Settlement Agreement Maryland - US Dept of Justice 6th Monitors Report 2010

7/31/2019 Settlement Agreement Maryland - US Dept of Justice 6th Monitors Report 2010

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SettlementAgreementbetweentheStateofMarylandandtheUnitedStatesDepartmentofJustice

SixthMonitorsReport

1

SettlementAgreement

Between

TheStateofMarylandandtheUnitedStatesDepartmentofJustice

SIXTHMONITORSREPORTFor

the

Cheltenham

Youth

Facility

and

Charles

H.

Hickey,

Jr.

School

ForthePeriodofJanuary1,2008throughJune30,2008

Submittedby

KellyDedel,Ph.D.

TimothyHoward

MichaelCohen,M.D.

PeterLeone,Ph.D.

EricTrupin,Ph.D.

BillWamsley

June30,2008


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SixthMonitorsReport

2

MonitoringTeamMembersAreasofResponsibilityandTourDates

KellyDedel,

Ph.D.

LeadMonitor

ProtectionfromHarm,SuicidePrevention,andQualityAssurance

February1214,2008(CYF)

April89,2008(Hickey)

April2223,2008(CYF)


TimothyHoward

CoMonitor

ProtectionfromHarm,SuicidePrevention,andQualityAssurance

April

4,

2008

(Hickey)

May910,2008(CYF)

MichaelCohen,M.D.

MedicalServices


April2324,2008(CYF)

June11,2008(HickeyandCYF)

PeterLeone,Ph.D.

EducationServices

April25and27,2008(CYF)

May5and

7,

2008

(Hickey)

June5,2008(Hickey)

EricTrupin,Ph.D.

MentalHealthServicesandSuicidePrevention

April23,2008(CYF)


BillWamsley

FireSafety

April2122,2008(CYF)

April23

24,

2008

(Hickey)


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SixthMonitorsReport

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TableofContents

Introduction.................................................................................................................................................. 5

MajorFindings.......................................................................................................................................... 8

OverallCompliance................................................................................................................................. 13

PolicyDevelopment

................................................................................................................................

18

ProtectionfromHarm................................................................................................................................ 20

ProtectionfromAbuse........................................................................................................................... 20

ReportingofStaffMisconduct,YouthonYouthViolenceandStaffUsesofForce............................... 23

HealthCareInquiriesRegardingInjury................................................................................................... 26

UseofForce............................................................................................................................................ 27

SeniorManagementReview.................................................................................................................. 29

StaffTraininginBehaviorManagement,DeEscalationandCrisisIntervention................................... 31

BehaviorManagementProgram............................................................................................................ 32

StructuredRehabilitativeProgramming................................................................................................. 34

Staffing.................................................................................................................................................... 36

SecuritySystems..................................................................................................................................... 38

RestraintPractices

..................................................................................................................................

39

Seclusion................................................................................................................................................. 40

DueProcess............................................................................................................................................ 42

AccesstoToilets..................................................................................................................................... 43

AdmissionIntakeandOrientation.......................................................................................................... 43

EmploymentPractices............................................................................................................................ 44

Classification........................................................................................................................................... 45

SuicidePrevention...................................................................................................................................... 47

ImplementationofPolicy....................................................................................................................... 47

SuicideRiskAssessments........................................................................................................................ 48

MentalHealthResponsetoSuicidalYouth............................................................................................ 49

Supervisionof

Youth

at

Risk

of

Self

Harm

..............................................................................................

50

HousingforYouthatRiskofSelfHarm.................................................................................................. 53

RestrictionsforSuicidalYouth................................................................................................................ 51

DocumentationofSuicidePrecautions.................................................................................................. 52

AccesstoEmergencyEquipment........................................................................................................... 53

SuicideandSuicideAttemptReview...................................................................................................... 54

MentalHealthCare.................................................................................................................................... 55

AdequateTreatment.............................................................................................................................. 55

EstablishmentofDirectorofMentalHealth.......................................................................................... 55

AdmissionsConsultationandReferral................................................................................................... 56

MentalHealthScreening........................................................................................................................ 56

Mental

Health

Assessment

.....................................................................................................................

57

TreatmentPlans..................................................................................................................................... 57

MentalHealthInvolvementinHousingDecisions.................................................................................. 58

InformedConsent................................................................................................................................... 58

MentalHealthMedications.................................................................................................................... 59

MentalHealthDevelopmentalDisabilityTrainingforDirectCareStaff................................................ 60

TransitionPlanning................................................................................................................................. 60


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SixthMonitorsReport

4

MedicalCare............................................................................................................................................... 61

AppropriateCare.................................................................................................................................... 64

MedicalDirector..................................................................................................................................... 66

HealthAssessments................................................................................................................................ 66

MedicationAdministration..................................................................................................................... 67

MedicalandMentalHealthRecordsRetrieval....................................................................................... 67

MedicalandMentalHealthRecordSystem........................................................................................... 68

SpecialEducation....................................................................................................................................... 69

ProvisionofRequiredSpecialEducation................................................................................................ 70

SupervisionofEducation........................................................................................................................ 71

ScreeningandIdentification................................................................................................................... 71

Parent,Guardian,andSurrogateInvolvement...................................................................................... 71

IndividualizedEducationPrograms........................................................................................................ 72

VocationalEducation.............................................................................................................................. 75

Staffing.................................................................................................................................................... 76

Section504Plans.................................................................................................................................... 76

FireSafety................................................................................................................................................... 77

FireSafety

Precautions

at

Hickey

...........................................................................................................

77

FireSafetyPrecautionsatCYF................................................................................................................ 79

ComplianceandQualityAssurance........................................................................................................... 81

DocumentDevelopmentandRevision................................................................................................... 81

DocumentReview................................................................................................................................... 83

QualityAssurancePrograms................................................................................................................... 84

CorrectiveActionPlans........................................................................................................................... 85


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SixthMonitorsReport

5

Introduction

OnJune29,2005,theStateofMarylandenteredintoaSettlementAgreementwiththeUnitedStates

DepartmentofJusticeconcerningtheconditionsofconfinementattheCheltenhamYouthFacility(CYF)

andtheCharlesH.Hickey,Jr.School(Hickey),twojuveniledetentioncentersoperatedbytheMaryland

Departmentof

Juvenile

Services

(DJS).

During

the

summer

of

2005,

the

Parties

jointly

agreed

upon

and

appointedaMonitoringTeamtoreview,assess,andreportindependentlyontheStates

implementationofandcompliancewiththeSettlementAgreement.

Originally,DonDeVorewasselectedasthejuvenilejusticeexpertandMonitoringTeamLeaderbythe

Parties.Mr.DeVoreresignedfromhisdutiesduringthefirstreportingperiod(June30,2005to

December31,2005).InMarch,2006,thePartiesjointlyappointedDr.KellyDedeltoreplaceMr.DeVore

astheMonitoringTeamLeaderandtoassessandreportontheProtectionfromHarm,Suicide

PreventionandQualityAssuranceprovisionsoftheAgreement.TimothyHowardwasappointedtoserve

astheCoMonitorintheareasofProtectionfromHarm,SuicidePreventionandQualityAssurance.The

othermembersoftheMonitoringTeamincludeDr.MichaelCohen(MedicalServices),Dr.PeterLeone

(EducationServices),Dr.EricTrupin(MentalHealthServicesandSuicidePrevention),andBillWamsley

(FireSafety).

InMay2007,theStateandtheDepartmentofJusticeamendedthisAgreementtoincludetheBaltimore

CityJuvenileJusticeCenter(BCJJC).OnlyasubsetoftheprovisionsapplytoBCJJCandaremonitoredby

theapplicablemembersofthesameteamselectedforHickeyandCheltenham.Findingsrelatedto

BCJJCarediscussedinaseparatereport.

TheAgreementplacestheburdenofdemonstratingcomplianceontheState,whichmusthavesufficient

documentationandotherevidenceavailabletodemonstratetheproperimplementationofallpolicies

andprocedures.Usingacombinationofdocumentandyouthrecordreviews,observations,and

interviewswithDJSadministrators,facilitystaff,andyouth,themembersoftheMonitoringTeam

assessedthe

facilities

current

policies

and

practices

relevant

to

the

56

provisions

of

the

Agreement.

Wheneverpossible,teammemberssupportedtheirconclusionswithmultiplesourcesofinformation.

Thisisthe6thMonitorsReport.Asbefore,theMonitoringTeamcontinuedtoreceiveoutstanding

cooperationfromDJSadministratorsandstaff,aswellasusefulassistancefromstaffoftheDepartment

ofJusticeandMarylandAttorneyGeneralsOffice.Inparticular,theDJSsCRIPACoordinatorwas

particularlyhelpfulandimmediatelyresponsivetoalloftheMonitoringTeamsrequests.DJS

administratorswereclearlycommittedtoensuringthatthefacilitiescontinuedtoprogresstoward

substantialcompliancewithinthetimeallottedbytheAgreement.

ExitconferenceswereheldaftertheconclusionofeachMonitorstours.Staffatalllevelsoffacility

operations

and

administration

took

a

keen

interest

in

the

Monitors

findings

and

their

recommendations

forimprovingfacilityoperations.Staffwerediligentintheireffortstoprovideunfetteredaccessto

documents,staffandyouthinorderfortheMonitorstoundertakecomprehensiveaudits.Responsesto

questionswerebothtimelyandthorough,andthequalityofthisreportwasmuchimprovedbythehigh

levelofcooperationreceivedfrombothParties.

