the standard:
 Integrated Treatment Plans for 10 youths currently on one of the PROGRESS Units  Case notes for 10 youth currently on one of the PROGRESS Units
Analysis and Interpretation.
ITP Goals & Objectives Three of eight primary clinicians were represented in the sample. Objectives written during the period of March, April and May 2013 were reviewed. For this standard, ITP goals and objectives were assessed to determine whether they were measurable, realistic, strength‐based and addressed development of skills needed to change behaviors that led to placement. Based on the ITPs reviewed:

Total 167

Measurable Realistic Strength Based
154 (92%) 167 (100%) 13 (8%)

Skills Focused 39 (23%)

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 The use of strengths in objective development has increased slowly.  There appeared to be an increase in objectives being stated in a forward moving way
with an increasing focus on identifying, practicing/acquiring, and demonstrating positive behaviors (as opposed to removing, eliminating, or decreasing negative behaviors).  Although there is a slight increase in objectives with skill development as the focus, the facility is still not meeting ODYS’ standard at this time.  Nearly all objectives being developed are observable, realistic and measurable.
ITP Documentation in Case Notes Interventions were reviewed to determine if they were documented and appropriate to ITP goals and objectives. In addition, the type and intensity of services were reviewed to determine appropriateness to the ITP and the individual youth.
This analysis involved calculating the number of treatment contacts per youth during a 13‐week period (3/1/13‐5/31/13). Once calculated, the average number of each type of contact was averaged across the 10 youth in the sample for the entire 13‐week period and also per week. Results are presented in the table below.

CBT Group Skill OT MH/SA Ind

A and/or B Sets

Group SW

13‐week 8.2

43.7 16 10

11.4

period

Per week .63

3.36 1.23 .77

.88

Ind Psych

15.7 caseload 8 non‐caseload 1.2 caseload

.62

non‐

caseload

Range of Daily treatment contacts 3/1/13 – 5/31/13: 0 – 5

Average number of days on which youth received no treatment contacts 3/1/13 – 5/31/13: 7.4 (2.46 days per month; .56 days per week)

Estimated average daily treatment contacts per youth 3/1/13 – 5/31/13: 1.27

The estimated average daily treatment contacts seem to be an accurate reflection of what is occurring. Furthermore, taking into consideration that “treatment” does not include additional programming, such as school, volunteer services, recreation services, or meals, this ratio of treatment is a reasonable expectation.

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Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 23 of 44 PAGEID #: 2683
With regard to the average daily number, seven out of the ten youth (70%) were on the PU for the full 92 day period between March 1, 2013 and May 31, 2013. The other three youth were on the PU for 1, 74 and 78 days.  Interventions are documented at various levels of detail in all group and individual case
notes with the exception of CBT Core A, Core B Curriculum, and Core B Skill Set groups. Those notes simply identify the date, skill set discussed, and/or lesson covered. CBT Core A, Core B Curriculum and Core B Skill Set are primarily provided by Youth Specialists and facilities were therefore permitted to document the date, skill set discussed and/or lesson covered for these groups.  Documentation of having addressed specific ITP objectives is found in approximately 30‐40% of individual case notes.
o Group notes are dictated by the group subject and focus on details regarding youths’ behavior and apparent investment in the group.
o Individual case notes that do not address specific ITP objectives are, in large part, focused on current youth issues.
Individual and group treatment sessions should always connect back to the youth’s ITP. This is an area that has been addressed and will continue to be addressed as needed.
Based on the case notes reviewed:  Occasionally, a single objective, as phrased, actually represented 2 and sometimes 3 separate objectives. Objectives need to be better focused and limited in scope so that progress toward them can be measured easily.  Over time the number of objectives that focus on skill acquisition has increased, but given that less than ¼ of objectives were skill‐focused, this is an area in need of improvement.  Strength based objectives do not represent a high percentage of objectives written during this period. However, the inclusion of strength based objectives has increased over time, and continued to increase in June and in July to date. However, the percentage remains relatively low and this represents an area for further attention and development. In May 2013, ODYS Central Office reviewed several ITPs and provided written feedback and technical assistance to the facility. The feedback and technical assistance included but was not limited to discussion of SMART goals, strength based goals and objectives, skill acquisition, duration and frequency.  Case notes reference general, broad objectives in most cases. They need to be more specific in order to be more individualized.  Based on clinical expertise, staff is delivering treatment, training and interaction at a high level of frequency. Treatment expectations are guided by OYAS standing, mental health status, and number of other factors. Individual contacts with behavioral health staff identified in policy guidelines for both youths on the mental health caseload and for Progress Unit in general are exceeded. When the total number of treatment contacts are analyzed in terms of time, the ten youths in this sample were provided an average of 90.13
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Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 24 of 44 PAGEID #: 2684
hours of treatment through this 91 day period of time. At this pace, youths with an OYAS level of low will have met their treatment target (100 hours) within 4 months of admission, moderates will have met their target (200 hours) within 6‐7 months, and highs would have met their target (300 hours) within 10‐11 months of admission. These figures and frequencies must be considered in the context of the number of days and hours youths were in seclusion, days and hours youths are available for treatment, and actual number of days on the units (some youths were not on Progress every day through this 3 month period). What looks to be an average of one treatment hour per day would, in fact, turn out to be at least somewhat higher, if not significantly higher, if such an analysis was produced.
Conclusions and Recommendations.
The facility is in partial compliance with this standard based on the following:
1. Substantial compliance with the standard that goals and objectives be realistic and measurable.
2. Partial compliance with the standard that goals and objectives focus on skill acquisition. 3. Partial compliance with the standard that goals and objectives be strength‐based. 4. Substantial compliance with the standard that interventions are documented. 5. Partial compliance with the standard that documentation connects the intervention to ITP
goals and objectives. 6. Substantial compliance with the standard that treatment is at an appropriate level of
intensity.
The following steps are recommended:
1. Continue to focus on writing simple, concrete, measurable objectives. 2. Continue to identify skills to enlist in achieving objectives as well as those that a youth needs
in order to continue moving forward. 3. Identify an instrument BHS staff can utilize to identify strengths in the following areas:
emotional, personality, and character. Ensure these strengths are incorporated into the youth’s ITP goals and objectives. 4. Ensure that group notes are more individualized and have specific references to youth’s individual ITP goals so as to better integrate treatment across providers. 5. Provide continual, frequent, and on‐going training and discussion among BHS staff for developing ITPs.
(3) Standard: Progress Reporting and Promotion. Progress toward treatment goals and behavioral expectations is assessed on a weekly basis. Youth are promoted to the next higher phase when they have met their treatment goals and behavioral
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expectations. Behavior not related to AOV, serious STG activity, possession of major contraband, or repeated verbal threats to cause serious harm are not used as a basis to withhold promotion.

Methodology. The following information was used to determine compliance with the standard:
 Movement History  IDT Minutes from March 1, 2013 through May 31, 2013

Analysis and Interpretation.

Promotion/Demotion Compliance A random sample of ten youth who were on the PU between 3/1/13‐5/31/13 was reviewed. Although a random sample was reviewed, several primary and secondary parameters were also considered during the case selection process in an effort to review at least nine cases involving youth who recycled through the PU Phases and at least one case where the youth did not recycle through the PU Phases during the period under review.

A total of 121 IDT discussions occurred during the period under review. Of this number, the PU was 94% compliant with the following: The IDT minutes clearly identified whether the youth was on track for promotion, his promotion was withheld, youth was promoted, or youth was demoted. The table below is a breakdown of the compliance.

ON TRACK FOR PROMOTION, PROMOTION WITHHELD, PROMOTION, DEMOTION

Yes = In compliance No = Out of compliance

#

Question/Issue

Total # of IDT Yes

No

Compliance

Discussions

Percentage

1. IDT action taken complied

with the treatment goals,

121

114

7

94%

behavioral expectations and

four criteria (AOV, major

contraband, STG Activity,

repeated verbal threats to

cause serious harm)**

**The above item was reviewed in reference to policies and standard operating procedures in

effect during the period under review (March 1, 2013‐May 10, 2013)

Based on the data, PU non‐compliance in this area was due to:  Youth demotion from Transition 1 to Phase 2 for sexual misconduct and for not meeting behavioral expectations. Demotions should only occur when a youth has engaged in an Act of Violence, major contraband, STG Activity or repeated verbal threats to cause serious harm.  Several youth were demoted for sexual exposure. The demotion criteria identified above was not met.

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 Youth’s promotion from Phase 1 was withheld based on a threatening conduct and four previous secondary violations. Youth had been informed by the IDT during the previous week that he would get promoted if he received no violations that week. However, he received another violation. The youth should not have been promised a promotion to Phase 2 in part because the youth had four prior secondary violations. A Phase 1 youth cannot have primary or secondary violations when being promoted to Phase 2.
 Youth was promoted to Phase 2 even though he did not meet his goals and objectives. A Phase 1 youth must meet his goals and objectives in order to promote to Phase 2.
Although the IDT makes the recommendation for demotion, the facility Superintendent must approve all phase demotions prior to implementation.
On several occasions youth were informed during IDT meetings that they would be promoted the following week if they did not receive any Youth Behavioral Incident Reports (YBIRs) between that time period and the next IDT meeting. Several youth received YBIRs which resulted in a demotion or in a promotion being withheld.
Recycled Cases Nine out of the 10 cases reviewed during this time period (90%) involved youth who recycled through the PU. However, it must be noted that as mentioned earlier these nine cases were specifically selected for review based upon primary and secondary parameters established when determining the random sample criterion. The ten cases were selected to determine if trends for recycling or promotion could be identified.
Based on the data, there was no clear indication why youth recycled through the Phases. The 9 youth who were recycled accumulated a total of 13 demotions. In 8 out of 13 instances (62%), the youth’s goals and objectives were not discussed during the most recent IDT meeting prior to the demotion. This indicates that just prior to demotion, the goals and objectives were only discussed 38% of the time for these youth. As a result of ODYS discovering this trend, it should be explored further to determine if this is one factor which contributes to the youth’s recycling through the Phases.
For the one youth who advanced through the phases without being demoted, his goals and objectives were discussed at all IDT meetings preceding his promotion. This is a 100% compliance rate involving the discussion of goals and objectives immediately prior to the four promotions. When discussing the goals and objectives, the IDT discusses whether the youth has been meeting his goals and objectives. Treatment interventions are also discussed. Further exploration is needed to determine if this may be a factor involving youth who promote through the phases without recycling.
IDT Meeting Compliance During the period under review, a total of 39 IDT meetings were held with each Unit conducting 13. The IDT was 80% compliant in conducting weekly IDT meetings to discuss the youth’s progress. In other words, 2 youth were not reviewed weekly.
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For the two non‐compliant cases, one youth was promoted from Phase 2 (Cedar Unit) to Transition 1 (Buckeye Unit) on March 1, 2013 but an IDT meeting was not held for him until March 12, 2013. The second youth was promoted from Phase 2 (Cedar Unit) to Transition 1 (Buckeye Unit) on March 14, 2013 but an IDT meeting was not held for him until one week later on March 21, 2013. These two cases are similar in that when both youth transferred from Phase 2 and Transition 1, there appeared to be a system breakdown and the youth were not integrated into the Buckeye Unit weekly IDT meeting schedule in a timely fashion.

The IDT was 100% compliant in meeting with all ten youth face‐to‐face at least bi‐weekly to discuss the youth’s progress. The table below highlights this data.

IDT WEEKLY & BI‐WEEKLY MEETING COMPLIANCE

Yes = In compliance No = Out of compliance

#

Question/Issue

# of Youth

Yes

No

Reviewed

1. Did the Interdisciplinary Team

(IDT) meet at least once/week

10

8

2

to review youth’s progress?

2. Did the IDT meet face‐to‐face

with the youth at least

10

10

0

twice/month to review the

youth’s progress related to his

ITP?

Compliance Percentage
80%
100%

Documentation of Goals and Objectives in the IDT Meeting Minutes A total of 121 IDT discussions occurred during the review period and the IDT averaged twelve discussions per youth. Discussion of the goals and objectives during the IDT meetings is an area still needing improvement.
A discussion of the goals during the IDT meetings never exceeded 77% for all PU Phases and a discussion of the objectives never exceeded 74%. On several occasions during Phase 1, Phase 2 and Transition 2, the goals were discussed but not the objectives.
Although receiving the lowest rating in both areas of goals and objectives, data reflects that the Buckeye Unit (Transition 1) consistently discussed objectives whenever the youth’s goals were discussed. However, as indicated below, these discussions occurred on very rare occasions.
The table below gives the compliance breakdown for all PU Phases as related to documentation of goals and objectives during IDT meetings. There appeared to be an issue where the goals and objectives were
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not routinely reviewed or discussed during IDT meetings when the youth transitioned to the Buckeye Unit. DYS recently addressed this issue with the facility and anticipates improved compliance during the 3rd Quarterly PU report.

GOALS & OBJECTIVES DOCUMENTED IN THE IDT MINUTES

Yes = In compliance No = Out of compliance

GOALS

Unit Name & Phase

Total # of IDT

Yes

No

Discussions

Sycamore (Phase 1):

44

34

10

Cedar (Phase 2):

35

23

12

Buckeye (Transition 1):

30

7

23

Buckeye (Transition 2):

12

5

7

OBJECTIVES

Sycamore (Phase 1):

43

32

11

Cedar (Phase 2):

35

22

13

Buckeye (Transition 1):

31

7

24

Buckeye (Transition 2):

12

4

8

Compliance Percentage
77% 66% 23% 42%
74% 63% 23% 33%

The skills needed to achieve the goals and objectives were either not being discussed during the IDT meetings or were not being documented. There was also limited discussion and documentation on engaging the youths’ families.

The IDTs conscientiously and consistently discussed the youth’s medication compliance rate for those youth taking medication. Documentation of Phase 1 (Sycamore Unit) IDT meetings looked to be the strongest and most detailed. However, significant improvements were made by staff on Transition 1 (Buckeye Unit) during the May 21st and May 28th IDT meetings. The Buckeye Unit began formatting the IDT meeting minutes in the same manner as the Sycamore Unit. Thus, the meeting minutes were more structured. Furthermore, the IDT minutes clearly reflected the status of each youth’s progress with his goals.

Several youth involved in the Phoenix (Gang) program attended the IDT meetings and the IDT discussed youths’ involvement with gang‐related activities. However, the Gang Coordinator was not present to add to this discussion and no information was provided by the Gang Coordinator.

Documentation of Treatment Interventions When Needed In six out of the seven applicable cases reviewed, treatment interventions were adjusted when warranted. This is an 86% compliance rate. On the one case where the treatment intervention was not adjusted, the IDT struggled with identifying new interventions to support the youth.

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ADJUSTMENT OF TREATMENT INTERVENTIONS IN THE IDT MINUTES

Yes = In compliance No = Out of compliance

#

Question/Issue

# of Youth Yes No

Not

Compliance

Reviewed

Applicable Percentage

1. Did the IDT weekly

minutes clearly identify

10

6

1

3

86%

adjustments needed to

help the youth achieve

his goals?

Conclusions and Recommendations. The facility is in substantial compliance with this standard.

The IDT was 94% compliant in its action taken related to PU Phase promotions and demotions. Demotion non‐compliance involved sexual misconduct and sexual exposure. Promotion non‐compliance involved a youth being promoted although not meeting his goals and objectives and another youth being promised a promotion from Phase 1 to Phase 2 although he had four prior secondary violations.

There is no clear indication why youth recycled through the PU Phases. However, a trend was discovered which revealed that at the most recent IDT meeting just prior to demotion, the goals and objectives were only reviewed and discussed 38% of the time. The recycling issue should be explored further to determine if this is one factor of possibly several which contributes to the youths’ recycling through the Phases.

