Input:
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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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.
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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

.

;

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:I

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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

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 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
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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.
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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

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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.

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• 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.

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• 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

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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
   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

Case: 2:08-cv-00475-ALM-MRA Doc #: 93 Filed: 02/06/12 Page: 10 of 104 PAGEID #: 1873

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.

11

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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

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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
   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

14

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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

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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

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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

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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

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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
   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

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• 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

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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

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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

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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
   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

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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

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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
   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

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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
  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

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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

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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

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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

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

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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.

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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
   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

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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

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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
   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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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
   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

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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

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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

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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,

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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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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

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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

68

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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

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• 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
   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.

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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

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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

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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

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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

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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:

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• 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.

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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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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.

87

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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,

91

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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

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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

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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
   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

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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;

95

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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.

96

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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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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

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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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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

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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

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

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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.

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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.

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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.

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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

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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

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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.

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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

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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

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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
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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

I

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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

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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

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- 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.

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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.

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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.

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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

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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

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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.

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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

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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.

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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.

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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.

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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.

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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
  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

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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.

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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.

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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

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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.

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(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

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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.

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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.

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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.

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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
  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

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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

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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

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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-‐

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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)

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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

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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.

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   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.

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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.

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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.

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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
   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.

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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.

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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

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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

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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.

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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.

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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.

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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
   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.

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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.

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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.

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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
   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.

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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.

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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
   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.

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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.

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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
  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

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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

59.

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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

61.

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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

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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

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

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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.

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Sources
  of
   Information

• Staff
  Interview
   • Observation
  of
  Interdisciplinary
  Treatment
  Team
  meeting
   • Review
  of
  provided
  documents

   • Youth
  interview

68.

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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
  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.

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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
   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

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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.

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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

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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

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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

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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

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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
  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

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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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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.

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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

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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
  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

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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

88.

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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
  mon

Output:
On May 16, 2008, the Attorney General, on behalf of the United States, 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 Fourteenth Amendment, the Individuals with Disabilities Education Act (IDEA) 20 U.S.C. §§ 1400-1482, and the Rehabilitation Act of 1973, 29 U.S.C. § 794 et seq.

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 alleged harm and undue risk included unwarranted use of force and seclusion, and inadequate grievance and investigation procedures, while the alleged inadequacies of the health and education services were more total and included lack of dental care, and inadequate intake, screening, and treatment.

The facilities sued were Circleville Youth Center, Cuyahoga Hills Boys School, Indian River School, Marion Juvenile Correctional Center, Mohican Youth Center, Ohio River Valley Youth Center, Scioto Juvenile Correctional Center, and the Freedom Center. 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.

On June 12, 2008 in accordance with a joint motion of the parties, the court (Judge Algenon L. Marbley) ordered the entry of a stipulation to injunctive relief for the Scioto and Marion centers and conditionally dismissed the claims against the other facilities. The other facilities were already under a stipulated injunction from the related case S.H. v. Stickrath, linked below (Clearinghouse code: JI-OH-0004), so the claims were dismissed on the condition that the United States have access to all relevant Ohio Department of Youth Services (ODYS) policies and the monitor from the Stickrath. The Independent Fact Finder's 214-page  report from that case contains useful background for the issues in this case. The Court entered the Stipulation for Injunctive Relief on June 24, 2008.

The injunction required Ohio to develop a wide variety of policies, procedures and practices to remedy the undue harm, inadequate medical and mental health care access, and inadequate special education services to which it subjected the juveniles detained in its facilities. In addition, the injunction appointed a monitor, Fred Cohen, to conduct investigations and report periodically on the state's compliance and required the state to train its employees, develop any additional documents or forms necessary to comply with the injunction, and to create and collect data to assess its performance. The terms of the injunction also guaranteed the Department of Justice access to the youth and staff at the Scioto and Marion centers and to all relevant records. Ohio had one year to revise its policies, training materials, and assessment tools so as to comply with the injunction, which was to last for three years or terminate early upon a showing of a year of substantial compliance.

Monitor Fred Cohen, who had acted as the monitor for both the S.H. case and this case, resigned from monitoring duties only for this case on September 24, 2009. On December 15, 2009, the Court approved modification of the stipulation to provide a new monitoring scheme in which the DOJ acted as monitor through a team of experts. The modification also recognized that the injunction ceased to apply to the Marion facility, which had been closed.

On February 26, 2010, the court ordered ODYS to develop a new meal policy that would ensure that it fed the juveniles committed to the facilities. ODYS had promulgated a protocol that said that youth who refused to go to the cafeteria would not receive a meal. It was applied inconsistently and appeared to deny food to those who refused out of fear. The issue led to a show cause hearing because of discrepancies in the summaries and data provided to the court and to a subsequent order to submit a new policy.

By the consent of the parties, the court amended the injunction on June 6, 2011, to remove many provisions. The monitoring section was redone, and the DOJ relinquished that role to a team of experts. Most notable was that the 3-year expiration clause was removed, making the injunction terminable only on a showing of substantial compliance for two reporting periods. The court adopted a revised version of the injunction that reflected the two amendments in a single document on June 28, 2011.

On January 18, 2013, as a result of problems with the Progress Unit indicated in the Monitor's Third Report, the parties entered into a consent order that laid out a series of requirements meant to ensure that youth on the Progress Unit are not subjected excessive seclusion, that they receive structured programming, that they be screened to ensure they were not sent to the unit for symptoms of mental illness, and that they be given treatment plans that include reasonable goals designed to enable them to leave the unit. The order would be terminated only upon a showing of substantial compliance for six months.

The Monitor's Fourth Report and the First Status Report on Progress Unit were completed in 2013 and included an evaluation of the Scioto Facility. Both reports stated that Ohio was not in substantial compliance with the respective injunctions.

As a result of the State's inability to comply with the consent order, on March 12, 2014 the Department of Justice moved to supplement its original complaint by also including the state's use of unlawful seclusion at all of its juvenile correctional facilities. The court approved this motion on March 28, 2014 and DOJ filed a supplemental complaint on March 31, 2014. At the time that DOJ filed its supplemental complaint, it also sought a temporary restraining order to stem the state's seclusion of juveniles with mental health disorders.

The Department of Justice announced a final agreement with the State of Ohio on Wednesday, May 21, 2014. While Ohio was working to eventually eliminate disciplinary seclusion of youth, this agreement included interim measures that would taken to ensure that seclusion only occurred under certain conditions and for a limited duration. The state also agreed to reduce the potential harms caused by seclusion by increasing access to therapeutic, educational and recreational services while a young person is in seclusion.

On Feb. 11, 2015, the monitoring Correctional Institution Inspection Committee, issued a report showing a dramatic decline in use of seclusion.

The court-appointed monitors submitted final reports in 2015, establishing that the defendant had achieved substantial compliance with the agreement's provisions. The report on the DYS facilities for boys was submitted June 10, 2015, and the report on the DYS-contracted facilities for girls was submitted on November 30, 2015. The monitors submitted their final status report, "The Ohio Model: A Report on the Transformational Reform of the Ohio Department of Youth Services, 2007-2015," on December 7, 2015. The report documented improvements including recording and review of uses of force; a meaningful grievance system; abolition of disciplinary seclusion and dramatic reductions in pre-hearing seclusion; educational programming; increased family visitation; improved mental health treatment; and reduction of the incarcerated population.

On December 3, 2015, the parties made a joint motion to terminate the consent decree. The consent decree was terminated on December 9, 2015, and the case is now closed.