TheStateisboundbytheSettlementAgreementforaperiodofthreeyearsbeginningJuly1,2005and

endingJune30,2008.TheMonitorisrequiredtosubmitastatusreporteverysixmonths.Thisreport


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SixthMonitorsReport

6

coversthesixthreportingperiod,January1throughJune30,2008.Itisorganizedasfollows:usingthe

samenumberingsystemfromtheAgreement,eachprovisionisprovided,verbatim,followedby

separatecomplianceratingsforCYFandHickey,adiscussionoftheMonitorsfindings,

recommendationsforreachingcompliance,andtheevidentiarybasisfortheMonitorsconclusions.

ThreecomplianceratingsweredevelopedjointlybytheParties:

SubstantialCompliance: Substantialcompliancewithallcomponentsoftheratedprovision.Noncompliancewithmeretechnicalities,ortemporaryfailuretocomplyduringaperiodofotherwise

sustainedcompliancewillnotconstitutefailuretomaintainsustainedcompliance.Atthesametime,

temporarycomplianceduringaperiodofsustainednoncomplianceshallnotconstitutecompliance.

Thestandardsagainstwhichcompliancewillbeassessedarethosethatareconstitutionallyrequired

andrequiredbyFederalstatute.Adherencetobestpracticeisnotrequiredtoachievecompliance

withtheAgreement.

PartialCompliance:Compliancehasbeenachievedonmostofthekeycomponentsoftheprovision,

butsubstantialworkremains.

NonCompliance:

Non

compliance

with

most

or

all

of

the

components

of

the

provision.

WhiletheAgreementremainsineffectforthreeyearsfromwhenitwassigned(untilJune30,2008),an

opportunitytoterminatespecificsectionsoftheAgreementexistsiftheStatemaintainssubstantial

compliancewithindividualprovisionsfor18consecutivemonths.Therefore,wheretheStatehas

achievedsubstantialcompliance,thestartingdateofthe18monthperiodisnotednexttothe

compliancerating.Duringthepreviousfifthmonitoringperiod,threeprovisionswereterminatedfrom

theAgreementwithrespecttoCYFandHickey:

SectionIII.F.ii DirectorofEducation.TheStateshalldesignateadirectorofeducationwithinthe

facilities.Thedirectorshallmeetminimumstandardsasspecifiedbythestate.TheStateshall

providethe

director

with

sufficient

staff

and

resources

to

perform

the

tasks

required

by

this

agreement

SectionIII.F.iii SpecialEducationScreening.Qualifiedprofessionalsshallprovidepromptand

adequatescreeningoffacilityyouthforspecialeducationneeds,includingidentifyingyouthwho

arereceivingspecialeducationintheirhomeschooldistrictsandthoseeligibletoreceivespecial

educationserviceswhohavenotbeensoidentifiedinthepast.

SectionIII.F.iv ParentInvolvement.TheStateshallappropriatelynotifyandinvolveparents,

guardiansorsurrogateparentsinevaluations,eligibilitydeterminations,IndividualEducation

Programs(IEPs),placementandprovisionofspecialeducationservices.

Duringthecurrentmonitoringperiod,additionalprovisionswereterminatedfromtheAgreement.Atthestatelevel:

SectionIII.D.ii EstablishmentofDirectorofMentalHealth.TheStateshalldesignateadirector

ofmentalhealth.Thedirectorshallmeetminimumstandards,asspecifiedbytheState,to

overseethementalhealthcareandrehabilitativetreatmentofyouthatthefacilitiesby

performingtasksrequiredbythisAgreement


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SixthMonitorsReport

7

ForBOTHfacilities:

SectionIII.B.xiv AccesstoToilets.TheStateshalldevelopandimplementwrittenprocedures

andpracticesatthefacilitiestoprovideallyouthwithtimelyaccesstotoiletsasneeded.

SectionIII.C.v HousingforYouthatRiskofSelfHarm.TheStateshalltakeallreasonable

measurestoassurethatallhousingforyouthatheightenedriskofselfharm,includingholding

rooms,seclusionroomsandhousingforyouthonsuicideprecautions,isfreeofidentifiable

hazardsthatwouldallowyouthtohangthemselvesorcommitotheractsofselfharm.

AtCheltenhamonly:

SectionIII.B.vii BehaviorManagementProgram.TheStateshalldevelopandimplementan

effectivebehaviormanagementprogramatthefacilitiesthroughouttheday,includingduring

schooltimeandshallcontinuetoimplementthebehaviormanagementplan.TheStateshall

developandimplementpolicies,proceduresandpracticesunderwhichmentalhealthstaff

provideregularconsultationregardingbehaviormanagementtodirectcareandotherstaff

involvedin

the

behavior

management

plans

for

youth

receiving

mental

health

services,

and

shall

developamechanismtoassesstheeffectivenessofinterventionsutilized.

SectionIII.B.x SecuritySystems. TheStateshalladequatelymaintainhousingunitsecurity

systems,includingindividualroomdoorlocks.

AtHickeyonly:

SectionIII.D.viii InformedConsent.ConsistentwithStatelaw,theStateshall,priortoobtaining

consentfortheadministrationofpsychotropicmedications,provideyouthand,asappropriate,

theirparentsorguardianswithinformationregardingthegoals,risks,benefitsandpotential

sideeffects

of

such

medications

offered

for

their

treatment,

as

well

as

an

explanation

of

what

theconsequencesofnottreatingwiththemedicationmightbe,andwhethera

recommendationismadeinadosageormannernotrecognizedbytheUnitedStatesFoodand

DrugAdministration.

SectionIII.D.ix MentalHealthMedications. TheStateshalltkeallreasonablemeasuresto

assurethatpsychotropicmedicationsareprescribed,distributed,andmonitoredproperlyand

safely.TheStateshallprovideregulartrainingtoallhealthandmentalhealthstaffoncurrent

issuesinpsychopharmacologicaltreatment,includinginformationnecessarytomonitorforside

effectsandefficacy.

While

these

provisions

are

no

longer

actively

monitored,

they

are

included

in

this

report

for

the

sake

of

continuityandclarity.


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SixthMonitorsReport

8

MajorFindings

SincetheAgreementwassignedin2005,DJScurednearlyallofthedeficitsnotedintheDOJsFindings

Letter.1Inpart,thesechangesweremadepossiblebythesignificantfiscalresourcesthatwere

dedicatedto

improving

the

conditions

of

confinement

and

the

quality

of

care

at

Hickey

and

Cheltenham.

Theseresources,alongwiththeunwaveringcommitmentofagencyandfacilityadministrators,clerical

staff,professionalandlinestaff,andcommunityvolunteers,haveradicallyimprovedthecareand

treatmentofyouthandalsoenabledtoStatetosatisfynearlyalloftheextensiverequirementsofthis

Agreementinjustthreeyears.

Tobesure,therehavebeenmanyprogrammaticchangesthatsubstantiallyimprovedthequalityofcare

atCheltenhamandHickey.Thesearediscussedthroughoutthebodyofthisreport.Manyofthese

programmaticimprovementsweregreatlyfacilitatedbychangestothefacilitiesconfiguration.For

example:

The

size

of

the

facilities

and

the

level

of

crowding

have

been

drastically

reduced.

At

the

time

the

DOJconducteditsinitialtourin2003,Cheltenhamhad180bedsandhoused216youth(20%

overcapacity).SincetheAgreementwassigned,Cheltenhamreduceditscapacityto110beds

andtheaveragedailypopulationforthefirstfourmonthsof2008was100youth.WhentheDOJ

conducteditstour,Hickeyhad330bedsforbothdetainedandcommittedyouthandhoused

263youth.Currently,Hickeyoperatesonlya72beddetentionprogramandtheaveragedaily

populationforthefirstfourmonthsof2008was60youth.

Staffsupervisionofyouthhasimproveddramaticallygivenenhancedstaffyouthratios.Inits

FindingsLetter,DOJnotedthatstafftoyouthratioshadbeenashighas120duringtheday

and160atnight.Obviously,thelackofsupervisioncreatedmanyopportunitiesforviolenceto

occur.ThroughoutlatterpartoftheperiodtheAgreementwasineffect,bothfacilitieswere

routinelystaffed

at

18

during

the

day

and

116

at

night.

Since2005,theStatespentapproximately$1.9milliontoimprovethephysicalplantatbothfacilities.

Amongtheimprovementswerenewmedicalclinicsatbothfacilitiesandtherenovationofabuildingat

Hickeywhichsituatedfacilityadministratorsinsidethefacilitysfenceandalsoallowedforexpanded

youthindoorrecreationareasandincentiveprograms.Inaddition,theStatecommittedover$2.5

millionperyearforacontractwithGlassHealth&Associatestoprovidementalhealthcaretoyouthat

bothfacilities.

Inordertoincreasestaffyouthratiostoacceptablelevels,theStatebothauthorizedovertimepay

(oftenbetween10and20FTEshiftsperdayateachfacility)andsoughtfundingfromtheLegislatureto

createnew

merit

and

contractual

positions.

Approximately

75

contractual

positions

have

been

convertedtomeritpositionswhichincurfringebenefitcostsbutalsomakethesepositionsmore

attractivetoprospectiveemployees.Further,13newdirectcarepositionswereaddedtothefacilities

rostersin2007.

1DOJFindingsLetter,issuedApril,2004,availableat:

http://www.usdoj.gov/crt/split/documents/cheltenham_md.pdf


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SixthMonitorsReport

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Overall,Cheltenhamsoperatingbudgetincreasedbynearly70%overthespanoftheAgreement,

despitethesignificantreductionsintheyouthpopulationcitedabove.Similarly,atHickey,whilethe

operatingbudgetdecreasedapproximately5%,thecapacityreductionatthatfacilitywassosignificant

(330bedsto72beds)thattheperyouthexpendituresincreased147%overthetermoftheAgreement.