Recommendations include the following: 1. Review and comply with SOP 303.01.07 “Unit PROGRESS” to ensure future compliance related to promoting and demoting youth. 2. Comply with SOP 404.02.01 “Interdisciplinary Team” inclusive of engaging the youths’ families and encouraging their participation in the IDT meetings whenever possible. 3. Complete ODYS Form 404.02.01.A “Interdisciplinary Team Agenda/Meeting Minutes” when documenting IDT meeting minutes. 4. Re‐evaluate the practice of promising promotions based on the youth’s anticipated behavior. 5. Develop clinician’s strengths around articulating goals and objectives that are concrete, measurable, strength‐focused and skill‐based. 6. Develop a plan for discussing and documenting, during the IDT meetings, the youth’s ITP goals, objectives and skill development needs. 7. In development of the above plan comply with SOP 404.02.01 “Interdisciplinary Team. 8. Clearly discuss and document during IDT meetings, skill acquisition needed by youth to assist the youth in achieving identified goals and objectives. 9. Continue adjusting treatment interventions as needed. Seek consultation from Central Office when the IDT comes to an impasse related to treatment intervention options.

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Case: 2:08-cv-00475-ALM-MRA Doc #: 120 Filed: 09/26/13 Page: 30 of 44 PAGEID #: 2690
(4) Standard: Inter‐Disciplinary Team. [Note: this standard applies only to the S.H. Agreement.] A psychiatrist, psychologist or designee facilitates an Inter‐Disciplinary Team (IDT) meeting. Attendees include social workers, psychologists, occupational therapists, medical staff, educators, recreation staff, Unit Managers and Youth Specialists. If a member of the IDT cannot attend, written input shall be submitted to the IDT.
Methodology. The follow information should be used to determine compliance with the standard:
 IDT Minutes
Analysis and Interpretation.
IDT Meeting Facilitation A psychiatrist, psychologist or staff member approved by a psychiatrist or psychologist shall facilitate the IDT meetings. The IDT minutes generated between March 1, 2013 and May 31, 2013 were reviewed. These indicated that the IDT facilitator differed across units (i.e., whether facilitated by a psychiatrist, psychologist or other staff), but that all three units have 100% compliance ratings for this part of the standard. It should be noted that Dr. Ryan, one of DYS’s contracted psychiatrists, attended every IDT meeting on both Sycamore and Cedar with the exception of 1.
IDT Meeting Attendees The staff present for each of the IDT meetings was tabulated for each unit. Monthly attendance rates for each discipline are noted in the tables below, along with an average attendance rate for the 3‐month period reviewed. On the Sycamore Unit, overall, all disciplines were represented in at least 85% of the IDT meetings, except for Recreation staff who did not attend any meetings. In addition, several disciplines’ (OT, medical, education, and Unit Manger) attendance dropped off in May. The underlying reasons for this decrease will be explored to ensure it does not become a pattern.
On the Cedar Unit, all of the disciplines were present for at least 93% of the IDT meetings, except for Recreation staff (0%) and the Unit Manager (62%). There were no significant differences across the three months reviewed.
On the Buckeye Unit, representation across the disciplines was more problematic. Education and social work were represented only 54% and 33% of the time, respectively, and OT, recreation and medical staff never attended.
Below are three tables that depict the information pulled from the sole source of data. It directly relates to the items in question. An analytical breakdown of the raw data is provided below. Further exploration is needed to determine why certain staff was consistently not in attendance during these IDT meetings.
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Sycamore Unit: Phase 1 Criteria
Facilitated by a psychiatrist or psychologist or staff member approved by psychiatrist Social worker in attendance Psychologist in attendance Occupational therapist in attendance Medical staff in attendance Educator in attendance Recreation staff in attendance Unit manager in attendance Youth specialist in attendance Written note provided when not in attendance

March rating
100%
100% 100% 100%
100% 100%
0%
100% 100%
0%

April rating
100%

May rating
100%

Average Rating for 3 month period 100%

80% 100% 100%
80% 80% 0%
100% 100%
0%

100% 100% 75%
75% 75% 0%
75% 100%
0%

93% 100% 93%
85% 85% 0%
93% 100%
0%

Cedar Unit: Phase 2 Criteria
Facilitated by a psychiatrist or psychologist or staff member approved by psychiatrist Social worker in attendance Psychologist in attendance Occupational therapist in attendance Medical staff in attendance

March rating
100%
100% 100% 100%
100%

April rating
100%
100% 75% 100%
100%

May rating
100%

Average Rating for 3 month period 100%

100% 100% 100%
100%

100% 93% 100%
100%

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Educator in attendance Recreation staff in attendance Unit manager in attendance Youth specialist in attendance Written note provided when not in attendance

100% 0% 50%
100% 0%

75% 0% 75% 100% 29%

100% 0% 60%
100% 0%

93% 0% 62% 100% 10%

Buckeye Unit: Transition Criteria
Facilitated by a psychiatrist or psychologist or staff member approved by psychiatrist Social worker in attendance Psychologist in attendance Occupational therapist in attendance Medical staff in attendance Educator in attendance Recreation staff in attendance Unit manager in attendance Youth specialist in attendance Written note provided when not in attendance

March rating
100%
50% 100%
0%
0% 75% 0% 100% 100% 0%

April rating
100%
60% 100%
0%
0% 60% 0% 80% 100% 0%

May rating
100%

Average Rating for 3 month period 100%

0% 100%
0%
0% 25% 0% 100% 100% 0%

33% 100%
0%
0% 54% 0% 92% 100% 0%

Written Notes Provided When Not in Attendance This is an area needing improvement. Only one unit (Cedar) had any notes with explanation and even that was a compliance rating of only 10%. It should be noted that the complete exclusion of the recreation staff skewed this data especially since the IDT was unaware that recreation staff should have been attending these meetings. Clearly, this is a practice that needs to be greatly improved if DYS is ever to reach substantial compliance with this area.

Conclusion and Recommendations The facility is in partial compliance with this standard.

The significant deficiency noted with this analysis shows that a recreation staff was never in attendance on any of the units. The reason for these absences must be explored.

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The second deficiency is that on PU Phase 2 (Cedar Unit) the rate of compliance for the Unit Manager was only at 62%. The reason for such low attendance must be explored.
The third deficiency was the IDT minutes for Transition Phase 1 and Transition 2 (Buckeye Unit) in general. The other concerning aspect of the Buckeye Unit IDT minutes is that there were only 4 categories which reached an acceptable compliance rating (80% and above). The necessary representatives of the various disciplines are clearly not attending the Buckeye Unit’s IDT meetings. This needs to be addressed.
The analysis revealed correctable problems with attendance at IDT meetings. Attendance rates on Sycamore took a downturn in May 2013. Attendance by recreation staff was problematic across all units. Unit Manager attendance on Cedar Unit was inconsistent. Multiple disciplines had attendance problems on Buckeye Unit. As a result, the facility is only in partial compliance with this standard. To resolve these problems, the facility needs to develop a Program Improvement Plan to:
a. Determine why the recreation staff does not attend IDT meetings and develop a plan to ensure compliance.
b. Ensure representatives from all disciplines are consistently present at the IDT meetings on all three units, as required by the Court Order.
(5) Standard: IDT Substance. Youth appear before an Inter‐Disciplinary Team (IDT) at least bi‐weekly. IDT meetings for each youth involve a structured and specific discussion of each youth’s goals and objectives, behavioral expectations and progress toward meeting them.
 When goals and expectations are met, the youth is promoted.  If goals and expectations are not met, the IDT identifies the areas in need of improvement so
the youth know what is required for promotion. The IDT also revises the treatment plan or its implementation to better address the underlying causes of the youth’s unwanted behaviors.
Methodology.
The following information should be used to determine compliance with the standard:  IDT Minutes from March 1, 2013 through May 31, 2013.  Individual Treatment Plans, and updates from March 1, 2013 through May 31, 2013.
Analysis and Interpretation.
IDT minutes completed between March 1, 2013‐May 31, 2013 were reviewed from PU Phase 1 (Sycamore Unit), PU Phase 2 (Cedar Unit) and Transition Unit (Buckeye Unit).
Ten youth cases were reviewed. The IDT minutes revealed 100% compliance with the youth attending IDT bi‐weekly meetings as required.
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The IDT was 80% compliant with conducting weekly IDT meetings to discuss the youth’s progress. This is because two youth were not reviewed weekly as required and case documentation and analysis revealed a breakdown in integrating the youth into the IDT meeting schedule when the youth was promoted from Phase 1 (Cedar Unit) to Transition 1 (Buckeye Unit).
Throughout the review of the IDT Meeting process, there are numerous references to new arrivals on the unit, and a tendency to defer seeing such individuals promptly, and instead allowing them to “settle in” to the new environment. Unfortunately, that practice is somewhat contradictory to expectations for treatment planning and execution as listed in ODYS SOP 303.01.07 “Unit PROGRESS.” That SOP, newly approved in May of 2013, specifies certain time requirements for youth to be given their Behavioral Expectations, develop or update their ITP to address problem behaviors that lead their referral for placement on PU in the first place, and meet with the IDT to have this information reviewed and signed off by members of the IDT. The ITP exists now in a version in the electronic behavioral health database that allows for timely updates and revisions, but doesn’t really lend itself to a form where IDT members actually can “sign off” on the document.
IDT minutes indicated that the youth were engaged in the treatment plan process, and that treatment interventions were being discussed with them. However, on one occasion the treatment intervention was not adjusted. Based on the documentation, the treatment intervention was not adjusted because the IDT came to an impasse and was uncertain on what intervention method to introduce next. In this case, the treatment interventions were adjusted in 6 out of the 7 applicable cases when warranted. This is an 86% compliance rate.
Although goals and objectives were reviewed and discussed among the IDT, this is an area still needing improvement. The goals and objectives were discussed on an inconsistent basis and neither Unit exceeded 77% for review and discussion of goals. Moreover, neither Unit exceeded 74% for review of objectives during the IDT meetings.
The IDT consistently discussed the youth’s behaviors and behavior assignments. Conversely, the demonstration of acquisition of skills was discussed less frequently.
The IDT minutes have a structure to them that generally follows the format of listing information by youth individually, including goals / objectives / commentary on progress being made, along with summary paragraphs discussing topics like medication changes and special treatment plans such as Behavioral Contract, Intensive Behavioral Contracts, and Safety Plans. Towards the end of the minutes, there are quick comments on new arrivals on a unit. This is not generally similar to the structure of IDT Minutes as specified in ODYS Form 404.02.01.A, “Interdisciplinary Team Agenda /Meeting Minutes,” which covers many of the same topics, but specifies a different arrangement of information, in which youth are grouped into topics of interests. This difference in the form and format completed by the facility compared to what is in policy needs to be resolved.
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SOP 404.02.01 “Interdisciplinary Team” also requires that a youth complete a Juvenile Relational Inquiry Tool. All IDT minutes lacked documentation of the status of this requirement. The SOP also indicates that family members and parole staff should be included in IDT meetings, but these interactions generally are not listed as taking place.
Conclusions and Recommendations.
The facility is in partial compliance with this standard. There is evidence that the IDT minutes for Sycamore and Cedar have vastly improved from the past. The IDT Minutes for these units revealed documentation that youth were meeting with the IDT bi‐weekly as required. There are notations that treatment interventions were being discussed with the youth. Goals and objectives are sometimes presented for report and discussion among the IDT members, and comments about youth’s behaviors and behavior expectations were discussed. However, the minutes contained missing discussion surrounding skill acquisition and relevant interventions. These units are clearly working as a team and are driven to support and assist the youth with whom they work. This is strong evidence that these minutes will be in substantial compliance by the next report.
In order to meet the standard associated with IDT Substance, all three IDTs must: 1. Follow the SOP for documenting IDT meeting minutes. 2. Document in the meeting minutes:
a. Where the youth is in treatment b. Exactly where the youth is in relation to behavior expectations and skill acquisition as
related to his goals and objectives c. That the youth knows exactly what he needs to do in order to get promoted.
(6) Standard: Length of Stay A Length of Stay (LOS) record is maintained for each youth to document the date placed on Phase 1, promoted to Phase 2, promoted to Transition, and transferred to the general population. Youth are expected to promote to the next phase within 30 days (or be referred for review, as described by Standards 7‐8, below). Across the three phases, the outer limit is 90 days.
Methodology. The following information should be used to determine compliance with the standard:
 Youth’s movement history
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Analysis and Interpretation.
Promotion to the next phase within 30 days There were 16 youth on the PU during this three month period. One youth was excluded from all analyses due to an extreme outlier which would skew the data (he was on the PU for 1 day during the period under review). A “stay” in the tables below is defined as a finite period of time spent on a single unit.
Four out of the 12 stays (33%) on Phase 1 were over 30 days. In other words, 67% of the Phase 1 stays were shorter than the expected maximum. Three out of the 17 stays on Phase 2 were over 30 days; for a compliance rating of 82% over 30 days. Three out of the 17 stays on Transition were over 30 days; for a compliance rating of 82% over 30 days. There was a total of 10 stays over 30 days (out of 46 total stays), for an overall compliance rating of 78%. Please see the charts at the bottom of this section. Ten out of the 16 youth (63%) had at least one stay over 30 days. Conversely, only 38% of the youth on the PU advanced through all three phases spending less than 30 days on each phase, for a total LOS of 90 days or less.
Finally, it is noteworthy that the average LOSs for all three phases is below 30 days. This suggests that there is significant variability in the length of time youth stay on each phase. As discussed above, some of the youth spend more than 30 days on a phase (33% Phase 1; 18% Phase 2; and 18% Transition), but the remaining youth spend significantly less time on each phase, which brings the average down.
Recycled Cases As previously discussed, ten cases were reviewed to analyze reasons for youth recycling through the PU. Based on the data, there was no clear indication why youth recycled through the Phases. However, it must be noted that the 9 youth who were recycled accumulated a total of 13 demotions. In 8 out of 13 instances (62%), the youth’s goals and objectives were not discussed during the most recent IDT meeting prior to the demotion. This trend should be explored further to determine if this is one factor which may contribute to the youths’ recycling through the Phases.
Conclusions and Recommendations The facility is in partial compliance with this standard.
The primary concern revealed by this analysis is the proportion of youth who do not pass through the PU as quickly as anticipated. Looking at all three phases together for individual youth, about two‐thirds of the youth on the PU get hung up at some point in the process. Most often, the delay occurs on Phase
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I. Phase 1 is an adjustment period for the youth, which could explain why this phase is where a delay most often occurs. In order to meet the standard associated with the Length of Stay, a QIP should be developed to address the following issues:
1. Continue streamlining procedures and services on the PU. 2. Continue Quality Assurance/Quality Improvement of ITPs, IDT minutes, and services. 3. Monitor effectiveness of ITPs, IDT minutes and services.
The two tables below depict the information pulled from the primary source of information for the months of March, April, and May 2013. An analytical breakdown of the raw data is provided below.

Phase 1 2 Transition

# of youth 10 16 14

# of stays 12 17 17

Average LOS (days) 26 23 28

Phase
1 2 Transition Total

Over 30 days on a Phase

# of youth # of Total # of

stays

Stays

4

4

12

3

3

17

3

3

17

10

10

46

Compliance Rate 67% 82% 82% 78%

(7) Standard: Central Office Review Board Composition and Timelines. A Central Office Review Board (CORB) conducts a review of any youth who has been on Phases 1 or 2 of the PU for more than 28 days. At a minimum, the CORB must consist of an Administrative Psychiatrist, the Bureau Chief of Facility Programs, and Behavioral Health Administrator. The CORB review is completed by the 35th day on the Phase. As of November 2012, only Phase 1 and Phase 2 are subject to review by the CORB.