Finally,theStatehascommittedtospendingapproximately$500,000peryeartofundaQuality

ImprovementunittoensurethatthereformsenactedunderthisAgreementremaininplace.

OneofthekeyissuescitedintheDOJsFindingsLetterwasthelevelofviolenceinthefacilities.Both

facilitiesparticipateinthePerformancebasedStandardsprogram(PbS),anationalprojectthatpermits

facilitiestocomparetheiroutcomesinkeyareasovertimeandalsopermitscomparisonstoafield

averageconstructedusingratesfromallparticipatingfacilities.2Severaloutcomemeasureshave

particularrelevancetotheAgreement,andthusresultsfromtheApril2008datacollectionperiodare

presentedhere.DuringthecourseoftheAgreement,theDJSalsodevelopedaninternaldatabase

throughitsOfficeofInvestigationsandAudits(OIA)whichcould,buthasnotyetbeenusedtoprovide

manyofthesamefunctionsasPbS.

StandardSafety11trackstheratesofyouthonyouthassaults,calculatedasaratewhichcontrolsfor

thesize

of

the

population

so

that

facilities

with

different

characteristics

can

be

compared

to

each

other.

AsshowninthegraphforHickeybelow,therateofviolencewasatitshighestpointinOctober2006.

Thepast18monthshavewitnessedsignificantdecreasesintherateofyouthonyouthassaults,

decreasingfrom1.892inOctober2006to1.012inApril2008(a47%decrease).Similardecreaseshave

alsobeenobservedwhentheratesarecomparedtothenationalfieldaverage(representedbythe

ribbonrunningthroughthebarchart),althoughtheratesofyouthviolenceatHickeyremain

significantlyhigherthanthefieldaverage.

2NotethatparticipationinPbSisvoluntaryandthusthefieldaverageisconstructedusingonlyasubsetof

detentionfacilitiesoperatingintheUnitedStates(fortheApril2008FieldAverage,n=39oftheapproximately760

detentioncentersnationwide).


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SixthMonitorsReport

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ThegraphforCYF,below,revealsamorevariabletrend,butasignificantlylowerrateofyouthviolence

ascomparedtoHickey.JustbeforetheAgreementwassigned,therateofyouthviolenceatCYFwasat

itshighest(October,2004).ByOctober2006andApril2007,therateofyouthonyouthassaultshad

decreasedconsiderably,(October2006rate=0.287;April2007rate=0.311).Therateofyouthviolence

roseagaininOctober2007,butthendecreasedslightlyduringthecurrentmonitoringperiod.Overtime,

CYFsrateofyouthviolencehasfluctuatedbothaboveandbelowthenationalfieldaverage.3In

summary,therehascertainlybeenadecreaseintheoverallrateofyouthviolenceatCYFsincetheAgreementwassigned,butthefacilitywasnotabletosustaintheverypositivechangesthatwere

witnessedin2007.Movingforward,continuoususeofthesedataandanalyticaleffortstounderstand

therootcausesofthesechangeswillallowthefacilitytoidentifythosefactorsthatcontributetoa

reductioninyouthviolence.Withoutthistypeofanalysis,positivechangesmayoccur,buttheywillnot

beabletobesustainedoverthelongterm.

YouthsafetyisreflectedinanotherPbSoutcomemeasure,Safety13(graphsnotshown).InOctober

2007,44%oftheyouthatHickeyreportedthattheyfearedfortheirsafety,whichwasanalltimehigh

forthefacility.ThemostrecentyouthsurveyfromApril2008revealedasharpdecrease,downtoonly

11%. AtCYFinApril2008,23%ofyouthreportedthattheyfearedfortheirsafety,whichis76%higher

thanthepriorreportingperiod(13%)ofOctober2007.Thereasonsforthesechanges,andtheir

relationshiptotherateofyouthviolenceshouldbeexploredmoreclosely.

ThePbSprojectalsotrackstherateofviolenceagainststaffinStandardSafety12.Asshowninthe

graphontheleftbelow,atHickey,theratesofviolenceagainststaffhavebeenconsistentlyhigherthan

thefield

average

for

the

past

four

reporting

periods.

While

these

rates

reflect

relatively

low

raw

numbers(i.e.,inApril2008,therewere2assaultsonstaff)andmaynothaveresultedinanyinjuryto

staff,thefactthatthisproblemhaspersistedovertimeisaconcern.CYF(graph,lowerright)hadnot

3Again,comparisonstothePbSnationalfieldaverageareopentointerpretationbecauseparticipationinthe

programisvoluntaryandthefieldaverageincludesonlyasubsetofdetentionfacilitiesoperatingintheUnited

States(n=39ofapproximately760detentionfacilities,nationwide).


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SixthMonitorsReport

11

hadanyassaultsonstaffoverfourreportingperiods(throughoutallof2006and2007),buthad1in

April2008.

WorkingconditionsforstaffarereflectedinanotherPbSoutcomemeasure,Safety14(graphsnot

shown).AroundthetimetheAgreementwassigned,between40%and60%ofHickeystaffreported

thattheyfearedfortheirsafety.InApril2008,thisproportionhaddecreasedto25%.Reducingtherate

ofyouthviolenceatHickey,asdiscussedabove,wouldlikelyresultinstafffeelingsafer.AtCYF,atits

peak,30%ofstaffreportedconcernfortheirsafetyinApril2006.Thisproportionhasdecreasedover

time,landingat19%inApril2008,whichisa33%decreaseoverthepastfewyears.

Thus,overtheperiodoftheAgreement,whilebothfacilitieshavesuccessfullybuiltasolidinfrastructure

andestablishedmanyoftheprocessesandpracticesknowntoprotectyouthfromharmandimprove

thequalityofcare,significantworkremainstoreducetherateofviolenceinthefacilities.Usingthe

newlydeveloped

processes

and

sources

of

information,

both

facilities

must

focus

on

the

causes

of

youth

violenceanddevisetargetedstrategiesthatimpacttheconditionswhichcreatetheopportunitiesfor

youthviolencetooccur.

Anyremainingareasofconcernandfinalremarksineachsubstantiveareaaresummarizedbelow:

ProtectionfromHarm:

Bothfacilitiesareinsubstantialcompliancewith16ofthe17(94%)provisionsrelatedtoprotection

fromharm.TheyremaininpartialcompliancewiththesingleprovisionrelatedtoClassification.

TheDepartment

must

implement

its

housing

classification

instrument

at

both

facilities.

Full

implementationwillrequiretrainingstaff;completingtheinstrumentforallyouthcurrentlyhoused

atthefacilities;completingtheinstrumentforyouthadmittedtothefacilities;andassigningyouth

toroomsthatarecommensuratewiththeirassessedsupervisionlevel.Implementationwillalso

requireDJStocollectdataover30to60daystoassesstheextenttowhichthesystemisoperating

asdesigned,andtomakemodificationsasneeded.Documentationthattheproperprocedureswere

followedforseveralmonthsthereafterwillberequiredtosubstantiatecompliancewiththis


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SixthMonitorsReport

12

provision.AsagreedbytheParties,temporarycomplianceduringaperiodofsustainednon

complianceshallnotconstitute[substantial]compliance.

SuicidePrevention:

Bothfacilitiesremaininsubstantialcompliancewithall9oftheprovisions(100%)relatedtosuicide

prevention.

Therigorousfacilitybasedauditingmechanismsestablishedtopromotecompliancewiththis

Agreementwillbeanessentialfeatureofongoingqualityassurance.Althoughtimeconsumingfor

clericalandadministrativestaff,theregularauditsofthesedocumentswillensurethatprocedures

continuetobefollowedandthatstafftakeappropriateactiontoobtainhighqualitymentalhealth

careforyouthwhodemonstrateanelevatedriskofselfharm.

MentalHealthCare,MedicalCare,SpecialEducationandFireSafety:

Bothfacilitiesareinsubstantialcompliancewithall9oftheprovisions(100%)relatedtomental

healthcare.

Bothfacilitiesareinsubstantialcompliancewithall6provisions(100%)relatedtomedicalcare.

Bothfacilitiesareinsubstantialcompliancewithall8provisions(100%)relatedtospecialeducation.

Bothfacilitiesremaininsubstantialcompliancewiththeprovision(100%)relatedtofiresafety.

QualityAssurance:

TheStateisinsubstantialcompliancewithall4provisions(100%)relatedtoQualityAssurance.

TheDJSOfficeofQualityAssuranceandAccountabilityisfullyabletoassumethedutiesperformed

bytheMonitoringTeam.Acomprehensivesetofstandards,clearmethodology,qualitywritten

report,anddetailedcorrectiveactionplansshouldensurethattheconditionsofconfinement

envisionedbythisAgreementcontinuetobeprovidedatbothHickeyandCheltenham.


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SixthMonitorsReport

13

OverallCompliance

TheStateisinsubstantialcompliancewith100%ofthe6agencylevelprovisions. Amongthefacility

levelprovisions,bothfacilitiesareinsubstantialcompliancewith98%oftheprovisions.Bothfacilities

remaininpartialcompliancewiththesingleprovisionrelatedtoClassification.

IntheFifthMonitorsReport,HickeyandCYFwereinsubstantialcompliancewith43and37provisions,

respectively.ThisSixthreportevidencesanetgainof6provisionsatHickeyand12provisionsatCYF.

Theseratings,separatedbysubstantiveareaoftheAgreementandbyfacility,areprovidedinTable1

below.

Table1.OverallCompliance,bySubstantiveArea

SubstantiveAreaTotal

Provisions

Substantial

Compliance

Partial

Compliance

Non

Compliance

Hickey CYF Hickey CYF Hickey CYF

ProtectionfromHarm 17 16 16 1 1 ~ ~

SuicidePrevention 9 9 9 ~ ~ ~ ~

MentalHealth* 10 10 10 ~ ~ ~ ~

Medical* 5 5 5 ~ ~ ~ ~

SpecialEducation 8 8 8 ~ ~ ~ ~

FireSafety** 1 1 1 ~ ~ ~ ~

TOTALFACILITYLEVEL 50 49 49 ~ ~ ~ ~

MentalHealth

1

1

~

~

Medical 1 1 ~ ~

QualityAssurance 4 4 ~ ~

TOTALAGENCYLEVEL 66

(100%)~ ~

*Oneormoreprovisionsareagencylevelissues.

Table2,below,comparesthecomplianceratingsfromtheMonitorsFifthandSixthReports.Thecurrent

compliance

ratings

were

compared

to

those

from

the

Monitors

Fifth

Report

to

determine

whether

the

ratingsevidencedslippage,werethesame,orshowedimprovement.Thoseprovisionsonwhich

substantialcompliancehadbeenpreviouslyachieved,andwasmaintained,weremarkedaccordingly.


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SettlementAgreementbetweentheStateofMarylandandthe

Table2.ComparisonofComplianceRatingsfrom4TH

and5TH

Monitors Reports

Provision

Hickey Status CYF

5th

report

6th

reportSlippage

No

ChangeProgress

Compliance

Maintained

5th

report

6th

reportSlippage

ProtectionFromHarm

ProtectFrom

Abuse

PC

C

X PC

C

Reporting C C X PC C

HealthCareInq. C C X C C

UseofForce C C X PC C

SrMgmtReview C C X PC C

TrnginBehMgmt C C X C C

BehMgmtPrgm PC C X C C

Programming C C X C C

Staffing C C X PC C

SecuritySystems

C

C

X C

C

RestraintPractices C C X PC C

Seclusion C C X PC C

DueProcess C C X PC C

AccesstoToilets C C X C C

Adm/Orientation C C X C C

EmpPractice C C X C C

Classification PC PC X PC PC

17 TOTAL ~ 1(6%) 2(12%) 14(82%) TOTAL ~


15/85



and5TH

Monitors Reports

Provision

Hickey Status CYF

5th

report

6th

reportSlippage

No

ChangeProgress

Compliance

Maintained

5th

report

6th

reportSlippage

SuicidePrevention

ImplementPolicy

C

C

X C

C

SuicideRiskAssesst C C X C C

MHResponse C C X C C

Supervision C C X C C

Housing C C X C C

Restrictions C C X C C

Documentation C C X C C

EmergencyEquipmnt C C X C C

Review C C X C C

9

TOTAL

~ ~ ~ 9(100%) TOTAL ~

MentalHealthCare

AdequateTreatment C C X C C

DirofMH C C X C C

Consult/Referral C C X C C

MHScreening C C X C C

MHAssessment PC C X PC C

TreatmentPlans C C X C C

Housing C C X C C

InformedConsent

C

C

X C

C

MHMedication C C X C C

DevelopDisability C C X C C

TransitionPlanning PC C X PC C

11 TOTAL ~ ~ 2(18%) 9 (82%) TOTAL ~


16/85



and5TH

Monitors Reports

Provision

Hickey Status CYF

5th

report

6th

reportSlippage

No

ChangeProgress

Compliance

Maintained

5th

report

6th

reportSlippage

MedicalCare

AppropriateCare

PC

C

X PC

C

MedicalDirector C C X C C

HealthAssessments PC C X PC C

MedicationAdmin C C X C C

RecordRetrieval C C X C C

RecordSystem C C X C C

6 TOTAL ~ ~ 2 (34%) 4(66%) TOTAL ~

SpecialEducation

ProvisionofSPED C C X C C

Supervision

C

C

X C

C

Screen/Identification C C X C C

Parent/Surrogate C C X C C

IEPs C C X C C

VocationalEducation C C X C C

Staffing C C X C C

Section504Plans C C X C C

8 TOTAL ~ ~ ~ 8 (100%) TOTAL ~

FireSafety

Precautions

C

C

X C

C

1 TOTAL ~ ~ ~ 1(100%) TOTAL ~


17/85



and5TH

Monitors Reports

Provision

Hickey Status CYF

5th

report

6th

reportSlippage

No

ChangeProgress

Compliance

Maintained

5th

report

6th

reportSlippage

ComplianceandQualityAssurance

DocumentDevelopt

C

C

X C

C

DocumentReview C C X C C

QAPrograms PC C X PC C

CorrActionPlans PC C X PC C

TOTAL ~ ~ 2(50%) 2(50%) TOTAL ~

TOTAL56Provisions HICKEY ~ 1(2%) 8 (14%) 47 (84%) CYF ~

AtHickey,

compliance

was

maintained

on

84%

of

the

provisions

(n=47).

Progress

was

evident

on

14%

of

the

prov

ratingsremainedthesamefor2%oftheprovisions(n=1). AtCYF,compliancewasmaintainedon73%ofthepro

evidenton25%oftheprovisions(n=14),andthecomplianceratingsremainedthesameon2%oftheprovisions


18/85


SixthMonitorsReport

18

PolicyDevelopment

ThefoundationofcompliancewithalloftheprovisionsofthisAgreementisasetofcomprehensive

policiesthatestablishstandardsforcareineveryaspectoffacilityoperations.Duringtheperiodthis

Agreementwas

in

effect,

atotal

of

22

policies

were

drafted

to

address

provisions.

These

include:

AdmissionandOrientation

BehaviorManagement

Classification

CriminalBackgroundChecks

GeneralDocumentationofLogBooks

IncidentReporting

KeyControl

PerimeterSecurity

PharmaceuticalServices

PhotographingofInjuries

PostOrders

Recreation

ReportingandInvestigatingChildAbuse

SafetyandSecurityInspections

Searches

Seclusion

SuicidePrevention

TreatmentServicesPlan

UseofCPMTechniques

VideotapingIncidents

YouthGrievances

YouthMovement

and

Count

Mostofthesepoliciesarerelatedtogeneralfacilityoperationsandpracticestoprotectyouthfrom

harm.TheothersubstantiveareasofthisAgreementarealsocoveredbywrittenguidelinesand

standards.DJShasonlyoneagencypolicyrelatedtoeducation(CoordinationwithCommunityAgencies

andEducationalInstitutions),butproceduresaregovernedbytheMarylandStateDepartmentof

Education(MSDE)specialeducationregulations.Bothschoolsusetheseguidelines.

Withregardtomedicalservices,theDJShasninepoliciescoveringthefollowingareas:

Sickcall;

Youthparticipationinexperimentalresearch;

Notification

of

illness,

injury,

surgery

or

death;

Communicablediseases;

Firstaidkits;

Handlingcontaminatedwaste;

AIDS;

Pharmaceuticalservices

Emergencymedicalservices;and

Bloodbornepathogens.


19/85


SixthMonitorsReport

19

Mentalhealthservicesareguidedbyfivepoliciescovering:suicideprevention,substanceabuse

treatment,psychologicalevaluations,drugandalcoholabuseassessment,andtreatmentplanning.The

treatmentplanningpolicyiscurrentlybeingrevised.Finally,facilityoperationsrelativetofiresafetyare

coveredbypoliciesthatdiscuss:useofflammable,toxicandcausticmaterials,emergencyevacuation

procedures,andsafetyandsecurityinspections.

ThesepoliciesprovideasolidfoundationforeffectivelyoperatingDJSfacilities.Theextenttowhichthey

havebeenproperlyimplementedisdiscussedinthesubsequentsectionofthisreport,whichdiscusses

eachofthe56provisionsindividually.


20/85


SixthMonitorsReport

20

ProtectionfromHarm

Provision

III.B.i

ProtectionfromAbuse:TheStateshalltakeallreasonablemeasurestoassure

thatyouthareprotectedfromviolenceandotherphysicalorsexualabuseby

staffandotheryouth.

Status

HickeySchoolSubstantialCompliance

(asofJune30,2008)

CheltenhamYouthFacilitySubstantialCompliance

(asofJune30,2008)

Discussion DuringthetermofthisAgreement,bothfacilitiesdevelopedasolidinfrastructure

thatincludesthekeyelementsknowntopromoteyouthandstaffsafety.These

include:

Procedurestoattractandretainqualifiedstafftoallowforappropriatestaff

youthratios;

Anincidentreportingprocessandsystemofreviewbyseniormanagers;

Acurriculumforsafecrisisinterventionthatemphasizesdeescalationand

usesphysicalandmechanicalrestraintsonlyasalastresort;

Asystemforinvestigatingandrespondingtoallegationsofstaffabuseand

misconduct;

Abehaviormanagementprogramthatsetsclearexpectationsforbehavior

andprovidesasystemofincentivesandconsequencesthataremeaningfulto

youth;

Stronglimitsontheuseofisolationasaresponsetomisconduct;and

Structuredprogrammingthatminimizesyouthsidletime.