Methodology. The following information should be used to determine compliance with the standard:
 Signed reviews from the months of March, April, May  The spreadsheet of timeline deadlines  The movement history Analysis and Interpretation

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Reviews completed by the 35th day During the months of March, April, and May 2013, 7 cases were reviewed by the CORB. Of those 7, 6 reviews occurred within the appropriate timeframe, for a compliance rating of 86%. One review was delayed because of a complication with the timeline involving one youth. This youth was on Phase 1 for 78 days. His review was due on 3/4/13. Unfortunately, due to multiple factors, including a lack of communication between the manager of the spreadsheet and the writer of the report, a delay in information received from the facility staff, and timing of an interview opportunity, his review did not occur until 3/29/13. Once the review was held (3/29/13), the youth’s 28 day expectation was re‐initiated and he transitioned prior to meeting the 28 day deadline created by the 3/29/13 meeting.

The table below depicts the information pulled from the three sources of information. It directly relates to the items in question. An analytical breakdown of the raw data is provided below.

Name Phase 35th Day Affected

TB

1

3/7/13

TB

1

4/26/13

CC

1

3/4/13

BD

1

5/6/13

AF

2

5/21/13

DP

2

4/25/13

DS

1

5/22/13

Date review signed
4/2/13 4/26/13 3/21/13, revised 3/29/13 5/3/13 5/21/13 4/26/13 5/21/13

Interviewed
3/26/13

Admin Psych
y y y

Reviewed by Bureau
Chief
y y y

BHSAs
y y y

y

y

y

y

y

y

y

y

y

y

y

y

Administrative Psychiatrist present Of the 7 reviews that occurred during this time period, there was a rating of 100% compliance with the expectation for the Administrative Psychiatrist to be present.

Facility Programs Bureau Chief present Of the 7 reviews that occurred during this time period, the Bureau Chief reviewed all seven of the reviews prior to submission. Due to the demands of the Bureau Chief’s schedule, it is often difficult to attend every meeting, especially when the tight timeframe is taken into account. Therefore, the Bureau Chief consulted with the DOJ monitors and received approval to not attend such meetings as long as the

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Bureau Chief reviewed the cases and provided feedback when necessary, which explains why the first and sixth reviews did not appear to meet the 35th day timeframe.
Behavioral Health Administrator Of the 7 reviews that occurred during this time period, there was a 100% compliance rating with the expectation that several Behavioral Health Administrators are present for these meetings. Conclusion and Recommendations. The facility is in substantial compliance with this standard. In order to maintain substantial compliance, the CORB will continue to follow its established process. (8) Standard: Central Office Review Board Substance ‐ Partial Compliance The CORB utilizes a comprehensive summary of the youth’s clinical formulation, treatment, progress and challenges to date. The summary is reviewed by each CORB team member prior to the case review. The CORB issues specific recommendations for refocusing the youth’s treatment and sets specific timelines for subsequent reviews. Recommendations are communicated to the IDT, which notifies the youth if the treatment plan has been modified. Methodology. The following information should be used to determine compliance with the standard:
 Signed CORB reviews from the months of March, April, May 2013  IDT minutes Analysis and Interpretation. A thorough review of 6 CORB reviews was performed to ensure compliance with this standard. Because the sample size is such a small number, the percentages are not quite as meaningful as if it were a larger sample size. The table below provides a breakdown of the data (the “yes” column denotes compliance).
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CORB Tasks/Recommendations: CORB review by 35th day Administrative Psych sig Bureau Chief sig BHSA sig Documents Packet reviewed IDT Minutes reviewed Case Review Summary provided PROGRESS Unit History provided (promotions, demotions) Need for difference approach to treatment intervention Need for different treatment goals Contraindicataions for continued placement If Yes, more appropriate placement determined Written recommendations provided Established timeline for next review Primary Clincian and IDT: ITP documentation address CORB recommendations IDT met with youth at next scheduled IDT after Review Youth's summary prepared by Primary Clinician and submitted to CORB Includes Clinical formulation Includes Treatment Progress Includes Challenges to date Includes Youth's history Includes Mental Health diagnoses Includes Past Treatment (including Meds) Includes Psychiatric Progress notes Includes Results of Psychological Testing Includes Treatment Goals Includes Treatment interventions and responses Includes Need treatment delivered Includes IDT's conclusions/reasons youth is not progressing

Yes

No

N/A

4

2

0

6

0

0

1

5

0

6

0

0

5(83%) 1(17%)

0

4 (67%) 2(33%)

0

6

0

0

6

0

0

6

0

0

6

0

0

0

6

0

0

0

6

6

0

0

6

0

0

3(50%) 3(50%)

0

2(33%) 4(67%)

0

6 6 6 6 6 6 6 4 (67%) 5(83%) 5(83%) 2(33%) 3

0 0 0 0 0 0 0 2(33%) 1(17%) 1(17%) 2(33%) 3

0 0 0 0 0 0 0 0 0 0 2(33%) 0

Overall, the results were positive. The CORB is clearly reviewing the documentation prior to writing the reviews, they are providing relevant recommendations that have not been tried by the IDT, and they are creating original comprehensive case conceptualizations before offering recommendations.

For their part, the frontline staff is clearly providing much of the necessary materials to the Central Office Review Board in a timely manner; however there are some definite areas of weakness, as is evident by the chart. There is evidence of genuine attempts to adjust the youth’s treatment prior to the reviews and then also to implement all recommendations provided and to ensure that they are communicating all changes to the youth.
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Conclusions and Recommendations As noted in the chart above, there is clear evidence that both parties are working to ensure compliance with this standard. There are some areas that can be improved, such as the IDT meeting with the youth at the next meeting and the CORB following up to ensure that the recommendations offered are followed. Whether this is a failure of actual follow up or documentation of that follow up is not able to be determined from the raw data. Furthermore, because there were only 6 examples used, it will be necessary in the future to continue monitoring these actions.
In order to move from partial compliance to substantial compliance:
1. Central Office must ensure the facility follows through and implements the CORB recommendations.
2. Central Office must take a more supportive role in these reviews by means of communicating with facility frontline staff to determine support needed in order to implement the suggested recommendations and to address any barriers the staff may experience in relation to the recommendations.
[II.13] Phase Demotions Status: Substantial Compliance
(1) Standard: Phase Demotion. A deliberative process is utilized to demote youth to a lower phase. Demotions are imposed only for the following reasons: an act of violence, STG activity that promotes or directs an individual to carry out an act of violence, possession of major contraband, repeated verbal threats to cause serious physical harm to staff or other youth. All demotions are approved by the facility Superintendent.
Methodology. The following information should be used to determine compliance with the standard:
 Phase Demotion Summary Form  AMS reports  IDT Contact and Discussion (via email or summary of verbal discussions with UM, Youth
Specialists, SW, Psychology Staff)  IH documentation
Analysis and Interpretation.
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Progress IDT Staff made a total of 25 requests for demotion during the review period of March, April & May of 2013. Of the 25 requests, 11 were denied for demotion (44%) and 14 were approved (56%). During the period of review, the 14 approved for demotion were for the following reasons:
 6 youth (43%) were demoted due to an act of violence (AOV)  6 youth (43%) were demoted due to repeated verbal threats  2 youth (14%) were demoted due to possession of major contraband
o 0 youth were demoted due to possession of STG material The IDT team began addressing possession of STG material as a treatment issue rather than punishment despite the offense being eligible for demotion. This approach resulted in no youth being demoted for possession of STG material.
10 youth accounted for 14 of the demotions as 3 youth had multiple demotions. The following is a breakdown of the youth with multiple demotions:
 Youth MG2 (there are two youth with the initials MG) was demoted three times, once for possession of contraband, once for repeated verbal threats and once for a Youth on Staff assault o On 3/20/13, demoted from Buckeye Transition Phase 2 to Buckeye Transition Phase 1 o On 4/12/13, demoted from Buckeye Phase 1 to Cedar (Phase 2) o On 5/1/13, demoted from Cedar (Phase 2) to Sycamore (Phase 1)
 Youth WH was demoted twice for repeated verbal threats, which included youth walking toward staff with his fist balled up while making threats to physically assault staff o On 3/19/13, demoted from Buckeye Transition Phase 1 to Cedar (Phase 2) o On 3/22/13, demoted from Cedar to Sycamore (Phase 1)
 Youth DS was demoted twice for repeated verbal threats o On 3/19/13, demoted from Buckeye Transition Phase 1 to Cedar (Phase 2) o On 4/17/13, demoted from Cedar to Sycamore (Phase 1)
The following youth were demoted a single time for the following reasons:
 On 4/2, BD was demoted from Buckeye Transition Phase 1 to Sycamore for a youth on staff assault o The team made two recommendations for demotion prior to the 4/2 assault:  On 3/19/13, IDT recommended BD for demotion based on youth receiving YBIRs consistently. The recommendation for demotion was denied and the team was encouraged to address his behaviors through a behavioral contract.  On 3/29/13, BD was involved in a youth on youth fight. IDT recommendation for demotion was denied and the team was encouraged to revise his behavioral contract.
 On 4/2/13, TR was demoted from Buckeye Transition Phase 1 to Sycamore for a youth on staff assault. o On 3/19, IDT recommended TR for demotion for threatening conduct, but was denied. IDT was encouraged to work with TR on how to handle change and his aggression.
 On 5/31/13, AF was demoted from Cedar to Sycamore for a youth on staff assault.
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o The team made two recommendations for demotion prior to the 5/31 assault:  On 5/16/13, IDT recommended AF for demotion based on youth receiving YBIRs, refusing programming, and not making progress on his ITP goals. The request was denied and the Superintendent on 5/16/14 because the reason for demotion did not meet the Court Order. The Superintendent subsequently reviewed the Court Order as it related to phase demotions with the Unit Manager.  On 5/24/13, IDT resubmitted their recommendation for demotion stating threatening conduct and the recommendation was denied pending additional documentation illustrating youth’s threatening conduct.
 On 3/19/13, MG1 was demoted from Buckeye Transition Phase 2 to Cedar for having $50 found on his person after a strip search. The IDT recommended the demotion; however, youth was not demoted until youth was proven by the IH process to have had contraband in his possession. o The IDT made a subsequent request for demotion which was denied. On 5/23/13, IDT recommended demotion due to possession of STG material. The recommendation was denied. MG1 was taking a picture during the school graduation party and held up gang signs. He was also found with a STG letter. The letter did not direct anyone to carry out an act of violence. Nor did the letter mention any past violence. The Superintendent encouraged the IDT to address his STG affiliation, poor decision making skills and their impact and how to build positive/healthy relationships.
 On 3/22/13, DP was demoted Buckeye Transition Phase 1 to Cedar (Phase 2) for making repeated threats of harm. This youth was admitted into the program due to his involvement with orchestrating an assault on a unit manager. He was documented as having a conversation with the same youth who carried out the assault on the unit manager. o On 3/28/13, IDT recommended demotion due to threatening conduct. The recommendation was denied because it was one isolated incident and there was no evidence that there were repeated verbal threats.
 On 3/23/13, TB was demoted from Cedar to Sycamore for youth on staff assault.  On 5/25/13, TH was demoted from Buckeye Transition Phase 1 to Sycamore for a youth on staff
assault.
The development and implementation of the Superintendent’s Review for Demotion form assisted in identifying the act(s) that lead to the request for demotion, a description of the incident, the evidence that was reviewed and the deliberative process that was used to justify the decision and the identification of the phase that the youth was being demoted to, if the request for demotion was approved.
Conclusions and Recommendation: The analysis revealed several dynamics in support of a finding of substantial compliance. First, phase demotions were incremental. Youth who committed repeated verbal threats or had possession of contraband/STG material were not demoted all the way to Phase I, but instead were demoted
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incrementally to the next more restrictive phase. Only when a youth’s behavior resulted in acts of violence against a staff member were they demoted to Phase 1. Second, nearly half of the demotion requests were denied when the act in question was not of sufficient severity or not properly documented, showing that the Superintendent strictly adheres to the requirements of the Court Order. Finally, occasionally youth have engaged in one of the “big 4” infractions but were not demoted at all; instead, the Superintendent required the IDT to exhaust less punitive sanctions and additional treatment options prior to demotion. In order to maintain substantial compliance, ODYS will continue to ensure that the documentation supports the requirement of a deliberative process to determine whether the facts of the incident support the youth’s eligibility for demotion and why.
[II.14] Policies, Procedures and Handbooks Status: Substantial Compliance
(1) Standard: Policies and Procedures Policies and procedural manuals are current, accurately describe the operation of the PU, and provide guidance to staff in implementing the standards for the Unit. The Youth Handbook accurately describes the operation of the PU so youth know what to expect from the program and what is expected of them.
Methodology. The following information is used to determine compliance with the standard:
 Email from monitor Kelly Dedel, PH.D dated April 10, 2013 stating ODYS is in substantial compliance with this provision.
 PU Policy Effective May 31, 2013  PU Handbook Effective May 31, 2013  PU Handbook Revised 6‐19‐2013 to reflect ODYS Central Office new address so youth could mail
grievance to the correct address
Analysis and Interpretation. The Court Order granted DYS 60 days from the day of signing to submit policies, procedures and Handbooks that accurately describe the operation of the PU. Per the 1st PU Status Report DYS submitted these materials to the Monitor within the required timelines.
Recommendations. In order for ODYS to continue to maintain substantial compliance with this provision DYS will review policy, procedure and handbooks yearly and continue QA/QI to ensure that what is outlined in policy is actual practice on the PU.
44

 Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 1 of 22
CLOSED,PROTO
U.S. District Court Southern District of Ohio (Columbus) CIVIL DOCKET FOR CASE #: 2:08−cv−00475−ALM−MRA

United States of America v. Strickland et al Assigned to: Judge Algenon L. Marbley Referred to: Magistrate Judge Mark R. Abel Lead case: 2:04−cv−01206−ALM−TPK Member case: (View Member Case) Cause: 42:1981 Civil Rights Interested Party Kelly Dedel, Ph.D. Lead Monitor
Plaintiff The United States of America

Date Filed: 05/16/2008 Date Terminated: 06/24/2008 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff
represented by Kelly Dedel, Ph.D. One in 37 Research, Inc. 1608 NW Riverscape Street Portland, OR 97209 503−799−0915 Email: Kelly.Dedel@gmail.com PRO SE
represented by Alexandra L. Shandell U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 202−307−6123 Fax: 202−514−4883 Email: Alexandra.Shandell@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Alphonse Adam Gerhardstein Gerhardstein & Branch Co. LPA 441 Vine Street Suite 3400 Cincinnati, OH 45202 513−621−9100 Fax: 513−345−5543 Email: agerhardstein@gbfirm.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Cynthia Coe 601 D Street, NW Washington, DC 20530 202−353−1121 Fax: 202−514−0212 Email: cynthia.coe@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Mark Thomas D'Alessandro United States Attorney's Office − 2 303 Marconi Boulevard 2nd Floor Columbus, OH 43215 614−469−5715 Email: mark.dalessandro@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 2 of 22
Benjamin O Tayloe , Jr. United States Department of Justice 950 Pennsylvania Ave. N.W. Washington, DC 20530 (202) 514−8103 Fax: (202) 514−0212 Email: benjamin.tayloe@usdoj.gov TERMINATED: 07/24/2014
Gregory Gonzalez Department of Justice 601 D Street, NW Room 5920 Washington, DC 20004 202−305−2941 Fax: 202−514−6903 Email: gregory.gonzalez@usdoj.gov TERMINATED: 01/12/2009
Jacqueline K Cuncannan Department of Justice 950 Pennsylvania Avenue, NW SPL, PHB Room 5730 Washington, DC 20530 202−616−2556 Fax: 202−514−4883 Email: Jacqueline.Cuncannan@usdoj.gov ATTORNEY TO BE NOTICED
Judith Preston U.S. Department of Justice 601 D St NW Washington, DC 20004 202−514−5464 Fax: 202−514−0212 Email: judy.preston@usdoj.gov ATTORNEY TO BE NOTICED
Rashida Jamila Ogletree US Department of Justice Special Litigation Section 950 Pennsylvania Avenue NW Washington, DC 20530 202−305−3712 Fax: 202−514−4883 Email: Rashida.Ogletree@usdoj.gov ATTORNEY TO BE NOTICED
Silvia Dominguez U.S. Department of Justice Civil Rights Division 601 D Street, NW Suite 5013 Washington, DC 20530 202−616−8547 Fax: 202−514−4883 Email: Silvia.Dominguez@usdoj.gov TERMINATED: 05/29/2014
Stacy K Grigsby United States Department of Justice 950 Pennsylvania Ave. N.W. Washington, DC 20530 202−514−4151 Fax: 202−514−0212