Aswillbediscussedinthefollowingsections,DJShasimplementedpolicies,

proceduresandpracticesrelevanttoeachkeyarea.Someofthesepracticeswere

implementedsmoothly(e.g.,theOfficeofInvestigationsandAdvocacy

investigations),while

others

required

more

heroic

efforts

(e.g.,

many

staff

continuetoberequiredtoworkdoubleshiftsinordertomeetprescribedstaff

youthratios).Inallcases,thecommitmentoflinestaff,supervisors,and

administratorsresultedinsignificantenhancementstothewayyoutharetreated

andtheconditionsunderwhichtheyareconfined.

TheStatehasyettoachievesubstantialcomplianceononlyoneprovisionofthe

protectionfromharmsectionofthisAgreement:Classification.Asdiscussedin

detailinIII.B.xvii,theStatedevelopedandattemptedtovalidateaclassification

systemduringthesecondyearofthisAgreement.Thissystemsufferedfroma

varietyofproblems(confusingterminologyandinaccessibledata)andthusin

April2008,

the

DJS

decided

to

create

anew

system

that

was

better

aligned

with

Marylandssystem.WhiletheMonitorsupportsthisdecisionandbelievesitwill

resultinaclassificationsystemthatismorefullyintegratedintotheDJSsoverall

mission,thischangedidnotoccuruntillateinthefinalmonitoringperiodand

thusthenewsystemcouldnotbeimplementedinthetimeremainingbeforethe

terminationoftheAgreement.

Whilealloftheissueslistedabovearediscussedindetailundertherelevant


21/85


SixthMonitorsReport

21

provisions,oneissuefallsunderthismoregeneraldiscussion.Adequate

protectionfromharmrequiresadependablesystemformonitoringyouths

safetyandwelfareanytimetheyareconfinedtoalockedroom.TheDepartment

hasembracedthisstandardbyrequiringyouthtobecheckedat30minute

intervalsduringsleepinghours(althougha15minutestandardisusedbythe

CYF).

AtHickey,theGuardToursystemwasputintouseinthelatterpartof2007.The

previousMonitorsReportnotedsomeinconsistencyinthefrequencyof

overnightchecksandalackofvariationintheonsetofcheckscommensurate

withtheyouthsstaggeredbedtimes. Duringthecurrentmonitoringperiod,five

weekswerechosenrandomlyforreview.Acrosseachofthethreehousingunits,

checkswerefarmoreconsistent,withonly3percentofshiftsexhibiting

significantgapsinchecks(i.e.,gapsinwhichyouthwerenotcheckedfor60

minutesormore).Mostoftheshiftsreviewedindicatedthattheonsetofchecks

paralleledyouthsstaggeredbedtimes,andforthemostpart,checkscontinued

untiltheyouthwereawakenedformorninghygiene.

AtCYF,theGuardTourwasimplementedduringthecurrentmonitoringperiod.

Whilecompliancewithfacilityoperatingprocedureswasstrongduringtheinitial

periodofimplementation,itwasnotsustainedthroughoutthemonitoring

period.InearlyFebruary,2008,checksattheproperintervalswerebeing

executedbythemajorityofstaffassignedtoeachofthehousingunits.Staff

appearedtounderstandthemechanicsofthesystemandtouseitproperly.

However,anexaminationofGuardTourreportsforweeksrandomlychosenin

lateFebruary,MarchandAprilhigherratesoferrorwerenoted.Atotalof33

shiftswerereviewedfor3housingunits,foratotalof99shifts.Ofthese,46%

(n=46)shiftsshowedseveredeparturesfromtherequiredoperatingprocedure

(e.g.,two

or

more

periods

exceeding

60

minutes

where

no

checks

were

conductedatall;failingtocommencechecksatyouthsbedtime,insteadwaiting

untilafter3rdshifthadbegun;orendingcheckswellbeforetheyouthswake

time(4a.m.orearlier).Inotherwords,youthsafetywhenconfinedtotheir

roomswasnotproperlyverifiedonnearlyhalfofthenightsobserved.Although

notasignificantenoughproblemtoprecludeasubstantialcomplianceratingon

thisprovision,immediateattentiontothisproblemisrequired.

Thus,thefacilitieshaveachievedsubstantialcomplianceonallbutoneofthe

provisionscontainedinthissectionoftheAgreement.Someofthereformswill

endurewithoutsignificantmaintenance,oversightorrefreshertrainingstaff

have

simply

changed

the

way

they

do

business.

However,

in

other

areas,

continuedvigilancewillbenecessarytoensurethattheinitialimplementation

takesholdandbecomesapermanentpartofhowtheStateapproachesthe

youthinitscare. WithregardtoClassification,inparticular,continuedeffortis

neededtoensurethatthesystemisimplementedasitwasdesigned.

Evenwiththesechanges,incidentsofviolencecontinuetooccuratthefacilities.

However,withthesatisfactionofthisAgreementcomenewtoolstounderstand


22/85


SixthMonitorsReport

22

andaccuratelytargetthecausesofviolencewiththeintentionofreducing

violenceovertime.AbsenttheinfrastructurecreatedviathisAgreement,

strategicviolencereductioneffortswouldnotbepossible.

Recommendations Bothfacilitiesareinsubstantialcompliancewiththisprovision,asofJune30,

2008.

ItisstronglysuggestedthatCYFtakeimmediatestepstoensurethatthe

GuardTourpolicyisproperlyimplemented.

EvidentiaryBasis Alldocuments,interviews,andobservationslistedinthesubsequent

provisionsoftheProtectionfromHarmsectionofthisAgreement.

GuardTourreportsfromHickeyfortheweeksofJanuary13,January27,

February24,March23andApril6,2008.

GuardTourreportsfromCYFfortheweeksofFebruary2,February24,March

16,March30andApril13,2008.


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SixthMonitorsReport

23

Provision

III.B.ii

ReportingofStaffMisconduct,YouthonYouthViolenceandStaffUsesofForce:

TheStateshalldevelopandimplementappropriatepolicies,proceduresand

practicestoenhancethereportingtoappropriateindividualsofincidentsofstaff

misconduct,youth

on

youth

violence

and

staff

uses

of

forces,

and

to

provide

that

suchreportingmaybedonethroughconfidentialmeans,withoutfearofretaliation

formakingthereport.TheStateshalldocumentandreportappropriatelyandwith

sufficientdetailallsuchincidents.

Status

HickeySchool

SubstantialCompliance

(asofOctober25,2007)

CheltenhamYouthFacility


(asofJune30,2008)

Discussion Thefollowingpoliciesarerelevanttothisprovision:

UseofCrisisPreventionManagementTechniques

IncidentReporting

ReportingandInvestigatingChildAbuseandNeglect

YouthGrievances

IncidentReporting: Policy.Theresponsibilitytoreportincidentsofstaff

misconduct,youthonyouthviolence,usesofforceandothertypesofincidentsup

thechainofcommandisdiscussedintheDepartmentsIncidentReportingpolicy.

BothfacilitiesalsohaveaFacilityOperatingProcedure(FOP)thatprovidesspecific

proceduresforcompletingtheincidentreportitself.Inaddition,thetraining

departmentdraftedaStepByStepGuideforCompletingtheDJSIncidentReporting

Form.Thismanualisanexcellenttrainingtool.

Training. Afourhourreportwritingtrainingprogramismandatoryforalldirect

carestaff.

With

only

one

exception,

all

staff

at

both

facilities

participated

in

this

coursein2007.

Practice.Toassesscompliancewiththisprovision,asampleofincidentreports

(IRs)werereviewedateachfacility.Thissamplewasnotchosenrandomly,but

ratherwaspurposefullyselectedtofocusonthoseinvolvingseriousincidents

(groupdisturbances,usesofforcewithinjury,youthonyouthassaultsrequiring

offgroundsmedicaltreatment)andarandomsampleoflessseriousyouthon

youthassaultsandmoreroutineusesofforce.

Overall,theprocessforreportingincidentsofstaffmisconduct,youthonyouth

violence,andtheuseofforcehasbeenfullyimplemented.TheDepartments

incidentreportingform(introducedinSeptember2006)broughtnewstructure

andguidancetotheprocessandresultedinhighqualitynarrativedescriptionsof

theincidents.TheIRpacketsatbothfacilitieswerewellorganized,easilyretrieved,

andusefultothetaskofassessingthecausesofviolencesothatitcanbe

prevented.ThefactthattheIRformsareautomatedpermitstheDepartments

OfficeofInvestigationsandAudits(OIA)toproduceusefulstatisticalreportsonthe

type,frequency,locationandtimeofallincidentswhich,inthefuture,maylend


24/85


SixthMonitorsReport

24

themselvestocreativestrategiestoreducethelevelofviolenceinthefacilities.

Atotalof24incidentreportsgeneratedbetweenJanuary1andmidApril2008

werereviewedatHickeyandatotalof33werereviewedatCYF.Whileasmall

numberofreportshaddeficiencies,themajorityofreportsconformedtogenerally

acceptedpractices

in

the

following

areas:

Descriptionsoffactorsthatprecipitatedtheevent(e.g.,wastheassault

completelyunprovokedorhadtheyouthhadanearlierverbalaltercation?

Whatdidtheyouthdojustbeforethefight?);

Accuratelistingofthestaffandyouthpresentandwherestaffwereposted

whentheincidentbegan;

Detailedaccountsofthefightorassault(e.g.,onepunchortheexchangeof

blowsandkicks);

Descriptionsofthewayinwhichstaffintervenedandtheyouthsresponsesto

thoseinterventions(e.g.,thespecificphysicalrestrainttechniqueusedand

howitwasexecuted);

Statementsfromyouthwhowereinvolvedandwhowitnessedtheincident(or

awritten

statement

from

youth

indicating

their

refusal

to

provide

a

statement);and

Statementsfromstaffinvolvedorwhowitnessedtheincident.

Thesedetailsareessentialforasubstantivereviewbymanagementandalsofor

determiningwhetheraspecificincidentshouldbeinvestigatedbytheOfficeof

InvestigationsandAudits(OIA).PriortothedatethisAgreementtookeffect,

incidentreportswerenotwrittenforeveryincidentthatoccurred.Thosethatwere

generatedusuallylackedsufficientdetailtodeterminewhathappenedandhow

staffresponded.Now,however,thereportsprovidesufficientinformationto

assessstaffshandlingofspecificsituationsandalsotoidentifypatternsandissues

thatare

ripe

for

strategic

violence

prevention

efforts.

StaffKnowledge:Structuredinterviewswereconductedwithdirectcarestaffat

eachfacility(n=10atCYFandn=11atHickey).Allstaffreportedthattheyhad

receivedtraininginverbaldeescalationandCrisisPreventionManagement(CPM)

inthepastyear.Allstaffaccuratelyunderstoodtheirresponsibilitytoreport

incidentsinvolvingyouthonyouthviolenceandtheuseofforce,tonotifytheShift

Commanderoftheincident,andtoobtainmedicalattentionfortheyouth

involved.

GrievanceProcedure: Theincidentreportingprocessissupplementedbyaformal

grievance

procedure

as

a

means

for

youth

to

report

perceived

misconduct

or

abuse

bystaff.

AllgrievancesfromJanuarythroughApril,2008werereviewedandtheYouth

Advocatesateachfacilitywereinterviewed.Mostofthegrievancesdiscussednon

safetyrelatedissues(e.g.,clothing,activities,pointdeductions,etc.).Whenstaff

misconductwasalleged,thecomplaintwasforwardedtoinvestigatorsfromthe

OfficeofInvestigationsandAudits(OIA)asappropriate.Youthinterviewedatboth


25/85


SixthMonitorsReport

25

facilities(n=11atHickeyandn=12atCYF)reportedthatstaffexplainedthe

grievanceprocesstothemandthattheyknewhowtousethesystem.Youthwho

hadfiledgrievancesreportedthattheissueswereresolvedtotheirsatisfaction.

Seriousandpersistentissuesarebroughttotheattentionofthefacility

Superintendents.Theprocessisclearlyoperatingasitwasdesignedandprovides

youthat

both

facilities

with

free

access

to

aconfidential

grievance

process.

ReportingChildAbuseandNeglecttoChildProtectiveServices:Staffatboth

facilitiesaremandatedchildabusereportersbyStatestatute.Assuch,theyare

requiredtoreportallegationsofabusetotheDepartmentofSocialServices(DSS).

DJSpolicy[ReportingandInvestigatingChildAbuseandNeglect,Policy#010103,

effective2/2000]states,Anyemployeewhohasreasontobelievethatachildhas

beenabusedorneglectedshallimmediatelynotifythelocalDepartmentofSocial

Services(DSS)forsuspectedneglectortheappropriatelawenforcementagency

forsuspectedabuse.Ratherthanrequiringeachindividualtoreporttheincident

toDSSandlawenforcement,DepartmentpolicydesignatestheFacility

Administratorastheresponsibleparty[seeDJSNotificationofIncidentspolicy].

Acrosstheincidentsandformalgrievancesreviewedandyouthandstaff

interviewedduringthismonitoringperiod,theMonitoringTeamdidnotidentify

anyallegationsofmisconductorabusethathadnotbeenpromptlyreportedto

CPSandlawenforcementbydirectcareoradministrativestaff.

Recommendations Hickeyhasbeeninsubstantialcompliancewiththisprovisionforapproximately8

months,beginningOctober25,2007.

CYFisinsubstantialcompliancewiththisprovisionasofJune30,2008.

EvidentiaryBasis Policyreview

CY2007

Training

records

for

all

direct

care

staff,

compiled

by

DJS

at

the

requestoftheMonitor

CYF

Youth interviews,n=12

Staffinterviews,n=10

Incidentreports,n=33,selectedpurposefullyfromthoseoccurringbetween

January1andApril10,2008

Grievances submittedtotheYouthAdvocatebetweenJanuary1andApril10,

2008

Hickey

Youthinterviews,n=11




GrievancessubmittedtotheYouthAdvocatebetweenJanuary1andApril15,

2008


26/85


SixthMonitorsReport

26

Provision

III.B.iii

HealthCareInquiriesRegardingInjury:Anurseorotherhealthcareprovidershall

question,outsidethehearingofotherstafforyouth,ifappropriate,eachyouth

whoreportstotheinfirmarywithaninjury,regardingthecauseoftheinjury.If,in

thecourseoftheyouthsinfirmaryvisit,ahealthcareprovidersuspectsabuse,

thathealth

care

provider

shall

immediately:

a. Takeallappropriatestepstopreserveevidenceoftheinjury(e.g.,

photographtheinjuryandanyotherphysicalevidence);

b. Ifareporthasnotalreadybeenmade,reportthesuspectedabusetothe

appropriateauthorities;

c. Documentadequatelythematterintheyouthsmedicalrecord;andifone

hasnotalreadybeeninitiated,completeanincidentreport.

Status

HickeySchool


(asofApril25,2007)



(asofSeptember14,2006)


Photographingof

Injuries

NotificationofIncidents

DJSHealthStandard#10

TheDepartmentsNursingReportofInjuriesForm(theBodySheet)istobe

completedforallyouthinvolvedinanincident,whetherornottheyouthis

injured.Acrossthe57IRsreviewedduringthismonitoringperiod,aBodySheet

waslocatedforeachoftheyouthinvolvedintheincidents.Whileaverysmall

minorityoftheformshaderrors(e.g.,timeordatewasnotindicated,Injury

SeverityRatingwasnotcompleted),therateoferrorswasacceptable.Further,

photographinginjuriesforevidentiarypurposesisroutineandphotoswerelocated

forevery

youth

involved

in

the

57

incidents

reviewed.

Inthesmallnumberofinstanceswhenyouthallegedabuseormistreatmentduring

thecourseofthenursesinterview,appropriatestepswerenearlyalwaystakento

ensurethattheallegationswerereportedtothefacilityadministratorortoOIA.In

twocases(oneateachfacility),nursesdidnotreporttheallegationimmediately,

butthenursingsupervisorcaughttheerrorwithin24hours.Althoughnevera

pervasiveproblem,theMonitorhasnotedsimilarconcernsinpriorreport.Nurses

compliancewithmandatoryreportinglawsmustbereinforcedfrequently.

Recommendations CYFhasbeeninsubstantialcompliancewiththisprovisionforapproximately21

months,beginningSeptember14,2006whileHickeyhasbeeninsubstantial

compliancefor

approximately

14

months,

beginning

April

25,

2007.

EvidentiaryBasis CYF



Hickey




27/85


SixthMonitorsReport

27

Provision

III.B.iv

UseofForce:TheStateshalldevelopandimplementcomprehensivepolicies,

proceduresandpracticesgoverningtheusesofforcetoassurethattheleast

amountofforcenecessaryisusedonyouthforthesafetyofstaff,youthresidents

andvisitors.

StatusHickey

School

Substantial Compliance

(asofDecember31,2007)

CheltenhamYouth

Facility


(asofJune30,2008)


UseofCrisisPreventionManagement(CPM)Techniques

VideotapingofIncidents

Policy: TheDepartmentsUseofCrisisPreventionManagement(CPM)Techniques

policywasissuedonMarch27,2007andclearlyarticulatestheroleofphysical

restraintinthecontinuumofinterventionsusedtoensurethesafetyofstaffand

youth.

Training: Atotalof21staff(10atCYF;11atHickey)wereinterviewedabouttheir

trainingandcomfortlevelusingtheCPMtechniques.Allstaffreportedthatthey

receivedannualtraininginCPM.Staffresponsessupportedanunderstandingthat

acontinuumofprogressivelymorerestrictiveresponsesshouldbeused,limiting

theforcetotheleastamountrequiredtoensuresafety.Whenaskedto

demonstrateparticularrestrainttechniques,staffwereabletodoso.

ForthepreviousMonitorsreport,stafftrainingrecordswereanalyzedto

determinetheproportionofstaffwhoreceivedannualtrainingintheuseofCPM

duringCY2007.4AtbothHickeyandCYF,allstaffreceivedCPMtrainingin2007.At

thetime

this

report

was

drafted,

only

one

third

of

CY2008

had

elapsed

and

thus

theserecordswerenotanalyzed.

AttheinceptionofthisAgreement,manystaffhadnotreceivedtraininginthe

properuseofforceforseveralyears.Currently,allstaffreceivethistrainingatleast

annually,andstaffwhoexhibitalackofskillinthisareaarefrequentlyreferredfor

additionaltraining.Further,theCPMtrainingmodulewasenhancedduringthe

previousmonitoringperiodtoemphasizedeescalationandcommunication

strategies.

Practice:TheDepartmentsIncidentReportFormrequiresstafftoidentifythe

specificCPMtechniquesusedandautomaticallygeneratesaUseofForceReport

anytimetheincidentiscodedassuch.Staffarealsoaskedtodescribetheuseof

forceintheaccompanyingnarrative.

4OnlystaffwhowerehiredpriortoJanuary1,2007wereincludedintheanalysis,giventhatstaffhiredafterthat

datewererequiredtosatisfyEntryLevelTraining(ELT)requirementsduringCY2007andwerenotyetsubjectto

annualtrainingrequirements.