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 3 of 22
TERMINATED: 01/24/2011 PRO HAC VICE
Vincent Herman 601 D Street, NW Suite 5025B Washington, DC 20004 202−305−3318 Fax: 202−514−0212 Email: vincent.herman@usdoj.gov TERMINATED: 01/24/2011
Deborah F Sanders United States Attorney's Office − 2 303 Marconi Boulevard 2nd Floor Columbus, OH 43215 614−469−5715 Fax: 614−469−5240 Email: Deborah.Sanders@usdoj.gov ATTORNEY TO BE NOTICED

V.
Defendant
Ted Strickland Governor of the State of Ohio

represented by J Eric Holloway Eric Holloway Law Group, LLC 5650 Blazer Parkway Suite 100 Dublin, OH 43017 614−734−8340 Fax: 614−522−6789 Email: Eric@EricHollowayLaw.com TERMINATED: 01/26/2012 LEAD ATTORNEY
Thomas Nathaniel Anger Ohio Attorney General Criminal Justice 150 East Gay Street 16th Floor Columbus, OH 43215 614−644−8742 Fax: 877−584−2041 Email: thomas.anger@ohioattorneygeneral.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Dustin J Calhoun Ohio Department of Youth Services 30 West Spring Street 5th Floor Columbus, OH 43215 614−728−7353 Email: Dustin.Calhoun@dys.ohio.gov ATTORNEY TO BE NOTICED
Erin C Reed Office of the Ohio Attorney General BCI&I 1560 State Route 56 SW P.O. Box 365 London, OH 43140 740−845−2204

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 4 of 22

Fax: 740−845−2020 Email: erin.reed@ohioattorneygeneral.gov TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller Ohio Attorney General's Office 150 E. Gay Street 16th Floor Columbus, OH 43215 614−644−8693 Fax: 877−586−0406 Email: jason.fuller@OhioAttorneyGeneral.gov TERMINATED: 03/09/2012

Judith B Goldstein Ohio Attorney General Criminal Justice Section/Corrections Litigation 150 East Gay Street Columbus, OH 43215 614−644−7233 Email: jgoldstein45@gmail.com ATTORNEY TO BE NOTICED

Mindy Ann Worly Ohio Attorney General's Office Criminal Justice Section 150 E. Gay Street 16th Floor Columbus, OH 43215 614−728−0161 Fax: 866−474−4985 Email: mworly@ag.state.oh.us TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. Ohio Parole Board 770 W. Broad Street Columbus, OH 43222 614−752−1200 Email: richard.cholar@odrc.state.oh.us TERMINATED: 03/09/2012

Defendant Ohio Department of Youth Services

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 5 of 22

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Thomas Stickrath Director of Ohio Youth Services

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Thomas Teague Superintendent of the Circleville Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 6 of 22

(See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Katie Needham Superintendentof the Cuyahoga Hills JuvenileCorrectional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Marci Sutherland Superintendent of the Freedom Center

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 7 of 22

LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Beth Oprisch Acting Superintendent of the Indian River JuvenileCorrectional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 8 of 22

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Dion Norman Interim Superintendentof the Marion Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Larry Gongwer Acting Superintendent of the Mohican Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 9 of 22

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Fred Nelson Superintendent of the Ohio River Valley Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant
Chris Money Superintendent of the Scioto Juvenile Correctional Facility

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 10 of 22

(See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Judith B Goldstein (See above for address) ATTORNEY TO BE NOTICED

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Defendant The State of Ohio

represented by J Eric Holloway (See above for address) TERMINATED: 01/26/2012 LEAD ATTORNEY

Thomas Nathaniel Anger (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Dustin J Calhoun (See above for address) ATTORNEY TO BE NOTICED

Erin C Reed (See above for address) TERMINATED: 11/22/2010 ATTORNEY TO BE NOTICED

Jason Michael Fuller (See above for address) TERMINATED: 03/09/2012

Mindy Ann Worly (See above for address) TERMINATED: 06/24/2013

Richard Thomas Cholar , Jr. (See above for address) TERMINATED: 03/09/2012

Date Filed 05/16/2008 05/16/2008
05/20/2008

# Docket Text
1 Civil Cover Sheet (sr) (Entered: 05/16/2008)
2 COMPLAINT filed by The United States of America against Dion Norman, Larry Gongwer, Fred Nelson, Chris Money, The State of Ohio, Ted Strickland, Ohio Department of Youth Services, Thomas Stickrath, Thomas Teague, Katie Needham, Marci Sutherland, Beth Oprisch (sr) (Entered: 05/16/2008)
3 MOTION for Leave to Appear Pro Hac Vice of Stacey K. Grigsby U.S. Dept. of Justice (Filing fee $ 200) by Plaintiff The United States of America. (Attachments: # 1 Certificate of Good Standing) (D'Alessandro, Mark) (Entered: 05/20/2008)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 11 of 22

05/20/2008 05/22/2008 06/05/2008
06/12/2008 06/24/2008 01/09/2009 01/12/2009 06/09/2009 06/09/2009
06/16/2009 09/21/2009 09/29/2009 09/29/2009 10/02/2009 10/05/2009 10/09/2009

4 MOTION for Leave to Appear Pro Hac Vice of Benjamin O. Tayloe, Jr. U.S. Dept. of Justice (Filing fee $ 200) by Plaintiff The United States of America. (Attachments: # 1 Certificate of Good Standing) (D'Alessandro, Mark) (Entered: 05/20/2008)
5 ORDER granting 3 & 4 Motions for Leave to Appear Pro Hac Vice of Stacy K. Grigsby and Benjamin O. Tayloe, Jr. Signed by Mark R. Abel on 05/22/2008. (sr) (Entered: 05/22/2008)
6 Joint MOTION for Settlement as to Scioto Juvenile Correctional Facility and Marion Juvenile Correctional Facility, Unopposed MOTION to Dismiss conditionally the Complaint as to the six remaining state−operated juvenile correctional facilities ( Responses due by 6/30/2008) by Plaintiff The United States of America. (Attachments: # 1 Text of Proposed Order Stipulation for Injunctive Relief) (Gonzalez, Gregory) (Entered: 06/05/2008)
7 ORDER FOR ENTRY OF STIPULATION AND FOR CONDITIONAL DISMISSAL OF COMPLAINT. Signed by Algenon L. Marbley on 06/12/2008. (cw, ) (Entered: 06/12/2008)
8 STIPULATION FOR INJUNCTIVE RELIEF. Signed by Algenon L. Marbley on 6/24/2008. (cw, ) (Entered: 06/24/2008)
9 First MOTION to Substitute Attorney Greg Gonzalez by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 01/09/2009)
10 ORDER granting # 9 Motion to Substitute Attorney. Attorney Silvia Dominguez added for The United States of America. Attorney Gregory Gonzalez terminated. Signed by Mark R. Abel on 1/12/09. (rew ) (Entered: 01/12/2009)
11 MOTION to Clarify Stipulation by Plaintiff The United States of America. (Tayloe, Benjamin) (Entered: 06/09/2009)
12 Memorandum of Law in Support of its 11 MOTION to Clarify Stipulation by Plaintiff The United States of America. (Attachments: # 1 Exhibit A (Kim May 9, 2007 Letter), # 2 Exhibit B (Swisher April 28, 2008 Letter), # 3 Exhibit C (Cohen Jan 30, 2009 email), # 4 Exhibit D (Cohen Feb 18, 2009 email), # 5 Exhibit E (Cohen April 6, 2009 email), # 6 Exhibit F (Cohen April 23, 2009 email), # 7 Exhibit G (Cohen May 19, 2009 email), # 8 Exhibit H (Cohen March 18, 2009 email), # 9 Exhibit I (Gerhardstein March 26, 2009, 18:38 EST email), # 10 Exhibit J (Gerhardstein March 26, 2009 19:22 EST email), # 11 Exhibit K (Cohen May 12, 2009 email), # 12 Text of Proposed Order) (Tayloe, Benjamin) Modified text and terminate event as motion on 6/9/2009 (er1 ). (Entered: 06/09/2009)
13 NOTICE of Appearance by Vincent Herman Plaintiff The United States of America (Herman, Vincent) (Entered: 06/16/2009)
14 Response Pursuant to Court's Order of Aug 31, 2009 by Plaintiff The United States of America. (Attachments: # 1 Appendix A −− Sept 9, 2009 Letter) (Tayloe, Benjamin) (Entered: 09/21/2009)
15 NOTICE by Plaintiff The United States of America and Parties in S.H. Regarding Monitor's Resignation in U.S. v. Ohio and Motion to Modify Briefing Schedule (Attachments: # 1 Appendix A −− Sept 24, 2009 Letter from Monitor Cohen) (Tayloe, Benjamin) (Entered: 09/29/2009)
16 Position of the Monitor Regarding Joint Notice to the Court Regarding the Monitor's Resignation in U.S. V. Ohio, and Motion to Modify Briefing Schedule (pes1) (Entered: 09/29/2009)
17 NOTICE OF WITHDRAWAL OF DOCUMENT 16 filed by Monitor Fred Cohen. (pes1) (Entered: 10/02/2009)
18 ORDER holding Joint Notice re: Monitor's Resignation and Motion to Modify Briefing Schedule [doc.143] in Abeyance. Signed by Judge Algenon L. Marbley on 10/05/2009. (cw) (Entered: 10/05/2009)
19 NOTICE by Plaintiff The United States of America and Parties in S.H. Regarding Monitor's Resignation in U.S. v. Ohio (Tayloe, Benjamin) (Entered: 10/09/2009)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 12 of 22

11/06/2009 11/06/2009 11/23/2009 11/23/2009 11/24/2009
11/25/2009 12/01/2009

20 ORDER Setting a Telephonic Status Conference for 11/6/2009 03:30 PM before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/06/2009. (cw) (cw). (Entered: 11/06/2009)
21 ORDER Setting Telephonic Status Conference for 11/16/2009 03:00 PM before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/06/2009. (cw) (Entered: 11/06/2009)
22 NOTICE of Appearance by J Eric Holloway Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Holloway, J) (Entered: 11/23/2009)
23 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Filing Joint Proposed Modifications to the Stipulation for Injunctive Relief in U.S.A. v. Ohio (Holloway, J) (Entered: 11/23/2009)
24 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 23 Notice (Other), Notice (Other) of Filing Exhibit A (Dedel C.V.) to Joint Proposed Modifications to the Stipulation for Injunctive Relief (Holloway, J) (Entered: 11/24/2009)
25 NOTICE of Appearance by Richard Thomas Cholar, Jr Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Cholar, Richard) (Entered: 11/25/2009)
26 Transcript of Telephonic Status Conference held on 11/16/2009, before Judge Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

12/15/2009
12/15/2009 02/22/2010 02/26/2010 02/26/2010

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 12/22/2009. Redacted Transcript Deadline set for 1/4/2010. Release of Transcript Restriction set for 3/1/2010. (pes1) (Entered: 12/01/2009)
27 ORDER ADOPTING Proposed Modifications to the Stipulation for Injunctive Relief 23 Notice Directing Monthly Payments be made from Prison Account of, ORDER re 23 Notice (Other), Notice (Other) filed by Dion Norman, The State of Ohio, Thomas Stickrath, Fred Nelson, Katie Needham, Ted Strickland, Marci Sutherland, Chris Money, Larry Gongwer, Ohio Department of Youth Services, Thomas Teague, Beth Oprisch. Signed by Judge Algenon L. Marbley on 12/15/2009. (cw) (Entered: 12/15/2009)
28 ORDER finding as moot 11 Motion to Clairfy. Signed by Judge Algenon L. Marbley on 12/15/2009. (cw) (Entered: 12/15/2009)
29 ORDER SETTING Status Conference for 2/24/2010 10:00 AM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 2/22/2010. (cw) (Entered: 02/22/2010)
30 ORDER. Signed by Judge Algenon L. Marbley on 2/26/2010. (cw) (Additional attachment(s) added on 2/26/2010: # 1 Attachment 1) (cw). (Entered: 02/26/2010)
31 ORDER. Signed by Judge Algenon L. Marbley on 2/26/2010. (Attachments: # 1 Attachment 1) (cw) (Entered: 02/26/2010)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 13 of 22

02/26/2010 03/03/2010
03/09/2010
03/17/2010 03/17/2010 03/17/2010

Notice of Correction: [doc # 30] removed because it improperly contained confidential information. (cw) (Entered: 02/26/2010)
32 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 31 Order of Compliance with Order (Attachments: # 1 Exhibit A, Summaries) (Holloway, J) (Entered: 03/03/2010)
33 MOTION for Order to Grant Relief from Court Order; Motion for Extension of Time in the Alternative by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit A, Declaration of Chris Money) (Holloway, J) (Entered: 03/09/2010)
34 ORDER granting 33 Alternative Motion for an Extension of Time. Signed by Judge Algenon L. Marbley on 03/17/2010. (cw) (Entered: 03/17/2010)
35 **SEALED** Transcript of Status Conference Proceedings held on 2/24/2010, before Judge Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. (pes1) (Entered: 03/17/2010)
36 Transcript of Status Conference Proceedings held on 2/24/2010, before Judge Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

04/09/2010
04/09/2010
04/12/2010 04/13/2010
04/13/2010 06/02/2010

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 4/7/2010. Redacted Transcript Deadline set for 4/19/2010. Release of Transcript Restriction set for 6/15/2010. (pes1) (Entered: 03/17/2010)
37 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Compliance with Court Order (Attachments: # 1 Index of Exhibit B) (Holloway, J) (Entered: 04/09/2010)
38 Unopposed MOTION for Order to Permit Defendants to Manually File Exhibit B by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Holloway, J) (Entered: 04/09/2010)
39 ORDER granting 38 Motion for Order for Leave to File Documents Manually. Signed by Judge Algenon L. Marbley on 04/12/2010. (cw) (Entered: 04/12/2010)
40 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 37 Notice (Other), Notice (Other) of Manually Filing Exhibit B to Notice of Compliance with Court Order (Doc. 37) (Holloway, J) (Entered: 04/13/2010)
***Manual Filing of Exhibit B, in CD format, re 172 Notice of Compliance with Court Order has been filed with the Clerk's Office. (er1) Modified on 4/14/2010 to clarify text (kk2). (Entered: 04/13/2010)
41 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 37 Notice

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 14 of 22

06/04/2010 06/14/2010 06/17/2010 06/24/2010 06/24/2010 06/24/2010 06/25/2010 06/29/2010 07/01/2010 07/12/2010
07/12/2010 07/12/2010