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SixthMonitorsReport

28

Amongthe57incidentreportsreviewedacrossthetwofacilities,mostofthe

narrativesfullydescribedtheuseofforce,howitwasexecuted,lessrestrictive

measuresthatweretriedbeforehand,andtheyouthsresponsestoeachmeasure.

Supplementaryinformationisavailableinthestaffwitnessstatementsinwhich

eachpersoninvolvedintherestraintaccountsforhisorherbehavior.These

accountsdemonstrate

staff

do

not

automatically

advance

to

the

most

restrictive

holdavailable(e.g.,takekidstothefloorimmediately);instead,theywork

progressivelythroughaseriesoflessrestrictivetechniques,gaugingtheyouths

responsebeforeadvancingtomorerestrictivetechniques.

StaffhavemadeexcellenteffortstoadoptCPMlanguageandtoprovidevery

detaileddescriptionsoftheiractions.However,thoseauditingtheincidentreports

mustrecognizethattherewillbeoccasionswhenthetimingoftheincident,

positioningoftheyouth,orotherfactorsmakeitimpossibletouseaspecificCPM

technique.Inthesesituations,staffshouldsimplydescribe,ratherthanlabel,their

actionstodemonstratethattheyapproachedtheyouthwithcareandmoderated

theirresponsestoonlywhatwasnecessarytobringthesituationsafelyunder

control.

Videotaping: TheDepartmentsVideotapingpolicywasissuedinSeptember,

2007.Despitetheexistenceofthepolicyandtheavailabilityofcameras,battery

packs,andblanktapes,videotapingisstillnotaroutinepractice.Moststaff

indicatedtheywerenotcomfortableusingthecameraduringincidentsastheyfelt

theirinvolvementincontrollingtheyouthsbehaviorwasahigherpriority.If

staffinglevelsareincreased,thevideotapingpolicymightbefollowedmore

dependably.Whenitiscaptured,videotapedfootagehasbeenextremelyhelpful

asatrainingaidforstaff.

Staffand

Youth

Perceptions:

All

of

the

staff

interviewed

reported

that

physical

restraintwasusedasalastresortandthattheleastrestrictivetechniqueswereto

beusedtocontrolyouthinvolvedinanaltercation.Noyouthreportedobserving

staffhit,slap,kick,orotherwiseinjureayouth.


months,beginningDecember31,2007.CYFisinsubstantialcompliancewiththis

provisionasofJune30,2008.


CYF


Staffinterviews, n=10



Hickey

Youthinterviews,n=11





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SixthMonitorsReport

29

Provision

III.B.v

SeniorManagementReview:TheStateshalldevelopandimplementasystemfor

reviewbyseniormanagementofusesofforce,allegedchildabuseandyouthon

youthviolence.

Status

HickeySchool





(asofJune30,2008)


OfficeofProfessionalResponsibilityandAccountability,StandardOperating

Procedures

VideotapingofIncidents

IncidentReports: TheDepartmentsIncidentReport(IR)requiresaSupervisorto

revieweachIR.Thisreviewservestwopurposes:1)toensuretheIRpacketsare

complete;and2)toprovideathoughtfulcritiqueofhowstaffhandledtheincident,

howsimilarincidentscouldbepreventedinthefuture,andtoidentifyanytraining

needs.

Amongthe57IRsreviewedacrossbothfacilities,themajorityoftheIRsupervisory

reviewsevidencedanadequatecritiqueofthewayinwhichstaffhandledeach

situation.AfewSupervisorslimitedtheircommentstoalistofthedocumentsthat

weremissingfromtheincidentreportpackage.ItistheSupervisorsresponsibility

toensurethepackageiscomplete.Simplyidentifyingmissingdocumentsdoesnot

enhancetheusefulnessoftheincidentreportand,absenteffortstocollectthe

missinginformation,Supervisorswillnothavetheinformationtheywouldneedto

completeasatisfactorycritique.Movingforward,Supervisorsshouldbeheldfirmly

responsibleforcreatingcompleteincidentreportpackagesandofferinginitial

commentson

staffs

handling

of

the

incident.

InternalFileAudits:Atbothfacilities,thefacilitySuperintendentorhisdesignee

conductsanauditofeachincidentoncethepackageissubmittedbythe

Supervisors.Whiletheauditprocessatbothfacilitiesisusuallytimelyandrequires

staffresponse,thisprocesscaneasilybedisruptedbyanauditorsabsenceora

lackofvigilancearoundstaffresponsiveness.Atbothfacilities,thesecritiquesoffer

thekeystostrategicviolencepreventionefforts.Byprobingforthecausesof

violenceortheenvironmentalconditionsthatcreatedtheopportunityforviolence

tooccur,thefileauditsareacriticalstepinstrategicviolencepreventioninitiatives

toenhancethesafetyofthefacilities.

OIAInvestigations: All20oftheOIAinvestigationscompletedJanuary1through

April30,2008werereviewed(9fromHickey;11fromCYF).Noneoftheincidents

wereacceptedforreviewbyChildProtectiveServices,butsomewerejointly

investigatedbytheMarylandStatePolice.Ofthe20investigations,20%(n=4)were

sustainedforvarioustypesofmisconduct(e.g.,failuretoproperlysupervise,

falsifyingdocumentation,excessiveuseofforce).Allstaffweredisciplinedina

timelymanner.


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30

TheOIAinvestigationsmeetcontemporarystandardsintermsoftheir

methodologyandquality,andarealsocompletedinaverytimelymanner. The

practiceofhavingonsiteinvestigators,theprocessesbywhichincidentsare

investigated,thequalityofthewrittenproductsandreasonablenessofthe

findings,and

the

consistency

with

which

staff

are

disciplined

are

all

core

componentsoftheprotectionfromharmenvisionedbythisprovision.OIA

investigatorsroutinelydebriefwithfacilityadministratorstoidentifypracticesand

proceduresthatcouldbestrengthenedintheefforttoprotectyouthfromharm.


months,beginninginOctober25,2007.CYFisinsubstantialcompliancewiththis

provisionasofJune30,2008.


OIAinvestigationscompletedbetweenJanuary1andApril30,2008,n=20

CYF


Incidentreports,

n=24,

selected

purposefully

from

those

occurring

between


Internalfileauditscompletedontheincidentsreviewed

Interviewswithfacilityadministrators

InterviewswithonsiteOIAinvestigators

Hickey




Internalfileauditscompletedontheincidentsreviewed


Interviewswith

on

site

OIA

investigators


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SixthMonitorsReport

31

Provision

III.B.vi

StaffTraininginBehaviorManagement,DeEscalationandCrisisIntervention: The

Stateshalldevelopandimplementacurriculumforappropriatecompetencybased

stafftraininginbehaviormanagement,deescalationtechniques,appropriate

communicationwithyouth,andcrisisintervention.Suchtrainingshallbe

completedbefore

staff

may

work

independently

with

youth.

Status

HickeySchool






Discussion Thefollowingregulationsandpoliciesarerelevanttothisprovision:

MarylandCorrectionalTrainingCommission(COMAR12.10.01)

BehaviorManagement

Professionalstandards(e.g.,ACAstandard3JDF1D09)suggestthattrainingfor

directcarestaffshouldinvolve,ataminimum,120hoursofbasictrainingduring

thefirstyearofemploymentandanadditional40hoursofinservicetrainingeach

yearthereafter.

Topics

should

include

use

of

force

(discussed

more

specifically

in

III.B.iv,above)alongwithinterpersonalrelations,communicationskillsand

counselingtechniques.Currently,theMarylandCorrectionalTrainingCommission

requiresa120hourtrainingduringthefirstyearofservice,butonlyan18hour

annualinservicetraining.ThisprerequisiteissupplementedbyDJSpolicywhich

requires40hoursofannualinservicetraining. TheDJShasaddedtoitsrequired

courses.Theynowinclude:suicideprevention,childabusereporting,incident

reportwriting,verbaldeescalation,CPM,bloodbornepathogens,gangawareness

andadolescentmentalhealthanddevelopment.

TrainingrecordswerereviewedforstaffhiredpriortoMay1,2007toassessthe

extentto

which

training

requirements

for

new

hires

are

being

met.

5

Staff

hired

priortoMay1,2007shouldbefullycertified.AtHickey,all97staff(100%)hired

beforethisdatewereproperlycertified.AtCYF,however,ofthe96staffhired

beforeMay1,2007,11(11%)werenotfullycertified.Mostoftheserequiredfield

trainingtocompletetheircertifications.Whilethe89%successrateissufficientto

achievesubstantialcompliance,itisessentialthatELTandfieldtraining

requirementsbecompletedwithinthetimeallottedbytheDJS.

Annualtrainingrecordsfor2007werereviewedforallstaffatbothfacilitiesforthe

previousMonitorsReporttoassesstheextenttowhichdirectcarestaffmetthe

40hourannualtrainingrequirement.Giventhatbothfacilitieswerefoundtobein

substantialcompliancefortheFifthMonitorsReportandbecauseonlyonethird

of2008haselapsedatthetimethisreportwasdrafted,additionalannualtraining

recordswerenotreviewed.

AtHickey,allstaffreceivedtrainingintheareasrequiredbytheDepartmentin

2007,exceptforaverysmallnumberofstaffwhodidnotupdatetheirCPR

5StaffhiredafterMay1,2007arestillwithinthe12monthwindowavailableforcertification.