(Other), Notice (Other) of Supplemental Compliance with Court Order (Attachments: # 1 Exhibit A, Ast Declaration, # 2 Exhibit B, Monitor Cohen Email) (Holloway, J) (Entered: 06/02/2010)
42 ORDER Setting a Show Cause Hearing for 7/1/2010 09:00 AM in Courtroom 1 − Columbus before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 06/04/2010. (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3, # 4 Exhibit 4, # 5 Exhibit 5) (cw) (Entered: 06/04/2010)
43 ORDER re: Show Cause. Signed by Judge Algenon L. Marbley on 06/14/2010. (cw) (Entered: 06/14/2010)
44 ORDER Setting Status Conference for 6/22/2010 @ 3:30 PM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 06/17/2010. (cw) (Entered: 06/17/2010)
45 MOTION for Order to Grant Protective Order by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit A, Email of Parties' Agreement) (Holloway, J) (Entered: 06/24/2010)
46 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 43 Order of Compliance (Holloway, J) (Entered: 06/24/2010)
47 PROTECTIVE ORDER FOR THE PROTECTION OF CONFIDENTIAL INFORMATION, granting 45 Motion for Order to Grant Protective Order. Signed by Judge Algenon L. Marbley on 06/24/2010. (cw) (Entered: 06/24/2010)
48 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 43 Order of Delivery of Documents for In Camera Review (Holloway, J) (Entered: 06/25/2010)
49 Order. Internal documents regarding meal refusal policy, due by June 24, 2010. Rescheduling the hearing on the Order to show cause for 7/14/2010 at 9:00 a.m. before the Honorable Algenon L. Marbley, Courtroom 1. Opening briefs due by 7/2/2010 and memoranda contra due by 7/9/2010. (Attachments: # 1 Attachment 1) (cw) (Entered: 06/29/2010)
50 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Filing Pre−Hearing Brief Regarding Show Cause Hearing (Holloway, J) (Entered: 07/01/2010)
51 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio Notice of Supplemental Compliance with the Courts February 26, 2010 Order (Attachments: # 1 Exhibit A, Slagle Declaration, # 2 Exhibit B, Ast Declaration) (Holloway, J) (Entered: 07/12/2010)
52 Response to Plaintiffs Pre−Hearing Brief; Plaintiffs' Motion to File Instanter and Plaintiffs' Motion for Extension to Respond to Monitor's Report by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Holloway, J) (Entered: 07/12/2010)
53 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of First Supplement to Notice of Delivery of Documents for In Camera Review (Holloway, J) (Entered: 07/12/2010)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 15 of 22

07/12/2010 07/12/2010
07/13/2010
07/13/2010
07/13/2010 07/16/2010 07/30/2010
09/20/2010 09/21/2010 10/12/2010 10/21/2010 11/22/2010 01/10/2011 01/11/2011 01/13/2011 01/21/2011

54 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Recall of Inadvertently Produced Documents (Holloway, J) (Entered: 07/12/2010)
55 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Supplement to Pre−Hearing Brief Regarding Show Cause Hearing (Attachments: # 1 Exhibit A, Baker Declaration, # 2 Exhibit B, Daniels Declaration, # 3 Exhibit C, Darnell Declaration, # 4 Exhibit D, French and Clay Declarations, # 5 Exhibit E,Randle Declaration) (Holloway, J) (Entered: 07/12/2010)
56 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio Second Notice of Supplemental Compliance with the Courts Order (Attachments: # 1 Exhibit A, Slagle Declaration) (Holloway, J) (Entered: 07/13/2010)
57 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio Second Supplement to Pre−Hearing Brief Regarding Show Cause Hearing (Holloway, J) (Entered: 07/13/2010)
58 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Objections to the Show Cause Hearing (Holloway, J) (Entered: 07/13/2010)
59 ORDER Parties are to submit the new policy by 7/30/2010. Signed by Judge Algenon L. Marbley on 07/14/2010. (cw) (Entered: 07/16/2010)
60 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Compliance with the Courts July 16, 2010, Order (Attachments: # 1 Index of Exhibits, # 2 Exhibit A, Policy, # 3 Exhibit B, Training Material) (Holloway, J) (Entered: 07/30/2010)
61 NOTICE by Plaintiff The United States of America First Compliance Report (Attachments: # 1 Compliance Report) (Dominguez, Silvia) (Entered: 09/20/2010)
62 NOTICE by Plaintiff The United States of America re 61 Notice (Other) Expert Reports (Attachments: # 1 Supplement) (Dominguez, Silvia) (Entered: 09/21/2010)
63 NOTICE of Appearance by Erin C Reed for Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Reed, Erin) (Entered: 10/12/2010)
64 NOTICE of Appearance by Rashida Jamila Ogletree for Plaintiff The United States of America (Ogletree, Rashida) (Entered: 10/21/2010)
65 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Reed, Erin) (Entered: 11/22/2010)
66 First MOTION for Hearing Status Conference by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 01/10/2011)
67 MOTION to Withdraw 66 First MOTION for Hearing Status Conference by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 01/11/2011)
68 Mail Returned as Undeliverable. Mail (Doc. 59 Order) sent to Stacy K Grigsby on 7/16/2010. (Attachments: # 1 contents) (kjm1) (Entered: 01/14/2011)
69 MOTION to Withdraw as Attorney by Plaintiff The United States of America. (Herman, Vincent) (Entered: 01/21/2011)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 16 of 22

01/24/2011 02/02/2011 02/08/2011 02/10/2011 02/16/2011 04/06/2011
04/27/2011 04/27/2011

70 ORDER granting 69 Motion to Withdraw as Attorney. Attorney Stacy K Grigsby and Vincent Herman terminated. Signed by Magistrate Judge Mark R. Abel on 1/24/2011. (er1) (Entered: 01/24/2011)
71 ORDER finding as moot 66 Motion for Hearing; granting 67 Motion to Withdraw. Signed by Judge Algenon L. Marbley on 2/2/2011. (cw) (Entered: 02/02/2011)
72 NOTICE by Plaintiff The United States of America Second Compliance Report (Attachments: # 1 Compliance Report, # 2 Expert Report, # 3 Expert Report, # 4 Expert Report, # 5 Investigation Report) (Dominguez, Silvia) (Entered: 02/08/2011)
73 NOTICE of Appearance by Jason Michael Fuller for Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Fuller, Jason) (Entered: 02/10/2011)
74 NOTICE by Plaintiff The United States of America re 72 Notice (Other) Addendum to Second Compliance Report (Attachments: # 1 Compliance Report, # 2 Expert Report, # 3 2007 Findings Letter) (Ogletree, Rashida) (Entered: 02/16/2011)
75 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 74 Notice (Other), 72 Notice (Other) Objections to the Second Compliance Report (Fuller, Jason) (Entered: 04/06/2011)
76 Sealed Transcript. Excerpt of Sealed Show Cause Proceedings held on 7/14/2010 before Judge Algenon L. Marbley. (Court Reporter S. Evans) (pes1) (Entered: 04/27/2011)
77 Transcript of Show Cause Proceedings held on July 14, 2010 before Judge Algenon L Marbley. Court Reporter/Transcriber Shawna J Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

04/27/2011

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 5/18/2011. Redacted Transcript Deadline set for 5/31/2011. Release of Transcript Restriction set for 7/26/2011. (kk2) (Entered: 04/27/2011)
78 Transcript of Show Cause Proceedings held on July 15, 2010 before Judge Algenon L Marbley. Court Reporter/Transcriber Shawna J Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

05/09/2011

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 5/18/2011. Redacted Transcript Deadline set for 5/31/2011. Release of Transcript Restriction set for 7/26/2011. (kk2) (Entered: 04/27/2011)
79 NOTICE by Plaintiff The United States of America Third Compliance Report (Attachments: # 1 Supplement Compliance Report, # 2 Supplement PFH Expert Report, # 3 Supplement Spec Educ Expert Report, # 4 Supplement Mental Hlth Expert

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 17 of 22

05/20/2011 06/06/2011 06/17/2011
06/20/2011 06/20/2011
06/28/2011 08/25/2011
08/26/2011 09/01/2011
10/26/2011 10/27/2011 11/02/2011 01/25/2012 01/26/2012 02/06/2012 02/07/2012 02/07/2012

Report, # 5 Supplement Medical Expert Report) (Dominguez, Silvia) (Entered: 05/09/2011)
80 Joint MOTION to Amend/Correct 8 Stipulation and Order by Plaintiff The United States of America. (Attachments: # 1 Memorandum in Support, # 2 Text of Proposed Order) (Dominguez, Silvia) (Entered: 05/20/2011)
81 ORDER AMENDING CERTAIN PROVISIONS OF STIUPLATION; granting 80 Motion to Amend/Correct. Signed by Judge Algenon L. Marbley on 06/6/2011. (cw) (Entered: 06/06/2011)
82 Joint MOTION for Extension of Time to File New date requested 6/20/2011. TO FILE AMENDED STIPULATION by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Holloway, J) (Entered: 06/17/2011)
83 ORDER granting 82 Motion for Extension of Time to File amended stipulation. Signed by Magistrate Judge Mark R. Abel on 06/20/2011. (sr) (Entered: 06/20/2011)
84 NOTICE by Plaintiff The United States of America re 83 Order on Motion for Extension of Time to File, 81 Order on Motion to Amend/Correct Joint Notice of Amended Stipulation for Injunctive Relief (Attachments: # 1 Text of Proposed Order Amended Stipulation for Injunctive Relief) (Dominguez, Silvia) (Entered: 06/20/2011)
85 AMENDED STIPULATION FOR INJUNCTIVE RELIEF. Signed by Judge Algenon L. Marbley on 06/28/2011. (cw) (Entered: 06/28/2011)
86 Unopposed MOTION for Protective Order by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Proposed Protective Order) (Holloway, J) (Entered: 08/25/2011)
87 PROTECTIVE ORDER. Signed by Judge Algenon L. Marbley on 8/26/2011. (pes1) (Entered: 08/26/2011)
88 NOTICE by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio of Amended Certificate of Service to Motion (Doc. 86) (Fuller, Jason) (Entered: 09/01/2011)
Minute Entry for proceedings held before Magistrate Judge Mark R. Abel: Telephone Conference held on 10/26/2011. (Rubey, Rachel) (Entered: 11/03/2011)
89 Unopposed MOTION for Protective Order by Defendant Ohio Department of Youth Services. (Cholar, Richard) (Entered: 10/27/2011)
90 ORDER granting 89 Motion for Protective Order. Signed by Judge Algenon L. Marbley on 11/2/2011. (cw) (Entered: 11/02/2011)
91 MOTION to Authorize Exchange of Information by Plaintiff The United States of America. (Attachments: # 1 Exhibit Memorandum of Understanding) (Ogletree, Rashida) (Entered: 01/25/2012)
92 NOTICE by Defendant The State of Ohio of Substitution of Counsel (Worly, Mindy) (Entered: 01/26/2012)
93 Monitor's First Report on the Amended Stipulation dated 6/282011 by Lead Monitor Kelly Dedel, Ph.D. (pes1) (Entered: 02/06/2012)
94 ORDER re 91 MOTION to Authorize Exchange of Information filed by The United States of America, Responses due by 2/21/2012; replies due by 2/28/2012. Signed by Judge Algenon L. Marbley on 2/7/2012. (cw) (Entered: 02/07/2012)
95 ORDER re 93 Notice (Other) filed by Kelly Dedel, Ph.D., objections due by by 3/8/2012; responses due by 3/22/2012. Signed by Judge Algenon L. Marbley on 2/7/2012. (cw) (Entered: 02/07/2012)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 18 of 22

02/14/2012 02/28/2012
03/08/2012 03/08/2012
03/09/2012
03/22/2012 04/18/2012
04/25/2012 06/22/2012 11/28/2012
11/29/2012 12/19/2012
12/27/2012
01/18/2013 02/14/2013 02/28/2013 03/07/2013 03/21/2013 06/18/2013 06/18/2013 06/21/2013

96 RESPONSE in Opposition re 91 MOTION to Authorize Exchange of Information filed by Defendant The State of Ohio. (Worly, Mindy) (Entered: 02/14/2012)
97 REPLY to Response to Motion re 91 MOTION to Authorize Exchange of Information filed by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 02/28/2012)
98 Objection re 93 Notice (Other) Monitor's First Report by Defendant The State of Ohio. (Worly, Mindy) (Entered: 03/08/2012)
99 Objection re 93 Notice (Other) Monitor's First Report by Plaintiff The United States of America. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E, # 6 Exhibit F) (Ogletree, Rashida) (Entered: 03/08/2012)
100 NOTICE of Appearance by Dustin J Calhoun for Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio (Calhoun, Dustin) (Entered: 03/09/2012)
101 Response re 99 Objection (non motion), to the Monitor's First Report (Doc. 93) by Defendant The State of Ohio. (Worly, Mindy) (Entered: 03/22/2012)
102 NOTICE OF WITHDRAWAL OF DOCUMENT by Defendant The State of Ohio (Attachments: # 1 Memorandum of Understanding) (Worly, Mindy) (Entered: 04/18/2012)
103 NOTICE of Appearance by Jacqueline K Cuncannan for Plaintiff The United States of America (Cuncannan, Jacqueline) (Entered: 04/25/2012)
104 Monitor's Second Report on the Amended Stipulation dated 6/28/2011 by Monitor Kelly Dedel, Ph.D. (pes1) (Entered: 06/22/2012)
105 ORDER SETTING TELEPHONIC STATUS CONFERENCE: Status Conference set for 11/29/2012 11:00 AM before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/28/2012. (cw) (Entered: 11/28/2012)
106 SCHEDULING ORDER. Signed by Judge Algenon L. Marbley on 11/29/2012. (cw) (Entered: 11/29/2012)
107 Unopposed MOTION to Approve Consent Judgment by Plaintiff The United States of America. (Attachments: # 1 Text of Proposed Order Proposed Consent Order, # 2 Exhibit Monitor's Third Draft Report) (Cuncannan, Jacqueline) (Entered: 12/19/2012)
108 RESPONSE to Motion re 107 Unopposed MOTION to Approve Consent Judgment filed by Plaintiff The United States of America. (Gerhardstein, Alphonse) (Entered: 12/27/2012)
109 CONSENT ORDER. Signed by Judge Algenon L. Marbley on 1/18/2013. (cw) (Entered: 01/18/2013)
110 Monitor's Third Report on the Amended Stipulation signed June 28, 2011. (pes1) (Entered: 02/14/2013)
111 ORDER re 110 Notice (Other). Deadline to file objections 3/8/2013 at 12:00 p.m. Signed by Judge Algenon L. Marbley on 2/28/2013. (cw) (Entered: 02/28/2013)
112 Objection re 110 Notice (Other) Defendants Objections to the Monitors Third Report by Defendant The State of Ohio. (Worly, Mindy) (Entered: 03/07/2013)
113 Response re 112 Objection (non motion) to the Monitor's Third Report by Plaintiff The United States of America. (Cuncannan, Jacqueline) (Entered: 03/21/2013)
114 Monitor's Fourth Annual Report. (pes1) (Entered: 06/18/2013)
115 Monitor's First Status Report on Progress Unit. (pes1) (Entered: 06/18/2013)
116 NOTICE of ORDER VACATING 374 Order to Show Cause in related case 2:04CV1206. Signed by Judge Algenon L. Marbley on 6/21/2013. (cw) (Entered: 06/21/2013)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 19 of 22

06/24/2013 07/30/2013 09/26/2013 09/26/2013 12/18/2013
12/19/2013 12/19/2013
12/20/2013 12/24/2013
12/24/2013 01/14/2014 01/16/2014 03/05/2014 03/12/2014 03/12/2014 03/13/2014
03/20/2014
03/21/2014

117 NOTICE of Appearance by Thomas Nathaniel Anger for Defendant The State of Ohio (Anger, Thomas) (Entered: 06/24/2013)
118 Monitor's Fourth Report Addendum − Mental Health Provisions. (pes1) (Entered: 07/30/2013)
119 STATUS REPORT: Monitors Progress Unit Compliance Report. (cw) (Entered: 09/26/2013)
120 STATUS REPORT: Second Progress Unit Status Report by Defendant Ohio Department of Youth Services. (cw) (Entered: 09/26/2013)
121 MOTION for Order to Terminate Case by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Anger, Thomas) (Entered: 12/18/2013)
122 REPLY to Response to Motion re 121 MOTION for Order to Terminate Case and Request for Postponement of Automatic Stay filed by Plaintiff The United States of America. (Attachments: # 1 Exhibit) (Dominguez, Silvia) (Entered: 12/19/2013)
123 RESPONSE to Motion re 121 MOTION for Order to Terminate Case and Request for Postponement of Automatic Stay filed by Plaintiff The United States of America. (Attachments: # 1 Exhibit Corrected Exhibits ABC) (Dominguez, Silvia) (Entered: 12/19/2013)
124 NOTICE of Appearance by Cynthia Coe for Plaintiff The United States of America (Coe, Cynthia) (Entered: 12/20/2013)
125 NOTICE OF WITHDRAWAL OF DOCUMENT by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio re 121 MOTION for Order to Terminate Case (Anger, Thomas) (Entered: 12/24/2013)
126 NOTICE OF WITHDRAWAL OF DOCUMENT by Plaintiff The United States of America re 122 Reply to Response to Motion for Order to Terminate Case and Request for Postponement of Automatic Stay (Coe, Cynthia) (Entered: 12/24/2013)
127 STATUS REPORT: Monitor's Fifth Report. (cw) (Entered: 01/14/2014)
128 ORDER Setting Settlement Conference for 1/29/2014 10:00 AM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 1/16/2014. (cw) (Entered: 01/16/2014)
129 NOTICE of Appearance by Alexandra L. Shandell for Plaintiff The United States of America (Shandell, Alexandra) (Entered: 03/05/2014)
130 MOTION Leave to Supplement Complaint re 2 Complaint, by Plaintiff The United States of America. (Attachments: # 1 Exhibit Attachments) (Dominguez, Silvia) (Entered: 03/12/2014)
131 MOTION for Temporary Restraining Order by Plaintiff The United States of America. (Attachments: # 1 Exhibit Attachments) (Dominguez, Silvia) (Entered: 03/12/2014)
132 ORDER SETTING LOCAL RULE 65.1 CONFERENCE re 131 MOTION for Temporary Restraining Order filed by The United States of America, (Status Conference set for 3/26/2014 10:00 AM in Chambers before Judge Algenon L. Marbley.). Signed by Judge Algenon L. Marbley on 3/13/2014. (cw) (Entered: 03/13/2014)
133 AMENDED DOCUMENT by Plaintiff The United States of America. Amendment to 131 MOTION for Temporary Restraining Order , 130 MOTION Leave to Supplement Complaint re 2 Complaint, Declaration. (Attachments: # 1 Exhibit) (Dominguez, Silvia) (Entered: 03/20/2014)
134 RESPONSE in Opposition re 130 MOTION Leave to Supplement Complaint re 2 Complaint, filed by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio.

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 20 of 22

03/21/2014
03/24/2014 03/24/2014 03/25/2014
03/25/2014 03/28/2014 03/31/2014 04/04/2014

(Attachments: # 1 Exhibit Affidavit) (Anger, Thomas) (Entered: 03/21/2014)
135 RESPONSE in Opposition re 131 MOTION for Temporary Restraining Order filed by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit Affidavit) (Anger, Thomas) (Entered: 03/21/2014)
136 REPLY to Response to Motion re 130 MOTION Leave to Supplement Complaint re 2 Complaint, filed by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 03/24/2014)
137 Unopposed MOTION to Continue Rule 65.1 Preliminary Conference by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 03/24/2014)
138 ORDER RESETTING LOCAL RULE 65.1 CONFERENCE. The Court will hold the Local Rule 65.1 preliminary conference on Tuesday, April 1, 2014 at 2:00 p.m. in the Court's Chambers, Room 319. Signed by Judge Algenon L. Marbley on 3/25/2014. (pes1) (Entered: 03/25/2014)
Reset Hearings: Rule 65.1 Conference set for 4/1/2014 at 02:00 PM in Chambers before Judge Algenon L. Marbley. (pes1) (Entered: 03/25/2014)
139 OPINION AND ORDER granting 130 Motion for Leave to File Supplemental Complaint. Signed by Judge Algenon L. Marbley on 3/28/2014. (pes1) (Entered: 03/28/2014)
140 COMPLAINT (Supplemental Complaint) against All Defendants, filed by The United States of America. (Sanders, Deborah) (Entered: 03/31/2014)
141 Transcript of Local Rule 65.1 Conference Proceedings held on 4/1/2014, before Judge Algenon L. Marbley. Court Reporter/Transcriber Shawna J. Evans, Telephone number 614−719−3316. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.

NOTICE RE: REDACTION OF TRANSCRIPTS: Within 5 business days of this filing, each party shall inform the Court, by filing a Notice of Redaction, of the party's intent to redact personal data identifiers from the electronic transcript of the court proceeding. The policy is located on our website at www.ohsd.uscourts.gov (Forms − Electronic Availability of Transcripts). Please read this policy carefully.

04/14/2014 04/17/2014
04/18/2014 04/29/2014 04/30/2014

For a complete copy of a transcript, please contact the Court Reporter or the Clerk's Office. Redaction Request due 4/25/2014. Redacted Transcript Deadline set for 5/5/2014. Release of Transcript Restriction set for 7/3/2014. (er1) (Entered: 04/04/2014)
142 ANSWER to 140 Complaint filed by All Defendants. (Anger, Thomas) (Entered: 04/14/2014)
143 Joint MOTION for Extension of Time to File New date requested 4/25/2014. by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Anger, Thomas) (Entered: 04/17/2014)
144 ORDER granting 143 Motion for Extension of Time to File. The Parties shall file their Agreed Order no later than 4/25/2014. Signed by Judge Algenon L. Marbley on 4/18/2014. (cw) (Entered: 04/18/2014)
145 MOTION for Temporary Restraining Order Renewed by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 04/29/2014)
146 RESPONSE to Motion re 145 MOTION for Temporary Restraining Order Renewed filed by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit, # 2 Exhibit) (Anger, Thomas) (Entered: 04/30/2014)

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 21 of 22

05/20/2014
05/21/2014 05/27/2014 05/29/2014 06/03/2014 06/30/2014
07/24/2014 05/07/2015
06/16/2015
06/17/2015 11/05/2015 12/03/2015
12/07/2015
12/08/2015

147 Joint MOTION For Entry of Agreed Order and Grid by Defendants Larry Gongwer, Chris Money, Katie Needham, Fred Nelson, Dion Norman, Ohio Department of Youth Services, Beth Oprisch, Thomas Stickrath, Ted Strickland, Marci Sutherland, Thomas Teague, The State of Ohio. (Attachments: # 1 Exhibit, # 2 Exhibit) (Anger, Thomas) (Entered: 05/20/2014)
148 ORDER finding as moot 131 Motion for TRO; finding as moot 145 Renewed Motion for TRO; granting 147 Motion for Entry of Agreed Order. Signed by Judge Algenon L. Marbley on 5/21/2014. (Attachments: # 1 Exhibit A) (cw) (Entered: 05/21/2014)
149 MOTION to Withdraw as Attorney Silvia Dominguez−Reese by Plaintiff The United States of America. (Dominguez, Silvia) (Entered: 05/27/2014)
150 ORDER granting 149 Motion to Withdraw as Attorney. Attorney Silvia Dominguez terminated. Signed by Magistrate Judge Mark R. Abel on 05/29/2014. (sr1) (Entered: 05/29/2014)
151 NOTICE OF WITHDRAWAL OF DOCUMENT by Plaintiff The United States of America Withdrawal Without Prejudice of Motion for Temporary Restraining Order (Coe, Cynthia) (Entered: 06/03/2014)
152 ORDER in case 2:08−cv−00475−ALM−MRA; granting (393) Motion for Leave to File; granting (402) Motion to Withdraw in case 2:04−cv−01206−ALM−TPK. Signed by Judge Algenon L. Marbley on 06/30/2014. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 06/30/2014)
153 NOTICE of Substitution of Counsel − Judy Preston substituting for Benjamin Tayloe as to Plaintiff The United States of America. (Preston, Judy) (Entered: 07/24/2014)
154 ORDER SETTING STATUS CONFERENCE − Status Conference set for 7/23/2015 10:00 AM in Courtroom 1 − Columbus before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 5/7/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 05/07/2015)
155 STATUS REPORT: Compliance Report with The Grid filed by Lead Monitors, Kelley Dedel, Ph.D., William Harrell, J.D., and Subject Matter Experts, Daphne Glkindmeyer, M.D. and Andrea Weisman, Ph.D. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 06/16/2015)
156 ORDER Resetting Status Conference: reset for 9/3/2015 02:00 PM in Chambers before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 6/18/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 06/17/2015)
157 ORDER SETTING FINAL HEARING for 12/8/2015 02:00 PM in Courtroom 1 − Columbus before Judge Algenon L. Marbley. Signed by Judge Algenon L. Marbley on 11/5/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 11/05/2015)
158 Joint MOTION Terminate Consent Decree re (409 in 2:04−cv−01206−ALM−TPK, 409 in 2:04−cv−01206−ALM−TPK) Order, Set Deadlines/Hearings ( Responses due by 12/28/2015) by Defendants Ohio Department of Youth Services, The State of Ohio, Ohio Department of Youth Services, Harvey J Reed. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (Anger, Thomas) (Entered: 12/03/2015)
159 FINAL STATUS REPORT: A Report on the Transformational Reform of the Ohio Department of Youth Services, 2007−2015 by Interested Parties William Harrell, J.D., LL.M., Kelly Dedel, Ph.D., Federal Court Monitors and Terry Schuster, J.D. Special Assistant to the Monitors. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 12/07/2015)
160 FINAL STATUS REPORT: Monitors' Review of DYS' Contracted Programs for Girls Submitted by Kelly Dedel, Ph.D., Lead Monitor, William Harrell, J.D., Lead Monitor, Daphne Glindmeyer, M.D. Subject Matter Expert and Andrea Weisman, Ph.D.,

Case: 2:08-cv-475 As of: 08/09/2018 12:45 PM EDT 22 of 22

12/09/2015

Subject Matter Expert. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 12/08/2015)
161 ORDER granting (158) Joint Motion to Terminate the Consent Decree in case 2:08−cv−00475−ALM−MRA; granting (410) Joint Motion to Terminate the Consent Decree in case 2:04−cv−01206−ALM−TPK. Signed by Judge Algenon L. Marbley on 12/9/2015. Associated Cases: 2:04−cv−01206−ALM−TPK, 2:08−cv−00475−ALM−MRA (cw) (Entered: 12/09/2015)

 U.S. Department of Justice
Civil Rights Division
Assistant Attorney General 950 Pennsylvania Avenue, NW - RFK Washington, DC 20530
May 9, 2007
The Honorable Ted Strickland Governor State of Ohio 30th Floor 77 South High Street Columbus, OH 43215-6117
Re: Investigation of the Marion Juvenile Correctional Facility, Marion, Ohio
Dear Governor Strickland:
I am writing to report the findings of the Civil Rights Division’s investigation of conditions at the Marion Juvenile Correctional Facility (“Marion”), located in Marion, Ohio. On April 15, 2005, we notified you of our intent to conduct an investigation of Marion, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 (“CRIPA”), and the pattern or practice provision of the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141”).1 At that time, we informed you that our investigation of Marion would focus on protecting residents from harm, medical care, grievances, and provision of special education.2 As we noted, both CRIPA and Section 14141 give the Department of Justice authority to seek a remedy for a pattern or practice of conduct that violates the constitutional or federal statutory rights of children in juvenile justice institutions.
We note that the State has worked cooperatively and, under the leadership of Director of Ohio Youth Services Thomas Stickrath, has unequivocally indicated its clear desire to improve both facilities since being placed on notice of possible constitutional deficiencies. Prior to the Department of Justice investigations of Marion and Scioto, the State hired a team of
1 Prior to initiating our Marion investigation, on March 16, 2005, we notified you of our intent to conduct an investigation of the Scioto Juvenile Correctional Facility (“Scioto”).
2 Our Scioto investigation focused on the same issues with the addition of mental health care.

- 2 -
expert consultants, led by Mr. Fred Cohen, to evaluate the constitutional conditions at the girls’ section of the Scioto facility.3 Mr. Cohen issued an Interim Report on August 16, 2004 and an Action Plan on September 28, 2004. In each of these documents, Mr. Cohen found constitutional deficiencies in the areas of protection from harm, medical care, mental health care, grievances, and provision of special education. The State has agreed to adopt and stipulate to Mr. Cohen’s findings, for the purpose of our investigation, and to apply those findings regarding the girls' facility to Marion and the entire Scioto facility.
Given the State’s stipulation that the conditions identified in our April 15, 2005 notice letter are constitutionally deficient, we agreed to conduct limited facility tours.4 On June 27-29, 2005, we conducted an on-site inspection of Marion, accompanied by expert consultants in mental health care and medical care. We returned to Marion on July 19 and 20 for an on-site inspection with our special education consultant. During our inspections, we interviewed mental health providers, medical providers, other staff, youth residents, teachers, and facility administrators. Before, during, and after our visit, we reviewed an extensive number of documents, including policies and procedures, mental health records, youth detention records, unit logs, education records, and orientation materials. Consistent with our commitment to provide technical assistance and conduct
3 Although the main Scioto facility houses female youth, a separate section of the facility acts as state-wide intake for all male youth.
4 This investigation is anomalous because Mr. Cohen's 2004 factual findings regarding the conditions of confinement at Scioto revealed significant deficiencies in each of the areas that were the subject of our investigation and because the State has stipulated to all of Mr. Cohen's generally well-supported findings. Together, these factors created the unusual circumstance in which it was not necessary for the Department to conduct a facility tour regarding each of the specific subject areas of our investigation. However, we did tour Marion regarding areas in which we required additional factual information to make a thorough and complete finding or to frame appropriate corrective measures. For example, we toured Marion with a special education consultant in response to the State's concern that Mr. Cohen's extensive findings regarding special education in Scioto were not reflective of the conditions in Marion.

- 3 -
a transparent investigation, we conducted an exit conference with facility staff and Ohio Department of Youth Services officials upon the conclusion of the tour, during which our expert consultants conveyed their initial impressions and concerns.
We commend the Marion staff for their helpful, courteous, and professional conduct throughout the course of this investigation. We also wish to express our appreciation for the cooperation of Ohio Department of Youth Services officials and staff.
Consistent with our statutory obligation under CRIPA, we set forth below the findings of our investigation, the facts supporting them, and the minimum remedial steps that are necessary to address the deficiencies we have identified. As described below, we conclude that youth confined at Marion suffer harm or the risk of harm from constitutional deficiencies as to: protecting residents from harm; certain discrete elements of medical care; mental health care; grievances; and special education services. Notwithstanding the foregoing, we are pleased to report that our review indicates that Marion’s general medical programs are, for the most part, good. In particular, we find that Marion’s medical quality improvement program, environmental conditions, and management of special dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
I. BACKGROUND
The State of Ohio, through its Department of Youth Services, owns and operates Marion, located approximately 45 miles north of Columbus, Ohio. Marion is Ohio’s only maximum-security juvenile justice facility. Its population consists entirely of juvenile males, aged 12 to 21, adjudicated, of felony-level crimes, in juvenile courts. Marion’s rated capacity is 336. Its facilities include 12 housing units, a mental health unit, a transitional unit, and a super-max unit.
II. FINDINGS
As a general matter, States must provide confined juveniles with reasonably safe conditions of confinement. Youngberg v. Romeo, 457 U.S. 307 (1982); Nelson v. Heyne, 491 F.2d 352 (7th Cir. 1974); see also Miletic v. Natalucci-Persichetti, No. C-3-89-299, 1992 WL 1258522, *2, *4 (S.D. Ohio Feb. 6, 1992) (holding, in a case against the Ohio Department of Youth

- 4 -
Services, that “a juvenile who is involuntarily committed to a correctional as opposed to mental health facility has a right to treatment under the Fourteenth Amendment similar to that which was recognized in Youngberg . . . .”).
A. PROTECTION FROM HARM
Juveniles in state custody have a constitutional right to reasonable safety. See Youngberg, 457 U.S. at 315-16 (“personal security constitutes a historic liberty interest protected substantively by the Due Process Clause”) (internal quotation omitted).
Our review of conditions of confinement at Marion reveals significant constitutional deficiencies regarding use of physical force, grievance investigation and processing, and use of seclusion. For purposes of our investigation, the State has stipulated to Mr. Cohen’s August 2004 findings regarding the Scioto girls' facility, agreeing that Mr. Cohen’s findings for each of the above-mentioned subject areas apply to Marion. In addition, our experts concur with Mr. Cohen's findings and suggested remedies.
1. Use of Physical Force
Juveniles at Marion have a right to be free from unnecessary restraint and the use of excessive force. Youngberg, 457 U.S. at 315-16.
The State has stipulated to apply the findings made by its expert regarding protection from harm issues at Scioto to Marion.5 Because of the State’s stipulation, the Department agreed not to perform a separate fact-finding exercise at Marion regarding protection from harm issues.
In his report, Mr. Cohen concludes that “there has been (and remains) a culture of violence among the uniformed staff, that verbal and physical abuse are common, [and] sexual misconduct by staff occurs . . . .” Mr. Cohen indicates that he and his team of experts “have the most serious reservations as to whether [the State’s] investigators are presently able to produce the quality of investigative work required to identify those use of force
5 In 2004, the State hired Mr. Cohen and a team of experts to review protection from harm issues in Scioto’s Girls’ Program after 14 Scioto staff had been indicted on charges relating to physical and sexual abuse of youth at Scioto.