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32

certifications.AtCYF,over95%ofstaffreceivedtraininginsuicideprevention,

reportwriting,childabusereporting,verbaldeescalation,andCPMduring2007.

Smallerproportionsofstaffreceivedtraininginbloodbornepathogens(66%)and

gangawareness(63%).Thesesuccessratesconstitutesubstantialcompliancewith

thisprovision.

Recommendations

Bothfacilities

have

been

in

substantial

compliance

with

this

provision

for

approximately6months,beginningDecember31,2007.


CYF

Summarytableofannualtrainingrecordsforn=88certifieddirectcarestaff,

preparedbyDJSfortheFifthMonitorsReport

CertificationrecordsforallstaffhiredpriortoMay1,2007(n=96)

Hickey

Summarytableofannualtrainingrecordsforn=75certifieddirectcarestaff,

preparedbyDJSfortheFifthMonitorsReport

Certificationrecords

for

all

staff

hired

prior

to

May

1,

2007

(n=97)

Provision

III.B.vii

BehaviorManagementProgram:TheStateshalldevelopandimplementan

effectivebehaviormanagementprogramatthefacilitiesthroughouttheday,

includingduringschooltimeandshallcontinuetoimplementthebehavior

managementplan.TheStateshalldevelopandimplementpolicies,proceduresand

practicesunderwhichmentalhealthstaffprovideregularconsultationregarding

behaviormanagementtodirectcareandotherstaffinvolvedinthebehavior

managementplansforyouthreceivingmentalhealthservices,andshalldevelopa

mechanismto

assess

the

effectiveness

of

interventions

utilized.

Status

HickeySchool


(asofJune30,2008)



(asofJune30,2006)


BehaviorManagementProgram

AbehaviormanagementprogrampolicysignedintoeffectonJanuary3,2008.

CYFhasbeenincompliancewiththisprovisionforover18months,andsothe

provisionis

no

longer

actively

monitored

at

that

facility.

HickeyadoptedtheprogramthathasbeeninuseatCYFduringtheprevious

monitoringperiod.Writtenguidelinesforstaffandyouthweredraftedanddirect

carestaffreceivedbehaviormanagementtraininginNovemberandDecember,

2007.Youthandstaffinterviewedunderstoodtheprogramruleswithgreat

specificity,andyouthindicatedthattheyareinformedoftheirpointtotalsand

levelsonadailybasis.Asdesigned,theBMPmeetsprofessionalstandardsinthatit


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allowsyouthtoearnpointsforpositivebehavior;aspointsaccrue,youthare

promotedtohigherlevelsthatcarryincreasingprivileges.Youthmayalsouse

pointstopurchasearangeofcompellingincentives(food,activities,etc.).TheBMP

structurewouldalsoallowbonuspointstobeaddedwhenyouthdemonstrate

additionaladaptivebehaviors(althoughthisfeaturehasnotyetbeenimplemented

ateither

facility).

Finally,

in

response

to

arange

of

minor

and

major

rule

violations,

pointsarededucted,resultinginalossofprivilegesandareducedabilityto

purchaseincentives.

Hickeyhasexertedconsiderableenergytodevelopanarrayofmeaningful

incentives.Youthonhigherlevelsarepermittedtoattendspecialevents,

tournaments,movienights,andtouseagameroomthathasvideogames,arcade

games,andotheractivities.IncentiveRoomsineachhousingunitfeature

comfortablebedding,atelevisionandDVDplayer,videogames,booksandother

comforts.Thisincentiveisopentoyouthofalllevelswhoseapplicationsare

reviewedbyapaneloffacilitystaff.Hickeyalsooperatesacommissary,stocked

usingfacilityfunds.Youthreportthattherangeofincentiveshasimprovedand

thatthe

items

and

activities

are

all

of

great

value.

In

terms

of

consequences,

a

detailedlistofminorandmajorruleviolations,alongwithallowablepoint

deductions,isarticulatedinwrittenBMPguidance.Youthwhobelievepointswere

deductedunfairlymayusetheformalgrievancesystemtoairtheirconcerns.The

Monitorreviewedthesegrievancesandfoundtheresolutiontobebothfairand

appropriate.

TheBMPPointLogswerereviewedforeachunitforthemonthsofMarchand

April,2008.Withalimitednumberofexceptions,youthareawardedpointsona

dailybasiswhentheycomplywithfacilitynormsandpointdeductionsarewithin

therangesprescribedinthewrittendocumentation.Whenyoutharetransferred

betweenunits,

their

points

were

transferred

with

them.

Although

the

core

componentsoftheprogramhavebeenadequatelyimplemented,mechanical

problemscontinuetoplaguetheBMP.Alargenumberofcalculationerrorsare

notedthroughoutthepointlogseitherinsummingpointsforthedayorin

tallyingthevariousdeductionsthataretaken.Whilevery,veryfewoftheerrors

arelargeenoughtoresultinchangestotheyouthslevel,ifleftuncorrectedfora

significantperiodoftime,theycouldeventuallydoso.Further,inaneffortto

motivatestafftocompletethedocumentationproperly,ifstaffdidnotsigntheline

onwhichpointdeductionswerenoted,thesepointswererestoredtotheyouth.

AlthoughtheMonitorsupportseffortstoencouragestaffaccountability,this

particularremedythreatenedtounderminethesystemasawhole.Amethodfor

staff

accountability

that

does

not

impact

the

youths

points

so

significantly

is

recommended.Untilthenumberofcalculationerrorsdecreasestoanacceptable

level,morefrequentaudits(e.g.,every2or3days)isrecommended.

Finally,HickeyusesGuardedCarePlanstosatisfythesecondportionofthis

provision.Theseplans,developedbyayouthstreatmentteam,outlinespecific

actionstobetakenwithyouthforwhomtheBMPhasnotbeenparticularly

effective.


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34

Insummary,thestructureoftheBMPatbothfacilitiesisadequateandbothhavea

mechanismforconsultationbetweenmentalhealthanddirectcarestaffforyouth

whoarestrugglingwiththeBMP.AtitsmostbasicleveltheBMPiscapableof

reinforcingfacilityrulesandencouragingpositivebehavioramongyouth.Although

notrequired

by

the

Agreement,

the

BMP

could

be

used

to

advance

each

youths

individualtreatmentgoals.Awardingpointswhenyouthdemonstrateadaptive

skillsandachieveindividualtreatmentobjectivesisasensibleintegration.Further,

byfocusingoncatchingtheyouthdoingtherightthing,staffwouldhavean

opportunitytobeapositiveandbenevolentforce,whensooftentheirrolesare

limitedtosanctioningtheyouthandenforcingrules.

Recommendations CYFhasbeeninsubstantialcompliancewiththisprovisionfor23months,

beginningJune30,2006.Hickeyisinsubstantialcompliancewiththisprovisionas

ofJune30,2008.

EvidentiaryBasis CYF

Provisionwasnotactivelymonitoredduringthisperiod

Hickey


Staffinterviews, n=11

ReviewofPointLogsfromallcottagesforMarchandApril2008

Reviewofwrittenprogramguidanceforyouthandstaff


Provision

III.B.

viii

StructuredRehabilitativeProgramming:TheStateshallprovideappropriate

structuredrehabilitative

programming

to

youth

in

the

facilities.

Status

HickeySchool







Recreation

Giventherelativelyshortlengthsofstayamongdetainedyouth,thePartieshave

agreedthatintensiverehabilitativeprogrammingmaynotbefeasible.However,

bothagreed

that

this

provision

suggests

that

youth

should

be

engaged

in

structuredactivitiesthroughouttheday,i.e.,thatthedailyscheduleshouldnotbe

dominatedbyunstructuredfreetime.Implementingapredictablestructurewitha

highlevelofactivityisessentialtomanagingthebehaviorofadolescents.In

addition,structuredgrouptimeshouldbeusedtobegintoaddresstheissuesthat

broughttheyouthtothefacilityinthefirstplace.Programstoimprovedecision

makingskills,selfregulation,frustrationtoleranceandcommunicationare

essential.


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SincetheinceptionofthisAgreement,thedailyschedulesatbothfacilitieswere

fortifiedwithadditionalprogramming.Notonlydodirectcarestaffconductgroups

onthehousingunitsthroughouttheweek,mentalhealthstaffalsoengageyouth

inrehabilitativeprogrammingthroughouttheweek(e.g.,AggressionReplacement

Training,interactive

journaling,

victim

awareness,

etc.).

Both

facilities

have

also

devisedanarrayofstructuredrecreationalopportunitiesandtournamentsfor

youthsothatfreetimeisnotdominatedbytelevisionandboardgames.Areview

ofunitlogbooksandinterviewswithstaffandyouthindicatedthatstaffdonot

deviatefromthepublishedschedule,exceptinemergencysituations.

AtCYF,thewoodworkingshopandnewceramicsclassreceivedveryfavorable

reviewsfrombothstaffandyouth.Thenewvolunteercoordinatorbroughtfour

additionalweeklygroups(empowerment,characterdevelopment,jobreadiness,

andselfadvocacy)tothefacilityduringthelatterhalfofthemonitoringperiod.At

Hickey,newrecreationalopportunitiesweredevelopedandtheMonitorsnoted

muchimprovedstructureduringtheyouthsfreetime.Whiletheseprograms

havenot

fully

coalesced

into

an

integrated

rehabilitative

package

that

is

focused

onteachingadaptiveskills,theyarefarmorestructuredandinteractiveand

successfullylimityouthsidletimetoacceptablelevels.

Recommendations Bothfacilitieshavebeeninsubstantialcompliancewiththisprovisionfo

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