- 5 -
incidents that merit corrective actions for staff who violate the [Department of Youth Services’] use of force policy.” Finally, Mr. Cohen concludes that “there can be no debate on the constitutional obligation under the Fourteenth Amendment to provide a safe environment. Scioto has not met its obligations to provide such an environment . . . .”
In reviewing use of force incidents at Scioto, Mr. Cohen reported that “verbal and physical abuse are common.” In his report, Mr. Cohen stated that he and his team “found countless examples of situations where no force at all should have been used and others where the force used was excessive.” Further, according to Mr. Cohen, verbal abuse is rampant and often serves, perhaps intentionally, to precipitate physical confrontations with juveniles. Based on these assessments and the State’s stipulation as to their applicability, we conclude that youth at Marion are subject to use of excessive force and physical abuse.
In addition, from document review and youth interviews, our medical consultant found that Marion youth are at significant risk of physical trauma due to youth-on-youth fights. Youth have indicated they believe that staff encourage youth to fight.
Finally, we note that Marion currently allows use of a physical restraint technique directing staff to place an arm across a youth’s chest below the neck and push on the cheek with the back of the hand. As our medical expert observed during the tour, use of any technique calling for an arm to be placed across the neck during a physical altercation or other incident exposes the youth to a significant risk of harm. This practice is especially problematic in light of allegations we have received that youth have been choked by staff during altercations.
2. Grievances (Investigations and Processing)
Just as prisoners and juvenile detainees have a constitutional right of access to the courts, they have a right to a grievance system that does not carry risk of punishment as a price for using it. See Thaddeus-X v. Blatter, 175 F.3d 378, 394 (6th Cir. 1999); see also Bounds v. Smith, 430 U.S. 817, 822 n.17 (1977) (“Our main concern here is protecting the ability of an inmate to prepare a petition or complaint.”) (internal quotation marks and citations omitted).
An adequately functioning grievance system ensures that youth have an avenue for bringing serious allegations of abuse and other complaints to the attention of the administration. It

- 6 -
also provides an important tool in alerting the administration about dangers and other problems in the facility’s operations.
We adopt the following findings by the State’s expert, regarding the Scioto girls' section, based on the State's stipulation as to their applicability at Marion. As part of Mr. Cohen’s assessment, the State’s experts conducted a review of Scioto’s incident investigation and grievance process,6 finding that several factors contribute to its inadequacy. In particular, Mr. Cohen’s report finds that investigations are “pedestrian, time consuming, and full of errors or oversights.” The State’s experts also determined that, with the exception of a few cases, investigators rarely attempt to determine if officers followed existing protocol.
Additionally, investigations contain few facts other than repetition of the complaint and denials by involved individuals. The investigations reveal a trend of repetitive questioning of involved youth, as though questioning was to continue until the youth provided the “correct” answer. Incidents involving physical aggression contained no evaluation of events preceding the incident, nor questions regarding use or attempted use of lesser physical interventions.
In addition, although grievances contain serious allegations such as verbal harassment and abuse, use of physical force, loss of programs and privileges, sexual harassment, and untreated medical issues, such investigations rarely result in corrective action for staff or youth or any attempt to recognize or identify patterns of behavior requiring intervention.
The inadequacies in Marion's grievance system contribute to the State’s failure to ensure a reasonably safe environment. An adequately functioning grievance system ensures that youth have an avenue for bringing serious allegations of abuse and other complaints to the attention of the administration. It also provides an important tool in evaluating the culture at the facility, and alerting the administration about dangers and other problems in the facility’s operations.
3. Seclusion
Based on the State's stipulation as to their applicability at Marion, we adopt the following findings by the State’s expert
6 Mr. Cohen’s team reviewed the 984 incidents filed from January 1, 2003 through August 18, 2004.

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regarding the Scioto girls' section. The State's experts reviewed over 200 seclusion reports regarding Scioto girls from May 2004 to June 2004. In his report, Mr. Cohen concluded that staff use seclusion as a first response and often hold youth in seclusion for hours even though they do not pose an imminent threat. Additionally, the State's expert found that Scioto's routine use of seclusion as immediate punishment is often accompanied by use of force.
B. MEDICAL AND MENTAL HEALTH CARE
Juveniles in state custody have a due process right to adequate mental health care. The Supreme Court in Youngberg broadly labeled health care as “medical care,” but recognized that this would include care provided by various disciplines, including persons with appropriate training in psychology. See id., 457 U.S. at 322-323, n.30. The Sixth Circuit also has recognized that medical care encompasses mental health care. See Horn v. Madison County Fiscal Court, 22 F.3d 653, 660 (6th Cir. 1994) (“A detainee’s psychological needs may constitute serious medical needs, especially when they result in suicidal tendencies.”).
1. Medical
We are pleased to report that our review indicates that Marion’s general medical programs are, for the most part, good. In particular, we find that Marion’s medical quality improvement program, environmental conditions, and management of special dietary needs for youth are appropriate. However, certain discrete aspects of medical care, identified below, substantially depart from generally accepted professional standards of care and expose youth to harm.
a. Identification of Health Problems and Initial Health Assessments
Marion’s health records are inadequate insofar as they do not contain problem lists. Such lists document all identified active health problems and are necessary tools in monitoring youth health status and providing adequate health care. Marion’s initial health assessments are similarly inadequate, due to the absence of problem lists.
Separately, as a matter of technical assistance, we note that Marion’s assessments are conducted in a central area of the clinic that is, at best, marginally confidential, as conversations can be easily overheard. Nurses should use

- 8 -
private exam rooms for such assessments and ensure that non-professional staff are unable to overhear the confidential assessment.
b. Evaluation and Treatment of Sick Residents
Marion’s sick call procedures make youth access to medical case dependent upon line staff. Marion’s current system forces youth to submit requests through line staff in a non-confidential manner, breaching youths’ rights to privacy and confidentiality. Marion should implement a system in which youth can submit sick call requests confidentially and independent of the line staff.
Marion’s medication management is well-organized. However, Marion’s policy of discontinuing medication not on the Prison Health Services formulary constitutes a departure from generally accepted professional standards of care, because it requires youth to become unstable before receiving proper medication.
c. Dental Care
Marion’s dental program fails to meet the dental needs of its youth. We found numerous instances of youth with significant, untreated, dental needs. Separately, Marion fails to provide pain medications adequate to relieve severe dental pain, reflecting inadequate dental care. In addition, Marion’s current dentist only works two days per week to meet the needs of its population of approximately 275 youth. This is not adequate.
d. Special Services for Chronically Ill and Disabled Youth
We find that Marion’s care provided to patients with asthma substantially departs from generally accepted professional standards, as youths’ asthma medications are discontinued upon admission to the facility. Marion should continue to provide such necessary medication without delay.
Finally, we note that Marion, through its contractor, Prison Health Services, inappropriately denies youth access to specialist care, such as diagnostic tests and consultations, when such care is clinically indicated. For example, Marion denied a facility physician's request for an echocardiogram, to examine a youth's significant heart murmur, finding the youth to be “asymptomatic” because he was not yet showing disability due to decompensated heart disease. This is a substantial departure from generally accepted professional standards.
e. Disease Prevention and Health Promotion

- 9 -
Thirty percent of Marion’s youth had incomplete immunizations, and youth are not fully immunized for their age. This is a substantial departure from generally accepted professional standards.
f. Medical Quality Improvement Program
While we find that Marion’s current medical quality improvement program is adequate, we suggest that Marion place more emphasis on areas relevant to its population, such as completing immunizations, reviewing grievances, and reviewing hospitalizations.
g. Special Dietary Needs for Youth
Marion adequately manages food allergies and special medical diets.
h. Abuse Reported By Medical Professionals
While nurses at Marion assess youth after a use of physical restraint, they only report suspected abuse to the facility administration, rather than to State child abuse authorities. This reporting scheme is a substantial departure from generally accepted professional standards and, in light of the State’s stipulation regarding use of excessive force, is especially problematic.
2. Mental Health Care
The Constitution requires that youth in juvenile justice institutions receive adequate mental health care. Youngberg, 457 U.S. at 323, n.30; Nelson, 491 F.2d at 360; see also K.H. v. Morgan, 914 F.2d 846, 851 (7th Cir. 1990); A.M. v. Luzerne County Juvenile Detention Center, 372 F.3d 572, 585 n.3 (3d Cir. 2004). We find that mental health care at Marion is constitutionally inadequate.
In 2004, Mr. Cohen, the State’s expert, concluded that the Scioto girls’ facility’s mental health unit “is little more than a residence for girls with mental disorders” and that “[m]ental health care is so deficient” that it was not feasible to comment on the various elements of such care, indicating that “[a] more refined analysis must await another day – a day when constitutionally required, minimally acceptable care is instituted.”
Given the severity of Mr. Cohen’s assessment, and the

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State's stipulation applying such findings to Marion, we toured Marion with a mental health expert. We found serious deficiencies in the provision of mental health care regarding the facility’s identification of youth with significant mental health problems (“case finding”), and in the screening, assessment, treatment planning, and monitoring of youth with such problems. In addition, we found discrete or underlying problems regarding the facility’s efforts to involve family in treatment decisions, and regarding staffing, restraints, and environmental conditions.
a. Case Finding
We find that Marion’s efforts to identify youth with mental disorders are significantly lacking. Our observations and interviews with youth indicate that a significant number of youth manifesting mental health disorders are not identified and thus, not treated. Marion’s current 20 percent rate of youth identified as having such disorders is quite probably a significant underestimate. One of Marion’s own staff psychologists estimated that the actual rate of mental disorders within Marion’s population is between 30 and 40 percent (an estimate consistent with current prevailing research). Marion’s failure to adequately detect youth having significant mental disorders is a substantial departure from generally accepted professional standards.
b. Screening, Assessment, Treatment Planning, and Monitoring
Initial screening of all Marion youth is conducted at the intake section of the Scioto Juvenile Correctional Facility. These assessments, which provide the basis for ongoing mental health care at Marion, are addressed in a separate letter. Regarding onsite treatment at Marion, we were unable to find evidence that the facility provides any further assessment of a youth’s adjustment to the new facility, such as systematic rescreening. Additionally, the psychology records we reviewed indicated that Marion does not take into account individuals’ difficulties or strengths when designing and implementing treatment plans. Further, it was evident that clinical team meetings do not review, and modify as warranted, treatment plans in a formal manner or consider whether goals are being met. This is a substantial departure from generally accepted professional standards. Further, Marion does not base determinations on empirical information, making such determinations overly reliant on subjective reporting by line staff.
We find that psychopharmacological treatment at Marion for youth identified as needing such treatment is based on an adequate psychiatric assessment and, a cursory, but explicit,

- 11 -
plan for treatment with medication. We also find that follow-up is adequate, although Marion should ensure that it gathers information from collateral sources when assessing a youth’s target symptoms. Lastly, as a matter of technical assistance, we recommend that the facility reconsider its aversion to prescribing stimulants. Given Marion’s care in monitoring medications, the facility should be comfortable allowing its youth access to the therapeutic benefits of such medications.
c. Mental Health Unit
Marion’s intensive mental health unit appears to be serving an appropriate population and providing adequate care. We suggest that Marion consider using any extra beds in the area for short-term treatment for youth with more acute disturbances.
d. Suicide Prevention Activities
We find that Marion’s plan for assessing acute risk and preventing suicides is thorough and effective.
e. Family Involvement
As a matter of technical assistance, we find that Marion’s efforts to engage youths’ families in their mental health care are lacking. Families are an extremely important source of clinical information, and their support can make an enormous impact on a youth. We understand that some families may live far from Marion or not be responsive to outreach. Nevertheless, we believe that an increased effort by Marion staff will lead to productive outcomes for its youth.
f. Staffing
Marion’s social work staff is not adequate to provide more than superficial care for youth with significant mental health disorders, and this constitutes a substantial departure from generally accepted professional standards. The Psychology Department is severely understaffed at Marion. Such inadequate staffing reduces the ability of mental health staff to collaborate appropriately with other staff in monitoring progress of youth on the mental health list and those without identified disorders. Additionally, poor staff size reduces psychologists’ availability to youth, reduces flexibility in responding to specific treatment needs and designing appropriate responses, and contributes to inconsistent recordkeeping.
Psychiatry staffing is adequate to meet the needs of youth currently identified as having mental health disorders. However, as noted above, the number of youth with significant mental

- 12 -
health disorders is much higher than currently identified by Marion, and the facility will need to maintain adequate psychiatric staff as its mental health caseload changes.
g. Restraints
Marion uses four-point restraints, forced medications, and restraint beds to manage severely mentally ill youth. We urge Marion to work to identify such youth early and transfer them to mental hospitals rather than resorting to the extreme behaviormanagement options listed above.
h. Environmental Conditions
Shower heads in some units pose suicide risks (e.g., hanging hazards) as they are not constructed in a manner that would allow a rope or similar implement to slip free. Easy access to such hazards increases the possibility that potentially suicidal youth will seriously harm themselves. Marion should replace such shower heads.
C. SPECIAL EDUCATION SERVICES
Students with disabilities have federal statutory rights to special education services under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C.A. §§ 1400-1482 (West 2000 & Supp. 2006). Marion serves its special education population though the Hickory Grove High School. The school’s faculty numbers slightly more than 30 individuals, including five special education teachers. As of September 2005, the school served 226 students. Of those, approximately 94 students have been identified as having special education needs. We conducted our own on-site review of the provision of special education at Marion. In addition to our review, our expert consultant reviewed Ms. Ava Crow's findings regarding Scioto and determined that similar concerns exist in Marion.7
1. Child Find
The IDEA requires that states implement systems to identify all students who are eligible for special education services and provide such services to all those identified as having
7 Ms. Crow, acting as part of Fred Cohen's team, reviewed education services provided by Scioto's girls' section. The State has agreed to adopt and stipulate to Mr. Cohen’s findings, for the purpose of our investigation, and to apply those findings to Marion and the entire Scioto facility.

- 13 -
disabilities. 20 U.S.C. § 1412. We find that Marion violates many of these “Child Find” requirements of the IDEA.
When youth enter the Ohio juvenile correctional system, they are inadequately evaluated for special education needs at the Scioto intake facility; this “evaluation” process consists of a document request for special education records from a youth’s prior school. There is no additional direction provided by the Ohio Department of Youth Services to guide intake personnel in conducting a thorough assessment to identify items in a youth’s record that should merit further investigation regarding special education placement. Once placed at Marion, youth appear to receive no additional special education screening; none of the teachers who we interviewed could recount ever having referred a student for such an assessment. In light of the above, we find that Marion is not in compliance with its Child Find obligations under the IDEA.
2. Eligibility Determinations
Under the IDEA, Marion is required to conduct a thorough eligibility evaluation of a child suspected of having a disability. See 20 U.S.C. § 1414 at (b)(4), (b)(5), and (c)(5). The IDEA requires that eligibility decisions are to be reviewed every three years. Approximately six percent of Marion’s evaluations were more than three years old and thus not in compliance with the IDEA. In this regard, the shortage of psychological staff at Marion contributes to the facility’s inability to complete necessary eligibility assessments.
3. Implementation of Individual Education Plans
The IDEA requires that each student with a disability have an Individualized Education Plan (“IEP”), and describes the IEP components required to ensure that each student receives adequate special education services. We find that Marion’s IEP process does not ensure that students with disabilities receive such required special education services.
For example, Marion conducts IEP meetings without the full compliment of professionals who should attend and contribute to the development of the IEP. Although the IEP meeting we observed contained a substitute for the principal or vice principal, it contained no regular education teacher, transition services representative, or psychologist (or other individual with skill in interpreting test results).
Furthermore, the IDEA requires that the IEP be a document containing equal contributions from the school and the parent.

- 14 -
However, at one IEP meeting we observed, although the parent was present via telephone, she had minimal involvement. Throughout the meeting, the special education teacher merely read the “draft” IEP to those present. The parent was not given any opportunity to collaborate in developing the document, and the teacher ratified the IEP upon concluding her oral presentation.
Additionally, the IDEA requires IEPs to be reviewed at least annually. Our document review revealed that at least 12 percent of Marion’s IEPs had not been revised within the IDEA’s time requirements.
Lastly, our document review revealed a clear need for professional development to properly address youth reading problems. The majority of special education records we reviewed revealed substantial deficits in simple reading skills. Moreover, we reviewed a record for one non-special education youth showing lower level reading performance than others currently receiving special education services. This problem reflects the deficiencies described above regarding the special education assessment process.
4. Monitoring of IEPs
We find that Marion’s practices for monitoring progress of students with disabilities is inadequate. Marion should monitor IEPs to ensure that youth receive access to a free and appropriate public education, as required by the IDEA. If monitoring is not conducted frequently and appropriately, educators are unlikely to recognize students' inadequate progress and modify instruction to improve progress.
Our document review and teacher interviews revealed a general lack of knowledge of how to use objective data and quantitative methods to assess students’ progress. All educational records we reviewed consisted of subjective evaluations with little basis supporting the stated conclusions. For example, an estimated 80 percent of the required blocks on the IEP forms uniformly read “quarterly progress reports based upon records reviews and teacher interviews.” Our review raises doubts as to whether such reviews are actually occurring. Marion also does not appear to have adequate professional development for preparing teachers to monitor progress of IEP goals.
In addition, while the IDEA requires consideration of positive behavioral interventions for students whose behavior interferes with their learning or that of other students, our document review revealed only one such individualized intervention, despite the needs of Marion’s youth. Teachers we

- 15 -
interviewed indicated that they believe “only a couple” Marion students have such interventions. This does not comply with the IDEA.
5. Classroom Instruction and Management
Finally, as a matter of technical assistance, we encourage Marion to make maximum use of the instructional time available to provide important educational opportunities for students with disabilities. Furthermore, in order to ensure that students with disabilities are served appropriately, we encourage Marion to increase its school staffing.
III. REMEDIAL MEASURES
In order to rectify the identified deficiencies and protect the constitutional and statutory rights of the youth confined at Marion, the facility should implement, at a minimum, the following measures:
A. Protection from Harm
1. Ensure that youth are provided with safe living conditions and are protected from abuse, use of excessive force, undue seclusion, and undue restraint.
2. Develop appropriate policies and procedures that govern the use of force, requiring reliable documentation and limiting use of force to situations where a youth is physically violent and poses an immediate danger to himself and/or others or the youth is physically resisting institutional rules and the institution has attempted a hierarchy of nonphysical alternatives.
3. Prohibit verbal and physical punishment, and use of force practices that are incompatible with minimum actions necessary to prevent harm or obtain compliance with reasonable orders, including practices such as shoving, pushing, kicking, striking, or using inappropriate holds on youth.
4. Monitor and supervise staff, maintaining appropriate staff ratios and holding staff accountable for the use of excessive force or abuse.
5. Develop policies and procedures to ensure that seclusion and restraint are only used in appropriate, documented, instances by trained staff.
6. Provide youth with an effective and reliable process to raise grievances, without exposing them to retribution from

- 16 -
staff, ensuring that all grievances are reviewed and addressed in a timely matter that provides youth with notification of the final resolution.
7. Employ sufficiently trained and independent investigators to ensure that all incidents of violence, use of force, or serious injury are adequately investigated, and documented, and that appropriate personnel actions are taken in response to substantiated findings.
B. Medical and Mental Health Care
1. Ensure that youth receive routine, preventative, and emergency medical and dental care consistent with current, generally accepted professional standards, including identification, assessment, diagnosis, and treatment of individuals with health problems.
2. Develop policies and procedures to ensure that youth are provided with: complete and accurate health records, access to confidential health care, a complete initial health assessment, appropriate access to health services, appropriate medications and care to manage chronic illness, access to specialty consults, and proper immunizations managed according to generally accepted medical standards.
3. Maintain appropriate dental staffing and require that generally accepted professional standards are followed to ensure that: youths’ restorative needs are met in a timely manner, youth are not denied appropriate pain medication, needed prosthetic dental services are provided, and health records contain adequate documentation of outside dental consults.
4. Provide mental health and rehabilitative treatment consistent with generally accepted professional standards and ensure that there are an adequate number of qualified mental health professionals to provide mental health and rehabilitative services in a timely manner to all youth who require such services.
5. Develop and implement policies, procedures, and practices to ensure that, consistent with generally accepted professional standards of care, youth are: (1) systematically evaluated in response to problem indicators to address potential manifestations of mental or behavioral disorders in youth who have not been previously identified as requiring treatment; and (2) provided appropriate mental health care, substance abuse care, and treatment services.
6. Ensure that any youth determined at screening to be at immediate risk is immediately referred to a qualified mental

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health treatment professional for: assessment, treatment, and other appropriate actions, including facility transfer when necessary.
7. Implement policies, procedures, and practices according to generally accepted professional standards to ensure that: youth identified in screening receive timely, comprehensive, and accurate assessments by qualified mental health professionals; and assessments are designed to incorporate data necessary to identify youth with mental disorders and contribute to a plan for managing the youth’s risk.
8. Develop and implement policies and procedures consistent with generally accepted professional standards of care to: (1) ensure that treatment determinations are made by an interdisciplinary team through integrated treatment planning; (2) create and implement treatment plans that are current and individualized; (3) maintain readily accessible records containing meaningful, accurate and coherent assessments of the individual’s treatment plan progress, goals, and objectives.
9. Develop and implement a system to ensure that mental health issues are adequately considered in making housing decisions and that mentally ill youth receive appropriate housing.
10. Prior to administration of prescribed psychoactive medication, Marion must: (1) ensure that youth and their parents (or guardians, if parents have lost custody due to abuse or neglect) are provided with goals, risks, benefits, and potential side effects of the medication, along with the potential consequences of not treating with the medication; (2) follow state law in order to administer such medication without consent.
11. Develop and implement policies, procedures, and practices to ensure that psychoactive medications are prescribed, distributed, and monitored properly and safely, consistent with generally accepted professional standards of care.
12. Provide training to all staff who interact directly with youth regarding mental health information, developmental disabilities, recognition of signs and symptoms of trauma, teenage development, strength-based treatment strategies, and suicide risks.
13. Create transition plans for youth leaving the facility that are consistent with generally accepted practice standards.
14. Develop and implement polices and procedures to maintain oversight of mental health services and ensure that such

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services are provided consistent with generally accepted professional standards of care.
C. Special Education
1. Provide prompt and adequate screening, and ongoing rescreening and referral, of youth for special education needs and ensure that all students requiring special education services receive services in compliance with the IDEA within a reasonable time following intake.
2. Ensure that all eligible youth have current, accurate IEPs that are developed and implemented consistent with IDEA requirements.
3. Create and implement a system to routinely develop, implement, and monitor youths' IEPs, with involvement of parents and guardians, as required by the IDEA.
4. Develop and implement a staffing plan that allows for a sufficient number of certified special education teachers and staff to provide all youth with the opportunity to attend school full-time and to obtain adequate educational services while providing teachers with sufficient time to plan lessons, grade assignments, and participate in special education meetings.
5. Develop a quality assurance program to ensure the quality of IEPs, compliance with the IDEA, and monitoring of teaching staff on compliance issues.
6. Ensure that special education staff receive in-service training and maintain current educator licenses appropriate to the courses they teach.
* * *
As stated above, we appreciate the cooperation we have received from Ohio Department of Youth Services officials and facility staff throughout this investigation. We hope to be able to continue working with the State in an amicable and cooperative fashion to resolve the deficiencies found at Marion. Provided that our cooperative relationship continues, we will forward our expert consultant reports under separate cover. Although this report is our consultants’ work – and does not necessarily reflect the official conclusions of the Department of Justice – the observations, analyses, and recommendations contained in the reports provide further elaboration of the issues discussed in this letter and offer practical assistance in addressing them.
In the unexpected event that we are unable to reach a resolution regarding our concerns, the Attorney General is

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empowered to institute a lawsuit pursuant to CRIPA to correct the deficiencies of the kind identified in this letter 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working cooperatively with you. We have every confidence that we will be able to do so in this case. The lawyers assigned to this matter will be contacting your attorneys to discuss this matter in further detail. If you have any questions regarding this letter, please contact Shanetta Y. Cutlar, Chief of the Civil Rights Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/s/ Wan J. Kim Wan J. Kim Assistant Attorney General
cc: The Honorable Marc Dann Ohio Attorney General Department of the Attorney General
Thomas J. Stickrath Director Ohio Department of Youth Services
Dion Norman Superintendent Marion Juvenile Correctional Facility
The Honorable Gregory A. Lockhart United States Attorney Northern District of Ohio

 DYS Seclusion Hours Correctional Institution Inspection Committee

February 11, 2015

Seclusion Defined

Under DYS policy 301.05.04, seclusion is the involuntary confinement of a youth alone in his or her own room or in a safe room for a brief period.
 The use of regular seclusion and prehearing seclusion shall be used as a cooling off period and shall be discontinued at the point the youth is able to successfully demonstrate he or she has calmed down and safely able to return to population.
 Youth placed in seclusion are checked visually by staff at least every 15 minutes (recorded on a Youth Intervention Monitoring Log) and are visited daily by personnel from administrative, clinical, social work, religious, and/or medical units.
 Youth placed in seclusion shall be afforded living conditions and privileges approximating those available to the general population. Exceptions shall be justified by clear and substantiated evidence.

CY 2014 Total Seclusion

Hours By Facility

Cuyahoga Hills JCF
12.5%
Scioto JCF 0.8%

Circleville JCF 49.2%

Indian River JCF
37.5%

DOJ Seclusion Litigation Update (Press Release)
Justice Department Settles Lawsuit Against State of Ohio to End Unlawful Seclusion of
Youth in Juvenile Correctional Facilities
“The United States and private plaintiffs announced on May 21, 2014 that it reached an agreement with the state of Ohio, under which the State Department of Youth Services (DYS)
will dramatically reduce, and eventually eliminate, its use of seclusion on young people in its custody. DYS will also ensure that young
people in its juvenile facilities receive individualized mental health treatment to prevent and address the conditions and behaviors that led to seclusion. The order resolves allegations that the state subjects young people with mental health needs in its custody to harmful seclusion and withholds treatment and programming, in violation of their
constitutional rights.”
Key Statistics
In 2014, there were 66,027 reported hours of seclusion, a 64.8% decrease from 2012.
Positively, the DYS system-wide rate of seclusion hours per youth decreased 57.3%
during this period.
The largest number of seclusion hours occurred at Circleville JCF, totaling 32,492
reported hours or 49.2% of all hours.
Circleville JCF also reported the highest rate of seclusion hours per youth, with 255.8
hours.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

DYS Seclusion Hour Rates Per Youth CY 2011 - 2014
400

350

300

250

200

380.4

150

358.1

458.8

100 152.8
50

0 2011

2012

2013

2014

* Data was calculated by dividing DYS’ total number of seclusion hours each year (rounded to the nearest whole number) by its average annual population for 2014. NOTE: the data does not take into account whether the same youth was involved in multiple incidents resulting in the use of seclusion. ** Seclusion data was provided by the Ohio Department of Youth Services for 2011 through 2014. Population data was provided by the Ohio Department of
Youth Services for January 2011 through December 2014.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

Total Seclusion Hours by Month CY 2014

CHJCF

CJCF

IRJCF

SJCF*

Settlement Agreement

* Seclusion data was provided by the Ohio Department of Youth Services for 2014. **Please note that seclusion hours were rounded to the nearest whole number.
Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

350,000 300,000 250,000

Total Seclusion Hours by Facility CY 2011-2014
2014 2013 2012 2011

200,000

150,000

100,000

50,000

0

Circleville JCF

Cuyahoga Hills JCF Indian River JCF Ohio River Valley JCF

Scioto JCF

*Data provided by the Ohio Department of Youth Services for 2011 through 2014. **Please note that Ohio River Valley JCF closed September 2011 and Scioto JCF closed May 2014.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

Seclusion Hour Rates Per Youth CY 2014
300

250 255.8
200
150

190.3

100

50
0 Circleville JCF

49.1 Cuyahoga Hills JCF

Indian River JCF

80.0 Scioto JCF

* Data was calculated by dividing a facility’s total number of seclusion hours (rounded to the nearest whole number) by its average annual population for 2014. NOTE: the data does not take into account whether the same youth was involved in multiple incidents resulting in the use of seclusion. **Please note Scioto JCF closed in May 2014, therefore affecting the rate and average population.
Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929

2014 Seclusion Hour Statistics

Month CHJCF CJCF IRJCF SJCF*

January

1,810

9,514

4,570

117

February

1,497

6,521

4,203

219

March

1,398

7,531

7,252

224

April

1,184

2,926

4,592

0

May

362

2,210

1,184

0

June

368

1,149

641

0

July

371

266

436

0

August

436

452

262

0

September

116

227

499

0

October

159

459

356

0

November

307

829

502

0

December

233

408

237

0

Total 8,241 32,492 24,734 560

Total
Hours
16,011 12,440 16,405 8,702 3,756 2,158 1,073 1,150
842 974 1,638 878
66,027

*Scioto Juvenile Correctional Facility closed May 2014. **Data provided by the Ohio Department of Youth Services for January through December 2014. Data differs slightly from DYS data to ensure agreement within the brief; the differences may be due to rounding issues. ***Please note seclusion hour totals were rounded to the nearest whole number.

Correctional Institution Inspection Committee Riffe Center, 77 S. High Street, 15th Floor, Columbus, Ohio 43215, PHONE (614) 466-6649, FAX (614) 466-6929


The Attorney General filed suit against the state of Ohio, its governor, the director of youth services, and the superintendents of its juvenile correctional facilities pursuant to 42 U.S.C. § 14141 for an alleged pattern or practice of violating the rights of juvenile detainees under the 14th Amendment, the Individuals with Disabilities Education Act (IDEA), and the Rehabilitation Act of 1973. The United States alleged that Ohio failed to protect the youth at its facilities from harm and undue risk of harm, failed to meet their medical and mental health needs, and failed to provide adequate special education services. The suit was filed as a result of Department of Justice (DOJ) investigations into the conditions of confinement at the Scioto and Marion centers that began in 2005. The Marion facility closed soon after the first injunction in this case. Ohio achieved substantial compliance in 2015, and the consent decree was terminated on December 3, 2015. 